# Woman by Natalie Angier >[!Abstract] Description > National Book Award Finalist: This look at the science of the female body is “a tour de force . . . wonderful, entertaining and informative” (TheNew York Times Book Review). From a Pulitzer Prize–winning journalist who covers science for the New York Times, Woman is an essential guide to everything from organs to orgasms and hormones to hysterectomies. With her characteristic clarity and insight, Natalie Angier cuts through still-prevalent myths and misinformation surrounding the female body, the most enigmatic of evolutionary masterpieces. In addition to earning a nomination for the National Book Award, Woman was named one of the best books of the year by NPR, the Los Angeles Times, the Chicago Tribune, and People, among others. “One knows early on one is reading a classic—a text so necessary and abundant and true that all efforts of its kind, for decades before and after it, will be measured by it.” —Los Angeles Times “Ultimately, this grand tour of the female body provides a new vision of the role of women in the history of our species.” —The Washington Post %% ## Front ### [[women have been regarded as the second sex]] > Admittedly, a Dionysian state of body is not easily won, for the female body has been abominably regarded over the centuries. It has been made too much of or utterly ignored. It has been conceived of as the second sex, the first draft, the faulty sex, the default sex, the consolation prize, the succubus, the male interruptus. We are lewd, prim, bestial, ethereal. We have borne more illegitimate metaphors than we have unwanted embryos. [Link](yomu://content/annotation/61FFEE1E-D416-4478-8830-9A29B349584C) ### [[women are the dark mysterium]] > We are the dark mysterium! We are hidden folds and primal wisdom and always, always the womb, bearing life, releasing life, and then sucking it back in again, into those moist, chthonic plaits. [Link](yomu://content/annotation/E5B93DF5-049B-4A93-80C4-B7BC62257D79) ### [[women are cyclical]] > The equation of the female body with mystery and sanctum sanctorum extends its foolish villi in all directions. We become associated with the night, the earth, and of course the moon, which like the bouncing ball of old Hollywood musicals so deftly follows our "inescapable" cyclicity. We wax toward ovulation, we wane with blood. [Link](yomu://content/annotation/C6C98B48-F579-44C6-88B0-525FFCDD76DE) ### the menstrual cycle is a natural calendar > Woman does not dream of transcendental or historical escape from the natural cycle, since she is that cycle. Her sexual maturity means marriage to the moon, waxing and waning in lunar phases. The ancients knew that woman is bound to nature's calendar, an appointment she cannot refuse. She knows there is no free will, since she is not free. She has no choice but acceptance. Whether she desires motherhood or not, nature yokes her into the brute inflexible rhythm of procreative law. Menstrual cycle is an alarming clock that cannot be stopped until nature wills it. ### menses definition ### etymology tells us where words come from > Moon, month, menses: same word, same world. Ah, yes. Etymology is ever the arbiter of truth. [Link](yomu://content/annotation/FD5028F7-91DD-434E-9D37-21C959507A45) ### we can learn so much about ourselves by studying other species > In fact, we have a great deal to learn about ourselves by studying other species. Of course we do. If you watch other animals and don't see pieces of yourself in their behaviors, then you're not quite human, are you? I, for one, want to learn from other animals. I want to learn from a prairie vole about the unassailable logic of spending as much time as possible cuddled up with friends and loved ones. I want to learn from my cats, professional recreationists that they are, how to get a good night's sleep. I want to learn from pygmy chimpanzees, our bonobo sisters, how to settle arguments peacefully and pleasantly, with a bit of genito-genital rubbing; and I want to discover anew the value of sisterhood, of females sticking up for each other, which the bonobos do to such a degree that they are rarely violated or even pestered by males, despite the males being larger and stronger. If women have managed to push the issues of sexual harassment, wife abuse, and rape into the public eye and onto legislative platters, they have succeeded only through persistent, organized, and sororal activity, all of which female bonobos perfected in their own protocognitive style long ago. [Link](yomu://content/annotation/7678ABA9-5C15-486D-906C-560C83ACE102) ### although I hope my audience does include men I write with the assumption that my average reader is a woman > And though I hope my audience will include men as well as women, I write with the assumption that my average reader is a gal—a word, by the way, that I use liberally throughout the book, because I like it and because I keep thinking, against all evidence, that it is on the verge of coming back into style. [Link](yomu://content/annotation/4929D5A1-5031-450E-A75C-F76E21AD78C2) ### I focus on research but also add my own thoughts > I am scientifically and medically accurate where I can be, opinionated where there is room for argument [Link](yomu://content/annotation/F00BA7C5-1BA5-4730-A17C-DE061D94396F) ### what makes a woman a woman is a personal opinion > My book sets out to tackle the question "What makes a woman?" But I can only sidle up to the subject of femaleness clumsily, idiosyncratically, with my biases, impressions, and desires flapping out like the tongue of an untucked blouse. Ultimately, of course, every woman must decide for herself, from her clay of givens and takings, what has made her a woman. - link to gender blog [Link](yomu://content/annotation/48D14D9A-7FDD-4709-A2C9-57210640F2E7) ## 1. UNSCRAMBLING THE EGG: IT BEGINS WITH ONE PERFECT SOLAR CELL ### [[at 20 weeks gestation the fetus will hold the most eggs she will ever have]] > I said a moment ago that my daughter had all her eggs in midfetushood. In fact she was goosed up way beyond capacity, a fatly subsidized poultry farm. She had all her eggs and many more, and she will lose the great majority of those glittering germ cells before she begins to menstruate. At twenty weeks' gestation, the peak of a female's oogonial load, the fetus holds 6 to 7 million eggs. ^-adse ### [[at birth a female will have lost millions of eggs already]] ### [[women start their reproductive years with 300,000-500,000 follicles]] > In the next twenty weeks of wombing, 4 million of those eggs will die, and by puberty all but 400,000 will have taken to the wing, without a squabble, without a peep. ^2f5w5 ### [[a woman will have around 500 menstrual cycle's in her lifetime]] > The attrition continues, though at a more sedate pace, throughout a woman's youth and early middle age. At most, 450 of her eggs will be solicited for ovulation, and far fewer than that if she spends a lot of time being pregnant and thus not ovulating. Yet by menopause, few if any eggs remain in the ovaries. The rest have vanished. The body has reclaimed them. ^-2fb0 [Link](yomu://content/annotation/EF8CE345-F547-434F-A5B6-5FDA72EDB7C9) **08/04/2023, 08:25** > The millions of eggs that we women begin with are cleanly destroyed through an innate cell program called apoptosis. The eggs do not simply die—they commit suicide. Their membranes ruffle up like petticoats whipped by the wind and they break into pieces, thence to be absorbed bit by bit into the hearts of neighboring cells. By graciously if melodramatically getting out of the way, the sacrificial eggs leave their sisters plenty of hatching room. I love the word apoptosis, the onomatopoeia of it: a-POP-tosis. The eggs pop apart like poked soap bubbles, a brief flash of taut, refracted light and then, ka-ping! And while my girl grew toward completion inside me, her fresh little eggs popped by the tens of thousands each day. By the time she is born, I thought, her eggs will be the rarest cells in her body. [Link](yomu://content/annotation/7BD6D5D8-FEF8-4BE6-BF26-36CEC2E91D71) **08/04/2023, 08:34** > And so, from an eggy perspective, we may not be such random, sorry creatures after all, such products of contingency or freak odds as many of us glumly decided during our days of adolescent sky-punching (Why me, oh Lord? How did that outrageous accident happen?). The chances of any of us being, rather than not being, may not be so outrageous, considering how much was winnowed out before we ever arrived at the possibility of being. I used to wonder why life works as well as it does, why humans and other animals generally emerge from incubation in such beautiful condition—why there aren't more developmental horrors. We all know about the high rate of spontaneous miscarriages during the first trimester of pregnancy, and we have all heard that the majority of those miscarriages are blessed expulsions, eliminating embryos with chromosomes too distorted for being. Yet long before that point, when imperfect egg has met bad sperm, came the vast sweeps of the apoptotic broom, the vigorous judgment of no, no, no. Not you, not you, and most definitely not you. Through cell suicide, we at last get to yes—a rare word, but beautiful in its rarity. > > We are all yeses. We are worthy enough, we passed inspection, we survived the great fetal oocyte extinctions. In that sense, at least—call it a mechanospiritual sense—we are meant to be. We are good eggs, every one of us. [Link](yomu://content/annotation/DD682B02-76DE-4536-BCC9-74C86E8937A4) **08/04/2023, 08:42** > Seeing a human egg is not easy. It is the largest cell in the body, but it is nonetheless very small, a tenth of a millimeter across. If you could poke a hole in a piece of paper with a baby's hair, you'd get something the size of an egg. Moreover, an egg isn't meant to be seen. The human egg, like any mammalian egg, is built for darkness, for spinning stories in visceral privacy—and you can thank that trait, in part, for your smart, fat, amply convoluted brain. An internally conceived and gestated fetus is a protected fetus, and a protected fetus is a fetus freed to loll about long enough to bloom a giant brain. So we lend new meaning to the term egghead: from the cloistered egg is born the bulging frontal lobe [Link](yomu://content/annotation/8880CB0D-FA5F-48AF-804B-7B758E349326) **08/04/2023, 08:42** > How different is the status of the sperm. A sperm cell may be tinier than an egg, measuring only a small fraction of the volume, so it is not exactly a form of billboard art either. Nevertheless, because it is designed to be externalized, publicly consumed, sperm lends itself to easy technovoyeurism. One of the first things Anton van Leeuwenhoek did after inventing a prototype of the microscope three hundred years ago was to smear a sample of human ejaculate onto a glass slide and slip it under his magic lens. And men, I will set aside my zygotic bias here to say that your sperm are indeed magnificent when magnified: vigorous, slaphappy, whip-tailed tears, darting, whirling, waggling, heading nowhere and everywhere at once, living proof of our primordial flagellar past. For mesmerizing adventures in microscopy, a dribble of semen will far outperform the more scholastically familiar drop of pond scum [Link](yomu://content/annotation/F8E09642-9A4E-452B-9187-6B912E7D24BE) **09/04/2023, 07:56** > The chance of an older woman giving birth to a baby conceived from her eggs through IVF is maybe 12 to 18 percent. If you heard that these were your odds of surviving cancer, you'd feel very, very depressed. [Link](yomu://content/annotation/C3120421-3E07-4A79-B9D9-F81968856CA4) **09/04/2023, 07:57** > Using donor eggs can make a woman of forty act like a twenty-five-year-old, reproductively speaking. Who knows why? But it works, oh girl does it work, so well that suddenly you're no longer in the teens of probability but instead have about a 40 percent chance of giving birth in a single cycle of in vitro maneuvers. That number starts to sound like a real baby bawling. If the wine is young enough, it seems, the bottle and its label be damned. [Link](yomu://content/annotation/93506C7C-4A3F-43C8-B618-3ABAA5BD26D8) **09/04/2023, 07:59** > To think of the egg, think of the heavens, and of weather. The body of the egg is the sun; it is as round and as magisterial as the sun. It is the only spherical cell in the body. Other cells may be shaped like cinched-in boxes or drops of ink or doughnuts that don't quite form a hole in the middle, but the egg is a geometer's dream. The form makes sense: a sphere is among the most stable shapes in nature. If you want to protect your most sacred heirlooms—your genes—bury them in spherical treasure chests. Like pearls, eggs last for decades and they're hard to crush, and when they're solicited for fertilization, they travel jauntily down the fallopian tube. [Link](yomu://content/annotation/3F6FD43C-F7E2-4F00-9D62-F3C9CD3055F1) **09/04/2023, 08:01** > Carol-Ann Cook points out the details of the egg. Surrounding the great globe that glows silver-white on the screen is a smear of what looks like whipped cream, or the fluffy white clouds found in every child's sketch of a sky. This is in fact called the cumulus, for its resemblance to a cloud. The cumulus is a matting of sticky extracellular material that serves to bind the egg to the next celestial feature, the corona radiata. Like the corona of the sun, the corona of the egg is a luminous halo that extends out a considerable distance from the central orb. It is a crown fit for a queen, its spikes and phalanges emphasizing the unerring sphericity of the egg. The corona radiata is a dense network of interlocking cells called nurse cells, because they nurse and protect the egg, and it may also act as a kind of flight path or platform for sperm, steering the rather bumbling little flagellates toward the outer coat of the egg. That thick, extracellular coat is the famed zona pellucida—the translucent zone—the closest thing a mammalian egg has to a shell. The zona pellucida is a thick matrix of sugar and protein that is as cunning as a magnetic field. It invites sperm to explore its contours, but then it repels what doesn't suit it. It decides who is friend and who is alien. The zona pellucida can be considered the mother lode of biodiversity, the place where speciation in nature often begins, for it takes only a minor change in the structure of its sugars to make incompatible what before was connubial. The genes of a chimpanzee, for example, are more than 99 percent identical to ours, and it is possible that if the DNA of a chimpanzee sperm cell were injected directly into the heart of a human egg, the artificial hybridization would produce a viable, if ethically repulsive, embryo. But under the natural constraints of sexual reproduction, a chimpanzee sperm could not breach the forbidding zona pellucida of a human egg. [Link](yomu://content/annotation/48C857BC-5AC4-4273-8816-EFF46484CCF2) **09/04/2023, 08:01** > The zona also thwarts the entry of more than one sperm of its own kind. Before fertilization, its sugars are open and genial and seeking similar sugars on the head of a sperm. Once the zona has attached to the head of a sperm, it imbibes the sperm, and then it stiffens, almost literally. Its sugars turn inward. The egg is sated; it wants no more DNA. Any sperm that remain at its threshold soon will die. Still, the zona's task is not through. It is thick and strong, an anorak, and it protects the tentative new embryo during the slow descent down the fallopian tube and into the uterus. Only when the embryo is capable of attaching to the uterine wall, a week or so after fertilization, does the zona pellucida burst apart and allow the embryo to join its blood with mother blood. [Link](yomu://content/annotation/3F05F4AB-4436-4B5C-ACCB-124EF4B6C483) **09/04/2023, 08:03** > The corona, cumulus, and zona all are extracellular, auxiliaries to the egg but not the egg. The egg proper is the true sun, the light of life, and I say this without exaggeration. The egg is rare in the body and rare in its power. No other cell has the capacity to create the new, to begin with a complement of genes and build an entire being from it. I said earlier that the mammalian egg is not like a bird's egg, insofar as it lacks the nutrients to sustain embryonic development. A mammalian embryo must tether itself to the mother's circulatory system and be fed through the placenta. But from a genetic perspective, the cytoplasm of a mammalian egg is complete, a self-contained universe. Somewhere in its custardy cytoplasm are factors—proteins, or bits of nucleic acid—that allow a genome to stir itself to purpose, to speak every word its species has ever spoken. These maternal factors have not yet been identified, but their skills have been showcased in sensational ways [Link](yomu://content/annotation/20B4F3FF-EEBF-41CB-B1EC-DF90F88B7DAE) **09/04/2023, 08:05** > Scientists often make much of the contrast between egg and sperm, the prolificacy and renewability of the man's gametes compared to the limitations and degradative quality of a woman's eggs. They speak in breathless terms of sperm production. "Every time a man's heart beats, he makes a thousand sperm!" Ralph Brinster burbled to the Washington Post in May of 1996. But a woman is born with all the eggs she'll ever have, he continued, and they only senesce from there. Yet the mere ability to replicate is hardly cause for a standing ovation. Bacteria will double their number every twenty minutes. Many cancer cells can divide in a dish for years after their founder tumors have killed the patient. Perhaps eggs are like neurons, which also are not replenished in adulthood: they know too much. Eggs must plan the party. Sperm only need to show up—wearing top hat and tails, of course. Incorrect re neurons? [Link](yomu://content/annotation/208DE731-1686-4424-AB9E-35F05CDEC39F) ## 2. THE MOSAIC IMAGINATION: UNDERSTANDING THE "FEMALE" CHROMOSOME **09/04/2023, 13:38** > Then one day Keith read about chromosomes. He read that humans have twenty-three pairs of chromosomes and that the pairs of chromosomes are the same in men and in women, with the exception of pair number 23—the sex chromosomes. In that case, women have two X chromosomes and men have one X and one Y. Moreover, a woman's two X chromosomes look pretty much like all her other chromosomes. Chromosomes resemble Xs. Not when they're inside the cells of the body, at which point they're so squashed and snarled together they resemble nothing so much as a hair knot. But when they're taken out of the cell and combed apart for viewing under a microscope by a geneticist or a lab technician who is checking a fetus's chromosomes as part of amniocentesis, they look like fat and floppy Xs. So women have twenty-three pairs, or forty-six, of these X-shaped structures, while men have forty-five Xs and that one eccentric, the Y chromosome. The Y physically resembles the letter it was named for, being stubby and tripartite and quite distinct in shape from all the other chromosomes in the cell. [Link](yomu://content/annotation/B2EAF761-65C5-490D-B025-E2077E788212) **09/04/2023, 14:18** > Let us consider the nature of the sex chromosomes, the X counterpoised against the Y. To begin with, the X is bigger, much, much bigger, both in sheer size and in density of information. The X chromosome is in fact one of the largest of the twenty-three chromosomes that humans cart around, and is about six times larger than the Y, which is among the tiniest of the lot (and it would be the smallest of all if it didn't have some nonfunctional stuffing added to it just to keep it stable). Gentlemen, I'm afraid it's true: size does make a difference. [Link](yomu://content/annotation/C262DC27-E77F-40F5-8AAA-BD8E6B3F6FC8) **09/04/2023, 14:23** > They share an extremely rare condition, so rare that their extended family may be the only people in the world to carry it. Called generalized congenital hypertrichosis, the syndrome is an atavism, a throwback to our ancient mammalian state, when we were happily covered in homegrown fur and had no need of sweatshops and Calvin Klein's soft-core porn. The term hypertrichosis explains all, trichosis meaning hair growth, and hyper meaning exactly what it says. Link to unusual syndromes - mermaid syndrome [Link](yomu://content/annotation/D49A42D9-00F7-464E-96F7-DBD94C84ECD0) **09/04/2023, 14:24** > Atavisms result when a normally dormant gene from our prehistoric roots is for some reason reactivated. Atavisms remind us, in the most palpable and surreal manner possible, of our bonds with other species. They tell us that evolution, like the pueblo builders of the Southwest, does not obliterate what came before but builds on top of and around it. Atavisms are not uncommon. Some people possess an extra nipple or two beyond the usual pair, a souvenir of the ridge of mammary tissue that extends from the top of the shoulder down to the hips and that in most mammals terminates in multiple teats. Babies on occasion are born with small tails or with webbing between their fingers, as though they are reluctant to leave the forest or the seas [Link](yomu://content/annotation/760B5120-3813-47B8-8395-ED069FC8CE90) **09/04/2023, 14:25** > In the case of congenital hypertrichosis, a gene that fosters the generous growth of hair across the face and body has been rekindled. Nothing else happens out of the ordinary, no skeletal deformities or mental retardation or any of the other sorrows that often accompany a genetic change. The people with the condition, this large and locally renowned family living on the border of Zacatecas, simply grow a kind of pelt. They make you wonder why human beings ever shed their fur in the first place, a puzzle that evolutionary biologists have yet to crack. And despite your nobler sentiments, they also make you think of werewolves. In fact, historians of myth have suggested that conditions like hypertrichosis—other types of excess hirsutism exist beyond this rare mutation—gave rise to the legend of the werewolf. [Link](yomu://content/annotation/80120C7F-C844-485D-B783-7B5377C7F983) **09/04/2023, 14:30** > A son, in fact, may rightfully be thought of as a mama's boy: he has her X chromosome alive in every cell of his body. He has no choice—it's the only X he's got, and every cell needs it. Thus he has more of his mother's genes operating in his body than he does of his father's, thousands more. Yes, the Y chromosome is there, and that is solely a father-to-son transaction; but remember that the Y is genetically impoverished compared to the X. If you do the calculations, your brother works out to be about 6 percent more related to your mother than to your father, and he is 3 percent more related to your mother than you are, because half your cells, on average, have the mother chromosome turned off, while all of his remain turned on. These are not inconsequential figures. In a way, I'm sorry to mention them. They disrupt the image of the matriline, of our female connectedness to the ancestral parade of mother, grandmother, great-grandmother, the blessed founding