How The Female Body Works

A free extract from my new book! You are WELCOME (and do please buy all of it)

So, before we get stuck in… the premise for this book:

Three-ish years ago, it started occurring to me I knew virtually nothing about my body. Like it was a car I’d been driving around for decades, without ever once reading the manual. I didn't even know where the manual was! Couldn’t remember the last time I’d seen it, honestly.

And… All these questions had started bothering me. Like: what is a hormone? No: REALLY? I know we talk about them endlessly, know we feel weak to their whims, buffeted around by them, like they’re Greek Gods having a laugh with our poor, mortal bodies… But, how do they work? What are they made of? Can you see them, under a microscope? And, given how violently they seem to impact our mood, our impulses, our actions… How much of our personalities is not “our” personality at all, but just… hormones?

Like: are we us … Or are we them?

Then I started wondering about boobs (do they need to be that shape? How much do they cost us, in the course of a lifetime?), and brains (is there a male brain and a female brain? Why are women twice as likely to get an Alzheimer’s diagnosis, than men? Twice as likely to be depressed?), and alcohol (does it impact women more violently?) and hot flushes (why do they happen? No, not just: “low oestrogen”… What’s the mechanism?) and so on and so forth UNTIL

I decided to find out.

I lined up a series of interviews with the most incredible experts in women’s bodies and women’s health. Academics and medics, midwives and neuroscientists. A group with massive brains filled with extraordinary knowledge, and hundreds and hundreds of years worth of experience working with women and our bodies, between them.

And then? I asked them EVERYTHING. Everything about every aspect of our bodies, at every point in our lifespan, from puberty through the menstrual cycle, fertility and infertility, breast and vaginas, pregnancy and birth, peri menopause and menopause, and older age.

The whole shebang.

I took those interviews, and made them into a book. A (I hope) funny one, a cool one; where the reader learns, as I learn. It’s been an extraordinary pleasure to work on. A privilege, actually. Learning has made me giddy and happy. It’s made me feel powerful, because: I get it, now! I get my own body.

Read it, and you'll get yours, too (or your partner’s, your mum’s, your kid’s, your friend’s. Men: I so want you to read it !)

So yeah. I’d be so happy if you bought it (here, here, or here, or wherever you usually buy books.)

And here’s a taster.

Of vaginas.

LOL.

Chapter Five

What’s a vagina?

Before I started thinking about it properly, or: asking experts about it… I definitely thought I knew what a vagina was.

Everyone knows, eh?
It’s the thing.
The very centre of femaleness. The heart of it. The heat of it. And it is naughty and rude and sacred and divine, depending on context and whom you ask.
I knew that!
I also knew about vajazzles – the practice, fashionable in the 2010s, of decorating the female pubic area with stick-on jewels. I knew about Brazilians – the removal of all or most pubic hair, because that is what social trends, most likely inspired by the aesthetic of pornography, demand. I knew from experience that a dose of thrush, a common yeast infection, can usually be sorted out with a smearing of natural yoghurt. I knew about vibrators, and that Gwyneth Paltrow advocates the inserting of jade “Yoni” eggs into vaginas for healing purposes (she sells them on her website Goop for US$66.)

I knew the essentials, right?
Guess what?
I didn’t.
I knew virtually nothing. Nor do you. Time to speak to some experts.

What, exactly is a vagina? I ask Dr Alison Wright, consultant obstetrician and gynaecologist at the Portland Hospital.

“That,” she replies, “is a surprisingly difficult question”. She’s a quietly, carefully spoken women who is also – forgive me, it’s my fash-mag training – incredibly well dressed. I’ve already enquired as to the origins of her shoes, already established that This Gynaecologist Wears Prada.

Back to vaginas.

“First of all,” Dr Wright says, “I feel very strongly that we should talk about ‘vaginas’. The word. Women coming to see me as patients will sometimes talk about ‘down below’. And I know they talked about that with their GP [too]. ‘Down below’. ‘Down there’. A lot of people don’t know what a bladder is...”

(The urinary bladder is a temporary storage reservoir for urine, located in the pelvic cavity. It is not your vagina.)

“And they don’t know what the pelvic floor is...”

(The pelvic floor muscles support the bladder, uterus and bowel; they are not your vagina either – though they are incredibly important to it; we’ll return to them.)

So: if we’re not calling things by their actual names, if we’re not distinguishing between organs and even muscle groups, how can we know what’s hurting us? What isn’t working? How can we communicate it to doctors, if we think of it just as one amorphous mass, labelled, vaguely, “down there”?

