The Emperor’s Pain-Free Uterus

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About the Guest

 

Dr. Karen Tang is author of It's Not Hysteria: Everything You Need to Know About Your Reproductive Health (but Were Never Told). She's a board-certified gynecologist, a minimally invasive gynecologic surgeon, and an internationally recognized leader in reproductive health, and social media. She received her MD and Masters in Public Health at Columbia University, her residency training in OB/Gyn at Beth Israel Deaconess/Harvard Medical School, and her fellowship in advanced gynecologic endoscopic surgery at Legacy Health in Portland. Her areas of medical expertise include endometriosis, fibroids, chronic pelvic pain, and gender affirming gynecologic care for transgender and non-binary individuals. Follow her on social media (@karentangmd) or learn more at karentangmd.com.

 

Transcript

 

KAREN TANG: I call it the “Emperor's New Clothes phenomenon,” where everyone's like, "I don't want to make it sound like I'm weird because I had this crazy thing happen." But then once everyone realizes other people are having it too, they're like, “Are you serious? It's not just me? It's everyone?” We're breaking down the silence and the taboo around talking about bleeding, periods, pain, all of that stuff, because that silence does keep people feeling like they're alone, like they’re isolated.

BLAIR HODGES: Meet Dr. Karen Tang. She's a brilliant gynecologist, and she says our ideas about women's health are still haunted by centuries of misinformation. She's working hard to dispel myths and make everyone more comfortable learning about reproductive health.

She says up to 90% of women and trans men experience menstrual abnormalities or pelvic issues at some point in their lives. Ninety percent! Too many people are suffering in silence, and that's why she wrote a comprehensive guide called It's Not Hysteria: Everything You Need to Know About Your Reproductive Health (but Were Never Told). Dr. Karen Tang joins us to talk about it now. If you've ever met with a gynecologist, this one's for you. If you haven't, this one is also very much for you.

 

The Wandering Womb in Ancient Greece – 02:15

 

BLAIR HODGES: Dr. Karen Tang joins us. Dr. Tang, welcome to Family Proclamations.

KAREN TANG: Thank you so much for having me.

BLAIR HODGES: Now, you're not a historian, but you did some historical research for your new book, It's Not Hysteria, because looking at the past can help people understand problems we're facing today. You write, "Women's bodies and medical concerns have been misunderstood, mismanaged, and outright dismissed from the beginning of recorded history."

You trace it back through this word “hysteria,” which is in your title. Take us back to ancient Greece and where this word came from.

KAREN TANG: I love this. Just like you said, the reason is because I do think the way we treat women's health and women's bodies, it didn't come out of nowhere. It's been ingrained in our cultures and the way we perceived all of this for thousands of years. It's something I thought was very interesting to look back and dig into—where did these myths and misinformation come from?

BLAIR HODGES: Did they do this in medical school, by the way?

KAREN TANG: No! Not at all! [laughs]

BLAIR HODGES: Okay.

KAREN TANG: I wish they did. I thought it was really fascinating. Even just one lecture. So, back in ancient Greek, ancient Egyptian times, there was this perception of something called "the wandering womb," which, I love this idea. They literally believed the uterus just wandered around. It moved around the body, it was seeking things or running away from things.

Some of the things it was seeking were sex and pregnancy. So the treatments for a lot of medical ailments for women were things like, you should get married and have sex, you should try and get pregnant.

Now, I mean, that sounds ridiculous. But I bet many of your listeners have probably been told the treatment for things like endometriosis is to go get pregnant. It's not uncommon for people to be told this. And there's a teeny, teeny bit of fact that underlies it.

For instance, in endometriosis, people do sometimes feel better temporarily when they're pregnant because of hormone changes. But it's obviously not a long-term treatment plan. You can't stay pregnant for twenty, thirty years. Again, it sounds ridiculous on the surface, but there are still some of these little elements that are still present today.

I trace it back through history into the 1800s where you have Freud, and where they thought the hysteria was this manifestation of anxiety and repressed mental issues that manifested as physical problems. This is where you get some of these ideas that a woman, it's usually a woman, who is complaining of a lot of things, seems highly anxious about their health, that it must be mental rather than physical.

And a lot of times, we're discovering obviously, women who complain about a lot of medical issues often do have a medical problem. Endometriosis, for instance, can cause many, many, many symptoms across so many different organ systems. It can affect your bowels, your bladder, your muscles, your nerves. It can cause migraines. When you see the list of complaints, sometimes people will be like, "Oh my gosh, that woman must be just super anxious or a hypochondriac."

BLAIR HODGES: Or her womb is wandering to all these places. [laughter]

KAREN TANG: It's going everywhere!

You get this combination of, your reproductive organs are going haywire, you're super anxious, it's making you a hypochondriac, and obviously some of those things are still present in the way people are seen today. Even though the stories, they sound very shocking, and very “wow, that's crazy”—obviously, I'm a doctor. In the field of medicine we pride ourselves on everything being very evidence based. But we're human beings.

A lot of times some of these myths and misinformation get absorbed whether we realize it or not. You get these ingrained biases which impacts how you see a patient, how you process the things they're saying, and the lens with which you're viewing someone's health concerns.

BLAIR HODGES: We should mention, too, that word hystera is the ancient Greek word for "uterus," where “hysteria” comes from, like hysteria is sort of a problem with your uterus.

KAREN TANG: It's literally referring to your uterus.

 

Nineteenth-Century Treatments – 06:30

 

BLAIR HODGES: Yeah, and it gets tied into these ideas about emotional health. So "hysterical" became this word in the late 1800s and through the early 1900s, and you talk about some of the treatments women underwent—some of them pretty horrifying—where they would want to treat insanity or mental illness or epilepsy with some intense surgical procedures.

KAREN TANG: Like removing your clitoris. I mean, we laugh but it was horrible. Looking back at this, the 1800s was like the wild west in medicine, especially with women's health. They literally tried all these different surgical treatments, like remove your ovaries, remove your clitoris, remove your uterus.

Obviously, those didn't last very long because there were a lot of complications and clearly they probably didn't fix the original problem. But there were times in the book I mention—there were thousands of oophorectomies, removal of the ovaries, used to treat hysteria. Again, there were all these thoughts.

There were things like the "rest cure," where you literally just had to be sedentary. You couldn't overstress yourself because you were too hysterical. You had to just be silent. Those of you who have read "The Yellow Wallpaper," the famous short story about a woman who is almost infantilized. She's literally trapped in a child's nursery because she's too hysterical and she needs to just sit there quietly, and it actually drives her mad. At the end of the story, she's broken free, but she's actually descended into madness a little bit.

But again, in the book I actually make the analogy of, sometimes the treatment is worse than the problem you're trying to treat. For instance, a lot of times for gynecologic conditions, we use birth control, which can work very well for certain things. It can decrease period pain and lighten bleeding, it helps with PMDD or premenstrual dysphoric disorder. But some people do have side effects with it. They can have mood problems. Sometimes the side effects are worse than the problem you're treating. It can cause migraines.

In the end, like I said, it's not as extreme as trapping someone in a room, but you can have someone who's like, "I actually was feeling better before this treatment started!" [laughter] Same thing.

With the birth control, I always say, if there was a situation where everything a man went through was treated with the same type of medication, does that sound like that would be okay to the general public? Probably not. But for women, we just use birth control for so many things. The problem with that is there's not enough research into alternative treatments, where we're like, “We have this and we know it works in some people. So we're just going to keep on using that for literally everything.”

It does work for a lot of things, but the fact that we just don't have more of an armamentarium for all of these vastly different conditions is again, I think, there's some misogyny in that and it goes back to the fact we just don't have enough research and funding.