matriarch. (On an interesting side note, male identical twins are more identical than female twins, again as a result of X inactivation. Male twins share the totality of their maternal X chromosomes, as well as having all the other chromosomes in common, but female twins have a diverging patchwork of maternal and paternal X chromosomes operating in different parts of their bodies.) [Link](yomu://content/annotation/CBBCE590-88A4-4465-B67C-FA72F4C1CC46) **09/04/2023, 14:32** > To begin with, think of the X chromosome as the Smart Chromosome. I suggest this not out of simple chauvinism—although I am a female chauvinist sow—but because a preponderance of genes situated on the X chromosome seem to be involved in the blooming of the brain. Studies suggest that mutations in the X chromosome are a frequent cause of mental retardation, a more frequent cause than mutations in any of the other twenty-two chromosomes. The corollary of all that retardation is brilliant: if so many things can go wrong with our favorite chromosome to result in mental deficiency, that means it holds an awful lot of important targets—genes necessary for the construction of intelligence. When one or more of those genes fail, brain development falters, and when all hum in harmony, genius is born. [Link](yomu://content/annotation/DD57CD38-9C8E-46F6-A75B-CF6F8C718625) **09/04/2023, 14:34** > To X out is to negate, to nullify. To sign one's name with an X is to confess to illiteracy. Yet we must take pride in our X chromosomes. They are large, as chromosomes go. They are thick necklaces of genes. They define femaleness, or rather they can define femaleness. [Link](yomu://content/annotation/3ABBDA1C-6D10-42DB-8008-F2BC024A5B69) **09/04/2023, 14:40** > She had what was then called testicular feminization and is now more commonly known as androgen insensitivity syndrome, or AIS. This is a fairly rare condition, affecting about one in 20,000 births. But in its rarity it has something to teach all of us, about how to think about the genetics of sex, and about the correspondence between our chromosomes—the readout from a fetal chromosome screen that will tell you, Ta da!, your baby is a girl or a boy—and our brains and our bodies. [Link](yomu://content/annotation/6D248AC2-8621-4184-8000-455806B6E06B) **09/04/2023, 14:41** > People with AIS do not exist to instruct a benighted world, and some resent being regarded as genetic anomalies that clarify genetic commonness, being the ones in the doctor's steel stirrups, being the ones whose faces are blotted out in textbooks but whose bodies are naked and available for public scrutiny. Nevertheless, we all need help in learning the obvious, which Jane Carden embodies and which we'll discuss here and in the next chapter: that women are made, not born; that women are born, not made; and that both statements are true in their profound and limited fashion. Link to gender in my writing [Link](yomu://content/annotation/8011C521-B597-45C1-B5AC-24C2CF29EB1A) **09/04/2023, 14:43** > If Jane's mother had had amniocentesis while pregnant with Jane, and if she wanted to know the sex of the baby, she would have been told, It's a boy—another son in a son-heavy family. And then, when the baby was born, the mother would have been told, Disregard the previous announcement, it's a girl. Jane has the external genitals of a girl: outer labia, clitoris, and vagina. She has no inner labia, though, and her vagina is short, extending to only about a third the length of a normal vagina. It ends abruptly in a kind of membrane, rather than leading to a cervix that serves as the gatehouse to the womb. She has no uterus or fallopian tubes. She used to have testes in her abdominal cavity, but they herniated noticeably downward into her pelvis and so were removed ten days after her birth. The excised testes were her "twisted ovaries." [Link](yomu://content/annotation/1CD02A45-0825-4EB7-801C-5D2A2706B14F) **09/04/2023, 14:46** > Here is what happened to Jane. She has a Y chromosome, in which are embedded a few dozen genes, most of them of as yet undeciphered function. But one gene on the forked-tongue chromosome is quite renowned for initiating the male narrative. It is called SRY, for sex-determining region on the Y chromosome. It used to be called TDF, for testes-determining factor, but genes, like syndromes, often go through periodic, inexplicable rehabilitations in which they get new names. In any event, SRY does something rather dramatic when it switches on during the eighth week or so of pregnancy: it starts building testes in a male fetus's abdominal cavity. Much later in fetal life, those magical little sacs of maleness drop down to the outside of the body, into the scrotum, and later still they paradoxically become pendulous symbols for bravery and strength—He's got balls!—despite their reputation as the most vulnerable region on a man's body. [Link](yomu://content/annotation/7B1599B1-73BD-4D90-AEBE-D3219FE36E86) **09/04/2023, 14:46** > In the fetus, the testes bud quickly and begin excreting androgens, hormones such as testosterone. Androgens in turn sculpt the primordial genital buds into a penis and scrotum. But it's not enough to make a male; at the same time, the fetus's female program must be stifled. To that end, the testes also secrete a hormone called m¨llerian inhibiting factor, which makes fetal structures that might otherwise develop into a uterus and fallopian tubes wither away. [Link](yomu://content/annotation/96589CA1-74C6-456F-97FA-A292FF2C0DC2) **09/04/2023, 14:46** > In Jane's case, much of this action unfolded according to standard operating procedure. Her Y chromosome performed as expected, and SRY switched on. She grew little internal testes. The testes worked. They secreted androgens. They secreted m¨llerian inhibiting factor. The inhibiting factor prompted the dissolution of Jane's primordial womb and tubes. But then something happened, or rather didn't happen. As it turns out, the Y needs the X to complete the creation of Adamically correct genitals. The quintessential female chromosome holds on its grand expanse a surprisingly large piece in the puzzle of man-making. Of its 5,000 genes, one is the gene that allows the body to respond to androgens. It's not enough to manufacture androgens; the various tissues of the body must be capable of sensing the hormones and reacting accordingly. That requires the contribution of an androgen receptor protein. The tissues of the fetus's immature genital bud must be dotted with androgen receptor proteins if the bud is to respond to androgens and form a penis. And that protein is encoded in the androgen receptor gene, on the X chromosome. [Link](yomu://content/annotation/8AA6BA79-B20B-4E41-875B-C93A1B062F30) **09/04/2023, 14:46** > Isn't it romantic? The androgen receptor gene could have been located anywhere in the genome, on any of the twenty-three chromosomes—on chromosome three, say, or number sixteen. But no, it's on our chromosome, the big fat boring X chromosome. Sheer coincidence, perhaps—although scientists can't say that for sure*—but still worth a fleeting "hah!" We make females, we make males; if you don't see what you want in the window, ask for it inside. [Link](yomu://content/annotation/15D75273-5896-44E2-9419-B6AE0A070CE4) **09/04/2023, 14:46** > Jane Carden had inherited on her X chromosome a mutated, nonworking version of the androgen receptor gene. As a result of the mutation, her body could not respond to the androgens her testes were releasing in considerable abundance, which meant she couldn't grow a penis or a scrotum. Her body was, and is, androgen insensitive, hence the name of her syndrome. [Link](yomu://content/annotation/2DE0CD1C-6071-4BBD-B49E-E3D2BD1A9C29) **09/04/2023, 14:47** > And so, being androgen-deaf, Jane's body took the course that a mammalian fetus will in the absence of androgens: it chose to go girl. The little knob of her external genitalia became outer labia, clitoris, and a short blind tunnel. The transformation was not complete—no inner labia, and the skin of her vaginal folds is oddly pale, not the usual mauve tone, as Jane puts it, of other white women's genitals. Still, she is a woman, as much of a woman as I or any menstruating, childbearing female I've ever met. With her breasts and rounded hips and comparatively slender neck (to me, one of the biggest giveaways of the female body), she can't help but strike the world as a woman. Most important, she has never doubted her female identity, even as she stood in the medical library, stunned, desperate, reading about her Y chromosome and the testes she had once possessed. [Link](yomu://content/annotation/2FF565A0-08AA-4F8C-A731-F7E86176BC01) **09/04/2023, 14:49** > There are quirky elements to androgen insensitivity syndrome. The absence of acne and male-pattern baldness: androgens are behind pimples and most cases of thinning hair, in men and women alike. They also stimulate the growth of body hair in both sexes. Jane has no underarm hair and nothing but a downy mist of light baby hair over her pubic region, again for lack of responsiveness to androgens. Some people with the syndrome look like mama mia women, the sort who become actresses and models. Jane had her testes taken out soon after birth and needed to take estrogen replacement therapy at adolescence to fill out her female form (and to protect her bones, which are dependent on estrogen). But some women with AIS are not diagnosed until well into adolescence. Their testes didn't herniate in infancy and nobody had reason to question their chromosomal status. When such girls reach puberty, the testes begin releasing substantial amounts of hormones, mostly androgens but estrogen as well. The hormones travel through the bloodstream to sites like the breast area, where the estrogen acts directly on the tissue. In addition, some of the androgens are converted enzymatically to estrogen. The breasts begin to grow, and grow, and grow, to larger proportions in fact than in most women, for it is a woman's capacity to respond to androgens that is part of what holds her breast growth in check. (High levels of androgens likewise keep a teenage boy's chest flat. The gynecomastia, or breast growth, seen in some older men is probably the result of declining testosterone levels; freed of the counteractivity of androgens, the men's circulating estrogen succeeds in prompting a modest growth of the bosom.) AIS women also often grow fairly tall, though why they do is not clear—perhaps another testicular hormone or gene on the Y chromosome promotes a manly height. Eventually, by age sixteen or so, after the AIS girls have developed adult bodies without starting to menstruate, they end up at a doctor's office, at which point their condition is diagnosed. [Link](yomu://content/annotation/64751A6A-CB10-440D-A5E3-417A92E80642) **09/04/2023, 14:52** > However much women with AIS identify themselves as women, they still feel set apart. Most keep their condition secret from all but a few close friends. Interestingly, many of them say the thing they regret most is not their inability to have children but the lack of menstruation, the event they see as a monthly voucher of femaleness. When other girls talk about their periods, girls with diagnosed AIS keep quiet and emotionally shrink away, as though, like the title character in the movie Carrie, they're worried that the "normal" girls will start pelting them with tampons and sanitary napkins. [Link](yomu://content/annotation/B9DBF6C1-34FC-45CF-AE11-4F358C188056) **09/04/2023, 14:55** > Another myth they defy is the one that promotes testosterone as the "hormone of aggression." If that platitude held, AIS women should be milder and more violet in their shrinking than the average woman. But the opposite is true: the women are, in their way, Joans of Arc of the temperament. One woman says she deliberately plays at being demure so that nobody will catch on to her condition. Jane claims she has balls when she needs them; the surgeons haven't excised them from her character. "I'm just like my mother, an aggressive, obnoxious human being," she said to me. "I'm the daughter my mother created. I'm the woman I was meant to be." Link anger to oestrogen [Link](yomu://content/annotation/A67B3960-0B4D-41FF-8100-1FAA2271C4A6) **09/04/2023, 14:54** > At the group meetings, the women talk about practical issues, such as how to find Lucite vaginal dilators that stretch the short canal into something big enough to accommodate a penis. They avoid euphemism. They talk about themselves as having a birth defect. They talk about scrutinizing their bodies in the mirror, searching for any lingering evidence of maleness. They talk about myths: the myth that links testosterone to libido, for example, in both men and women. If the myth were true, then these women should have no sex drive; they can't, after all, respond to the testosterone their bodies produce. Some sex researchers have said as much about AIS patients—that they're frigid, uninterested, dead in bed. The women themselves come close to spitting in rage at that sort of talk. Whether or not they manage to inflate their vaginas sufficiently to have intercourse, their erotic nature remains intact. They fantasize about sex. They are orgasmic. They lust when there is somebody worth lusting after. Link to oestrogen and sex [Link](yomu://content/annotation/E7186889-A420-42FD-A4E4-3FC80916F7CD) ## 3. DEFAULT LINE: IS THE FEMALE BODY A PASSIVE CONSTRUCT? **09/04/2023, 15:01** > I also consoled myself with the knowledge that the association of pink with girls and blue with boys is fairly recent. In the early part of the nineteenth century, the color codes were less absolute than they are today, but, if anything, pink was likelier to be put on boys and blue on girls than the reverse. So though we may at this point be convinced that one color is inherently feminine and the other masculine, the conviction clearly is nonsense. [Link](yomu://content/annotation/D744A3AE-7BEF-4F7C-83C8-E18CD40FC272) **09/04/2023, 15:06** > In a basic biological sense, the female is the physical prototype for an effective living being. As we saw with Jane Carden, fetuses are pretty much primed to become female unless the female program is disrupted by gestational exposure to androgens. If not instructed otherwise, the primordial genital buds develop into a vulva and at least a partial vagina. (The brain may also assume a female configuration, but this far fuzzier issue we will discuss later.) By the conventional reckoning of embryology, females are said to be the "default" or "neutral" sex, males the "organized" or "activated" sex. That is, a fetus will grow into a girl in the absence of a surge in fetal hormones, with no need for the impact of estrogen, the hormone we normally think of as the female hormone. Estrogen may be indispensable for building breasts and hips later in life, and for orchestrating the monthly menstrual cycle, but it doesn't seem to have much of a role in mapping out girlness to begin with. The male body plan, in contrast, is wrought when the little testes begin secreting testosterone, m¨llerian inhibiting factor, and other hormones. The hormones organize—or, more precisely, reorganize—the primordial tissue into a masculine format. [Link](yomu://content/annotation/E6118A40-B1A2-44E4-B832-026DD4D7131B) **09/04/2023, 15:07** > But the term default sex has such a passive ring to it, suggesting that girls just happen, that making them is as easy as unrolling a carpet downhill; you don't even have to kick it to get it going. A number of women in biology have objected to the terminology and the reasoning behind it. Anne Fausto-Sterling, of Brown University, has complained that the notion of female as default is an intellectual vestige of the male domination of developmental biology. The reason that nobody has found any of the chemical signals that activate the female blueprint, she argues, is that nobody has looked for them. From a man's perspective, the mechanism behind the growth of fallopian tubes simply can't hold the fascination of the recipe for a penis. Just because hormones don't appear to be responsible for female sex determination doesn't mean that nothing is responsible; other signaling systems exist and participate in fetal growth, though they're harder to find and study than a sharp and unmistakable burst of androgens. Compare with men as the default sex [Link](yomu://content/annotation/CC8688C0-30FC-46FD-91AC-F2D5E27A13DA) **09/04/2023, 15:08** > What we can do is reformulate the principle of female first into something less simplistic and inert than the ho-hum default mode. David Crews, of the University of Texas, proposes a lovely system for discussing the sex determination of an animal: the female is the ancestral sex while the male is the derived sex. The female form came first, and eventually it gave rise to the male variant. [Link](yomu://content/annotation/166A0A66-57A1-4EBE-9FA1-0C5F5562FA7B) **09/04/2023, 15:08** > What the notion of female as ancestral sex means, when stretched to its most interesting dimensions, is that males are more like females than females are like males. Males, after all, are derived from females; they have no choice but to hold in common those features—those girlish features, those pink pajamas!—that were modified in the making of them. But females have no such reliance on the male prototype to invent a sense of self. Self was there to begin with; we defined self. We don't need Adam's rib, we didn't use Adam's rib; our bones calcified and our pelvises hardened entirely without male assistance. [Link](yomu://content/annotation/E3864349-5F8F-43C7-90B9-8C8C4BAB184D) **09/04/2023, 15:13** > He has observed that the sex of a crocodile or a turtle is not dictated by an X or a Y chromosome, the SRY gene or the testes it can build. Instead, a baby reptile is sexualized by environmental elements, particularly the air or water temperature surrounding the egg while the creature is developing. All embryos begin with bisexual potential, and then, depending on whether it is mild or cold outside, they grow either ovaries or testes. (Generally, a colder temperature yields males, a warmer one yields females, and an intermediate temperature will give rise to a brood of 50 percent males and 50 percent females.) Importantly, neither sex is a "default" sex. A crocodile can't become a female just by not becoming a male. The pre-she must receive some kind of stimulus, pegged to temperature, that in turn sets off a physiological chain of events to build ovaries. So too to construct testes: the young reptile requires signals from the outside world to set the masculine protocol in motion. In other words, the business of sexualizing a reptile is active and multistep whatever the final outcome will be. [Link](yomu://content/annotation/583A9D4C-857E-4C7D-8816-1AC1468CD5E6) **09/04/2023, 15:16** > Among mammals, sexual reproduction is obligatory. If a mammal is to have offspring, it must mate with a member of the opposite sex. There is no such thing as a parthenogenetic mammal in nature, a female who can spin out her own clones. But some lizards—and fish, and a few other types of vertebrates—breed through self-replication, almost always producing daughters only, no sons. Parthenogenesis is not a terribly common strategy, but it occurs. In fact, it tends to appear and disappear over evolutionary time. A species that once was a sexually reproducing one, requiring the existence of males and females, will for any number of reasons lose the male and turn parthenogenetic. In other cases, a parthenogenetic species will discover the benefits of having a fellow around—specifically, because sexual reproduction gives rise to enhanced genetic diversity and thus to children with sufficiently varied traits to withstand changing times. Desiring change, the formerly hymeneal females, the cold-blooded madonnas, retreat to the Garden of Eden and start bickering over who is to take on the role of the male and get to be on top. In either evolutionary scenario, males come and males go, but the female remains. There is no species where there is no female. The female, the great Mother, is never lost. [Link](yomu://content/annotation/F7EC870A-F23E-4763-974B-B57740B6CB84) **09/04/2023, 15:17** > (You may wonder whether it's fair to call a parthenogenetic animal a female rather than a neuter, or even, just for the jazz of it, a male. The short answer is, of course it's fair. It's even accurate. A parthenogenetic lizard produces and lays eggs from which infant lizards eventually emerge, and a female animal, in her purest sense, is the animal with the eggs.) "Males evolved only after the evolution of self-replicating (= female) organisms," Crews writes. "Males have been gained and lost, but females have remained. The male pattern is derived and imposed upon the ancestral female pattern." [Link](yomu://content/annotation/6B53D797-DD44-496C-A0AE-CA00B44A49CB) **09/04/2023, 15:20** > Jane Carden said that for this reason, the freedom of role plasticity, she was glad to have been born woman—glad, we might say, that her ancestral female template was not overlaid with male appurtenances. > > "I wouldn't want to have been born without AIS," she said. "It was the only way for me to go through this lifetime as a woman. Female experiences are richer, I think, and we have a more complete emotional life. The range of personalities that men can exhibit is much narrower. I have the luxury of being extremely demure, what people associate with being very feminine one day, and being very aggressive and macho the next day. Both are tolerated in women, at least at this point in history. The analogues in men—well, we're just not there yet." [Link](yomu://content/annotation/71DCA3B0-B286-4C7C-B3E5-503565F1CCC8) **09/04/2023, 15:30** > Orchid flowers also were named after testicles, because the water bulb at the base of the plant looks like a little wrinkled scrotum. So when Georgia O'Keeffe used the orchid to represent female genitals, she incidentally committed a minor act of conjoinment of maleness with femaleness [Link](yomu://content/annotation/3E3732F9-CA4F-4529-A6B1-49FF009AA67F) **09/04/2023, 15:32** > The ancients also saw no difference between men's and women's capacity for sexual pleasure and the necessity of mutual orgasm for conception. Galen proclaimed that a woman could not get pregnant unless she had an orgasm, and his view prevailed until the eighteenth century. This is a sweet thought, one of my favorite glaring errors of history, and a roundabout acknowledgment of the importance of the female climax to life as we know it. Unfortunately, the insistence that an expectant woman was a postorgasmic woman spelled tragedy for a number of our foresisters. Women who became pregnant after rape, for example, were accused of licentiousness and adultery, since their swollen bellies were evidence of their acquiescence and their pleasure, and they were routinely put to death. [Link](yomu://content/annotation/61C62253-0D8F-4F98-9445-8CAB321AF68A) **09/04/2023, 15:34** > Male and female fetuses look identical until the ninth week of gestation, and our adult organs are