Clitoral erection occurs when the  corpora cavernosa , two expandable  erectile  structures, become engorged with blood. This may result from any of various  physiological  stimuli, including  sexual arousal . During sexual arousal, arterial blood flow to the clitoris is increased, and trabecular  smooth muscle  within the clitoris relaxes allowing blood to engorge the erectile tissues.  The  ischiocavernosus  and  bulbospongiosus muscles  contract to compress the dorsal vein of the clitoris to stop drainage of the clitoris, trapping the blood. [ 6 ]  The erectile tissues are composed of endothelium-lined vascular spaces in a trabecular matrix, with the  endothelium -lined vascular spaces surrounded by smooth muscle capable of contraction and relaxation.


During sexual arousal, arterial blood flow to the clitoris is increased, and within the clitoris, the arteries further branch to supply the erectile tissues. The trabecular smooth muscles of the erectile tissue relax increasing blood flow to fill the vascular spaces, and expanding the erectile tissues until they are fully engorged with blood. [ 7 ]  The ischiocavernosus and bulbocavernosus muscles contract, compressing the dorsal vein of the clitoris.  This compression of the vein restricts drainage of the erectile structures, trapping the blood. [ 8 ]  This process stretches the tunica albuginea.  As a result, the clitoris becomes  tumescent  to accommodate the increased intracavernosous pressure. The tunica albuginea of the clitoris is made up of one layer making it more elastic than the tunica albuginea of the penis, which is composed of two layers. [ 9 ]  Erick Janssen (2007) elaborates on this reporting that "the corpora cavernosa of the clitoris are essentially similar to that of the penis except that there is no subalbugineal layer interposed between the tunica albuginea and the erectile tissue.  In the penis, this [ 10 ]  tissue engorges with blood during sexual arousal and becomes compressed against the unyielding tunica, creating penile rigidity – a true erection.  The lack of this plexus in the clitoris indicates that while the organ can become tumescent or engorged, it cannot, like the penis, become stiffly erect. The clitoris thus does not become erect with sexual excitement, but engorged." [ 10 ]  In addition, the tunica albuginea around the glans is thinner than around the shaft in both the clitoris and penis. This gives the glans less firmness relative to the shaft. The extrusion of the glans clitoridis and thinning of the skin enhances  sensitivity  to physical contact. After a female has  orgasmed , the erection usually ends, but this may take time.


Priapism , while more common in males, is a condition that can also affect the clitoris. [ 3 ]  Symptoms include painful engorgement, swelling, and pain in the area around the clitoris. [ 11 ]


Among  capuchin monkeys , clitoral erection is possible and makes the clitoris more visible than in its relaxed state where it is hidden by a preputial fold. [ 12 ]


Clitoroplasty  is a type of  plastic surgery  involving the  clitoris . It encompasses several procedures, including clitoral reduction, clitoral reconstruction, and the creation of a neoclitoris in male-to-female  gender-affirming surgery . These surgeries aim to retain or restore sensation and function in the clitoris, often employing  nerve-sparing techniques .


Clitoral reconstruction  is surgery to restore the function and structure of the clitoris. Examples of clitoral reconstruction include its use to mitigate  congenital malformation  or repair damage caused by  female genital mutilation . [ 1 ] [ 2 ]


Clitoral reconstruction after female genital mutilation involves surgery to expose the remaining deep structures of the clitoris. As of 2023 [update] , there was little evidence for the therapeutic effectiveness of this procedure. [ 3 ]


Clitoral reduction  is the surgical reduction in size of the clitoris, used to treat  clitoromegaly . Unlike  clitoridectomy , the amputation of part of the clitoris, commonly considered a form of  female genital mutilation , modern clitoral reduction surgery aims to preserve sensation and function through the use of nerve-sparing  microsurgical  techniques. [ 4 ] [ 5 ] [ 6 ]


It should be distinguished from  clitoral hood reduction , an operation on the  clitoral hood  in which the clitoris itself is not damaged.


During  male-to-female gender-affirming surgery , a neoclitoris is made from the tissue of the  glans penis . [ 7 ]


In  female-to-male gender-affirming surgery ,  metoidioplasty  is an operation in which the clitoris is repositioned to create a  neophallus . [ 8 ]


In  gynaecology ,  Cusco's self-retaining bivalved speculum  is a kind of  speculums , used for  vaginal  and  cervical  examinations. It has a jaw that opens up like a duck bill.


The instrument was named after French surgeon  Édouard-Gabriel Cusco  (1819–1894). [ 1 ]


It comes in three models: side screw, centre screw, and special narrow virgin size. [ 2 ]  Cusco's speculum is usually 80 millimeters (3.1 in) long and 22 millimeters (0.87 in) broad. However, smaller and larger sizes are available. Cusco's speculum is used for introducing an  intrauterine contraceptive device , taking a  Pap smear ,  cauterization  of vaginal erosion, and  colposcopic  examination. [ 3 ]  It is preferred in  cryosurgery  because it protects the anterior and posterior vaginal wall. The advantage of Cusco's speculum is that it is self-retaining. Therefore, an assistant's help is not needed to keep the speculum in place. It also acts as the vaginal wall retractor. However, it reduces the space in the vaginal cavity and therefore is not a preferred instrument for  vaginal surgery . Because it covers most of the vaginal wall, small  lesions  on the vaginal wall may be masked by the blades of the device. [ 4 ]


A  cytobrush  is a plastic tool used to obtain cells from the  cervix  during the procedure of a  Pap smear . [ 1 ] [ 2 ]


This  gynaecology  article is a  stub . You can help Wikipedia by  expanding it .


The  development of the reproductive system  is the part of  embryonic growth  that results in the  sex organs  and contributes to  sexual differentiation . Due to its large overlap with  development of the urinary system , the two systems are typically described together as the  genitourinary system .


The reproductive organs develop from the  intermediate mesoderm  and are preceded by more primitive structures that are superseded before birth. These embryonic structures are the  mesonephric ducts  (also known as  Wolffian ducts ) and the  paramesonephric ducts , (also known as  Müllerian ducts ). The mesonephric duct gives rise to the male  seminal vesicles ,  epididymides  and  vasa deferentia . The paramesonephric duct gives rise to the female  fallopian tubes ,  uterus ,  cervix , and upper part of the  vagina . [ 1 ]


The mesonephric duct originates from a part of the  pronephric duct .


In the outer part of the  intermediate mesoderm , immediately under the  ectoderm , in the region from the fifth  cervical segment  to the third  thoracic segment , a series of short  evaginations  from each segment grows  dorsally  and extends  caudally , fusing successively from before backward to form the  pronephric duct . This continues to grow caudally until it opens into the ventral part of the  cloaca ; beyond the  pronephros  it is termed the mesonephric duct. Thus, the mesonephric duct remains after the atrophy of the pronephros duct.


In the male, the duct persists, and forms the tube of the  epididymis , the  vas deferens  and the  ejaculatory duct , while the  seminal vesicle  arises during the third month as a lateral diverticulum from its hinder end. A large part of the head end of the mesonephros atrophies and disappears; of the remainder the anterior tubules form the efferent ducts of the  testicle ; while the  posterior  tubules are represented by the  ductuli aberrantes , and by the  paradidymis , which is sometimes found in front of the  spermatic cord  above the head of the epididymis.


In the female, the mesonephric bodies and ducts atrophy. The nonfunctional remains of the  mesonephric tubules  are represented by the  epoophoron , and the  paroöphoron , two small collections of  rudimentary  blind tubules which are situated in the  mesosalpinx .


The lower part of the mesonephric duct disappears, while the upper part persists as the longitudinal duct of the  epoöphoron , called  Gartner's duct .


There are also developments of other tissues from the mesonephric duct that persist, e.g. the  development of the suspensory ligament of the ovary .


Shortly after the formation of the mesonephric ducts, a second pair of ducts is developed; these are the  paramesonephric ducts . Each arises on the lateral aspect of the corresponding mesonephric duct as a tubular invagination of the cells lining the abdominal cavity. The orifice of the invagination remains open, and undergoes enlargement and modification to form the  distal tubal opening  (abdominal ostium) of the  fallopian tube . The ducts pass backward lateral to the mesonephric ducts, but toward the posterior end of the embryo they cross to the medial side of these ducts, and thus come to lie side by side between and behind the latter—the four ducts forming what is termed the  common genital cord [ citation needed ] , to distinguish it from the  genital cords of the germinal epithelium [ citation needed ]  seen later in this article. The mesonephric ducts end in an epithelial elevation, the  sinus tubercle , on the ventral part of the cloaca between the orifices of the mesonephric ducts. At a later stage the sinus tubercle  opens in the middle, connecting the paramesonephric ducts with the cloaca.


In the male, the paramesonephric ducts atrophy (but traces of their anterior ends are represented by the  appendix of testis  of the male), while their terminal fused portions form the  prostatic utricle  in the floor of the  prostatic urethra . This is due to the production of  anti-Müllerian hormone  by the  Sertoli cells  of the  testes .


In the female, the paramesonephric ducts persist and undergo further development. The portions which lie in the  genital cord [ citation needed ]  fuse to form the  uterus   and  vagina . This fusion of the paramesonephric ducts begins in the third month, and the septum formed by their fused medial walls disappears from below upward.


The parts outside this cord remain separate, and each forms the corresponding  fallopian tube . The  ostium of the fallopian tube  remains from the anterior extremity of the original tubular invagination from the abdominal cavity.


About the fifth month a ring-like constriction marks the position of the  cervix  of the uterus, and after the sixth month the walls of the uterus begin to thicken. For a time the vagina is represented by a solid rod of epithelial cells. A ring-like outgrowth of this epithelium occurs at the lower end of the uterus and marks the future  vaginal fornix . At about the fifth or sixth month the  lumen  of the vagina is produced by the breaking down of the central cells of the epithelium. The  hymen  represents the remains of the sinus tubercle . [ 2 ]


The gonads are the precursors of the  testicles  in males and  ovaries  in females. They initially develop from the mesothelial layer of the peritoneum.


The ovary is differentiated into a central part, the medulla of ovary, covered by a surface layer, the  germinal epithelium . The  immature ova  originate from cells from the dorsal  endoderm  of the  yolk sac . Once they have reached the gonadal ridge they are called  oogonia . Development proceeds and the oogonia become fully surrounded by a layer of connective tissue cells (pre-granulosa cells). In this way, the rudiments of the ovarian follicles are formed. The embryological origin of  granulosa cells , on the other hand, remains controversial. Just as in the male, there is a  gubernaculum  in the female, which pulls it downward, albeit not as much as in males. The gubernaculum later becomes the proper  ovarian ligament  and the  round ligament of the uterus .


