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!

maya, it sounds like your PCOS is being inadequately treated, so I would suggest you need jountbmanagment with an endocrinologist, as well as a gynaecologist. Mirena is a great choice for bleeding and endometrial protection.
Laser hair removal can be very effective, and a great confidence boost in PCOS. Hope all goes well.

Sorry, joint management

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?

Lipstick - congrats on the twins, how wonderful.Your consultant’s suggestion is fairly standard IF vaginal birth is what you have chosen.
For twins, you need twin 1 to be head down, then when they are born, manage twin 2 either head or bottom first - which an already-working epidural is needed for. There is a significant risk of Twin 2 needing to be delivered by Caesarean. Vaginal delivery is slightly riskier than planned C/S, and maybe slightly more so for twins.

Vaginal birth is a great thing when it all goes well. Because it’s your first birth, induction and epidural, these are all risk factors for things not progressing as well as they might - not sure on figures, but I certainly don’t recall any failed inductions for twins.

An epidural on board is very useful for changing plan to a C/S during labour if things are not going as planned.

An elective Caesarean is a perfectly reasonable choice if that’s what you prefer.

Nurse15 - see my answer earlier for recovery times. Hysteroscopy less than laparoscopy, but depends if both diagnostic or treatment.

katie, your bleeding is not normal, or caused by stress. Scans are not very good at picking up polyps unless very experienced clinician, or a large polyp - so the fact that this has been suggested makes it likely one is present.
Whether the scan had looked normal or not, you should long ago have referred to a gynaecologist for a hysteroscopy, to look inside the uterine cavity, remove any polyps and take a sample of the uterine lining.
This will be treatable, dont worry.

katie - a Mirena is a very reasonable option to treat your pre-existing heavy periods after the investigations have been done. See prev posts for why it is very unlikely you would have hormonal side effects with it.

What would you do to help a woman that will not tolerate any form of internal exam or scan?

junior - this can be a term to describe different textures in the wall of the uterus, most commonly due to fibroids.

reel really kind of you. I am enjoying it very much, just wish I could type faster on my iPad.

Any chance you could answer my question on Page 14?

In your opinion, which HRT is best? (that an NHS GP would be willing to prescribe)
Pills , patches or gels/creams?
Which make/brand?

Tomorrow - it’s not dangerous no (tell your friend ). Leaving a coil in for longer than it should whilst you are still fertile runs a small risk of becoming pregnant, although rare! All coils should be removed when no longer needed for contraception, which is advised to be at 55y, as there is theoretically a risk of infection if never removed.
I’ve seen lots of coils left in until ripe old ages, at which point the risks of trying to take out are probably higher than leaving them in...

Hi @quince2figs, Great thread thank you.

I have two questions if you are still in the mood to answer them.

1. I had a manual removal of the placenta after dc1 (now have 3dc - and not planning any more) and the subsequent 2 births were straightforward. Is it just one of those things (they forgot to give me the injection until about 15 mins post birth)? I found the operation to remove it quite traumatic retrospectively - lots of drugs so off my tits, away from my newborn, hearing the surgeons guiding each other through it "careful not to put a hole in her womb" and also the whole image and feeling of someone's entire arm up your vagina. It is seven years ago and even writing this makes me cry though it is not something I think about often. The emotion is also combined with emotion over conception difficulties and an ill baby at birth (kidney issues diagnosed antenatally) and initial feeding and weight loss issues. But where would I go to resolve such issues? About four years later a senior midwife went through my notes with me by phone which was helpful. But many people have much worse problems so do I just get a grip and move on? And how?

2. I am obese (bmi 41) and found my treatment as a fat woman both ttc and while pg was pretty judgemental. It took two years to conceive though we did so naturally in the end (I had monthly but irregular periods anything up to 40 days) and all fertility appointments focussed on weight even when I pointed out I was from generations of fat but fertile women. And when I was pregnant the attitude of midwives made me feel quite shite as well as things like automatic referrals to obstetricians where the conversations would go something like:

• why have you been referred to me?
• because I am fat
• what a waste of time. next

except when they went like this:

• why have you been referred to me?
• because I am fat?
• hmmm yes you do have more chance of yourself or your baby dying. Not much we can do. Next.

