Monthly Archives: July 2012

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The surgical option

I’m not opposed to the surgical option, it’s just that there are many roads to Rome, and sometimes an indirect route is more satisfying. Don’t misunderstand; I’m an Ob/Gyn surgeon. It’s what I do, but not to the exclusion of everything else. There are times when surgery is necessary, life-saving, difficult to avoid. There are few ethical or acceptable options available in the case of a ruptured tubal pregnancy, for example. The patient presents in the emergency department bleeding internally, often in shock, sometimes requiring an immediate blood transfusion. Things do not go favourably for her if there is any delay in stopping the bleeding -operating, in other words.

On the other hand, fibroids -benign uterine muscle growths- present a different spectrum of choices. In the past -admittedly with fewer therapeutic tools at their disposal- surgery was the favored option if they were at all symptomatic. Medications meant to slow their growth or decrease vaginal bleeding, were fraught with side effects and seldom satisfactorily resolved the problem. Pain, anemia, or increasing symptoms from the ever-expanding tumours were often the only alternatives to surgery. And because there was a long-honoured tradition of removal, surgery was expected, maybe even desired. If all the female members of your family had hysterectomies, you might be inclined to view yours as inevitable, even if undesirable.

But there is a profound difference between life-saving surgery, and elective surgery. In the latter, options become important. The ability, and knowledge to be able to choose solutions, to see if they will work or even lessen the burden of the condition is an important step in problem solving. Moving from a simple attempt at life style or diet modification for, say, painful periods, to medications of increasing sophistication -and cost- to a hormone-containing intrauterine device, to laparoscopic investigation of the pain in the operating theatre might be a sensible route to follow. Or at least to know about.

For fibroids causing heavy menstrual bleeding -they don’t all do this, by the way- the use of antiprostaglandin medications (ibuprofen being the most widely known of these) to attempt to decrease the bleeding, maybe followed , if necessary, by the progesterone-containing intrauterine device if appropriate, and then if that fails, blocking off the blood supply to the artery that is responsible for providing nutrients to the growing fibroid (embolization)- all of these could be considered before resorting surgery.

Clearly there are features of each problem that might suggest other creative adaptations, although my point is not that they should be chosen, but rather acknowledged. We all have a right to determine our own unique paths through the thorns of life, and we should be given enough background and knowledge to allow us to make informed choices -choices whose logic and consequences we can understand. In  non-life threatening situations we may make a choice we regret, but if there are a series of progressively more serious options, we would probably be more accepting of their side-effects than if we had been forced into the treatment before we were ready.

Yes, I am a surgeon, and if surgery were the correct choice all along, then you will work your way along the path and eventually realize that for yourself. And come to accept it. It’s not my place to force you there. I am neither your father nor your boss. I do not possess absolute knowledge of the inevitable consequences of your actions. I see myself as merely a guide through a dark and often confusing forest, pointing out each fork in the road and offering suggestions that years of experience have taught me about the smoother trail.

It is, I hope, what doctors do.

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Words and Names

Words are important, let’s face it; they help us address those most existential of all entities: concepts. They describe things, modify things, name things. Without them, we’d no doubt be reduced to gestures -limited descriptors at best. The richness that is reality would still be there, but unexpressed, identified perhaps, but somehow unrepresented. To an extent then, we, the world -everything- is partly  how it is described. Words are powerful.

By now I’m sure you’re wondering what all this has to do with women’s health. Why is an obstetrician pretending he’s a philosopher? Words again, you’ll notice… Well, when we name something -a process, a condition- it engenders a certain expectation. If you name an experience, the name comes to represent what was experienced. Pain comes to mind. Or laughter. We know how it felt to experience these and if someone were to suggest that they were going to occur again, we’d probably have a pretty good idea what to expect. It’s what names are for, after all. Of course, what we call pain might be different from what someone else experienced, but we know what that experience meant for us. We would be able differentiate it from, say, tingling, or maybe fatigue. And if someone were to say you were going to experience pain, the very word would likely engender an expectation of something fairly identifiable and even relatively specific.

Okay, how about ‘labour’? You are a woman in your second pregnancy; your first labour was terrible. Maybe the contractions were deemed inefficient despite their pain, and augmentation with oxytocin was necessary. It seemed slow and interminable, punctuated with frustrations you could never have anticipated, delays that seemed unnecessary, maybe even resulted in something you wanted to avoid: forceps perhaps, or a Caesarian section. You have all that to look forward to (backward to?) again.

But do you? Well, we use the same word for second labours, sixth labours, whatever. So with minor variations on the theme, you expect the same thing. You know what to expect; you know what mindless suffering awaits, and if there was some trouble with the actual birth process, you know it will repeat: you haven’t changed. Your pelvic measurements are the same and this baby measured even bigger than your last baby on the ultrasound you had a month ago. So if anything, it’s going to be worse. Your midwife or obstetrician has tried to reassure you that second labours are quicker, more efficient creatures than first labours. Different creatures, in fact. But despite the rhetoric, something tells you they’re wrong. After all it’s still called ‘labour’ isn’t it? And you know what that means; you’ve experienced ‘labour’…

So why don’t we call subsequent labours by a different word if they really are different? Like the apocryphal description of different kinds of snow by the Inuit using different words: not all snow is the same, obviously, so if you were to hear a different description, a different word, you would expect that what you were going to see and experience was going to be different as well. Words are powerful.

I tell this to my patients and they usually laugh, politely to be sure, but secure in their knowledge that it’s all going to turn out the same no matter what I say. For one thing, I’m a man, so how would I know? And for another, and an even more convincing certainty, if it were truly different, there would be a different word for it.

