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 Hormonal IUD

A few of my readers and a not inconsiderable number of my patients have encouraged me to comment on the hormonal IUD (IntraUterine Device). In the UK, it is often known as the intrauterine system, but here in Canada it is best known as Mirena. It is a plastic T-shaped device containing a synthetic progesterone (levonorgestrel) inside a semipermeable membrane that allows a small and predictable amount of the hormone to diffuse through it and into the uterine cavity. The cavity, by the way, is also T-shaped -hence the shape of the device. Two thin monofilament nylon strings attach to the shaft of the T and protrude maybe a centimeter out of the cervix. If they are trimmed to an appropriate length, the man won’t notice them, but the woman can feel them to assure herself that the device is still in place. They are also how the IUD is removed.

The amount of progestin liberated is minute and shouldn’t have much effect on the rest of the body, but because progestins decrease the effect of estrogens on growth of the lining cells of the uterus, periods are often less heavy. Occasional spotting occurs in a small minority of wearers, but usually this disappears within a few months of its insertion. The device is good for five years and provides extremely good contraception that, unlike with oral contraceptives, is not affected by other medications that may be taken, and is not something that requires a daily smart-phone alert to remember.

In other words, it is by and large a well tolerated form of contraception, so I was surprised at the controversies swirling around it. True, the copper IUD has had its problem times. Quite a few years ago now, I think that too little thought was put into the selection of patients and IUDs were inserted into women with multiple sexual partners, or with a history of pelvic infections -both conditions which have since been shown to increase the risk of subsequent infections. Hopefully doctors are more careful about that nowadays… And anyway, those were copper IUDs which work by the copper ionizing and causing a (hopefully sterile) inflammatory reaction in the uterus. Sperm hate that, but germs often welcome the extra blood supply. Progestins, as I mentioned, don’t cause inflammation and in fact actually quieten uterine activity. So, apart from a very small risk of infection in the first month of use (perhaps from bacteria being introduced at the time of insertion) the device seems safe.

I also wondered if the controversy was related to the well-intended advice provided by the manufacturer about the risks. As one might hope and expect, pharmaceutical companies are supposed to disclose risks related to any of the components in their products. The Mirena contains a synthetic progesterone, so naturally other progesterone-containing products had their side effects listed. Depo Provera is one such medication and is well-known to have weight gain, spotting and even occasional irritability associated with it. Another product containing progestins are birth control pills. They sound even worse -especially when stripped of context: heart attacks, strokes, phlebitis -estrogen issues, mostly. But what a cursory reading of these problems misses, I suspect, is the minute dose of progestins that are being deposited only in the uterus without the need for huge amounts arriving from elsewhere that might really cause the unwanted effects.

In fact, I remember a patient that I had seen previously for contraceptive counselling who glared at me from the door, then sat down opposite me and pounded angrily on the desk. “I’m not going to let you shove a Mirena in me,” she said, as if she were going to leap over the desk and throttle me.

I tried to hide my startled reaction, all the while watching her other hand to make sure it wasn’t going for a weapon. “Why’s that?” I asked -somewhat timidly I have to admit.

The glare hardened. “Because it would be like wearing a bomb!” she screamed and walked out.

I put it down to too much media terrorist coverage at the time, but now I think I understand: we, as health professionals, should be helping our patients to navigate the labyrinthine halls of the internet complex. Not discouraging this, but helping them to read contextually instead. Carefully. Knowledgeably. Making them aware of the untrammelled pitfalls of naive searches; of Confirmation Biases that will limit their reading to what they want, or expect to find; and of agenda-driven blogs that may attempt to undermine any well performed research that hasn’t met with the writers’ experience.

The IUDs are not for everyone; they are merely members of a tool-kit of options, and as long as these are sensitively explored and adequately explained, they expand the choices in an admittedly personal and emotionally charged aspect of relationships nowadays. I’ve always hoped that the more choices there are, the more likely it is that one will actually be chosen. And used.

The use of the hormonal IUD is by no means confined to contraception either. I have to tell you that it has been one of the most useful tools I have at my disposal for patients with heavy, and otherwise uncontrollable menstrual bleeding. This can be especially troublesome in the years leading up to the menopause. It was, I suspect, why so many hysterectomies were being performed in that age group in years past. Progestins, remember, slow down the growth of cells in the uterine lining, so the less cells to shed with the period, the less heavy the period. Not a bad trade for hysterectomy. I make less money as a surgeon perhaps, but then again, I find that I sleep with less troubled dreams…