analogous structures, male to female. Inside its apricot-sized body, the antesexual two-month-old fetus has a pair of immature seedpods, the primordial gonads, which become testes in males, ovaries in females. It has a set of wolffian and m¨llerian ducts, one of which will be chosen depending on whether the fetus is to develop a seminal duct system or fallopian tubes. Externally, each begins with an undifferentiated genital ridge, a bump of tissue above a small membrane-shielded slit. Starting in the third month, the nub of flesh either grows gracefully into a clitoris or grows more emphatically into the head of a penis. In girls, the membrane around the primordial slit dissolves, and the slit opens to form the vaginal lips, which will surround the vagina and the urethra, from which urine flows. In boys, androgens prompt the slit to fuse and push forward to generate the shaft of the penis. [Link](yomu://content/annotation/561DB724-CE31-47BE-A2FC-59BD468F6204) **09/04/2023, 15:36** > As symbols go, the phallus is a yawn. Tubes that point and shoot, and there you have it. The obelisk pierces the heavens, the gun ejaculates bullets, the cigar puffs like a peacock, the hot rod screams, the hot dog is eaten. A phallus doesn't give you much to play with, metaphorically, and it doesn't lend itself to multiple interpretations. A hose is a hose is a hose. [Link](yomu://content/annotation/EF51623E-2F9A-4F9D-BDCC-0207B7D3F68B) **09/04/2023, 15:36** > But the vagina, now there's a Rorschach with legs. You can make of it practically anything you want, need, or dread. A vagina in its most simple-minded rendering is an opening, an absence of form, an inert receptacle. It is a four- to five-inch-long tunnel that extends at a forty-five-degree angle from the labia to the doughnut-shaped cervix. It is a pause between the declarative sentence of the outside world and the mutterings of the viscera. Built of skin, muscle, and fibrous tissue, it is the most obliging of passageways, one that will stretch to accommodate travelers of any conceivable dimension, whether they are coming (penises, speculums) or going (infants). I'm sure I'm not the only woman who dreamed during pregnancy that she was about to give birth to a baby whale, in my case an endangered blue whale. Oh, the human vagina in its role as birth canal can stretch, all right, and it must distend in proportion to the rest of us far more than the pelvis of a mother whale. You've heard, or experienced firsthand, how the cervix must dilate to ten centimeters, or four inches, before the laboring woman is given sanction to push. It must become as wide as the vagina is long. But those ten centimeters, O grunting, flailing lady, are not the width of the baby's head. No, the average seven-pound baby has a head five inches across, and some fat-headed infants have skulls nearly six inches wide. While the baby's head does compress into something the shape of a keel as it rams and glides its way to the light—thank Ishtar for the sutures, fontanel, and ductile plates of the newborn's skull—nonetheless you can count on your vagina's stretching during delivery to proportions unimagined when you had trouble negotiating your first tampon insertion. So the vagina is a balloon, a turtleneck sweater, a model for the universe itself, which, after all, is expanding in all directions even as we sit here and weep. [Link](yomu://content/annotation/068A466A-D93B-4564-A749-2DACECAECD02) **09/04/2023, 15:39** > Beginning on the border of the vaginal environment, we come to a small mountain, the mons pubis, also called the mons veneris, which means "mountain of Venus," the Love Mount. But let's not get carried away with woozy romance; veneris also gives rise to the term venereal disease. The mons veneris is made mons by a thick pad of fatty tissue that cushions the pubic symphysis, the slightly movable joint between your left and right pubic bones. The joint, which is relatively delicate and easily bruised by a bad jolt on a bicycle, is further cushioned at adolescence when the carpet of pubic hair grows in (assuming that you have requisite responsiveness to androgens) [Link](yomu://content/annotation/F18DE272-B52D-4D4A-96D1-7B893AB45958) **09/04/2023, 15:41** > The erotic and mythic taxonomy of our genitals continues. Inside the labia majora are the nymphae, named for the Greek maidens of the fountain, whose libidos were reputedly so robust that they gave birth to the concept of nymphomania.* The more pedestrian name for nymphae is labia minora, or little lips, the exquisite inner origami of flesh that enfolds the vagina and nearby urethral opening. The inner labia have no hair, but the sebaceous, or oil, glands within them can be felt through the thin skin as tiny bumps, like a subcutaneous scattering of grain. The nymphae are among the most variable part of female genitals, differing considerably in size from woman to woman and even between one labium and its partner. Like the labia majora, the labia minora swell with blood during sexual excitement, and to an even more emphatic extent, doubling or trebling their dimensions at peak arousal. Some of our primate relatives have very exaggerated labia minora, which they drag along the ground to dispense pheromones that advertise their ovulatory status. In the spring of 1996, scientists discovered a new species of marmoset in Brazil, whose most outstanding trait is the female's inner labia. Each flap of skin hangs down visibly, fusing at the bottom into a sort of genital garland. [Link](yomu://content/annotation/5647DAA6-533D-4729-82A7-DEBDF5402C08) **09/04/2023, 15:44** > Whatever the size of the labia, inner and outer, they sweat. The entire vulval area sweats, with the same insistence as the armpits. If you've ever worked out in a bodysuit, you've probably noticed after a good sweaty session that you have three fetching triangles staining your clothes, one under each arm and a third at the crotch. You probably have felt embarrassed and exposed, the Hottentot Venus in Lycra, or maybe you're worried that others will think you've peed in your pants. Don't be ashamed; be grateful. You need to wick away all that internal body heat if you're going to stay in the running, and frankly, a woman's armpits aren't as efficient as a man's at sweating. Be glad that the female crotch at least is more so. [Link](yomu://content/annotation/B2D84645-EC5A-4E6C-BAF0-A29D79AA31D8) **09/04/2023, 15:44** > The vulval area also secretes sebum, a blend of oils, waxes, fats, cholesterol, and cellular debris. The sebum serves as waterproofing, helping to repel with the efficiency of a duck's back the urine, menstrual blood, and pathogenic bacteria that might otherwise settle into the crevices of the mons veneris. The sebum gives the pelvis a sleek and slippery feel, as though everything, including the pubic hairs, had been dipped in a melted candle. Stationed at the outskirts of the genital habitat, the sebum acts as the first line of defense, the Great Wall of Vagina, to thwart disease organisms that seek to colonize the rich world within. [Link](yomu://content/annotation/27433C7E-737D-4450-93AD-44FCA46A039F) **09/04/2023, 15:46** > But really, anywhere you go, the story is the same," she said. "Women are taught that their vaginas are dirty. In fact, a normal healthy vagina is the cleanest space in the body. It's much cleaner than the mouth, and much, much cleaner than the rectum." [Link](yomu://content/annotation/01850839-877D-46FB-BF32-92FB23D2B2DC) **09/04/2023, 15:48** > In any event, men may well think of a vagina as smelling fishy, for as it happens, sperm is one of the ingredients that can make a good thing go bad. [Link](yomu://content/annotation/8F437721-E7A4-4AFE-868C-8C739EA5C22C) **09/04/2023, 15:48** > The crux of the vaginal ecosystem, said Hillier, is symbiosis, a mutually advantageous and ongoing barter between macro-environment and microorganism. Yes, the vagina is full of germs, in the sense of bacteria; it swims with life forms, and you hope it stays that way. But there are germs and germs. When conditions are healthy, the germs, or rather bacteria, in the vagina do a body good. They are lactobacilli, the same bacteria found in yogurt. "A healthy vagina is as clean and pure as a carton of yogurt," said Hillier. (Why do I suspect that we're not likely to see Dannon picking up on this slogan anytime soon?) And so the smell: "A normal vagina should have a slightly sweet, slightly pungent odor. It should have the lactic acid smell of yogurt." The contract is simple. We provide lactobacilli with food and shelter—the comfort of the vaginal walls, the moisture, the proteins, the sugars of our tissue. They maintain a stable population and keep competing bacteria out. Merely by living and metabolizing, they generate lactic acid and hydrogen peroxide, which are disinfectants that prevent colonization by less benign microbes. The robust vagina is an acidic vagina, with a pH of 3.8 to 4.5. That's somewhat more acidic than black coffee (with a pH of 5) but less piquant than a lemon (pH 2). In fact, the idea of pairing wine and women isn't a bad one, as the acidity of the vagina in health is just about that of a glass of red wine. This is the vagina that sings; this is the vagina with bouquet, with legs. [Link](yomu://content/annotation/7F32107E-6693-48F8-99F4-F85589B5484A) **09/04/2023, 15:49** > Vaginal discharge consists of water, albumin—the most abundant protein in the body—a few stray white blood cells, and mucin, the oily substance that gives the vagina and cervix their slippery sheen. Discharge is not dirt, certainly, and it is not a toxic waste product of the body in the sense of urine and feces. No, no, no. It is the same substance as what's inside the vagina, neither better nor worse, pulled down because we're bipedal and gravity exists, and because on occasion the cup runneth over. It is the lubricant beneath the illusion of carapace, reminding us that physiologically we are all aquatic organisms. [Link](yomu://content/annotation/217BA963-CE74-4993-8128-BF56751A71A4) **09/04/2023, 15:51** > Douching kills off the beneficial lactobacilli and paves the way for infestation by anaerobes and their trails of cadaverine. So while I rarely dispense medical advice, this one is easy: don't douche, ever, period, end of squirt bottle. [Link](yomu://content/annotation/7C3D1E90-B8CA-4168-8075-F80968BBC936) **09/04/2023, 15:52** > Sperm can't swim in the biting climate of a healthy vagina, so they're buffered in a solution of acid's biochemical yang, alkaline. Semen is highly alkaline, with a pH of 8. It is more alkaline than any other body fluid, including blood, sweat, spit, and tears. For several hours after intercourse, the overall pH of the vagina rises, momentarily giving unsavory bacteria the edge. Usually the change is fleeting and the woman's body has no trouble readjusting the pH thermostat back to status quo. The restoration is particularly easy when the sperm looks familiar—that is, when it belongs to the woman's regular partner. But in a woman who is exposed to the semen of multiple partners, the homeostatic mechanism sometimes falters, for reasons that remain unclear and probably have to do with an immunological reaction to all that strange sperm [Link](yomu://content/annotation/B42B8F5F-156C-46DE-BB8F-7FA472A9104A) **09/04/2023, 15:53** > If you sleep around a lot, your vagina becomes more alkaline. It becomes fishy, yes, but worse than that, an alkaline vagina is less able to defend itself against pathogens, including agents of venereal disease. Women with bacterial vaginosis are more susceptible to gonorrhea, syphilis, and AIDS. At the same time, if you sleep around a lot, you'll be exposed to a greater load of such venereal microbes. In sum, just when you need an acidic vagina the most, yours is turning alkaline. [Link](yomu://content/annotation/E5CC66F0-0430-4264-B663-18FE31DB0493) ## 4. THE WELL-TEMPERED CLAVIER: ON THE EVOLUTION OF THE CLITORIS **11/04/2023, 08:28** > For the record, the average penis is about 4 inches long when flaccid, 5.7 inches when erect. That's a bit bigger than the gorilla's 3-inch erection, but then there's the blue whale, the world's largest mammal, who has, yes, a 10-foot pole [Link](yomu://content/annotation/9C5C24A1-4F53-4B5F-BEA9-443CD3FCE2FF) **11/04/2023, 08:30** > The clitoris is usually spoken of as the homologue of the penis, and embryonically that's true: it arises from the same region of the fetal genital ridge as the shaft of the penis. But the comparison is not wholly accurate. A woman doesn't pee or ejaculate through her clitoris, of course. No urethra runs through it. She does nothing practical at all with her clitoris. The clitoris is simply a bundle of nerves: 8,000 nerve fibers, to be precise. That's a higher concentration of nerve fibers than is found anywhere else on the body, including the fingertips, lips, and tongue, and it is twice the number in the penis. In a sense, then, a woman's little brain is bigger than a man's. All this, and to no greater end than to subserve a woman's pleasure. In the clitoris alone we see a sexual organ so pure of purpose that it needn't moonlight as a secretory or excretory device. For this reason, maybe it's best that the clitoris normally is hidden within the vulval cleft: it is, in its way, a private joke, a divine secret, a Pandora's box packed not with sorrow but with laughter. [Link](yomu://content/annotation/5AF7B88F-CA31-4146-9B1D-A34A2FB71CBB) **11/04/2023, 08:32** > Glans is an annoying word, similar enough to gland to make you wonder if there is something glandular—that is, secretory—about this magic button. There isn't. Glans means "a small, round mass or body" or "tissue that can swell and harden," both of which apply to the glans clitoris [Link](yomu://content/annotation/E73B9AE9-69EF-43B1-9E54-DB6342F38E54) **11/04/2023, 08:34** > The clitoral glans is the wick of Eros, the site where the 8,000 nerve fibers are threshed together into a proper little brain. For many women, the glans is so sensitive that touching it directly is almost painful, and they prefer circuitous stimulation of the shaft or the entire mons [Link](yomu://content/annotation/5F6F6081-1D4F-4842-B896-2DC88032D5E8) **11/04/2023, 08:36** > Yet, again, let us not think of the clitoris as a literal counterpart to the penis. An aroused clitoris is swollen and springy, but it does not become rigid like a prepenetrant penis. We know that. Anybody with an intact sensory cortex and the right opportunities can affirm that an erect clitoris does not feel quite as stiff as a hard-on. What's surprising is that the reason for the difference only lately has come to light. In 1996, a team of Italian scientists exploring the microarchitecture of the clitoral shaft reported that, textbooks be damned, the clitoris does not have a venous plexus. In men, this tight-knit group of veins serves as the major conduit through which blood leaves the organ. During arousal, muscles in the shaft of the penis temporarily compress the venous plexus, with the result that blood flows in but then cannot depart, and lo, it is risen. The clitoris does not seem to have a distinct, compressible plexus; the vascularization of the organ is more diffuse. On sexual kindling, arterial flow into the clitoris increases, but the venous outflow is not clamped shut, so the organ does not become a rigid little pole. Why should it? It has no need to go spelunking or intromitting. And it may be that the comparatively subtle nature of its blood trafficking allows the clitoris to distend and relax with ease and speed, giving rise to a woman's blessed gift, the multiple orgasm [Link](yomu://content/annotation/12C5DF34-8211-49F3-8E6A-21E5684ECC13) **11/04/2023, 08:37** > Even the 1990s edition of Our Bodies, Ourselves proclaims that "until the mid-1960s, most women didn't know how crucial the clitoris was." Such ignorance was blamed on Freud, who came up with the theory that a clitoral orgasm is an "infantile" orgasm, a vaginal one a "mature" orgasm, and that only by shifting her focus from her vestigial phallus to her unmistakably feminine vagina would a woman find psychosexual fulfillment. [Link](yomu://content/annotation/0F6A3EBA-2CF0-4911-9ACF-9F1DB3582FCB) **11/04/2023, 08:38** > The origins of the word clitoris are unclear. It is found in all modern European languages and comes from the Greek, but how the Greeks got it is subject to dispute. No matter. Nearly all proposed roots carry libidinous connotations. One second-century source suggests the word is a derivation of the verb kleitoriazein, meaning to titillate lasciviously, to seek pleasure. Some etymologists have proposed that clitoris stems from the Greek word for key, as in the key to female sexuality, while others link it to the root that means "to be inclined" and that also gave rise to the word proclivity. (In non-European languages, the word for clitoris may refer to its appearance rather than its function. For example, in Chinese, the ideogram combines yin, for female, and tee, for stem, as the stem of an eggplant resembles a clitoris.) [Link](yomu://content/annotation/5E855A55-3F1A-49F0-A1A7-360B77DD35C6) **11/04/2023, 08:41** > Queen among the clitoral nobility is the bonobo, sometimes called the pygmy chimpanzee. The bonobo is a close cousin of the common chimpanzee, and the two species together are our closest living relatives. The bonobo is a sexual Olympian. Males, females, old, callow, no matter—it's sex, grope, hump, genito-genital rub-a-dub-dubbing, all the day long. Most of this sex has nothing to do with reproduction. It serves as the code of ethics by which bonobos survive group living. It is their therapy, their social lubricant and postquarrel salve, a way of expressing feelings, and it is often quick to the point of perfunctory. In a species in which sexuality is so important, and in which females engage in frequent homosexual as well as heterosexual and pangenerational trysts, it is no surprise that the clitoris assumes considerable stature. As a young adolescent, a female bonobo is maybe half the weight of a human teenager, but her clitoris is three times bigger than the human equivalent, and visible enough to waggle unmistakably as she walks. Only later, when the bonobo matures and her entire labial area swells, does it become difficult to descry the organ. But the clitoris is still there, and is drafted into service by its owner several times an hour. [Link](yomu://content/annotation/F1BAD351-C0F6-4391-AC61-76F3A353DCD2) **11/04/2023, 08:41** > Female spider monkeys and lemurs also have exceptionally large clitorises. The spotted hyena of Africa has a clitoris so large that it looks exactly like the male hyena's penis. The organ is nothing like the typical mammalian clitoris but is a vagina and clitoris in one elongated package. A female hyena has intercourse through this phallic projection. She gives birth through her clitoris, and if that thought makes you want to wince, go ahead and wince, because she sure does. Unlike the bonobo, the spotted hyena does not use her prodigious clitoris for quotidian sensuality, her interest in sex being confined to periods of estrus. Instead, the organ appears to be enlarged incidentally, as a result of the female's having been exposed prenatally to large concentrations of testosterone, which masculinizes the external genitals. (The hormonal status of the spotted hyena is of interest to us for reasons apart from genital anatomy, as I discuss at length in the chapter on female aggression.) [Link](yomu://content/annotation/B3C0A458-EA55-4EDA-B034-DB3964738F84) **11/04/2023, 08:43** > A search of Medline, the world's largest medical computer database, pulled up only sixty or so references to clitoris over a five-year span (compared to thirty times that number for the term penis). Only two academic volumes are devoted to the clitoris, one called The Clitoris, the other The Classic Clitoris, and both are decades old. Even gynecology textbooks give the clitoris short shrift, a mere page or two. Some of the professional disregard may be attributed to the fact that medicine focuses on illness and the clitoris, thankfully, is not a common site of disease. But at least in this country, the inattentiveness also reflects ordinary prudishness and the difficulty of winning a federal grant to study the morphology of small Greek keys. The clitoris obviously needs more Italian researchers. [Link](yomu://content/annotation/53A2831D-F79E-4870-AB9C-D19F1406AE87) **11/04/2023, 08:45** > For women who are anorgasmic, who cannot climax no matter how they thrash and struggle, the clitoris may seem the most overhyped and misleading knob of flesh this side of Pinocchio's nose. Sure, it works for some, but for others it is notoriously undependable. Marilyn Monroe, the most elaborated sexual icon of the twentieth century and surely the source of autoeruptive glee for thousands of fans, confessed to a friend that despite her three husbands and a parade of lovers, she had never had an orgasm [Link](yomu://content/annotation/AD1A3D55-8B0A-445E-B806-19EFFE59AEF1) **11/04/2023, 08:50** > The clitoris loves power, and it strives to reinforce the sensation of playing commando. Sex researchers have found that women who are easily and multiply orgasmic have one trait in common: they take responsibility for their pleasure. They don't depend on the skillfulness or mind-reading abilities of their lovers to get what they want. They know which positions and angles work best for them, and they negotiate said postures verbally or kinesthetically. Moreover, the positions that offer many women the greatest satisfaction are those that give them some control over the sexual choreography: on top, for example, or side by side. A movie that shows a woman reaching frenzied crescendo while being hoisted up and slammed against a wall in classic Last Tango in Paris fashion is not a movie directed by a woman. [Link](yomu://content/annotation/0C596D69-F5EF-44A7-B81C-42719D29B5DD) **11/04/2023, 08:51** > The clitoris not only applauds when a woman flaunts her mastery; it will give a standing ovation. In the multiple orgasm, we see the finest evidence that our lady Klitoris helps those who help themselves. It may take many minutes to reach the first summit, but once there the lusty mountaineer finds wings awaiting her. She does not need to scramble back to the ground before scaling the next peak, but can glide like a raptor on currents of joy. [Link](yomu://content/annotation/AC6AC61E-79B0-4A5E-8359-E855DF95A9C6) **11/04/2023, 08:56** > There is another body of evidence suggesting that the clitoris trades in the currency of power. Recent work from the British researchers Robin Baker and Mark A. Bellis suggests that orgasm offers women a recondite way to control male sperm, either by imbibing it or by repelling it. They propose that the timing of a woman's orgasm relative to a man's ejaculation influences whether or not his semen has a shot at fertilizing her eggs. If a woman climaxes shortly after her partner ejaculates, her cervix, the gateway to the uterus, will do a spectacular thing. As it pulses rhythmically, the cervix reaches down like