Applejack at the Gynecologist's
It was an ordinary Tuesday afternoon; you entered the front office of your gynecological clinic, a place which had become very familiar to you over the last two years of your work as the sole gynecologist in Ponyville. In truth, although you were not a pony, you were able to blow your local competition out of the water with two simple secret weapons within your arsenal, namely, fingers and five years of experience working as an OBGYN physician on Earth before being unexpectedly (and involuntarily) relocated to Equestria. Naturally, it took some effort to get used to the anatomy and medical conditions of horses, but over time, you had comfortably settled into your role as a much-needed expert that served Ponyville and its mares.
Your chief nurse gave you the patient note for the pony that was waiting for you in examination room № 2. You looked down at the humble clipboard and the info printed on the paper from the EMR, scanning the first line of information you could see:
Patient: APPLE, APPLEJACK
Age: 28
Patient ID Number: #35622
Reason for Visit: VAGINAL DISCOMFORT
You enter the examination room with Twilight Sparkle, who was ever-interested to learn more about medicine from an experienced practitioner; today, she was shadowing you, fulfilling her dream to be a medical student, at least in some perfunctory capacity. As you moved across the tile floor of the exam room to where Applejack was sitting, you could notice signs of pain. Her discomfort was evident by the way she shifted in her seat. With a warm smile, you introduce yourself and inquire, "What brings you in today, Applejack?"
Applejack meets your gaze, her expression filled with both discomfort and embarrassment. "Well, doc, I've been feelin' mighty sore, itchy, and downright uncomfortable 'down there' for the past three weeks."
You nod, acknowledging her concern. "I see. Can you tell me more about the pain and itchiness you've been experiencing?"
Applejack shifts uncomfortably, crossing her hooves over her chest. "It's been pretty near constant, doc. I’d reckon I’d say the pain feels like a dull ache, and the swelling and itchiness just simply won’t quit. It's been mighty bothersome, especially with all the work I do down on the farm."
You ask about the onset, duration, and frequency of her symptoms. "So tell me, Applejack, when did these symptoms first start, and how often do you experience them?"
Applejack furrowed her brow and took off the wide-brimmed hat she had worn into the office, placing it down on the examination table behind her. She looked at you pensively, thinking back.
"Well, I’d bet it’s been ‘bout three weeks now, and it's been pretty darn near every day since then. Sometimes it's worse after a long day of work buckin’ apples, but it never really goes away fully."
You inquire about any factors that worsen or alleviate her symptoms. "Have you noticed anything that makes any of your pain, swelling, or itchiness better or worse?"
Applejack shakes her head confidently. "Nothin' seems to make it better, doc. I've tried restin' more, changin' the way I walk to kick up less mud, tryin’ to air things out…down there… by keepin’ my legs farther apart to air things out, but nothin' seems to help even a bit. It just keeps a-botherin' me."
You proceed to ask about any associated symptoms, such as discharge, odor, or changes in urinary habits. "Have you noticed any other symptoms, like discharge, unusual odor, or changes in your urinary habits or frequency?"
Applejack blushes slightly, shifting once more in her seat. "Well, there's been a bit of ‘discharge’ I guess you could say, but nothin' too unusual, I reckon. Just a bit of yellowly slime leaks out every now-’nd-then.”
Taking notes on your clipboard, you inquire further. “Could you speak a bit more about that leaking discharge you mentioned? Do you happen to remember anything about the consistency or smell of it?”
“Well, ‘course I remember,” she answered, “it was about like some sort of mucus, I’d reckon it was ‘bout a soft sort o’ yeller color. Not too bright ‘nd not too dark. And the smell…it darn near knocked me on my back hooves when I gave myself a whiff. It was plum awful, doc!”
“Alright, thank you for explaining, but how about your bathroom tendencies, can you also tell me about those?”
“I haven't noticed any changes in my bathroom habits; I can still go as normal and I have no problem gettin’ it out of me."