 

Racism in Gynecology – 09:33

 

BLAIR HODGES: You also introduce us to some of the ways racism got embedded in the early field of gynecology. You're talking about important medical advances. However, some really problematic ethical things were happening.

KAREN TANG: Yes, so there's a lot that, even as a gynecologist, I never learned about in my training. It was only in recent years people started to learn about the history of J. Marion Sims, who we call the father of gynecology.

So literally this man, he was the president of various medical associations, he had statues all over the country, he's one of the most famous doctors in American history. He literally experimented on enslaved women. He practiced surgeries, specifically surgeries for obstetric fistulas, which are injuries that recur in childbirth, on enslaved women. It is really quite a horrifying history. There were only three women that we have names of, Anarcha, Betsy, and Lucy. Those are the women who have been talked about in recent years. Books have been written about them. But there were many other women who had no names recorded in history.

He became very famous. We even have instruments named after him. He invented the modern speculum, which is the instrument we use for pap smears. Even from the very origins of the field of gynecology in the United States there was this aspect of racism, and not just inequality.

BLAIR HODGES: The racist idea was that Black people can handle pain more, right?

KAREN TANG: Exactly. There was this perception that Black people did not feel pain to the same extent. He didn't actually do these surgeries on white women until anesthesia had been more established for surgical use. He didn't specifically say that, but at that same time period it was well-published that people thought slaves felt less pain, could handle more physical stress and discomfort, and that currently is still a perception.

There's a recent study from just a few years ago where they polled medical trainees, students, and residents. A huge percentage of them actually thought that was a medical fact, that Black people had a different density of nerve endings, that they had different pain perception, which is obviously not true biologically. Several studies have shown Black people are offered less pain medication for overtly painful things like appendicitis, broken bones. So again, that sort of legacy is still present—

BLAIR HODGES: —More Black women die in childbirth.

KAREN TANG: The Black maternal mortality is markedly higher, I think three to four times higher. It's four times higher in the UK. Even if you account for things like access to medical care, education level, income level—so for instance, some very famous women like Serena Williams, have said they've really had to fight for care. Serena Williams had a history of pulmonary embolism. It can kill you. She knew the symptoms and then postpartum she was like, “I think we need to get testing, I'm really having some serious problems here.”

She had a fight to get that testing done and she did have a clot. Regardless of how famous you are, how much money you have, these inequalities exist.

BLAIR HODGES: To kind of wrap up where we're at so far, you talked about how, early on, medical folks focused on the body. They thought about hysteria, then it kind of shifted over in the nineteenth century to the nervous system. This is when the rise of neurology happened. You mentioned some of the treatments like rest cure. “It's a nervous system problem here so take rest.” Electrotherapy was developed here to treat women, especially white women with nervous exhaustion.

KAREN TANG: [laughter] Exactly, yes.

BLAIR HODGES: That's the diagnosis they would give. Instead of just like, I don't know, the societal misogyny and sexism is wearing people out. But no, let's put them in a bed and shock them!

KAREN TANG: [laughter] Yeah.

BLAIR HODGES: And is this true? Maybe I'll run this by you. I've heard the vibrator was also developed at this time as a way of medically treating, which is maybe a positive development at this time?

KAREN TANG: Yes. I don't know the exact specifics, but that's my understanding, that the vibrator was used in this way. I actually have seen when I was doing research, I saw some graphic and it's like a drawing of a woman with water, like a stream of water being aimed at her genitals. So a similar idea, stimulating the genitals in a certain way would treat some medical ailments. I'm not sure exactly how accurate or if these are myths. But I've heard in the mix of all these negative things that one thing was the rise of the vibrator.

BLAIR HODGES: Gatekeeping wasn't great. A doctor would have to do it.

KAREN TANG: Right, yeah.

 

It’s All In Your Head – 14:07

 

BLAIR HODGES: So the body, nervous system, and then mind—you mentioned Freud. This is the idea that hysteria is connected to some kind of psychological problems. You say that also persists today. Women and people who are assigned female at birth will often hear, “This problem you're having that I can't quite figure out a medical diagnosis for, maybe this is something in your head.”

KAREN TANG: Exactly. You take this whole journey from, your uterus is broken to, it's your nerves, and now it's just manifesting your anxieties. That definitely is seen today, for sure. In the book I mentioned there's a whole category of mental health disorders they call “somatic disorders,” somatic form disorders, where there's no physical cause that's found so we just assumed it's being manifested as some sort of psychological issue that has kind of turned into physical symptoms.

It's like a ten-to-one ratio of women to men who are diagnosed with these. When you break it down, a lot of times when women are told we can't find anything, everything is normal, maybe it's that you're just too anxious, we'll find things like endometriosis, or autoimmune disorders. It's just they hadn't found the cause yet. A lot of these things that are the somatic disorders, probably are something physically there, we just don't know it yet.

A lot of the women's health issues I talk about in the book don't have an easy diagnostic test. Doctors really like facts, we like hard facts. Like an EKG that's abnormal, a blood pressure that's abnormal, blood glucose, but when there's not an easy—

BLAIR HODGES: A cyst or something.

KAREN TANG: Right. Something we can see. Endometriosis is usually not seen on imaging. It's so small usually you can't detect it. There's no blood test for it.

Same thing for premenstrual dysphoric disorder. It's based on what someone is saying they feel. There's no objective test. Pelvic floor issues. All of these things, we just take the person at their word based on what they're experiencing. We can't see it in an objective medical test. That leads to a lot of these delays of diagnosis, where someone runs a bunch of tests, and then they say, "Oh, actually everything looks normal. So there's nothing wrong."

That actually very, very commonly gets told to people, especially women, people assigned female at birth. Everything looks "normal," I'm making the air quotes, so therefore everything is normal, and whatever you're experiencing must be mental or emotional.

 

Research Problems Persist Today – 16:38

 

BLAIR HODGES: I'm glad you're taking us here because people can be shocked by the history you talk about in the book, It's Not Hysteria, and they can wonder how could people ever believed such weird things. Or be glad we don't live in such unenlightened times.

But you're also quick to point out, we still haven't reached the promised land, there's still a lot to learn. The modern medical system prides itself, like you said, on being evidence-based, using research studies to guide diagnosis and to prescribe treatments. But you also say research itself over the past one hundred years has been skewed against women. Let's talk about some of those problems that are persistent to the present.

KAREN TANG: I always say it's not the doctors are intending to be misogynistic. I'm a gynecologist. I don't think gynecologists are by nature bad people, it's just the system is so skewed, we have so little data. We have so little actual research on these things, that into that space of lack of information has sort of come all of these myths and things, and people being managed in a way that isn't as medically accurate as we would like it to be.

Part of that problem is, why is there so little research? There were actually formal restrictions on women being included in medical studies in the twentieth century. The NIH, the National Institutes of Health, which is the major funder for medical research in the world, did not require women be included in studies until 1993. There were several major studies with groundbreaking studies on things like cardiovascular health that did not have any female participants.

This is where a lot of times what we think of as facts, and are promoted as facts and this how we counsel patients, are only based on data for men. It's actually only recently when they start to study women specifically that we discover things like how heart attacks manifest with very different symptoms in women and men. Cardiovascular disease patterns are very different for postmenopausal women, pre-menopausal women, and men, but we don't have so much of that information because they just weren't studied.

In terms of medications, that same year, 1993, there were actually many decades before that, the FDA actively excluded women from being included in early drug trials, like early phase drug trials because of fear of birth defects. After the whole thalidomide issue they were just almost too extreme, being like, “We should just have no reproductive age women in the studies at all.”