a fish's mouth and sucks in the semen deposited at its doorstep. This has been shown on video. A microcamera was attached to a man's penis and the deep events of intercourse were recorded: the milky ejaculate streaming forth like woozy pennants, followed by the cervix dipping into the preferred gene pool and with viscous, fluttering motions appearing to paddle the semen up into the uterus. Now whether the cervical palpitations truly enhance the chance that the semen will reach an egg is not known. Baker and Bellis have preliminary evidence suggesting that when a woman climaxes anywhere from several seconds to forty minutes after her partner, her chances of being impregnated are slightly higher than if she doesn't climax or if the orgasm occurs before or after this rather widely gaping window of opportunity. [Link](yomu://content/annotation/3A5DECE9-7756-4044-937C-398627C1857C) **11/04/2023, 08:57** > The scientists' data are open to quarrel, but their general argument is compelling—that female orgasm is the ultimate expression of female choice. If a woman's sexual responsiveness is tied to her sense of power, of having freely chosen this partner at this moment, then her cervix might very well go the next step, taking up what the woman demonstrates through her rapture is the chosen seed. Baker and Bellis promote the concept of sperm competition: that just as males compete with one another by locking horns or swords, so their sperm compete in the vaginal tract for access to the egg. Female orgasm is thus a woman's way of controlling the terms of the underground debate. Small wonder, they say, that men often are obsessed with their sexual prowess, their ability to turn women on—and that even when a man cares very little for his partner's emotional well-being, he nonetheless wants to satisfy her sexually. The fate of his sperm, it seems, may depend on his erotic skills. Hypothetically, natural selection has favored those males who abide by the axiom "We aim to please." [Link](yomu://content/annotation/4213DDA0-1326-4316-A4E8-893E8E2EF73A) **11/04/2023, 09:01** > Yet the clitoris overspills its anatomical borders and transcends its anatomy. Other pathways feed into it and are fed by it. The 15,000 pudendal nerve fibers that service the entire pelvis interact with the nerve bundles of the clitoris. That's why the anus is an erogenous zone. Nerves are like wolves or birds: if one starts crying, there goes the neighborhood. In some women, the skin around the urinary opening is exceptionally sensitive, and because this periurethral tissue is pushed and pulled quite vigorously during coitus, such hypersensitivity could result in a comparatively easy stroll to orgasm through the thrustings of intercourse alone. Other women say they can climax best with the application of pressure deep within the vagina, which led the gynecologist Ernst Grafenberg and his partisans to propose the existence of a Grafenberg, or G, spot, a sort of second, internalized clitoris. The G spot is said to be a two-inch cushion of highly erogenous tissue located on the front wall of the vagina, right where the vagina wraps around the urethra, the tube that carries urine from the bladder. Some have said that the G spot is embedded in the so-called Skene's glands, which generate mucus to help lubricate the urethral tract. Others have said that the gee-whiz spot is actually the sphincter muscle, which keeps the urethra clamped shut until you're ready to void. Still others question the existence of a discrete G spot altogether. Let's not bother inventing novel erogenous loci, they say, when the existing infrastructure will do. The roots of the clitoris run deep, after all, and very likely can be tickled through posterior agitation. In other words, the G spot may be nothing more than the back end of the clitoris. [Link](yomu://content/annotation/96349613-7A38-4801-AF88-5F90CB29A22A) **11/04/2023, 09:02** > Anatomy is not epiphany. When scientists have tried to quantify the discrete components of orgasm, they've had very little luck. In one study, for example, researchers at the University of Sheffield recruited twenty-eight adult women to measure the duration, intensity, and vaginal blood flow associated with climax. A small heated oxygen electrode was inserted into each woman's vagina and held in place on the vaginal wall by suction. The woman was then asked to masturbate to orgasm, to indicate when the orgasm began and when it ended, and to grade its intensity on a scale from one (pitiful) to five (transcendent). Throughout the session, the electrode gauged vaginal blood flow, indicating how congested the vaginal tissues became. The average orgasm, as indicated by the woman's signing of "start" and "all done," turned out to be surprisingly prolonged, lasting an average of twenty seconds—much longer than the twelve seconds, on average, the women guessed in retrospect. Yet there was no correlation between length and strength; the intensity rating a woman assigned to her orgasm had nothing to do with how long it lasted. Neither did relative blood flow correlate with perceived pleasure. [Link](yomu://content/annotation/C74D7020-6642-499E-930E-CDA0A4A5486F) **11/04/2023, 09:07** > Children with unusually large clitorises have had their protrusions surgically reduced—whittled back, towed in, or amputated altogether. They have been clitoridectomized. This is not an operation that we normally associate with high-minded Western medicine, but clitoridectomies are fairly common. In this country, about two thousand babies a year undergo some form of "adjustment" to reconfigure a clitoris deemed abnormally prominent. There are no official guidelines for what constitutes "clitorimegaly," but anything projecting beyond the mollifying lips of the vulva is a candidate for a clitoridectomy. When a baby is born with equivocal genitals, surgery was, and is, the norm. We may tolerate sexual ambiguity in rock stars, but not in infants. [Link](yomu://content/annotation/553149EA-38FA-4B8E-9373-03177FB81F25) **11/04/2023, 09:08** > The intersexual activists in this country truss their grievances by equating their stories with the far more publicized custom of ritual genital amputation practiced in Africa. The unarguably vile practice goes by various names, including female genital mutilation, or FGM; African genital cutting; and female circumcision—although as many have pointed out, it is more akin to penile amputation than to male circumcision and should not be given the courtesy of comparison. The tradition dates back at least two thousand years, and it has never been much of a secret, but the general impression until recently was (a) that it was fairly uncommon, confined mostly to small remote villages, and (b) that it was on its way out. Neither has proved to be true. At least one hundred million women living in twenty-eight countries have had their genitals cut, and two million girls are added to the ranks of the lacerated each year. In some countries, including Ethiopia, Somalia, Djibouti, Sierra Leone, Sudan, and Egypt, the prevalence rate approaches 100 percent. Some girls and young women have fled their native homes, vulva intact, and sought asylum abroad, but putatively enlightened nations such as the United States have been slow to sympathize, or to acknowledge that the threat of genital carnage counts as persecution. Now we in America have a self-congratulatory bill banning African genital cutting in this country, though the bill doesn't prevent the medically approved cutting of any clitorime-galic Susans who may be born; nor does it come with the necessary teeth of economic sanctions against nations where girls are sheared en masse. [Link](yomu://content/annotation/DABBA74A-5DA8-4B97-84FC-28B10F154275) **11/04/2023, 09:09** > In learning about genital vandalism, we have heard about the gradations of the procedure. The "mildest" form is a straightforward clitoridectomy that removes part or all of the organ. Intermediate dismemberment eliminates the inner labia along with the clitoris. Infibulation, the grisliest horror show of all, chops away clitoris and inner labia, and then incises the outer labia to create raw surfaces that can be stitched together to cover the urethra and vagina, leaving just enough of an opening for the passage of urine and menstrual blood. Eventually, when the infibulated girl marries and must accommodate her husband's penis, the stitches are removed and the scarred skin of the outer labia is pushed apart. [Link](yomu://content/annotation/E704ACA3-0CFF-4DCC-A250-E7817B8E9C12) **11/04/2023, 09:10** > However limited or extensive the cutting, it is done without anesthesia, under unsterile conditions, and the tool used is whatever crude blade the local low priestess of mutilation—it is often a woman—has deemed the most appropriate instrument for the ritual. It is usually performed on a young girl of seven or eight, who may anticipate the ceremony with a certain excitement, thinking at last she will be counted a woman, but who ends up screaming in pain and must be held down by several adult women as she flails to escape, unless she is fortunate enough to pass out from the shock and pain and loss of blood. Sometimes the girl hemorrhages to death immediately, or dies soon afterward of sepsis, tetanus, or gangrene. If she survives, she may suffer chronic pelvic pain from wounds that do not heal, or infections from urine and blood that cannot flow cleanly. Cysts often form along the line of the scar, some growing as big as grapefruits and making the woman feel ashamed, fearful that her genitals are returning in monstrous form or that she is dying of cancer. When an infibulated woman gives birth, she is like a poor, mewling hyena on first parturition, her infant having no choice but to tear its way to the light. [Link](yomu://content/annotation/23B3D959-F754-4FF9-B179-8DA74842E711) **11/04/2023, 09:11** > According to its proponents, genital cutting serves several purposes. It supposedly tames a woman, abridging her innate wantonness and discouraging her from any thoughts of cuckoldry. Less familiar to westerners is the cosmetic objective of the pruning, the desire to accentuate the visual discrepancy between female and male. Eliminating the clitoris, the woman's penis-equivalent, is a start; losing the labia, which can resemble a scrotum, takes the polarity to an extreme. No protrusion, no pouches, no confusion. As photographs of infibulated women show, the operation can produce a smooth pelvic profile that is superfemi-nine by some infantile mental module of femininity. In fact, it looks like it belongs on everybody's favorite feminine fetish, the smooth-groined doll named Barbie [Link](yomu://content/annotation/2B49D0D2-AF41-4FDE-9606-F6E076DB590F) **11/04/2023, 09:12** > Genital cutting is an extreme abuse of human rights. Like slavery and apartheid, it is unacceptable. How can we stop it? By talking about it with angry, unbitten tongues. By never forgetting about it, and by not letting the issue slide back into obscurity now that we have learned of its pervasiveness and tenacity. Some recommend that efforts to end the practice respect the underlying belief systems of those who cut and have been cut. The nonprofit organization Population Council has argued that it is no good barking about a woman's right to sexual integrity to an audience that values sexual modesty. Instead, the council recommends we should emphasize the risks of genital cutting to a woman's most cherished asset: her fertility. Fine. Let's be sensitive, not self-righteous. Emphasize reproductive health over a carnal entitlement program, responsibility over narcissism. Say what you will—just put down that knife. [Link](yomu://content/annotation/D6EDFB8B-0376-4BCD-8E20-6F941A759CF3) ## 5. SUCKERS AND HORNS: THE PRODIGAL UTERUS **12/04/2023, 6:54 am** > An ultrasound scan revealed the likely cause of her excessive bleeding: a fibroid, a benign tumor that grows in the muscle tissue, or myometrium, that makes up the middle layer of the uterus. The professional term for fibroid is leiomyoma, or simply myoma, to reflect the tumor's muscular origin, but fibroids are as common as freckles and deserve their common name. At least a quarter of women over thirty have fibroids, and the true figure may be closer to half. In most cases, fibroids are asymptomatic and despite their designation as tumors should just be left alone. But if they grow too big or are located in a bad spot, they can cause cramps, bleeding, constipation, and other unpleasantnesses. [Link](yomu://content/annotation/1B8EDD71-786E-4F01-ABFB-BED3F0711842) **12/04/2023, 6:56 am** > the only part of the body that is unique to women, the one organ that doesn't have an anatomical equivalent in the male: the uterus. [Link](yomu://content/annotation/DD1CCC35-F7CA-43FA-8A15-E6D15AD3F088) **12/04/2023, 7:01 am** > As we've discussed, Galen and all who followed him for nearly the next two thousand years conceived of the female body as a sock taken off in a hurry—that is, as a male's body turned inside out. The vagina was an inverted penis, the labia a foreskin equivalent, the uterus an internal scrotum, and the ovaries a woman's testicles. Galen was no fool, and he was on the right track in observing the principle of genital equivalency. The adult genitals are homologous, though not entirely as Galen reckoned. Yes, the ovaries do correspond to the testes, but the female analogue of the penis is the clitoris, not the vagina, and the labia are the structural counterpart to the scrotum rather than the foreskin. Both sexes have responsive breast tissue as well, and a man's bosom is capable, under certain hormonal conditions, of swelling to brassiere-ready proportions, a condition known as gynecomastia (which means "female-like breasts"). [Link](yomu://content/annotation/0713B46E-2A13-42CB-94BC-F1475F97DD31) **12/04/2023, 7:02 am** > But when we come to the uterus, anatomical homology breaks down. During the development of a male fetus, müllerian inhibiting factor eliminates the proto-womb when the structure is no bigger than a caraway seed, leaving nothing for the fetus's fidgety androgens to reinterpret. MIF also sweeps away the incipient fallopian tubes, but the second set of primordial pipes is retained and retrained into seminal ducts. The uterus alone offers a clear case of presence versus absence, to have or have not [Link](yomu://content/annotation/48E66430-9DF2-4105-AD35-ABB72D9337F2) **12/04/2023, 7:03 am** > The uterus has borne the freight of extraordinary medical myths. Hippocrates believed that the organ wandered untethered through a woman's body, giving rise to any number of physical, mental, and moral failings; the word hysteria, after all, comes from the Greek hystera, for womb. Hippocrates also believed that the human uterus had as many as seven chambers and was lined with "tentacles" or "suckers." His bizarre errors were the result of laws and religious customs that forbade the dissection of the human body and required the great man of oath to extrapolate from the study of other species, which often do have wombs with multiple cavities and hornlike structures. [Link](yomu://content/annotation/F51425A0-87CA-4F3C-BA25-2CE4101D9B81) **12/04/2023, 7:04 am** > Hippocrates' blunder persisted until the Renaissance, when Leonardo da Vinci's gorgeous drawing of an opened uterus, revealing the fetus and its umbilical cord within, showed his awareness that the human womb has only one cavity. But in other anatomical drawings he illustrated a different fable of the time, that a "milk vein" extends from the uterus up to the breast, to transform blood from the pregnant uterus into milk for the newborn child [Link](yomu://content/annotation/36267B15-4EFA-42C4-B6A4-748147F021B5) **12/04/2023, 7:04 am** > As recently as the nineteenth century, physicians argued that the uterus competes directly with the brain for an adequate blood supply. Thus any effort a woman made to nourish her mind through education or career could come only at the expense of her fertility. [Link](yomu://content/annotation/4572F509-F4E0-4AF7-9937-C8E94B1C9078) **12/04/2023, 7:05 am** > The war of the womb continues to this day. One of our most bellicose and indefatigable of issues, the abortion debate, distills to a question of who owns the uterus, woman or fetus (or a fetal proxy such as the church or state). Moreover, despite the fact that only half the population is endowed with one, the uterus is the site of the two most common surgical procedures performed in the United States. First is the cesarean section, in which the uterus is sliced open for the swift retrieval of an infant (who may or may not need this Green Beret approach to its delivery). Second is a far more severe storming of the uterus, the hysterectomy [Link](yomu://content/annotation/8AB9601B-2F33-4524-84E4-89BDDF092DCE) **12/04/2023, 7:12 am** > Horbach points out the ovaries to me. They are each about the size of a large strawberry, and they are smoke-colored and bumpy. They look like moist seedpods. On one is a noticeable white cyst, the probable spot of Phillips's last ovulation, when a ripe egg burst through the follicle and left behind a fluid-filled pocket that is still healing [Link](yomu://content/annotation/2537D90A-A765-4939-B603-ADB305E466DA) **12/04/2023, 7:13 am** > Horbach also indicates the fallopian tubes, or oviducts, which are attached to the uterus. The tubes are exquisite, soft and rosy and slim as pens, tipped like a feather duster with a bell of fronds, called fimbriae. Gabriel Falloppius, the sixteenth-century anatomist after whom the structures were named, thought that the oviducts looked like trumpets and that they served to expel "noxious fumes" from the uterus. To me they look like sea anemones, flowers of flesh, the petals throbbing to the cadence of blood. [Link](yomu://content/annotation/7FFD4530-8348-4AFF-A956-88728231DB78) **12/04/2023, 7:16 am** > Phillips's cervix: a shiny, taffy-colored tubular structure that reminds me of the head of a penis [Link](yomu://content/annotation/4708556A-4631-4EF6-ADA8-0F4EA2032F00) **12/04/2023, 7:16 am** > The fibroid: it is so big and purposeful in appearance that I can't believe it wasn't a functioning part of Phillips's anatomy. It looks like a turnip, a tough swirl of purplish tissue that Horbach says reminds her of brain tissue [Link](yomu://content/annotation/7C8F69BA-C00A-4ED3-AE76-30C71323D180) **12/04/2023, 7:16 am** > The body of the uterus: at this point, not exactly photogenic. It is an unremarkable pouch about the size of a child's fist, a timorous adjunct to the fibroid that it sustained for so long [Link](yomu://content/annotation/DD03B838-85A4-4951-A3E3-89380FB6F6B0) **12/04/2023, 7:17 am** > With the cervix and uterus gone, Phillips's vagina now opens directly into her abdominal cavity, so the surgeons stitch it closed. The vagina may not be as dirty as legend has it, but it is an orifice, and you don't want it to serve as a gateway between the public and the personal [Link](yomu://content/annotation/AE6EC39F-1230-4EB7-AE82-63B7A31D7020) **12/04/2023, 7:17 am** > Over time, Phillips's other viscera will reposition themselves and fill in the space where her reproductive organs once dwelled. The surgeons are ready to close up [Link](yomu://content/annotation/C0335D17-9E7A-42EF-A752-13DAA5186179) **12/04/2023, 7:21 am** > The womb does not define a woman, philosophically, biologically, or even etymologically. A woman does not need to be born with a uterus to be a woman, nor does she have to keep her uterus to remain a woman. [Link](yomu://content/annotation/9A7780F4-0FBB-4344-9EF0-4F41DFA2BC73) **12/04/2023, 7:25 am** > an internally conceived and gestated fetus is a protected fetus, and a protected fetus has the luxury of developing an elaborated central nervous system. The uterus and its attendant placenta mother the offspring as it will never be mothered again, not even by its own mother postpartum. [Link](yomu://content/annotation/37B3F6B2-2850-4E3E-B84B-66859FE5911F) **12/04/2023, 7:26 am** > The womb may have nothing to do with the intellect of the woman who bears it, but it has everything to do with the brain of the fetus it bears. [Link](yomu://content/annotation/98E9D90A-84B0-47C5-ABF5-77877E5CE6FD) **12/04/2023, 7:32 am** > Structurally, the uterus is not complicated. In an adult woman who is not pregnant, it weighs about two ounces and is roughly three inches long. It has two parts, each making up about half its length: the body, or fundus, in which the fetus develops, and the cervix, which projects down into the vagina and opens slightly for the release of menstrual blood and more gapingly for the birth of a baby. If you look at the cervix from a gynecologist's-eye view, it resembles a glazed doughnut. A doctor who worked in a woman's health clinic once said that doing pelvic exams made her hungry, and she wasn't kidding or being lewd; she just liked doughnuts. [Link](yomu://content/annotation/E349CC96-A042-4520-8EDF-D578728B8B7E) **12/04/2023, 7:36 am** > In other ways the uterus is a sandwich, a muscle hero. The cervix and fundus are both composed of three tissue types. The meat in the middle is the thick myometrium, built of three inter-wrapping sheets of muscle. On the outside of the myometrium is a slick covering, the serous membrane, which is similar in texture and function to the sacs surrounding the heart and lungs. Like those sacs, the uterine serous membrane keeps the organ wet and cushioned. > > On the other side of the myometrium is the uterine lining, the endometrium. The body likes to work in threes, and so the endometrium is made of three layers of mucous membrane. Unlike serous membrane, mucous membrane breathes and snorts and secretes. It absorbs water, salts, and other compounds. It releases mucus, a mixture of white blood cells, water, the sticky protein known as mucin, and cast-off tissue cells. Menstruation is in part a mucus discharge. During menstruation, two of the mucous sheaths are shed, thence to be reconstructed when the cycle begins anew. Like one who has reached enlightenment, the third, deepest endometrial layer escapes the wheel of death and rebirth, and it is to this stable foundation that a placenta moors itself if a fetus should be favored with a home. [Link](yomu://content/annotation/518BFEB3-791E-4A2B-BAA9-4AB7B3B9AAA8) **12/04/2023, 7:37 am** > Hippocrates thought that the womb wandered, and he meant wandered, took a transcorporal journey up to the breastbone, even to the throat, becoming particularly frantic when it wasn't fed on a regular basis with semen. (By Hippocrates' estimation, the uterus of a whore would be far calmer than that of a virgin.) He was wrong, of course, but that does not mean the uterus is an immobile stone. In fact, it is springy and fungible. It is held loosely in its pelvic girdle by six ligaments, flexible bands of fibrous tissue that offer support for the organ and also enclose the blood vessels that nourish it. The position of the uterus shifts in the pelvis depending on whether you're prone or upright, your bladder is full or empty, and other such unremarkable circumstances. If you're