The periphery of the testicles are converted into the  tunica albuginea . Cords of the central mass run together and form a network which becomes the  rete testis , and another network, which develops the  seminiferous tubules . Via the rete testis, the seminiferous tubules become connected with outgrowths from the mesonephros, which form the efferent ducts of the testicle.


In short, the descent of the testicles consists of the opening of a connection from the testicle to its final location at the anterior abdominal wall, followed by the development of the gubernaculum, which subsequently pulls and translocates the testicle down into the developing scrotum. Ultimately, the passageway closes behind the testicle. A failure in this process can cause  indirect inguinal hernia  or an infantile hydrocoele.


After the separation of the rectum from the dorsal part of the cloaca, the ventral part becomes the primary  urogenital sinus . [ 3 ]  The urogenital sinus, in turn, divides into the superficial definitive urogenital sinus and the deeper anterior vesico-urethral portion.


The definitive urogenital sinus consists of a caudal cephalic portion and an intermediate narrow channel, the pelvic portion.


The vesico-urethral portion is the deepest portion, continuous with the allantois. It absorbs the ends of the mesonephric ducts and the associated ends of the renal diverticula, and these give rise to the  trigone of urinary bladder  and part of the  prostatic urethra . The remainder of the vesico-urethral portion forms the body of the bladder and part of the prostatic urethra; its apex is prolonged to the umbilicus as a narrow canal, the  urachus , which later is obliterated and becomes the  median umbilical ligament  of the adult.


The  prostate  originally consists of two separate portions, each of which arises as a series of diverticular buds from the epithelial lining of the urogenital sinus and vesico-urethral part of the cloaca, between the third and fourth months. These buds become tubular, and form the glandular substance of the two lobes, which ultimately meet and fuse behind the urethra and also extend on to its ventral aspect. The median  lobe of the prostate  is formed as an extension of the lateral lobes between the common ejaculatory ducts and the bladder.


Skene's glands  in the female urethra are regarded as the homologues of the prostatic glands.


The  bulbourethral glands  in the male, and  Bartholin's gland  in the female, also arise as diverticula from the epithelial lining of the urogenital sinus.


Until about the ninth week of gestational age, [ 4 ]  the external genitalia of human males and females look the same, and follow a common development. This includes the development of a genital tubercle and a membrane dorsally to it, covering the developing  urogenital opening , and the development of the  labioscrotal fold .


In  placental mammals , the urogenital folds become the ventral aspect of the penis in the male and the  labia minora  ( primates  including humans)/ labia vulvae  (non-primates) in the female. [ 5 ] [ 6 ] [ 7 ]


Even after differentiation can be seen between the sexes, some stages are common, e.g. the disappearing of the membrane. On the other hand, sex-dependent development include further protrusion of the genital tubercle in the male to form the  glans  and  shaft  of the penis and in the female, the  glans  and  body  of the clitoris. [ 8 ] [ 9 ]  The labioscrotal swellings evolve into the  scrotum  in males, and into the  labia majora   (dissipated in non-primates) in females. [ 8 ] [ 10 ]


There is initially a  cloacal membrane , composed of ectoderm and endoderm, reaching from the  umbilical cord  to the tail, separating the cloaca from the exterior. After the separation of the rectum from the dorsal part of the cloaca, the ventral part of the cloacal membrane becomes the  urogenital membrane .


Mesoderm extends to the  midventral line  for some distance behind the umbilical cord, and forms the lower part of the abdominal wall; it ends below in a prominent swelling, the cloacal tubercle, which after the separation of the rectum becomes the  genital tubercle . Dorsally, to this tubercle the sides are not really fused. Rather, the urogenital part of the cloacal membrane separates the ingrowing sheets of mesoderm.


The genital tubercle develops into the  primordial phallus , the first rudiment of the  penis  or  clitoris . [ 8 ]


The terminal part of the phallus, representing the future glans becomes solid. The remainder of the phallus, which remains hollow, is converted into a longitudinal groove by the absorption of the urogenital membrane.


The term genital tubercle still remains but only refers to the future glans  [ 4 ]


In both sexes, the phallic portion of the  urogenital sinus  extends on to the under surface of the cloacal tubercle as far forward as the apex. At the apex, the walls of the phallic portion come together and fuse, obliterating the  urogenital opening . Instead, a solid plate, the urethral plate, is formed. The remainder of the phallic portion is for a time tubular, and then, by the absorption of the urogenital membrane, it establishes a communication with the exterior. This opening is for a while the primitive urogenital opening, and it extends forward to the corona glandis.


The following developments occur in both males and females, although a difference in the development between the sexes already can be seen:


In the female, a deep groove forms around the phallus. The sides of it grow dorsalward as the  labioscrotal folds , which ultimately form the labia majora in females. The labia minora, in contrast, arise by the continued growth of the lips of the groove on the under surface of the phallus; the remainder of the phallus forms the  clitoral glans . [ 8 ]


The labioscrotal folds extend around between the pelvic portion and the anus, and form a  scrotal  area. During the changes associated with the descent of the testes, this scrotal area is drawn out to form the scrotal sacs. The penis is developed from the phallus.


As in the female, the urogenital membrane undergoes absorption, forming a channel on the under surface of the phallus; this channel extends only as far forward as the  corona glandis .


Later, this opening, which is located on the dorsal side of the penis, [ 11 ]  closes from behind forward. Meanwhile, the urethral plate of the glans breaks down centrally to form a median groove continuous with the primitive ostium. This groove also closes from behind forward, leaving only a small pipe running in the middle of the penis. Thus, the urogenital opening is shifted forward to the end of the glans.


A.—Diagram of the primitive urogenital organs in the embryo previous to sexual distinction.


B.—Diagram of the female type of sexual organs.


C.—Diagram of the male type of sexual organs.


Dilation  (or  dilatation )  and curettage  ( D&C ) refers to the  dilation  (widening or opening) of the  cervix  and surgical removal of sections and/or layers of the lining of the  uterus  and or contents of the uterus such as an unwanted fetus (early abortion before 13 weeks), remains of a non-viable fetus, retained placenta after birth or abortion  as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping ( curettage ). It is a  gynecologic  procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester  abortion  or  miscarriage . [ 1 ] [ 2 ] [ 3 ] [ 4 ]


D&C normally refers to a procedure involving a  curette , also called  sharp curettage . [ 2 ]  However, some sources use the term  D&C  to refer to any procedure that involves the processes of dilation and removal of uterine contents which includes the more common  suction curettage  procedures of manual and electric  vacuum aspiration . [ 5 ]


D&Cs may be performed in pregnant and non-pregnant patients, for different clinical indications. Such examples are for Early Abortion, Removing the remains of a non-viable pregnancy or retention of placenta from a pregnancy loss/abortion. Treatment of menopause induced anomalies with menstrual cycle.


A D&C may be performed early in pregnancy to remove pregnancy tissue, either in the case of a non-viable pregnancy, such as a  missed  or  incomplete miscarriage , or an  undesired pregnancy , as in a  surgical abortion . [ 6 ]  Medical management of miscarriage and medical abortion using drugs such as  misoprostol  and  mifepristone  are safe, non-invasive and potentially less expensive alternatives to D&C.


Because medication-based non-invasive methods of abortion now exist, dilation and curettage has been declining as a method of abortion, although suction curettage is still the most common and preferred method to ensure complete removal of remains as the method is a completed process used for termination of a First-Trimester Pregnancy. [ 7 ] [ 8 ]  The  World Health Organization  recommends D&C with a Sharp Curette as a method of surgical abortion ONLY when manual  vacuum aspiration  with a suction curette is unavailable. [ 9 ]


For patients who have recently given birth, a D&C may be indicated to remove retained placental tissue that does not pass spontaneously or for postpartum hemorrhage. [ 10 ]


D&Cs for non-pregnant patients are commonly performed in tandem with  Hysteroscopy another diagnostic procedure, for the diagnosis of gynecological conditions usually involving abnormal bleeding; during menopause or with various abnormal structures growing within the uterus [ 11 ]  to remove the excess uterine lining in women who have conditions such as  polycystic ovary syndrome ; [ 12 ]  to remove tissue in the uterus that may be causing abnormal uterine bleeding, such as endometrial  polyps  or  uterine fibroids ; [ 3 ] [ 2 ]  or to diagnose the cause of  post-menopausal bleeding , such as in the case of  endometrial cancer .


Hysteroscopy  is a valid alternative or addition to D&C for many surgical indications, from diagnosis of uterine pathology to the removal of fibroids and even retained tissue of Pregnancy . It allows direct visualization of the inside of the uterus and may allow targeted sampling and removal of tissue inside the uterus. [ 13 ]


Depending on the anticipated duration and difficulty expected with the procedure, as well as the clinical indication and patient preferences, a D&C may be performed with  local anesthesia ,  moderate sedation , deep sedation, or  general anesthesia . [ 14 ]  The first step in a D&C is to place a  speculum  in the vagina so as to see the cervix. Often, a  tenaculum  is placed to steady the cervix. Next, the provider will dilate the  cervix . This can be done with  Hegar  or similar dilators. [ 6 ]  The amount of dilation depends on the amount of tissue to be removed as well as the size of the instruments to be used. After sufficient dilation, a curette, a metal rod with a handle on one end and a loop on the other, is then inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. If a  suction curette  is used, as in a  vacuum aspiration , a plastic tubular curette will be introduced into the uterus and connected to suction to remove all tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or by  pathology  for abnormalities (in the case of treatment for  abnormal bleeding ). [ 2 ]


The most common complications associated with D&C are infection, bleeding, or damage to nearby organs, including through uterine perforation. [ 15 ]  Aside from the surgery itself, complications related to  anesthesia  administration may also occur.


Infection  is uncommon after D&C for a non-pregnant patient, and society practice guidelines do not recommend routine prophylactic antibiotics to patients. [ 16 ]  However, for curettage of a pregnant patient, the risk of infection is higher, and patients should receive antibiotics that cover the bacteria commonly found in the vagina and gastrointestinal tract;  doxycycline  is a common recommendation, though azithromycin may also be used. [ 16 ]


Another risk of D&C is  uterine perforation . The highest rate of uterine perforation appears to be in the setting of postpartum hemorrhage (5.1%) compared with a lower rate in diagnostic curettage in non-pregnant patients (0.3% in the premenopausal patient and 2.6% in the postmenopausal patient). [ 17 ]  Perforation may cause excessive bleeding or damage to organs outside the uterus. If the provider is concerned about ongoing bleeding or the possibility of injury to organs outside the uterus, a  laparoscopy  may be done to verify that there has been no undiagnosed injury.


