I’m a consultant gynaecologist - AMA

[quince2figs]

I have worked in a variety of settings - hospital obstetrics and gynaecology incl labour ward, PMS and menopause, currently community contraception and unplanned pregnancy services, NHS and non. Ask away!

I am 25w with vasa previa with insertio velamentosa. I'm receiving very good care and feeling lucky that it was detected, but surprised that it is not routinely checked for when other (in my case multiple) risk factors are present as the fetal mortality rate is so high. Mine was caught by chance.
Am I being unrealistic to expect it to be checked for — are there just too many potential complications to check for them all?

Tommy - no, no evidence for more regular smear tests (this is only recommended if HIV positive). Auto-immune conditions no problem for a Mirena, and often a good choice as oestrogen usually not the best option.

Is0127 - long waits extremely common presently. The maximum should be 18 weeks from referral to being seen. There are 2 week wait urgent refs for suspected cancer.
Sorry, very unsure what the problem is from your post.

Catching - there is no magic age. Severe endometriosis is miserable, and hysterectomy is an option. However, although it will stop more endometriosis being deposited, it won’t get rid of any pain you get from current scar tissue, and the hormonal cycle every month will continue if you still have your ovaries, meaning that any endo deposits there now will still respond to this, and give you cyclical pain. I have seen many women have uterus only removed with no improvement of their symptoms....possibly even worse symptoms as they can then have post-op scarring and pain from that.
Removal of tubes and ovaries too is more likely, therefore, to reduce endometriosis pain, BUT you will be plunged straight into a post-menopausal state, which is deeply unpleasant when you are recovering from poss major surgery. HRT can be used, of course, but if you are below 45y, or certainly 40y, the change from normal oestrogen levels to practically none is a shock (in contrast to natural peri and post menopause).
Mirena? Zoladex? Maybe Depo Provera? Be sure you have been offered other possible options first, to consider.
Otherwise, if you don’t want any or more children, it’s your decision.

If your first labour resulted in a third degree tear, how likely or what are the odds of it happening in a second labour?

Do you think the advice that 3 c sections is the most a woman should have is outdated now given the advances made in surgical techniques?
I know women who were told this in the 80s when they’d had classical c section incisions but I wonder if there shouldn’t be this ‘limit’ and it should be case by case ?

Also how do you feel about sterilisation at the same time as a cs-do you think it’s somethung that should be done at a separate time ?

@Hedgehog80 I’ve been actively encouraged to have a fourth caesarean so maybe that recommendation is just one at your hospital?

Can I ask if you have any idea what this might be. Family member, 65 years old. She gets a pressure feeling in her vagina and always itchy in the same place on one side (inside). GP has done all sorts of swaps and nothing has come back (not even thrush) but she tried canasten cream and pessaries etc. even tried cream Eastriol (sp?) cream as they thought it might be thinning due to age etc. that did nothing and she used it for months. She recently saw a gynecologist due to unexplained bleeding but that turned out to be fibroids which they removed. The gynecologist couldn't see anything. They thought this might stop the pressure etc but it didn't. She still has the pressure feeling daily (and the itching). GP is at a loss and has told her to live with it! Any suggestions please?

Hi quince, I’d be really grateful if you could give your opinion on this:

I’m late 50s, bit late to menopause but prior to 18 months ago, although my periods had been getting more sporadic, they were still really heavy. So I had the Mirena coil fitted which stopped them totally – bliss!

6 months later, I started having bladder frequency/urgency problems. I also started getting nerve tingling/burning in my lower legs (feet and calves) – it got quite intrusive.

I had blood/urine tests to rule out various things, comprehensively done, then had an ultrasound which showed multiple fibroids, the largest of which (only marble sized) was pressing on my bladder. One urodynamics later (after consultant – thankfully retired now - said it wouldn’t be due to fibroids) next consultant wrote saying it was the fibroids. By this time I’d googled bladder training - that helped slightly.

Referral to Neurology for the leg stuff didn’t help. Basically it’s not getting worse. However I’ve been given amitriptyline in low 10mg dose but increasing – up to 25mg now. Oddly it’s sorted the bladder problems (wonderful to have a decent wee again!!!!), but the leg tingling has now become more pronounced when I’m sitting upright – at work or in the car.

So my questions are – have you heard of either the Mirena (it’s still in the right place btw!) or fibroids causing nerve problems in the lower legs? I’m so fed up of being what it’s not! I’ve even started taking oestrogen HRT 50mg which hasn’t helped. Don't know whether to have the Mirena whipped out (which I realise is beneficial to me) or get something to shrink the fibroids.

Do you know much about lichen sclerosis? My mum has this and is finding it very difficult to get treated. She is in constant pain and it’s getting worse all the time :(

All our local hospitals seem to say 3 is the limit, Ive had friends go and be told the same as I was and I find it odd that this advice has been the same for about 30 years ? I’ve had 5 c sections. Was warned after 3, sterilised under pressure with 4 then had it reversed for baby number 5. My fifth c section was actually the easiest recovery !

Hi OP since my ectopic pregnancy which ruptured so had right Fallopian tube removed and a D&C I'm suffering with ovulation pain and endometriosis type symptoms ( I have a majority of the symptoms) I have since had another DD but even before her pregnancy I was really struggling there was just over 1 year gap. During my early scan to make sure the pregnancy wasn't ectopic I was asked if I was diagnosed with endometriosis but I couldn't answer

@Hedgehog80 How strange it varies so much although my third caesarean birth ended in my baby dying, so maybe that is why they encouraged a fourth pregnancy and for it to be a caesarean delivery.