You continue your line of questioning, asking about any recent sexual activity or changes in hygiene practices. "Have you been sexually active recently, or have there been any changes in your hygiene practices?"
Applejack hesitates, but then shakes her head vehemently. "Nothin' out of the ordinary, doc. Just the usual farm work and takin' care of the animals. Ain't had no time for anythin' else."
You listen attentively as Applejack volunteers more information about her symptoms. "Doc," she begins, her voice tinged with discomfort, "I gotta admit, it hurts real bad sometimes when I gotta pee, like a burnin' sensation. And I've been feelin' like I gotta go more often, like there's a fire under my tail."
You nod sympathetically, noting her increased urgency and the painful urination on the paper in front of you. "I see, Applejack. Thank you for sharing that with me. It sounds like you're experiencing some urinary symptoms as well, which can be concerning. I completely understand; we can definitely have a look at that too while you're here. After this exam, I’ll have you give a urine sample so we can check for bacterial growth, but based on your symptoms, I’ll prescribe a week-long course of an antibiotic to preemptively manage a UTI, just in case you have one."
Applejack nods, her expression reflecting a visible relief. "Yeah, it's been mighty bothersome, doc. Feels like I can't even take a proper break without feelin' like I gotta run to the outhouse."
As she continues, Applejack also admits, "And about that odor I mentioned earlier, doc... It's been gettin' worse. Real worse. I noticed it myself, and I reckon it ain't somethin' normal. I have gone a few months without doing much bathin’, but I think that what’s a-happenin’ down there is something mighty nasty and it left me feelin’ powerful sick after I gave ‘er even a passin’ smell. I thought I oughta warn ya 'fore you start yer examination."
You appreciate her honesty and assure her that addressing these concerns is crucial for her health. "Thank you for letting me know, Applejack. It's important to be upfront about concerns like these. We'll make sure to address all your symptoms and concerns during the examination."
Putting on your professional demeanor, you nodded. "Well, Applejack, let's get to the bottom of this. Please make yourself comfortable and lie down on the examination table. Let me get the stirrups ready for you too."
Applejack complied, settling onto the table. I set up the two metal stirrups and helped her maneuver herself into a more easily examinable position.
"Alright, Applejack," you say, preparing the necessary tools. "I'm going to start by examining the external genitalia. That means the stuff between your legs without getting much deeper than that for now. You may feel some pressure, but it shouldn't be painful. And of course, if you feel uncomfortable or want me to stop, you can let me know at any time."
“Sounds good, Doc!” she responded.
You sanitized my hands, dried them, and then put on nitrile gloves, preparing to observe Applejack. Moving into place, you gently spread her labia, signs of inflammation and tenderness were exceedingly evident. "Applejack, it seems like there's some redness and swelling here. Have you been engaging in any activities that could have caused irritation?"
She blushed. "Well, doc, I do spend a lot of time workin' on the farm. Gets mighty dirty and sweaty down there, I reckon."
“A quick question: do you wash after getting sweaty?”
“Not really, doc. I am usually just so plum tuckered out after bucking apples all day I usually just head off and hit the hay after a long day.”
You nodded, the surgical mask you were wearing covered your understanding smile. "I understand, Applejack. It's important to keep the area clean and dry to avoid such issues. I would recommend washing more often, such as each time after you get a sweat going, at least once everyday or every other day. Now, let's proceed with the internal examination."
You take a moment to compose yourself and then speak up, "Alright, Applejack, I'm going to begin with a manual internal exam before using the speculum. This will help me understand what's going on more thoroughly. It might be a bit uncomfortable, but I'll be as gentle as possible. Please let me know if you experience any pain."
Applejack nods, her face showing a subtle nervous grin with trust still shining through in her green eyes. "Okay, doc, I'll do my best."
You put on a new pair of sterile gloves and apply a small amount of lubricant to your fingers. Gently, you insert your index and middle fingers into her vagina, feeling for any abnormalities. "Applejack, you might feel some pressure now."
