Check out this sneak peak of What's Up Down There? Questions You'd Only Ask Your Gynecologist If She Was Your Best Friend (on shelves Sept 28)!

Intro: Let’s Talk About Coochies and Boobs

Brrrrringgggg….The phone rings. Caller ID says it’s Chloe. I pick up.

All I hear are giggles. Then a snort, followed by a cackle.

“Chloe?” I say.

Chloe snorts again.  I shake my head and smile.

I hear someone yell, “Don’t say vagina so loud!”

They’ve done this before. Chloe and Piper are in Manhattan celebrating some girl time away from the kids, obviously talking about sex over a few cocktails.  Whenever they think up questions about their girl parts, they call me. They are my best friends, and I am a gynecologist. 

A clanking noise indicates that Chloe must have dropped the phone. Then I hear Piper’s voice.  She says, “We’ve made a bet, and you gotta help us out.  If a woman squirts fluid when she has an orgasm, is it pee?”

They collapse into a fit of giggles again, and I wish my job didn’t keep me from zipping off to New York on a girl bonding lark.  I want to be with them, leaning on each other for information and support, broaching topics most people don’t dare venture near.

I answer the question.  Piper wins the bet. We air kiss into the phone – “Mmmwhah!” – and hang up.

Five minutes later, the phone rings again. It’s Piper.

“Is it true that your uterus can fall all the way out of your vagina and wind up hanging between your legs?”

I answer the question. This time, Chloe wins the bet.

Ten minutes pass. Brrrriiing.Chloe fires off more questions. “Why is it that my crotch smells like fish sometimes?” “Why do boobs get smaller when you breastfeed?”  “How come I have a droopy box since I gave birth?”

They put me on speakerphone so that it feels more like I am there, sipping a glass of wine with my girls in a swanky Manhattan bar, instead of sitting at home with my beeper on. 

Chloe and Piper like to brag about having a gynecologist on call 24/ 7. In addition to being their friend, I’ve delivered their babies, performed their Pap smears, and helped them with issues ranging from postpartum blues to pelvic prolapse. It’s a role I’m proud to play. 

When Chloe and Piper returned from New York, we sat together with our significant others over shrimp Caesar salads.  Chloe, always the rabble rouser trying to embarrass the guys, asked, “Have you ever heard of a gynecologist finding something weird stuck up someone’s vagina?”

So, mid-salad bite, I answered the question. Yup.  You can bet I’ve seen my share of stuff stuck in vaginas. Although actually, the up-the-butt stuff tends to be way more common. (“Really, Doc, I swear, I fell on that Lysol can/gerbil/cucumber/toothpaste tube.”) Although there are many colorful answers, one came to mind instantly.  The guys at the table rolled their eyes, but everyone put down their forks, riveted.

It was 3 a.m., and Mildred, a frequent flyer to our ER, showed up for the umpteenth time complaining of pain in her “passion flower.” The ER paged me, the gynecologist on call, to come see her. Since I had not met Mildred before, the nurse felt compelled to warn me before I started the pelvic examination. “Just so you know,” she said, “Mildred uses her vagina like a purse.”

Thinking the nurse was euphemistically informing me that Mildred was a prostitute, I asked how long she’d been hooking.  The nurse explained, “No, she’s not a prostitute. She literally uses her vagina like a purse. She stuff it with money, Motrin, keys … you know, purse stuff.”

I went to see Mildred, who politely shook my hand.  “Oh, hi Doc,” she said. “Let me get ‘er ready for ya, sweetie.” She then proceeded to pull down her pants and begin yanking things out of her vagina like it was Mary Poppins’ magic carpet bag (or, in this case, carpet box).  There was a plastic baggie of pills, a wad of bills, a tube of lipstick, a pen. Half expecting her to pull out a red scarf that magically turns into a bouquet of flowers, I was on the verge of busting out laughing, when I suddenly realized that there was something very wrong with this picture.

It’s tempting to laugh when gynecologists tell vagina stories. But sitting in that room with Mildred, I realized that something tragic probably happened that made Mildred think using her vagina as a handbag was a good idea. My heart filled with compassion for her, and when I asked her flat out whether she had a history of sexual abuse, she put her head on my chest and cried like the eight-year old she was when she was first violated. She admitted that she hated her “passion flower” and figured, since it had done nothing but bring her trouble, she might as well put it to good use.  After our early-morning chat about owning and respecting her beautiful, sacred yoni, Mildred swore she would buy a purse and save her passion flower for the purposes God intended. God only knows what happened to her, but my heart still aches to think of her.

With this book, I’m not trying to gross you out or make you lose your appetite for shrimp Caesar salad. Nor is my primary goal to elicit giggles (though you will laugh plenty – as you can see, we gynecologists have some stories!).  Instead, I aim to quit skirting the issues, the way many doctors do.  I’m not going to tell you the “safe” answer or hedge my bets.  I’m not going to worry whether insurance companies will agree with my recommendations or whether lawyers will sue me. I’m just going to talk to you like a friend, someone you can trust to tell it to you straight.