sitting down now, not particularly in need of a toilet break, and not pregnant, your uterus is probably tipped slightly forward, its fundus leaning toward a spot an inch or two above your pubis, that hard bone in your crotch. If you were to stand up, again with an empty bladder, and push your shoulders back with military crispness, your uterus would assume a nearly horizontal position, like a pear that's fallen over. [Link](yomu://content/annotation/97BFF8F4-FD3B-45B4-96AD-EE16D59873A6) **12/04/2023, 7:38 am** > The uterus is at its most physiologically flamboyant when pregnant. An organ that weighs two ounces before pregnancy grows to two pounds by pregnancy's end, a gain that is independent of the weight of the fetus or placenta. Its volume increases a thousandfold. No other organ undergoes such dramatic changes in adulthood unless it is diseased. Yet give it a mere six weeks postpartum, and it has retreated to its fisty proportions. In effecting the changes of pregnancy, the myometrium does most of the heavy lifting. The muscle cells multiply at the beginning of pregnancy and then enlarge, or hypertrophy, in the second trimester, just as muscle cells elsewhere do if you diligently subject them to exercise. In the final trimester, the cells neither divide nor hypertrophy, but the whole uterine wall simply stretches and stretches and stretches, until you feel, mama, as though you might burst. In fact, rupture of the uterus during pregnancy is surprisingly rare. Placental mammals, after all, have been around for 120 million years, enough time to work out the bugs of the distendable womb. [Link](yomu://content/annotation/55D28A29-6F2C-4190-BF00-ADB9C140B460) **12/04/2023, 7:39 am** > Four thousand years ago, a woman wanting word of her condition mixed her urine together with barley seed; if the barley grew faster than usual, it signified pregnancy. No one knew it at the time, but the test probably worked because estrogen spurs the growth of many cell types—mammal, insect, grain. It is a potent biotroph, an ancient signal from organismic Babel, as I will discuss in detail later. For now, suffice it to say that estrogen stimulates myometrial cells to divide and enlarge. [Link](yomu://content/annotation/FD9C72FD-A0F2-4045-8904-FF07829662A1) **12/04/2023, 7:40 am** > The hormone also throws muscle cells into a state of electrical excitation. It makes them twitch. A uterus that twitches too much is a uterus that expels a fetus. Therefore, even as it is urged to expand, the myometrium must be tranquilized. That is the job of progesterone, the so-called hormone of pregnancy; progesterone means pro-gestation. Progesterone inhibits the contractibility of muscle cells. Throughout the whole nine months of baby-baking, the negotiation between estrogen and progesterone is a dynamic one. Small, fleeting contractions pass over the swelling womb like local thunderstorms flickering over the desert. The more advanced the pregnancy, the more insistent these so-called Braxton Hicks contractions become [Link](yomu://content/annotation/EE0B5306-BABF-4F55-8067-E87EF7E1EEA9) **12/04/2023, 7:43 am** > There is no clearer rite of passage, no surer demarcation between childhood and adulthood, than menarche, the first period. When people talk of the indelibility of a strong memory, they speak of recalling exactly where they were when Kennedy was shot or the Challenger space shuttle exploded. But what a woman really remembers is her first period; now there's a memory seared into the brain with the blowtorch of high emotion. With some exceptions, a girl loves getting her first period. She feels as though she has accomplished a great thing, willed her presence into being. Emily Martin interviewed a number of women from different social classes about their thoughts on menstruation, and all gave joyful accounts of menarche. One recalled bursting into song in the bathroom. Another rushed to tell her girlfriends in the school cafeteria that her period had just started, and they responded with a small celebration, buying her ice cream [Link](yomu://content/annotation/7852E8C3-6200-47FB-82C2-C8A89E833FC7) **12/04/2023, 7:44 am** > After the heady triumph of menarche, most of us soon begin thinking of menstruation as a hassle, a mess, an embarrassment. We try to be cavalier, and we try to scold ourselves into pragmatism, yet still we feel uncomfortable paying for a box of tampons or napkins when the salesclerk is male. There are innumerable myths and taboos surrounding menstruation, some, not surprisingly, attributable to our familiar medicine men, Hippocrates, Aristotle, and Galen (most easily remembered by the acronym HAG). Hippocrates argued that fermentation in the blood precipitated menstruation, because women lacked the male ability to dissipate the impurities in the blood gently and sweetly through sweat; to him, menstrual blood had a "noisome smell." Galen believed that menstrual blood was the residue of blood in food that women, having small and inferior bodies, were unable to digest. Aristotle assumed that menses represented excess blood not incorporated into a fetus [Link](yomu://content/annotation/953C4CA7-950A-4D0A-8425-3B20F9B94B83) **12/04/2023, 7:46 am** > The notion that menstrual blood is toxic has pervaded human thinking, west to east, up to down. Given the noxious fumes they exude, menstruating women have been said to make meat go bad, wine turn sour, bread dough fall, mirrors darken, and knives become blunt. Menstruating women have been confined to huts, to home, to anywhere but here. Some anthropologists have suggested that hunting societies have been particularly stringent in keeping women quarantined during their monthly flow, in part because of fears that menstrual odor attracts animals. Even today, women are warned not to go camping in grizzly country if they are menstruating, lest a very large ursine nostril pick up the scent. Whether the warning has merit remains unclear. When biologists in North Carolina recently tried to determine the best way to lure a bear, they found menstrual blood to be of almost no use. [Link](yomu://content/annotation/A7ABC8D2-E25A-41DC-9C6D-40974F9BACEE) **12/04/2023, 7:47 am** > In fairness, views of menstruation have not been uniformly negative, and the same potent ingredients that menstrual blood supposedly carries have on occasion been considered therapeutic. Moroccans have used menstrual blood in dressings for sores and wounds, while in the West blood has been suggested as a treatment for gout, goiter, worms, and, on the theory of using fire to fight fire, menstrual disorders. The ancient practice of bloodletting, which dominated medicine for hundreds of years, may well have been a mimic of menses, although the fact that women shed blood naturally did not spare them from extraphysiologic drainings whenever they fell ill [Link](yomu://content/annotation/AE775482-4673-480B-BDC6-60EF92DA185C) **12/04/2023, 7:53 am** > Most of us think of menstruation as a passive business, decay aided by gravity [Link](yomu://content/annotation/CFA47DDD-F4C6-43DF-A9DF-E3D8086B3AFF) **12/04/2023, 7:53 am** > That is not in fact what happens. Recall the lesson that contemporary biology teaches us: dying is as active as living. Eggs die by undergoing apoptosis; that is, they commit suicide. So too is menstruation a dynamic and directed affair. [Link](yomu://content/annotation/3DE27C3D-55D2-4C77-B458-D33763FBEFB6) **12/04/2023, 7:53 am** > The first relevant mechanism is a specialized type of artery. Feeding into the two superficial layers of the endometrium, the ones that are disposed of each month, are three spiral arteries, so named because they look like corkscrews. During pregnancy, the spiral arteries serve as important conduits of blood for the placenta. Yet their purpose extends beyond fetal feeding. Several days before a woman's period begins, the tips of the spirals grow longer and more tightly coiled, like a Slinky that's being pulled and twisted at the same time. Circulation to the endometrium grows sluggish—the calm that presages calamity. Twenty-four hours before the onset of bleeding, the spirals constrict sharply. The faucets are twisted off, the blood flow ceases. It is a heart attack of the uterus. Deprived of blood and therefore of oxygen, the endometrial tissue dies. Then, as abruptly as the arteries squeezed shut, they temporarily open again, allowing blood to rush in. The blood pools in pockets beneath the dead endometrium, causing the lining to swell and burst, and the period begins. Their mortal work complete, the spiral arteries constrict once again. (Fibroids disturb the ritual of menstruation because their parasitic blood supply does not conform to the squeeze-relax-squeeze pattern of the spiral arteries.) [Link](yomu://content/annotation/609A46B2-8F04-422F-BAB8-7F5D0515835D) **12/04/2023, 7:54 am** > A second outstanding feature of menstruation is the quality of the blood. Most blood is poised to clot. Unless you are a hemophiliac, when you cut yourself the blood flows briefly and then coagulates, for which you can thank your platelets and sticky blood proteins such as fibrin. Menstrual blood does not clot. It may seem goopy at times, and the dead tissue accompanying it may pass out in clots—our slimy medusas!—but the blood proper contains very few platelets and does not form the interlocking coagulatory mesh that characterizes blood released from a wound. The only reason that menstrual blood does not keep flowing is that the spiral arteries constrict in the wake of endometrial death. [Link](yomu://content/annotation/4B62C1AB-A05E-4F3D-91ED-B4331157B666) **21/04/2023, 19:26** > Until recently scientists have been almost exclusively male; men do not menstruate, and so scientists have not delved terribly deeply into the ultimate causes of this strictly female phenomenon. The physiology of menstruation, the how of it, was of sufficient interest to gynecologists to be explored in some detail. Not until the early 1990s, though, did anybody seriously ponder the why of menstruation, when Margie Profet presented in the Quarterly Review of Biology a theory too provocative to be ignored. [Link](yomu://content/annotation/52EDAD65-537B-4AEE-B5CB-F92FF7C5CB59) **21/04/2023, 19:26** > Menstruation, she decided, is extraordinarily expensive. Shedding and replenishing endometrial tissue on a monthly basis burns a lot of calories, and for our Pleistocene ancestors, who likely spent most of their brief lives on the rim of malnutrition, every calorie counted. Moreover, when you lose blood, you lose iron, an essential micronutrient and another scarce commodity for our forebears. Finally, menstrual cycling makes women less efficient in reproduction. All that building up and tearing down of the uterine lining limits the time when a woman might conceive. If evolution is so keen on reproduction, why devote this much effort to counterproduction? [Link](yomu://content/annotation/727A7539-1203-42ED-9C9F-64A77C292F27) **21/04/2023, 19:26** > Menstruation, she suggested, is a defense mechanism, an extension of the body's immune system. We bleed to rid the uterus of potentially dangerous pathogens that might have hitched a ride inside on the backs of sperm. Think of it. The uterus is a luxurious city just waiting to be sacked, and sperm are the ideal Trojan horse. Bacteria, viruses, and parasites all can find passage to the womb by playing opportunistic gene jockey, and it so happens that scanning electron micrographs of sperm reveal a cartoonish mob scene, the tadpole cell at the center surrounded by a cluster of microbial hangers-on. If permitted to linger in the uterus indefinitely, the pathogens might run amok, sickening, scarring, or killing us. Our endometrium must die, Profet proposed, so that we might live. Anyipathogen hypothesis [Link](yomu://content/annotation/9E35BF97-795D-48A1-8A62-E32E0F317FA4) **21/04/2023, 19:27** > Why, for example, is the shedding of the endometrium accompanied by a river of blood? The body can discard dead tissue without the use of blood. We replace the lining of the stomach on a regular basis, for example, and blood has nothing to do with it. Profet suggested that we bleed because blood carries the body's immune cells, the T cells, B cells, and macrophages, and the immune cells participate in routing out whatever nasty pathogens have tried to infiltrate the uterus. [Link](yomu://content/annotation/DBEB4EA3-171E-4CF1-98BB-9109215F5C01) **21/04/2023, 19:27** > Why shed the lining rather than resorbing it into the body, as a more logically parsimonious system might do? To avoid the risk of recycling diseased tissue [Link](yomu://content/annotation/6E380C13-929E-4D56-B96C-DE6EA07C21AE) **21/04/2023, 19:27** > And why do we bleed so heavily compared to other female mammals, any of which, presumably, are at risk of unintended spermatic donations? We bleed by the pint because we are an amorous species. We do not limit intercourse to a defined season of estrus, and we use sex for many nonreproductive reasons—to bond, to barter, to appease, to distract. Therefore, we must bleed heavily to cleanse ourselves [Link](yomu://content/annotation/88CB3039-47AF-41E6-A930-F157C9E34161) **21/04/2023, 19:28** > Beverly Strassmann, of the University of Michigan, took up the challenge with spitfire enthusiasm, publishing a lengthy exegesis in the same journal that had presented Profet's theory. Strassmann noted that Profet's hypothesis led to several predictions: first, that the uterus should be more riddled with pathogens prior to menstruation than after it; second, that the timing of menstruation should bear some relation to the timing of a female's greatest risk of pathogenic infiltration; and finally, taking a cross-species comparison, that the heaviness of a primate's period should correspond to the relative promiscuity of the animal—in other words, the more sexually active the species, the heavier the bleeding. [Link](yomu://content/annotation/79CA27DB-AF84-44FF-BFE6-11222090441A) **21/04/2023, 19:28** > Strassmann concluded that none of these predictions were supported by the evidence. In various studies, specimens of uterine smears taken from women throughout their menstrual cycle showed no significant difference in the bacterial load from one phase to the next; if anything, the concentration of microbes was lowest, rather than highest, right before menstruation. In fact, blood is an excellent growth medium for many types of microbial flora, offering not only protein and sugar but iron, and we all know what the iron in spinach does for Popeye. Researchers have shown that they can expedite the proliferation of Staphylococcus aureus in culture by feeding it iron, which is probably why a tampon left in place too long is tempting territory for this agent of toxic shock syndrome. Refuting the anti pathogen hypothesis [Link](yomu://content/annotation/87527D61-64D4-45FE-9D58-5DE634A7795E) **21/04/2023, 19:32** > So if not for defense against microbes, what of our bleeding? Why the extravagant, wasteful system of menstruation? Here Strassmann strikes at Profet's core assumption—that menstruation is so costly it demands evolutionary justification. Far from being expensive, Strassmann argues, periods are a steal. Calorie for calorie, the Shiva approach to reproduction, the perpetual death and rebirth of the uterine lining, is cheaper than maintaining the uterus in fertile form would be [Link](yomu://content/annotation/D8314217-6EA1-45B8-88BD-BE2A451D9E30) **21/04/2023, 19:33** > Strassmann calculated that the uterine lining at its ripest uses seven times more oxygen than it does at its thinnest, after menstruation. The need for more oxygen translates into a need for more calories. In addition, the secretory endometrium revs up the entire body, as the hormones it releases stimulate tissues from brain to bowel. Again, a higher metabolism demands more calories. [Link](yomu://content/annotation/53E5481B-6712-477B-AA48-7F5E10AEA7A1) **21/04/2023, 19:34** > The uterus, then, is like a deciduous tree, an oak or a maple, and the endometrium acts like the leaves. When the weather is warm, when sunlight sings, the tree awakes and invests in leaves. The branching pattern of the tree—its trunk, its branches, its twigs—is like the branching of the body's vascularization, parceling out water rather than blood. The homology of the pattern is no coincidence. Holy water, sacred blood, they are one and the same, and branching is the most hydraulically efficient means of pumping the fluid from a central source—the heart, the trunk—out to all extremities. Thus nourished, the leaves bud, unfurl, thicken, and darken. The leaves are photosynthetic factories, transforming sunlight into usable energy. That energy allows the tree to create seeds and nuts, the acorns that are embryonic trees. The leaves are expensive to maintain—the tree must deliver them water, nitrogen, potassium, the nutrients from the soil—but they repay the tree by spinning sunlight into gold. In the same way, the endometrium is metabolically expensive and yet generative as well. It has the potential to nourish an embryo. In both cases, too, the investment is worthwhile only at certain times. For a tree considering foliation, that time is spring and summer, when there is abundant sunlight, water that is not frozen, and soil that is soft enough to be mined for nutrients. Then and only then can a leaf repay its debt with interest. For the uterus, the time corresponds to the moment when there might be something worth nourishing, a ripened egg that has met its match. Interestingly, a leaf dies in fall as the endometrial lining dies at the end of a fallow cycle. The corpuscle at the tip of the twig constricts, shutting off water and killing its dependent leaf. [Link](yomu://content/annotation/CA3F3AF7-5E51-4875-9A16-F5FBCFADB969) **21/04/2023, 19:35** > The putative cost-effectiveness of cyclic endometrial death does not, however, explain the need for menstrual blood. Can't we have retrenchment without seeing red? The blood, in Strassmann's view, is beside the point. It is a byproduct of the loss of a tissue that is by necessity highly vascularized. If you're going to lose that tissue, you're going to have to spill some blood. Those fancy spiral arteries that destroy the endometrium and so start the flow, the ones that Profet thought were evidence of the adaptiveness of menstruation? Those arteries are there for the sake of the placenta, Strassmann says. That is their reason to be—and, come menstruation, not to be. The placenta is a spectacular thing, but it is vampirous. It needs blood, and the spiral arteries give it blood. Each month they spread their coiled fingers through the endometrium; if a placenta forms, they will deliver it blood. When the endometrium dies, it takes with it the vascularization, the tips of the spiral arteries, the fingers of blood. As it happens, the vascular architecture of the uterus in many other mammals is less ornate, and those mammals exhibit little or no menstrual bleeding. The species that have spiral arteries—humans and certain other primates—also shed the most blood. It's a structural thing, Strassmann says, a matter of plumbing rather than defense. We could resorb and recycle the tissue and the blood; that would certainly be a parsimonious approach, a nod to Miser Nature. And we do resorb, to a point. But the human uterus is quite large compared to the human body, and we simply can't take it all back. Nor can other primates with wombs large relative to their body size, and those, as a rule, are our sisters in blood. [Link](yomu://content/annotation/7B5ADC6B-F4C8-4463-A97D-8AD4A2006EC0) **21/04/2023, 19:40** > If there is one lesson I've learned in observing biology, it is that nothing in a living organism is just one thing. Nature's economy lies above all in making maximum use of what is, a process that we may call pleoaptation, the adaptation of an organ or system to multiple uses [Link](yomu://content/annotation/07B620D8-DC4C-48E3-9409-765FAF6B3F81) **21/04/2023, 19:40** > Enter the antipathogen aspect of menses, the ability of bloodshed to purify and rout, the womb as warrior. This is a selfish, active, and erotic explanation for menses, an acknowledgment that we are carnal beings whose sexual activity far exceeds any reproductive needs. In our defensive bleeding, we are not helping our offspring or our mates or the whole damned race; we are helping ourselves. [Link](yomu://content/annotation/B40AEF65-BB38-47B1-A6F5-59CB7271BCC1) **21/04/2023, 19:40** > Let us help others too. When your daughter or niece or younger sister runs to you and crows, "It's here!" take her out for a bowl of ice cream or a piece of chocolate cake, and raise a glass of milk to the new life that begins with blood [Link](yomu://content/annotation/E96A131E-9EF3-47FD-AFE4-227D08D6FC5E) ## 6. MASS HYSTERIA: LOSING THE UTERUS **21/04/2023, 19:47** > More recently, though, the uterus has emerged as a maker as well as a taker. Yes, it responds to steroid hormones from the ovaries and other organs, but it also expresses hormones and releases them into the global marketplace of the body. It makes proteins, sugars, and fats, all of which figure in Strassmann's analysis of the metabolic costs of menstruation. It makes prostaglandins, chemicals that exert an array of effects on the body. Most notably, prostaglandins prompt the smooth muscle tissue of the body to contract. [Link](yomu://content/annotation/E2DE5688-F67B-4B96-A46A-D702BFEBBE8C) **21/04/2023, 19:48** > There is more to the womb's inventory. The organ fabricates drugs that in other contexts would be illegal. It synthesizes and secretes beta-endorphins and dynorphins, two of the body's natural opiates and chemical cousins to morphine and heroin. It makes anandamide, a molecule almost identical to the active ingredient in marijuana. Until recently, these compounds were thought to be the exclusive property of the central nervous system—the brain and spinal cord. After all, we learned about natural opiates and natural marijuana by studying the impact of their plant-borne equivalents on the brain. The brain was thought to make these compounds endogenously because the brain sometimes needed them, perhaps to ease pain, perhaps to facilitate pleasure. Now it seems that the brain is an anodynic also-ran. The uterus produces at least as much opiate material as neural tissue does, and it makes ten times more of the cannabis equivalent than any other organ of the body does [Link](yomu://content/annotation/EB7AD2AD-5524-45F9-976C-4E75144DBA88) **21/04/2023, 19:48** > We do not yet know why, though it's easy to spin theories. A pregnant woman will tell you in no uncertain terms of what use a steady stream of natural painkillers might be. If the womb is going to make such a spectacle of itself, the least it can do is to offer a source of comfort as it grows. Perhaps it makes opiates and cannabinoids so that it doesn't hurt too much in distention. Or perhaps the fetus is the intended beneficiary of the womb's pharmacopoeia. It is a tight squeeze in there, after all. #research - do we know now??? [Link](yomu://content/annotation/C3DCDEEF-BB9C-4752-86B0-C87B7836C72E) **21/04/2023, 