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  • Dr Sean Holland

Some gynaecological diagnoses are not all doom and gloom

One thing that I quickly became cognizant of when I started working in the field of women's health and counselling women regarding their various gynaecological concerns was the dire advice that some women were receiving from other clinicians, and these days social media, in respect of common gynaecological complaints. It strikes me that an almost sledge-hammer approach is occasionally taken when it comes to conveying to women the true import of their diagnosis and the potential ramifications of the same.


Two diagnoses that best illustrate my point are polycystic ovarian syndrome and endometriosis. First a brief introduction to both of these conditions - and I do mean brief (for further information there are a variety of reputable sources available - a good place to start is the Royal Australian and New Zealand College of Obstetricians and Gynaecologists website: www.ranzcog.edu.au ):


Polycystic ovarian syndrome (PCOS)

In essence, this is a physiological abnormality that manifests with certain cardinal features but, as with most health conditions, has quite a spectrum of severity. The accepted cardinal features are two or more of the following:

  • loss of regular ovulation, most commonly characterised by women reporting a cycle in excess of, and often markedly in excess of, the traditional 28 days;

  • features of excess androgen effect (androgens being the so called 'male' hormones, a small amount of which are normally produced by all women) such as acne and unwanted body hair;

  • polycystic ovarian morphology on ultrasound assessment

The condition can often be associated with marked metabolic dysfunction, particularly in regards to a woman's ability to process carbohydrates and generally maintain a healthy weight range, though this is certainly not always the case. It may also impair fertility.


Endometriosis

Arguably one of the most high profile, non-cancerous, gynaecological conditions affecting women. Its ramifications can be severe (for a moving example, read the story of Lena Dunham (American actor and writer): https://www.lennyletter.com/story/lena-dunham-opens-up-about-her-endometriosis ), however, thankfully, for most women their experience will be nothing like that of those women that do have severe disease. So what is this condition then? Put simply, endometriosis arises when tissue, identical to that lining the inside of the uterus, grows outside of the uterus. This can be anywhere in the body (I've seen cases of women with nose bleeds due to endometriosis) but is most commonly within the pelvic cavity surrounding the uterus. The problem with the condition is that this ectopic tissue responds just like the lining of the uterus to a woman's hormonal menstrual cycle; growing and then bleeding with menstruation. This leads to the typically painful periods experienced by women with endometriosis and additionally causes the formation of scar tissue and distortion of the normal pelvic anatomy. These latter effects then lead to issues with bladder, bowel and sexual dysfunction, including infertility.


This then brings me back to the introduction of today's post...the sledge-hammer that some women are hit with when either of the above diagnoses are first made.


Here are some of the reported statements that women tell me they have received when being informed that they have PCOS or endometriosis:

"You better hurry up and get pregnant (to a 21 year old, otherwise healthy lady, who was not then in a relationship)"

"You will never fall pregnant on your own (obstetric practices are full of these miracle pregnancies)"


My problem with such statements is the absolutism with which they are weighted. Leaving aside whether or not the advice may or may not be valid in a particular individual's circumstances, and too often it is not, to me the delivery of such statements betrays a lack of regard for the woman and an unwillingness to take the time to explore the subtleties of her medical diagnosis. Too many women have come to me with such histories and such advice in clinical circumstances where it is obvious, on exploring their history, that the advice is, to say the least, extreme. It is true that conditions such as endometriosis and PCOS can impact upon fertility. It is true that a higher proportion of women with these conditions will require medical assistance in falling pregnant as compared to women without these conditions. What is not true, is the suggestion that having one or even both of these conditions means that a woman will have trouble falling pregnant. It is simply true that she may have trouble. The distinction is all too important.


The challenge, as I see it (and this is a challenge for all medical practitioners, not just gynaecologists), is to be willing to take the time necessary to tailor an explanation and advice to the individual woman and the specifics of her diagnosis as opposed to taking a generic one-size-fits-all approach that all too often over emphasises the worst potential aspects of their presentation. Of course, there are presentations, such as that of Ms Dunham, that are extreme, that represent the worst possible excesses of a particular disease and for which hard to deliver statements of fact are required. But disease is a spectrum, like humanity in general, and my belief is that clinicians have a duty of care to ensure that our patients understand their condition, as it pertains to them and their lives, and not simply treat our patients as another statistic.

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