Welcome to Colonoscopy Land

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Many of the people who read this newsletter the most are people who haven’t gone over to paid. I’m constantly saying I’m going to pay for things and take weeks to actually do it, so I get it. But maybe today is your day.

A few months into my first semester at college, I was just friendly enough with two girls on my dorm floor that we decided we’d go to the grocery store to pick up supplies to make dinner in our crappy dorm kitchen. I went to go fetch an ingredient, and when I came back, I saw my friends whispering about something, then furtively darting down an aisle.

They had known each other since high school, so there was a pre-established closeness there. I walked up, and they quickly stopped talking. I remember it feeling weird and awkward, accentuating the feelings of weird and awkward that had pretty much typified those first few months of college. But then I realized what they were standing in front of: the yeast infection medicine.

“Oh, does someone have a yeast infection?” I asked, and when one of them sheepishly nodded, I very matter-of-factly picked up the Monistat-3 (don’t yell at me about the 1-day treatment, way too pricey for an 18-year-old) and told her that her nightmare would soon be over. Looking back, it was the first real moment of intimacy in a friendship that has now lasted twenty-two years.

And it happened only because I had early knowledge of something that kinda sucks but is pretty common. I took a lot of antibiotics as a tween and teen, and one of the side-effects was experiencing many of the gynecological discomforts normally associated with adulthood (or at least being sexually active) long before that was the case. I had my first yeast infection at age 12, my first UTI at 14, my first pelvic exam at 15. It was all unspeakably mortifying at the time, even with supportive and understanding parents and medical providers. But it equipped me to talk frankly and empathetically when friends went through it the first time themselves.

There’s nothing wrong, or bad, or embarrassing about a yeast infection or a UTI. It’s just a body being a body. We talk about so many other aspects of bodies being bodies. But because of a stack of taboos related to sexual organs and the materials that come out of them, there’s often a limited amount of resources — particularly the sort of casual ones that actually make you feel better — about the various conditions related to them.

This is all my preamble to telling you about my first colonoscopy, which I had earlier this week at the age of 40. I had a friend who started getting them in his 20s because of family history, and he talked me through the build-up to mine. You may or may not have that friend, but maybe you can find some sort of intimate comfort in this piece — and use it as a way to generate even more with others in your life. These irrational taboos, and the silence that accumulates around them, are responsible for so much unnecessary suffering and loss. So let’s talk about pooping your guts, the best fake sleep of your life, and having no memory of getting a camera pushed up your butt.

But first, some quick caveats and stats.

Like a lot of people, I have a family history of colorectal cancer, which makes me “high risk.” It’s the third most common cancer in the world; in 2020, 106,180 people were diagnosed with it in the United States alone (and 1.8 million people were diagnosed worldwide). Chances are fair-to-good that someone in your family has been diagnosed at some point; if you don’t know, it’s worth asking older family members explicitly, because sometimes people just kinda forget these things. If you’re high risk, you should talk to your doctor about when you should get your first colonoscopy. I got mine at 40 because a family member got one at 37 and found some polyps. Also my mom bugged (very lovingly) a lot.

For people without family history or high risk conditions, the current guidance — which has very recently changed — is that you should get your first one when you turn 45 years old. Not 50 — 45. If you don’t believe me, believe the American Cancer Society. 12% of the people diagnosed with colorectal cancer in 2020 were people under 50. I think a lot of younger people think this is something they need to start worrying about when they’re grandparents. But it’s increasingly a younger person’s disease, too.

Black people are 20% more likely to get colorectal cancer than other races and 40% more likely to die from it. Some of this has to do with environmental racism, some of it might have to do with genetics, and some of it — at least the mortality rate — has to do with lack of access to care and institutionalized racism within the medical community. But if you are a Black person between the ages of, oh, 30 and 45, bring it up at your next doctor’s appointment, even if that means you need to make a new doctor’s appointment for a yearly diagnostic check-in.

