I was visiting my grandparents abroad in Pakistan, when my khala (aunt) who lived in Pakistan approached me in private. She asked me what I knew about periods.
My khala is ten years younger then my mom and has always been considered my “cool” aunt; the one who would take me to get my second piercing without asking my mom. She’s also the one who would speak freely on how pregnancy changed her body, and gave me a glimpse of her postpartum belly.
But for some reason, when she asked me what I knew about periods, I was embarrassed. My response was, “You mean like the punctuation?” I was desperate to end the conversation before it began. I don’t know why, but I was horrified at the thought of having to speak about a natural milestone in every young woman’s life.
Growing up, I was raised not to lie, cheat, or curse, but I distinctly remember I was also told not to say the “p” word — pregnancy. This was to avoid having to answer any questions about where babies came from. I still haven’t been able to figure out if it is the culture or religion that discourages the talk of because of bodily changes. I am inclined to think it is a little bit of both. I have a few Muslim patients who are from multiple backgrounds who have told me of similar stories and experiences in their childhoods.
When I was in middle school and got my first period during gym class, I already had an idea of what was happening from other girls in school. When I went home and told my mother I had gotten my period, she handed me a pack of pads, and from then on, that was the only option I had known for menstrual hygiene. The first time I learned about tampons was in college. I recall the first time I learned how to use one — it was in the bathroom of the college library with a friend talking me through it from outside the stall. I never really understood why tampons were frowned upon or discouraged.
Fast forward 15 years. I am now a pelvic pain physician who educates and treats women daily on conditions that cause pelvic pain. I often encourage the use of tampons as a gauge to see how a patient is progressing with their treatments. I once even had to explain to a patient that using a tampon or doing an internal vaginal exam would not cause the hymen to break. The patient was terrified she would lose her virginity.
What is pelvic pain, you ask? Generally speaking, anything that causes pain above the knees and below the belly button. If only it was as simple as an infection that you treat with antibiotics — in actuality, women have pelvic pain from many different causes, and I could write textbooks on
this topic, however I will limit this dicussion to a few major causes. I often call myself a detective because I’m trying to figure out the cause of this pain. Some women have pain for short intermittent bouts, and some have constant continuous pain. The important thing to realize is neither pain is worse then the other, as treatments do overlap.
When a woman has pain inserting a tampon due to tight pelvic muscles, though the pain is only with that activity, it is still considered something that is not normal. Pain with tampon insertion can also tell me that there is a high likelihood she will also have pain with intercourse.
Neither of these pains are normal, and many times Muslim women do not realize they have this pain until the first time they are intimate. Intercourse is also something that most Muslim parents very rarely speak about. I myself had never spoken to anyone regarding this prior to my wedding night. I do remember on my wedding night, my husband’s older cousin — who happens to be a physician herself — encouraged us to pray two rakah sunnah before we were intimate. It was random, and it was awkward, even for me, an American-born 26 year old doctor.
Pain is not normal, and many times Muslim women do not realize they have this pain until the first time they are intimate. There was never an emphasis that intercourse should pleasurable for both partners, but this is mostly because it is never discussed. Intercourse should be pleasurable for both partners.
What I learned of the “birds and the bees” was limited to health class in middle school. It certainly wasn’t discussed at home. Watching scenes of intimacy on television was never comfortable, and the channel was quickly changed. It’s to no surprise that many Muslim women have painful intercourses and don’t consider it an issue. There was never an emphasis that intercourse should pleasurable for both partners, but this is mostly because it is never discussed.
Intercourse should be pleasurable for both partners. Muslim women have a tendency to dismiss these “small” amounts of pain, and think that it’s not worth discussing or treating since it is not constant or continuous.
I can say this because I treat pelvic pain in New York City. In my practice, I see both males and females. The percentage of Muslim women that I see are maybe two percent of all my patients. Does that mean Muslim women have less pelvic pain? Probably not. It does mean, though, that Muslim women are probably less likely to seek help.
Vaginismus is a condition where the muscles of the vagina contract when something is entering it. There are many reasons for muscles to contract. I hear very often that it’s normal to have pain with sex as a virgin, or that the pain is because her spouse is too large for her. Once again, women are found blaming themselves for their pain. This is certainly not true, and if they were having intercourse with multiple partners, they might find that the pain doesn’t change depending on the partner.
There are so many treatment options including pelvic floor physical therapy, vaginal valium suppositories, use of dilators and wands to relax pelvic floor muscles, and trigger point injections. Understanding the cause of vaginismus is vital to treating it. Many women have fear of intercourse, as well as anxiety or guilt with it, that may trigger vaginismus. If there are issues in the relationship, including an abusive sexual partner or if she feels too vulnerable in her partner’s presence, this can contribute to vaginismus. I always ask my patients about any history of unwanted sexual contact, because a history of sexual abuse or premature exposure to sexual imagery at a young age may also cause vaginimus. When there is a psychological component to the condition, it is important that the patient seek cognitive behavioral therapy in addition to the treatment protocol to address these issues.
Getting back to the women who have pain that isn’t so short lived — one of the major causes of this type of pain is endometriosis. What is endometriosis, you ask? Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body.
Did you know 1 in 10 women has endometriosis? It affects a whopping 176 million women worldwide. About 40 percent of the female patients in my private practice have endometriosis. That number is strikingly high, but how many of these women are Muslim? Less than two percent. Is it safe to say endometriosis does not afflict Muslim women? Absolutely not! The question should be, why are more Muslim women not being diagnosed with endometriosis? Most pre-teens learn little about menstruation, and then go on to speak even less about it with their family members, the people they are closest to. Women with endometriosis typically have pain during their menstrual cycle, but they may also experience pain that doesn’t correlate to their cycles – this is what makes this disease so unpredictable and frustrating.
Many women are told it is a normal part of being a woman to have painful periods, and that they shouldn’t speak about it, much less make a fuss about it. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways. Many young women are unable to go to school, work, or even carry out activities of daily living. Many of my patients have told me they used to throw up due to the pain. Some would visit the emergency room multiple times a year. Of the 40 percent of my patients that have endometriosis, the majority of these women are Caucasian and African American. Many of these women go undiagnosed for seven to ten years.
The current Meyer’s theory of endometriosis has shown that endometriosis can be present during fetal development, and may simply be activated at puberty when estrogen levels increase in the body, and periods begin. Many women who are placed on birth control that suppresses estrogen may find relief in symptoms.
However, some Muslim women believe going on birth control prior to marriage is taboo. When a woman comes in and I suspect endometriosis, I ask the patient if their mother had painful periods. Nine out of ten times, they say that either their mother or a maternal aunt had painful periods, and that is why she thought it was normal.
Because endometriosis can affect many organ systems, the symptoms often overlap with different conditions. If you or someone you know answers yes to any of the following questions, you may want to discuss the possibility of having endometriosis with your physician: Do you have painful periods? Do you have pain in between your periods? Do you have abdominal bloating that makes you feel and look like you are pregnant when you aren’t? Are you constipated more often then not? Do you have painful intercourse? Do you have pain with tampon insertion? Do you have urinary frequency or urgency symptoms?
If you are a mother of a daughter, please make sure you learn the difference between normal periods symptoms versus endometriosis. No woman should have to wait years before diagnosis.
Now that I’m in my mid-thirties, I speak about periods and intercourse both publicly and in private with my patients. I have had the opportunity to educate my own mother on endometriosis and the toll it takes on women. It is fascinating to finally be able to break the cycle of this stigma associated with menstruation and intercourse. I urge you to explore doing the same.