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!

Hi op.
When you get a chance please do check out my post (think its 2 pages back)
thank you

JohnnyMc - I hadn’t heard if Marget McCarthy, so just looked her up. She is a GP that feels most screening tests do more harm than good, and chooses herself not to go for smears.

Her argument is correct at the basics: the definition of a screening test is that it covers everyone in a population, who has no symptoms. Many women will have abnormal results who do not have cervical cancer, and of these some will have treatment to prevent progression on to cervical cancer, which they may not have needed.

However, the UK cervical screening programme is a fantastically successful one, as the intervention for majority of women (not all if speculums are a problem) is minimal - a smear, and most will never need treatment.
Yes, it is impossible to avoid causing worry to women who have abnormal results, and maybe then just need a colposcopy or repeated smears, but no biopsy.
Smears are not 100% at picking up cancer or pre-cancer either.
Cervical cancer may not have any symptoms, or not specific ones, until it is advanced and either untreatable or will require hysterectomy.

The changes that have happened since the age went up to 25y and HPV testing of samples came in has improved this a lot. There is lots of work towards possibility of a self-taken swab in the future.
Of course, the most important move has been to vaccinate teenage girls for HPV. We just need to do this for boys too! Then in a few decades time, the incidence of cervical cancer will have reduced dramatically.
Everyone’s choice not to partake in screening.
I’ve worked in a country where many women don’t access smears, and saw lots of advanced cervical cancer at a young-ish age. Wouldn't wish that on anyone.

I'm quite embarrassed to be asking this Q & it's something that's niggled me & concerned me a bit, but not enough to seek advice on it.

I'm 45, had the mirena coil fitted about 11/12 years ago. It stopped my periods, save for the odd one every 6 mths or so. I had it fitted for contraception reasons at the time but haven't required that for some time. I never had it removed.

I've had a smear & swab taken about 4/5 years ago & have been asked about my periods when that's happened & no one has ever told me I should have it removed. I don't suffer any negative symptoms (other than weight gain which has been as issue since it was fitted) and I'm quite content to not be having periods.

My question is, are there any risks with me not having this removed? I've never found anything to say there are or what happens if it's left in & ive just got used to the 'status quo'. I dread having to go through a procedure to have it removed so I've just ignored it for the most part. But I do still have niggling doubts about what harm it could do/be doing.

Hi OP,
10 yrs ago my smear showed Cin 1 but I then found out I was pregnant so nothing could be done. Following birth I had follow up smear which showed Cin 3 so had Colp, was told it was only a tiny area affected so was treated with Lletz. Test of cure was successful and was tested hpv negative. Thankfully put back on 3 yrly smears which have all been normal until last Yr which tested hpv positive but no abnormal cells. Am currently waiting for results of follow up smear. Nervously!!
I'm 44 and going through peri atm.
My DH and I are 100% faithful so any idea why the hpv has reoccurred?

Many thanks

@Lipsticktraces

I had twins vaginally, with T2 manually turned from breech after I'd delivered T1. No pain relief, labour started naturally at 36+6, (but also not my first babies.) Everything went fine although the manual turning was absolutely the worst bit of the birth, (my poor sore tummy!)

If you're worried, take all the pain relief you can get. My twin delivery was the best birth experience I've had.

Good luck, hope it all goes well, and you're not suffering too much in the heat.

OP this thread is brilliant, as are you, so thank you.

I take metformin for PCOS. I was wondering if you believe this to be an effective treatment?

1sttime - apologies, I am familiar with the killer cells theory, but know nothing more. Bananafish - thanks for posting info and links, I have learnt some more.

I have what I think is a very bad prolapse after the birth of my son almost 4 years ago. My GP keeps fobbing me off. She checked me and said I had a slight prolapse and just to do pelvic floor excercises, which I have been doing anyway but nothing seems to help. Eventually, after arguing for over a year I got her to refer me to a gynecologist, however nothing has ever came of this referral and everytime I ask I am told the waiting list is just really long, I do not believe its 3 years long, I think shes just again fobbing me off.

Meanwhile, I have to push on the bit between my butt and vagina everytime I need a shit. Sorry for begin graphic, but I can;t really think of any other way to describe it. I have a huge bulge sticking out all of the time, which I can feel most of the time which is seriously uncomfortable, I also feel quite gross which has affected my sex life a lot.