While my girlfriends get to indulge every question they’ve ever had about coochies, boobs, sex, butts, and women’s health – usually giggling with me over a glass of wine – most women don’t have a gynecologist at their beck and call, and end up talking amongst themselves, often perpetuating myths and repeating misinformation.  This bookaims to bridge the chasm between the questions real women have and the answers a gynecologist would give you after she took off her white coat and sat down with you over a cup of coffee (or a cocktail). 

Most of all, I’m going to approach your intimate questions the way I think we should all practice medicine- by practicing love, with a little bit of medicine on the side. What does love have to do with gynecology? Everything.Trust me on this.  When we approach our bodies with love, acceptance, and nurturing kindness, we pave the way for magic to unfold, the kind of magic I’m blessed to witness every day. So spread your legs and open your heart. Let’s explore together what it means to be truly, wholly, and authentically female.  You might even discover that being open to the part of you with the capacity to give birth just might help you give birth to YOU.

Sample Q&A

Doesn’t it gross you out to look at skanky snatches all day long?

No. It’s really not like that.  When you’re a doctor, you get used to dealing with things others consider gross. When I was a medical student, I had a patient with severe abdominal pain who hadn’t pooped in 10 days. When we did an X-ray, the radiologist unofficially wrote on the wet reading “Diagnosis: FOS” (doctor speak for Full Of Shit.)  We tried laxatives, enemas – you name it. Nothing worked. So as the medical student with the smallest hands, it was my job to glove up, slather on the lube, and go poop hunting.  There I was, up to my elbow in someone’s bum, pulling out one hardened, putrified poop ball after the next. It took hours.  Once you’ve done that, vaginas are a piece of cake.

Truth is, most women primp for the gynecologist. They respect the fact that someone’s gonna go face-to-coochie. They shower, trim their pubes, and sometimes even spritz on a little Chanel #5. For the most part, I’ve found that women practice good hygiene, even when I worked in public health clinics with women who were lucky to find fresh water to bathe. 

Sure, there are exceptions.  My paranoid schizophrenic patient Dalia never showered.  Every time she came to see me, I had to plug my nose before I could get near her.  But skanky snatches are no grosser than the vomit my patients hurl on me when they’re in the throes of pain, the loogie a smoker hacks up, or the poop excreted by a woman during childbirth. 

If you’re a mother, you deal with this stuff all the time.  Look at what our kids put us through.  But just as you snuggle your little one when she pukes in your hair, we gynecologists do what we must to care for our patients. Sure, sometimes, what we must do is a wee bit distasteful.  But just like motherhood, the joys and rewards of helping women outweigh any of the downsides.

Is pubic hair supposed to be the same color as the hair on your head?

Not necessarily. While in some people, the carpet matches the drapes, so to speak, it’s not the case for everyone. The presence of two distinct colors of hair in the same person is called heterochromia.  My patient Molly is a fiery redhead, and she got teased her whole childhood by guys who nicknamed her “Fire Pie,” referencing the bright red bush they envisioned. But Molly got the last laugh. Turns out her bush is a dark, chocolate brown without so much as a fleck of red.  It’s not uncommon for people with light-colored hair on their head to have darker pubic hair. Keeps ‘em guessing, I suppose.

Do little old ladies still have sex?

Absolutely. While some older women choose to close up shop down there, many are still open for business- and thriving. Let me tell you a story.

When I was a brand new OB/GYN, I was seeing patients in the continuity clinic, where we young docs got to practice having our own clinic.  Mrs. Kaufman was my very first patient, and I’ll never forget her. She was 84 years old, and the words scratched on the top of her chart read, “Patient complains of vaginal itching.” 

Before I entered her room, I stood outside her door, scrolling through the differential diagnosis for vaginal itching in my tired, stressed brain.  Yeast infections, bacterial vaginosis, trichomoniasis, atrophic vaginitis, psoriasis, vulvar cancer, warts.  Could an 84-year old actually have warts?

Mrs. Kaufman looked like a storybook grandmother, clad in a hand-knit lavender sweater, long white hair knotted neatly into a bun, with bifocals on a string around her neck.  “Hi Mrs. Kaufman. I’m Dr. Lissa Rankin,” I said, stuttering over the title and fumbling through her chart.

“Well, hello Dr. Lissa,” she said, gazing up from her knitting and smiling.

Doing what I’d rehearsed in my head, I shook her hand and sat on the rolling stool next to her.  “What brings you to see the doctor today?” 

She stood up and put her hand on my shoulder, looking me right in the eye.  “Honey, I got me an itch.”

