It's Not Hysteria

By Karen Tang

10 min read

Why does it matter? Because the medical system was built to dismiss you — and knowing that is the first step to dismantling it.

You went to the doctor. You described the pain. They ran some tests, told you everything looked fine, and sent you home. Maybe they suggested you try to relax. Maybe they said it was stress. Maybe, if you pushed back, they used a word like anxious. And you walked out wondering whether you were catastrophizing — whether the problem was, somehow, you.

It wasn't you. What happened in that office has a name, a history, and a paper trail going back centuries. The dismissal of female pain as psychological rather than physical isn't a bias a few bad doctors have — it's a pattern baked into medical education, research funding, and the institutional architecture of healthcare itself. This book names the pattern, traces exactly how it was built, and then does something the medical system rarely bothers to do: hands you the tools to dismantle it, one appointment at a time.

The Disease That Replaced Hysteria Is Still Called Hysteria

Anarcha was a teenager, likely enslaved for her entire life, when a surgeon in Alabama opened her body for the thirtieth time. No anesthesia. Just the hands of James Marion Sims, the man history would call the Father of Gynecology, practicing the fistula repair technique that would make him famous. We know her name only because Sims kept records. We know almost nothing else.

Sims's speculum — the instrument descended from a bent pewter spoon, still in use in gynecology offices today — was refined through those experiments on Anarcha, Betsey, Lucy, and perhaps a dozen other enslaved women. He didn't operate on white patients until the techniques were perfected. He justified the absence of anesthesia by appealing to a belief widespread in 1840s medicine: that Black people felt pain less acutely than white people did. The belief was never scientific. It was convenient.

Here is where the story should end, tucked safely in the past. Except it doesn't. A 2016 survey of medical students and residents — people currently training to become your doctors — found that half of them still endorsed the same idea: that Black people have thicker skin, less sensitive nerve endings, lower pain perception. The belief that licensed Anarcha's suffering didn't disappear with slavery. It went into medical school without the paperwork.

The pattern runs wider than race. The ancient Greek concept of the "wandering womb" — the idea that the uterus literally drifted around the body when deprived of pregnancy — sounds absurd today, yet doctors still tell patients with endometriosis to get pregnant as a treatment. The 19th-century "rest cure," which prescribed social isolation and intellectual idleness to women diagnosed with hysteria, sounds like satire, yet patients are still told their unexplained pain is psychological. Somatic symptom disorder — the current diagnostic label for bodily complaints when no physical cause has been confirmed — is diagnosed at a ten-to-one female-to-male ratio. That ratio is not evidence that women's pain is more often imaginary. It is evidence that medicine has underfunded the search for physical causes.

Hysteria was never a diagnosis. It was a filing system for everything medicine hadn't bothered to understand yet.

Seven Years Is Not Bad Luck — It's a Diagnostic System Built to Fail You

The seven-year wait for an endometriosis diagnosis is not an unfortunate side effect of a complicated disease. It is what happens when the tool used to rule something out is incapable of detecting it in the first place.

Endometriosis begins as microscopic flat spots on pelvic surfaces — lesions as small as one millimeter, distributed across tissue like faint pencil marks on paper. A standard pelvic ultrasound cannot see them. Yet ultrasound is exactly the test doctors order when a patient reports debilitating period pain, and when it comes back clean, the patient is told there is nothing wrong. The instrument that missed the disease becomes the proof of her hysteria.

A design flaw worth addressing becomes a system when you add what happens in medical training. Physicians are still taught that a patient who presents with severe pain, bowel symptoms, bladder urgency, and fatigue but has a normal ultrasound is probably anxious. Not that those symptoms are the clinical signature of endometriosis — which they are. The education builds the dismissal in before the doctor ever meets you.