As you carefully palpate the vaginal walls, you note the areas of tenderness and swelling. "There's some noticeable inflammation here," you observe, moving your fingers slowly to ensure comfort. "How does this feel, Applejack? Any pain?"
Applejack winces slightly but shakes her head. "It's not too bad, doc. Just a bit sore, I reckon."
You continue the examination, checking the condition of the vaginal walls and the position of the cervix. The cervix feels tender to the touch, and there's a slight discharge present. "I can feel some swelling and tenderness around the cervix as well," you say, keeping Applejack informed of your findings. “Twilight, could you write that down on my clipboard? My hands are a bit occupied at the moment…”
Twilight, who was standing in the room quietly before this moment, eagerly moved from her observing role in the corner to help you with documenting your findings.
After completing the internal exam, you carefully withdraw your fingers and dispose of the gloves. "Alright, Applejack, we're done with this part. Everything indicates some inflammation and tenderness, which matches your symptoms. Next, I'll use the speculum to get a better view inside and take some samples for testing. Are you ready?"
Applejack takes a deep breath and nods. "Ready as I'll ever be, doc."
You prepare for the speculum examination, explaining each step to ensure Applejack feels comfortable and informed throughout the process. Once you were confident that she understood what you were going to do and was ready for the potential discomfort associated with the use of the speculum, you got ready to proceed.
“Can I get closer to watch this part,” Twilight asked you. “I have never seen a doctor use a speculum before.”
“Sure, as long as that is okay with our patient here.”
“No problem with me, doc!” Applejack chimed in.
With Twilight now watching carefully, you insert the speculum into Applejack’s vagina, gently opening it to get a clear view. "Applejack, take a deep breath and try to relax. This may feel a bit uncomfortable, but again it should not necessarily be painful."
As you inspected the vaginal walls, signs of inflammation were once again keenly evident. "It appears that the inflammation extends internally as well, Applejack. I'll take a sample to send for testing and make sure we're addressing the issue correctly."
Applejack nodded. "Do what'cha gotta do, doc. Just wanna get back to feelin' normal again."
I carefully collected a sample with a cotton swab. "This will help us determine the underlying cause of your symptoms, Applejack. In the meantime, I'll prescribe a topical cream to alleviate the inflammation and itchiness."
Twilight Sparkle, who had been observing the proceedings, now spoke up. "Applejack, it's important to follow the doctor's instructions and keep the area clean and dry in the interim too. It will aid in the healing process."
Applejack nodded, grateful for the support. "Thanks, Twi. I appreciate ya bein' here."
Inspecting the area further, you noticed a peculiar sight. Under Applejack’s clitoral hood, there appeared to be a waxy, creamy yellowish-brown substance. Unable to resist your curiosity, you leaned in to inspect it more closely. Lo and behold, it was smegma; you conjectured that the unusual flecks of brown coloring was due to a combination of dirt and additional dead skin.
With a hint of concern, you explained to Applejack what you had discovered. "Applejack, it seems that you have a something called smegma around your clitoral region. Don't worry, it's quite normal, but let me explain what it is and where it comes from."
Applejack raised an eyebrow. "Smegma? Is that some sort of fancy word for dirt or somethin', doc?"
You nodded. "You could say that, Applejack. Smegma is a combination of dead skin cells, oils, and other bodily secretions that can pile up, so to speak, in the folds of the genital area. It acts as a natural lubricant and helps keep the delicate tissues in that area healthy and protected. When it gets to be too much and accumulates in one spot, it can sometimes cause clogs in pores and glandular ducts, just like a clog in a culvert pipe on the farm, for instance."
Twilight Sparkle chimed in. "Applejack, it's important to remember that maintaining good hygiene is necessary and important when it comes to smegma. Gentle cleaning with warm water and a mild soap will help keep the area fresh and prevent any excessive buildup of smegma."
Applejack blushed. "Well, I never thought I'd be havin' a conversation about smegma, but I reckon it's good to know. Gotta keep things clean and healthy, even down there on the farm."