19:53** > In truth, any time a woman visits a doctor she risks intervention. [Link](yomu://content/annotation/02EE2FE2-5F7F-433A-B06B-10AD814449D6) **21/04/2023, 19:53** > Nora Coffey, the founder of the organization Hysterectomy Education Resource Services, or HERS, who is among the most zealous opponents of hysterectomies, suggested to me that European women keep their organs by keeping to themselves. Quite simply, they don't visit the doctor as often as we do. They reserve the delightful experience for times of real illness. We Americans patronize the health-care profession even when we're healthy. It's part of our chirpy wellness mindset. Women in particular are habituated to regular doctor visits, through the sacred annual gynecological checkup. We go in for a Pap smear, and we go in for a pelvic palpation: everything still in there? We think of this as wise preventive medicine, but doctors can't help themselves. They look for blemishes and portents. They seek the anomalous. And when they find a deviance from the norm, whatever the norm may be, of course they must tell the patient about it. They may counsel no action for the nonce beyond watchful waiting, but it's too late: the egg of worry has hatched. Now the woman will wonder, Is it getting worse? Could it be the reason that I'm feeling fatigued, crampy, not quite divine? Is this the case for prostate issues? more testing now finding more ‘normal’ abnormalities #research that cancer cells develop all the time in most bodies but the body sorts itself [Link](yomu://content/annotation/86684612-6593-40A1-85C6-70BBDAD87973) **22/04/2023, 5:31 am** > I think of the largest fibroid on record, a mass that weighed 143 pounds when it was removed from a woman in 1888. Not surprisingly, the woman died soon after surgery [Link](yomu://content/annotation/A564493B-5BF8-4A65-B7DF-E8DB4899E4D4) **23/04/2023, 4:37 pm** > It's easy to denounce hysterectomies, she says, and to bewail their frequency, and to argue that women are being misled by hidebound, greedy surgeons. But is it not an insult to women to assume naivete and gullibility? If a woman spends years in pain and discomfort, sick and bleeding and consumed with the six inches of body between bellybutton and crotch, says Cain, who is she or anybody else to counsel, Oh, no, you mustn't have a hysterectomy. Under no circumstances should you have a hysterectomy. "We don't validate women's pain enough," Cain says. "We underestimate pain, we belittle it, and we undertreat it." [Link](yomu://content/annotation/47CFC119-0D31-40A4-B445-19E4811B2E43) **23/04/2023, 4:37 pm** > I spoke with many intelligent women who had done their homework. They were assiduous and enlightened medical consumers who read everything they could find on hysterectomies. They knew their options, and most had tried other procedures before settling on a hysterectomy. The one thing they resented was the self-righteousness of the wards of the womb. They complained about being made to feel weak and ashamed for their decision [Link](yomu://content/annotation/B7FCD4BD-6083-49F6-ACCF-3723B9CA3692) **23/04/2023, 4:40 pm** > I interviewed dozens of women in their forties and early fifties who sought help for their fibroids and were told hysterectomy, period. When they asked about a myomectomy, their doctors argued against it. But is a myomectomy really as bloody and dangerous as it's portrayed? In many cases, the fibroids that give a woman difficulty can be removed hysteroscopically, through a tube like a periscope that is threaded up the vagina and into the uterus. The doctor inserts a tool into the hysteroscope and then shells out the offending tumors, chipping away at them until only their husks remain. This sort of hysteroscopic myomectomy can be done in an office and does not even count as true surgery, let alone as a bloody horror show. Yet few women hear of the option, one reason being that it requires a skillfulness not all gynecologists command. If your doctor has no experience with hysteroscopic myomectomies, find one who does; the procedure is the best first-line attack against symptomatic fibroids. [Link](yomu://content/annotation/C1C50032-0253-42CE-B250-A518D865D88A) **23/04/2023, 4:41 pm** > Even when the fibroids are inaccessible to hysteroscopic scoop-out, they can be removed abdominally, by opening the uterus, cutting out the fibroids, and sewing the uterus back up again. Now we're talking about major surgery, but if you research the medical literature, you'll find that abdominal myomectomies compare favorably with hysterectomies in factors such as blood loss, postsurgical complications and infections, and healing time [Link](yomu://content/annotation/06E36CF3-86D6-4C1F-A882-36A0C5AA28C5) **23/04/2023, 4:42 pm** > In fact, while it's true that a woman who has fibroids is prone to fibroids, the great majority of the tumors will give no trouble at all, so that even if a new fibroid does appear in the wake of a myomectomy, it will likely be meaningless, the way most fibroids are. Just because one fibroid caused you misery doesn't mean your next one will [Link](yomu://content/annotation/EFCFB639-B458-441D-B50F-C96CB06C5591) **23/04/2023, 4:49 pm** > A woman must know the particulars of her sexual and emotional demesne. If her erotic life is important to her, for example, and her orgasms tend to be deep and pulsating, she should try anything before relinquishing her uterus. We have been schooled in the primacy of the clitoris to female sexuality, but it is the contractions of the uterus and cervix that lend a climax its subterranean vibrato. [Link](yomu://content/annotation/2E2C2809-115B-4CB4-A56C-A8F57CFEB491) **23/04/2023, 5:13 pm** > She may have decided on a "conservative" operation that removes the uterus while leaving the ovaries in place. By saving her ovaries, she thinks, her bio-chemical status will remain stable and she will avoid the threats to heart, bone, and brain that come with an abrupt cessation of ovarian hormones. Unfortunately, there are no guarantees; it turns out that a third of the time the ovaries never recover from the physical trauma of the hysterectomy, and they end up in vivo but inert. Moreover, even when the ovaries survive, a heightened risk of high blood pressure and heart disease remains, possibly because the extraction of the uterus eliminates one source of prostaglandins that help protect blood vessels [Link](yomu://content/annotation/C86F576A-CAC8-4D11-A0E8-CDB26605D302) **23/04/2023, 5:14 pm** > there are plenty of women out there who will testify for each possibility (or shall we say ovarify, given the origins of testify in the word testis, a reference to the male practice of swearing by something while gripping his most sacred possessions?) [Link](yomu://content/annotation/7BFD63F2-3D8D-434D-B5A3-408DB35D44D9) ## 7. CIRCULAR REASONINGS: THE STORY OF THE BREAST [Link](yomu://content/annotation/A866BCE6-905B-4524-8D4F-560FB2EB8750) **23/04/2023, 19:32** > In fact, the swelling of the breasts in pregnant and lactating women occurs quite independently of pubertal breast development, and in a more uniform manner: a small-breasted woman's breasts grow about as much during pregnancy, in absolute terms, as a busty woman's breasts do, which is why the temporary expansion is comparatively more noticeable on a small-breasted woman. For all women, maternal augmentation results from the proliferation and distention of the cells of the ducts and lobules (the dairy equipment), increased blood flow, water retention, and the milk itself. Small-breasted women have the same amount of lactogenic tissue as large-breasted women do—about a teaspoonful per nonlactating breast—and when they lactate, they can make as much milk. Given the functional nature of lactation, it is under selective pressure to follow fairly standardized rules of behavior Womens breast size has noyhing to do with milk production [Link](yomu://content/annotation/11674869-C184-4329-A884-C8CE94E798E1) **24/04/2023, 06:44** > Sarah Blaffer Hrdy has written: "The Latin term for breasts, mammae, derives from the plaintive cry 'mama,' spontaneously uttered by young children from widely divergent linguistic groups and often conveying a single, urgent message, 'suckle me.'" [Link](yomu://content/annotation/BB70B477-FA8C-485A-8ADF-0A5C8116A4CD) **26/04/2023, 06:41** > A mammary gland is a modified sweat gland, and milk is highly enriched sweat. Prolactin, the hormone responsible for milk production, predates the evolution of mammals, originally serving to maintain salt and water balance in early vertebrates such as fish—in essence, allowing fish to sweat [Link](yomu://content/annotation/5F1AEE11-FA55-4452-A446-82EBF4B57031) **26/04/2023, 06:41** > In monotremes, the platypus and the spiny anteater, which are considered the most primitive of living mammals, the milk simply seeps from the gland onto the nippleless surface of the mother's skin, rather as sweat does, and is licked off by the young. [Link](yomu://content/annotation/86E22E9E-CF36-46FA-B6FC-BCFE24B940CC) **26/04/2023, 06:42** > Breast tissue begins to develop early, by the fourth week of fetal life. It grows along two parallel milk ridges, ancient mammalian structures that extend from the armpits down to the groin. Males and females both have milk ridges, but only in females do they receive enough hormonal stimulation later in life to achieve complete breastiness. [Link](yomu://content/annotation/F36317FD-1E82-410D-B909-8BD2FB1F9FAD) **26/04/2023, 06:47** > Early in adolescence, the brain begins secreting regular bursts of hormones that stimulate the ovaries. The ovaries in turn discharge estrogen, and estrogen encourages the body to lay down fat "depots" in the breast. That adipose tissue is suspended in a gelatinous matrix of connective fibers that extend from the muscle of the chest wall to the underside of the breast skin. Connective tissue can stretch and stretch, to accommodate as much fat as the body inserts between its fibers; the connective tissue's spring gives the breast its bounce [Link](yomu://content/annotation/CC65FE75-D678-4A25-BA69-966D924FF654) **26/04/2023, 06:48** > Estrogen is necessary to the aesthetic breast, but it is not sufficient; the hormone alone does not explain the wide variability in breast size. A woman with large breasts does not necessarily have higher estrogen levels than a small-breasted woman. Rather, the tissue of the breast is more or less responsive to estrogen, a sensitivity determined in part by genetic makeup. Among the sensitive, a very small amount of estrogen fosters an impressive bosom [Link](yomu://content/annotation/C9197501-570A-46AC-BC38-F39C4960DDAC) **26/04/2023, 06:49** > Estrogen-sensitive women who take birth control pills may discover that they need bigger bras, while the estrogen-insensitive can swallow oral contraceptives by the foilful and find their breasts unmoved. Even some children are extremely sensitive to estrogen [Link](yomu://content/annotation/B8297CF5-4A23-4A34-841C-18570FCA75B8) **26/04/2023, 06:49** > Berton Roueche, the great medical writer, recounted the story of a six-year-old boy who began growing breasts. Eventually, the source of the hypertrophy was traced to his vitamin tablets. A single stamping machine had been used to punch out the vitamins and estrogen pills. "Think of the minute amount of estrogen the stamping machine passed on to the vitamin tablets," Roueche wrote. "And what a profound effect it had." The boy's breasts retreated on cessation of the vitamin tablets, and his parents could breathe again [Link](yomu://content/annotation/E7AA52BE-F779-4243-8C16-67151B93631C) **26/04/2023, 06:52** > The average brassiere size is a 36B, and it has been since the modern bra was invented about ninety years ago. On television shows like Star Trek, however, every woman of every race, whether human, Vulcan, Klingon, or Borg, is as bold in bust as in spirit, and no cup less than C will be cast [Link](yomu://content/annotation/C9FDD841-949C-4258-BF80-574AD82CEEC4) **29/04/2023, 06:26** > Estrogen also helps spur the elaboration of the practical breast, the glandular tissue that presumably will soon secrete its clouded, honied sweat. A series of firm, rubbery ducts and lobes begin threading their way through the fat and ligamentous glue. Each breast usually ends up with between five and nine lobes, where the milk is generated, and each lobe has its independent duct, the conduit that carries the milk to the nipple. The lobes are subdivided into about two dozen lobules, which look like tiny clusters of grapes. The lobes and lobules are distributed fairly evenly throughout the breast, but all the ducts lead to a single destination, the nipple. As the ducts converge on the nipple, curling and bending like snakes or strands of ivy, their diameters widen. The circuitry of lactation follows the hydrodynamic pattern that we recognize from trees, or the veins in a leaf, or the blood vessels in the body. The lobes and lobules are the foliage, the fruits and leaves, while the ducts are the branches, thickening into a braid of trunks. But while in a tree or the body's vasculature the fluid of life is pumped from the widest conduit out to the narrowest vessel or vein, here the milk is generated in each tiny lobular fruit and pulsed to the spacious pipeline below. The ducts perforate the skin of the nipple, and though these portals ordinarily are concealed by the warty folds of the nipple tip, when a woman is nursing her nipple balloons out and looks like a watering can, each ductal hole visible and visibly secreting milk. > > The ducts and lobules do not fully mature until pregnancy, when they proliferate, thicken, and differentiate. Granular plugs the consistency of ear wax, which normally keep the ducts sealed up, begin breaking down. The lobules sprout microlobules, the alveoli. The dairy farmers commandeer the breast. They push fat out of the way to make more room for themselves. The breast gains as much as a pound while lactating. The areola, that pigmented bull's-eye surrounding the nipple, also changes markedly in pregnancy. It darkens and seems to creep down the hillock of the breast, like lava spreading slowly from the peak of a volcano. The areola is permeated by another set of modified sweat glands, the little goosebumps called Montgomery's glands, and the bumps multiply in the maternal breast and exude lubricating moisture to make the sensation of suckling bearable. After weaning, the lobules atrophy, the ducts regress, the areola retreats, and the fat reclaims dominion over the breast—more or less. Women who breastfeed their children often complain that their breasts never recover their former bounce and bulk. The fat grows lazy and fails to reinfiltrate the spaces from which it was edged out by the gland. The aesthetic breast is a bon vivant, after all, a party favor. For reliability, look to the ducts and lobules. They'll return when needed, and they're not afraid to work up a sweat I just love how she describes things… making them more understandable. Visual. [Link](yomu://content/annotation/95D6DD6A-F4DB-4E93-9E3A-5DE0C3CD02C2) **29/04/2023, 06:29** > So too do the Amazons, those mythical female warriors who lived apart from men, consorting with them once a year solely for the sake of being impregnated, and who reared their daughters but slayed, crippled, or abandoned their sons. The Amazons are most famed for their self-inflicted mastectomies, their willingness to cut off one breast to improve their archery skills and thus to resist conquest by the male hordes surrounding them. For men, Yalom writes, "Amazons are seen as monsters, viragos, unnatural women who have misappropriated the masculine warrior role. The missing breast creates a terrifying asymmetry: one breast is retained to nurture female offspring, the other is removed so as to facilitate violence against men." For women, the Amazon represents an inchoate wish, a nostalgic longing for the future. "The removal of the breast and the acquisition of 'masculine' traits suggests this mythic Amazon's desire to be bisexual, both a nurturing female and an aggressive male, with the nurturance directed exclusively toward other women and the aggression directed exclusively toward men." [Link](yomu://content/annotation/A192DA6A-B19C-4B0D-990B-69E35AFEC796) **29/04/2023, 06:35** > Early scientists too had to have their say on the breast. In the eighteenth-century, Linnaeus, the ever-colorful Swedish taxonomist, paid the breast a dubious honor by naming an entire class after it: Mammalia, literally "of the breast," a term of Linnaeus's invention. [Link](yomu://content/annotation/13F06837-A759-4D4B-AF1F-A1FD7EFD225B) **29/04/2023, 06:35** > In the same volume in which Linnaeus introduced the term Mammalia, he also gave us our species name, Homo sapiens, man of wisdom, the category distinguishing humans from all other species. "Thus, within Linnaean terminology, a female characteristic (the lactating mamma) ties humans to brutes, while a traditionally male characteristic (reason) marks our separateness," Schiebinger writes. [Link](yomu://content/annotation/E3462DFD-712C-45B2-9BB4-0871F623FA55) **29/04/2023, 06:48** > High cheekbones, a high butt, and a high bosom are nice, but none should be viewed as the sine qua non of womanliness. If breasts had something important to say, they would be much less variable and whimsical than they are. They would be like mere mammary glands, a teaspoon per breast per woman. If breasts could talk, they would probably tell jokes—every light-bulb joke in the book. [Link](yomu://content/annotation/ED5F3B49-B968-4986-93A8-ACECFFC71078) ## 8. HOLY WATER: BREAST MILK **30/04/2023, 08:08** > The milk of a Greek goddess was said to confer infinite life on those who drank it. When Zeus sought divinity for his son Hercules, born of an adulterous affair with the mortal Alcmene, he sneaked the infant into the bedroom of his sleeping wife, Hera, and put him to her breast for a taste of infinity. A musclehead from the start, Hercules suckled so hard that Hera awoke, and she shook him off in outrage, spurting milk across the skies—hence the Milky Way. Hercules already had swallowed enough, though, to join the ranks of the immortals. [Link](yomu://content/annotation/8A6C73E7-5137-478A-86BA-063D0BB48AC2) **30/04/2023, 08:09** > As Valerie Fildes describes in her classic study, Breasts, Bottles, and Babies, the Ebers papyrus of the sixteenth-century B.C. recommended human milk as a treatment for cataracts, burns, eczema, and "expelling noxious excrements in the belly of a man." [Link](yomu://content/annotation/3A12A6CE-9F2F-45C9-BE47-C801E12FAAA5) **30/04/2023, 08:12** > The placenta and the mammary gland have much in common. They are specialists, and they are temporary workers. They are designed to nourish a baby. No other organs are so fleeting, so single-minded, as the placenta-mammary dyad. They exist only for the baby, and if the baby does not call on them, they are retired. They are expensive organs, and they are not maintained unless absolutely necessary [Link](yomu://content/annotation/C8E96E37-C353-4344-8243-A008790356B2) **30/04/2023, 08:15** > Milk production begins midway through pregnancy. The foliate lobules where milk is made thicken, proliferate, and surround the ducts until you can't see the ducts for the leaves. At the tips of the lobules, the alveolar cells quiver and distend and begin secreting a yellowish fluid of protein and carbohydrates, the colostrum. Some of it may make its way to the nipple and ooze out, but most gets reabsorbed in the ducts; there's no reason for it to go anywhere yet. The alveoli are simply making a dry wet run. Many hormones contribute to the glandular expansion, and to keeping the sequence sensible. Progesterone stimulates the division and maturation of the alveolar cells, but it also prevents them from getting ahead of themselves. If not for the high levels of progesterone (and to a lesser extent estrogen) that characterize pregnancy, the alveolar cells would pay heed to another hormone, prolactin, the breastfeeder's friend. During pregnancy, the pituitary gland, at the base of the brain, begins releasing evermounting quantities of prolactin. Prolactin urges the alveolar cells to synthesize milk. Progesterone counsels delay. For as long as gestation lasts, progesterone wins. [Link](yomu://content/annotation/CB70C73A-B8C6-4234-9477-EB24674592AE) **30/04/2023, 08:16** > After delivery, progesterone and estrogen levels drop precipitously. For some women, the hormone crash leads to temporary depression and stasis, but for their mammary glands the change is bracing. The alveolar cells are freed to take up the circulating prolactin, and they absorb it greedily. At first they make what they are accustomed to making: colostrum, the sticky fluid of protein, carbohydrates, and other ingredients. But no fat—that comes later. Colostrum is yellow because it's rich in carotenoids, the same compounds that give carrots and squash their yellow-orange tint and that are needed to make the A and B vitamins. Colostrum is ten times richer in carotenoids than mature milk will be. If it looks like pus, it also acts like pus: colostrum contains a wealth of white blood cells and antibodies, as pus does, and it helps a newborn, whose immune system has yet to mature, resist the pathogens that will be more than happy to attack it. Colostrum is also rich in the loosened epithelial tissue that had kept the ducts plugged. [Link](yomu://content/annotation/3AA40D16-D70F-4D2F-84C6-979AFF85B21A) **30/04/2023, 08:17** > What is milk? How does a fluid earn its milk stripes? By definition, milk is the product of the mammary gland, just as gastric juice is the product of the stomach and saliva the product of the salivary glands. [Link](yomu://content/annotation/739DC400-9290-4EE6-8876-362F961F4CEA) **30/04/2023, 08:18** > Animals that must put on a lot of fat in a short amount of time drink fatty milk. Perhaps the fattest milk in nature is elephant seal milk, which is fatter than butter. An elephant seal pup has but four weeks to suckle, and as it does it expands from its birth weight of seventy-five pounds to a weaning weight of three hundred pounds. For her part, the mother eats nothing the entire time, and so loses six hundred of her fifteen hundred pounds. As one scientist put it, she essentially slices a slab of blubber from herself and slaps it onto her young. [Link](yomu://content/annotation/A006BC5C-DDC2-491E-92F1-EA2311301A85) **30/04/2023, 08:19** > Humans grow slowly, and our milk is among the least proteinaceous mammary product around. Rat's milk has twelve times the concentration of amino acids of human milk. Cow's milk is four times protein-heavier than our milk, which is the main reason that you can't give a baby cow's milk without first processing it into infant formula. A newborn's immature kidneys are not equipped to handle the high protein content of cow's milk. A human infant could handle the milk of a gorilla, chimpanzee, or orangutan, however. The milk of great apes is quite similar to our milk in every aspect that has been examined. [Link](yomu://content/annotation/7617289A-7C00-454F-8436-30A1DFB65E3E) **02/05/2023, 