Another potential risk is  Asherman's syndrome , a condition where intrauterine adhesions lead to  subfertility ,  amenorrhea , or  recurrent pregnancy loss . Although older studies [ 18 ] [ 19 ] [ 20 ]  described a high (25-30%) risk of developing this condition after dilation and curettage for treatment of miscarriage, these procedures were likely done using sharp curettage, which is no longer routinely performed in modern miscarriage and abortion care. Newer studies [ 21 ] [ 22 ]  reflect the common technique of suction curettage and demonstrate a much lower risk of Asherman's syndrome, with incidence in large prospective trials ranging from 0.7 to 1.6%. A history of multiple (>3) procedures [ 21 ]  and sharp curettage [ 22 ]  were identified as risk factors for developing clinical Asherman's syndrome. A systematic review in 2013 concluded that recurrent miscarriage treated with D&C is the main risk factors for intrauterine adhesions. [ 23 ]  There are currently no studies linking asymptomatic intrauterine adhesions and long-term reproductive outcomes, and similar pregnancy outcomes have been found after miscarriage regardless of whether surgical treatment, medication management, or conservative management (i.e.  watchful waiting ) was chosen. [ 23 ]


Donut pillow ,  donut cushion  or  doughnut cushion  is a designation for different types of pillows, all named after the shape of the pastry  donut . There are donut pillows as seat cushions, which serve a more favourable distribution of pressure on the abdomen, as well as donut pillows to place under other parts of the body when lying down.


Some shops with  interior decorations  offer decorative donut cushions with  polyesterfilling .


Seat rings (ring cushions) made of firm cold foam with cotton terrycloth covering, are available in stores for  medical supply . The recess in the middle serves to protect the  perineum , the  vaginal entrance , the  anus  and the  coccyx  from pressure due to the bodyweight.


Donut seat cushions facilitate pain-free or at least pain-reduced sitting for women after childbirth ( postpartum ), when an  episiotomy  or  perineal tear  has been sutured, and promote healing of the perineal suture. [ 1 ] [ 2 ]


For people suffering from  coccygeal pain ,  medical treatment   without   surgery  is the  gold standard . This includes reduced sitting, use of a donut cushion and  physiotherapy . [ 3 ]


In patients undergoing heart surgery lying in supine position for hours, a donut-shaped reduces injuries on the  sacrum . [ 4 ]  For patients lying supine on the operating room table, a nurse may place a flat donut pillow under their  pelvis  to provide pressure relief at the sacrum. [ 5 ]  Lying supine under  anaesthesia  also creates pressure points on the head, which can impair skin function and also affect the blood circulation to the face, possibly leading to facial skin damage. Special medical donut pillows reduce the creation of pressure points but can create  shear forces  on the skin, so pillow design aims to avoid both problems. [ 6 ]  Gel donut pillows are available for  infants  and  children  who are hospitalised to prevent harmful pressure on the  occiput  in the supine position. [ 7 ]


Pressure ulcers  may develop as a result of prolonged pressure on bony prominences. Their development begins in the subcutaneous tissue and often reaches the  dermis  and the outer skin after several days. Such tissue damage can be avoided by proper padding. Surgeries on the  spinal column  are performed in  prone positioning . In this case, gel donuts under the  kneecaps  are part of the positioning aids. [ 8 ]


In one study, 23 patients suffering from  chondrodermatitis  were given a special donut-shaped pillow to place underneath while sleeping so that the affected ear was no longer subjected to pressure. Thirteen of them continued to be pain-free after a one-year follow-up period. [ 9 ]


Elongated labia  (also known as  sinus pudoris  or  macronympha , [ 1 ]  and colloquially as  khoikhoi apron  or  hottentot apron ) is a feature of certain  Khoekhoe  and other African women [ citation needed ]  who develop, whether naturally or through artificial  stretching , relatively elongated  labia minora , which may hang up to 10 centimetres (4 in) outside the rest of the  vulva  when they are standing in an upright position.


The "apron" designation was apparently gained from the tendency of early European descriptions to misidentify the pair of labia as a single, wide organ, which they called, in French a  tablier , or "apron". [ 2 ]


The characteristics of this trait were known as early as the 1680s, the first European note on the subject being made by Anderson and Iverson, who visited the  Cape of Good Hope  in 1644, in relation to the  "Hottentots"  of that region, [ 3 ]  but became extensively documented in the late 18th and 19th century. [ 4 ] [ better source needed ]  The case of  Sarah Baartman  was significant. For many years, the identification of Baartman was questioned because she demonstrated this feature. Historically, elongated labia minora were said to be portrayed by a " Negro ". So it is because of this trait that Baartman was considered to be part of the so-called "inferior race". [ 5 ] [ clarification needed ]


When Captain  James Cook  reached  Cape Town  in 1771, towards the end of  his first voyage , he acknowledged being “very desirous to determine the great question among natural historians, whether the women of this country have or have not that fleshy flap or apron which has been called the  sinus pudoris ”; eventually a physician described treating patients with labia ranging from  1.3 to 7.6 or 10.2 centimetres ( 1 ⁄ 2  to 3 or 4 in) long. [ 6 ]


In  East Africa ,  Monica Wilson  recorded the custom through her fieldwork with the  Nyakyusa people  in the 1930s, and in Southern Africa  Isaac Schapera  worked with the  Nama people , the largest group amongst the  Khoikhoi , also discussed labia stretching in  The Khoisan Peoples of South Africa  (1930). [ 7 ]  According to Schapera, some females were observed to exhibit elongated labia minora which sometimes projected as much as 10 cm below the vulva when standing. [ 8 ]  There was debate among these early anthropologists as to whether and in what circumstances such instances of elongated labia should be considered a physiological feature or the result of artificial manipulation. [ 8 ]


Labia may be shaped by intentional  labia stretching , a familial practice usually performed by an older aunt on girls beginning at the age of five. This practice formerly fell into the category of Type IV  female genital mutilation , [ 9 ] [ 10 ] [ better source needed ]  but in 2008 the  World Health Organization  reclassified the practice as a body modification procedure due to a perceived lack of harm and a reported positive perception of women's sexuality by those who practice it. [ 11 ]


The  Dr. Ephraim McDowell House , also known as  McDowell House , was a home of medical doctor  Ephraim McDowell .


The home was declared a U.S.  National Historic Landmark  in 1966 for its role as the site of the world's first  ovariotomy , performed without anesthesia by Dr. McDowell in 1809. [ 2 ]


Ephraim McDowell (November 11, 1771 – June 25, 1830) was an American physician.


He was born in  Rockbridge County, Virginia  and moved with his family to  Danville, Kentucky  in 1784. He studied under Dr. Humphrey in  Staunton, Virginia , then attended lectures in medicine at the  University of Edinburgh , Scotland, from 1793 to 1794 and studied privately with  John Bell .  In 1795. he returned from Scotland, settled in Danville, Kentucky and began his practice as a surgeon. [ 3 ]


Dr. McDowell played a prominent role in his community.  He was a founder of  Trinity Episcopal Church  in Danville and a founder and original corporator of  Centre College  in Danville.  Dr. McDowell became a member of the  Philadelphia Medical Society  in 1817. [ 3 ]


He removed a  urinary stone  and repaired a  hernia  for  James K. Polk . [ 4 ]


On December 13, 1809, Dr. McDowell diagnosed an  ovarian tumor  in Jane Todd Crawford of  Green County, Kentucky ,  In his house on Christmas morning, 1809, Dr. McDowell removed a 22.5-pound (10.2 kg) tumor without anesthetic or antisepsis. Mrs. Crawford made an uncomplicated recovery, returning to her home 25 days later and living another 32 years. This was the first successful removal of an ovarian tumor in the world. [ 5 ]


The house was built in three stages. A brick ell was constructed 1792–1795. Dr. McDowell purchased it in late 1802. He added the front, clapboard portion in 1803–1804 and the small brick office to the left of the back porch in 1820. The house was remodeled at the same time.


After McDowell's death in 1830 the house was sold. It was the home of a  Centre College  president for a short time. Later the entire area became slum and tenement property. The house deteriorated badly. Dr. August Schachner, of Louisville, led the efforts to buy the house for restoration. In 1921 he visited the house. "Since our last visit, the house has continued its downward course until it has reached a point where it now seems almost beyond redemption. The room that served as the original office of Dr. McDowell is now used as a shoe-shining booth for Negroes. The room in the rear of the corresponding front room on the second floor,"(the operating room) "which is on a lower level by several feet, is used as a dump for the ashes from the grates of the rooms on the second floor."


The  Kentucky Medical Association  bought the house in 1935 and deeded it to the state of Kentucky, who had it restored by  Works Progress Administration  (WPA). It was dedicated on May 20, 1939. In 1948, Kentucky returned the property to the Kentucky Medical Association.


The  Kentucky Pharmaceutical Society  restored the Apothecary Shop in the late 1950s with help from the  Eli Lily Foundation . It was furnished by the  Pfizer  Laboratories. It was dedicated and presented to the Kentucky Medical Association on August 14, 1959. [ 6 ]


Female ejaculation  is characterized as an expulsion of fluid from the  Skene's gland  at the lower end of the  urethra  during or before an  orgasm . It is also known colloquially as  squirting  or  gushing , although research indicates that female ejaculation and squirting are different phenomena,  squirting being attributed to a sudden expulsion of liquid that partly comes from the bladder and contains  urine . [ 1 ] [ 2 ] [ 3 ]


Female ejaculation is physiologically distinct from  coital incontinence , with which it is sometimes confused. [ 4 ] [ 5 ]


There have been few studies on female ejaculation. [ 6 ]  A failure to adopt common definitions and research  methodology  by the scientific community has been the primary contributor to this lack of experimental data. [ 7 ]  Research has suffered from highly selected participants, narrow case studies, or very small sample sizes, and consequently has yet to produce significant results. Much of the research into the composition of the fluid focuses on determining whether it is, or contains, urine. [ 6 ] [ 8 ]  It is common for any secretion that exits the vagina, and for fluid that exits the urethra, during sexual activity to be referred to as  female ejaculate , which has led to significant confusion in the literature. [ 8 ]


Whether the fluid is secreted by the Skene's gland through and around the urethra has also been a topic of discussion; while the exact source and nature of the fluid remains controversial among medical professionals, and are related to doubts over the existence of the  G-spot , [ 9 ] [ 10 ] [ 8 ]  there is substantial evidence that the Skene's gland is the source of female ejaculation. [ 1 ] [ 8 ]  The function of female ejaculation, however, remains unclear. [ 8 ]


In questionnaire surveys, 35–50% of women report that they have at some time experienced the gushing of fluid during orgasm. [ 11 ] [ 12 ] [ 13 ]  Other studies find anywhere from 10 to 69%, depending on the definitions and methods used. [ 14 ] [ 15 ]  For instance Kratochvíl (1994) surveyed 200 women and found that 6% reported ejaculating, an additional 13% had some experience and about 60% reported release of fluid without actual gushing. [ 16 ]  Reports on the volume of fluid expelled vary considerably, starting from amounts that would be imperceptible to a woman, to mean values of 1–5 ml. [ 17 ]


The suggestion that women can expel fluid from their genital area as part of  sexual arousal  has been described by women's health writer Rebecca Chalker as "one of the most hotly debated questions in modern  sexology ". [ 18 ]  Female ejaculation has been discussed in anatomical, medical, and biological literature throughout recorded history. The reasons for the interest in female ejaculation have been questioned by  feminist  writers. [ 19 ]


In the 16th century, the Dutch physician  Laevinius Lemnius , referred to how a woman "draws forth the man's seed and casts her own with it". [ 20 ]  In the 17th century,  François Mauriceau  described glands at the  female urethral meatus  that "pour out great quantities of saline liquor during coition, which increases the heat and enjoyment of women". [ 21 ]  This century saw an increasing understanding of female sexual anatomy and function, [ 22 ]  in particular the work of the  Bartholin  family in Denmark.


