Tuesday, December 21, 2010

Whites-Do's and dont's

‘Doc, I wish I had come to you earlier. I just didn’t know who to talk to this about’-is a common refrain of many women to their Gynaecologist.
 Most of my patients come to me after suffering a while, because they are too shy to talk about their illnesses even to their mothers or daughters.
A common ailment across age groups is white discharge from the vagina. The medical term used is 'Leucorrhoea' but commonly referred to as Whites.
Excessive discharge is normal during the middle part of the menstrual cycle-when a sticky strand may stretch even outside the vagina-this disappears soon after the egg bursts from your ovary.
It is also normal to have discharge at time of sexual arousal and in pregnancy.
In late pregnancy, excess vaginal discharge may be a sign of onset of labour or may be a break in the 'bag of waters' that surrounds your baby-warranting a visit to the hospital.
In young girls prior to onset of periods, excessive discharge may be due to a foreign body-beads, toy parts or grains in the vagina-this needs to be checked out by a doctor who can telescopically remove the same.
In women of reproductive age group, the commonest cause of whites is a vaginal infection.
Three types of usual infections are – fungal, trichomonal or bacterial.
Thrush/yeast/fungal/ candidiasis/moniliasis is the commonest.
This occurs when the normal bacteria in the vagina which maintain acidic environment die out -as following antibiotic therapy. This also occurs if  vaginal acids are neutralised by alkaine semen [after frequent sexual intercourse] or taking alkalinisers for urinary infections. Yeast thrives in a moist, sugary environment that happens after exercise, in summer or the monsoons or after binging on sweets or in diabetics. Tight clothes, synthetic materials & excessive pubic hair, trap moisture, create friction, damage skin and encourage fungal growth.
Thrush is seen a curd like discharge that doesn't smell too much and is accompanied by itching and soreness and burning while urinating.
Trichomoniasis is sexually transmitted, accompanied by profuse greenish, frothy discharge and dyspareunia-pain during sexual intercourse.[though this can occur in any vaginal infection-its severity isgreater in Trichomoniasis.] Partner treatment is important here else chances of a recurrence are high.
Bacterial vaginitis may cause a foul smelling, greyish or yellowish discharge and needs local and/or oral antibiotics.
The cervix which is the mouth of the uterus may have an ulcer, a growth or an erosion[ overgrowth of mucus producing inner lining] which causes the discharge or may be elongated and herniated-this needs to be thoroughly checked and surgically treated .
Sometimes a fibroid in the uterus or a swollen fluid filled fallopian tube may also cause vaginal discharge and would show up on sonography.The treatment options for these would be put before you by your gynaecologist.
To reduce the spread of HIV, which either partner is more likely to get, if there is unprotected intercourse in the presence vaginal infection, doctors or sometimes nurses adopt a 'syndromic approach' to treatment-they treat all three types of infection with a combined vaginal tablet or a kit of oral medicines.
Worms migrate from the bowel to the vagina, carrying with them germs that may cause an infection. This is common in India and sometimes, deworming helps relieve the infection. It also helps improve your nutrition and resistance in general.
Other sexually transmitted diseases like gonorrhoea, herpes or syphilis may also present as a white discharge. Your doctor may order tests before starting treatment.
Older women who lose hormonal support and hence have thin vaginal skin, may need short term or local hormonal therapy besides treating their infection.
 Even a mild vaginal infection can spread to the uterus, pelvis and blood and have serious consequences especially in pregnancy or after a surgery. Vaginitis also makes you prone to other infections. Hence it needs to be treated quickly, and completely.
Some simple things you can do to avoid repeated infections are:
Cut the sugars from your diet
Trim your nails-fungal spores and worms eggs get caught under long nails, and reinfect you by an itch-scratch cycle.
Keep you hair trimmed down there for hygiene-to avoid trapping moisture and germs
Use cotton inners-natural fibres breathe and keep you dry avoiding frequent infections.
Use tissues to gently dab yourself dry after passing urine, instead of washing with water.
Wash after intercourse if you are not trying for a baby and dab yourself dry.
Loose clothes like skirts, Parallels, or Salwars or Sarees are better than tightly fitted trousers or Churidars. Jeans, Jeggings and Tights are totally unsuited to Indian weather-put them away till you’re fine.
If possible, sleep without a panty so that your parts stay aerated and you avoid infection.
Douching your vagina is not a good idea. Let your natural defense mechanism take over.
Eating yoghurt and pro-biotics colonises your bowel with friendly bacteria which migrate to the skin and vagina and protect you from future infection.
Use a mild soap or a special pH controlled perineal wash for your privates-that keeps the natural resistance mechanisms going.
Using condoms protects against infections –so insist on it.
Some panty liners contain chemicals that may causes irritation and allergies-avoid these.
Sterilise your panties by soaking them in half a bucket of water into which a cap full of dettol or similar antiseptic solution is added, for a couple of hours. Wash thoroughly with detergent before use. You need to do this only once, not daily.
During your periods, change sanitary pads every few hours and wash atleast thrice a day. The glue from some makes of pads and panty liners doesn’t wash off. It traps germs and re infects you. Change the make or keep a separate set to use only during your periods[with a pad]
Above all, your vaginal discharge may just be the symptom of something more serious-see your doctor and get things cleared.
Asking your partner to go for a check and maybe adopt some of the measures mentioned above-might help both of you.
Severe Infections may need long term oral treatment -follow your doc’s advice and try not to give up half way.
Let there be White no more!