I am worried that the longer this goes on, the less likely it is to be able to be fixed. However I cannot afford to go private as I have a host of other issues after the birth which have left me physically disabled so I am not currently working.

My mother says this can be fixed with a simple operation. My question is basically, is this true, and does it sound to you like my GP is just bullshitting me about the referral, and is there any way to actually get a referral without going via my very unhelpful GP!?

I don't imagine hormones are something you specialize in, but this is something else I keep asking medical professionals and not getting a satisfactory answer. Basically, I used to get this horrendous pain in my right side, but it was only once a month of so and for a few hours at a time. This went away totally when I was pregnant. I did not get it at all. For a few weeks after the birth, I didn't get it either. Then all of a sudden it was back with a vengeance. Now it doesn't let up much at all, the pain is there, worse, average 20 hours a day and its totally disabling. I get a few hours each day (usually, sometimes the break does not come) where I am totally normal..but then it comes back. Now, I think this is clearly some issue with hormones, given the fact that it went away totally in pregnancy, however the pregnancy seems to have made it much worse also. But my GP, pain clinic, consultant, everybody say this is not possible. They also took out my gallbladder thinking it may be that, but fucked up the operation leaving me almost dead and in hospital for 2 weeks with huge drains sticking out of my side...and longterm nerve damage to add to the normal pain. So have been very unlucky medical wise.

If this is possible to answer, do you think this could possibly be a hormonal problem?! Noone else seems to be investigating anymore and they have just written me off on morphine. However the morphine they did have me on (80mg per day) worked OK, but was not enough to actually allow me to have a resemblance of a normal life. But now, they reckon thats too high a dose to be on so cut me down to 40mg per day, which is unbearable, whilst refusing to add in anything else to substitute the loss of pain relief. Ugh. Sory for the bit of a rant, but I am so annoyed by the whole situation and am actually reduced to doing cold water extractions on cocodamol tablets to get the pure codeine, and self medicating with alcohol and weed. Due to everyone refusing to help me, and taking away the little bit of help they did at one stage give.

Six - I haven’t heard that theory re: carbs/vegetarians having earlier menopause or worse symptoms. If anything possibly the reverse if the vegetarian eats soya products?
Premature menopause (ie: periods stopped under 40y) can be due to oophorectomy, chemo or radiotherapy, or medical treatment for breast cancer. Otherwise can have no known cause - some think there is a familial link, but I’m not sure this has ever been proven, and is not thought to be genetic, as such.
Perimenopausal symptoms, as I mentioned above, we are now increasingly recognising are common earlier than otherwise thought, years before the menopause, and can overlap with menstrual changes and PMS.
For a fantastic explanation of this concept, which seems to confuse many doctors (even gynaecologists), please do watch the late, great Victoria Wood in this clip:
m.youtube.com/watch?v=RluZrWkdkrk

Chango - if you mean vaginal prolapse, then see a urogynaecologist to assess whether this is accurate diagnosis, and how big it is. If you have symptoms, then physio will stop the prolapse getting bigger, but won’t get rid of it - but may be enough to reduce symptoms.
Surgery would be the only definitive option to get rid of the prolapse itself, but unless pelvic floor issues addressed, this can cause other problems and has risks. Prolapse can also recur.

HelloFlamingo - I presume the germ cell tumour has been surgically removed, but not the other ovary?
HRT is possible by transdermal route (patch/gel) if you have had previous clots. All depends on your age and if your family complete.

May i ask my question again. Why isn't it routine to quickly scan women in early labour to check lie of baby, etc. DS1 was posterior but midwife didn't know, reg mentioned it when things went pear shaped because DS1 had cord wrapped round neck. Wouldn't it be more efficient?

Irh3891

Does it feel like they are more in the anal area? Like everything is stuck together? That's what mine feel like and I didn't deliver vaginally. It's horrible and so achey and sore.
:-(

Sunshiness - interesting isn’t it? I have no idea. I couldn’t see myself wanting to specialise in Male urology, ever!
I am going to be honest that possible reasons are having power over women and their most intimate areas, and some may like looking at women’s genitalia all day. There are misogynists and people with personality disorders in medicine too. Apologies if that upsets anyone.