In the 17th century, the Dutch anatomist  Reinier de Graaf  wrote an influential treatise on the reproductive organs  Concerning the Generative Organs of Women  which is much cited in the literature on this topic. De Graaf discussed the original controversy but supported the  Aristotelian  view. [ 23 ] [ 24 ] [ 25 ]  He identified the source as the glandular structures and ducts surrounding the urethra.


[VI:66-7]The urethra is lined by a thin membrane. In the lower part, near the outlet of the urinary passage, this membrane is pierced by large ducts, or lacunae, through which pituito-serous matter occasionally discharges in considerable quantities.


Between this very thin membrane and the fleshy fibres we have just described there is, along the whole duct of the urethra, a whitish membranous substance about one finger-breadth thick which completely surrounds the urethral canal... The substance could be called quite aptly the female 'prostatae' or 'corpus glandulosum', 'glandulous body' ... The function of the 'prostatae' is to generate a pituito-serous juice which makes women more libidinous with its pungency and saltiness and lubricates their sexual parts in agreeable fashion during coitus.


[VII:81] The discharge from the female 'prostatae' causes as much pleasure as does that from the male 'prostatae'


He identified [XIII:212] the various controversies regarding the ejaculate and its origin, but stated he believed that this fluid "which rushes out with such impetus during venereal combat or libidinous imagining" was derived from a number of sources, including the vagina, urinary tract, cervix and uterus. He appears to identify  Skene's ducts , when he writes [XIII: 213] "those [ducts] which are visible around the orifice of the neck of the vagina and the outlet of the urinary passage receive their fluid from the female 'parastatae', or rather the thick membranous body around the urinary passage." However he appears not to distinguish between the lubrication of the perineum during arousal and an orgasmic ejaculate when he refers to liquid "which in libidinous women often rushes out at the mere sight of a handsome man." Further on [XIII:214] he refers to "liquid as usually comes from the  pudenda  in one gush." However, his prime purpose was to distinguish between generative fluid and pleasurable fluid, in his stand on the Aristotelian semen controversy.


Krafft-Ebing 's study of sexual perversion,  Psychopathia Sexualis  (1886), describes female ejaculation under the heading "Congenital Sexual Inversion in Women" as a perversion related to  neurasthenia  and homosexuality. [ 26 ]


the intersexual gratification among ...women seems to be reduced to kissing and embraces, which seems to satisfy those of weak sexual instinct, but produces in sexually neurasthenic females ejaculation


It is also described by  Freud  in pathological terms in his study of  Dora  (1905), where he relates it to hysteria. [ 27 ]


The pride taken by women in the appearance of their genitals is quite a special feature of their vanity; and disorders of genitals which they think calculated to inspire feelings of repugnance or even disgust have an incredible power of humiliating them, of lowering their self-esteem, and of making them irritable, sensitive, and distrustful. An abnormal secretion of the mucous membrane of the vagina is looked upon as source of disgust.


However, women's writing of that time portrayed this in more positive terms. Thus we find  Almeda Sperry  writing to  Emma Goldman  in 1918, about the "rhythmic spurt of your love juices". [ 19 ] [ 28 ]  Anatomical knowledge was also advanced by  Alexander Skene 's description of para-urethral or periurethral glands (glands around the  urethra ) in 1880, which have been variously claimed to be one source of the fluids in the ejaculate, and now commonly referred to as the  Skene's glands . [ 29 ]


Female ejaculation is mentioned as normal in early 20th century 'marriage manuals', such as TH  Van de Velde 's  Ideal Marriage: Its Physiology and Technique  (1926). Certainly van de Velde was well aware of the varied experiences of women. [ 30 ]


It appears that the majority of laymen believe that something is forcibly squirted (or propelled or extruded), or expelled from the woman's body in orgasm, and should so happen normally, as in the man's case. Finally it is just as certain that such an 'ejaculation' does not take place in many women of sexually normal functions, as that it does take place in others.


In 1948, Huffman, an American gynaecologist, published his studies of the prostatic tissue in women together with a historical account and detailed drawings. These clearly showed the difference between the original glands identified by Skene at the urinary meatus, and the more  proximal  collections of glandular tissue emptying directly into the urethra. [ 31 ]


The urethra might well be compared to a tree about which and growing outward from its base are numerous stunted branches, the paraurethral ducts and glands.


Most of the interest had focused on the substance and structure rather than function of the glands. A more definitive contemporary account of ejaculation appeared shortly after, in 1950, with the publication of an essay by  Gräfenberg  based on his observations of women during orgasm. [ 32 ]


An erotic zone always could be demonstrated on the anterior wall of the vagina along the course of the urethra...analogous to the male urethra, the female urethra also seems to be surrounded by erectile tissues...In the course of  sexual stimulation , the female urethra begins to enlarge and can be felt easily. It swells out greatly at the end of orgasm...Occasionally the production of fluids is ...profuse...
If there is the opportunity to observe the orgasm of such women, one can see that large quantities of a clear transparent fluid are expelled not from the vulva, but out of the urethra in gushes. At first I thought that the bladder sphincter had become defective by the intensity of the orgasm. Involuntary expulsion of urine is reported in sex literature. In the cases observed by us, the fluid was examined and it had no urinary character. I am inclined to believe that "urine" reported to be expelled during female orgasm is not urine, but only secretions of the intraurethral glands correlated with the erotogenic zone along the urethra in the anterior vaginal wall. Moreover the profuse secretions coming out with the orgasm have no lubricating significance, otherwise they would be produced at the beginning of intercourse and not at the peak of orgasm.


However this paper made little impact, and was dismissed in the major sexological writings of that time, such as  Kinsey  (1953) [ 33 ]  and  Masters and Johnson  (1966), [ 34 ]  equating this "erroneous belief" with  urinary stress incontinence . Although clearly Kinsey was familiar with the phenomenon, commenting that (p. 612);


Muscular contractions of the vagina following orgasm may squeeze out some of the genital secretions, and in a few cases eject them with some force


as were Masters and Johnson ten years later, who observed (pp 79–80):


Most women do not ejaculate during orgasm...we  have  observed several cases of women who expelled a type of fluid that was not urine


(emphasis in original) yet dismissed it (p. 135) – "female ejaculation is an erroneous but widespread concept", and even twenty years later in 1982, [ 35 ]  they repeated the statement that it was erroneous (p. 69–70) and the result of "urinary stress incontinence".


The topic did not receive serious attention again until a review by Josephine Lowndes Sevely and JW Bennett appeared in 1978. [ 36 ]  This latter paper, which traces the history of the controversies to that point, and a series of three papers in 1981 by  Beverly Whipple  and colleagues in the  Journal of Sex Research , [ 37 ] [ 38 ] [ 39 ]  became the focal point of the current debate. Whipple became aware of the phenomenon when studying urinary incontinence, with which it is often confused. [ 40 ]  As Sevely and Bennett point out, this is "not new knowledge, but a rediscovery of lost awareness that should contribute towards reshaping our view of female sexuality". Nevertheless, the theory advanced by these authors was immediately dismissed by many other authors, such as physiologist Joseph Bohlen, [ 41 ]  for not being based on rigorous scientific procedures, and psychiatrist  Helen Singer Kaplan  (1983) stated: [ 42 ]


Female ejaculation (as distinct from female urination during orgasm) has never been scientifically substantiated and is highly questionable, to say the least.


Some radical feminist writers, such as  Sheila Jeffreys  (1985) were also dismissive, claiming it as a figment of male fantasy: [ 43 ]


There are examples in the sexological literature of men's sexual fantasies about lesbian sexuality. Krafft-Ebing invented a form of ejaculation for women.


It required the detailed anatomical work of Helen O'Connell [ 44 ]  from 1998 onwards to more properly elucidate the relationships between the different anatomical structures involved. As she observes, the female perineal urethra is embedded in the anterior vaginal wall and is surrounded by erectile tissue in all directions except posteriorly where it relates to the vaginal wall. "The distal vagina,  clitoris , and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit". [ 45 ] [ 46 ] [ 47 ]


Female ejaculation appears in 20th-century  anthropological  works, such as  Malinowski 's Melanesian study,  The Sexual Life of Savages  (1929), and Gladwin and Sarason's "Truk: Man in Paradise" (1956). Malinowski states that in the language of the  Trobriand Island  people, a single word is used to describe ejaculation in both male and female. [ 48 ]


Both the male and female discharge are called by the same name ( momona  or  momola ), and they ascribe to both the same origin in the kidneys, and the same function, which has nothing to do with generation, but is concerned with lubricating the membrane and increasing pleasure


In describing sexual relations amongst the  Chuukese   Micronesians , Gladwin and Sarason state that "Female orgasm is commonly signalled by urination". [ 49 ]   Catherine Blackledge  [ pl ] [ 22 ]  (p. 205) provides a number of examples from other cultures, including the  Ugandan   Batoro ,  Mohave  Indians,  Mangaians , and  Ponapese . (See also Chalker 2002 pp. 531–2, Ladas et al. 1983 pp. 74–5)


Historically in Rwanda, the  kunyaza  sexual technique has the reputation of triggering female ejaculation (kunyara). The ancient sexual practice has been exercised for over 150 years in east and central Africa. Amongst the Buganda tribe of Uganda, the sexual practice is called kachabali (spraying the wall). [ 50 ]


There have been few studies on female ejaculation. [ 6 ]  Much of the problem in arriving at a consensus relates to a failure to adopt generally agreed-on definitions [ 7 ] [ 51 ]  or research methodology. [ 7 ]  Research has used highly selected individuals, case studies, or very small numbers of subjects, making generalization difficult. For instance, much of the research into the nature of the fluid focuses on determining whether it is or contains urine. [ 6 ] [ 7 ]  Rodriguez et al. stated that "many individuals refer to any fluid expressed from the vagina or urethra during coitus as female ejaculate, which leads to significant confusion in the literature." [ 8 ]