I’m so terribly sorry to hear that VocalDuck 💐 💕 xx

Thank you @Hedgehog80 It’s comforting to hear you went on to have five caesareans though.

I’ve had 4, uncomplicated, vaginal births all big babies (none under 9lb). My fourth was over 10lb, in fact close to 11lb with no suggestion of gestational diabetes.

If I were to consider a fifth (big if but just in case!) would I be offered an ELCS bearing in mind how huge my last baby was? I birthed in a midwife unit without transfer or significant injury (very minor tear) but I’m terrified that any further would be even bigger and clearly a distocia risk.

Thank you so much for taking the time to answer so many questions.

Can I ask about response to local anaesthetic? I had a pudental block for ventouse delivery of ds2. I'm not sure it really worked and felt very sorry for the poor spr who was trying to stitch me up after as I just couldn't stay still . Thing is, some of the times I was leaping off the bed she said she was nowhere near me... but I'm sure I could feel things. Is that possible??? Or had I just got myself worked up into a state because it's pretty grim?!?! For me the stitching was far and away the worst part of the whole birth! And removal of staples after cs with ds1 was the worst bit of my experience with him (despite it being a tricky emergency section when fully dilated) so maybe it's psychological and I just don't deal well with people doing stuff to me!

Also, do you think your type of labour has any relation to family history? All the women in my family (grandma/ mum/ aunt/ me/ cousins) seem to struggle to get into labour (lots of inductions) but once labour starts it seems to be short and relatively managable for all of us (my poor cousin gave birth on the pavement!). Has any research been done to investigate whether family history has any predictive value or if it's just a conincidence?

On a related note- do you think women get enough say on when they go into hospital in labour? I found midwives very keen to keep me out both times but with both I really think I should have been in much sooner and things would have been less hairraising for all concerned. And as I said my cousin gave birth on the pavement after being turned away. Is there a reason we're not listened to when we say we want to come in??? Sorry that's really a midwife question but guess service provision/ guidelines may have a bearing and be something you have experience of???

Thanks for your time

Shiraz - entirely your choice! You are very likely to have severe hyperemesis again (but not certain). As long as you are prepared for that, and are managed properly, then the only risk is your symptoms.
I have never, in my long career, told a woman she “must not” have any more children. I have been very frank in informing of risks with further pregnancies in some unlucky women - but it is their choice and body, not mine.

ItsClem examination during induction or labour not really representative of non-pregnant examination, as may have been trying to break waters/check dilatation/ find position of baby, so a lot more invasive.
Vaginas do have curves in them though, and the cervix can be off to one side and/or angled- I think lots of people imagine like the inside of a toilet roll, with rigid, parallel sides, and the cervix directly at the top - not the case at all!
Most women find that after pregnancy, esp a vaginal delivery, that the vagina “feels” different, which I guess is not surprising. Pregnancy and ageing generally mean that the vaginal walls are not as toned, and most women will develop a small prolapse of the walls at front or back. This is normal, really, and no problem if no symptoms. Not to be confused with a uterine prolapse (uterus becoming lower due to pelvic floor loss of tone- which is also more or less normal if mild).
It would be worth getting examined by someone xoerienced to check that any suturing has been done correctly, no infection or irritation, could be atrophic if you are breastfeeding/on Depo as oestrogen levels lower...

Why isn't it routine to scan women in early labour to check things like cord wrapped round neck and position of baby? Wouldn't that help vis a vis informed choice and risk management and avoid hours/days of fruitless labour resulting in exhausted women then suffering instrumental birth or emcs quite unnecessarily.

Also do you address women as equals whilst expecting them to use your title ladt name whilst you and all around use their first names or call them love, darling, desr or "mum"?

How much training did you have in the fertility side of reproductive medicine - you said you specialise in contraception, but just wondering if training covered infertility / assisted conception, or if this is purely elective?

Do you think IVF will be available at all on the NHS in 5 years time, or do you think this will be purely accessible to those who can self fund cycles privately?

roomin - very poorly done by many nurses/doctor that do speculums, I’m afraid. Medical students in the UK have to achieve the competency of doing this, but don’t get feedback on how it was for the patient... and many male doctors never again do one. A lot of female doctors rarely do them unless in GP or O&G/ Contraception, and an astonishing amount of people in those specialties are incredibly brusque (that’s being polite). I’ve certainly been on the receiving end of a bloody awful speculum when having a smear done once, just because the nurse was rough and seemed to forget she was examining a person, not just a cervix.
There is quite poor understanding of reasons why women might find it difficult, and that saying “just relax” won’t work , and that we should ensure women have the power to stop an examination at any time.

I sought training to address this, and do a lot of psychosexual medicine now, mostly seeing women with painful sex, but also problems with speculums. I am planning to visit the My Body Back project next year!

Vickie - how awful for you. Of course this is unacceptable, but glad you were treated well in the end.

I've had 4 sections - no pressure at all to avoid more pregnancies although I was finished after my 4th.

Thank you for this quince2figs

Yogagin - there may some newer imaging techniques but I am unsure. National guidance clearly states laparoscopic diagnosis of endo unnecessary, but obv can be used for surgical excision/ablation.
The presence or severity of endo at laparoscopy is poorly correlated with severity or presence of symptoms, ut pe,vic lain often multifactorial too.
There are non-surgical options, which can be used to see if typical symptoms improve or resolve. If so, you have your diagnosis and treatment.