Vulva La Revolution

Today's guest is one of the most remarkable women in medicine in this country. She began her career as an exercise physiologist, went back to medical school, graduated with honors, and became the first female doctor from Western Australia to obtain the certificate in reproductive endocrinology and infertility, the highest qualification available to a fertility specialist in Australia. She's a paediatric gynaecologist at Perth Children's Hospital, a senior lecturer at the School of Women and Infant Health at the University of Western Australia, and the founder of WOOM, a multidisciplinarian women's health hub in West Perth. She also co-created Charlie.Health, Australia's first, expert led, period and fertility tracker. She is here today because she believes every girl deserves to understand the body that she lives in. Dr. Tamara Hunter, welcome to literacy. Welcome to the podcast.

Thank you.

We ask all of our experts this one question. What do you wish someone had told you when you were younger that had nothing to do with your field and everything to do with being a woman?

Life is about failing forward. So I think so many young people, but but females in particular, we always worry about failing. We always think that we're going to embarrass ourselves or we're going to take a step backwards. But every mistake that you make is an opportunity to learn something. So fail forward. Fail lots.

Yeah. That's a great message too. It's encouraging for failure as well, and not just the people pleasing and having to do everything right and having to be perfect at everything. Like failure is a part of the journey, isn't it?

Yeah. The more you fail, the more you know you're learning and you're gaining wisdom and you're moving forward.

Yep. It's all about like how you frame it.

It is. How you frame it.

Perfect. Um, we're taught to understand and looked after so many parts of our body, but often we are told our privates are private. So even we don't get a look at it. And is becoming familiar with your own genitalia in a mirror a super important thing for a young girl to do?

I think it's essential. I see so many young girls who sit in front of me and they're just so squeamish and uncomfortable. In fact, when they come with mum, they often defer to mum to talk about their things.

Really?

So, mum, can you start? And it's only when we get comfortable with each other that they're happy to talk about periods and pain and all the things down below. But I I think it is really important for a young girl to have a look at herself and understand that it might not look like what you see on social media because what you see on social media often is not real.

Yep. Or it's not gonna look like what you see in porn

Oh 100%.

Like and everyone is so different.

Yeah.

Like I think it's I don't think I took a mirror to my own Vulva for I think I was in my late 20s, early 30s, until I actually said, Oh yeah, that's or nursing school.

Yeah.

Oh yeah, that's what it looks like.

And and who gets a library book out on anatomy? No. No, most people don't. So they're either gonna go looking online, and the easiest place for them to search are your social media sites, which is not the right place to be looking for biological and anatomical information. So understanding what you look like, but also understanding that there is a huge range of normal, that's the place to start.

Yeah. Most girls get a quick look or a quick talk in year six, and then they're expected to figure, you know, most of the rest of the stuff out, including myself. Um, I didn't know my vulva was not my vagina again, until my 30s, which is an embarrassing amount of time. Um but what I , I never knew that that's what it was called. Never mind, like what was happening inside my uterus. I knew I had a period, but I didn't know why I had a period. Can you walk us through like what a period actually is and why we have them as

women?

Right. So let's talk about it as a menstrual cycle.

Yeah.

So there's actually two aspects to it that work together. There's the ovaries, which is where all of our eggs are, and our brain is communicating with our ovaries to tell us to ovulate. But then the ovaries are kind of communicating with the other part, which is the uterus, the house, the temple, where the baby goes. So the the way I describe it is that the brain talks to the ovaries to release a group of eggs every month. And out of that group of eggs, one of them is actually released midway through a month or midway through a cycle. And that is called ovulation. But those eggs that are released from little follicles or cysts, we often call them, also produce hormones that make the house nice. So estrogen grows the lining, and then once the egg has been released, progesterone, which is also released, a hormone that is released, then makes the lining of the uterus nice and ready to receive an embryo. So you've got these two separate structures that are talking. When the egg is released from the ovary, there is a cyst that remains that's called the corpus luteum, and that continues to secrete progesterone, which keeps the lining nice should a little embryo come down the tubes and arrive in the uterus. But if you don't conceive, which we don't want you to conceive as a 15-year-old, if you don't conceive, that cyst on the ovary that's producing the hormones, it has a limited lifespan.

Okay.

