Most of my job as a midwife is recognizing normal. In school, we learn that 90% of what we will see will be normal and healthy. Recognizing abnormal is the kicker.
As a student our range of what is normal is very small, like a tiny sliver. But with more experience, more exams, more histories, more understanding of the wide variety of women’s bodies, the scope of what we recognize as normal and abnormal becomes larger. Our confidence grows. But then there’s still that 10% of abnormal. Of an unsure exam. Of a history that sends up little red flags.
I had two experiences in the past few weeks that were amazing lessons in normal vs. abnormal, and reinforced what I already know to be true: that women know their bodies best and we need to listen to women’s concerns, no matter what.
I had a young woman come into my exam room for a breast check. She was feeling a lump behind her nipple and was very concerned. I conducted a breast exam, and, as I do most of the time when there is a positive self breast exam (woman feeling herself) and negative clinical breast exam (I feel), I reinforce the normalcy of irregular, glandular breast tissue. Everything I’m feeling here is normal.
It is a difficult line to walk, to try and reinforce normal while also making sure that the woman’s concerns feel heard, validated. But we also know that women know their bodies best. I had her come back a month later. She was due for a pap smear, and I wanted to check again, and see if she could still feel the lump as well as repeat my exam. All of these follow-up steps are laid out in a very, very thick book of medical standards and guidelines that all the providers at my clinic follow.
So she came back, and could still feel the lump. I couldn’t.
And you know what we do at this point? We say, you know your body best. If you’re concerned, we’re concerned. And I sent her for a breast ultrasound and mammogram. And you know what? There was a lump. The radiologist couldn’t feel it either, but the imaging showed a (most likely) benign fibroadenoma (a fibrous, rubbery lump of tissue that is generally considered benign). She’s scheduled for a follow-up clinical exam and mammogram in 6 months, because the radiology recommendation was to keep an eye on it.
But what if it wasn’t benign? What if this woman had been seen by a provider who doesn’t trust that women know their bodies best?
I think we all know the answer to that question.
On a less serious note, I had a visit with a post-menarchal (recently experienced her first period) woman recently to discuss abnormal menstrual cycles.
“Why are my periods so irregular? This can’t be normal! I can never tell when it’s coming!” She declared from the exam table, exasperated. “And I get these weird, shocking pains on the sides sometimes! What is that? Do I have an STD?”
Upon further investigation, I discovered that this young woman’s periods were coming every 27-35 days, and she was experiencing mid-cycle pain on one side or the other for about the past year.
I started to explain that her periods were what we would consider as regular and normal. That having a period that you can count on to come monthly, between 26 and 35 days, lasting anywhere from 3 to 7 days is absolutely within the range of normal. That the pain she was experiencing once a month actually has a funny German name, called mittleschmertz, or the pain associated with ovulation.
She further explained that all of her friends had periods that came on the same day every single month. I further asked if they were on birth control pills. They were. I, again, gently explained why the pill was making her friends’ periods come at exactly the same time, and why her cycle was different, and she proceeded to start crying. I gave her a minute, worried I had been too dismissive of her concerns, that I had upset her by reinforcing normal.
Instead, she expressed extreme embarrassment. “Why don’t I know anything about my body?” she cried.
I took a deep breath. Most women don’t know much about their bodies. We don’t talk about it, and lots of schools don’t teach it.
I feel like they talked about it in school once, but why didn’t I know any of it?
I took another deep breath. I had the luxury of time that day, working with another provider to quickly finish up the last visits of the afternoon. I was going to dive into it. “Because we live in a culture that doesn’t discuss what’s normal for women’s bodies. We don’t talk about it with our mothers, our sisters, our friends. Our culture doesn’t value that knowledge. It’s not your fault for not knowing.”
She sighed. “Yeah. It’s true. There’s just so much I didn’t know.”
I continued with the rest of the visit, sharing with her what I saw on her exam, describing her very normal outer and inner labia, the pink healthy vaginal walls, her cervix looked healthy, and that she was having normal discharge.
Reinforcing normal takes a long time in exams, but I always try and review that everything I’m feeling, hearing, seeing looks healthy and normal. When we discuss self-breast exams we talk about recognizing your own normal from abnormal, because a woman who knows how her breasts feel, where all of her glandular tissue lives normally will more easily be able to recognize change than me, someone who has five minutes, just the one time, to discern normal from abnormal.
So yes, 90% of our jobs is finding normal, but it also needs to be 100% listening to what a woman knows to be her own normal.