 It didn't matter if they said they were not sexually active, if they were a lesbian, if they were using birth control, it did not matter. They just excluded everyone of childbearing age. So again, we don't have information on how medications affect women, because they didn't study it.

BLAIR HODGES: You give example after example. I was also really surprised by the disparity of funding. For example, you say the National Institutes of Health allocated eighty-four million for Crohn's one year—no shade to any of our Crohn's folks out there, but that impacts about .21% of the population. So eighty-four million for .21%, compared to twenty-seven million for endometriosis, which you say impacts ten percent of women. These huge disparities in funding are surprising.

KAREN TANG: Fibroids affect seventy percent of white women, eighty percent of Black women. Now, not all of them will have symptoms, but that is a massive percent of the population. Fibroids has a fraction of the funding of endometriosis.

I actually just did an interview for the Times in the UK, and the reporter actually went and did some more looking up of these NIH numbers. She found a similar scale of difference for something like lupus. Lupus is obviously a very serious condition, as is Crohn's, it's not to say they're not serious, it's just they get way more funding, again, sometimes orders of magnitude more funding, despite having a tiny fraction of the number of people affected compared to things like endometriosis and fibroids, which cause incredible pain, loss of work, really severe issues that affect people's quality of life.

It goes to show what people in the medical system think of as "serious"—again, air quotes—medical conditions worthy of funding, worthy of research, compared to "just" women's health. So because some of these are like, “It just causes painful periods. Doesn't everyone have painful periods?” They're supposed to deal with it, as opposed to lupus and Crohn's are really serious medical problems.

BLAIR HODGES: Those conditions suck, they suck for sure. There's no question we want to confront those things, but as you mentioned, the fact that so many women are dealing with painful periods every month and there's this baseline expectation amongst a lot of people that they're just supposed to deal with it.

You also mention other things like physician specialists, there aren't enough specialists being trained. There's also ongoing insurance discrimination issues, there's provider burnout that happens. There's a lot of systemic issues that are harming women's health.

KAREN TANG: Yes, exactly.

 

Confronting Myths – 21:44

 

BLAIR HODGES: But it's not just the system. There's some individual ignorance happening as well. I think your book does a good job introducing people to the basics. As you say, a lot of women feel afraid or alone or ashamed of any reproductive issues that come up. A lot of men just stay out of it. Not to mention nonbinary folks or trans folks who are also trying to navigate gender identity while they're also dealing with potential reproductive issues. I thought your book's basic breakdown of anatomy and sex ed was kind of nice. What were some of the biggest myths you wanted to confront there? When you were talking about the actual kind of plumbing down there.

KAREN TANG: [laughs] There's so much. You just mentioned ten different things I want to address which is great.

Super quick, before we move on too fast, the system issue is a huge one. I think this is something we as a society need to confront sooner rather than later because OBGYNs are burning out. Because of insurance reimbursement being so poor, this is part of the reason OBGYNs only get like ten minutes per patient, and there's no way to actually effectively diagnose and treat all of these complex issues during that time. Then they burn out more and then they drop out, and then women have a hard time getting into see a gynecologist at all. It's a very difficult problem we need to address.

The specifics of the anatomy and debunking myths, this is why I want not just women and people assigned female at birth to read the book, but everyone, because so many of the topics are not only related to just the people who have them. But it talks about, how do how does pregnancy happen? How does birth control work? Abortion.

BLAIR HODGES: What's a period?

KAREN TANG: What’s a period! [laughter] If it’s not affecting you, it is affecting someone you know!

BLAIR HODGES: I've been married to a woman for eighteen years and I knew the basics, but I still learned a ton in this book. I learned a lot more about what's going on.

KAREN TANG: Well thank you, I’m glad.

BLAIR HODGES: Give us a couple of myths about periods. We've got to confront these myths.

KAREN TANG: So number one myth is obviously, you already said it, that it's supposed to be bad. Everyone has a bad period and you just have to deal with it. That is definitely not true.

It's very common to have just cramps. But if something is severely painful, that is not normal. I always say, even if something is common, it's not normal. If it's affecting your quality of life, it's keeping you from working or going to school or having sex or exercising, that is something to see your doctor and get an evaluation for. That's very important.

That also goes for things like menopause. Everyone who's started having periods is going to go through menopause, but it's been this perception for all of human history that you just had to deal with it. It was this shameful secret when you got to a certain age that you didn't want to talk about. You're going through the change.

But now so many people like Oprah, Drew Barrymore, Halle Berry, they're speaking out because they're like, “This is crazy. It's horrible. We deserve treatment for this. We deserve medications and options to help us with this.”

I think it's great we're finally debunking these myths. Just because something is possible or a lot of people go through that you have to just deal with it and just suffer, or it's woman's lot in life.

With other myths, I do a lot of social media. So especially on TikTok there's a lot of funny videos where they will show a man a picture of the female anatomy and be like where's the clitoris? Point out the clitoris and they can't find it. It's hilarious. I hope men do read this because it is helpful just to know.

BLAIR HODGES: Guess what? There's different holes that pee come out of versus the vagina. The vagina isn't the whole thing, either. That's the vulva.

KAREN TANG: Like what do the words mean? People think “vagina” means the outside and the inside, everything—but it's only the internal canal. The number of holes thing is funny, but apparently a lot of men don't realize how many holes there are. There's this myth that you can't pee with a tampon in, which it sounds funny but it is kind of sad. Because if you don't know how the body works, if you have a partner, if you have a sister, or a mom or a friend, you can't understand what they're going through.

Then obviously, recently, we have the political aspect. We have people legislating women's bodies who don't understand how the bodies work. You always hear in the news that some lawmaker thought you could implant ectopic pregnancies back in the uterus, or they thought IVF was “XY and Z.”

BLAIR HODGES: Or that a body can “shut down a rape” or something.

KAREN TANG: Right. If you didn't enjoy sex you can't get pregnant. There are all these myths that get perpetuated even among people with power to affect laws about women's bodies.

 

Social Media Education and Activism – 26:20

 

BLAIR HODGES: Have you seen the algorithm impacting the reach on any of these points? Have you seen certain discussions take off? What has taken off in terms of these myths?

KAREN TANG: I'll take both directions. So experiences where people thought they were the only person and they are surprised to find lots of other people have that too.

For instance, some of my most viral videos about—on the surface, you wouldn't think it's a common thing, but when you see the comments you realize a lot of people are going through this. One of them was rectal pain with periods, like stabbing butt pain when you have your period. I've gotten millions of views, thousands of comments, being like, "Oh my God, I have that too. I thought I was the only one."

BLAIR HODGES: Is it a feeling of like intense, a stabbing—

KAREN TANG: A stabbing or shooting pain in the rectum. And that can be a muscle spasm or it can be a sign of endometriosis.

BLAIR HODGES: Okay. So people are like, wait a minute. This is happening to multiple people.

KAREN TANG: Right.

BLAIR HODGES: And then you see that discussion spread.

KAREN TANG: It spreads, because people are so amazed that they comment, they engage, they share it. They're like, “Did you know about this?” Those type of videos.

Another interesting one that went super viral I was not expecting, there's something called a decidual sac, which is a phenomenon where literally instead of having a little bit of tissue come out with your period over several days, it comes out all at once, at the same time.

BLAIR HODES: When I hear “decidual” I think of tree roots.

KAREN TANG: Yeah. Literally, it's all of the tissue in the uterus comes out at once and it looks like a blob. It can be quite painful because so much is coming out at the same time. People bleed heavily, this thing comes out, they're really scared. They're in a lot of pain. Again, people are so freaked out about this. They're like, “What is that?” People even think they're having a miscarriage.

