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!

Thanks for taking the time @quince2figs 👍appreciate it

Hels - can’t see how that is a cosmetic procedure, when it is after birth trauma and is causing you pain? Seek a second opinion.

user149 - tricky area - I’m going to be brutally honest, and say that most midwives cannot suture as well as reasonably experienced doctors. This is not to put them down, but acknowledging that if this is the only “surgery “ you have ever done, it’s not a great part of the body or time to be trying to put a complicated area back together with a few mls of local. O&G doctors are all surgically trained, after all.
The standard seems to be that as long as women aren’t bleeding from the sutures then it’s ok. A lot of midwives I know hate suturing and don’t feel well trained enough to do so - but there is pressure on them not to wait (potentially hours ) for a doctor to come out of theatre to suture. Worse is that many will “leave” tears as long as they are not bleeding “to heal themselves” - well they might, but not necessarily anatomically!
No one ever looks at your perineum these days after you have been stitched. It’s a major cause of pain or sexual problems. DO NOT get me wrong, some doctors are poor at suturing and some m/w are great, but I feel strongly it is a medical job. Very politically incorrect viewpoint, though.
Whoever does it, it’s vital there is sufficient pain relief, even if that means going into theatre... again, agree, men would never have their penis or scrotum sutured with a bit of local or gas and air, and told to “be a good boy now” and all the other patronising crap you hear.
I had a ventouse, so had my episiotomy sutured by the doctor that did it, followed by a normal delivery but a 3rd degree tear (huge baby), so had that sutured in theatre. I would have asked for a senior doctor to suture a second degree tear, yes, sorry.

SOuper. -see my earlier comments on how painful Pipelles can be - hysteroscopies often worse. If you would like local and can tolerate it, fine - but you should have the choice of GA or of stopping the procedure if too painful.
Again, endemic view that women will “just cope”, or that it doesn’t really matter if they are in pain.
Great campaign, had not seen that.

Are you supposed to get a local with a pipelle biopsy?! I've had about 12 or so (all private), never thought to ask if local was an option. If the sample is at the fundus of the womb, how would a local for this area work in any case?

(I personally found them OK, obv not brilliant, but pretty straightforward. I always had two biopsies done, because there was such little tissue to sample - sadly in my last round of tests, there wasn't a single bit of usable tissue, the lab said there wasn't a single endometrial cell in either sample!)

We are thinking about ttc number 2. I had a very long, slow labour with DC1 and didn't get pain relief when I really needed it. I have been having counselling for ptsd which is helping, but I'm still pretty terrified at the prospect of giving birth again. I would really like to get reassurance that next time I could get pain relief when I need it. Is there anything you would suggest on this in terms of discussing with midwife/ consultant?

I got stuck at 3cm for I think about 20 hours. Loved both gas and air and then epidural when I finally got it (at about 6cm). When DD was born I hadn't slept for two nights and can barely remember anything from the day she was born. I felt so down about how I hadn't been able to cope with the pain.

Great thread, OP.

What are the options for a woman who wants a smear, but can't tolerate a speculum, because if excruciating pain?

5 years ago I was told I had 'chocolate cysts' on ovaries and elevated CA125.. gynae said either investigate now or go have babies, I chose the latter..
Years later and issues that were previously there still are so return to (different) gynae - male this time - who passed me to general surgery to rule all alternatives out.. this results in diagnoses of a uterine prolapse.
Should I push for further investigations as to raised bloods (never been redone) and original cysts ? It seems they have a structural issue to focus on but I'm still concerned about underlying issues as previous generations of women all ended up with hysterectomy in their 40's? Is there a genetic link?

Locally two towns near us have stopped doing vasectomies on the nhs because 'there are other options for birth control'
What do you think of this? Apart from condoms it's basically putting all the responsibility onto the woman.