There are also problems involved in the collection of specimens and issues of contamination. Since the area of interest is the para-urethral glands, it is impossible to completely separate the secretions from urine, especially considering that there may be  retrograde ejaculation  into the urethra towards the bladder. Research has attempted to use chemicals that are excreted in the urine so that any urinary contamination can be detected. Further methodological issues include the fact that the composition of the fluid appears to vary with the menstrual cycle, [ 52 ]  and that the biochemical profile of the para-urethral tissues varies with age. [ 53 ]  Other issues relate to the sensitivity and specificity of the markers chosen. The key questions are the source of the fluid produced, and its composition. [ 41 ]


Whether the fluid is secreted by the Skene's gland through and around the urethra has also been a topic of discussion; while the exact source and nature of the fluid remain controversial among medical professionals, and are related to doubts over the existence of the  G-spot , [ 9 ] [ 10 ] [ 8 ]  there is substantial evidence that the Skene's gland is the source of female ejaculation. [ 1 ] [ 8 ]  The function of female ejaculation, however, remains unclear. [ 8 ]


Some research has distinguished between female ejaculation and what is colloquially known as squirting or gushing. These terms are used by the public interchangeably, which often leads to confusion. In these research publications, it is suggested that "real" female ejaculation is the release of a very scanty, thick, and whitish fluid from the Skene's gland, while the "squirting" or "gushing" (shown frequently in pornography) is a different phenomenon: the expulsion of clear and abundant fluid, which has been shown to be a diluted fluid from the urinary bladder. [ 1 ] [ 2 ]


Towards the later part of the 20th century, there was significant confusion between female ejaculation and  coital incontinence . In 1982, Bohlen explained the accepted wisdom: [ 41 ]


The previously accepted notion that all fluid expelled during a woman's orgasm is urine is now being challenged... sexologists must take care not to assume now that any fluid produced at orgasm is "female ejaculate".


Scientific studies from the 1980s and later have demonstrated that the substance produced is distinct from urine, though it does show similarities such as alkalinity with urine. [ 16 ]  Davidson's study of 1,289 women found that the sensation of ejaculation was very similar to that of urination. [ 12 ]  One study by  Gary Schubach  used  urethral catheterization  in order to separate urine from orgasmic expulsions from elsewhere in the body. Seven women claiming to have ejaculations expelled large volumes of urine through the catheter at orgasm, and little to no other fluid. [ 54 ]


It may be important for physicians to establish whether there is in fact any incontinence in women who report ejaculation, to avoid unnecessary interventions. [ 4 ] [ 5 ]  It is also important for physicians to distinguish orgasmic ejaculation from vaginal discharges which may require further investigation and treatment. In individual cases, the exact source of any reported discharge may not be obvious without further investigation. [ 55 ]


Critics have maintained that ejaculation is either  stress incontinence  or  vaginal lubrication . [ 8 ]  Research in this area has concentrated almost exclusively on attempts to prove that the ejaculate is not urine, [ 56 ] [ 57 ]  measuring substances such as  urea ,  creatinine ,  prostatic acid phosphatase  (PAP),  prostate-specific antigen  (PSA), [ 15 ]   glucose  and  fructose [ 58 ]  levels. Early work was contradictory; the initial study on one woman by Addiego and colleagues, reported in 1981, [ 38 ]  could not be confirmed in a subsequent study on 11 women in 1983, [ 59 ]  but was confirmed in another 7 women in 1984. [ 60 ]  In 1985, a different group studied 27 women and found only urine, [ 61 ]  suggesting that results depend critically on the methods used. [ citation needed ]


A 2007 study on two women involved  ultrasound ,  endoscopy , and biochemical analysis of fluid. The ejaculate was compared to pre-orgasmic urine from the same woman, and also to published data on  male ejaculate . In both women, higher levels of PSA, PAP, and glucose but lower levels of  creatinine  were found in the ejaculate than the urine. PSA levels were comparable to those in males. [ 14 ]


Ultrasounds from a 2014 study, involving seven women who reported recurring massive fluid emission during sexual arousal, confirmed thorough bladder emptiness before stimulation, noticeable bladder filling before squirting and demonstrated that the bladder had again been emptied after squirting. Although small amounts of prostatic secretions are present in the emitted fluid, the study suggests that squirting is essentially the involuntary emission of urine during sexual activity. [ 2 ]


One very practical objection relates to the reported volumes ejaculated, since this fluid must be stored somewhere in the pelvis, of which the  urinary bladder  is the largest source. The actual volume of the para-urethral tissue is quite small. By comparison, male ejaculate varies from 0.2–6.6 ml (0.01–0.22 US fl oz) (95%  confidence interval ), with a maximum of 13 ml (0.44 US fl oz). [ 62 ]  Therefore, claims of larger amounts of ejaculate are likely to contain at least some amount of urine. The eleven specimens analyzed by Goldberg in 1983, [ 59 ]  ranged from 3–15 ml (0.1–0.5 US fl oz). [ 60 ]  One source states that Skene's glands are capable of excreting 30–50 ml (1–2 US fl oz) in 30–50 seconds, [ 63 ]  but it is unclear how this was measured and has not been confirmed. One approach is to use a chemical like  methylene blue  so that any urinary component can be detected. [ 60 ]  Belzer showed that in one woman he studied, the dye was found in her urine, but not her orgasmic expulsion. [ 37 ]


PAP and PSA have been identified in the para-urethral tissues, using biochemical and immunohistochemical methods, suggesting that the ejaculate is likely to arise from the ducts in these tissues, in a manner homologous to that in the male. [ 64 ] [ 65 ] [ 66 ] [ 67 ] [ 68 ]  Another marker common to the prostate/para-urethral tissue in both sexes is  human protein 1 . [ 69 ]


PSA occurs in urine, and is elevated in post-orgasmic samples compared to pre-orgasmic. Simultaneous collection of ejaculate also showed PSA in both urine and ejaculate in all cases, but in higher concentration in the ejaculate than in the urine. [ 70 ]  Wimpissinger et al., 2007 reports the PSA level in urine in the 0.16–0.8 ng/mL range, and in female ejaculate in the 105.9–213.49 ng/mL range (two participants), more than a hundredfold difference. [ 8 ]


Sexual functions, and orgasm in particular, remain poorly understood scientifically. [ 71 ] [ 72 ] [ 73 ]  Regardless of the facts relating to the details of female ejaculation, the social significance of the popular accounts through the feminist health care movement has been considerable. [ 18 ]


The debate in the current literature focuses on three threads: the existence of female ejaculation, its source(s) and composition, and its relationship to theories of female sexuality. [ 19 ]  This debate has been influenced by popular culture, pornography, and physio-chemical and behavioral studies. There is some resistance from feminists to what has been perceived as a male lens in interpreting the data and construct. [ according to whom? ]  Often the debate is also tied to the existence of the G-spot; [ 56 ] [ 74 ]
stimulation of the anterior vaginal wall simultaneously stimulates the para-urethral tissue (the site of the  Skene's glands  and ducts, and a proposed likely source of ejaculation fluid), and so has been suggested as the trigger of ejaculation. These tissues, surrounding the distal urethra, and anterior to the vagina, have a common embryological origin to the prostatic tissue in the male. [ 75 ] [ 76 ]


In an extensive survey, Darling and colleagues claim support for the existence of ejaculation, [ 13 ]  while in a sharply critical response, Alzate [ 61 ] [ 77 ]  states that direct experimentation fails to provide any evidence. [ 78 ]  Alzate states:


the ignorance and/or confusion still prevalent among women about the anatomy and physiology of their sexual organs may make them mistake either vaginal lubrication or stress urinary incontinence for an "ejaculation."


Shannon Bell  argues that the debate is confused by the discussion of two separate phenomena. [ specify ]  She comments that Alzate simply dismisses women's subjective experiences in favour of rigorous scientific proof, and is typical of male sexologists withholding the validity of experience from women. Bell's critique lies at the heart of feminist concerns about this debate, namely a tendency to "disregard, reinterpret, and overwrite women's subjective descriptions." For some, she states, it is more a matter of belief than of physiology. Bell further questions why feminists have not been more outspoken in defense of women's control over female ejaculation, pointing out that the literature frames the discussion in only five separate ways; procreation, sexual pleasure, deviance, pathology, and a scientific mystery. [ 19 ]


The discussion entered popular culture in 1982 with the publication of the best-selling book  The G Spot and Other Recent Discoveries About Human Sexuality ,  by Ladas, Whipple, and Perry. [ 79 ]  The book discussed female ejaculation and brought the issue back into discussions of women's sexuality both in the medical community and among the general public. [ 18 ] [ 70 ] [ 80 ]  This was a popular account of three papers by the authors, the previous year, at the suggestion of Alice Khan Ladas. [ 37 ] [ 38 ] [ 39 ]  Rebecca Chalker notes that this book was largely met with scorn, skepticism and disbelief. [ 18 ]  The chapter on 'Female Ejaculation' is largely based on anecdotal testimony, and illustrates another issue in the debate, the weight placed on anecdotes and small numbers of observations rather than biomedical investigation or clinical trials. Importantly, a number of the women stated that they had been diagnosed with urinary incontinence.


The book by Ladas, Whipple, and Perry. [ 79 ]  advances another feminist theory: that because women's pleasure in their sexuality has been historically excluded, the pleasure of ejaculation has been either discounted or appropriated by health professionals as a physiological phenomenon. [ 81 ]  Whipple continued to publicise her discoveries, including a 9 min video made in 1981  Orgasmic Expulsions of Fluid in the Sexually Stimulated Female . [ 82 ]  In 1984, the  Journal of Sex Research  described the debate surrounding female ejaculation as 'heated'. [ 63 ]
Josephine Sevely then followed up her 1978 study by publishing "Eve's Secrets: A new theory of female sexuality" in 1987, emphasising an integrated rather than fragmented approach to understanding  female sexuality , with the clitoris, vagina and urethra depicted as a single sexual organ. [ 83 ] [ 71 ]  This not only challenged the traditional fragmentation of female sexuality into clitoral vs. vaginal sensation, but also sexualised the urethra. [ 19 ]


The continuing debate is further illustrated in the angry exchange of letters between the author and researchers in the  American Journal of Obstetrics and Gynaecology  in 2002 following the publication of 'The G-spot: A modern gynecological myth' by Terence Hines, [ 80 ]  articles and book chapters continue to appear with subtitles such as "Fact or Fantasy" (2002). [ 18 ]  As of 2007, [ 14 ] [ 84 ]  and 2008 [ 71 ]  the existence of a female prostate and of ejaculation are a matter of debate.