Pressing on with your exam, you peer closely at the outer layer, examining the area where the Bartholin's cyst is located. "Applejack," you begin, "it seems that you have what we in the medical profession call a Bartholin's cyst. It's a fluid-filled sac that develops near the opening of the vagina."
Applejack tilts her head, her expression one of pure confusion. "A Barthol-what now? Doc, speak plain English, would ya?"
You chuckle, trying to find a way to explain it in a more relatable manner. "Well, Applejack, think of it like a little pocket of fluid that's decided to set up shop in a rather inconvenient location. It can cause discomfort and swelling, which is what you've been experiencing."
She nods, a flicker of understanding crossing her face. "Alright, doc, I reckon I get the idea now. So what's the plan to fix this here cyst?"
You explain the treatment options to her, emphasizing the importance of keeping the area clean and dry, above all. "Applejack, we'll start with warm compresses to help reduce the swelling and encourage the cyst to drain on its own. If that doesn't work, we may consider other interventions, such as drainage or surgical removal."
Twilight Sparkle, who has been observing the examination, chimes in. "Applejack, it's crucial to follow the doctor's instructions and take good care of yourself. Remember, a healthy body leads to a healthy farm."
As the discussion continues, you couldn't help but notice the intense olfactory presence of the smell emanating from Applejack. The combination of dirt, sweat, and the cyst itself created quite the pungent aroma that, somewhat unexpectedly, pierced your nostrils.
You pause for a moment, trying not to let the smell distract you. "Applejack, I’ll say it again just for thoroughness, it's important to maintain good hygiene, especially during the summer months when we all get sweatier and spend more time around more potential germs in nature. It’s just…well, I just noticed the smell you mentioned earlier."
Applejack sheepishly scratches her head. "Doc, I reckon I'm used to the farm life's smells so I am a bit more used to it than the average pony. But if you say so, I'll make sure to give myself a good scrubbin'."
As the examination continued, another issue with Applejack's external genitalia became apparent. There was a flaking white plaque issue on her vulva. Though it could be one of many dermatological issues, you had a few ideas of what it could be. To differentiate between lichen simplex chronicus and lichen sclerosus (the two options highest on your list of potential diagnoses at this stake), you asked Applejack some questions, all while trying to keep a friendly tone.
"Applejack," you started, "have you noticed any intense itching or scratching in this area? And does it feel like the skin has become thick and leathery?"
She bent up her brow and tapped her face with her hood. "Well, doc, I reckon it gets mighty itchy down there, especially when I've been sweatin' or workin' hard. And now that you mention it, the skin does feel a bit tougher than usual."
You nodded. "Alright, Applejack, it seems like we might be dealing with what’s called lichen simplex chronicus. I know it is a long term, so I’ll make sure you have it written down on your patient note. Basically, it's a condition where the skin becomes thickened, rough, and itchy due to repetitive scratching or irritation."
"Applejack,” Twilight Sparkle joined the conversation. “It's important to break any sort of cyclical spiral of itching and scratching to allow the skin to properly heal. Finding ways to manage stress and using gentle moisturizers can help alleviate the symptoms."
You were somewhat surprised and considerably annoyed by an observing student being so vocal, but decided against reprimanding an alicorn in front of a patient.
Applejack listened and then responded with understanding. "Well, I'll be sure to give that a try, doc. Anything else I need to know?"
You paused, contemplating whether you should add a touch of lightheartedness to the situation. "Actually, Applejack, there's one more possibility we should consider. It's called lichen sclerosus. It's a condition where the skin becomes thin, fragile, and may have a wrinkled appearance, almost like a raisin."
Applejack's eyes widened, her face contorting in surprise. "A raisin? Doc, you sure know how to make these things sound appetizin', don't ya?"
You shared a laugh, trying to brighten the mood. "Well, Applejack, it's not quite as delicious as a raisin, but it is something we need to address. Lichen sclerosus can cause discomfort and may increase the risk of certain complications. A thorough examination and possibly a biopsy will help confirm the diagnosis."