15:10** > A malnourished woman in a developing country generates surprisingly nutritious milk, while a chubby woman in the Midwest does not have comparatively high-calorie milk. "One of the things about lactation that is an endless source of fascination to those of us who study it," says Peter Reeds, a professor of pediatrics at Baylor College of Medicine, "is the remarkable ability of lactating mammals, humans included, to preserve a narrow range of milk composition in the face of even a disadvantageous diet." If a woman is not eating what she needs to maintain that perfect formula, the mammary gland borrows from her body stores, the 7-Eleven that never closes. At the same time, the woman does not sacrifice quite as much as might be expected, for breast milk has evolved through compromise. The mother gives, but she does not give to the point of risking her future health and fertility. Breast milk is designed to be maximally exploited without maximally exploiting. [Link](yomu://content/annotation/C271E34E-BF40-4C0F-BE3D-A2E9F68DFDBE) ## 9. A GRAY AND YELLOW BASKET: THE BOUNTEOUS OVARY **03/05/2023, 06:00** > THE OVARY IS no beauty. Most internal organs jiggle and glow and are rosy pink. The ovary is dull and gray. Even a healthy ovary looks sickly and drained of blood, as though it had given up hope. It is the size and shape of an unshelled almond, but a lumpy and irregular almond. It is scarred and pitted, for each cycle of ovulation leaves behind a white blemish where an egg follicle has been emptied of its contents. The older the woman, the more scarred her pair of ovaries will be. One might argue that the ovaries are no less visually appealing than the male equivalent, the testicles, but that is hardly high praise; recall that Sylvia Plath in The Bell Jar likened testicles to poultry gizzards. [Link](yomu://content/annotation/F160005A-6A4F-494A-B8A0-02ECB4CD51AA) **03/05/2023, 06:01** > We have looked at the egg. We turn now to its basket. [Link](yomu://content/annotation/766E88E0-9D88-4D81-982E-997CEF2FC4DE) **03/05/2023, 06:08** > Far from being dull, the cycle is dynamic and athletic. In describing it, I run the risk of sounding like a Victorian anatomist. Those scientists were astounded by the ovarian cycle. Some were simply fascinated by it; others were disgusted by it. All wrote gothically of it, and found in the monthly follicular rupturing and oozing yet another reason to pity the fairer, better, bruised and battered sex. Rudolf Virchow, the father of modern pathology, compared the bursting of the follicle to teething, with the egg forcing its way to the surface of the ovary as a tooth bud pokes through the gums, causing pain and "the liveliest disturbance of nutrition and nerve force." French doctors likened ovulation to the rupture of an acute abscess, while Havelock Ellis saw the monthly release of an egg as a "worm" that "gnaws periodically at the roots of life." In the eyes of the historian Jules Michelet, Thomas Laqueur writes, "woman is a creature 'wounded each month,' who suffers almost constantly from the trauma of ovulation, which in turn is at the center of a physiological and psychological phantasmagoria dominating her life." The ovary may be an almond in size, but for the voyeurs among Victorian physicians, it certainly was no almond of joy. [Link](yomu://content/annotation/D70265CB-B337-4662-9EAB-6AABF6456AC3) **03/05/2023, 06:09** > To me, the swelling of the ovarian follicle and its release is less ghoulish, less an act of carnage, and more in keeping with many acts of reproduction, sexual optimism, and high emotion. The follicle swells like a lobule in the breast swells with milk, or like the tear ducts swell with water and salt, or like the genitals congest during arousal—and then whoosh, the tension is released, and the lively fluids overspill their bounds [Link](yomu://content/annotation/446C47E2-DA01-44EF-B3A4-9EC2B503D0F1) **03/05/2023, 06:10** > the ovulatory cycle (which we generally call the menstrual cycle because we can see the blood but we can't see the egg). [Link](yomu://content/annotation/15CA5826-6F3E-48BE-BF90-589B52304497) **03/05/2023, 06:15** > Any woman who has ever used an ovulation predictor kit in an attempt to get pregnant knows of the LH surge, because it is the detection of the surge that tells her, Have sex today, as soon as possible; your egg is ready to pop. Whether the surge is the ideal event to shoot for is open to question, though. A large study of fertility patterns published in 1995 revealed that the day of ovulation is the last possible time for conception to occur, and that most pregnancies are the result of intercourse that took place one, two, up to five days before ovulation; sperm is built to endure for days and may need time to reach the egg. The finding was surprising. Fertility experts had thought that you had at least a day and maybe two after the rupturing of the follicle to conceive, but no, the emancipated egg is either too sensitive for this world or a Mussolini for punctuality. In any event, its extrafollicular lifespan is no more than a few hours. Thus, if you wait for the LH peak to have sex, the sperm may well arrive too late. The party is over. The egg has passed out.) [Link](yomu://content/annotation/83766FF5-DF53-4685-841B-814BE1ED163D) ## 10. GREASING THE WHEELS: A BRIEF HISTORY OF HORMONES **03/05/2023, 08:24** > Hormones have effects, they have failings, they have meanings. Hormones are far more important than most of us realize, but not in the ways that most of us think. [Link](yomu://content/annotation/89260255-0E27-4B88-A99F-598AD28B42EA) **03/05/2023, 08:25** > We want to explain ourselves to ourselves, and hormones look like a clean and quantifiable way to do so, to distinguish male from female, competitor from cooperator, domesticated from feral. We are incorrigible categorizers. [Link](yomu://content/annotation/780FF229-B714-4173-B993-E536C89A2371) **03/05/2023, 08:26** > In the past, hormones were talked of as keys, each designed to fit into a specific receptor—the metaphorical lock—located on different tissues of the body and brain. In so fitting, a hormone would swing wide the door to a defined suite of behaviors and reactions. Now the metaphor has rusted. It turns out that the body offers up multiple locks to the pryings of any given hormone, and sometimes the hormones exert their might without the need for any lock at all. Instead they can ramrod their way through from blood into tissue, or slip in between the cracks, leaving us agog once more at how potent, how exquisite, and how crude these chemical emissaries can be. [Link](yomu://content/annotation/6049A49A-68A7-4D1A-9BE1-B5321FD26A3E) **03/05/2023, 08:27** > Hormone comes from the Greek horman, which means to arouse, to excite, to urge. This is what a hormone does. It excites. It urges, though sometimes what the hormone urges is a sense of calm, a call to rest. By the classic definition, a hormone is a substance secreted by one tissue that travels through blood or another body fluid to another tissue, whereupon the hormone arouses the encountered tissue to a new state of activity. [Link](yomu://content/annotation/DD41BB9F-CC7E-4380-BEFF-D597075AB6B1) **03/05/2023, 15:26** > Steroids are ancient in nature and play communicative roles in many organisms. Molds secrete steroids. A female mold releases a steroid hormone that will induce a neighboring mold to grow the equivalent of male reproductive organs. Once the solicitee has complied with the request and enmaled himself, he releases another steroid hormone into his surroundings, which induces the female to grow toward him. Come and get it! he cries, and she comes, and she gets it [Link](yomu://content/annotation/E106A228-E0C9-42E4-BAD7-BC3B481388B0) **04/05/2023, 06:27** > Pigs love steroid hormones; during courtship, a male pig will spit on his sowheart's face and in so doing expose her to a pungent steroid compound that causes her to freeze with rear legs conveniently parted. All of which might help explain the now quaint term male chauvinist pig—yessir, a bit of spit and the little woman is yours! [Link](yomu://content/annotation/EEE23545-085C-4F18-B478-63756BBDEF19) **04/05/2023, 06:28** > There are hundreds, if not thousands, of varieties of steroid and steroidlike hormones in nature. By definition, a steroid hormone is an elaboration of that ubiquitous and unfairly maligned molecule cholesterol [Link](yomu://content/annotation/FE407731-2E37-4273-A2AB-7DE5D7645E66) **04/05/2023, 06:28** > Cholesterol is a steroid in structure, but it is a no-frills steroid and not in itself a communications vehicle. Only with chemical embellishment does it assume the mercurial role of hormone [Link](yomu://content/annotation/00F19ABB-A041-4413-919D-EE38543A0928) **04/05/2023, 06:28** > All steroid hormones in vertebrates are built of cholesterol. The choice of cholesterol as the foundation for these hormones makes sense, because the body brims with it. Even if you never touch cholesterol-rich food such as eggs, oil, and meat, your liver continues to make cholesterol around the clock, and with reason. Cholesterol is an essential component of the plasma membrane, the fatty, protective coat surrounding every cell. At least half of the average cell's membrane consists of cholesterol, much more than half in neurons. Without cholesterol, your cells would fall apart. Without cholesterol, new cells could not be manufactured. There would be no way of replacing the cells of the skin, gut, and immune system, which die by the millions each day. Cholesterol is the fat of the earth and the fat of the brain. [Link](yomu://content/annotation/019FC37F-BD9D-4A5D-8626-975D652C7F4E) **04/05/2023, 06:31** > The role of the testicles in cultivating the many changes of puberty also was known for centuries. Boys with promising soprano voices were accordingly gelded before adolescence to prevent their vocal cords from thickening and their pitches from lowering. According to contemporary accounts, the best of the castrati were magnificent to hear, for they combined the sweetness and luster of a woman's timbre with the power afforded by a man's comparatively large lungs. Castration mania reached a peak in the seventeenth and eighteenth centuries, when thousands of parents had their sons orchiectomized in hopes of stardom and wealth; ever and obnoxiously are stage parents among us. But by the nineteenth century, tastes and operatic singing techniques had changed, and the diva soprano supplanted the castrato as the keeper of the angel's registers. [Link](yomu://content/annotation/15DBAAD3-8701-43F4-9348-8C888F7B6B15) **04/05/2023, 06:33** > Castration continued in the laboratory, however, as Arnold Adolph Berthold fathered the modern science of endocrinology in the mid-nineteenth century with a series of landmark rooster experiments at the University of Gottingen. He removed the testicles of young male chickens, an operation that if allowed to run its course would give rise to capons. Famed among poultry fanciers for their soft and flavorful flesh, capons lack the plumage, sexual bombast, and tendency to crow exhibited by full-fledged roosters. But Berthold's birds didn't stay neutered for long. He took the excised testicles and implanted them inside the young birds' bellies, and lo, the birds matured into perfectly normal roosters, all crest, comb, and cock-a-doodle-do. Dissecting the animals, he observed that the transplanted gonads had taken root in their new position, doubled in size, and sprouted a blood supply; they were even filled with sperm, as adult testes should be. Because the nerves to the testes had been irreparably damaged in the course of the transplantation, Berthold concluded that the testicles were not exerting their impact on the body by grace of the nervous system. Instead, he correctly surmised, some sort of substance, some eau vitale, must be traveling from the gonadal tissue through the bloodstream to other parts of the body, thus transforming cockerel into cock. What that substance might be he had no way of determining. [Link](yomu://content/annotation/7F3FAE04-8CD1-4B86-BFAD-867C598B14A7) **04/05/2023, 06:34** > Estrone is an estrogen, the family of hormones that we call female hormones, although both sexes—all sexes—have them. There are at least sixty forms of estrogen in the body, any body, but three hold sway: estrone, estradiol, and estriol. They are named for the number of hydroxyl groups (pairs of hydrogen and oxygen atoms) that festoon each hormone's torso. You can teach your baby daughter to count with estrogens. Estrone has one hydroxyl group, estradiol two, and estriol three. Counting hydroxyl groups is a chemist's way of naming names, not a biologist's; the number of hydroxyl groups doesn't predict anything about the molecule's behavior. More doesn't mean better, fewer doesn't mean duller. But the chemists got there first, so they got to play Adam. [Link](yomu://content/annotation/677AD38D-8D16-4B54-A1EA-EBBC78542C03) **04/05/2023, 06:36** > Estrogens were the first, and they remain, in their way, the finest. They have grown more interesting with time, not less. They are part angel, part anarchist. Estrogens keep us healthy and make us sick. They build our breasts and then corrupt them with tumors. They ripen eggs and nurture new life in the womb, but they also give rise to those ropy purple fibroids that can expand like zucchinis or pumpkins, until we cry aunt and have the uterus abolished. In 1929 chemists isolated the world's first hormone, estrone [Link](yomu://content/annotation/6F1AD1D5-653E-47F4-A927-2245BF15549A) **04/05/2023, 06:38** > How difficult it is to keep track of the contradictions. We are told that women in the industrialized world are steeped in too much estrogen, all kinds of estrogen; that what with our excess fat, our perpetual menstrual cycles rarely broken by pregnancy or lactation, our birth control pills, our taste for alcoholic libations, even estrogenic chemicals in our surroundings, we end up being exposed to far more of the hormone than our ancestors ever were, and this abundance is bad and a source of disease. Then we are told that we don't get enough estrogen, that we weren't supposed to live much past menopause, when our ovaries stop serving up significant doses of estrogen. Therefore we need to take estrogen supplements for years and years. We are told that estrogen keeps our hearts strong, our bones sturdy, and our wits sharp: estrogen as a Marvel comics superheroine. Can we therefore discard the old image of estrogen as the hormone that makes women tender, softhearted, practically filleted? [Link](yomu://content/annotation/E02744C4-59CA-4B3A-B451-947AD9559DF1) **04/05/2023, 06:39** > I admire estrogen because it is so obliging of our demands and our capriciousness. It is our scapegoat, our whipping bitch. Over the years it has been demonized, glorified, excommunicated, and resurrected, and just like a woman, it can still take a joke. To appreciate estrogen, we need to begin by separating estrogen the hormone—what we know and what we don't know about its powers and constraints—from estrogen the parable, the imagined ingredient in Wicca's medicine chest, source of lunacy and the malign feminine. [Link](yomu://content/annotation/0AEAA688-A0CB-45B4-98CE-9D80D843B55B) **04/05/2023, 06:40** > The estrogens are called female hormones, and that is partly inaccurate and partly reasonable. From the age of twelve through fifty, women have three to ten times more estrogen circulating through their bloodstream than men do. In middle age, men and women become closer estrogenic kin, for not only do a woman's levels of the hormone drop, but a man's gradually rise. [Link](yomu://content/annotation/9380847A-9321-45AC-BA73-AECFE8EB796C) **04/05/2023, 06:42** > Roughly speaking, the different estrogens are produced by different tissues of the body, though there's a lot of overlap, redundancy, and the usual unknowns about who does what when and to what end. Estradiol, the principal estrogen of our reproductive years, is the product of the ovaries. It flows out of the cells of the follicles and from the corpus luteum, the yellow matter that forms like a blister on a ruptured follicle. Estradiol is considered the most potent of the three estrogens, at least according to standard assays of estrogen activity—that is, it makes a rat's vagina cornify so clearly it looks like the waving fields of Iowa. Estriol is generated by the placenta and to a lesser extent by the liver. It is the major "pregnancy estrogen," the source of any charming gestational glow you might have—if you aren't green with nausea. As mentioned above, the placenta also synthesizes estrone. So too does adipose tissue. Fat women often are spared overt symptoms of menopause such as hot flashes and covert ones such as thinning bones; even as their ovaries cease the monthly efflux of estradiol, their peripheral tissue compensates by manufacturing estrone. Very muscular women fare well in menopause too, not only because they're fit and their hearts are hardy and their bones are strengthened by years of weight-bearing exercise, but also because muscle makes modest amounts of estrone. For any postmenopausal woman who forgoes patches or conjugated extracts of horse piss, estrone will be the predominant estrogen until departure [Link](yomu://content/annotation/0E9DE6A3-1038-4EC1-A28C-533B666F4EA6) **04/05/2023, 06:43** > This is a lesson learned only recently, that the body makes and consumes estrogen globally. During the golden age of hormone research, scientists thought that they didn't need to look beyond the gonads: the ovaries made estrogen, the testes made testosterone. Hence the term sex steroids. They thought that the gonads made sex steroids to do sexy things, or rather reproductive things—to control ovulation, for example, and thicken the uterine lining. But no, estrogen's role is not limited to good breeding. The body makes estrogen everywhere, and the body eats estrogen everywhere. Bones make estrogen, and bones eat estrogen. The blood vessels make estrogen and devour estrogen. The brain makes estrogen, and it responds to estrogen in ways we are only beginning to understand. The body loves estrogen. It chews it up and then demands more. The half-life of estrogen' is brief, maybe thirty to sixty minutes, and then it is broken down, to be recycled or eliminated. But there's always more, produced and consumed locally or disseminated transcorporeally [Link](yomu://content/annotation/C316381F-E2ED-482F-B85A-DA432FCA645B) **04/05/2023, 06:44** > Here is what we've learned about the pervasiveness of estrogen. To make estrogen, you need an enzyme called aromatase. With aromatase, a tissue of the body can transform a precursor hormone into estrogen. The precursor may be testosterone—yes, the "male" hormone, which women make in their ovaries, their adrenal glands, and possibly in places like the uterus and the brain. Or the precursor can be another androgen, like androstenedione, a hormone that deserves much deeper scientific understanding than it currently can claim. Who knows but that androstenedione is an amplifier of female aggression and anger? Suffice it to say here that women generate androstenedione in the ovaries and adrenals, and that androstenedione can, through the mediating activity of aromatase, be transmuted into the bittersweet cordial estrogen. [Link](yomu://content/annotation/B5E2C210-20FB-4919-AA44-3E6768FF8D8B) **04/05/2023, 06:46** > Even as most systems of the body slide into decrepitude, aromatase activity picks up its pace, becoming ever more efficient at converting precursors into estrogen. That could explain why older men are more estrogenized than their younger counterparts, and why postmenopausal women don't crumble, don't lie down and die, just because their ovaries no longer give them monthly estradiol highs. Their breasts, bones, blood vessels, are yet creating estrogen [Link](yomu://content/annotation/61A7E412-A8DF-4EF7-B10D-C732E4CCB2C3) **04/05/2023, 06:47** > But it is not enough to make estrogen. The means to understand the hormone must be present too. Estrogen speaks to the body through an estrogen receptor, a protein that recognizes it and surrounds it and then changes shape, as a blanket's shape is changed when someone is lying beneath it. In its altered shape, the receptor activates genetic changes within the cell, turning some genes on, others off [Link](yomu://content/annotation/CADF0EDE-F887-4A79-BEE2-5D706A505DB5) **04/05/2023, 06:47** > So we know that a given organ is sensitive to estrogen if the cells of that organ contain estrogen receptors. And we are, it seems, outlandishly sensitive to estrogen. As aromatase is everywhere, so too are estrogen receptors. Look in the cells of the liver, bone, skin, blood vessels, bladder, brain. Look anywhere; estrogen receptors are everywhere. The trick nowadays, says Benita Katzenellenbogen, who has studied estrogen biochemistry for twenty-five years, is to find a tissue that doesn't have estrogen receptors. Maybe the spleen, she shrugs [Link](yomu://content/annotation/49305448-5A25-4972-99F9-71130F1D7F42) **04/05/2023, 06:48** > In 1996 scientists realized that we have not just one type of estrogen receptor, as they had thought for decades, but two, each a distinct molecular character but each capable of clasping estrogen and allowing the cell to react to the hormone. The proteins are called estrogen receptor-alpha and estrogen receptor-beta. Some cells of the body are alpha-rich, some beta-rich, some doubly blessed. And within any given cell there may be thousands of copies of each receptor type. Thousands of alpha receptors, thousands of betas. In some cells, tens of thousands. That's why it takes so little hormone to get such a big response: entire armies of receptor proteins stand ready and able to detect whatever tiny amount of estrogen may be floating by. [Link](yomu://content/annotation/A1CEC583-67FA-486B-B0E3-D0FD881319C0) **04/05/2023, 06:49** > In different tissues, estrogen receptors do very distinct things—that is, they turn on a different set of genes in the liver than they do in the bone or the breast or the pancreas. [Link](yomu://content/annotation/0964413C-1DB2-4D26-890A-211F3FBBA88E) **04/05/2023, 06:50** > Estrogenesis, Part 17. Once again we've underestimated our steroid heroine. Estrogen, it turns out, doesn't need a receptor to make itself understood. Yes, it connects with alpha and beta. But that connection and the consequent shape-shifting of the receptors take time. Estrogen also can work almost instantaneously. It may, for example, rattle cell membranes just by touching them. As estrogen drifts through a cell membrane, it briefly opens tiny pores that allow ions to flow into and out of the cell. The membrane's charge changes— zap!