“Yes! Just call it the ‘vagina’. If you’re ‘bleeding from somewhere down there’ - it might be rectal bleeding.”

It might be your foot, to be fair.
“It might. So: the vagina.”
Yes!
“It’s the passage between the womb - and the outside.”

“Oh, we really need to teach women and girls this,” says Dr Shazia Malik, a consultant obstetrician and gynaecologist who’s worked in women’s health for over 30 years. I arrange to interview her to talk about her sub-specialism: reproductive health and infertility, but when I raise the topic of vaginas – in a very nice cake shop near her consulting rooms – ouf ! Her face lights up like fireworks.

“They’re one of my pet subjects!”

There’s a substantial lack of vagina-knowledge out there, huh, I say.

“Yes! But you can’t blame women for that! We need to give women the information, really, that they should have got at school.”

Like?
“‘This is what your vagina can do! This is where it is! This is what keeps your vagina healthy. What is your vulva? How is that different to your vagina?”

The vulva, I learn, is the outside bit of your genitalia, the visible bits, the labia, the tip of your clitoris – but only the tip. Dr Philippa Kaye - officially my boobs expert, though it turns out she knows a thing or two about vaginas, too - thinks not nearly enough people know this, either.

“When people think of the clitoris, they think of a little nobble,” Dr Kaye tells me (literally moments after we say hello). “Actually, that little nobble is like the tip of a nose. It’s got what looks like legs and bulbs, which extend down in the vulva, and fill with blood during arousal, like a penis fills with blood during arousal. That’s why most women will not reach orgasm from penetration alone. Because they need that whole area stimulated.”

I’ll leave that to sink in.

Meanwhile:

What’s the vagina made of? I ask Dr Alison Wright.“Mucosa: tissue,” she says. Mucosa is a moist inner lining, which coats some organs and body cavities, the digestive and respiratory systems, for example, as well as the reproductive. This lining is attached to the vaginal muscles by fascia, connective tissue.

And what does it do?

“What is the job of the vagina?” asks Dr Malik. “Is it just there for you to have sex? Or to have babies? No! It is to connect the outer world to your cervix, your womb, your fallopian tubes and your ovaries. It’s an organ, a separate organ.”

Dr Malik tells me that the vagina changes during puberty, when it becomes proportionally larger. The vulva – that outer visible area – becomes covered in pubic hair, darker and more pigmented; then continues to change through the course of the reproductive life. During childbearing years, your vaginal mucosa responds to your hormonal cycle. It is at its thickest mid-cycle, around ovulation. In menopause, depleting oestrogen levels mean that it becomes less hydrated and more irritated, and the mucosa gets thinner. Until recently, that menopausal phase had been called “vaginal atrophy” – a term that’s not only quite gross but also misleading, because it also affects tissues outside the vagina. It’s now called GSM, genitourinary syndrome of menopause.

THE VAGINAL MICROBIOME

In the early 2020s, medical and wellness communities started to show huge interest in the gut microbiome, the microorganisms that populate our digestive tract and which are, it transpired, crucial to both men and women in terms of supporting many aspects of our health – our immune systems, mood and behaviours among them. There has been much, much less discussion of the vaginal microbiome, an equivalent collection of microorganisms, located in the vagina. Ina Schuppe Koistinen, associate professor at the Karolinska Institutet in Sweden, and something of an expert in vaginal microbiome, describes it as “all the microbes that are present. That’s bacteria, but also viruses, fungi and all kinds of single-cell organisms.”

Just like the gut microbiome, the vaginal microbiome has a significant impact on our overall health.

How healthy yours is depends on how well balanced it is, with specific reference to bacteria called Lactobacilli. Lactobacilli – particularly, a subset called Lactobacillus crispatus – is the main line of defence against infection. It can get disrupted by fragranced soaps and harsh detergents, which is why, Dr Malik says, we need to get rid of the idea that the vagina is somehow dirty. “We’ve got to kill that concept,” she says.

The microbiome is responsible for the way vaginas smell. Dr Malik is passionate about telling young girls that their vaginas shouldn’t not smell – they should have a healthy odour. This smell has been described as tangy, fermented, sour, or as metallic – like a jar of pennies – during menstruation, because of the iron present in blood.