As the examination continued, you noticed increased scarring of the vulva, further indicating a higher likelihood of lichen simplex chronicus on your list of differential diagnoses. To better understand the situation, you inquired about Applejack's scratching habits, all while maintaining an open-minded tone.
"Applejack, so, I have noticed some increased scarring in your genital area, which suggests that scratching may be exacerbating the condition. So, tell me, how and when have you been scratching down there?"
Applejack blushed, scratching the back of her head with her hoof sheepishly. "Well, doc, I reckon I can't help myself sometimes. It gets mighty itchy, especially when I've been workin' up a good sweat on the farm. I can't resist the urge to give it a good scratch."
"I can imagine, Applejack. But scratching can further irritate the skin and worsen the symptoms. We need to find ways to avoid scratching. Have you tried any strategies to resist the urge to scratch?"
Twilight Sparkle, always eager to provide support, added her two cents. "Applejack, finding alternative activities to distract yourself when the itching starts can be helpful."
Applejack raised an eyebrow, a mixture of curiosity and amusement on her face. "Well, I reckon I've got plenty of things on the farm that could keep my hands busy. Maybe I'll try milkin' the cows or gatherin' extra apples instead!"
"Applejack," I inquired, "when you do scratch the area, could you describe for me the technique you use? We want to get to the bottom of what might be exacerbating the bacterial nature of your cyst."
Applejack's cheeks turned a shade redder as she contemplated the question. "Well, doc, I simply ain't never really thought about my scratchin' technique before. I just sorta go at it, ya know? Like a wild stallion kickin' up a storm!"
You couldn't help but mentally visualize her vivid analogy. "I appreciate your enthusiasm, Applejack, but perhaps we need to refine your scratching technique a bit. Aggressive scratching can lead to breaks in the skin, increasing the risk of bacterial infection. We want to avoid that."
Applejack nodded, a mixture of embarrassment and determination on her face. "Well, I reckon it's time to rein in my scratchin'. No more ‘wild stallion’ antics. I'll aim for a gentle, hoof-pat instead."
You ponder the implications of what she had just said, given Applejack's equine nature, using her hooves to scratch might not be the best idea, especially considering they were prone to getting dirty from being in contact with the ground on the farm.
"Applejack, maybe scratch that hoof-based scratching technique. We wouldn't want any added dirt or bacteria making matters worse. Now, let's explore other options. Have you ever tried scratching against something else, like a tree or perhaps any stationary objects?"
Applejack's eyes widened with amusement, a grin spreading across her face. "Scratchin' against a tree, you say? Well, doc, I reckon I have unintentionally scratched my backside against the barn door a time or two. It's like a built-in scratcher right there!"
You couldn't help but laugh at the mental image of Applejack using the barn door as her personal scratching post. "Well, Applejack, it seems you've discovered a creative solution.”
Twilight Sparkle, with a smile, added her input. “Just be careful, we don't want any unintended consequences, like you getting stuck or damaging the barn door!"
Applejack nodded, her laughter contagious. "You got it, doc. I'll be sure to scratch responsibly and keep an eye out for any potential hazards. The barn door will just have to stay on standby for those ol’ itchy emergencies!"
Before getting too wrapped up in the humor of the exchange, you had a revelation. Scratching against trees or old barn doors may not be the best solution after all, given the potential for harboring bacteria and fungus. With a chuckle to yourself, you rethought your approach and offered an alternative suggestion.
"Applejack, let’s rethink that scratching-on-objects idea. We need to keep things clean and hygienic. But fear not, I have another plan. Is there anyone in your family who could be trusted with a specialized brush to help you manage your scratching tendencies and keep the area cleaner?"
Applejack raised an eyebrow, her eyes sparkling with curiosity. "A specialized scratchin' brush, huh? Well, doc, I reckon my Big Mac has a mouth as steady as a surgeon's; he could hold the brush in his mouth and help me out, I’d guess. He's been known to give a good back scratch when needed. Maybe he could lend a hoof in this plan of yers!"
