Tuesday, January 8, 2013

The Wonders and Perils of being a Woman

As salaam alaikum,

I performed my first circumcision yesterday, after seeing one performed for the first time since third year medical school. The baby boy was pretty much done with me when I injected the lidocaine into his penis and screamed the rest of the time until his father found an effective way to dispense sugar water. That was at least reassuring that I had sufficiently numbed the area as he stopped crying as I made the actual incision.

My mother, of course, upon telling her the news (I get excited when I get to do procedures!) was ambivalent. Although a practicing Muslim, she wonders how necessary circumcisions actually are. I reassured her that physicians are actually using anesthetic now based on a study 20 years ago. When my brother and I were kids, they were just performing the procedure and not giving any anesthesia because it was assumed that the baby boys weren't really feeling pain.

Only one way in which the medical establishment has been less than genius.

According to my preceptor, an observational study performed a little while back demonstrated that adult men who are circumcised as adults reported feeling less sensation than they did while uncircumcised. My mind immediately drifted to FGM, and it did make me feel bad about circumcision.

That is, until one of my guy friends said, whatever, I enjoy sex anyway.

He then celebrated "winning" the conversation by making the most inappropriate comment. It was my fault...clearly walked into it.

To which I responded...whatever, man, y'all can have it...I'm just glad I'm female.

I've said it before, and then I immediately think, not that being female is at all simpler. Not at all. And I'm not talking from a social, gender perspective...I'm speaking strictly biological for a second.

When we are born, because of our mother's hormones, sometimes we bleed from our vaginas and our breasts express milk. Once our mom's hormones calm down, we go into our presumed asexual infant existence. Except, we're never entirely asexual, because infants do engage in self-stimulation postures at pretty young ages. Not anything any young parent likes to think about...the foreshadowing of your baby's sexuality.

Anyway, at base, we as females, because of our anatomy, are more prone to urinary tract infections. Baby boys with foreskin are more at risk for urinary tract infections than circumcised baby boys, but not as much as baby girls. Urinary tract infections and any potential causes of sepsis in infants is serious and requires hospitalization.

As we grow up and are little girls, we're still more prone to urinary tract infections, something that will continue until we're adult women. At least as adult women our UTIs are considered "uncomplicated" and can be treated even empirically without visiting clinic if we have them often enough. But of course, the wonders of biological womanhood do not end with infections, though it begins there.

And in many ways, it continues. Because of our anatomy, we are also more prone to sexually transmitted diseases. With the exception of men who engage in receptive anal sex, we are more likely to contract HIV, for example, than our male partner(s). While human papilloma virus, HPV, infects both men and women, women bear the brunt because of those virulent strains that can lead to cervical cancer.*

Of course, the greatest vulnerability, biologically and anatomically, are the consequences of our reproductive system. We are one of the few mammals that menstruates instead of undergoing an estrous cycle, where the lining is reabsorbed. The monthly shedding of unfertilized uterine lining, which begins when we are very young, is not painless for all of us. Some of us, myself included, have overactive prostaglandins that lead to a fair amount of inflammatory pain in our uteri and surrounding organs, making the monthly cycle painful without fair amounts of pain medication or birth control.

(I often think that women who just bleed for their period without pain complain to much about bleeding. If I could ever just bleed for menstruation, I'd probably blissfully forget I was bleeding.)

Of note, one of the wonders of not having the estrous cycle is that our sexuality as females is not restricted to those moments in the cycle when we are fertile as it is with mammals on estrous.

We also blessedly don't get to count on being assaulted by our male counterparts when we are "in heat."

Pregnancy, of course, is the greatest consequence of our reproductive system. Our anatomy is the receptive anatomy, and our gamete, the ovum, is the receptive gamete that receives the other for fertilization. Our gamete, unlike the male gamete, is with us from our own gestation. As fetuses, we have already made most all of the ova we will have.** By the time we are born, they're already declining. By the time we menstruate, we have thousands less ova than when we were born. And even as we menstruate, we lose more ova than are not fertilized each month. But they're with us all of our lives, in these bodies that we carry through triumph and tribulation, and we really don't understand the impact our decisions and our ingestions make on our gametes.

The ovum, unlike the sperm, has more cytoplasm and contains mitochondria, powerhouses necessary for aerobic energy generation in our cell. It also contains its own unique genetic material, different from what is found in the nucleus of our cells. In that way, the genetic material from mitochondria we only inherit from our mothers.

And once fertilized and implanted, because not all fertilized eggs are implanted, the female body begins a ingeniously orchestrated balance of hormone and cytokine expression that begins the symbiotic relationship between fetus and maternal body. Our scientists and physicians still do not understand how the female body does not reject in the womb what in any part of the body would be regarded as foreign material and attacked by our immune system before it could divide into a morula.

And the female body is taken through so many changes in the course of a pregnancy. So many stresses, and not just the expansion of the uterus, pushing intestines and bladder and lungs aside in favor of the growing fetus, affecting digestion, urination and breathing. So many other physiologic changes happen, importantly including the increase in fluid volume, the relaxation of the connective tissue in the body, not only in the hips, but everywhere, which is the reason why some women's nose looks different during pregnancy. The connective tissue in the feet also relax, which is why some women notice a change in shoe size after pregnancy. But the hips expand to make room for the presenting part of the fetus with impending delivery. The hormone balances that we do not entirely understand can cause morning sickness, hyperemesis gravidarum, and yes, alterations in mood.