People with IBS and other gastrointestinal issues get colonoscopies fairly regularly and way before age 45. Chances are high that someone in your extended friend group has had one (this was true in mine!) and just doesn’t talk about it much, but if you bring it up in the group chat, they’ll probably talk with you about it, and be happy to work to normalize the discussion.

Will my health insurance cover it? Almost certainly yes, but you need to investigate to figure out your co-pay. I have insurance through Regence BlueCross BlueShield, obtained on the Washington State Health Exchange. Before my procedure, I did one of those calculator-thingies through the website to figure out what I’d owe out-of-pocket. ($900, but my deductible is $500, so that’s what I’ll pay. Still a significant amount of money, and a big barrier for a lot of people).

And now for the nitty-gritty, the watery-poopy, the total memory wipe. If you don’t like poop talk, fine, whatever, just go schedule your colonoscopy and skip to the end.

To begin at the beginning: the best way to force yourself to get a colonoscopy is to just get it on the damn books. It’ll still be months away, which means you won’t feel like you have to deal with it until a few weeks before, when a nurse calls you to talk through the timing ahead of the big day. About a week before, you’re supposed to try to stop eating stuff that tends to get stuck in your colon: quinoa, brown rice, popcorn, raw vegetables like broccoli, super greasy fast food, that sort of thing. I had marked it in my planner like it was a date with destiny: ELIMINATE WHOLE GRAINS.

That elimination gets serious about three days before, which is also when a nurse at the colonoscopy center called me just to make sure I remembered that I needed to begin eliminating in earnest. I still had some tortilla chips and Dot’s Pretzels during the Super Bowl, but then dinner was a plain chicken breast and white rice. The next morning, 25 hours before the procedure, I woke up, had three eggs and a cup of black coffee, and said farewell to solids. You can drink clear and clearish liquids (Ginger Ale, Lemon Spindrift, Yellow Gatorade, that sort of thing) and eat things that are effectively clear liquids (Lemon Sorbet) but nothing red or purple, which stains the colon and apparently makes it look like you’re bleeding all over when viewed through the butt camera.

I hate diets for a lot of reasons, one of them being that when I restrict myself from something it makes me think about it constantly. So that day of restriction was fairly miserable. It felt texture-less, like there was nothing to look forward to save drinking a massive container of liquid that was going to going to make me poop myself. I was cranky and bored and my brain felt foggy. None of this got better with time. I know people say that once you get through the first day of a fast everything is clarified but no, no thank you.

At 4 pm, I started drinking what’s called “the prep.” The prep is a mix of stuff that makes you poop and keep pooping until there is no poop left in the twists and turns of your colon so that the butt camera can get in there and take a good look around. There are several types of prep and seemingly little standardization in the type that a given person receives. Some people get two pills and a small amount of liquid to drink. Some people just get a small amount of liquid to be consumed in two parts. Under my insurance, that smaller amount of liquid would’ve cost $100, so I opted for the generic, which is the big gallon jug you see next to my dog Steve in the photo above. Some people really, really dislike the taste (it seems like it used to taste much worse even just ten years ago); mine had a lemon-flavored additive that made it taste something akin to lemony sweaty gym socks.

The general advice about drinking the prep, whether it’s the small or large portion:

Definitely put it in the fridge, because it tastes less barfy when cold

If you find yourself gagging (I did not) use a straw

Try alternating big drinks with sucking on a lemon or lime

You’re supposed to consume half of your prep during the first session, so I spent somewhere between 60-90 minutes going through five tall water glasses filled with the stuff. I edited while I was doing it simply to distract myself. At some point, I started googling “how long does colonoscopy prep take to start working,” because I was worried that my poop was somehow resistant to the prep. I was, of course, very wrong. About three hours after the first sip, I started pooping.

If you’ve had what my friends and I refer to as “poopy death” in some capacity, none of this will be alarming. I’ve had it at various points in my life, some related to travel, others related to bad food. All of those cases involved a lot more cramping and discomfort than what was happening in my colon, which really just felt like a smooth and organized evacuation. I mean, I had shigella for three weeks after coming back from Cambodia in 2018. This was nothing by comparison.