I have struggled for years to come up with another word, but alas, with no success -no Nobel Prize for advancement of women’s psychological health, no media attention whatsoever.  I suspect I’ve not even been particularly convincing, coming at it as I do from the ‘other side’… But Hope springs eternal, eh?

Any suggestions?

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Victim

One of the things about illness is that it seems unfair -especially if it involves pain or limitation. To some degree, I suspect we all give in to self-pity in the throes of the process; maybe it’s a coping mechanism: a world view that allows us center stage for a while, an excuse to treat ourselves to some unaccustomed luxury. And why not? It’s only a temporary aberration, limited not only in duration, but in magnitude as well. Tomorrow will undoubtedly be better – the flu will have diminished, the sprain begun to heal. Reality -Life- will peek around the corner and beckon us.

But suppose it’s not; suppose its the same -or worse? Suppose the pain and debility persist and we find ourselves powerless in the grip of something we cannot understand, let alone control? What then? What if you seek help and are told there’s nothing to be done, or that the treatment, even if successful, will come at a once-unacceptable price? At what point do you become someone else? Something else? At what point do you somehow become a victim –someone demeaned? Disempowered? At what point, in other words, do you give up? Assign blame -or assume guilt?

These are vexing questions to which I have no clever answers. But they are problems -dilemmas- that we all encounter as we travel through our days. Certainly the chronicity of pain is a problem in gynaecology. A problem in endometriosis in particular. Perhaps in some future blog I will discuss the condition more fully, but for now suffice it to say endometriosis has the potential for becoming a chronic source of on-going pain with treatment regimes that might include surgery and affect fertility. It is surrounded by myth and misinformation that adds to the burden; it has variable clinical presentations making diagnosis or even suspicion difficult. It can be over-diagnosed on the basis of inadequately investigated symptoms carrying with it the inevitable worry and concern about the future. It can be under-diagnosed leading to multiple unsuccessful treatments and distrust of the medical establishment and their lack of effective medication -a gold mine for alternative therapies.

All understandable I suppose, and yet treated or untreated, I have concerns for the person behind all this -the person experiencing the pain, the person who is experiencing this by herself, as we all must experience pain. I remember an ad in a medical journal years ago. It was an advertisement for a medication for endometriosis and it was a picture of a beautiful woman in an alluring nightie curled up in the fetal position on a rumpled bed. The caption read: “Trapped in her own body!” I was sufficiently disturbed by it to fire off a letter to the company. What it had assumed -indeed encouraged everyone to think- was that she was a victim, someone on whom a punishment, or at the very least an unfair condition, had been imposed.

Unfair? Of course it is unfair -but the word, the description, is inapplicable, really. Pain, diseases, injuries are not judgeable as fair or otherwise. Some are perhaps preventable, some avoidable, all undesirable but unfair..? I suppose I take issue more with the powerlessness of the woman implied in the ad, though. The message is to surrender, I think, like in one of those police shows where the criminal is surrounded with no chance of escape. For him, we are led to believe, the chances of anything he does that might result in his freedom are non-existent. He must give up, not only his freedom and perhaps how he would like to see his life unfold, but also hope.

The analogy is wearing thin here, for sure, but I’d like to think that hope is not what that woman in the ad has lost, that she does not think of herself as merely an undefended receptacle for pain, a defenseless body being assaulted and beaten on a bed somewhere. I’d like to think that she still sees herself as a person, a subject. Not an object: a thing acted upon, something incapable of acting on its own behalf -powerless. I realize that I say this from the  safety of my own health, as an unexperiencing voyager upon the surface of someone else’s disease. And yet despite the distance imposed I can still feel the suffering, however dilute. I can still encourage her to take some control, if only of very little. Any control, any sense of being able to influence direction is important. Even if the outcome, the destination, is unknown, walking along a path wherever it leads, is better than staying lost. It is hope renewed. It is the first step to recovery.

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Out of Control

Are any of us in control? Or is the concept merely one that flatters us, plays to our sense of place in the vast and chaotic events that engulf us? Are we, for example, truly in control when we get in a car and drive off? We don’t plan accidents, but they happen. We don’t plan death -by and large we try to avoid it- but no matter our strategy, it is inevitable. We paint little pictures of ourselves in control -where we work, how we play, what we eat- but is it control we paint or merely small random scenes in a movie whose plot, let alone its ending, is not yet known?

I ask these questions, because I see them surfacing daily in my work. Perhaps we all do, and so frequently we no longer notice them. But there are ramifications to their very presence that impact in ways I cannot ignore. Or rather, I try to look for other paths that mimic control -that paint the same picture.

Pregnancy, for example. If there were ever a process that defies control and yet musters ultimately vain attempts to assume command, it is pregnancy. It sounds so simple: read everything about it that supports your position, set goals and write them down for those who would usurp control, and approach each stage as a soldier would a battle with courage and resolve.

I do not argue the purpose of the exercise, merely its attainability. We need goals. We need roles to play that respect who we are and what we think, endorsements for our unique predilictions. We often find them at work or at least we befriend those who validate our choices. We partner with them, have babies with them.

But some things defy control because they themselves are dynamic, constantly changing -like a twig floating down a meandering stream. The direction is known and by and large predictable, and yet there are forces at work that are hard to anticipate in advance. Things that make it impossible to know exactly where, how, or even when the journey will end.

There are some things we can do, of course. No one would argue that lifestyle choices such as proper nutrition, exercise, and some knowledge of the changes that often occur along the way are helpful and important; recognition, too, of different routes, detours, or changed conditions that might alter the arrival; preferred options should there be a choice.

And options are a form of control -shared control, perhaps- much like a choice of detours still deflect you from your originally anticipated route. But you still arrive; the destination hasn’t changed. And in pregnancy, destination is everything.