It was my impression that this was a relatively rare phenomenon. It turns out, after having seen this video go viral on every platform—I can't even count how many millions of views this has on all the platforms, thousands of people are having this and just not telling their doctor because they're like what the hell is that? I don't want to tell anyone because it's so embarrassing or weird.

All of these things that are shared experiences, I call it the “Emperor's New Clothes” phenomenon where everyone's like, "Oh my God, I don't want to make it sound like I'm weird because I had this crazy thing happen." But then once everyone realizes the other people are having it too, they're like, “Are you serious? It's not just me? It's so many people!”

So I kind of love that, that we're breaking down the silence and the taboo around talking about bleeding, periods, pain, all of that stuff, because that silence does keep people feeling like they're alone. Like they're isolated.

On the opposite extreme, things that are doing very poorly in the algorithm are anything using the correct terms. Literally if you say “vagina” it will get censored, especially on TikTok.

BLAIR HODGES: I've seen that. You have to put on the captions and leave letters in the word.

KAREN TANG: You have to misspell the word. I know. It's terrible. We've complained about this. Doctors have complained about this a lot, that we can't use the actual anatomic terms because it's felt to be dirty or it's sexual.

BLAIR HODGES: Like it’s pornographic or something.

KAREN TANG: I'm a gynecologist! I should be able to say the word “vagina” in an educational post.

I was on Jonathan Van Ness's podcast. At one point we literally just said the word vagina a bunch of times just to say it's just a word. There's nothing dirty about it. You can say it. I put a clip of that on TikTok and it got, like, no views. You could see the difference in the suppression. It was actively suppressed by the algorithm. It's ironic because we were just saying we should be able to talk about this in a public forum.

A nurse actually just told me her daughter, her five-year-old daughter, the kindergarten teacher called their mother and was like, "Your daughter was saying bad words." The teacher didn't even say it. It was so shameful they couldn't even say the word at first. “She said a really bad word!”

Mom's like, "Oh my God, did she say the F word? What happened?"

"She said that girls have vaginas."

The nurse was like, are you serious? Even from that young age it's so perpetuated and ingrained that it's dirty, it's shameful, it's embarrassing, don't talk about it. And that gets internalized. People think it’s shameful, like I shouldn't talk about my body, I shouldn't talk about sex or what I'm going through—discharge, periods, leaking with urine.

Every woman, every person assigned female at birth, everyone with a vagina has these experiences. But somehow, it's become so socially ingrained that you don't talk about it. That's why I wanted to write the book, too, was to get people talking. My greatest hope is people will read this in book clubs and talk about it with their friends and realize they share these things with everyone around them and just didn't realize it.

BLAIR HODGES: For people that want to follow your stuff, they can follow you on TikTok, Instagram, YouTube. It's @KarenTangMD. That's where you're found. Again, we're talking about the book, It's Not Hysteria: Everything You Need to Know About Reproductive Health (But Were Never Told).

 

Misinformation on the Socials – 31:08

 

BLAIR HODGES: I imagine it can be frustrating when you can't say particular words when you're trying to do public education about it. On the flip side, do you also find yourself having to battle misinformation on those platforms? Because anybody can start an account and anybody can become an influencer if they have a certain look, if they have a certain vibe, they can make certain claims. There's a lot of anti-COVID stuff, anti-vaxxers, ways to spread misinformation there. Do you find yourself having to work against that type of misinformation?

KAREN TANG: Oh my god, so much! The problem is the algorithms do favor misinformation because if it's shocking, if they propose something in a very shocking way designed to get a response—if people comment, if they share it, did you see this crazy thing—It will spread like wildfire.

BLAIR HODGES: The platforms want attention capture. Their goal is to keep people there. Whatever does that, whether it's true or false, that's what they're more likely to promote.

KAREN TANG: Exactly. They will boost the hell out of misinformation videos. It's very, very hard to fight misinformation because they're so effective at gaming the algorithms.

The problem is that especially the pseudoscience space, anyone can put the word "doctor" in front of their name, make claims, and if they say it in a science-y or authoritative sounding way, then people will be like, "Oh my god, it must be true." When you look at it, they're like a chiropractor, or a lot of them get these online PhDs that have nothing to do with health but they call themselves doctor all over the place. Usually, if you look into their websites, they're selling expensive supplements, courses, coaching, all this garbage, and basically just making lots of money profiting off of misinformation.

A lot of times they do it by making people scared. They say for instance in my space, "Birth control is poisoning your body. It's poison. It's dangerous." So women are like, “Oh my god, I'm taking birth control. Is it dangerous?” Then they'll say, “You have to take this detox supplement.” People will flock to that kind of thing because they're so scared. They're like this legitimate sounding person is saying this horrible thing and like I don't want to hurt my body.

It is very difficult because cold hard facts are very unsexy. It's very hard to go viral with, “Let me just tell you the bare bones facts from what we know about research studies.”

BLAIR HODGES: Or, “Here's what we think,” too. Sometimes medical sciences is humble.

KAREN TANG: We have to be very transparent about that. We have to say when we just don't know. We don't have a great answer. This is the best we know. That doesn't sound as attractive as “I have the answer and it's going to fix your life. Just sign up for my course, blah, blah, blah.” It is very hard to compete with that.

I only started doing social media maybe four years ago, just pre-pandemic. I didn't know how to use Instagram, TikTok, all this stuff. Other doctors who had started in that space had said we need to get on there as medical professionals because we need to try and fight some of this misinformation. It became very important during COVID because of the misinformation about vaccines and masking and social distancing. There's so much misinformation out there.

The medical profession as a whole is very far behind the curve, behind some of these influencers who have learned to monetize the misinformation.

BLAIR HODGES: I encourage people to look into people's credentials. I encourage them to seek medical consensus. It's not always going to be right. But I'm not a specialist enough to say I know better than the consensus, recognizing the consensus isn't always perfect. I’m also looking at what people are trying to sell me. Those are the assessments I make.

KAREN TANG: That was a perfect summary. I will say, look at their credentials, look at where they may have a conflict of interest in selling you something, and then number three, if they're saying something different than everyone else, there's a reason. I always tell people that nothing in medicine is black and white. No one is one hundred percent right all the time. No one is one hundred percent wrong all the time. If someone's saying “I know more than every other specialist who has devoted their entire life to doing the research and trying to analyze the data. They're all wrong. I'm the only one who knows”—that clearly is usually completely wrong.

BLAIR HODGES: The other problem I see with these outliers is they're not involved in the ongoing work with other people. Their claims aren't being vetted. They're not being peer reviewed, a lot of them. That's another thing.

 

Becoming an Intersectional Gynecologist – 35:22

 

BLAIR HODGES: You personally, you came to try to do the influencer thing. You've gained a following there. But I'm wondering about your decision to become a gynecologic surgeon to begin with. Why was this your field? What drew you here?

KAREN TANG: It's interesting. I didn't know at the beginning of my training that's what I was going to end up doing. I was actually quite scared of surgery. I think a lot of women especially—it's very intimidating. It sounds like it's a very hierarchical system. There's going be a lot of yelling and intensity.

BLAIR HODGES: We've all heard things about surgeons!

KAREN TANG: Surgeons like throwing stuff and it's very high stakes and very nerve wracking. I knew I liked talking and counseling and teaching people. Teaching has always been something I really felt was important and I valued. I thought I was going to do primary care for those reasons.

Then I did a master's in public health. During that time, everything I wanted to study was women's health, reproductive health. Then clearly OBGYN became the front runner. I think a lot of people don't realize OBGYN is a surgical field as well. We do surgeries for all women's health, but I didn't know that until I was a medical student.

