Trolling for a Cause

Okay, full disclosure: in my day, ‘trolling’ was either dropping a baited fishing line in the water behind the boat as you cruised, or watching out for Billy Goat Gruff villains under the next bridge. I didn’t realize just how much I was in need of a more recent update. I mean why does everything now seem to have an online reference? A diktat. That which was once perfectly happy as a denotative word, complete with papers as an official definition, has since wandered onto the wild side beyond the tracks and reinvented itself as a ‘connote’ –or whatever the noun for its once respectable verb might be. I suppose I could look upon their ilk as metaphors, but I suspect they are a little too slippery to be confined like that.

Maybe what has drawn my interest this time is an article I saw a while back on my BBC news phone app: http://www.bbc.com/news/world-asia-38267176 That I am being critical of matters to which I may, online at least, be naively party, has not escaped my notice. Irony, if not denotatives, can sometimes coexist, I suppose.

At any rate, it’s the issue of media advice I wish to address here. And the issue, I must confess, is problematic to say the least. In brief, a young London woman, Dami Olonisakin, began to write a sex and relationship blog, Simply Oloni, in 2008 because she felt that a lot of women didn’t have anyone to speak to. ‘It began as a personal lifestyle blog and she wanted to be the person that someone could speak to without being – or feeling – judged.’ Fair enough. She wanted ‘to give out impartial advice – something she believes can be more valuable than the opinion of a friend or a relative, who could be too emotionally involved.’ The identities of the participants and their problems were kept confidential and indeed she did not set herself up as an expert, merely an intermediary, as it were. She posted the problems on her Twitter account for her ‘26,000 followers to also share their advice and tips on the dilemma.”

It became quickly apparent, as she herself admits, that not every reader was happy with reporting the sorts of problems she receives. ‘”Not everyone has accepted that women are allowed to talk about sex freely, and we are allowed to embrace our sexuality; whether it’s choosing to keep your virginity until you’re married, or wanting to have casual sex, or wanting to be friends with benefits,” she says. “Your sex life is not a decision for other people to dictate.”’ And the critics were apparently not kind in their responses -they ‘trolled her’, to lapse into the vernacular for a moment: ‘”I’ve had trolls online telling me I’m ‘disgusting’ for suggesting that girls dating more than one man [at a time] is fine,” she says.’

A lot of things can be said under the cloak of online anonymity, to be sure and I suppose venting it serves some purpose or other… but as the inadvertent recipient of ‘trolling’ for writing a supportive comment on a news item a friend had posted online, I can attest to the concern –and even fright- that the vitriolic response elicited. It was almost as if someone had entered my house while I slept and spray-painted a hateful epithet on the bedroom wall. Perhaps I deserved it for daring to evince support for something in public -sorry, online; nobody agrees with everything, after all, but it was the emotions, the hatred, oozing from the words that felt threatening. And yet, maybe that’s just my age talking -presumably most youth today have evolved an internet shell under which they can shelter. But as the devastating effects of internet bullying have demonstrated, the shell is far from impervious. Far from universally distributed.

As bad as ‘trolling’ and internet bullying may be, however, I am more drawn to the courage of Oloni in recognizing the need that women –all of us, really- have a desperate wish to be heard. And to be heard impartially, non-judgmentally. Friends, clergy, and even doctors have the unfortunate habit of diagnosing and then advising; sometimes the person doesn’t want a diagnosis, let alone a treatment –she just wants someone to listen. Often the simple act of describing something to a dispassionate ear, is in itself a cure –or at least a relief. We don’t always require advice either –sometimes just a respectful silence. An acknowledgment.

This is often readily apparent in the privacy of my consulting room. I am a gynaecologist by trade, but occasionally ‘sounding board’ would describe it better. Deborah, a normal-appearing 38 year old Caucasian woman, was a good example.

She had been sent to me by a worried family doctor because of her heavy periods. Nothing the GP tried seemed to be working, so in desperation she had sent her reluctant patient to me to see what I could do for her. All of her tests were normal –iron stores, haemoglobin level, ultrasound of the uterine lining, and even a biopsy of those same cells (just in case) as she put in brackets.

On taking her history, Deborah assured me that her periods were quite regular and predictable, and on the whole, not any different from what she had experienced for years.

