Researchers predict that from 2010 to 2050, 43.8 million women in the US alone will experience symptomatic pelvic organ prolapse and stress urinary incontinence, often a result of a weakened pelvic floor . Unfortunately, this is a troubling reality that is virtually invisible to society and even to those with uteruses. The lack of social discussion around reproductive health and the natural aging process of uterus-possessing bodies presents a kind of epistemic injustice where without the concepts and interpretive tools to articulate these experiences, the discipline of medicine itself can be hindered. When doctors, researchers, and patients are unable to understand how these intimate issues impact us as social beings, the nature of medical treatment itself is affected.
All of us have an interesting group of muscles slung across our pelvis that prevents our organs from falling through our bodies. Dysfunction of this pelvic floor can lead to a slurry of medical issues such as the inability to defecate, involuntary urination (incontinence), and organs beginning to fall through our bodies (prolapse). Those that possess a uterus and vaginal opening can especially be at risk for genital prolapse. Old age as well as traumas to the uterus like birth can weaken the pelvic floor muscles and increase an individual’s risk for vaginal and uterine prolapse. With a whopping 93.6% of women in the US experiencing some degree of genital prolapse , it can become a daunting medical reality that is strangely invisible to society.
Even more socially under-discussed are the treatment options for pelvic organ prolapse despite national rates of female prolapse surgeries increasing from 92,503 in 1988 to over 200,000 surgeries a year in 2022 [1,3]. Treatments can include mechanical devices called pessaries inserted into the vagina to support the walls of the pelvic floor or surgical management like a sacrocolpopexy where the pelvic floor is surgically supported . This procedure can be done through the vagina without a mesh or a mesh can be attached to the front and back walls of the vagina and the sacrum (tail bone) through either a full abdominal incision or laparoscopy (keyhole incisions) .
We all also likely know a woman above the age of 45 who has gone through or is going through menopause a technical medical term for when a woman loses her period for over 12 months . But less talked about is the transitional period between having a period and menopause called perimenopause. Perimenopause can be a distressing period plagued by hot flashes, mood and sleep changes, irregular vaginal bleeding, unwanted hair growth, and drops in estrogen leading to vaginal atrophy and dryness .
The social taboo that enshrouds discourse on intimate health perpetuates a kind of hermeneutical injustice for women’s health. A form of epistemic (relating to the concept of knowledge) injustice, hermeneutical injustice arises when we are unable to both understand and communicate experiences due to the lack of concepts and interpretive tools to do so. For instance, before the concept of sexual harassment, people were unable to describe why behaviors that were then known as “flirting” were actually violating and inappropriate. Without acknowledging the medical realities of possessing a uterus and vagina, we too can commit a harmful injustice.
Medical evaluation and resource allocation for these prolapse surgeries are often inadequate despite affecting a significant portion of the US population. In the medical code documentation of surgeries called ICD-9 procedure codes, researchers in 2015 found that pelvic organ prolapse surgeries with specifically designated mesh kit procedures or minimally invasive sacrocolpopexies had no codes at all . Findings emphasized that ICD-9 procedure codes did not keep up with changes in clinical practice, making it harder to analyze patient outcomes. Another survey of complications of vaginal prolapse surgery performed by members of the Society Of Gynecologic Surgeons had less than 15% of surgeons respond to inquiries about patient wellbeing after surgery despite multiple requests for participation . Even with menopause and pelvic organ prolapse impacting a consequential proportion of the US population, it still remains a medical topic entangled with undercurrents of implicit shame. Shame and silence around reproductive health continues to affect patient doctor interactions preventing proper treatment, evaluation, data gathering on patient outcomes, and research at large.
How we go about developing the concepts and interpretive tools to discuss these medical realities socially still remains unclear. But the treatment development around IUD insertion may provide an example of how we can work towards more epistemically just reproductive care. Gynecology itself still reckons with its dark and horrific origins in the US where many of the early surgical techniques and knowledge about the female reproductive system came from nonconsensual experimentation by white male doctors on their slave women. Outlined in Harriet A. Washington’s novel Medical Apartheid , the tools used today in gynecology like the speculum were not designed with the female patient’s perspective in mind—with many tools resembling cold metal cranks and probes. Part of this overlooking of the patient’s comfort and care came from the misconception that the interior parts of the womb were numb—that no pain was felt when tools poked and prodded the uterus. In 2013, a study noted the poor accuracy medical providers had when assessing pain during IUD insertion (an intrauterine contraceptive device inserted directly into the uterus) leading to patients passing out, vomiting, or left traumatized by the procedure . But after this study, medical institutions got to work developing pain management options like topical or injected anesthetics and steroids to provide humane reproductive care .
Deeply entwined with both socio-cultural taboos and the dark history of gynecology, it’s difficult to develop an awareness of when physicians and medical institutions unknowingly commit hermeneutical injustices. However, it seems that when epistemic reflection on doctor patient relationships is valued, medical institutions can work towards mitigating these wrongs. It further seems to necessitate that as a culture we should make efforts to normalize the natural progressions of uterus and vagina possessing bodies and contemplate the complexities of society’s cultural and epistemic interactions with medicine.
Wu, J. M., Kawasaki, A., Hundley, A. F., Dieter, A. A., Myers, E. R., & Sung, V. W. (2011). Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050. American journal of obstetrics and gynecology, 205(3), 230.e1–230.e2305. https://doi.org/10.1016/j.ajog.2011.03.046
Onwude J. L. (2012). Genital prolapse in women. BMJ clinical evidence, 2012, 0817.
Bradley, S. L., Weidner, A. C., Siddiqui, N. Y., Gandhi, M. P., & Wu, J. M. (2011). Shifts in national rates of inpatient prolapse surgery emphasize current coding inadequacies. Female pelvic medicine & reconstructive surgery, 17(4), 204–208. https://doi.org/10.1097/SPV.0b013e3182254cf1
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Murphy, A. M., Clark, C. B., Denisenko, A. A., D'Amico, M. J., & Vasavada, S. P. (2021). Surgical management of vaginal prolapse: current surgical concepts. The Canadian journal of urology, 28(S2), 22–26.
Gold E. B. (2011). The timing of the age at which natural menopause occurs. Obstetrics and gynecology clinics of North America, 38(3), 425–440. https://doi.org/10.1016/j.ogc.2011.05.002
Delamater, L., & Santoro, N. (2018). Management of the Perimenopause. Clinical obstetrics and gynecology, 61(3), 419–432. https://doi.org/10.1097/GRF.0000000000000389
Young, S. B., Kohorn, E. I., Braz-Martin, S., Baker, S. P., & Society Of Gynecologic Surgeons (2004). A survey of the complications of vaginal prolapse surgery performed by members of the Society Of Gynecologic Surgeons. International urogynecology journal and pelvic floor dysfunction, 15(3), 165–170. https://doi.org/10.1007/s00192-004-1127-y
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