BLAIR HODGES: I didn't know until I read your book. I mean, I figured surgery was involved. I didn't think about the specialization of that.

KAREN TANG: People think of pap smears and babies. But it's a very diverse field. When I was doing my residency, I didn't realize there were sub-specialties of OBGYN that were surgical. Gyn-oncology, where they treat ovarian cancer, uterine cancer. Urogynecology, which is for things like prolapse and incontinence. They do the repairs of those. It's almost a combination of urology and plastic surgery with reconstructing the pelvis.

My field is mainly invasive surgery, like doing minimally invasive surgeries for endometriosis and fibroids and cysts. There's a lot of surgical fields in gynecology. I was like, “I'm actually really good at this!” I was a violinist. I trained with my hands. I was like. “This is really fun.” It's great to be able to have a tangible result for people relatively quickly that you can do something and see a result pretty much right away. That was great.

Plus, as a gynecologist we can have that longitudinal care. We can counsel people. I counsel people on menopause, PCOS, birth control, sexual health. It's a great field. I think it's really great. It's also tough because of all the social issues we're facing nowadays. But it is still I think one of the best fields, obviously, that's why I went into it.

BLAIR HODGES: You're also paying attention to intersections a lot. You're a woman of color yourself, so you're attuned to how the medical field and medical experiences often differ by race and how racism can get involved there. You've also experienced reproductive issues you talk about in the book, including miscarriages and other things. So you're personally in the mix yourself.

KAREN TANG: Being someone who has gone through a lot of these things, I think every woman at some point has had one of these issues in the book.

The bladder health issue, again, no one talks about this, but I mentioned seventy-five percent of women who are postmenopausal at some point will have leaking of urine. If you've had a pregnancy and given birth, you leak urine. We joke when we see other moms at the trampoline park at children's birthday parties we're like looking at each other like, we're not doing that! [laughter]

It's not just writing an encyclopedia. It's writing about it from the experience of someone who's gone through some of these things, or has heard the stories of people who've been through it, if I haven't been through it myself.

With the intersections, like you said, I wanted to make sure I included transgender and nonbinary people, intersex people, because they are left out of these conversations a lot. They obviously are affected by gynecologic issues. I made sure I had expert readers and sensitivity readers who were helping me with those chapters. Actually my book tour event on Tuesday at Harvard bookstores is with Schuyler Bailar, who's a transgender man who is an excellent educator in transgender issues. We've had some great discussions on YouTube and Instagram about shared topics like going to a gynecologist as a transgender person and the experience of that and how do you advocate for yourself?

It was very important for me that this book wasn't just an encyclopedia of some facts about the uterus, but about the experience of people who go through some of these problems. What challenges do they face? What questions could they have? How do they find the right solutions for them?

Thank you for that question. I don't think anyone's ever brought up the intersections and me as a person, like as a human being going through it.

BLAIR HODGES: It's important. You mentioned being inclusive about gender, too. There are sections in the book that specifically speak to that. But also, you signal to that throughout the books. You don't silo it off as though it's oh and there's also this other thing, but you use inclusive language, so that throughout the book it's just a normalized part of it. I really appreciate it.

To remind people, the name of the book is It's Not Hysteria: Everything You Need to Know About Reproductive Health (But Were Never Told) by Karen Tang. She's a board-certified gynecologist and a minimally invasive gynecologic surgeon, and an internationally recognized leader in reproductive health. You may have seen her work featured in places like the Washington Post, SELF magazine, NPR, and elsewhere. She's joining us from Philadelphia, where she lives with her husband and three kids.

 

Preparing for a Gynecology Appointment – 40:29

 

BLAIR HODGES: Let's talk about exams and procedures. The latter part of your book is helpful. I've never been to a straight-up gynecology appointment with my partner. Sometimes she'll talk to me about stuff that went on there, but this was great for me to just get the basics of it. Also I think even for women who go, to be able to triangulate. I'm sure women often will talk to each other about how their visits go, but you walk us through a routine visit.

Let's talk about the tips you give people. What they can expect at an exam so people can make the most of their time. Because like you said, sometimes these visits go way too fast.

KAREN TANG: That's a great question and so important because, as I mentioned earlier, some of these OBGYN appointments can be very fast, fifteen minutes, ten minutes.

The first thing is actually to tell the office, when you're even just scheduling the appointment, if you have a lot of concerns—you're specifically having pain or period issues or many questions, menopause. Tell them when you schedule because sometimes people will book what's called just like an annual exam, like a checkup, and those are extremely short visits. There's not enough time to cover a lot in them. What happens is people will show up, they wait for their appointment, and then there's literally no time to discuss anything.

BLAIR HODGES: It's basically quick questions, a pelvic exam, and that's it?

KAREN TANG: Preventative care, pap smear, breast exam. Exactly. Number one is just make sure you tell them when you schedule what your issue is and ask about the length of time. There are certain appointment times longer than others.

Then obviously, reading the book, preparing your concerns, your questions, having things organized. I have a chapter in the book on what you're going through, what symptoms you're going through, your period, so you can have everything organized and ready to go to share with your doctor. It's not that they're spending a lot of time trying to pull all the information out in a long and lengthy way.

Also having an idea of what some of the options they might present you could be and what your thoughts on them are. For instance, what do you think about birth control? What do you think about surgeries, procedures? Right off the bat if you can say “I'm a little bit nervous about hormones,” or “I really don't want to do anything surgical,” it can help the doctor focus the time in their counseling.

Then in terms of the exam, how to make it more comfortable is usually—hopefully it's this way in every office, but it may not necessarily be—the doctor should talk with you before they're doing any sort of sensitive exam. You should be able to have time to talk face to face without being like literally up in the stirrups. I think people sometimes, if they're just literally in the stirrups, they're feeling vulnerable, they don't feel comfortable sharing a lot of things at that time. You can ask, “Will I have a couple of minutes to talk with the doctor before we're doing the exam?” Just to make sure you can get your concerns out there in a comfortable, safe way.

Then with the actual literal exam, I talk through how to make it more comfortable. It's like the dentist. It's not everyone's favorite thing to do [laughter], but there are definitely tips and tricks for making it the least uncomfortable and smooth as possible. We talk about the pelvic floor muscles, little things to relax them before you have an exam because it can be more uncomfortable if you're tensing everything.

BLAIR HODGES: And how some people have conditions, like vaginismus.

KAREN TANG: Yeah, and also obviously definitely feel comfortable sharing with your doctor if you have a history of trauma. If you've had some sort of experience that makes them more difficult, emotionally or physically, we obviously take that definitely into consideration. So feel comfortable sharing that.

BLAIR HODGES: You basically clench? It's a reaction because of trauma.

KAREN TANG: Exactly. It's an involuntary tensing of the muscle. Sometimes we will actually give people a Xanax or something. Now there's more use of things like nitrous oxide for exams if people are nervous or uncomfortable.

 

Pelvic Exam Basics – 44:13

 

BLAIR HODGES: For guys and people who haven't done this, just give us a quick description of what that actual pelvic exam is. What happens at that moment?

KAREN TANG: So there's different components of it. We don't always do all of the exam on every patient. For instance, if someone's in the ER with an issue, they sometimes think they had a pap smear done, but that's not necessarily true.

A pap smear, which people have heard of usually and equate with the entirety of the pelvic exam, is just a test for cervical cancer. A lot of people think it's synonymous with the whole pelvic exam. It's just a portion of it. A pap smear is basically taking a soft brush and touching the cervix to check for cervical pre-cancer or cancer. It's usually done with a speculum, which is a little duckbill thing that opens the walls of the vagina so you can see the cervix, which looks like a doughnut at the end of the vagina.