Also do you think that because you only see the problematic labours your view is slightly skewed of labour?
It's obviously only my experience but I had two labours started off by induction which ended up in a catalogue of interventions and then I had a non intervention labour (hate the term 'natural' and I believe everyone births their baby regardless of which exit route it takes) which was hands off and it happened as it should. I also think that the research I did before my second helped so much during the labour. Knowing why the pain was happening and what it was doing was really useful. Do you think that if we educated girls better that having that understanding of how your body works would help women feel more in control of their labour and birth?

Hi OP. Thanks for doing this thread!

I've had a localised pain issue down there since I was mid teens. Sort of between the vaginal entrance and the perineum, by the vagina. When it started it hurt constantly, some days walking was basically impossible. I saw a few gynos after being treated for thrush several times by GP and having swabs, they gave me antidepressants and a local anaesthetic gel (lidocaine I think) then discharged me saying they didn't know when that did not work. After two years of fighting I gave up, it still hurts to touch years later but flares of general pain are rarer. I've never been able to pin down what triggers them but more frequent in hot weather and long car journeys suck. I also have PCOS but they said it was not linked.

Do you have any insight at all? Possible causes, things that might help, anything really.

I'm also terrified of pregnancy and childbirth due in part to this and part poor treatment during the time I was being seen causing more pain. I just get fobbed off with "it might fix it" if I ask a Dr but contact in the wrong place is horrific and the thought of being examined makes me want to vomit, let alone a baby pushing past. :(

Thanks for doing this thread Op.

My question, do normal hormone levels in blood tests rule out PCOS?
I've always had irregular cycles (over 6 months without a period at times, though they have been much more regular since having DS), excessive facial hair (only removal that works is shaving but it means I have a constant shaving rash and within 12 hours I have stubble again), struggling to maintain healthy weight (if I'm not putting a lot of effort into loosing it, then I'm gaining) ,gestational diabetes, can't remember ever not feeling tired, acne, depression which comes and goes every couple of years and has led to suicide attempts (I am OK atm).

Sorry I know you're not in a position to be diagnosing on a thread like this but when I realised this could all be linked to PCOS, I was so hopeful that there could be an end to it. Blood tests were all normal, GP has asked for a scan but thinks it will be refused, and has referred me to a gyno but has said it will be a very long wait.

I'm currently Ttc #2.

Argh I read the first reply and felt compelled to set the record straight. As a GP, can I tell you that consultants have no idea what it’s like for us?You can accuse us of not referring patients early enough, but if we referred every patient with a potential problem your clinics would be overwhelmed within a matter of days. My patients already wait months to see a hospital specialist, they’d be waiting years if GPs weren’t such effective gate keepers. Trust me, if we get it wrong sometimes it’s only because we’re seeing hundreds of people with similar problems, and the vast majority can be managed effectively in a GP setting.

But hey, if you want us to refer them all, we’ll happily do it. It’ll save us loads of time. You’ll need to persuade your hospital trust to employ a few more consultants, nurses, clinic staff etc though...

Can I add to that, that when I saw the gp with my prolapse, she referred me straight away. It was the registrar who saw me that sent me away with a "don't be so melodramatic, you've had a baby, it's normal to be doubly incontinent" took nearly two years to get the guts to ask for a second opinion (the second, highly qualified, gynae consultant was like at how bad it was), then another two years wait for surgery. Can't fault my gp at all.

What can you tell me any positive about LS
Devastated to get a diagnosis and starting to wonder if I will ever have sex that isn’t painful ever again

Great thread OP.

Please may I ask if alternatives to HRT are safe if you have had a PE whilst on the contraceptive pill? My GP said they ‘wouldn’t touch me with a barge pole’ as far as HRT is considered, but I’m absolutely dreading the menopause as I know it’s going to cause me all sorts of psychological issues plus all my friends seem to have suffered awful prolapses etc post-menopausally. I’d Iove HRT but don’t think it’s an option. I’m 47 and touch wood no real signs of anything happening yet. Thank you.