—but then quickly reverts. For most tissues of the body, such transient fluctuations mean nothing. But for some organs, flux is the crux of strength [Link](yomu://content/annotation/E5FB86CD-FBF6-4C43-8833-82F49582DABA) **04/05/2023, 06:53** > The man was twenty-eight years old and six foot nine and sick of being asked if he played basketball. He didn't. He couldn't. His knees were too knocked, his feet were too splayed, and his gait was too awkward. What he could and did do was keep growing. He'd grown an inch since he was twenty-six. He wore a size 19 shoe, six sizes bigger than the biggest shoe you can find in an ordinary men's footwear department. And as the man grew, his gait worsened, which is why he finally consulted a doctor. The doctor referred him to an endocrinologist, who determined that the young man had bones that were both too young and too old for him. Too young, because the ends of them hadn't fused together, as they usually do in late adolescence; too old, because the bone shafts were full of holes. He had a serious case of osteoporosis. He had other problems as well, including insulin resistance like that seen in a diabetic. His blood estrogen levels were elevated, but he wasn't feminized, the way men are when they have a disease that results in excess estrogen production; he didn't have gynecomastia, and his voice wasn't high. He looked like a very tall, knock-kneed, but indisputably masculine fellow. > > Eventually he ended up in the office of Dr. Eric P. Smith of the University of Cincinnati College of Medicine, who saw in the patient's symptoms evidence of what medicine had thought was impossible: the man was deaf to estrogen. Smith knew about experiments with mice at Rockefeller University. The researchers had created genetically engineered mice that lacked estrogen receptors. They were so-called ERKO mice—their Estrogen Receptor genes had been Knocked Out, or deactivated. The biologists had worried that such a manipulation would prove fatal—that without the ability to respond to estrogen, the ERKO mice would die in utero. But no, they lived, they were born, they seemed just about normal. Smith decided to check his patient's DNA to see whether his estrogen receptor genes were mutated as well. Had nature done to this man what the Rockefeller researchers had done to their mice? Nature had. Both copies of the tall man's estrogen receptor gene were defective. The genes couldn't direct the synthesis of estrogen receptor protein. The man had aromatase, so he made estrogen, plenty of it. But he couldn't make estrogen receptors. All that estrogen was going to waste, falling on cellular ears that could not hear. > > From the first recorded case in history of an absence of estrogen receptors, Smith and his colleagues concluded several things, which they reported in the New England Journal of Medicine: that estrogen is essential to the maturation and preservation of bones not only in women, as had been known, but also in men; that estrogen metabolism affects glucose metabolism and therefore the risk of diabetes; and that, contrary to dogma, estrogen is not essential to fetal survival. Fetal mice don't need it, and fetal humans don't need it. Estrogen, we overrated you. > > "What the evidence now suggests," says Evan Simpson, of the University of Texas, "is that estrogen doesn't seem to be important to fetal development, but that it is more important than we thought to maintaining the body later in life." [Link](yomu://content/annotation/3315D5BF-78A0-4C38-A3AC-15918D71D9A2) **04/05/2023, 06:55** > Before we dismiss estrogen as an embryonic incidental, let's recall the latest finding: that genes have not one but at least two estrogen receptors. The man with no estrogen receptors and the mice who donated theirs to science turn out to lack only the alpha estrogen receptor. They still have their beta estrogen receptors, and so they may not be as unresponsive to estrogen as originally supposed. Nature loves redundancy. If something is critical enough, nature hires understudies. The understudies may not be perfect, but they'll do in a pinch. Estrogen receptor-beta is unquestionably a poor preserver of adult skeletal mass, and so the man with no alpha receptors has bones that look like kitchen sponges [Link](yomu://content/annotation/78407FE8-078E-4CDB-B56B-80341C9D32E5) ## 11. VENUS IN FURS: ESTROGEN AND DESIRE **05/05/2023, 6:08 am** > A FEMALE RAT can't mate if she is not in estrus. I don't mean that she doesn't want to mate, or that she won't find a partner if she's not in heat and sending forth the appropriate spectrum of olfactory and auditory enticements. I mean that she is physically incapable of copulating. Unless she is in estrus, her ovaries do not secrete estrogen and progesterone, and without hormonal stimulation, the rat can't assume the mating position known as lordosis, in which she arches her back and flicks aside her tail. The lordosis posture changes the angle and aperture of the vagina, making it accessible to the male rat's penis once he has mounted her from behind. There is no rat's version of the Kama Sutra. An ovariectomized female won't assume lordosis, and hence she can't mate—unless, that is, she is given hormone shots to compensate for the loss of the natural ablutions of the ovarian follicle. [Link](yomu://content/annotation/A60ABF43-FD9C-48D6-AB07-EADEA08D06A2) **05/05/2023, 6:08 am** > In a female guinea pig, a membrane normally covers the vaginal opening. It takes the release of sex hormones during ovulation to open up the membrane and allow the guinea pig to have sex. What do other animals do? [Link](yomu://content/annotation/0399B80A-B1AD-426C-9D6C-EC49483F2D19) **05/05/2023, 6:08 am** > For both the rat and the guinea pig, as well as for many other female animals, mechanics and motivation are intertwined. Only when she is in heat is the female driven to seek a mate, and only when she is in heat can her body oblige her. Estrogen controls her sexual appetite and sexual physics alike. [Link](yomu://content/annotation/08293759-9A50-400E-9399-B763F35D0942) **05/05/2023, 6:11 am** > In a primate, Wallen continues, hormone pulses may not make the female bow down in lordosis, but they clearly influence her sexual motivation [Link](yomu://content/annotation/17F28454-CFEF-4C62-AD76-DB2C3F016C9B) **05/05/2023, 6:13 am** > When a female rhesus is alone with a familiar male and no other monkeys are there to spy on her, she will mate with the male regardless of where she is in her breeding cycle. But a female under the constraints of the social group does not have the luxury of freewheeling carnality. If she sidles up to a male and begins engaging in a bit of heavy petting, other group members strive to intervene, raucously and snappishly. A female rhesus doesn't often bother defying convention. What does she look like, a bonobo? > > Hormones change everything. They tint her judgment and sweep her from Kansas to Oz. When she is ovulating and her estrogen levels soar, her craving overcomes her political instincts and she will mate madly and profligately, all the while out-snarling those who would dare to interfere [Link](yomu://content/annotation/D29315F9-468F-4671-AE91-EA13D16008AF) **05/05/2023, 6:25 am** > In a study of young women who spent a lot of time dancing in nightclubs, the scientists found that as the women approached the day of ovulation, their outfits became progressively skimpier, more flaunting of flesh: the hemlines rose with estrogen levels as if with a bull market. (Of course, it doesn't hurt that midcycle is also the best time to wear your tightest and most revealing clothing, as that is when you are free of premenstrual water retention and blemishes and any fear of leaking menstrual blood.) [Link](yomu://content/annotation/B178E513-3AE5-4DB2-B189-55D26209793B) **05/05/2023, 6:25 am** > A number of researchers lately have suggested that it is testosterone, not estrogen, that is the "true" hormone of libido, in men and women alike. They point out that the ovaries generate testosterone as well as estrogen and that androgen levels spike at midcycle just as estrogen levels do. How can we neglect testosterone when men have so much of it and men love sex so madly, don't they? Many textbooks on human sexuality declare flatly that testosterone is the source of all lust, and some women have added testosterone to their hormone replacement regimens in an effort to shore up their ebbing libido. But if testosterone is relevant to female lust, evidence suggests that it is as a handmaiden to estrogen rather than as Eros descended [Link](yomu://content/annotation/8EF854C2-C74E-494D-B4B0-8CB0334F07F1) **05/05/2023, 6:27 am** > If estrogen is to help at all, it should help us best when our minds must be wonderfully concentrated. Ovulation is a time of danger and of possibility. Estrogen is like hunting magic, the hallucinogenic drug that Amazonian Indians extract from the skin of the poison-dart frog to lend them the sensorial strength of heroes [Link](yomu://content/annotation/9FF35E0F-2C43-4677-81B4-7F937BD84CD5) **05/05/2023, 6:28 am** > But estrogen is also at the behest of history and current affairs. If you are in a sour, reclusive mood to begin with, the hump of estrogen at ovulation, or its unopposed premenstrual energy, may make you feel more rather than less reclusive. Estrogen is a promoter, not an initiator. We can understand this by considering how estrogen contributes to breast cancer. The hormone is not, strictly speaking, a carcinogen. It does not crack or destabilize the genetic material of breast cells, in the way radioactivity or toxins such as benzene can. Yet if an abnormal cell exists, estrogen may stoke and stimulate it, abetting its growth until a minor aberration that might otherwise regress or be cleaned up by the immune system survives and expands to malignant dimensions. [Link](yomu://content/annotation/A8DFEFC9-2504-4C18-B45D-840BD91DDCEA) **05/05/2023, 6:31 am** > Each of us is a privately held chemistry lab, and we can play with ourselves if we want. You may find your ovarian cycle too boring to dwell on or you may try to explore its offerings, and you may be disappointed or you may not. It took me many years to realize that my orgasms were very strong at midcycle. I always knew that they were good right before menstruation, but I thought that had to do with mechanics, the congesting of the pelvis with premenstrual fluid, and I didn't attend to the other side of the equation, because I didn't believe in it. When I started to investigate the link between rising estradiol and the quality of climax, I found a wonderful connection. The midway orgasms are deep and resounding, accentuated, maybe by estrogen, maybe by decoy testosterone, maybe by autohypnosis. I could be experiencing a placebo aphrodisiac. It doesn't matter. As a chemist, I'm an amateur, and I can't do a controlled experiment with myself. Nevertheless, on matters that count I'm a quick study, and I've learned to find my way home to ecstasy whatever the moon, month, menses, may be doing. [Link](yomu://content/annotation/2B0A45DE-09C6-44F8-8021-6E64264D520E) ## 12. MINDFUL MENOPAUSE: CAN WE LIVE WITHOUT ESTROGEN? Outdated info. Against HRT (the old kind) [Link](yomu://content/annotation/B11CF7DC-BE4E-4143-8CB1-4C7FB053A041) ## 13. THERE'S NO PLACE LIKE NOTORIETY: MOTHERS, GRANDMOTHERS, AND OTHER GREAT DAMES [Link](yomu://content/annotation/A6D458D1-0F6D-49C0-94E3-5D0C930419BA) ## 14. WOLF WHISTLES AND HYENA SMILES: TESTOSTERONE AND WOMEN [Link](yomu://content/annotation/3BA4DC1D-3657-455C-B726-9A39B02CBB70) **07/05/2023, 7:33 am** > The spotted hyena, Crocuta crocuta, is an African carnivore that some people say is ugly, but they are wrong. The spotted hyena doesn't look like any other mammal. Its rear legs are shorter than its front legs, the better to run long distances. Its neck is mammoth, a redwood trunk of muscle, which powers its jaw and allows it to pulverize every bit of its prey, meat, skin, bones. The spotted hyena mashes bone to powder; its scats look like chalk. The face of the spotted hyena is a blend of felid, canid, ursid, and pinniped. The hyena soul is pure fury. A lion cub is born helpless, blind and toothless. A hyena pup emerges with its eyes open and its canines fully erupted, and it strains toward the throats of its siblings. Often one newborn pup will kill another. After the initial bloodletting ceremony, the survivor settles down and, in the universal spirit of the young, turns playful. [Link](yomu://content/annotation/0532F58F-A7CF-49CD-8EDA-541A819D874A) **07/05/2023, 7:33 am** > What makes the spotted hyena truly unusual, though, is its sexual appearance and behavior. As I mentioned earlier, the external genitals of males and females look alike. Each seems to have a penis and scrotum. But where the male's genitals are indeed a penis and scrotum, the female's apparent phallus is a combination of her vagina and clitoris, while her faux scrotum is fused labia. The female does everything through her phallus—urinates, copulates, and gives birth. Her first birth, through that slender tunnel, is agonizing. She is ripped apart by the descending pup. Many female hyenas die during first parturition. For those who survive, subsequent births are much easier—a fact that even a human mother can understand. The first is the worst. [Link](yomu://content/annotation/7A18CC64-ED39-4E09-A9CD-F23862EB02B8) **07/05/2023, 7:33 am** > The spotted hyena's exceptional genitalia have misled naturalists from Aristotle through Ernest Hemingway, who thought the animals were hermaphrodites. Even after realizing that there were two sexes, per usual, scientists were stumped by the hyena's behavior and social organization. Males and females are roughly the same size, yet the females invariably rule. They are the dominant sex. [Link](yomu://content/annotation/BAC69B62-C057-420F-BBE4-979FCF407131) **07/05/2023, 7:37 am** > And now I must reiterate the almighty fact that a hormone does not cause a behavior. We don't know what hormones do to the brain or the self, but we do know what they don't do, and they don't cause a behavior, the way turning a steering wheel will cause a car to veer left or right. Nor does the ability to behave in an aggressive or dominant fashion require a hormonal substrate. If hormones do anything, any little thing at all, they merely raise the likelihood that, other things being equal, a given behavior will occur. An estrogen peak at midcycle may make one's eros a shade brighter or tauter, nothing more. At the same time, it helps to remember the concept of biofeedback: behaviors and emotions can change the hormonal milieu and the connections between neurons. The brain is pliant. Synapses linking one brain cell to another arise and die and arise again. [Link](yomu://content/annotation/F541CA38-4B73-45F2-875D-5D88336177B3) ## 15. SPIKING THE PUNCH: IN DEFENSE OF FEMALE AGGRESSION [Link](yomu://content/annotation/1D7FCED3-4E9F-464B-9A2D-74180A7B7BC2) **07/05/2023, 8:02 am** > "Young children are like animals," says Kaj Björkqvist, of Turku Akademi University in Finland. "Before they have language, they have their bodies. And through their bodies they can be aggressive, and so that is what they do, that is how they are. They are physically aggressive—boys, girls, all of them." Björkqvist studies female aggression. He has done cross-cultural comparisons of children in Europe, North America, the Middle East, and Asia. Everywhere he has found that young children are physically aggressive, and that before the age of three, there are no significant differences between girl aggression and boy aggression. [Link](yomu://content/annotation/763F2D3F-65EC-4D79-8210-B49CA7AE99F8) **07/05/2023, 2:35 pm** > Only among humans have males succeeded in stepping between a woman and a meal, in wresting control of the resources that she needs to feed herself and her children. Only among humans is the idea ever floated that a male should support a female, and that the female is in fact incapable of supporting herself and her offspring, and that it is a perfectly reasonable act of quid pro quo to expect a man to feed his family and a woman to be unerringly faithful, to give the man paternity assurance and to make his investment worthwhile [Link](yomu://content/annotation/265EE575-CBB4-4328-8424-FE7C53970DF7) ## 16. CHEAP MEAT: LEARNING TO MAKE A MUSCLE [Link](yomu://content/annotation/70A4F4A2-0724-4774-875D-1F7F677E46B7) **08/05/2023, 12:25 pm** > To understand a woman's profound need of muscle, it helps to consider the constituents of a nonexistent yet utilitarian couple, the Reference Woman and the Reference Man. This couple is a medical and political construct, a post-Hiroshima Atom and Eve. In the 1950s, under the aegis of the Atomic Energy Commission, scientists set out to determine the potential impact of nuclear radiation on the human body. They wanted to know how much alpha, beta, and gamma radiation the body could tolerate, and because different tissues react divergently to radiation, they had to come up with estimates of what substrates the average man and average woman were made. In the portraits that emerged, the Reference Hominids are both twenty-five years old. This is the age at which the body's various organs are thought to be at their peak size and performance and its metabolic set point is well established. The weight that you are at age twenty-five is the weight at which your body is likely to feel most at home. It is the weight that your metabolism strives to attain, adjusting itself up or down if you gain or drop a few pounds [Link](yomu://content/annotation/0DF44361-8B4D-483D-B1C5-0B75CD3E56C8) **08/05/2023, 12:26 pm** > Our Standard Woman weighs 132 pounds, the Standard Man 154. She is 27 percent fat, 63 percent lean body mass. He is 16 percent fat, 84 percent lean. When we think of lean we think muscle, but lean includes everything that is not fat—muscle, bones, organs, water. In the Atomic Woman, about half of the lean mass, or 34 percent of her body weight, is thought to be muscle tissue, which means that she is almost as fat as she is muscled [Link](yomu://content/annotation/B485B1BA-0035-4638-BD1D-2AEF24F37FE9) **08/05/2023, 12:28 pm** > Women need muscle, as much muscle as they can muster. They need muscle to shield their light bones, and they need muscle to weather illness. If they have less muscle naturally than men do, they must work that much harder to compensate [Link](yomu://content/annotation/9A720753-764D-4E2D-B370-579676112BD8) **08/05/2023, 12:30 pm** > Miriam Nelson, a physiologist at Tufts University, has taken women in their seventies, eighties, and nineties, women who couldn't leave their apartments or rise from their chairs, women in nursing homes, and she has trained them twice a week with weights the way weightlifters in gyms train with weights—not timidly, not holding back for fear of their frailty or fear that they might, heavens, "bulk up," but with intensity, using as high a weight as the women can manage. After only four months in the program, these women, these sedentary, often arthritic women with dowager's humps and hummingbird bones, grew astonishingly strong, were as though healed by a carnival preacher, tossing aside canes and walkers, getting down on their hands and knees to garden, canoeing, shoveling snow. The women did not become visibly larger. They gained about 10 percent in muscle mass—respectable, but not terribly detectable. Of far greater importance, they doubled or trebled their strength. They became stronger than they had been in middle age. Their muscles hadn't been chastened by time. They hadn't learned their lesson. They hadn't learned to submit. Instead, the muscles repaid use with their stalwart Protestant ways and became productive again. The coordination between muscle and nerve improved. The muscles became infiltrated with nerve twigs and with capillaries bearing blood and oxygen. They were like telltale hearts, still thumping under the floorboards, not dead yet. [Link](yomu://content/annotation/B693EE38-8350-4787-B32F-2D95E41C0CD7) **08/05/2023, 12:31 pm** > woman's need of muscle is practical. She is a long-lived specimen, one of the longest this planet knows. Time will try to steal muscle and bone, but time in this case is not invincible. Muscle can be retrieved and restored, and when the muscle swells, the bone rejoices. It's very difficult to add to your bone density after age thirty, but by owning muscle you can keep the bone you have from departing, for muscle yanks on bone, and the mechanical action goads the bone to turn over, to be replenished, rather than to stagnate and gradually dissolve. [Link](yomu://content/annotation/7315198E-4991-420B-ABD0-65959B78A687) **08/05/2023, 12:39 pm** > Men take strength for granted. Women have to fight for it. They have to trick themselves into their strength, or rather their strengths. Physical strength is but one allele of strength. There are all the other strengths: of self-conviction, of purpose, of being comfortable in your designated plasm. I don't know if physical strength can enhance those other, intangible strengths, if a better-braced body can give one ovarios of heart. It's a good gimmick, though, a place to start, or to return to when all else fails. The body will be there to do its bit, to take another crack at life, and to propel you forward, suitcase in hand, not on wheels. The trappings of physical strength are so persuasive that you can almost hear the spotted hyenas giggling in the dark. [Link](yomu://content/annotation/7F5E4C81-45C1-4AE8-9E9E-6F635C698040) ## 17. LABOR OF LOVE: THE CHEMISTRY OF HUMAN BONDAGE [Link](yomu://content/annotation/40F1ED6B-0535-4C50-99F8-0279CDA7752B) **08/05/2023, 12:51 pm** > Years and years after a woman has delivered a child, she continues to carry vestiges of that child in her body. I'm talking about tangible vestiges now, not memories. Stray cells from a growing fetus circulate through a woman's body during pregnancy, possibly as a way for the fetus to communicate with the mother's immune system and forestall its ejection from the body as the foreign object it is. The fetal-maternal cell dialogue was thought to be a short-lived one, lasting only as long as the pregnancy. Recently, though, scientists have found fetal cells surviving in the maternal bloodstream decades after the women have given birth to their children. The cells didn't die; they didn't get washed away. They persisted, and may have divided a few times in the interim. They're fetal cells, which means they've got a lot of life built into them. A mother, then, is forever a cellular chimera, a blend of the body she was born with and of all the bodies she has borne. Which may mean nothing, or it may mean that there is always something there to remind her, a few biochemical bars of a song capable of playing upon her neural systems of attachment, particularly if those attachments were nourished through a multiplicity of stimuli, of sensorial input—the hormonal pageantry of gestation, the odors of fetal urine, the great upheaval of delivery, and the sight and touch of the newborn baby. [Link](yomu://content/annotation/D9DE073B-D17F-434B-92C0-D9609B4F640D) ## 18. OF HOGGAMUS AND HOGWASH: PUTTING EVOLUTIONARY PSYCHOLOGY ON THE COUCH [Link](yomu://content/annotation/50947BE2-F094-41B2-B439-D3B2D1A0CF66) ## 19. A SKEPTIC IN PARADISE: A CALL FOR REVOLUTIONARY PSYCHOLOGY [Link](yomu://content/annotation/8470AE41-F162-41FD-A457-532AB3FD07AA)