“I shouldn’t have mentioned them to Dr. Cameron,” she said once I had finished the history. “My mother and her sister both have heavy periods, so neither of them seemed at all worried when I was a teenager. But my GP seemed adamant: they were too heavy. In fact, she put me on all sorts of pills to decrease the flow…”

“And did they work?” I’m not sure why I interrupted her at that point, except for her eyes. They kept wandering to the pictures on the wall, or out the window to the tree outside. It was almost as it they feared to seek shelter on my face.

She shook her head at first, and then grinned. “Well, actually I didn’t take them -they were samples anyway, so…” She thought about it mid-sentence, and then suddenly revised it. “Well, actually I did take one and it made me feel sick, so that was it for the pills, I figured.” She shook her head sadly and then sent her eyes to explore the wooden carving of a woman holding a baby I’d positioned on my desk behind a plant to make it look as if she were hiding. “I felt like that woman,” she said, pointing at the carving. “You know, like I needed to hide from all her well-meaning advice.”

She was silent for a moment, so I waited. “I think Dr. Cameron had a thing about periods, actually. Each time I’d return for follow-up, she would smile and shake her head in that conspiratorial way women have –you know: ‘what a life we have to live’, and all that. She tried several contraceptives that I never took. And then she suggested a progesterone IUD that I refused.” Deborah finally allowed her eyes safe passage to my cheeks. “I only let her do the biopsy because she felt so upset about her treatment failures. She needed to find something. An explanation. Or better still, a solution.

“But I started to get really worried when she began to hint that I might need surgery. ‘Maybe just an ablation to get rid of the lining cells of the uterus,’ she added –probably because my face went pale.”

Deborah sat back in her chair and scrutinized my face, obviously more relaxed than when she’d entered the office. “Dr. Cameron suggested I see a gynaecologist that she was going to recommend, but I didn’t recognize the woman’s name. And anyway, I wasn’t so sure I wanted to discuss it with another woman…” A mischievous grin surfaced on her lips. “I figured I needed a non-participant… Neutral territory,” she added, her eyes twinkling. “And anyway, my mother sees you and she’s still got her uterus at seventy-three, so…” She blinked; it was my turn, apparently.

I shrugged and tried to suppress chuckling at her posture. She was comfortably ensconced –slouched, actually- in the far-from-comfortable wooden captain’s chair across from my desk, looking like she didn’t have a care in the world. I couldn’t remember anybody owning the chair –owning the office– like she did at that moment. “Well, Deborah, I have to say that I’m not worried about you.”

“No ablation? No hysterectomy…?” She pretended to pout. “Nothing?”

I smiled. “Well, if the periods get worse, you could always come back…”

The mischievous look returned. “Don’t worry, my mother would make me.”

 

The Manopause

The menopause can be a mysterious time, although the mechanism is easily enough defined: the cessation of menses because of the lack of estrogen production by the ovary. The concept may be simple, but the ramifications and folklore that surround it less so. It has always worn its myths like a hood, obscuring the face beneath, confusing the experience like shadows on a rainy day.

Descriptions are legion, but ultimately unhelpful in dissipating the fog the definition drags with it: hot flushes, sleep disorders, irritability, worries about cognition and memory, regrets about the loss of fertility, and concerns about sexual function and desires… And although some symptoms may cross the gender divide, many -if not most- are unique to women. Unique to ovaries.

And the response to the change can be unique as well.

I hadn’t seen Elizabeth for a long time –in fact I couldn’t remember ever seeing her. Memory deficits are not the sole prerogative of the estrogen deficient –although in fairness, when I tried to look it up, it must been well over ten years since her last visit because the chart had been destroyed. The legal limit that we are required to keep records had obviously been exceeded.

She treated it as if it had only been a month or two, and greeted me with a smile usually reserved for someone who is supposed to go over some frequently-repeated test results. Someone she’d seen in the mall last week, and at a restaurant the week before. But there was a hint of suspicion in her smile.

“Elizabeth,” I said, extending my hand when I greeted her in the waiting room. “Nice to see you again,” I continued as I led her down the corridor to my office. She looked at me politely and sat down in a chair by the window across from my desk, perhaps waiting for me to reminisce.

The referral letter said only that I had seen her before and that she seemed angry about something. She was 55 years old, was on no medications, and she had some questions about the menopause.  “So, what can I do for you, Elizabeth?” A rather predictable opening, I suppose, but it didn’t commit me to anything –in other words it didn’t disclose the fact that I couldn’t remember a thing about her.

She probed me with her eyes for a moment, suspecting, I think, that I didn’t recognize her. But if she was disappointed, she didn’t betray it with her face. The ghost of a smile reappeared, and her eyes relaxed enough to twinkle through her glasses.