So it will just stop, it will collapse at about 14 days after ovulation. That means the hormonal stimulation of the lining also stops. And then because the lining is not being stimulated, it'll just shed. And that's the menstrual bleed. So really we've got a cycle of in a cycle of activity happening. We've got the ovary producing the follicle that produces the egg, but also produces the hormones, and it's the hormones that firstly grows the lining, and then when the hormones are withdrawn, the lining sheds, and then the whole thing starts again. And for most girls, that's around about 28 days, with day 14 plus or minus being ovulation.

So the first half is called, is that the luteal phase?

No, the first half is the follicular follicular phase in the ovary, but the proliferative phase of the lining.

Okay.

And then after ovulation, it's called the luteal phase of the ovary, but the secretary phase of the lining. So there's kind of two systems that work together.

Yeah.

And then it's all controlled by the brain.

I was under the assumption that your ovaries make your hormones, not the eggs. I didn't know that that's, I thought your hormones triggered your ovaries, and then that's what triggered the epithets. So still learning stuff.

Yeah, I know. It is really complex, which is why it is so amazing that we make humans in this way. But so the brain produces hormones. One is called FSH or follicle stimulating hormone. And follicle stimulating hormone stimulates the follicles, cysts, to grow through that first two weeks of the cycle. Out of the follicle, the egg is released. So these follicles not only release the egg, but they also create the hormones.

Wow.

So the hormones, you're right, they're from the ovary, but within the ovary, they're actually from the follicles. And a girl is born with all the follicles, all the eggs she's ever gonna have. So once you've got them dumped in your ovaries when you're about 20 weeks of pregnancy. That's what they do. That's it. Yeah.

That is incredible.

Yeah.

Okay, so period is the shedding

Shedding after the progesterone is withdrawn. Yeah.

That makes a lot more sense.

Yeah.

Science is now using menstrual blood for its stem cells in it to repair spinal cords, to treat heart disease, diagnose endometriosis early, um, and to provide plants with nitrogen-rich fertilizer. I have been watching. It's amazing. Um, what does that tell us about the way that women should be thinking about their periods? Because the shameful waste and biological value are like two very different ways to look at period blood.

Do you know, you just bringing that up made me think of how women's byproducts have been used through the centuries. So many of the fertility drugs that we have created to use in IVF and fertility medicine were actually made from nuns' urine.

Really?

I know, right? So yeah. And of course. When we do pregnancy tests, we're actually pregnant testing a hormone in the urine. When we uh we can also use special tests to assess if someone is ovulating by weighing on a stick.

Yeah.

So there's lots of byproducts from when you do a breath test to check for alcohol level, you're actually processing the metabolite of alcohol in the breath that you breathe out.

Yeah.

So there's lots of byproducts that we use in the body for indicating different things. As far as a therapeutic uh benefit, that's kind of interesting because if you think of the lining, the lining is it's like skin, it's like superficial epithelial cells that have had their blood supply kind of withdrawn, and so it's just shedding so that a new layer can grow up under hormonal influence. Um the amount of stem cells there would be quite minimal. Uh, but you know, you can get stem cells from the inside of your mouth, you can get stem cells from a blood test.

Yeah.

It doesn't actually surprise me that that is just another way of accessing stem cells because you're absolutely right. It is you're shedding tissue that is the lining, but you're also bleeding as well, because the spiral arterioles which supply the lining are also open at the time of a menstrual cycle. So you're getting blood as well. But it yeah, it's a different, it's kind of just flipping it on its head, really, and and thinking of well, how else can we use it's framing it differently? Yeah, yeah. Sustainability.

Yeah. Well, and it's also it's not something your period is not something to be shameful of or embarrassed about, like the fact that there's value in what we do as a woman and what we get from that is is flipping in its on its head, kind of.

Well, I always utilise the menstrual cycle as an indicator, a biomarker if there's something going on in a female. So for example, if a female has what we now call polyendocrine metabolic ovarian syndrome, or it used to be PCOS, it's now PMOS, uh, one of the biomarkers for that is an irregular cycle where they might only have six cycles a year instead of 12 cycles a year. Um when young athletes who work very hard in their sport and perhaps are not re-feeding themselves well enough, they'll often lose their periods. And so that's an indicator for me that something is going wrong. So there is actually a lot about the menstrual cycle that can tell us about a female's health.

That's amazing. Now, with the menstrual cycle, how much is like an how much are you bleeding every month and what's the typical length and what's the typical amount of pain that a young girl should be in? We'll talk about pain in in a little while, but like what's the what's what's what's normal?