Dr Malik is vehemently anti-douche, the practice of washing your vagina with products. “You mustn’t douche your vagina!” she says. “I’m forever saying: ‘Use warm water to wash around your vulva. And just warm water...’ But do wash with soap around your anus when you open your bowels, so you haven’t got any of those gut bacteria lingering there on your panties waiting to get into your vagina.”

Douches, Dr Malik adds, are not only a commercial con born of the misogynistically whiffy belief vaginas are inherently dirty, and therefore any smell they produce is by definition unpleasant and unhealthy; they are also, potentially, actively dangerous. She believes douches disrupt and destroy healthy vaginal microbiome, and that they can even push an infection – an STI, should you be suffering from one – further up into the uterus, fallopian tubes and ovaries.

When your vaginal microbiome is out of balance, disrupted or destroyed, you can get infections, such as thrush. Thrush is a common yeast infection, which can affect both the vagina and the penis. It causes itchiness, irritation and a white, cottage cheese-y discharge. It’s not an STI, it’s generally harmless, but it can be uncomfortable; heaven knows, it once drove me half-crazy on a French exchange trip. At the same time, a healthy vagina will also have a discharge; it’s how it cleans itself, among other things.

“Did you know your vaginal discharge changes through the menstrual cycle?” Dr Malik asks. I did not. “Mid-cycle, you get a thin watery discharge, because your body ovulates around mid-cycle. That’s when you would get pregnant – if you were trying to get pregnant. That discharge changes to facilitate the sperm. To get it through the cervix.”

No way! And yet, at the same time: of course!

According to a study published in 2024, a healthy vaginal microbiome also plays a role in protecting against persistent UTIs, urinary tract infections. Studies have found that UTIs are 30 times more common in women than men, and that four in 10 women who suffer from them will get one at least once every six months.

Which is miserable.

In older women, UTIs can cause a sudden confusion, a delirium, a sort of temporary dementia.

Which is actively very dangerous.

Our propensity toward them is believed to be because women have a shorter urethra (the channel between the bladder and the point where pee is released, your pee channel basically) than men, which means there’s less distance for bacteria to travel, so more of them get up to your bladder and cause painful mayhem. That shorter urethra also means that the anus -the bum - and the entrance to the urethra are much closer in women than men. For this reason, Dr Malik says we need to teach girls not to wear pants at night.

Really?

“Super important. The opening to your vagina is a few centimetres from your anus. Your gut is full of different bacteria to your vagina; so if you wear panties at night, any of the bacteria around your anus has a warm moist environment to proliferate.”

Right there in your pants?

“In your panties! Then they can get into your vagina.” During the day, she says: “Wear cotton underwear as much as possible, don’t teach [girls and women] that only slinky under- wear, only G strings, are the thing!”

“Wash your underwear separate to your other clothes, at a high temperature. You can’t kill the bacteria until you wash at 60–70 degrees. Thrush is a fungus – it will not die at low temperatures.”

I had no clue and promptly overhaul my knicker-washing strategy.

THE PELVIC FLOOR

Remember I told you we’d get back to the pelvic floor muscles? It’s time.

And I know that, just reading those words alone, most of you have instantly, quietly started doing “Kegels” – tried to, anyway. Attempted what you imagine/hope/vaguely comprehend to be Kegels (named for Dr Arnold Kegel, the American gynaecologist who developed them, in the early- to mid-20th century); a kind of clenching, rhythmic gripping, contractions of something deep and inner, staccato tensing of the muscles you switch on when you’re trying to stop yourself from farting or peeing. Kegels: which you know you’re supposed to do, though you don’t really know why? And you kind of think it’s embarrassing? Because it’s hidden and connected with your lower pelvis, which is always a little shame-laden? And because they’re weird and not-quite-knowable and who can ever really say if you’re doing them right because, what’s the measure, and also: what’s the point?

Dr Alison Wright explains that the tissue that makes up the vagina lining, the mucosa, is surrounded by muscle and fascia. This, then, is the pelvic floor.

“It runs from our pubic bone to the coccyx,” aka the tailbone, the nobbly bit at the very bottom of your spine, “which is where it attaches. It supports the vagina, and also the bladder neck, so it’s quite low down. It also supports around the anus, the back passage. I demonstrate it like this...”

Dr Wright makes a cradle of her hands.

“It cradles the bladder neck at the front, the vagina in the middle, and your anus, at the end.”