We don't necessarily always do a speculum exam. For instance, if we're checking to see if anything hurts or signs of infection, sometimes we can do that with just a vaginal swab, or we can check with the fingers to feel the size and the shape of the uterus internally. Those are the components of it.

We also check the skin of the vulva. We're looking at the vulva, the vagina, the pelvic floor muscles, the uterus, the ovaries, some combination of those.

The whole thing is usually just a few seconds. I'm pretty quick with my exams. The whole thing probably takes less than one to two minutes. People think of it as this long drawn-out process. It really shouldn't be. Then we don't necessarily do every exam at every visit. It's important to talk with your doctor, like “What tests are you going to do today? What's it for?” Like, if you’re concerned—

BLAIR HODGES: Maybe an IUD insertion?

KAREN TANG: Yeah, so we talk about IUD insertions and pain control methods for that. That's gotten a lot of talk on TikTok and stuff.

To be fair, I think in the past gynecologists really just were not great at counseling about different pain control options. I'm a pain specialist so I've always talked about it more than most people. But now there's actually a focus on making it comfortable. A lot of gynecologists for instance are getting nitrous oxide systems, looking at things like putting local anesthetic into the uterus with gel or a straw because the numbing medicine shots are actually kind of painful themselves.

We're trying to think of creative ways to make things like endometrial biopsies—which are biopsies of the tissue inside the uterus, IUD insertions, colposcopies—which are tests for abnormal pap smears where we take biopsies of the cervix—

BLAIR HODGES: So you’re actually taking a piece of the cervix out to test its cells—

KAREN TANG: Like a small piece of the cervix, yeah. We're trying to be more purposeful about pain control options and making it as comfortable as possible for patients.

 

Empowering People to Make Choices – 46:43

 

BLAIR HODGES: One of the things you emphasize over and over again is you want people to be willing to ask questions and to advocate for themselves. It also made me wonder, though, about patients who might be afraid to make ultimate decisions about something. Maybe you encounter patients who just want the doctor to make the decision for them. What's your suggestion about that kind of scenario? I imagine I might be that type of person, to be like, “Just tell me what to do.”

KAREN TANG: And that's totally fine. Actually, in one of the last chapters, it was sort of like, what do you do now? How do you talk with your doctor? And I say this, like some people are like, “I just want the doctor to tell me, I don't want to have to sift through different reams of information. I want you to use your expertise and tell me what you would do.” Patients ask me all the time, “What would you do if you were me?”

That's absolutely a valid response. I tell people, it depends on what your preference is.

And then some people want to literally vet every piece of information. They want to look it up themselves, they want to look at the study. A lot of engineers are like this, they just want to see the data. They're like, “give me the link to the study, I want to look at it myself.”

Then some people are like, “I'd like to take my time and reflect on it.” Maybe they ask some friends or my husband. Ask somebody to bounce the ideas off of. They don't want to decide right then.

Other people are, like I said, “I just feel more comfortable, doctor, if you tell me what you think is best.”

It's all valid. All of those are perfectly great ways to go about it. It's just most important to figure out what's right for you. Where people feel upset or disappointed is when this is not a good fit for how I want to do this. Sometimes I tell people it's great to do second opinions, third opinions, if you're just not a great fit for the way a particular doctor does things. It's—not like dating, I don't want to say that [laughter], but it is about finding a fit. You know, doctors are human beings—

BLAIR HODGES: Well, I think of therapy in the same way, you want to find a therapist that you vibe with.

KAREN TANG: Exactly! People will try different therapists. There's sometimes just a better communication style, where communication is different. So again, doctors are human beings. We have ways we communicate or ways we do stuff. So it is important to feel like you are with a doctor who is communicating with you and working with you in the way you feel most comfortable.

BLAIR HODGES: Karen, it's so helpful to hear all this. Like I said, these are appointments I haven't really taken part in. When my partner was pregnant, I went to a lot of appointments and got to know some circumstances there, which is really fascinating. But when it just comes to basic reproductive health, myself and probably a lot of men in particular, I don't think have been as plugged into this. I think it's important and useful if we would get more plugged in. Then as you said, sometimes it's taboo for even women to talk about some of the things even with each other. The kind of work you're doing, I hope can really spark more conversations about this stuff.

KAREN TANG: That’s my hope for sure.

 

Talking Fibroids – 49:33

 

BLAIR HODGES: Let's dig into a few specific issues, examples of some of the things you touch on in the book. For example, you've mentioned fibroids a number of times. Maybe take thirty seconds or so and describe what those are, because, as you said, they affect up to eighty percent of Black women.

KAREN TANG: And so many people haven't heard of them. They are benign tumors, meaning they're noncancerous masses that grow in the wall of the uterus. A lot of times they're small and they don't really cause too many problems. But they can grow bigger, they can push into the cavity of the uterus. They cause a lot of severe symptoms in some patients.

So for instance, they can cause lots of bleeding, to the point of hemorrhaging, ending up in the emergency room getting transfusions level of bleeding. They can cause severe pain, especially with periods. They can grow so large they almost cause pregnancy-like symptoms. They can push on your bladder and make you need to urinate a lot or push on your rectum and cause constipation. They can grow literally to fill the entire abdomen, so someone looks pregnant. They can affect fertility because if they compress the cavity, they can prevent implantation of a pregnancy or they can cause miscarriage.

I always make this an example, and I said this in the book, if something affected eighty percent of white men and caused hemorrhaging, severe pain, emergency room visits, and infertility, can you imagine that no one would know it was? But we don't know what causes them! We don't know where they come from. Can you imagine that?

We're just like, we just don't know where they come from. No one knows. It's a mystery. We would respond to it like a global pandemic. All of the national medical societies would be banding together to fight it. The fact that it mostly affects Black women, it also affects a lot of white women, like seventy percent of white women may have it, but just the injustice of the fact that no one knows what they are is pretty illuminating.

I was just interviewed on NBC News and the reporter had been on various shows, she had given interviews because she had fibroids and it took going to an emergency room hemorrhaging for her to get a diagnosis. She's obviously very tapped into health. She covers health topics all the time and had a family history of fibroids. So they run in families.

A lot of these things like endometriosis and fibroids do run in families. Sometimes people may not necessarily know there was a history of fibroids but what is very commonly said is people were like, "My mom had a hysterectomy. My grandmother had a hysterectomy. My sister had fertility issues. I'm not sure why."

That's a very suggestive story for both fibroids and endometriosis. People will say this all the time, like “I don't know why they had all these hysterectomies but they did.” They were having miscarriages, trouble getting pregnant. It's usually either because of endo or fibroids and just it wasn't talked about.

 

Mental and Physical Health – 52:25

 

BLAIR HODGES: With endometriosis you also say, this is where the mind and body connection can be considered, you say people shouldn't dismiss a patient's emotions because having stress and having issues can exacerbate something like endometriosis. What's happening there? What are some of the treatment options people have when it comes to fibroids and endo?

KAREN TANG: The mental health component is very important because it's like a chicken or the egg—because these things are so stressful they experience depression and anxiety, and depression and anxiety worsen pain. They worsen muscle spasms, which is associated with both of them. The muscles get inflamed by endometriosis or fibroids and tighten up and cause pain. The more stress, the more muscle spasm, the more pain, the more stress. All these things become these cycles.

When I counsel patients in the office, I do say we need to break the cycle. Not only are we talking about treatments for the fibroids themselves, not just the endometriosis, not just the fibroids, I'm sending them to a physical therapist, like a pelvic floor physical therapist. I'm sending them to a mental health professional, to GI doctors, to bladder specialists, because each of those things needs to be addressed in order to break these cycles of things influencing each other.