But you definitely shouldn’t be going anywhere. Some people told me that they just sat on their toilet for hours, but anyone who’s had hemorrhoids knows that that’s asking for a different sort of trouble. I recommend just being a room’s distance away from a toilet, because things get very liquidity very quick, and once you have the first poop, it’s like breaking the seal — more come in quick succession.

At some point, the character of the poop begins to change. The two-year-old I used to nanny would sometimes look out the window at his dog, who had digestion issues, and say “Palanga is peeing out of her butt.” And that — that’s it. That’s drinking the prep. Your body begins to feel like one long tube through which the prep is flowing with very little encumbrance. Since your head already feels like it’s floating outside of your body, the entire situation begins to feel somewhat farcical. I mean, bodies, right?

If you talk to people who have had colonoscopies, everyone will tell you something different about their scheduling strategy. Some people like them in the middle of the day, because you drink the first half of the prep the day before, poop a bunch, go to bed, then wake up in the morning and drink the second half of the prep about 5-6 hours before your procedure. To me, that option sounded like more fasting, so my friend recommended an early morning appt, which would require a slightly different schedule: first half of prep starting at 4 pm, second half in the middle of the night, but then wake up and go straight to the procedure. (Would I do the same again? Probably.)

I stopped pooping around 10 pm — at some point, you get enough distance from the time you stopped drinking the prep that it stops forcing its way through you — and fell asleep for about three hours. [Small but important tip: put a towel down when you sleep, because there is a very high likelihood that your butt will leak juuuuuuuust a bit.]

Around 1 am, I woke up, came out to the living room, and began drinking my poop juice in the dark while huddled in a blanket on the couch. I drank a glass, then did the day’s Wordle; drank a glass, then started playing Spelling Bee; drank a glass, and blearily responded to some messages on Instagram about my post about prepping for the colonoscopy. My cousin (who shares my family history) asked if she should talk to her doctor about getting one (yes); at least a dozen people told me that they’d been getting them for years because of GI issues and wish that more people would talk about them.

I pooped about six more times, which definitely sounds wild when you type it out, fell asleep again around 2:30 am, then woke up to my alarm at 6:15 a.m. (I live on an island, so we had to wake up in time to catch the ferry). I felt dehydrated from all of that pooping (I tried to drink water throughout the day and night in addition to the poop juice; a person can only drink so much) but you’re supposed to stop all fluids several hours before your intake time. My partner, Charlie, dropped me off for my 7:40 am appointment, and I was almost immediately taken into the back room.

This is the part that low-key blew my mind. I think I had imagined a pretty cold, sterile doctor’s office situation, like pretty much every doctor’s office I’ve ever experienced. But the colonoscopy back room felt, no joke, like a party. There were a bunch of gurneys lining the wall, each with curtains between them — much more like, say, an E.R., or a field hospital set-up. There was a radio blasting Oldies, and at least a dozen other patients in various stages of prep or recovery, and at least a dozen staff members, laughing and chatting and moving people with confidence around the room. The guy next to me, who sounded in his 40s, was coming out from anesthesia, and slurring about how much he loved “those good party drugs.” (I couldn’t see him, just hear him). Was I delirious? I dunno, but all of it really helped underline that this was not a big deal. The poop, the butts, we’re all doing it together.

A nurse later told me that they see between 50 and 70 imaging patients every day. They had the routine down like clockwork, but it never felt impersonal. One nurse asked me to undress and put on a gown (you can keep your bra and socks on — oh, and your mask, too; everyone was masked) and closed the curtain. She offered me a warm blanket just out of the dryer, and then offered me another one once I got situated. She took my medical history, and another nurse inserted the IV in my arm, which was less painful than getting my Covid booster shot. The anesthesiologist stopped by to tell me what the drugs would feel like, and then the doctor came by to introduce herself and tell me how they destroy the polyps (aka cell growths) if they find them, but also send them out for testing to see if they’re pre-cancerous. At this point, Fleetwood Mac’s “You Can Go Your Own Way” was playing on the radio, and I was feeling just great.