She didn’t look the merry type, I decided. Her hair was greying and pulled back tightly in a bun. Her outfit was severe: a black, loosely hanging dress that covered her ankles but not her jewelleryless arms. She was a thin, tall woman and sat as straight as a pole in the chair, her white skin even more pallid where it met the dress.

“How will I know when I’m in the menopause?” she said suddenly, as I glanced at the computer screen searching for more clues.

I met her eyes half way, and smiled reassuringly. I hadn’t had a chance to take a history, so I had to be careful with my answer. “Well, in many women, the symptoms can be very subtle, but generally speaking, the usual tip-off is an irregularity of menstruation and eventually its cessation. And, of course, there are often hot flushes, irritability and…

Her face turned smug and her smile condescending. “But I haven’t had a period for years, doctor…” She sat back in the chair and regarded me with some ill-disguised amusement. I must have looked confused, because she sighed both audibly as well as visually –performance art. “You took my uterus out fifteen years ago…”

I did my best to retain a modicum of Aequanimitas: I tried not to blush.

“Big fibroids,” she continued, to add to my discomfort. “You said one of them was the size of a basketball… I thought you’d remember.” I was blushing now, and about to apologize, so she backed off. “It has been a long time, I suppose.”

I attempted a smile, but I think it came out as rather forced and weak. I decided I’d better take a more detailed history before I addressed her concerns. “I’m sorry, but unfortunately I no longer have your records so I’m going to have to ask you a few questions… First, are you having any symptoms of the menopause?”

She frowned a look of concern unrolled onto her face. “Why don’t you have my records? You did my surgery…” Her eyes suddenly tied me to my seat. “Suppose I developed complications?”

I started to feel defensive. “The law requires us to keep the files for only 10 years unless there is an ongoing  attendance,” I said, rounding off the numbers for her. “I haven’t seen you for longer than that, and you haven’t declared any complications in that fifteen years that I know of…”

She lengthened herself to the full length of her spine and glared at me. “My complication may be the menopause, doctor!”

I tried to stay neutral. Professional. “I’m sorry, Elizabeth, why do you think that?”

Her face crinkled into a little wrinkled ball, like a piece of paper someone had crumpled before throwing it away. “You took my uterus out!” She almost spit the words at me, as if I should have known that was the problem.

I sighed in an unsuccessful attempt to duplicate her previous performance. “Did I remove your ovaries as well?” At forty, I wouldn’t have.

She stared at me wordlessly for a moment. “You did a total hysterectomy you said, doctor.” She said the last word as an insult, not as a descriptive, or an honorific title.

I smiled and realized she had not really understood what I had done. “A total hysterectomy merely refers to the act of removal of the whole uterus –the total uterus. A partial hysterectomy, on the other hand, means I’ve only taken part of it out –left the cervix, usually…” Her expression didn’t change. “I wouldn’t have taken your ovaries out at that age, because… Well, first of all because they would still have been working and producing hormones, and secondly there would have been no need to do so.”

I hoped that would mollify her, but if anything, her face crinkled into an even smaller bun. Then why haven’t I had any hot flushes, or irritability?” She could see one of my eyebrows start to raise –it’s really hard to control that- and hissed audibly at me. I think it was a hiss, but maybe she was  just breathing through her teeth.

I tried to relax my expression –a Mindfulness technique. “Whether or not your uterus is present, the ovaries don’t last forever. They eventually stop producing hormones.” I realized I shouldn’t have used the word ‘last’ as soon as I said it; it just sort of slipped out.

She shook her head slowly in her anger. “You men are so insensitive about the ovaries! You just don’t know what they mean to us, do you?” I suppose it was a rhetorical question, because she continued the rant without stopping for a reply. “And I’m surprised to hear that attitude from a doctor!” She stopped talking for a moment and looked at me. “You weren’t like that back then…” The scowl returned. “And to tell you the truth, doctor, I don’t remember you like this at all…” She glanced around the office. “Not even the office.”

I was about to say something reassuring to her –like that I’d probably changed a few things in here over the years- when she suddenly stood up and wrinkled her nose. It was hard to spot in her overall expression, but I noticed it immediately. Her eyes closed briefly as if she could somehow block out everything that she didn’t like about where she found herself. And then, gathering herself up to her full six foot height, she thanked me for my time and stomped out.

You know, I still can’t remember operating on her… and I don’t think she does, either.

Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…