Wednesday, October 6, 2010

The Lowly Gynaecologist

“ A Physician works at cerebral level, a Surgeon at spinal level and a Gynaecologist at Lumbrical level”

This was the sneering statement made by a Physician while we were in training.
For the non medical people, it implies that a Physician [post graduate in internal medicine] uses his brain, a surgeon his inherent skill, while a gynaecologist merely uses her hands without thinking or talent- the Lumbricals being muscles in the hand.
This patronising attitude towards us gynaecologists continues through our working lives.

With the Nobel prize for medicine being awarded this year to Professor Robert Edwards, the originator of the test tube baby and the first gynaecologist to win the award, all of us gynaecologists feel vindicated. It was balm on our bruised egos.
Thinking back, Gynaecologists have given several firsts to the world of medicine-

Professor Ian Donald, first thought of holding an ultrasound probe over the adbdomen of a pregnant woman and got images of the baby, thus starting the whole new field of sonography-which is indispensable in  diagnosis in almost every branch of medicine and even used in therapy.

Professor Kurt Semm also a gynaecologist, removed an appendix laparoscopically and then started doing hysterectomies setting the trend for endoscopic surgery. The surgeons followed with Laparoscopic cholecystectomies etc.

Prof. Camran Nezhat again a gynaecologist first used an endovision camera and monitor to do laparoscopic surgery while looking at a screen and not peeping through the telescope with one eye shut. Today extensive cancer surgeries are possible because of this one small step /giant leap.

Then there was the test tube baby- Louise Brown the brain child of Sir Robert Edwards and Patrick Steptoe. Gynaecologists all over the world adopted their methods successfully –leading to a whole new field of assisted reproduction. With this came advances in culture media, incubators, operative microscopes, sterile environments and led to development of stem cell research, tissue preservation and even cloning.

Prof Charles Koh, started doing endoscopic tuboplasty [for repair of the fallopian tubes] and opened up the field endoscopic microsurgery –useful even to cardio-vascular surgeons.

Besides these landmark developments by Gynaecologists, I feel a 'Doctor for Ladies' is different from other consultants in many ways-She has to be both Physician to treat various diseases in pregnancy, taking into account the effects on the mother and the baby; and Surgeon to operate on various pathologies of women. Besides gynaecologists need to have a fair knowledge of endocrinology, oncology and breast diseases. Plus she has to know about and use psychotherapy and also step in to sort out the social problems of her patients. Women she has delivered look to her for baby care tips and a basic knowledge of paediatrics is also in her domain. She also has to educate- girls starting puberty, women getting married, or trying to have a baby, sort out physical marital problems and help women age in comfort.