Sadly, some women do still tend to trust a male consultant more, specifically in Gynaecology. Whether that is because they are elderly and still find women being a doctor a surprising thing, or more depressing that sexism and patriarchy is so entrenched in our society, that some women think male doctors are automatically more learned or intelligent? There is still a great deal of sexism in medicine that men are “naturally” better at surgery, and you would have to be unusual as a women to succeed in this.
I still see women who are clearly surprised that I am the consultant, and I’m late 40’s. When I did hospital medicine and was consenting people for surgery, with my scrubs on, having introduced myself, people would still think I was the junior doctor, a nurse or some kind of secretary.....and would assume my junior male colleague (or medical student) was the consultant!

Sheldon - see post above, and would support starting early.
See John Studd’s website for more info on how many women are wrong,y diagnosed as having anxiety or depression when perimenopausal...

quince thanks for answering so thoroughly. Yes, I misrepresented MMc by saying she is "against" smear tests - although I believe she cites a Cochrane review which says that the UK programme is based on an insufficient evidence base. I think MM is instead suggesting women should be given decision making aids to help them understand whether to engage with screening or not.

I think she calculates that a few hundred women will have to have biopsies to save 1 woman from dying of cervical cancer. And obviously biopsies can have implications for future pregnancies.

Sounds like you don't basically disagree that low risk women should have access to the facts and consider the benefits of screening?

Thank you OP for your generosity. Just THANK YOU!

GardenGeek - I knew this question would come up.
Have been examining women for 25 years. When I started, everyone had pubic hair apart from some Muslim Asian women, who for cultural rather than religious reasons shaved fully. Some women had a bikini line trim, which was considered quite radical.

Now? Under 25y, never any pubic hair, to the extent that young women think it is “dirty”, and we see them in STI clinics for what they think is warts or herpes, but actually shaving or waxing related injury or irritation.
25-40y - varies from none, to neatly trimmed.
40+ - rare to have none, most short or trimmed. Occasionally see full-on untrimmed pubic hair, likelihoood of this goes up with age, definitely.

Oh and thanks for your response to Sunshine - I have met a few male obs gynae consultants I felt deeply uncomfortable, particularly one at our local hosp who wrote the guidelines on multiple births. He is quite sneery and aggressively jokey iykwim. He is very very pro intervention, and to me it smacks of having power over something he can't do himself (give birth).

Thanks for this thread, you've restored my faith in gynae a bit after some bad experiences!

georgina - 10weeks is early days after a delivery.
When anyone pushes to have their bowels open, the pressure inside the abdomen increases, and this will push down on your vaginal walls. After a baby, these will be a bit more lax, and you may be feeling the back wall of the vagina when you bear down, which is normal if it then goes up again, if you see what I mean.
If you are constipated, as most women are after, due to fear that everything will unravel on the loo, or that it is painful, then you may actually be feeling hard stool as the lump.
If after a few months when the bowel function is normal and tissues have had a chance to heal, if the lump is still there, that is a small vaginal wall prolapse, or cystocoele. This is ok as long as symptoms have resolved. Give it some more time, and laxatives with pelvic floor exercises, as your GP as said.

Johnny - thanks. I do think patients should have the offer of screening and the meaning of results explained more clearly (for anything). I think MM’s figures will not apply to the revamped screening, as HOV testing is designed to do exactly that: avoid unnecessary biopsies.
In my experience, a lot of women avoid smears because they think it is to detect cancer, rather than pre-cancerous change, and are terrified.
Conversely, most women think they have had the “all-clear” after a normal smear, and are unaware that it can miss the rarer types of cervical change, or even ignore symptoms such as bleeding after sex, because of their normal smear.
Women aren’t told enough about things we can change to reduce risk of cervical cancer eg: stop smoking, or that it’s not hereditary.

Re: creepy male O&G doctors - I think many of us have encountered them. The more you think about it, the more disturbing it is.

Melamin - see my recent posts. BMS and WHC websites have names of specialists.

Beyond - the Mirena is licensed for 5yrs in the UK, but 7y in many countries. Still recommended to be changed after 5yrs, but extremely small risk of pregnancy if in up to 7y.
If you were over 45y when it was put in, for contraception, it can remain in until 55y, when should be removed.

If you are using it to protect the endometrium as part of HRT, the license is 4yrs, but national guidance says fine for 5y.

If you are using it for control of bleeding alone, then it can stay in as long as it is controlling your symptoms!

Pigeon, do you know, I can’t think of any in particular. I see a lot of different types of women in different settings, so guess things which might have shocked or surprised me when younger, no longer do.

Kalinda, yes you may do - but as you have no symptoms, it’s unlikely to be a problem or severe.