Then layer on a theory that was outdated before most practicing physicians were born. In the 1920s, a researcher named Sampson proposed that endometriosis formed when menstrual tissue spilled backward through the fallopian tubes during a period and implanted on pelvic surfaces. The theory has one immediately visible problem: endometriosis has been found in the belly button, inside the chest cavity, and in cisgender men with elevated estrogen levels. None of those locations can be reached by retrograde menstrual flow. The theory cannot explain what doctors are actually seeing in their operating rooms. Yet it persists, and its most damaging legacy is a specific reassurance that doctors still offer patients: that a hysterectomy will cure the disease, because without a uterus, there can be no retrograde menstruation. Endometriosis recurs in patients who have had hysterectomies. The cure built on the wrong theory leaves women post-surgical and still in pain. With no remaining explanation, doctors reach for the only one the training ever gave them: that something must be wrong with the patient.

Three doctors across seven years is not bad luck. It is what the architecture produces.

Your Body Is Not the Mystery — Your Doctor's Education Is

Think of your pelvis the way a contractor thinks about a building — not as a black box, but as a structure with distinct layers, neighboring systems, and load-bearing connections. A wall that's failing tells you something specific depending on whether it's the drywall, the insulation, or the frame. Your symptoms work the same way.

The uterus has three layers, and each produces a different category of trouble. The outermost surface is the serosa. Beneath it sits the myometrium, the thick muscle wall where fibroids grow — because fibroids are tumors of muscle cells, not of the lining. The innermost layer is the endometrium, the tissue that thickens each month and sheds as a period. In a healthy uterus, muscle and lining stay separate. In adenomyosis, the lining invades the muscle — the two layers merge, the wall thickens, and the result is heavy, painful periods that don't respond to treatments aimed at the wrong layer. Knowing which layer is involved isn't trivia. It's the difference between a fibroid surgery and an adenomyosis diagnosis.

Then there's the neighborhood. The uterus sits directly in front of the rectum, with a small connective tissue pocket between them called the posterior cul-de-sac. Endometriosis favors this space. When it grows there, it inflames the bowel wall — producing cramping, diarrhea, and pain with bowel movements that arrive precisely on schedule with a period. Because the symptom pattern looks like a bowel problem rather than a pelvic one, doctors who don't look gynecologically first send you to a gastroenterologist. You get an IBS diagnosis and a fiber recommendation. The actual address of the problem is half an inch away from where anyone looked.

That spatial map also clarifies what counts as normal signal versus noise in your cycle. A normal cycle runs anywhere from 21 to 45 days, lasts between 2 and 7 days of active bleeding, and produces a flow that doesn't require changing a soaked pad or tampon every hour. If you've never been given those numbers, you're not unusual — most patients haven't. But 'no one told me' and 'it must be normal' are two different things, and only one of them is true.

The Conditions You've Been Told to Endure Have Names, Mechanisms, and Treatments

Fibroids, endometriosis, adenomyosis, and PCOS are not vague chronic conditions you manage indefinitely until menopause rescues you. Each has a specific biological mechanism, a map of where it causes damage and why, and a treatment ladder that most patients are never shown past the first rung.

Take the fibroid example that clarifies everything else. A fibroid's symptoms are determined almost entirely by its location, not its size. A tiny tumor pressing into the uterine cavity can cause hemorrhaging severe enough to require a blood transfusion, while a much larger one on the outer surface may cause nothing but pressure. Treatments follow the same logic: tumors inside the cavity are removed through the vagina with no abdominal incision and a recovery measured in days; tumors embedded in the muscle wall require a different surgery entirely. When a doctor says your only options are birth control or a hysterectomy, they're describing a two-rung ladder in a building with six floors. Hysterectomy guarantees fibroids never return — but it is never medically required unless cancer is suspected. The alternatives include GnRH medications that shrink tumors, uterine fibroid embolization that cuts off blood supply without any incision, and radiofrequency ablation that destroys tissue while preserving the uterus. The full menu exists. It just requires knowing to ask for it.

Endometriosis adds its own counterintuitive layer: the staging system runs exactly backward from what you'd expect. A patient with Stage 1 disease — minimal, superficial lesions — is statistically more likely to be in agony than someone with Stage 4, whose pelvis may be locked in dense scarring. The reason is probably that people in severe pain seek treatment early, while silent disease progresses unchecked for years. Suffering and severity are not the same measurement, which means your pain being taken seriously should not depend on how advanced your disease has become.