With fibroids it's very important to point out, obviously we don't have time to go through every single treatment, but what happens a lot with these is patients are only really given one option. For fibroids it tends to be something like a hysterectomy, which is taking the whole uterus out. That is what we call “definitive management,” meaning that yes, if you take the whole uterus out the fibroids are gone, they can't come back.

But obviously if someone is a young Black woman who wants to get pregnant in the future that's not the right choice. Yet sometimes people will be presented with only one option, like you can only do a hysterectomy, you have too many fibroids, we can't do anything else. It's got to be a hysterectomy.

I always tell people there's never one answer in anything in medicine, including for cancer. Cancer doctors don't say this is the one and only choice. There's pluses and minuses and ones that are clearly more beneficial for certain situations. But if you are being told you only have one option, and they don't give you any other options, that's where it's important to seek a second opinion with a specialist. There are people who specialize in fibroids, people in my specialty, which is minimally invasive surgery, where we do a whole range of different treatment for fibroids.

If you are only being given one treatment, then please do seek a second opinion. It's interesting because for so much of these issues it skews in the opposite direction. Either you're told you can only get a hysterectomy, or if someone wants, say, a sterilization or hysterectomy but they're child-free and they don't want to have children, then they're told “Well, but you might change your mind.” They take away that choice.

BLAIR HODGES: Yeah, you say there's a lot of control happening here.

KAREN TANG: There's a lot of control issues and also this perception that if you could be pregnant, you should want to be pregnant. Sometimes people want to have a hysterectomy or want to get their tubes tied and they're told, “You don't have kids yet. So you're going to regret this later and I refuse to do that.”

It goes in the wildly extreme opposite directions sometimes with gynecology, where people's choices are being taken away. It's all about choice. Everyone should be given options so they can find the right choice for them.

BLAIR HODGES: The options are going to have different possible side effects or outcomes. There was a moment of the book when I thought, "Man, this particular thing Karen is describing sounds so terrible, why don't we just remove ovaries for anybody that is experiencing this?" You make the point that that can cause cascading health issues. It's a complicated decision to make about a hysterectomy or removing ovaries. These can have other repercussions on someone's health.

KAREN TANG: Going back to the history thing, I just did an interview about hysterectomies and how in the past we did used to, as a field, just take out ovaries much more freely, because just like you said, why not? It'll prevent XY and Z. It'll prevent ovarian cancer. But obviously taking out your ovaries and causing a sudden surgical menopause can cause lots of health issues. It can cause not just the hot flashes and vaginal dryness stuff, but cardiovascular disease, osteoporosis, loss of muscle mass, so all sorts of health issues.

In the past people thought that exact way. They're like, “This is terrible. Just take out everything.” But obviously now we know there are health ramifications for all of it. We have to balance all of the risks and benefits whenever we think about choosing a treatment.

 

Talking Menopause – 56:53

 

BLAIR HODGES: Right. And you mentioned menopause, I kind of assumed that once periods end with menopause, there was sort of a Shangri La waiting, like this is a time for people to just be done with it. But you say there's a whole new world of changes and possible medical problems. I couldn't help be like, can't women get a break?

KAREN TANG: The chapter on menopause starts with like, "If you're dealing with horrible periods and PMDD and bleeding, you may think that it's the promised land when it all stops." But then of course I just mention a bunch of the symptoms of menopause. Including things like brain fog, problems with sleeping, decreased libido, increased UTIs. A lot of things people don't realize are menopause symptoms. It really affects a lot of things.

BLAIR HODGES: You're encouraging people to try to take some action if they're experiencing these things. There are things that people can do. You're giving people a heads up of what they might expect. But you're also saying, “Look, there's some things that can be done.”

KAREN TANG: What I love is in the last two weeks, I feel I've had an influx of women who are perimenopausal. They haven't had their periods fully stop, which is menopause, where it's been more than twelve months since you had a period. But they're sort of in this time period where for a couple of years things are changing. They're not quite sure what's going on. Periods are a little irregular, they feel some of those symptoms. Now that people are more aware of perimenopause, menopause, they're coming in earlier. They're saying “I just want to nip this in the bud before it gets worse and before I'm really suffering. I want to take control of my health.”

I think that's fabulous. That's the exact goal for people to so they can take control and not have to wait until they're just feeling they're nearly dying of all of these horrible symptoms before they get treatment. Because that's kind of what's happened until now, you have to be dying in pain or hemorrhaging, or literally can't function with hot flashes before you get treatment.

Again, not that that's because individual doctors are being purposely mean, but that's just the culture. It was like you just have to deal with it and when you can't deal with it any more that's when you should get help.

I'm glad we're breaking that myth. You can get help when things are starting to be bothersome. That's the perfect time to get help. For endometriosis, the earlier on the diagnosis, the better. Don't wait for it to be horrible. As doctors, we should be jumping on these things much sooner too so they don't spiral and become severe endometriosis, infertility, debilitating menopause symptoms, all of that.

 

Talking PCOS – 59:24

 

BLAIR HODGES: For me one of the more discouraging sections was about PCOS, just because it seems to be one of the most mysterious ones. Is my impression right on that?

KAREN TANG: PCOS is again one of these conditions that it's not even one specific disease. It's a group of symptoms. We don't know. So back to the problem of “we just don't know.” We don't know what causes it. Is it a gene? An enzyme? No one knows.

You have to have two out of the three things to be diagnosed. Missing periods or very infrequent periods, signs of extra testosterone, like acne or facial hair, and then polycystic ovaries in an ultrasound, which is just teeny, teeny little cysts, which are basically just follicles holding eggs that aren't being released regularly.

It's a very mysterious condition. It can cause skin changes, it can cause fertility problems, it can cause also metabolic issues. It's very highly associated with diabetes. Seventy, seventy-five percent of people with PCOS will have insulin resistance or diabetes. They can have high cholesterol and high blood pressure.

It's just such a wild condition because it affects all of these things. Again, no one knows where it comes from. You can't prevent it. You can't treat the root cause of it. You can just sort of chase some of the symptoms of it. We can give things to regulate periods, give things to induce ovulation for fertility, help with the diabetes stuff, but nobody knows the origin. You can't address the origin, which is the problem with a lot of gynecologic issues.

 

Changing the Status Quo – 01:00:50

 

BLAIR HODGES: This was the hard part about reading the book, was

 

KAREN TANG: Sadness?

 

BLAIR HODGES: Yeah! And having to confront so many of these things. But I also think the book is really helpful because people can dip in and out of it. It's not written as though you have to read it front to back. There are clear sections.

If you want to look up something about PMS and PMDD, you've got a section on it. There's a couple of important sections on abortion. You talk about things like septic pregnancies and why access to abortion and outlawing those things is such a threat to women's health. You also talk about gender affirming care as well.

For people that are interested in all these issues and more they can check out the book, It's Not Hysteria: Everything You Need to Know About Reproductive Health (But Were Never Told).

As we're wrapping up here, Karen, I think a book like this can become dated. There's new stuff coming out all the time. What do you suggest for people to stay up to date?

KAREN TANG: I say this all the time. It would be great, it would be awesome if we rapidly made this book obsolete by having so many amazing groundbreaking things in women's health, but I will say I've been practicing medicine for fifteen years now. I finished my training in 2010 and I have seen very few groundbreaking things. Like the new nonhormonal medication for hot flashes, and then one new type of treatment for fibroids. That's it. Nothing else. No other new medication classes, nothing.

BLAIR HODGES: What can regular people do to help shift the status quo when it comes to reproductive health? What are we supposed to do? I feel like we're just waiting on more stuff to come around.