I nodded, making notes in the chart, wondering if she could tell by looking at me that I felt like I was play-acting the doctor thing.  Though I had jumped through all the hoops like a poodle at a pathetic, road-weary traveling circus, I definitely didn’t feel like a real doctor yet.  I went through the motions, sitting up straight and sticking a pen in my tied-up hair, while I asked the required litany of questions.  How long have you had the itch?  Where exactly is the itch?  Does anything make the itch better or worse?  Have you tried any home treatments?  Have you ever had an itch like this before?  I furrowed my brow, trying to look serious and doctorly.  Mrs. Kaufman answered my all questions.

Handing her a gown, I asked her to get undressed from the waist down while I stepped outside the exam room for a moment.  I snuck out the door, feeling my heart race.  I had never done a gynecologic exam without someone looking over my shoulder. 

When I walked back into the room, my expression must have betrayed my feelings, because Mrs. Kaufman patted me on the shoulder, as if she was the doctor and I was the patient. Awkwardly, I leaned over and pulled out one rickety metal stirrup that clicked and creaked as I tried to adjust it. Seeing me struggle, Mrs. Kaufman stood up from her chair, steadying herself with her cane, and pulled out the other stirrup for me, getting it just right the first time. 

I was about to give her my arm to help her onto the table, when she put both hands on my shoulders and said, “Sweetie, I gotta tell you something first.”  I was sure she was going to tell me she was onto me – that she could see right through my skin to the insecure child I felt like inside the white coat.

But Mrs. Kaufman surprised me.  She pointed a spindly finger between her pale, varicosed legs and said, “The itch.” She mimed scratching. “I think it’s from my new boyfriend’s beard.”

I was silent for a minute. Her new boyfriend’s beard? Then a mental image filled my head, and I officially lost it.  All artifices of professionalism flew out the door as I hiccupped laughter, tears rolling down my cheeks.  To my relief, Mrs. Kaufman laughed too. 

When we settled down, Mrs. Kaufman whispered, “Well, honey, if you can’t tell your gynecologist, who the hell can you tell?”

Mrs. Kaufman taught me a valuable lesson that day, and I’ll never forget her.  Just because we age doesn’t mean we go out of business.  When my patients experience menopause, most feel young at heart but may need help getting their bodies to cooperate with what their young spirits desire.  Whenever a woman going through menopause asks me whether she’ll be able to keep her sex life alive, I tell her about Mrs. Kaufman, who continues to inspire me. I hope I can be like her when I grow up.

Should I douche? If so, how often?

No, ladies. Please don’t douche.  Whoever decided douching was a good idea must have hated women. Elissa Stein, who co-authored Flow: A Cultural History of Menstruation with Susan Kim, says, “For years, they sold Lysol, the same bottle as the bathroom kitchen germ killer, as a douche. They launched a horrendous scare tactic ad campaign that assured women their husbands would leave them if they weren’t fresh and clean. Not only that, women believed Lysol was a spermicide and douching after sex could prevent or end pregnancy.”  I mean, seriously, people.  Lysol? In the poor innocent cooch?

Women who douche keep me in business, but unless you’re looking to fill up your gynecologist’s schedule, don’t do it. The vagina is a self-cleaning organism. Shoving it full of things meant to make you smell like a bouquet of flowers does more harm than good.  Douching washes out the vagina’s normal bacteria, allowing bad bacteria to overpopulate the delicate environment and increasing the risk of vaginal infections.  Some people can’t even tolerate using soap or bath gel on their private parts, since it can lead to itching, burning, and vaginal infections.  Believe it or not, warm water on a soft washcloth is all you need to keep yourself clean

Have you ever known Kegel exercises to really work and eliminate incontinence?

Absolutely. In fact, my patient Elise did her Kegel exercises so religiously that her boss Andrea started suspecting something was seriously wrong with Elise.  Elise would be sitting in a board meeting with a strained, serious look on her face, and when someone asked her a question, she seemed clueless, as if she hadn’t been paying attention. During lunch breaks, Andrea seemed distant and distracted. In the bathroom, Andrea noticed that Elise spent extraordinary amounts of time in the toilet. Finally, Andrea called Elise into her office.

Andrea confessed that she and the rest of the team suspected that Elise might be drinking on the job, using drugs, or suffering from some sort of mental illness.  Elise seemed so inattentive, and Andrea couldn’t begin to imagine what she was doing in the bathroom for so long. They asked her to take a drug screen, which Elise passed with flying colors.  With her job on the line, Elise finally confessed.  She was plagued with urinary incontinence, and when I told her to do her Kegel exercises religiously, she took it to heart. She did Kegels in the board room, Kegels in her office, Kegels in the lunchroom. And whenever she used the toilet, she practiced starting and stopping the stream of urine until all of the urine was released.