The terminology (such as female prostate and female ejaculation) invoke images of the female as merely an imitation of the male, mapping the female body onto the male, as if, like the  Galenic  view, it was incomplete. [ 85 ]  Furthermore, overemphasis of ejaculation may induce performance anxiety. [ 18 ]  For the reason that 'sameness' has been construed as a male perspective, some feminists reject the term ejaculation. Others argue it should be retained as a distinctive feminine characteristic distinguishable from the male, and imbued with different properties and purpose. A third concern is that of the increasing 'medicalisation' of women's sexuality, as expressed by Leonore Tiefer which finds its most extreme manifestation in the concept of  female sexual dysfunction . [ 86 ]
Tiefer has expressed concern that overemphasising ejaculation will drive women who might feel inadequate to seek medical attention (see Health implications below), [ 18 ]  as has the  Boston Women's Health Collective . [ 87 ]  Other criticism comes from  Barbara Ehrenreich [ 88 ]  and colleagues who see this new sexuality as one that privileges the male in control, penile retention and body position, but this is denied by others. [ 19 ]


Many women, before learning about ejaculation, experienced shame or avoided sexual intimacy under the belief that they had wet the bed. [ 63 ]  Others suppressed sexual climax, and sought medical advice for this "problem", and even underwent surgery. [ 18 ]


Contemporary  women's health  literature summarises what is considered factual as being that the amount of fluid varies greatly and may be unnoticeable, occurs with or without  vaginal stimulation , and may accompany orgasm or merely intense sexual pleasure, and orgasm may occur without ejaculation. Whether it can be learned or not, women report that they can induce it by enhancing their sexual response. [ 18 ]  Regardless, countless workshops now exist to teach women that learning how to ejaculate is an important form of feminine sexual expression. Sundahl describes it as a birthright and essential part of female creativity. [ 74 ]


The presence of chemical markers such as  PSA  or  PAP  in the female genital tract has been considered evidence in rape trials, [ 89 ]  but Sensabaugh and Kahane demonstrated in four specimens that PAP was an order of magnitude greater in a woman's ejaculate than in her urine. Recently, knowledge that these markers can be of female origin has led to acquittal based on forensic evidence. [ 76 ] [ 90 ]


Female pornographic performers who are alleged to ejaculate on film include  Hotaru Akane , [ 91 ]  Charley Chase, [ 92 ]  Annie Cruz, [ 93 ]   Cytherea , [ 94 ]  Jamie Lynn, [ 95 ]   Jiz Lee , [ 96 ]  Missy Monroe, [ 97 ]   Jenna Presley , [ 98 ]  and Flower Tucci. [ 99 ]  Fallon is known as the first pornographic actress to allegedly ejaculate on film. [ 100 ] [ 101 ] [ 102 ]  Tiana Lynn can allegedly ejaculate as well, and she claims to have discovered her ability during a scene with Mark Ashley. [ 103 ]


Sarah Jane Hamilton became known as one of the first alleged female ejaculators from Britain, [ 104 ]  though this was later dismissed by porn reviewer Pat Riley as urination in his review of  The British Are Coming  (1993). However, she has commented that she could not ejaculate on cue even though producers expect her to, like a male performer. [ 105 ]


In the  United Kingdom , the  British Board of Film Classification  has requested edits to pornographic films alleged to show female ejaculation, claiming there is no such thing as female ejaculation (and therefore the films must promote  urolagnia ), according to expert medical "advice" provided to the film board. [ 106 ] [ 107 ]  Urination during sex is considered obscene under the  Obscene Publications Acts . [ 108 ]  The Board later stated that it does not take any view on whether female ejaculation exists or not, but that all apparent recorded instances (presented to the Board) were of mere female urination being touted as female ejaculation. [ 109 ]


Easy on the Eye Productions released a press announcement on 6 October 2010, stating that the BBFC passed the DVD  Women Love Porn  (containing a sequence involving female ejaculation in the scene "Top Milf") on advice of legal counsel when the director,  Anna Span , pushed for a hearing with the Video Appeals Committee. Easy on the Eye Productions considered this an "historic victory", [ 110 ]  although the BBFC maintains that its stance remains "fundamentally unchanged" for future releases. According to the  Carnal Nation  site, the issue was first raised by the group  Feminists Against Censorship  (FAC) in 2001. [ 108 ]


In  Australia , a similar view has been taken with regard to Internet censorship proposals, which ban  pornographic websites  featuring female ejaculation. [ 111 ]


Femalia  is a book of 32 full-color photographs of human  vulvas , edited by  Joani Blank  and first published by  Down There Press  in 1993. [ 1 ]  A  reprint   edition  was published by  Last Gasp  in 2011. [ 2 ]  The photographs were taken by  Tee Corinne , Michael Perry,  Jill Posener , and Michael A. Rosen. The photographs are presented without commentary, except for Blank's brief introduction to the volume as a whole. [ 3 ] : 431   Blank wanted to present accurate images of the subject, in contrast to  pornographic  or  medical ones .


The word used as the book's title,  femalia , was taken from the novel  Vox  by  Nicholson Baker . [ 1 ] [ 4 ] : 143   The photographs by Corinne and Perry had been taken years before the book's original publication in 1993; those by Posener and Rosen were taken specifically for inclusion in the first edition of  Femalia . [ 1 ]


Femalia  grew out of Blank's long-term work as a feminist sex educator. She felt that medical and pornographic images of the female genitals were inadequate to her purposes. [ 3 ] : 430   In her introduction to the first edition, Blank lamented the absence of readily available photographic representations of the vulva other than heavily edited images in male-oriented pornography, and the resulting feeling on the part of a majority of women that "in one way or another, their genitals are not quite 'normal ' ". [ 1 ] [ 3 ] : 430


Feminist authors have sharply contrasted the portrayals of vulvas in  Femalia  with those in typical male-oriented  pornography  and in biomedical sources. [ 5 ]   Femalia 's  portrayals are characterized as accurate, honest, open, and truthful, as exhibiting "stark reality"; [ 5 ] : 86–87,362  [ 6 ] [ 7 ]  as promoting a positive view of the vulva; [ 8 ]  as emphasizing the diversity of the vulva in different women, [ 5 ] : 166,202,360,379  [ 6 ] [ 7 ] [ 9 ] : 181  [ 10 ] : 36  [ 11 ] : 264   as well as the diversity of opinions and perspectives about the vulva on the part of both men and women; [ 8 ] : 13   and as emphasizing female autonomy. [ 5 ] : 222  [ 10 ] : 36  [ 12 ] : 25   By contrast, portrayals of the vulva in pornography and in biomedical science are characterized as stylized and uniform, excluding women whose genitalia do not match their models. [ 5 ] : 86–87,360  [ 6 ]  Pornographic portrayals are further characterized as commodified, [ 5 ] : 202   and medical portrayals as sterile. [ 5 ] : 86–87   Feminist sex educators have advocated perusal of the images in  Femalia  as an exercise to help women to regard their genitals in a more positive light. [ 8 ] : 13  [ 13 ] [ 14 ] : 69


Librarian  Sanford Berman  has cited  Femalia  as an example to illustrate his thesis that libraries engage in inappropriate  self-censorship , often motivated by concerns about controversial sexual content, in deciding which books to stock. [ 15 ] [ 16 ]  Berman comments, "A detailed, artistic picture of a seashell adorns the cover. Were the contents strictly shell photos, the book might make it into at least some libraries. Shells, yes. Vulvas, no." [ 16 ] : 51


In a study of systematic differences in the depiction of female genitals in online pornography, anatomy textbooks, and feminist publications,  Femalia  was used as one of three sources of sample depictions in the feminist publications category. [ 17 ] : 76   This study found a statistically significant difference between online pornography and feminist publications in depicted protuberance of the  labia minora , with greater mean protuberance shown in the feminist publications. [ 17 ] : 77   It also found greater variation in measured genital proportions shown in the feminist publications than in the other two categories of sources. [ 17 ] : 77–78


Femalia  was used as one of two sources of sample depictions of female genitals (the other was  Penthouse ) in a psychological study of the relationship between women's aesthetic perceptions of female genitals and their attitudes toward  gynecological  examinations. [ 18 ] : 21   More specifically, the examinations in question were  Pap smears , and the relevant attitudes were anxiety, embarrassment, and likelihood of making or keeping an appointment for a Pap smear. [ 18 ] : 22–24


The  Royal Australian College of General Practitioners  (RACGP) has published a guideline document, authored by Magdalena Simonis under authority of the RACGP, intended to inform healthcare professionals about female genital cosmetic surgery (FGCS), such as  labiaplasty , and to advise them about management of patient requests for FGCS. [ 19 ]  In this document, Simonis identifies lack of appreciation of female genital diversity, not only on the part of the public but also on the part of healthcare professionals, as a contributing factor to the demand for FGCS. [ 19 ] : 2–6   She advocates the use of  Femalia  as a tool for patient education about genital diversity, [ 19 ] : 9,13   in part because it depicts female genitals without digital enhancement. [ 19 ] : 9   Simonis has further referenced this educational use of  Femalia  in slide and poster presentations intended to promote better management of the demand for FGCS on the part of healthcare professionals. [ 20 ] [ 21 ]


Medical anthropologist Eric Plemons has stated that:


The feminist commitment to ostensibly unmediated representation of 'natural' female genitals is one whose value has also been recognized by medical experts;  Femalia  has had an unanticipated life in clinical literature. [ 3 ] : 431


Plemons documents the use of  Femalia  as a resource to demonstrate the existence of female genital diversity, and to educate both clinicians and patients as to the range of normal vulval appearance. He attributes its widespread use by healthcare professionals to their belief that "it is one of very few photographic collections of 'normal' vulvas that exists". [ 3 ] : 431


Femalia  has been used as a way of assessing preferences for  perineal  and genital cosmetic appearance, to improve  cosmesis  in  trans women  undergoing genital  gender-affirming surgery . [ 3 ] [ 22 ]  Beginning in the year 2000, surgeon Neal Wilson began showing photographs from  Femalia  to his prospective patients and asking them to indicate which vulvas they found most aesthetically pleasing, as well as which ones they would choose for themselves. Wilson attempted to approximate through surgery the appearance of the photographs from  Femalia  selected by his prospective patients, even though he held that they set "impossible standards" because of the limitations of early 21st-century surgical technique. [ 3 ] : 429  [ 22 ]  Wilson has republished, in an online journal article, the three photographs most often selected by his patients. He has also provided summary statistics concerning his patients' choices of vulval photographs from  Femalia , as well as a short narrative summary of the specific anatomical features that he believed to be characteristic of the most popular photographs. [ 22 ]