A YouTube video by the excellent pelvic physiotherapist Carly Wallace (Restore Your Pelvic Floor, @carlywallacepelvi- chealthph5730) shows it as an entire big, broad sort of fruit bowl of muscle, a basin of muscle, inside which (ideally, neatly) sits our bladder, our uterus and our bowel.

The urethra comes through the muscles at the front; so does the vagina and the anus (rectum, bum, however you know yours). Kegels are a contraction, a squeezing and a lifting, of all those muscles – this, I realise, is where I and many other women before me have gone wrong in our understanding of Kegels. Merely tensing the I-don’t-want-to-pee-yet muscles – which is what I’d always done – isn’t enough to enhance pelvic floor strength. You have to think longer and broader than that: all the way along that cradle, from the muscles at the back of your body, around your bum, through the pee-muscles and up to the front of your lower belly, the pubic bone.

One of my many Pilates teachers tells me to think of the pelvic floor as the clasp along the top of a ziplock freezer bag, and clench as if you’re doing up one of those, from one end to the other.

What weakens the pelvic floor? I ask.

“Pregnancy, childbirth and age,” Dr Wright says. “It’s a double insult to women, I would say. The weakness starts mechanically in pregnancy and childbirth [the pressure of the growing baby, and the force with which it comes out of your body can weaken it], then can get worse, when our oestrogen levels drop, going through the menopause.”

It is not therefore, a problem that just affects women who’ve given birth vaginally – not by any means. It’ll come for all of us, to some degree or other, with time.

A weakening pelvic floor is a major issue, not just an embarrassing one. First, because it can mean you lose control of when you pee, which means your lifestyle is massively disrupted, horribly limited; your social life, your work life, your sex life, the whole shebang. I know one gynaecologist who rages against the normalising of women leaking “a little bit of pee”, in adverts, and so on. We should not, she thinks, ever believe that it’s inevitable or acceptable or otherwise dismiss it as a little bit of anything.

Beyond that, pelvic floors hold the womb, bladder, bowel and cervix up and in. If those muscles weaken, there’s a chance those organs will fall down and out, which is what is meant by the term “prolapse”, and which can only be corrected by specialist phys- iotherapy or surgery – and really? Who wants their inside organs on the outside?

Pelvic floors are crucial to sexual function. A weakened pelvic floor can make sex painful and reduce sensation; a stronger one, I learn from yet another brilliant pelvic floor influencer guru @femalephysioco, will create a stronger orgasm – although equally, too tight a pelvic floor can lead to pelvic pain. Pelvic floor muscles also provide lower-back stability: a weak pelvic floor can contribute to back pain, a strong one will help alleviate it.

Right, so: how do we strengthen them? Kegels?
“Yes,” says Dr Wright.
How can we tell if we’re doing it right, though?
“If you put two fingers in the vagina,” Dr Wright says, “which physios do – we have specialist pelvic floor physios in this country, but we need to have more. So put two fingers in and squeeze... That’s the mechanism by which you strengthen your pelvic floor.”

Dr Philippa Kaye suggests imagining you are trying to suck up a piece of popcorn from a chair with your vagina. “Women seem to automatically know what I mean!”

“They’re much better at this [sort of training and support of women] in France,” says Dr Alison Wright.

I know this, somehow, God knows how, as I’ve never given birth at all, let alone in France; but somehow – probably through the gift of vaguely salacious coverage in the press – I do know that, after you give birth, a French midwife will visit you with a box of tricks designed to help restrengthen your pelvic floor, including an electrical device that will contract the muscles surrounding your vagina – Slendertone for the pelvic floor. It’s all government mandated, the French call it “la rééducation périnéale après accouchement”, or “perineal retraining after child- birth”, and while it’s inspired some feminist eye-rolling based on the suspicion this is all about becoming adequately... uh, firm, again, for the delectation of ton mari, your husband, who might well be tempted to go off and find himself a mistress if you don’t, you know how the French are... There’s a massive health requirement for it, clearly, never mind that this argument does rather assume good sexual function is only important to men, when... Well. It’s not, is it?

So when should we start doing all this, caring for our pelvic floor, I ask Dr Wright. After we give birth? Mid-30s? 40, max?

“Ideally, at school.”
Blimey! Really?
“Yes. Start at school, do them every day, for the whole of your life.”

You’re doing Kegels again now, aren’t you? YEAH YOU ARE! I CAN SEE! (I can’t). But you should.

That is the end of my extract. If you liked it, if you learned something, if you’d like to know more about How The Female Body works, the rest of it is available here, here, or (singed copies) here, for £14.99.