Such deep reluctance to discuss intimate medical problems may be more common among women of my mother’s generation, but all women can understand it. Most of us have found it difficult at one point or other to talk to a physician about some delicate matter. There are many reasons for our reticence. Understanding them can help us overcome this reserve and take better care of our health.

Much of our discomfort is rooted in how we learned to view our bodies in childhood. “For example, we’re taught early on not to soil ourselves, so incontinence is extremely embarrassing,” says Diana Dell, M.D., assistant professor of obstetrics/gynecology and psychiatry at Duke University. “Similarly, we grow up believing that sexual issues must be kept secret.”

Women may also keep quiet about health concerns out of fear that their doctors won’t take them seriously, as indeed some doctors don’t. In a national survey published in 1993 by the Commonwealth Fund Commission on Women’s H9ealth, based in New York City, twice as many women as men reported being “talked down to” by physicians and more than twice as many women reported being told a condition was “all in their heads.” Jerome Groopman, M.D., a professor of medicine at Harvard Medical School, has seen this happen in his own family. When his Aunt Dorothy, 88, told her doctor she was experiencing nausea and loss of appetite, her doctor told her it was “nerves.” Luckily, her family didn’t accept that diagnosis and pressed the doctor to look for a medical cause. “It turned out that the medication she was taking for a heart condition was too strong,” says Dr. Groopman. “When the prescription was adjusted, Aunt Dorothy was fine.”

Silence Can Be Costly

Women worry, too, about looking foolish for being concerned over something that may be nothing. Humiliation, however, isn’t life threatening. But keeping quiet about worries can be. Fay Fulton, 37, of Washington, D.C., learned this during a regular checkup eight years ago when she asked her doctor to examine a freckle on her chest that looked funny. It was asymmetrical and had doubled in size. “I knew the signs of skin cancer, but the spot didn’t seem that odd,” she says, “and I was embarrassed to take my doctor’s time just to ask about a freckle.” She asked as an afterthought: “By the way, is this something to be concerned about?” It was melanoma. “Fortunately, we caught it in time.”

Communication also breaks down when doctors fail to ask about issues that women are reluctant to raise and when they’re uncomfortable discussing delicate subjects that do come up. In a 1998 Commonwealth Fund survey, less than half the women interviewed said their doctors had counseled them about basic health issues such as exercise, diet, smoking and alcohol use in the past year. The survey also found that the topics doctors discussed least often were sexually transmitted diseases (STD’s) and violence in the home. “Doctors worry that they may be insulting a patient by asking about these problems,” says Owen Montgomery. M.D., assistant professor of obstetrics and gynecology at the University of Pennsylvania School of Medicine. Dr. Montgomery has found, to the contrary, that patients who want to discuss these and other sensitive issues are often grateful to doctors who raise them. But bringing them up isn’t easy, especially when the issue is sex.

There Are No Taboo Topics

“Women are often embarrassed to talk about sexual problems because they’re afraid something is wrong with them or they’re reluctant to share pillow talk,” says Miriam Greene, M.D., an assistant professor of Obstetrics and Gynecology at NYU Medical Center in New York City and a member of FAMILY CIRCLE’S Health and Medical Advisory Board. “Patients will talk with me for 4 minutes and then, when my hand’s on the door, they’ll say, ‘By the way…’ That’s when we get to what’s really troubling them.”

What’s bothering women in many cases, she finds, is loss of desire––their own or a partner’s. “I’ll want to know the reason for that,” says Dr. Greene. “Are they not interested in sex? Is it painful?” Dr. Greene finds that no matter what the problem––whether it’s inability to achieve orgasm or uterine prolapse (a condition in which the uterus drops into the vaginal canal due to the weakening of supporting ligaments)––once she says, “That’s not unusual” and “I can help you with that,” the patient relaxes. “Then we can discuss what to do about it,” she says. “Sexual problems affect quality of life, and if your quality of life is not great, you ought to do something about it.”

If the problem is a known or suspected STD, most women realize they must do something about it, but that doesn’t make doing it any easier. When Gayle*, (names followed by an asterisk have been changed) 28, learned that a former sexual partner had gonorrhea, she made an emergency appointment with her doctor and walked nervously into his office later that day. “Even thought I was single and this was the 90’s, I worried about what he would think of me,” she says. She helped dispel her own anxieties by telling him, “I’m really embarrassed to be here.” He was reassuring. “Well, let’s see if there’s anything for you to be worried about,” he said. He asked about symptoms––she hadn’t had any––then took a specimen to test. “He didn’t look at me disapprovingly or lecture me,” says Gayle. “He was very businesslike. I found that comforting. Later, after the tests came back negative, he talked to me about practicing safe sex, and I was ready to listen.”

“If a doctor is going to work with patients, he or she needs to be comfortable talking about sexuality,” says Dr. Montgomery. “It is not the doctor’s job to moralize. Physicians need to know enough and ask enough questions to help a patient help herself.”

You’re Not Alone

A woman may also keep mum about a problem because she thinks she’s the only one ever to have it and doesn’t know it’s common and may be treatable. Urinary incontinence is one such problem. The National Association for Continence (NAFC) reports that as many as 25 million Americans, 80 percent of them women, suffer from bladder-control problems and those who seek treatment wait about seven years to do so.