Okay,

so this is difficult because I feel it's a very subjective experience. So every young woman who comes to see me, I don't get them to measure. So if I opened up a textbook, a normal menstrual cycle would be about 80 mils of blood. Now, what girl is actually going to collect all of her blood and measure it? None. Um, so for me, it's more about how I establish its impact on that person's quality of life.

Yeah.

So how often they're changing pads? Are they using super pads? Are they having to go to bed at night time with two pads lined up back to back? Are they finding in the morning that their sheets are soaked? Are they sitting on the toilet and passing big palm-sized clots? These are all the ways that I assess whether or not a menstrual cycle is normal for a young female or not. Typically, you would expect someone to bleed for no more than seven days. If their period goes for longer than seven days, I start to ask questions why.

Yeah.

But the volume is difficult to assess. So really, it's about how are they coping with the menstrual bleed each month?

Yeah. Okay.

Um, what is discharge? Why does it change throughout the month? Um, and when is it cause for concern? And is it a window into what our hormones are at?

Definitely.

Yeah.

Yeah. So all through the vagina, at the entrance to the vagina, the vulva, uh, right up to the cervix, there are glands that are called that are releasing secretions all of the time. You need lubrication in these tissues. They are very much under the control of hormones. And so there are some people that actually use their vaginal discharge to assess where they are in their menstrual cycle to time intercourse to have a baby.

Yeah.

So we know in the first half of the cycle, we call that the follicular uh half, where estrogen is predominant, the discharge will be like egg white. That's what people talk about, like egg white. And it increases in volume towards the middle of the cycle. After ovulation, it changes. So under the I guess influence of progesterone, it becomes thicker and much more creamier. And then it declines towards the end of the month. So by the time someone gets to their period, there's pretty much no discharge because there's no hormones around.

Yeah, that makes sense. And I I remember when we were trying to have a baby, um, the doctor told me look for sticky, that discharge?

Yeah, that egg white stickiness.

And is it when it's thicker, is it sticky as well, or is it a little bit more? Uh no, it no well, well, again, how would you describe sticky? Um, it's it's thicker and more creamier.

Yep. Yeah. Okay.

And sometimes, sometimes it's even yellow. So some girls will get really worried that after they've ovulated that thick, thicker, creamier discharge is actually quite yellow. That's normal.

It's normal too.

Yeah. When is it abnormal?

Yeah.

Profuse discharge, malodorous discharge, so it smells bad. Yep. Uh, particularly uh uh fishy kind of odour.

Yep.

Um where they might be having to wear pads because there's such a lot of discharge. Anything that bloods is blood stained is not normal.

Yeah, okay.

Um, and what about keeping the vulva clean? The vagina area, obviously, you don't touch. I'm under the assumption. But cleaning the vulva, I've heard mixed things. Do you clean it with soap and water? Is it just water?

I always tell my patients the vagina cleans itself.

Okay, the whole area.

Yeah, well, there's the odour aspect of it, and that's more managing sweating. Because there's not a lot of space down there. And so if you're wearing tight pants or clothing, you you will sweat. Uh so the body odor aspect of it, I think it is reasonable to just use a simple soap on the outside. During the reproductive years, when we've got a lot of estrogen around, the estrogen will keep the tissues nice and nourished and in good health. It also helps to manage the microbiome. So you're not going to get any pathological bugs that kind of overgrow. So, generally speaking, the vulval health is very simple, simple shower, bit of soap on the outside, perhaps in the hair-bearing areas, but definitely nothing that's perfumed inside the vulval tissues where there's no hair-bearing area. There's no necessity to do that. And in fact, if you are putting soap inside, you're probably going to start to cause imbalance in the microbiome, which could actually then increase discharge or cause irritation like itch and discomfort.

And then what kind of underwear should women be wearing? What's that's the is it a cotton? Is it rayon? Is it bamboo? What's the healthiest?

I don't think we have any good solid evidence on that. I think comfort. If it's uncomfortable, uh, don't wear it, perhaps.

Fair enough.

Um, you know, we all talk about natural fibres, but I don't think there's any evidence to show that the non-natural fibres actually increase vulvitis or infection risk or anything. I think comfort is important. I do think letting it air out is really important. So going commando at night time in a pair of boxer shorts or or loose pyjamas is is actually probably really good for our vulval health.

Yeah, fantastic. Um and just quickly before we move on about wiping, about why

we wipe front to back, correct?