@jellyinmybelly I had an SD with my dc2 and was terrified of it happening again with dc3. I didn’t go back to the original hospital but opted to give birth somewhere else after a second opinion from a very senior O&G consultant. He didn’t feel a CS was necessary and advised a vaginal delivery which I had after induction at 40 weeks + 4. DC3 was bigger and although it was a struggle midwife delivered her with the consultant in the room ( plus two pead doctors and a couple of other midwives). SD didn’t occur again but I was terrified of it happening again. If I were to go back in time I would probably have sought some counselling during my third pregnancy as I worried constantly about what might happen. If not happy with what any doctor tells you I would seek a second opinion.

@Changingagain not a Dr so will let OP respond, but I was told you can have normal bloods still for the diagnostic criteria for PCOS

The way it was explained to me (OP can correct!) the Rotterdam diagnostic criteria say

1. Irregular or absent ovulation
2. Clinical or biochemical signs of hyperandrogenism (ie either outward signs of excess male hormones such as hirsuitism or acne OR abnormal androgen blood levels - testosterone, free testosterone, SHBG & DHEAS were tested in my case)
3. Polycystic ovaries on ultrasound

And it's at least 2/3 for a PCOS diagnosis

Other characteristics that can be associated with PCOS but aren't part of the diagnostic criteria (as I understand it)

• elevated LH levels
• insulin resistance
• truncal obesity

I'm lean PCOS and have normal androgen levels, but acne, very irregular periods, and polycystic ovaries on ultrasound.

To my very uneducated mind it would seem like simply having normal bloods isn't enough to rule anything out given you seem to have 2/3 of the diagnostic criteria already, before even being referred for a pelvic ultrasound to look at your ovarian morphology

I'd push for a referral

I know you’re answering loads but can you look at my earlier post please?

Reposted below.

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 :(

Just curious and I know it was asked earlier, but you probably missed it as you have been so busy on this thread: what proportion of women do would you say remove most/ all their pubic hair? How does this vary in different age groups? Are women in their late 30s/ early 40s more likely to remove or still have most of their pubic hair?

Hii op. Hopefully I can get some advice please and thank you

Im 32 weeks preg (no.4) I have history of pph due to uterus not contracting.
Most being 2.5l and least beimg

This monkey is transverse and has been for a while. Hes plotting LGA like his brother (10lb at 38 weeks)

Consultant did mention they might try ECV but im relectuant. Hes in this position for a reason, one we cant see (imo please correct me if im wrong) and with him being bigger would it not be harder?

I did ask them whats the safest way to deliver, they said naturally but this cant happen if hes still in this position.

Is a section really that bad for someone likr me? They were saying increased risk of bleedimg etc
I would have thought being in theatre would be helpful to treat me if that did happen.

Also bigger babies-bigger bleeds? They might induce me at 37-38 weeks if hes gone higher than 90th centile.

Sorry last question
I have anterior placenta which used to be low. Could this moving up be causing him to be 'stuck' in this position. Big baby+ Big placenta in the way etc (my placenta fill those big dish things they put them in! I always get told that they are huge)

No g.d
'Normal fluid' etc

Thank you

Do you think if a patient is disinclined to take hormonal treatment for endometriosis there should be alternatives available? A male gynae suggested "it can't be that bad" if unwilling to take hormones (due to chronic headaches when previously tried)...

Mintychoc1

The point being made was that many GPs simply don't have the expertise in women's health that women have the right to expect. Seeing hundreds of patients with similar problems is not an excuse to miss appropriate referrals - if anything, you should be more able to work out which patients would benefit most from seeing a consultant.

I cannot think that any GP could read this thread and not feel ashamed that women are being harmed by ignorance and complacency in primary health care. Consultants are senior to you and if they're saying patients are arriving without having had appropriate referrals and proper care, you should be listening.

Wholeheartedly agree heart

Consultants aren’t senior to GPs?!!! Blimey I thought that attitude had died out when I was a junior doctor 25 years ago. Consultants have greater knowledge of their particular area than GPs do, but they have considerably less knowledge of other areas.
But really that statement sums up your attitude so I don’t see much point in further dialogue.

The registrar who fucked my referral up certainly wasn't senior to my gynae specialism GP