The  fern test  is a medical laboratory test used in  obstetrics  and  gynecology . The name refers to the detection of a characteristic " fern  like" pattern of  vaginal secretions  when a specimen is allowed to dry on a glass slide and is viewed under a low-power microscope. The fern test is most commonly used to provide evidence of the presence of  amniotic fluid  and is used in obstetrics to detect preterm  premature rupture of membranes  and/or the onset of labor. It also may provide indirect evidence of  ovulation  and fertility, although it does not predict the time of ovulation. [ 1 ]


Ferning was first described in the field of gynecology in 1945 by  Georgios Papanikolaou , inventor of the  pap smear , as a test for ovulation during a normal  menstrual cycle . [ 2 ]   When high levels of  estrogen  are present, such as just before ovulation (or during pregnancy), the cervical mucus forms fern-like patterns due to crystallization of sodium chloride on mucus fibers. This pattern is known as arborization or 'ferning'. When  progesterone  is the dominant hormone, as it would be in the second half of a normal cycle, the fern pattern is no longer discernible, and the pattern is completely absent by the 22nd day of a woman's cycle after ovulation (assuming a 28 day cycle). The disappearance of the fern pattern after the 22nd day suggests ovulation, and its persistence throughout the menstrual cycle may suggest an  anovulatory cycle . [ 3 ]


Ferning is now most commonly used as a test for prelabor rupture of membranes which refers to the rupture of the amniotic sac during pregnancy. The sodium chloride content of amniotic fluid secreted by the fetal kidneys may be indicative that membrane rupture has occurred,  though the pattern of 'ferning' seen in amniotic fluid is distinct from that seen in cervical mucus. Amniotic fluid tends to produce a more delicate pattern, compared to a thick and wide arborization pattern seen in dried cervical mucus. [ 1 ]


False positive  results are mostly attributable to cervical mucus, though have been reported due to semen and fingerprints, while false negatives are attributable to inadequate fluid available at the time of specimen collection, or contamination from leukorrhea, blood or meconium. [ 4 ]   Additionally, the accuracy of ferning is markedly less in women who are not in labor as compared to those in labor, with a reported sensitivity and specificity of 51% and 70%, respectively, in patients without labor and 98% and 88%, respectively, in patients in labor. [ 5 ]


Genitoplasty  is  plastic surgery  to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from  cancer treatment , or congenital disorders, endocrine conditions, or they may be cosmetic. [ 1 ]


Genitoplasty surgery includes the following:


The grafts used in genitalplasty can be an  allogenic , an  autograft , a  xenograft , or an  autologous  material. [ 13 ]


Genital reconstruction surgery can correct  prolapse  of the  urinary bladder  into the vagina and protrusion of the rectum into the vagina. [ 2 ]  Female infants born with a  46,XX  genotype but have genitalia affected by  congenital adrenal hyperplasia  may undergo the surgical creation of a vagina. [ citation needed ]  Vaginoplasty is commonly used to treat women with the congenital absence of the vagina. [ 3 ]  Other reasons for the surgery are to treat adrenal hyperplasia, microphallus, Mayer-Rokitansky-Kustner disorder and for women who have had a vaginectomy after malignancy or trauma. Reconstructive and corrective vaginal surgery restores or creates the vagina. [ 11 ]


Surgeries to modify the cosmetic appearance of infants' and children's genitals  are controversial due to their  human rights implications . There is no clinical consensus about necessity, timing, indications or evaluation. [ 14 ]


In  biology  and  medicine ,  gravidity and parity  are the number of times a female has been  pregnant  (gravidity) and carried the pregnancies to a viable gestational age (parity). [ 1 ]  These two terms are usually coupled, sometimes with additional terms, to indicate more details of the female's obstetric history. [ 2 ]  When using these terms:


In  biology , the term "gravid" ( Latin :  gravidus  "burdened, heavy" [ 4 ] ) is used to describe the condition of an animal (most commonly  fish  or  reptiles ) when carrying eggs internally. For example,  Astatotilapia burtoni  females can transform between reproductive states, one of which is gravid, and the other non-gravid. In  entomology  it describes a mated female insect. [ citation needed ]


In human medicine, "gravidity" refers to the number of times a female has been  pregnant , [ 1 ]  regardless of whether the pregnancies were interrupted or resulted in a  live birth . “Gravidity” is an important component of a patient’s reproductive history, as it provides insight into the risk factors that the patient has for pregnancy outcomes, such as risk for gestational diabetes, pre-ecclampsia, spontaneous abortion, preterm birth, fetal growth restriction, and more. [ 5 ]  The gravidity of the patient is associated with risk for other conditions as well, including risk for breast, ovarian, and endometrial cancer. [ 6 ]  Knowing a patient’s obstetric history in a prenatal assessment or early in gestation allows the patient to receive early intervention to prevent these associated risks. [ 5 ]


Terms such as "gravida 0", referring to a nulligravida, "gravida 1" for a primigravida, and so on, can also be used. The term "elderly primigravida" has also been used to refer to a female in their first pregnancy who is at least 35 years old. [ 7 ]   Advanced maternal age  can be a risk factor for some birth defects.


In human medicine,  parity  is the number of pregnancies carried by a female for at least 20 weeks (duration varies from region to region, 20 – 28 weeks, depending upon age of viability). If a female carries the fetus to viable age, even if ultimately the fetus is born deceased, this still counts as an instance of parity, as parity is based on the time of gestation prior to a birth, and not the status of the offspring once born. [ 8 ] [ 9 ]


A female who has never carried a pregnancy beyond 20 weeks is  nulliparous  and is called a  nullipara  or  para 0 . [ 10 ]  A female who has given birth once is  primiparous  and is referred to as a  primipara  or  primip . A female who has given birth two, three, or four times is  multiparous  and is called a  multip .  Grand multipara  describes the condition of having given birth five or more times. [ 11 ]  Grand multiparity is associated with adverse maternal and neonatal health outcomes. [ 12 ]


Like gravidity, parity may also be counted. A female who has given birth one or more times can also be referred to as para 1, para 2, para 3, and so on.


Viable gestational age varies from region to region.


A  nulliparous  ( / n ʌ l ˈ ɪ p ə r ə s / ) female (a  nullipara  or  para 0 ) has never given birth.  It includes females who have experienced  spontaneous miscarriages  and  induced abortions  before the mid-point of pregnancy, but not females who have experienced  pregnancy loss after 20 weeks . Nulliparity has been implicated in the development of various complications during pregnancy including preeclampsia, gestational diabetes and pre-term labor. [ 5 ]


Long-term and permanent nulliparity ( / ˌ n ʌ l ɪ ˈ p ær ɪ t i / ) are  risk factors for breast cancer . For instance, a meta-analysis, published in 1990, of 8 population-based studies in the Nordic countries found that never giving birth was associated with a 30% increase in the risk of breast cancer compared with females who have given birth, and for every 2 births, the risk was reduced by about 16%. Females having their first birth after the age of 35 years had a 40% increased risk compared to those with a first birth before the age of 20 years. [ 13 ]


In  agriculture , parity in biology is a factor in  productivity  in domestic animals kept for  milk production . Animals that have given birth once are described as "primiparous"; those that have given birth more than once are described as "pluriparous". [ 14 ] [ 15 ]  Those that have given birth twice may also be described as "secondiparous", in which case "pluriparous" is applied to those that have given birth three times or more.


A number of systems are incorporated into a female's obstetric history to record the number of past pregnancies and pregnancies carried to viable age. These include:


Though similar, GPA should not be confused with the TPAL system, the latter of which may be used to provide information about the number of miscarriages,  preterm  births, and live births by dropping the "A" from "GPA" and including four separate numbers after the "P", as in G 5 P 3114 . This TPAL form indicates five pregnancies, with three term births, one preterm birth, one  induced abortion  or miscarriage, and four living children. [ 19 ]


Some established journals have used GTPAL system ignoring "T", and even rearranging the letters within the remaining combination [this effectively reduces it to  GPLA  system. For instance G3P1L1A1]. [ 20 ]  Thus, individual choices of authors also seem to matter, which recognized journals often ignore.


In obstetrics, the term can lead to some ambiguity for events occurring between 20 and 24 weeks, [ 21 ]  and for multiple pregnancies. [ 22 ]


Gynaecologic cytology , also  gynecologic cytology , is a field of  pathology  concerned with the investigation of disorders of the female  genital tract . [ 1 ]


The most common investigation in this field is the  Pap test , which is used to  screen  for potentially precancerous lesions of the  cervix .  Cytology can also be used to investigate disorders of the  ovaries ,  uterus ,  vagina  and  vulva .


Gynaecologic cytology makes frequent use of the  Bethesda system  in order to grade the results of  HPV testing . [ 2 ]


This article related to  pathology  is a  stub . You can help Wikipedia by  expanding it .


Gynecologic pathology  is the medical pathology subspecialty dealing with the study and diagnosis of disease involving the female genital tract. A physician who practices gynecologic pathology is a gynecologic pathologist. The term originates from the Greek gyno-(gynaikos) meaning "woman" and the suffix -ology, meaning "study of".


Gynecologic pathologists specialize in the tissue-based diagnosis of diseases of the female reproductive system. [ 1 ]  This includes  neoplastic  diseases of the  vulva ,  vagina ,  cervix ,  endometrium ,  fallopian tube ,  uterus , and  ovary , as well as non-neoplastic diseases of these structures. [ 2 ]


In the United States, gynecologic pathology training typically involves obtaining a medical doctorate, followed by residency in  anatomic pathology  or combined  anatomic  and  clinical  pathology certified by the  American Board of Pathology . Fellowship training in  surgical pathology  or gynecologic pathology are additional credentials toward a career as a gynecological pathologist. [ 3 ] [ 4 ]


This  human reproduction  article is a  stub . You can help Wikipedia by  expanding it .


Modern historians' knowledge of  ancient Roman   gynecology  and  obstetrics  primarily comes from  Soranus of Ephesus ' four-volume treatise on gynecology. [ 1 ] [ 2 ]  His writings covered medical conditions such as uterine prolapse and cancer and treatments involving materials such as herbs and tools such as  pessaries .  Ancient Roman doctors  believed that  menstruation  was designed to rid the female body of  excess fluids . They believed that menstrual blood had special powers. Roman doctors may also have noticed conditions such as  premenstrual syndrome .