And we Again, this is a bit of a myth. Is it? Yeah, yeah. I mean, I work in paediatric gynaecology, so I see a lot of little girls who are pre-pubertal, there's no estrogen around, so their tissues are quite sensitive and they can develop uh uh what we call a sterile vulvitis. But there've been research studies done. Does wiping back to front increase the chances of getting vaginal or vulval infections? And the answer is no, it doesn't. So there are no rules on I know wiping back to front or front to front. I just think wipe, keep it clean. And if it hurts to wipe, then dab.

Dab. That's a good one. Just want to

talk quickly about pap smears and how they're done at a GP. And then once you get the first one at a GP, you're encouraged to do them at home. Um, it's very accurate, the science is showing at catching HPV, which is super important. Um, but are we missing things for girls by not seeing the cervix, like lesions or infections or um changes in appearance or anything like that?

Okay. So there's a couple of things I want to just clarify. So we now call it cervical screening tests.

Yep.

And the purpose of the cervical screening test is to screen for abnormal cells on the cervix. And the main cause, some 93% of cause of abnormal cells, and then consequently cervical cancer is human papillomavirus. So the majority of girls now are vaccinated as teenage girls around the age of 13, 14, they receive their vaccinations against the HPV virus.

Yep.

Interestingly, though, the current vaccine only covers nine strains. There are over there are a hundred strains of HPV.

Oh my god.

And it is sexually transmitted. So we're hoping that we're avoiding the nine strains that are most likely to lead to cervical change and cancer. But you could have HPV other that you still contract with sexual intercourse. So the cervical screening test in itself is still vital, even if a girl is having her vaccinations as a teenager.

Yeah.

We have not yet eradicated HPV-causing cervical cancer, but we're well on our way, and that's why it's such an important screening test. The studies have now shown us that girls can self-collect.

Yeah.

It doesn't mean they can take it home and do it when they want.

Okay.

So it is recommended for girls who are not wanting to go to their GP and have a speculum inserted into the vagina and have a cervical screen that they can self-collect, but it is recommended that they self-collect within a medical practice.

Oh, okay.

Yes. Because you can imagine teenage girls, let's face it.

Yeah, yeah, fair enough.

You know, it's it's a compliance, even young women. It's a compliance thing. So it is still encouraged to be screened every five years. If you're not going to go in and get it done with a GP, the GP can give you a swab to self-collect, and you can go in the bathroom and you can pop it in the pathology lab. Um so that's, I suppose, from the HPV perspective.

Yeah.

Where you want to have a look is if there are symptoms. So if a young girl comes into a GP and says, I've got some bleeding after sexual intercourse, or I've got some funny discharge, or I've got brownish loss after my periods. You want to have a look in the vagina and you want to have a look at the cervix. And the only way to do that is to use the speculum and have a look. And look, nobody loves it, but but it is something that can be well tolerated in a nice relaxed environment. Taking time, making sure there's lots of lubrication, a good table so you can see properly and you're not sort of poking around for minutes on end that is really traumatic for a young girl. But um yeah, cervical screening is still vitally important, even if you feel fine.

And with that five years, especially like you said, if there's only nine that are shown and there's what, 91 that different ones, is the a young girl who's quite sexually active or may have lots of different partners, is that five years? Is that an appropriate amount? Or should they be seen?

No, no, you don't want to over-screen.

Okay.

Um, it's costly to the public healthcare system to over-screen because don't forget, you've then got to um follow up all those patients who are being overscreened. So the data shows us clearly that five years is adequate enough time between one to the next, even if there's multiple sexual partners. Obviously, if someone is symptomatic, then they can get screened more frequently. Um, if a cervical screen comes back abnormal, then of course you're going to bring them back a year later just because HPV is a virus. So just like any virus, it relies on the immune system to clear it. The sneaky thing about the HPV is that it hides inside the cells of the cervix. And so the immune system is just surveilling, surveilling, surveilling, surveilling, doesn't see it. But if you're young, fit, and healthy, eventually it will. And so what we're doing by saying, hey, come back in a year, we're relying on the immune system to clear it. And here's here's the clincher here. It takes, on average, 10 years for an HPV, a human papillomavirus, to cause cell change to then cause cancer.

So super slow.

Really slow. Yep. And it's got to go from a low grade change to a high grade change to a cancer. The reason women out there are getting cervical cancer from HPV is that they're not getting their screening.

So super important every five years.

Yeah, every five years.

Yep.

From 25.

From 25.

If you've had the vaccine.

Okay, good to know. Um, there's so much variation in women's

anatomy. What do women need to understand about what's normal when it comes to the different shape of our anatomy and our labia?