Knowing this makes the system navigable in a way it wasn't before. Not easy — navigable. You now have enough of the map to recognize when you're being offered the minimum.

What You Carry Into the Appointment Matters More Than the Appointment Itself

The appointment isn't the event. What you bring through the door is.

Most people assume otherwise — that the right physician, in the right room, will ask the right questions and surface what's wrong. But a fifteen-minute slot is a fifteen-minute slot, and a doctor who can't see the shape of your problem in the first few minutes will default to whatever's easiest to rule out. What you bring through the door determines what the room can accomplish.

Here's the tactical problem most patients never know about. In the United States, the annual wellness visit — the one covered at no cost by most insurance plans — is structurally designed for preventive screenings like Pap smears and mammography referrals. It is not built to handle a complicated pain history or a decade of heavy bleeding. When a patient shows up to that appointment with a complex problem, the time simply isn't there; the visit ends, the problem goes unaddressed, and the patient leaves thinking she was seen when she was only screened. The fix is a single phrase when you call to book: ask for a problem visit or a surgical consult. These run longer by design. That one scheduling decision, made before you ever arrive, changes what the appointment can contain.

Once you're in the room, the quality of your language reshapes what a clinician can do with it. Telling a doctor your periods are 'really heavy' hands her a subjective impression she cannot act on. Telling her you soak through a super tampon every hour on your heaviest days, that you're passing clots the size of a plum, that you've started carrying extra clothes to work — that's a clinical picture. It points toward specific thresholds, specific tests, specific causes. The same upgrade applies to pain: not 'bad cramps' but a seven out of ten, arriving two days before your period, shooting down the left leg, unresponsive to ibuprofen. The more precise the data, the harder it is to file away as anxiety.

You are providing the road map. Labs confirm what a story suggests. The story has to come first.

The Silence Your Family Kept Is Making You Sick

A woman sits in an emergency room, hemorrhaging through her clothes, watching her blood pressure drop. When the doctor asks how long her periods have been this heavy, she says — honestly — that they've always been this way. Her mother's were the same. Her grandmother's too. No one ever said it was a problem.

This is how the pattern transmits, and it works precisely because it looks like cultural inheritance rather than diagnostic failure. Fibroids run in families. Because they do, the experience of soaking through clothing, passing clots the size of a plum, and living around a period that controls your calendar gets handed down generation to generation as normal — not as a symptom cluster pointing toward a treatable condition, but as the baseline. The silence isn't secretive; it's just never occurred to anyone that there was something to say. Heavy periods are what the women in this family have. That's the whole story. Until the ER visit, until the blood transfusion.

The tragedy is that this pattern hits hardest exactly where the disease is already most aggressive. Black women develop fibroids at roughly three times the rate of white women, with symptoms arriving ten to fifteen years earlier on average. Because heavy, debilitating periods are more prevalent in Black families, the normalization runs deeper — and the delay between first symptom and first treatment runs longer. The family history that should have been a signal instead became permission to endure.

Breaking the pattern is not complicated, but it requires understanding that your tolerance is not a character trait. It is information that got mistranslated somewhere upstream. The fix is direct: ask the women in your family to actually describe their periods. Not whether they had cramps, but whether they soaked through protection every hour, whether they passed large clots, whether they planned their lives around their heaviest days. Odds are, they did. Odds are, they thought it was just what periods were. Telling each other the truth — specifically, clinically, in terms a doctor could use — is how a pattern that has sent women to emergency rooms for generations stops repeating.

The silence your family kept wasn't stoicism. It was a symptom the system never taught anyone to name.

The Research Wasn't Done — and That's Not an Accident

The research gaps in women's health are not the result of difficult science or scarce funding. They are the result of a decision — repeated, institutionalized, defended for decades — to exclude women from the research enterprise and then apply the findings to their bodies anyway.