Uterine prolapse  occurs when the  uterus  (the end of which is also known as the cervix) begins to fall (prolapse) into the vaginal canal. In severe cases, a Uterine prolapse can protrude from the vagina. . [ 3 ]  It is possible that this condition was the origin of the  belief that the womb could move around . [ 4 ]  Ancient Roman gynecologists treated this condition by suspending the patient upside down from a ladder. This treatment was not universally accepted by ancient Roman doctors. Soranus of Ephesus criticized this treatment method. [ 5 ]  Another treatment at the time involved wrapping  aetites , which were magic stones used to protect the fetus and ease  childbirth , [ 6 ]  in the skin of  sacrificed animals . [ 7 ]  The only known mention of a  hysterectomy  comes from the work  Gynecology . Soranus writes that a woman with an inverted uterus infected with  gangrene  had her uterus and bladder removed. [ 8 ]


Ancient Roman physicians noticed that  breast cancer  and  ovarian cancer  occurred more frequently in some families than others. [ 9 ] [ 10 ]  Galen believed that menstruation would rid a woman of their  black bile , and therefore could cure  melancholia , which is a historical term for depression. Galen concluded that  menopause , or the cessation of the menstrual cycle, would lead to an excess of black bile and therefore breast cancer. The treatment for breast cancer consisted of  bloodletting  and  cupping therapy . [ 11 ]   Aulus Celsus  described the stages of breast cancer in his treatise  De Medicina . In the first stage, when the cancer was limited to a lesion,  caustics  were used, followed by an incision, then cauterization. This stage was called  cacoethes . Celsus considered this treatment effective only in the early stages. During the later ones it was thought to merely hasten the patient's death. [ 12 ]  While Celsus did not advocate for the removal of the  pectoral muscles , Galen believed the only way to get rid of breast cancer was to excise all infected regions from the body. [ 13 ]   Cervical cancer  was believed to be a disease that primarily affected married women, widows, and prostitutes. It was also believed that nuns and virgins would remain unaffected. [ 14 ]  The Romans' association between cervical cancer and frequent sexual intercourse may have been because a virus known as  human papillomavirus  is known to cause cervical cancer and is sexually transmitted. [ 15 ] [ 16 ]


There were surgical procedures for  abortion  in ancient Rome, but they were rarely used, and most abortions were conducted using herbs or other drugs. [ 17 ]  According to  Pliny the Elder ,  Ecballium elaterium  was the most effective abortifacient. The plant was also recorded to have functioned as  emmenagogue , an herb that induces  menstrual flow .  Dacus carota  may have also been valued as an effective abortifacient; the plant continued to be used into the  Middle Ages .  Dioscorides  states that when inserted like a  pessary  or consumed as a drink, it can stimulate menstrual flow.  Glechium , or  pennyroyal , was also a contraceptive in ancient Rome. When taken as a drink, the plant was also believed to increase menstrual flow. Other Roman medical writers, Quintus  Serenus Sammonicus  and  Aspasia the Physician , stated that  Glechium  only functioned as an emmenagogue when served in tepid water. In  On the Diseases of Women , it is mentioned that when the plant is consumed alongside wine, it can induce abortions. One of the most popular abortifacient herbs in ancient Rome was  Silphium , a plant native to  Cyrene . Cyrene developed an industry centered around selling the drug; merchants who sold it amassed large sums of wealth and Cyrenian  currency  bore images of the plant. According to Soranus, the plant could function as a  contraceptive  and as an  abortifacient . Soranus also mentions that upsetting or damaging the  stomach  and "congestion of the head" can appear as  side effects  of  silphium . According to the ancient gynecological text  On the Diseases of Women ,  silphium  should be mixed with  pepper ,  bull bile ,  rue , and  asphaltum  and crushed into a  powder  before being consumed. Pepper and  myrrh  were also mixed with  Aristolochia clematitis  to create another herbal abortifacient and  emmenagogue . Another expensive abortifacient in ancient Rome was the "Balm of Gilead," a plant native to  Gilead . Pliny claimed that the plant was "worth double its weight in silver."  Dioscorides , who called it "balsamum," stated that it functions as an abortifacient, stimulates  menstrual flow , and expels the  placenta . Soranus claimed that it also serves as a contraceptive, however only when the  juice  of the "balsam tree" was smeared over the orifice of the  uterus . [ 18 ]


Other herbal remidies were theorized to function exclusively as contraceptives. Soranus claims that rubbing old olive oil, honey, and sometimes  wool , onto the  cervix  could cause it to clot, closing it and preventing pregnancy. Soranus further suggests that white lead mixed with balsam  sap  or  cedar  and then combined with a clump of wool could inhibit pregnancy. Such a concoction likely functioned as an effective contraceptive due to the effects of  lead poisoning , which can lead to  miscarriage ,  infertility , or  birth defects . Various folk medicines also served as contraceptives in ancient Rome. Soranus claims that drinking a cold beverage prior to sexual intercourse could cool down the uterus, causing it close and block  sperm . Soranus believed that sperm was hot, and would therefore be rejected by a cooler uterus. Another contraceptive technique described by Soranus involves cleaning the uterus of the sperm. Soranus believed that if a woman held their breath and pulled away before their partner  ejaculated , the sperm would be prevented from embedding itself deep inside the  vagina . Afterwards, Soranus advised women to squat down whilst sneezing and wipe the sperm off, preventing  insemination . The  Latin poet   Lucretius  described a similar contraceptive method in his work,  De rerum natura ; he claims that "whores," or, in  Latin , " scorta ," utilize a technique by which they pull away before their partner  climaxes . Lucretius lambasts this technique, claiming that it is reserved for those who wish to avoid pregnancy whilst pleasuring their clients. [ 19 ]  Pliny describes another folk contraceptive; he writes that if a woman decapitated a hairy  spider  and removed two worms from its carcass, she could then tie them around her waist with  deer   hide . This ritual was believed to protect a woman from pregnancy for around a year. [ 18 ]


When surgery was used, it involved the usage of surgical instruments to penetrate the mother. Usually, this procedure ended with both the fetus' and the mother's death. [ 20 ]  Soranus advised that in the next 30 days following conception, woman should physically strain their bodies to ensure an abortion. Soranus recommended women carry heavy objects, exercise, purge, and eat unhealthy foods as part of this phase of the treatment. [ 21 ] [ 22 ]  In the next phase of treatment, women were instructed to take baths and  poultices  or  enemas , all of which were mixed with herbs such as  mallow ,  wormwood ,  rue , or  linseed . For the final stage, women were subjected to pessaries or  bleeding ; Soranus cautioned against any intensive bloodletting to avoid damaging the body. Ancient Roman doctors, including Soranus, believed that abortion was forbidden by the  Hippocratic Oath , which forbade giving a woman "a pessary to cause abortion". [ 23 ]  According to Soranus, the only exception was when pregnancy threatened the life of the mother. [ 5 ]  Both  Galen , a Greek doctor, and  Hippocrates  described the usage of pelvic floor muscle training, now known as  Kegel exercises , to treat  urinary incontinence . [ 24 ]  These techniques were theorized to be beneficial for one's physical, spiritual, and sexual health. [ 25 ]


Soranus believed that following  menarche , the first  menstrual cycle , a woman was physically mature enough to bear children. He believed that women were at their most fertile at the ends of each menstrual cycle because the vagina was moist and warm, but no longer congested. Soranus further believed that proper mental health was essential for fertility; he argued the body and  soul  must be in healthy condition for pregnancy to occur. According to Soranus, pregnancy and childbirth drained the vitality of the mother; he compared this process to the exhaustion of trees when burdened with excessive fruit-production. Thus, he argued, that relaxation and the avoidance of physically or emotionally strenuous activities was crucial for maintaining proper health in pregnancy. [ 19 ]


In ancient Rome  childbirth  had a high maternal mortality rate; modern scholars estimate that 17 women died in childbirth for every 1,000 births. Pregnancy-related complications, such as a  uterine hemorrhage , were far more common in the ancient world. [ 18 ]  Young ages of  marriage  may have also increased the likelihood of complications in childbirth. [ 26 ]  Roman doctors believed that the fetus could be injured through a "faulty fetus". Ancient gynecologists also believed that the fetus could harm the mother's health.  Hippocrates  divided  gestation  into forty-day periods. The first period represented the time when the risk of miscarriage was the highest; during the last forty days, the fetus was thought to be the most active. Soranus wrote that during pregnancy women began craving to eat materials such as charcoal. [ 27 ]


Midwives  were an important part of Roman childbirth care; archaeological evidence affirms the existence of a widespread and prominent midwife industry.  Epitaphs  dedicated to midwives typically advertise their perceived "wifely virtues" rather than their capabilities as medical professionals. Soranus recommends that three midwives be present to aid the mother during childbirth. The midwives were instructed to deliver the mother lying down to reduce pain and anxiety. Soranus advises midwives to avoid staring at the genitalia of the mother, as Soranus claims this can cause their body to contract out of shame. [ 28 ]  Soranus details the criteria for the selection and training of skilled midwives. He argues that competent midwives require literacy, proficiency in both medical theory and gynecological techniques, as well as adequate physical health. Soranus believed that mental characteristics were fundamental to a competent midwife: Midwives must be calm, fearless, supportive, and sympathetic with their patients. Unlike some of his contemporaries, Soranus did not believe that previous experience giving birth was mandatory for a midwife. [ 29 ]  According to Soranus, other Roman doctors believed that previous experience with childbirth was necessary to ensure the midwife could properly sympathize with the mother during the pain of childbirth. Soranus disagreed with these assessments, arguing that such sympathy was not restricted to those with prior childbirth experience. [ 28 ]  Compassion was lauded by Soranus as an essential characteristic of proper childcare. He recommended that  wet nurses  also possess sympathy; Soranus claimed that wet nurses lacking in these traits will be inattentive, failing to properly care for the baby and its needs. [ 28 ]  It is unclear if most Roman midwives fit these criteria.  Muscio , a writer of a 6th century gynecological treatise, describes using "women's words" in his text so poorly educated midwives could understand his work. Such claims indicate that a sizeable portion of midwives contemporary to Muscio may have been illiterate. [ 30 ]


Roman medical care, including care for childbirth, was not entirely distinct from Roman  religion . Amulets and other magical items were used to ensure the mother would give birth on time. [ 27 ]  Healing inscriptions from the temple of  Epidaurus  often record a female patient seeking divine intervention for gynecological concerns such as  infertility ,  reproductive  issues, or childbirth. [ 29 ]  It was believed that numerous pregnancies, oversized  embryos , or excessive stretching can deform the uterus, leading to reproductive issues. [ 19 ]


During a Roman  Caesarean section , the doctors would make an incision into the abdomen and uterus of the mother. [ 31 ]  Following this, the baby was removed. [ 32 ]  This practice could also be conducted on dead mothers in order to remove the babies from their corpses. [ 33 ]  It was rare for doctors to perform this operation, as it had a high mortality rate. According to  Roman religion  the god  Asclepius  was born through a Caesarian section. [ 34 ]  Roman historians  Suetonius  and  Pliny the Elder  also record  Julius Caesar  as being born by Caesarian section. [ 35 ]  However, the veracity of these claims is debated. [ 33 ]