You nodded. "He sounds like a good candidate, Applejack. Having a trusted family member who can help you with this sort of controlled scratching using a specialized brush (which I can certainly lend you) can definitely make a difference. Just make sure the brush is clean and dedicated for this purpose only to maintain hygiene."
Applejack grinned, imagining the scenario in her mind. "Well, doc, I reckon I'll have a talk with Big Mac and see if he's up for the task. He might just become the official family scratcher!"
"Applejack, I’m happy I could help, but let's get to the heart of the matter. The literature says that lichen simplex chronicus is often associated with emotional and psychological factors that trigger impulsive itching. So, tell me, what's been weighing on you lately? Anything you can think of?"
Applejack's glazed over with a thoughtful wistfulness. "Well, doc, I reckon there's always been this secret yearnin' in my heart to ride a rainbow-maned mare into the sunset. But I reckon that's more of a dream than a cause for all this scratchin'."
You chuckled, finding her response both endearing. "A rainbow-maned mare, huh? That's quite the aspiration, Applejack. While we may not be able to fulfill that particular dream, it's important to address and flesh out any underlying emotional or psychological factors that could be contributing to your itching tendencies."
Twilight Sparkle, always the insightful (and talkative) one, spoke up. "Applejack, stress, anxiety, or even unresolved emotions can manifest in physical ways. It's possible that your itching may be a response to these underlying factors. Identifying and solving them can help break the cycle."
Applejack scratched her head, contemplating the idea. "Well, I reckon I've been keepin' a lot of things pent up lately. Mostly with regard to the stress o’ farm life, I reckon. Maybe it's time to let some of those feelings out and find healthier ways to cope. Who knows, maybe that'll help calm down this itchin' business too! I’ve just been feeling so sick beyond this whole affair down there anyway.”
“Excuse me, how else have you been feeling ill?”
“Well, a little while after my last time a-goin’ through estrus, I started feeling all nauseous-like. I still feel really sick to my stomach and even feel hungry at weird times throughout the day.”
"Well, well, Applejack, it seems we have more than just itching to address here. Nausea after estrus, huh? Tell me, Applejack, have you ever experienced this nausea during or after your estrus before? And any particular triggers or peculiarities that you've noticed?"
Applejack shook her head. “Well, no, do. It’s never been like this as long as I can recall. And I can't quite put my hoof on any specific triggers. It just hits me like a wild rodeo ride out of the blue!"
“Okay, Applejack. It appears we might need to run some tests and gather more information to uncover the cause."
Turning to the quickest method of checking your leading suspicion, you pulled a rapid pregnancy out of a nearby drawer. After explaining the test and allowing Applejack to briefly leave the room and use the restroom facilities, you waited in the room with anticipation to see the results. Three minutes later the two lines of the test stared you head-on: the test was positive.
"Well, Applejack, it seems our investigation has taken an unexpected turn. The pregnancy test shows a positive result. Looks like you have a little pony on the way!"
Applejack's eyes widened in surprise, a mix of emotions crossing her face. "Well, I'll be darned, doc! Looks like the rodeo ride wasn't the only wild adventure I was on. A little pony? This changes everything!"
“We can run some blood tests for some extra certainty if you’d like, but these tests are pretty accurate and a false positive is relatively rare.”
“I swear to Celestia, I’m gonna rip Big Mac’s balls off…” Applejack muttered under her breath.
“What was that?”
“Oh, nothin’.”
"Congratulations, Applejack! This is a big moment!” Twilight Sparkle, always the supportive friend, interjected. “We'll need to ensure you receive proper prenatal care and support throughout your pregnancy journey. It's an exciting time, filled with important milestones."
Applejack's initial shock shifted to a look of trepidation. "Thank you, doc, but I reckon I'm gonna need all the support I can get. This little one's gonna be…interesting. I can darn near feel it.”
Author's Note
This story was written by a third-year US pharmacy student in Massachusetts doing an OBGYN pharm internship.
I would honestly love to hear your thoughts/comments about the story!