Celeste Gaspari, 48, of Burlington, Vermont, waited 10 years. Some time after the birth of her second child in 1986, she began experiencing leakage, a frequent consequence of pregnancy, which can weaken the muscles of the pelvic floor. She did Kegel exercises to strengthen these muscles, but the condition worsened, making it hard for her to run and exercise. “I was embarrassed,” she says. “I was too young to have to deal with this. Then, in my aerobics class, I noticed that other women were skipping the jumping-jack exercises just as I was. I thought, I bet they have this problem, too. That’s when I decided to get help.”

She consulted her obstetrician, who suggested a medication that might inhibit sweating as a side effect. “As a runner, I didn’t think that sounded right for me,” says Celeste. Rather than acquiesce, she asked her primary-care physician to refer her to a specialist. Of the three suggested, she chose to see Lindsey Kerr, M.D., a female urologist in Burlington who is also spokeswoman for the NAFC. “It was easier to talk to a woman,” says Celeste, and Dr. Kerr’s manner put her at ease. “She asked when I had leakage, didn’t repeat questions, sized up the situation quickly, named the tests I needed and told me my options, including risks and consequences. We tried a couple of things that didn’t help, and then I opted for surgery to raise the bladder back into the pelvic cavity. It worked.”

An estimated 1 million Americans are affected by some form of the even more embarrassing problem of fecal incontinence. This condition is eight times more common among women than men aged 25 to 45, largely as a consequence of difficult childbirth. (It can also be caused by birth defects, neurological disorders, autoimmune conditions, colorectal disease and accidents and other trauma.) Sadly, many cases go untreated because sufferers are too embarrassed to discuss the problem even with their doctors.

“Most physicians don’t query patients about incontinence, and people with severe problems are often hesitant to bring them up because they fear their only option is a colostomy,” says Michael P. Spencer, M.D., a colorectal surgeon in Minneapolis, Minnesota. “When women do raise the subject, they are often told it’s something they will have to live with.”

That’s what Maxine,* 42, was told when she finally went to her doctor for help with a problem that had begun with a badly performed episiotomy during the birth of her first child in 1986. Her doctor initially prescribed exercises to strengthen the muscles around the anus. “When that didn’t work, we tried biofeedback,” she says. When that proved ineffective, her doctor said she’d just have to live with it. “But I wasn’t living. I had become a virtual recluse. One day after a particularly embarrassing accident, I phoned him and cried, ‘I cannot live like this!’ I think that got his attention. He said he had recently learned about an implantable prosthesis designed to simulate the function of the sphincter muscle in severe cases of incontinence. I said, ‘Let’s do it.’” The operation took place in June 1998. “I cannot tell you how much everything has changed since,” says Maxine. “It saved my life.”

It’s Hard to Shock Doctors

The bottom line: Patients and physicians need to be candid with each other, even if it makes them uncomfortable. “There are lots of health issues women don’t discuss unless doctors ask,” says Cindy Pearson, executive director of the National Women’s Health Network in Washington, D.C. “Women have to break that cycle. You usually don’t want to talk about your sexual organs or bathroom habits, but sometimes you have to. Women need to realize that doctors are trained and have confronted all kinds of things. They deal with excrement. They put their hands in live people and touch their organs. However intimate the issue, keep in mind that the doctor has heard it before, many a time, and that whatever you say is confidential. So if a doctor doesn’t raise an issue, it’s imperative that you bring it up.”

Women need to know that any concern is appropriate to discuss. “I really believe the relationship between doctor and patient is a partnership that must be honored by both parties,” says Saralyn Mark, M.D., senior medical adviser to the Department of Health and Human Services Office on Women’s Health and an assistant professor of medicine at Yale. Doctors can’t treat problems they don’t know about. Says Dr. Montgomery, “You need to be your own best advocate.”

Speak Up for Yourself

You can beat embarrassment. Try these 12 expert tips.

• Tell a secret concern to someone you trust. You’ll get the support you need to discuss it with a doctor.
• Ask this person to escort you to the doctor and sit in the waiting room or beside you as you talk to the doctor.
• Learn all you can about a problem beforehand. Knowledge is power.
• Book enough time. Make two appointments if you must: one for an exam and one to talk to the doctor.
• Write down questions and concerns. Put the big ones at the top of the list.
• If you can’t read the list aloud, hand it to the doctor.
• Talk in the doctor’s office while you’re dressed, not in the examining room while undressed. You’ll feel more comfortable and confident.
• Remind yourself that you deserve attention. Trust that your doctor wants to hear your worries and symptoms in order to best help you.
• Consider seeing a specialist. Knowing that a doctor is familiar with problems like yours may ease your mind.
• If your doctor is a man and you’d rather see a woman, or vice versa, switch doctors. You’re allowed.
• If a doctor dismisses your concerns, find another doctor.
• If a doctor is a difficult personality but the best in a field, stay with him or her for the best care. But recruit a nurse or associate to act as your intermediary in getting answers to questions and information you need to take care of yourself. It helps to have an ally when dealing with such doctors.