Gynaecologists are often primary care physicians for pregnant women and for those who are too embarrassed to see a male family doctor for an ailment of a personal nature.

To all derisive statements made towards us by doctors of other specialities, I would like to say we are not only your equal, we are first among equals.

Congratulations to Sir Robert Edwards for getting the highest honour for his work. Sir, you do us all proud.

Monday, August 23, 2010

Treatment by halves

" Sonny, send your worst cases to your enemy"-An old Gynaecology Professor to his assistant.

At the Wadia Maternity and Gynaecological Hospital in Mumbai that is exactly what we get. Women who have undergone multiple surgeries that have failed, multiple cycles for infertility treatment and have exhausted their resources but not hope, have lost a number of babies and are taking that one final chance, mothers carrying babies with severe growth restriction or anomalies where the gynaecologist doesn't want to break the bad news, ART practitioners who want their patients to undergo laparoscopy cheaply and save money for IVF and so on.
I speak from hind sight and a review of cases that I have managed and here are some of my observations-
ART practitioners, seem to jump too soon into IUI and then IVF cycles and further ICSI if all fails.
Several patients have a simple problem like lack of knowledge of fertile period, insufficient frequency of coitus, use of lubricants or douches, washing off the ejaculate, pain during intercourse from infection or inadequate relaxation and just advising couples on these basic techniques works for them.

The cervical factor is another neglected area. Most IVF clinics do a transvaginal scan and a simple per speculum or per vaginal check is skipped. Cervical erosions, ulcers, small polyps chronic cervicitis contributing to her infertility are missed. The first time the cervix is looked at is during an IUI by which time its too late to treat and the doctor proceeds with the procedure-which is likely to fail if the infection has tracked into the uterus or results in an abortion should a pregnancy occur. A simple procedure like a cryo or thermo cauterisation cure the erosion and several patients conceive spontaneously after.

Sometimes the cervical canal is tortuous or stenosed or there are large cysts [Nabothian]-obstructing passage of sperms and causing infertility. A generous dilatation, rupturing the cysts, removing the polyps and lysing the adhesions cures the infertility or makes the IUI or Embryo transfer much smoother and bloodless and hence more likely to be successful.

Uterine polyps are treated by most gynaecologists by simply pulling it or curetting it out-increasing chances of recurrence. If done at hysteroscopy taking care to cut the base, the polyp is unlikely to recurr and the patient has better chances of pregnancy -spontaneously or assisted.

Fibroids not only distend the uterine cavity, make the endometrium inflamed and hostile to implantation, they may mechanically obstruct passage of sperm if they are close to the cervix or the fallopian tubes. They also make an IUI / ET a bit more difficult. With modern laparoscopic techniques, it is possible to have few or no adhesions after myomectomy and often patients conceive after the myomectomy.

Poly cystic ovaries or indeed any ovarian cyst needs to be diagnosed and ovarian drilling removes large unruptured follicles that mechanically obstruct newer ones, changes the hormonal environment, and these patients come back pregnant much to their surprise. If they are on treatment, ovarian drilling makes them sensitive to drugs like clomiphene to which they were hitherto resistant, reduces their requirement of gonadotropins and chances of Ovarian Hyperstimulation. However one needs to do just 4-5 punctures, with a minimum current for just a few seconds and copiously irrigate the ovary to avoid thermal damage to other eggs.

Endometriotic cysts are often punctured and left to nature by gynos not sufficiently confident of endoscopy-removing the cyst wall is essential to prevent recurrence of these cysts.

Tiny patches of endometriosis are also left untouched-these release several factors that inhibit ovulation, alter tubal and uterine peristalsis and interfere with conception. Removal of all endometriosis, makes a patient better responsive to ovulation induction and increases her chances of pregnancy.