The NIH didn't require researchers to include women in federally funded trials until 1993. That's not ancient history. The physicians who trained before that mandate — who are still practicing, still writing protocols, still teaching residents — built their clinical instincts on studies conducted almost entirely on men. Drug dosages, diagnostic thresholds, symptom presentations: extrapolated from male data onto female patients, with the extrapolation treated as a minor administrative detail rather than a catastrophic methodological hole.

The 2002 Women's Health Initiative study — the one that caused menopausal hormone therapy prescriptions to collapse almost overnight — was hailed as landmark research on women's health. Its average participant was 63 years old. The women who actually needed that research were in their late forties and early fifties, in the thick of the menopausal transition, debating whether to take hormones. The study that shaped a generation of clinical practice was studying the wrong women. The heightened cardiovascular and cancer risks it found were real — for women in their sixties, in whom those risks climb regardless of any medication. For younger women, subsequent research showed the picture was substantially safer. But by then, prescriptions had plummeted. Women were told to endure what was treatable because the original study design hadn't bothered to look at them.

The funding numbers show what the institution actually values. In 2022, the NIH allocated $37 million to smallpox research. Smallpox hasn't existed in the United States since 1949. Endometriosis, which affects at least one in ten women right now, received $27 million. Fibroids, which affect 70 to 80 percent of women by middle age, received $15 million. These are not the numbers of an institution overwhelmed by complexity. They are the numbers of an institution that has decided, year after year, what counts as a real medical problem.

The women who are still waiting for an endometriosis diagnosis after seven years of appointments are waiting, in part, because the research that would have improved detection was never funded.

Knowing the Options Is the Only Way to Know When You're Being Offered Too Few

When was the last time you asked your doctor why they recommended one treatment over another — and whether there were others they didn't mention?

The most consequential thing to understand about fibroid treatment is that hysterectomy carries a specific designation: it is the only procedure that guarantees fibroids cannot grow back, because there is no longer a uterus in which they can grow. The distinction matters enormously, because when a physician tells a patient with large or numerous fibroids that hysterectomy is her only real option, they are usually reasoning from recurrence risk, not medical necessity. Hysterectomy is never required unless cancer is suspected. What sits below it on the treatment ladder is substantial: GnRH medications that actually shrink tumors (the only medications that do); uterine fibroid embolization, which threads a catheter through a wrist or groin vein to cut off blood supply and causes fibroids to shrink by roughly half, with no abdominal incision; radiofrequency ablation, which destroys fibroids using heat while leaving the uterus intact. A doctor who presents birth control and hysterectomy as the two available options has handed you a two-rung ladder in a six-floor building.

And if you eventually choose hysterectomy after exhausting other options, you should know that even when the ovaries are preserved, the procedure disrupts blood flow between the uterus and ovaries through small connecting vessels. That disruption means early menopause may arrive anyway, a few years ahead of schedule, along with elevated cardiovascular risk. Definitive for fibroids is not the same as without consequences.

The framework that makes you harder to underserve is simpler than it sounds: every treatment recommendation has a mechanism and a trade-off. If you can't articulate what both are, you haven't been fully informed. Ask what the treatment does, how long it works, what it forecloses, and what the alternatives assume about your future. In practice, that sounds like: 'You've recommended embolization — what happens if the fibroid regrows, and why not ablation?' 'This is the best option for someone who doesn't want more children' is not the same as 'this is your only option.' You are allowed to make that distinction out loud, in the room, before you sign anything.

The Body That Was Told to Be Quiet

The most radical thing you can do is stop mistaking dismissal for diagnosis. When a doctor says nothing is wrong, that is a statement about what they looked for — not about what exists inside your body. The women who finally got answers weren't the ones who waited longest or suffered most quietly. They were the ones who walked back into the room with data, with the right appointment type, with the name of a specialist who had actually trained for this. They were the ones who understood that insisting isn't difficult behavior — it's how medicine gets corrected in real time, one patient at a time. You now know enough to distinguish a full treatment menu from a short one, a ruled-out diagnosis from an unfound one. That knowledge doesn't make the system less broken. It makes you harder to turn away at the door.