The undressing, the IV, the doctor conversations — all of that took, max, 20 minutes. Then two nurses wheeled my gurney into a darkened, private room, where they again explained the procedure and asked me to say, aloud, my name and what I was there for. They asked me to gently roll on my side, but didn’t touch me at all, and then I saw the nice face of the anesthesiologist, showing me two syringes: one filled with a liquid that will very briefly taste “metallic,” and another that will create a very brief “burning” taste.

Ten seconds later, I was gone to the world. I truly remember nothing. The next thing I knew, I was back in the original prepping space. Some people have told me that they have vague memories of looking at their colon on the screen. I have no memories at all. I asked the nurse how long I had been conscious, and she said I’d had a conversation with the doctor, which is honestly the only unnerving part of the ENTIRE THING.

A woman on Instagram told me that her husband is a nurse in a center like the one where I went to, and that 1) he loved his job and 2) they really had heard it all from people under sedation. I just hope I didn’t say anything too mortifying, or, like, tell them I was going to write this piece. The nurse handed me a sheet of paper with images of my colon on it, and told me I had four polyps, all of which they removed. Chances are high they’re benign, but if they’re not, it’s very good that I caught them at this stage, because once you start experiencing the sort of symptoms that make it clear that something’s not okay, it’s often too late. [Edit: they were all sessile serrated adenoma — which is non-cancerous but can become cancerous if not removed. Chances are good my grandmother had these at the same age, only she didn’t have a colonoscopy and died of colon cancer in her early 60s].

I thought I would feel woozy after the anesthesia, but my head felt pretty clear. The nurse helped me sit up, and since I felt okay doing that, she went on the other side of the curtain while I put on my clothes. Charlie was outside in the car waiting, and the nurse walked me down the stairs. The entire process took about 90 minutes. I got in the car, reveled in my first sip of coffee, and went to the grocery store and bought Animal Cookies, a family size pack of sour gummy worms, and two big things of Dot’s Pretzels. Somehow, I didn’t feel that hungry, and spent most of the subsequent 24 hours trying to rehydrate myself and slowly regain my brain function. I took a nice nap and a nice walk with the dogs. Writing this right now, 36 hours later, I still haven’t pooped. I’m not mad about it.

My experience was incredibly smooth, but I want to acknowledge — as my friend Virginia Sole-Smith would say — that I have all the privileges. When I told my doctor that I had a family history and a family member whose colonoscopy had found polyps, she referred me immediately and without question. Not only do I have health insurance, but I live in a place where I can easily drive to an appointment and be home the same day. I have a person in my life who I can depend upon to pick me up. I also had the ability to essentially not work during my recovery period.

I grew up in a medical family and feel comfortable in medical spaces, in part because I have not had discriminatory or negative experiences with the medical profession because of my race or my size. I didn’t have to weigh whether or not I could afford my co-pay, or have a medical professional shame me for deferring care. Medical apparatuses and offices were made for bodies my size, so I never had to worry about embarrassment or discomfort in the medical spaces I occupied, and my competency was never called into question because of the way I look or present or speak.

Put differently, the colonoscopy experience was incredibly straightforward for me, but until we eliminate the cost roadblocks and discriminatory elements of the current healthcare system, it’s not going to be straightforward for everyone. And no amount of detail about poop can change that.

It’s incredibly important to raise our comfort level with talking about this stuff. I hope we talk about it a lot more, and I’m very ready to field all of your questions in the comments. But it’s just as important, if not more so, to lower — if not altogether eliminate — these barriers to access.

If you have any questions AT ALL, please ask and I’ll do my best to answer in the comments — and if you had a different experience during your colonoscopy and have different advice, I’d love to hear that too.

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