When Elise explained what was happening, Andrea asked, “Well, is it working?” Turns out that Andrea, another patient of mine, was also suffering from stress urinary incontinence but didn’t believe that Kegels could actually work.  She and Elise began egging each other on at work, reminding each other to do Kegel exercises (on break, instead of in the board room).  Both reported significant improvement in their symptoms.

Elise and Andrea aren’t alone.  Studies demonstrate that when incontinent women are compliant with these safe, cost-effective pelvic muscle exercises, they demonstrate improvement when compared to placebo treatments., And as an added bonus, your orgasms may strengthen in intensity (woo hoo!)  So yes, Kegel exercises may be worth the effort. They don’t always work, and some patients need to pursue further treatment, but why not try? You’ve got nothing to lose (as long as you don’t lose your job!).

What is vaginal discharge made of? It it toxic waste or something?

No, it’s not toxic waste. In fact, unlike urine and feces, it doesn’t contain any waste products. What it does contain is:

• Fluid that seeps through the walls of the vagina

• Cervical mucous

• Uterine and tubal fluid

• Secretions from glands in the vulva

• Oil and sweat from vulvar glands

• Old cells from the walls of the vagina

• Healthy bacteria

Your vaginal discharge consists mostly of salt water, mucous, and cells, things that normally exist in your body.  There’s really nothing icky about it. Vaginal discharge is to your tailpipe what a lube job is to your car.  It helps maintain a healthy system and keeps your motor running.

Do I need to write a birth plan, or should I trust that my doctor knows what to do?

If you say the words “birth plan” to a group of OB/GYNs, you may see us cringe and roll our eyes. Why? Here’s a typical scenario from a doctor’s perspective:

Ava is 32 weeks pregnant with twins, and she is booked for a 7 1/2 minute appointment in your already overcrowded schedule. You’ve spent 15 minutes with her already, which means that your next three patients will be pissed off because you’re running behind. Just as you finish listening to her baby’s heartbeat, Ava hands you her birth plan and asks you to take a look. It is 23 pages long. The first 10 items read like this:

1. I will be bringing two musicians whose drums will guide my babies’ spirits into the world. I will need a guarantee that they will be permitted into the delivery room.
2. I do not want an IV under any circumstances.
3. I do not want to have my babies monitored. I am intuitively in touch with them, and if something is wrong, they will alert me.
4. Please do not restrict my intake of food or drinks. I intend to feed my body nourishing foods as it experiences this natural process.
5. I will scream bloody murder if the nurse even mentions the word epidural.
6. My 7-year-old daughter wants to deliver the twins, so while we trust you, we expect you will let her do the actual deliveries.
7. I do not, under any circumstances, want a C-section.
8. When the first baby is born, we want the umbilical cord to remain attached until the placenta is delivered.
9. When the second baby is born, we want both babies simultaneously brought to my breasts so one twin doesn’t feel more bonded than the other.
10. When the placentas are delivered, we want to save them. We will be bringing a blender into the delivery room so the placenta can be turned into a milkshake I will drink for nourishment.

(And this is just the first page.)

You think I’m kidding. You’re probably giggling and gagging right about now.  I swear to God, I’m not kidding.  Suddenly, you realize that you will be running at least an hour behind, not to mention that Ava is not going to be happy with what you need to say.

Such efforts to control an uncontrollable process have given birth plans a bad rap in the eyes of many a doctor or midwife. That said, I think birth plans can be a fabulous launching pad from which to have a heart-to-heart conversation about your personal childbirth wish list. But keep that in mind – it’s just a wish list. While I try to honor the requests on each woman’s list, my #1 priority is always “Healthy mom, healthy baby.”

If you want your doctor or midwife to be receptive to your birth plan, consider starting it with a statement that sets the tone for co-creation and collaboration during the birth process. Something like “I know we can’t predict the future, and we trust that you will do whatever is necessary to help us have a healthy childbirth, but if possible, we would love it if  [x, y, z ] could happen.”  Rather than putting your health care provider on the defensive, this will invite a spirit of trust and recognition that birth is simply not something we can plan.

Is a birth plan necessary? Absolutely not. My friend Amelie hired a doula to help her through her fourth delivery so that her poor husband, who simply does not like blood, could be off the hook. Her doula asked her to write a birth plan, which Amelie thought was ludicrous. After all, she had given birth three times. When her doula insisted, Amelie wrote, “Go to hospital. Get epidural. Have baby. Drink port.” Her doula was not amused, but I thought it was friggin’ hilarious. 

So no. A birth plan is not necessary. Sure, if you would like to communicate your desires to your health care providers, a birth plan can help.  But do us a favor: be reasonable. Assert your wishes, but release any fierce attachment to having those wishes come true, and bring up the birth plan at the beginning – not the end – of your prenatal visit.  And if things don’t go as planned, let it go. As long as you and the baby are healthy, you have been blessed.