But much more than this takes place in the body of a pregnant female. There are also risks. Pregnancy is a hypercoagulable state in which deep venous thrombosis and pulmonary embolism, the latter which could lead to death, is more common. Because of the increased fluid, women with cardiovascular disease have their systems stressed during pregnancy. All of a sudden, its not just about the anatomy and physiology of our reproductive systems. When pregnant, the entire female body comes into play in an important way to keep both female and fetus alive.

Then there are the various dangers within the reproductive unit, from the cervix to the sac to the placenta, all important for maintaining the pregnancy to term, all of which, for reasons that we don't entirely understand, can fail early and lead to preterm delivery. Diseases of placentation can lead to death of both fetus and female from bleeding.

But somehow, alhamdulillah, most pregnancies are relatively uncomplicated and carried to term.

But the perils of pregnancy are not over for the pregnant female at term. There is still labor.

Labor is something I've only experienced as an observer and practitioner. I've had the easy part of delivering babies from women who have carried them near or all 40 weeks, and then some for some women and whose bodies have undergone all of the changes, who lay before me experiencing the pain of their lives. The first pain is of the gradual decent of the fetal presenting part, which can also cause severe back pain. The next pain is that of contractions. When the presenting part gets very low, then its perineal pain. All the while still feeling the pain of contractions and back pain as baby makes its way low in the pelvis. The final primary pain I've heard women in the second stage of labor (the pushing stage!) describe is the "burning ring of fire." Especially women who opt for natural child birth feel the burning when the head is coming to crown, and then, as one woman aptly described, feel as if your "[buttocks] is being ripped apart" as the baby crowns and is born.

A baby is born, the entire reason for the female reproductive system has realized itself.

And still, the perils of pregnancy are not yet at an end!

The body takes some time to reverse from its pregnant state. Never does it revert to its pre-pregnant state. From head to toe, the female body has undergone some permanent changes. Even the hair reacts, as many women experience telogen effluvium, the loss of hair in masses which can happen after, but is not limited to, pregnancy. Right after delivery, the female body is still hypervolemic, still in that hypercoagulable state, still at risk in those ways. But the oxytocin that once drove the contractions to push baby is now the oxytocin of contracting the uterus back to size and milk let down.

The breasts have now transformed into what was for centuries the infant's only means of survival, and is still the infants best means of thriving.

The hips (and feet) remain in their relaxed state, the cervix, which expanded to 10 centimeters to allow the more-than-10-centimeter head of the baby through, will never be the same. The changes in the body make it easier for any subsequent births, as the body has motor memory and has already made its greatest expansion to accommodate the fetus.

The female body settles down from pregnancy but is never the same.

And whether the female is pregnant or delivers or not, for many the cycle continues until menopause, when the hormones that made us bleed and express milk as infants have run their course in our bodies. The hormones that protected the female body against heart disease and orchestrated the production of one or a few ova each month relent, and the reproductive system takes the rest of the female body with it into the final phase of change. The female body now is exposed to increased risk of cardiac disease, potential for osteoporosis, among other things about women's health that we are just coming to understand.

And thus, if only relegated by our anatomy, though I remain "glad" (understatement) that I'm a female, I acknowledge that it is a state of being that is not, nor has never been, simple.

And this is just speaking strictly anatomically, physiologically and pathophysiologically. This ignored most if not all social dimensions of being female, thus gender. There, it becomes even less simple.

Though explained in a dire way, what with all of the risks of disease and death, what makes us biologically female and the consequences that this small part of our bodies has on our entire bodies and, indeed, our entire beings, is perilous yes but more wondrous yet. We are powerful human beings with the capacity to carry living beings within our bodies, like our other mammalian counterparts. While both male and female components are necessary for the propagation of our species, the 40 week commitment of the female body and initial participation of the ovum, much more sparse than the male gamete in quantity and production, is absolutely integral.

And yet, like our male counterparts, we are so much more than our reproductive biology.

And so it continues...

* Once again, in men who engage in receptive anal sex, HPV can lead to anal cancer.
** Some studies are indicating that women have the capacity for gamatogenesis after birth and retain the capacity throughout their reproductive lives, which calls into question but does not definitively reverse the previous notion that women are born with all the ova they'll ever have.


  1. Congrats. It is a good procedure for boys and there actually are a lot of good health reasons behind circumcising. You should google: AAP circumcision. The American Association of Pediatrics has recently come out with the statement: "that the benefits of circumcision outweigh the risks"

    And this is a good link to check out too:



  2. Happy New Year!

    Pregnancy and childbirth is one of the weirdest processes life has to offer. I often wonder why women tend to forget to mention all of the physical changes/shock their bodies go through. My mom for instance sort of goes, um it hurt but you know it wasn't so bad...or something generic like that... ha, ha...

    I never knew that babies sometimes bleed or produce milk.

    I don't know why, but when I read the opening bit about the circumcision, my mind automatically went to FGC and I thought "What? they do that in the US now?"

    ok my comments seem disjointed, but it was nice to read about what you are doing at your job Dr. Chinyere.