So my question here really is do you think obs and gynae is particularly fattist and what can be done to be nicer to fat women? I am not saying you should pretend there aren't risks - but we are not going to stop getting or being pregnant (or getting or being fat in all likelihood) so a bit more kindness would go a long way. Obviously I am not accusing you of this at all, just sharing my experience.

namechange - your symptoms are strongly suggestive of endometriosis

Thanks so much quince. That's horrendous about the entrenched patriarchy and people just assuming you must be the junior doctor!

imwide - still trying to catch up, sorry!
I think the best and safest option is a Mirena plus an oestrogen-only patch or gel. Menopause matters website great for specific brand advice.

Great thread, thank you! Any advice about Vestibulodynia? Had it since I was about 21, though it took a few years for a diagnosis. I kept getting told probably Thrush, or bacterial vaginosis but tests all clear. Many years later and it is no better, the main issue is painful intercourse, and I have Instilagel (sp?) on prescription but would love for things to improve! Thank you :)

singadream - manual removal more likely if the syntocinin injection is not given or given late, as in your case. It is fairly common anyway, though.
Your experience sounds awful, and you have elements of PTSD. This is a really common reaction after childbirth, particularly when something goes wrong. I’m so sorry. I would suggest you ask your GP for referral to a gynaecologist with psychosexual clinic, and/or a proper debrief from the delivery unit.
We are reeeeeally bad at dealing with the aftermath of birth trauma as a profession, as we generally don’t acknowledge the possibility of it happening.

Weight - yes, there is a huge emphasis on the risks of being overweight in pregnancy now, partially because society as a whole is getting fatter. There is logic in being booked to deliver on a consultant unit, as risks at birth are significantly higher.
But yes, the antenatal conversations tend to be exactly as you have described (ie:useless) - and you can’t really do much about it once you are pregnant, can you?
There should be greater emphasis on supporting women to be as healthy as they can be before trying to conceive, and maybe keeping an eye on all women’s weight, as we used to, in pregnancy. Difficult to get that balance right.
I am fat too, so know how you feel.

twinkle - Instillagel is only treating symptoms, not cause. You need referral to a gynaecologist who runs a specialist vulval clinic. Psychosexual input and meticulous skin care can often help, and surgery is sometimes offered, but rarely helpful.

I'm not sure if I'll sound thick here...

Where does the amniotic sac grow? I always struggle to understand how the sac fits to the placenta/uterus/cord without leaking?? Is that a really stupid question?

thanks @quince2figs. What happens at a gynaecologist with psychosexual clinic? Is it basically counselling just by people who understand the terminology?

jellyin - I tend to use “fairy” when younger, and now moving to “vagina”. Ds is quite happy with “willy” and “balls”.
I was brought up with front bottom, though

Shoulder dystocia - wow, 7 minutes is long, and a whopping baby - I bet that put the wind up the midwives at home. Why the hell didn’t they do an epis with a stuck baby????

You’ve basically put my thoughts down in your post - a C/S would be entirely reasonable. If not, then definitely labour ward with a senior person delivering you.
Induction has pros and cons - yes, slightly smaller baby at 39/40, but higher risk of labour not going swimmingly. Induction is a risk factor for shoulder dystocia, especially if Cx closed.Maybe regular sweeps from 37/40, and induction at 39 IF possible to break waters?
I’m prob not the best person to ask as I insisted on going T+ with both of mine, and my 2nd was huge. Gives me cold chills now, wondering why the hell I took that risk! I was desperate for things to be as natural as possible.
Good luck.

Hi,
Not sure if my question was missed, you've been very busy! I asked about litigation and if you've had to go to court often to defend your practices.
I also wondered if you have performed or assisted with many peripartum hysterectomies.
No problem if you would prefer not to answer!

singadream - some gynaecologists undergo psychosexual training, which is really a misnomer - I do lots of this, and is really psycho-genital. Looking at the impact of events or relationships on sex/examinations/feeelings about future pregnancies.
It would be useful for this to be done by someone who also understands well what happened to you in labour.
If not, referral for psychosexual medicine elsewhere (still have the advanced training, but many GPs or sexual health doctors). Examination and your response to it is a vital part of this kind of therapy, and it can be just 1-2 sessions.
The Institute of Psychosexual Medicine website gives a list of specialists and where they work.
Looking just at the PTSD is another possibility, maybe with CBT.

anotherday - touch wood, not yet. Less likely in the fields I now cover.
I’ve assisted at 6 peripartum hysterectomies.