If there is a problem in sperm count or motility, the male partner is sent to an andrologist who may rule out hernias, hydrocoeles, varicocoeles and undescended testes but rarely bothers to do his sugars, thyroid function tests and take a history of exposure to high temperature or stress, do a semen culture and treat the infection. An exhorbitant nutritional supplement is prescribed that most men stop after a month because of the cost. It is so easy and cost effective to test and take a history to get at the real problem before jumping to do an IUI where the few poorly motile sperms will also be lost and then to ICSI. The chances of successful ART  are also increased by taking care of these other common problems.

Finally, many women have multiple cervical dilatations for various procedures and often have an incompetent os on top of a multiple gestation. Good idea to look out for this prior to infertility treatment and continue to look for it from 3 months onwards with a sonography[ most sonologists never comment on the cervix] and take a stitch if required, preventing a precious pregnancy aborting.

Male gynaecologists avoid proper exam of the patients breasts which is left to nurses. they often miss galactorrhoea and though the prolactin levels are normal, correction of the galactorrhoea does often restore normal cycles and fertility.

Thyroid disorders are missed if the tests are not done at a good laboratory-so looking for signs of thyroid disturbance and sending these patients blood to a good [although expensive] lab may be worth it.

So lets 'Look at the patient not just the disease'. Lets not be in a hurry to start an ART cycle. Lets take care of everything we possibly can-this would help our infertile patients get pregnant at minimum cost and carry their babies to term which is the final aim of both the patient and the doctor.

Saturday, January 2, 2010

The new age in women's surgery

When my mother needed a hysterectomy 25 years ago, she had her abdomen cut, her uterus removed and things stitched back.
My aunt got her uterus removed vaginally.
Both went through pain, prolonged recovery periods, bed rest, put on weight due to bed rest, had to stay home from work and were miserable.
A revolution in surgery started with a German gynaecologist Kurt Semm who did a hysterectomy using a telescope, thin instruments put in through fine metal tubes and coagulating protein in tissues using electrical energy and even stitching up through those tubes.
Endoscopy was adopted by all surgeons-general surgeons now remove appendices and gall bladders laparoscopically, gynaecologists remove uterii, fibroids, ovarian tumors and even repair hernias [prolapsed uterii]  and orthopaedic surgeons to repair joints and even neurosurgeons are reaching remote areas of the brain endoscopically.
When my son needed a major joint surgery, all he needed were 3 puncture wounds round his shoulder, was home in one day and doing everything himself in two days.
This is the new magical world of endoscopy. We look into the patient's abdomen with a telescope-the image magnified several times and coagulate and cut tissues precisely using excellent instruments and electrical power or ultrasound waves. The tissue to be removed is cut with a rotating blade and removed in strips through a small puncture wound. Essential suturing is done. The cavity is washed with saline and every fine bleeding point is taken care of. 
The patient recovery is amazing. She sits up and drinks on the same day and goes home the next.
A week later, her sutures are removed and the scars are invisible in a few months.
Like any surgery, these operations have their complications but in experienced hands with good instruments, the complications are negligible.
At my hospital, where two patients who underwent the same surgery but one with a cut on her abdomen and the other laparoscopically, were lying side by side and comparing notes.
The Laparoscopic one went home in a day and the one who had open surgery started crying and quarreling with the doctors for not doing a laparoscopic surgery on her. Yes. There is such a degree of difference in the two routes.
However, lack of good training, poor instruments, lack of experience and hurry and greed on part of doctors are giving this surgery a bad name.
Further, senior renowned doctors are not familiar with these techniques and in an attempt to keep their patients, malign laparoscopy.
No matter, this is the future and it is here to stay.
I wish my mother had had a laparoscopy and not suffered any pain, or been invalid.
I'm glad we now live in the age where no pain or disfigurement needs to be suffered even for a supramajor cancer surgery.
In future, with robots endoscopy will become even more accepted and done remotely.-Yes a surgeon in Bangalore will soon be able to operate on a patient in Bhatinda.