KAREN TANG: This is where people talking, sharing, speaking out—I always tell people you never know who's listening. My publisher publishes Melinda Gates as well. Melinda Gates just announced she's going to be dedicating a billion dollars to women's health funding. I have been trying to get my publisher to give her this book. There's always someone somewhere out there who has the ability to contribute to funding dollars, who is a researcher themselves, who is in government who can make policies, who works in an insurance company.

I'm praying someone out there who has the authority and the ability to make some actual tangible changes in this is out there listening, or if they're not listening to me maybe somebody out there hearing us now, maybe if you speak or you have a colleague or somebody you know, that it somehow reaches the people who are in the position they can make a huge change.

But in the meantime, most of us I think—just like the fact that so many people are talking about menopause has led to some important changes. The White House initiative on women's health and dedicating billions of dollars of funding came about because Maria Shriver and folks who are hearing these stories about menopausal women and how much they're suffering got to the point that it actually made a huge change.

There's a lot of advocacy groups for endometriosis in particular that have been very effective. There is a documentary I was actually just texting about called Below the Belt, and they've held screenings at universities with government, with senators, and Hillary Clinton is one of the producers on that.

BLAIR HODGES: So you feel like there's a movement happening.

KAREN TANG: People are just so fed up. They're like we've got to do something. That's speaking out, that's organizing, that's lobbying, raising funds. As regular human beings that's what we can do.

Then the first step is speaking out, sharing our stories, saying this is not okay, this is ridiculous. Then hopefully turning that outrage into something positive, like positive change.

Sometimes these interviews get very sad because it's so bleak. I like how we're taking it to an optimistic place before we end that we can make these changes. I do think we have the power in our voices joining together and speaking out and fighting for practical things that will make a difference.

It is changing. I think, you know, a lot of OBGYNs are on board with this. We're saying we need to improve access to pain control methods, improve counseling, be more nuanced instead of reacting so wildly to the “hormones are horrible, hormones are everything,” that we should have more nuance. I think the more we are talking, we are making some good changes. It's a start. We're going to get there.

 

Cover Art – 1:05:18

 

BLAIR HODGES: You're doing a lot of great work. People can follow you on social media. @KarenTangMD is where you can find Karen. Also the book, It's Not Hysteria: Everything You Need to Know About Reproductive Health (But Were Never Told).

Before we get to the final segment, Regrets, Challenges, & Surprises, I did want to ask about the cover art. It's really beautiful. Did you have a hand in putting that together? tell me something about that art on the front.

KAREN TANG: For those of you who don't know, in traditional publishing the author is among the last to know about the cover. Flatiron, my publisher, was great. They were very collaborative. We actually went through about four different cover concepts, which were totally different. They were very open to us scrapping entire ideas. They were like, “That doesn't fit well.” For this one we all went “Wow!”

For those who haven't seen it, I call it the vulva flame or rainbow vulva. It's literally this very colorful rainbow-colored flame, which obviously it looks like a vulva, the opening of a vagina. I say that if you think of it as fire, think of it as there's an element of pain, but illumination, sparking change. It's very eye catching. When you look at it in a bookstore, you're like, "Oh my God, what's that book?" It's great.

Of course I can't find his name, but I recently connected with the artist who does a lot of book cover art. He actually did the same art for the cover of The Adventures of Cavalier and Clay—

BLAIR HODGES: Oh wow!

KAREN TANG: —which is a completely different style of cover. It's got I think the Empire State Building on it, but this is a very talented artist and did a fabulous job with this. I think it was the perfect cover.

It's interesting because the UK version just came out yesterday and it has a completely different style. It's just very simple. It's a lightning bolt. It has the word "period" at the end of It's Not Hysteria. Like It's Not Hysteria, Period. The lightning bolt they told me, I didn't know this, it was a symbol of feminism and resistance in Europe. In Poland the lightning bolt was used as a symbol of resistance or reproductive rights. I didn't know that. It's very interesting what these symbols evoke in different places. It's kind of neat.

 

Regrets, Challenges, & Surprises! – 1:07:16

 

BLAIR HODGES: Let's talk regrets, challenges, and surprises. You can pick one, two, or three of those things. Your book is just now coming out so I don't know that there's much to regret or that you wish you could have changed at this point, but maybe there's something. Or what was the most challenging part about writing it, or something that just really surprised you in the course of doing this project?

KAREN TANG: I will say the most emotionally difficult part was actually trying to promote it. Again, I have an amazing publisher. Flatiron has published Oprah, Matthew Perry, Elliot Page, really heavy hitters. But we got no trade reviews for the book, except for Publishers Weekly came in right at the last minute with a starred review.

BLAIR HODGES: I was gonna say, it was starred, which is awesome.

KAREN TANG: It’s like the A++ review, but nothing else. No Kirkus, no Library Journal, and almost all of my publisher’s books get reviewed by these because it's a great publisher. My only thought is, it must be the "political stuff," like the abortion, gender affirming care. I don't know if they're trying to avoid political books.

Or is there a presumption this is just a lady book? I don't know. It was very difficult seeing how we were struggling so hard to get some sort of industry acknowledgement that the book existed, that it was hard to get press for initially.

Now that people have seen it and they're talking about it it's been very exciting. Now people have been reaching out to talk about it. But the week of the book coming out it was crickets. We had nothing. It was very frustrating because obviously I feel strongly about these issues. It affects every woman, everyone assigned female at birth, how is it that we're not getting the book out there?

That was very difficult. Anyone who has dealt with these issues and been frustrated by struggles to get someone to take it seriously, I felt the weight of all of their difficulties. I was like why isn't someone listening? This is crazy. It's so frustrating.

But I think now I'm starting to see the independent booksellers championing it. They're posting and tagging it on social media. “We can't recommend this book enough. Everyone should read this book.”

We had a feature in Bustle, in The Times in the UK, and it is really very moving. It's even more moving now because I think seeing people responding well to the book and realizing the importance of these issues has been very meaningful.

That was definitely very difficult for me. You felt like it was your child you had put so much care into and then everyone thought your child was terrible. Now I'm like, “Oh, people think the child is great!” [laughter] That was the biggest challenge.

BLAIR HODGES: Great.

That's Karen Tang, author of It's Not Hysteria: Everything You Need to Know About Reproductive Health (But Were Never Told). She's a board-certified gynecologist and a minimally invasive gynecologic surgeon. She's also on TikTok, YouTube, you can see her on Instagram as well, @KarenTangMD.

Karen, thanks for taking time to talk to us about the book. It really is terrific. I hope it continues to spread. You're calling for a revolution here. You're calling for systemic change and better individual understanding. I'm with you. I want to see it spread far and wide. Thanks for taking time to talk to us.

KAREN TANG: Thank you so much. This has truly been one of the best interviews I've ever done. I appreciate the amount of time and thought you put into this. It's absolutely true. Thank you so much.

BLAIR HODGES: Thank you.

 

Outro – 1:10:36

 

BLAIR HODGES: 

Thanks for listening! And hey, why not send this episode to your husband or partner who never seemed to care about your PCOS but needs to get their act together? Just text this to them and say, "Would you give this a listen? Let's talk about it." 

Thanks to Camille Messick who edited the transcript for this episode. You can find transcripts of every episode at the website familyproclamations.org, and there's a lot more to come on Family Proclamations.

If you're enjoying the show, please, please go to Apple Podcasts and leave a review. I read all the reviews. I cherish all the reviews. 

Mates of State provided our theme song. Family Proclamations is part of the Dialogue Podcast Network. I'm Blair Hodges and I'll see you next time.

 

[End]

 

NOTE: Transcripts are lightly edited for readability.