Right. Such a loaded question. Understand that there is a huge amount of variety. And I'm gonna give a plug for the Labia Library, which is a website that young girls can access. Um, there is also something called the Great Wall of Vaginas, which you can also access online. And it is collections of images of different vulvas that are classified within normal range.

Amazing.

So they're not the abnormal ones. I love it. Because when I get a young girl who comes in and says, my bits look abnormal, I want them chopped off, I'm like, whoa.

Y ep.

Maybe you need to actually see what is what is within the realms of normal. And we have very strict guidelines around what we should and should not be doing to the vulva and the labia of young girls. Um, if you think about it, these structures, this the similar structure in the male is the scrotal sac and the penis and the the testis. They are highly innovated, highly vascular structures.

Absolutely.

Well, so is the labia and so is the clitoris. And if you go cutting these structures, the chances for disfiguring scarring and chronic pain are significant. It's not a matter of, oh, can you just chop it off and nip and tuck and it'll look fine? Well, I might be able to do that, but I might actually cause you lifelong problems by doing that. So, what's most important is to understand that as an adolescent woman or adolescent girl, your vulva is still changing right through to your early 20s.

Does it really?

Yes. Yeah. Yeah, and just growth in general. So fat distribution and hormones and hair growth. I mean, that's another thing. Is women are waxing themselves to within an inch of their life now. So they're seeing things that a nice healthy growth of hair wouldn't have shown before. And so perhaps we're getting this very skewed opinion of what is normal and what is abnormal because of our cosmetic and our dilapidatory practices.

Yeah. Where do you think all the pressure? Because we saw when I was working in surgery, we saw a lot of labiaplasties, a lot of young girls coming in for labiaplasties. Where do you think the pressure is coming from? And when should a girl actually consider a labiaplasty?

Right. Well, the first thing I want to say is in this country, we have very clear guidelines around what is considered to be female genital mutilation, and that is narrowing the orifice to the entrance. There are clear guidelines that are put out by the uh the College of General Practitioners about who could be considered for labiaplasty and the general consensus is we not we should not be doing this on girls under the age of 18, most definitely.

Yeah, I've seen quite a few girls under the age of 18. So, what would be the reasons for a young girl under 18 to be having a labiaplasty?

I see a lot of young girls come in with their mothers, and a lot of it is driven by the psychosocial context. So, what how they view themselves. So the very first thing we have to do is teach them what is normal and what is abnormal, teach them to look at themselves. We actually do physical measurements on the length and shape and size of the labia to then determine, well, anatomically, is this within the realms of normal or is it not? Um, I would always get them to get a second opinion from another gynaecologist to make sure that I'm on the right path. I would always then get them to have a psychologist review to talk about self-esteem, self-confidence, self-definition. And in truth, it's actually as important to discuss this with the parents as it is the children, because every parent wants their child to be happy. And if we can just have a little nip and a tuck, Dr. Hunter, and that will make them happy. I think a lot of that is parental education as well as education of the young girl.

Yes.

Perhaps education that that boy that said that it doesn't look normal. Maybe he should kick him to the curb. Maybe he's not the right one for you.

Um and the names are mean.

Right.

And the the teasing, the bullying about um what they look like. That's it's cruel.

Yeah, it is.

And I can understand how that like is psycho -socially that's wired to to bother a young girl and then how she would

they're at the most vulnerable point in their life.

100%.

When you're talking about physical image, the place to get a girl is to tell her that her private bits don't look pretty.

Yeah. Exactly. It is, it's cruel. It's it's almost abuse. Yeah. Yeah, I would 100% classify that correctly.

Yeah. So so would there be girls that appropriately have labia plasty?

Yes, those whose inner labia extend out beyond the outer labia, the hair-bearing um labia majora, and there is obvious trauma to the tissues from being exposed.

Like as in being rubbed

Rubbed, um chafing. Yes, chafing, splitting, tearing.

Yep, fair enough.

But I would be doing the anatomical measurements, I would be looking at the state of the tissues, but I'd also be assessing the psychosocial context of how did you get to my office? Before I would even consider it. And really, my advice would always be if you're under 18, wait a little longer. You're going to notice changes that continue to happen right through into your early 20s. And then reevaluate whether or not it's something you really want to do.

Yeah, fair enough. Now that we understand what our cycles are meant to look like and what our bodies do each month, let's answer the next question. How much pain is too much pain? Head to episode two to continue our conversation with Dr. Tamara Hunter.