Gynaecological Diagnosis and Treatment- Chapter 4:

Q 4. 1 Which doctor should I see?

• Gynaecological symptoms are common and most can be adequately resolved in the primary healthcare setting (general practitioner’s surgery). The majority of general practitioners have speciality interests. General practitioners, who have had postgraduate training in gynaecology, should be encouraged to use their special skills for the benefit of patients. Those, who have interests outside gynaecology, should feel comfortable in referring their patients to a specialist relatively early.

• In the United Kingdom, the initial evaluation of your symptoms should be with your general practitioner; consultants (the senior hospital specialists) should generally see patients with non-urgent conditions only at the request of their general practitioners.

• Your general practitioner is best placed to advise you on the appropriate specialist after considering the clinical problem. If you have a particular specialist in mind your general practitioner may be happy to agree unless there are special circumstances where another specialist would be more appropriate. Your general practitioner can provide an invaluable summary of the problem to date for the consultant with details of investigations already undertaken as well as other essential background information. Once hospital diagnostic and surgical procedures have been completed, patients can be encouraged to return as early as appropriate to the care of their general practitioner for further monitoring and treatment.

Q 4. 2. What are symptoms and signs?

• A symptom is a problem that you report to your doctor such as heavy periods or pain in the pelvic area. A sign is an observation made by your doctor during examination such as a swelling on the uterus (usually a fibroid) or tenderness in a particular area.

Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?

• Many symptoms, such as pelvic pain, are common. Clinical examination and investigation will frequently demonstrate an abnormality. The abnormality indicates a diagnosis which in turn suggests one or more treatment options. It all seems so straightforward that it may be tempting to think that we could programme a computer to manage the investigation and treatment of patients. Medicine, however, remains as much an art as a science. During gynaecological investigation, there is a very good chance that at least one of the following will be detected but that does not necessarily mean that it is causing your symptoms.

• Table 4.1 Some common findings that may be detected during examination or investigation:

• Disorder

• Frequency

• Question Number

• Endometriosis

• Some authorities suggest most women have some endometriosis.

• 23.18

• Fibroids

• More than 50% of women will develop fibroids.

• 23.14

• Irritable bowel syndrome

• 15% of population currently; most people at some time of life.

• 23.36

• Pelvic adhesions

• Common after pelvic infection or with endometriosis. Almost 100% following surgery in the pelvis.

• 23.25

• Physiological ovarian cyst

• 100 %.

• 23.8

• Polycystic ovaries

• 20%.

• 7.6

• Polycystic ovary syndrome

• 7%.

• 7.6

• Premenstrual syndrome

• 95% some symptoms; 30% moderate; 5% debilitating symptoms.

• 25.2

• Prolapse, utero-vaginal

• Most women have at least some degree of laxity after childbirth.

• 30.1

• Retroverted uterus

• 20% of women have a womb that tilts backwards.

• 23.27

• The fact that you have pelvic pain and that during examination or investigation you are found to have a fibroid, endometriosis or a retroverted uterus, does not necessarily imply that the two are related. One cannot assume cause and effect. It will be part of your doctor’s clinical skill to advise you on whether these findings are the likely cause of your pain or just incidental and unrelated.

Q 4. 4 How do doctors arrive at a diagnosis?

• A diagnosis is ascertained from the combination of the history, clinical examination findings and results of investigations. The diagnosis of some conditions may rely more heavily on one of this triad than the others. Premenstrual syndrome can only be diagnosed from the history although a chart of symptoms may assist (Q 25.3). Pre-malignant conditions of the cervix are symptom and sign free but are usually diagnosed from the cervical smear test (Q21.8).

Q 4. 5 What does a gynaecologist do during a consultation?

• Your gynaecologist will listen to your story (history). Inevitably, this will require discussion of rather personal details including periods and contraception. A general and pelvic examination are usually required and some patients may understandably find this embarrassing. A male gynaecologist should have a nurse present to act as chaperone.

• Your gynaecologist will summarise the clinical and investigation findings and arrange any further tests as appropriate.

• You will require explanations and you should, as far as possible, be involved in choosing from the treatment options. Finally, your gynaecologist must complete all written documents, write to your general practitioner and often provide a prescription or ensure completion of arrangements for surgery.

• Invariably doctors have organised their clinics to ensure optimum utilisation of clinic time for the benefit of all their patients. In busy hospital clinics, the time allocated for each patient may be less than fifteen minutes. Although many patients, as well as their doctors, would wish for more time, additional time spent with them results in delays and less time for others. The doctor’s specialist skill lies in diagnosis and the application of medical and surgical treatments. We doctors are more than aware of the emotional turmoil that our patients may be experiencing but rarely is there time for us to explore these areas in the detail we would wish. When it is appropriate, we may be able to direct patients to allied professionals such as counsellors or nurse specialists who can provide invaluable support.

Q 4. 6 What is the purpose of the pelvic examination?

• The purpose of the pelvic, or gynaecological, examination is to check on the health of the genital organs. It includes inspection of the external genital area and often visualisation of the vagina and cervix by the introduction of a vaginal speculum. At this time, bacteriological swab samples and a cervical smear test can be taken (Q21.8). During the bimanual examination one or two lubricated gloved fingers are gently introduced into the vagina whilst the other hand is placed over the pelvic area. The doctor wishes to assess the size, shape and position of the uterus, possible enlargement of the ovaries and areas that are particularly tender. The doctor is likely to concentrate on the part of the examination that most relates to your symptoms.

Q 4.7 21 What are the risks of surgery?

• Surgery can be extremely effective but it is not free from risk. The risk may be small but should be balanced against the likely benefits. Complications can occur:-

•  at the time of surgery or within the first twenty-four hours (immediate),

•  during the next days or few weeks (intermediate)

•  in the long-term.

• There could be bleeding during the operation, within the first 24 hours of the operation (primary haemorrhage) requiring a return to the operating theatre or bruising or collection of blood over the next few days (secondary haemorrhage). A surgical cut results in scarring which could result in long-term discomfort. The objective of the operation may not be achieved. There may be specific recognised complications for particular operations. An example of a long-term psychological complication is regret at having been sterilised.

• Some complications are local such as:

•  Wound infection.

• There is always a tiny chance of an accidental or unavoidable injury however competent and careful the surgeon may be.

• Other complications may be of a more general nature:

• A general anaesthetic carries by itself a small risk; chest infection or breathing difficulties for example may occur.

•  A clot may occasionally form in a leg vein (deep venous thrombosis (DVT) and if it is dislodged it may travel to the lung (pulmonary embolism). The risk of this complication is increased:

• If you are overweight – if you have a history of previous thromboembolism or embolism. – with more complicated and time-consuming surgical procedures – when there is a delay in postoperative mobilization.

• The risks of surgery have fallen dramatically over the last century. A number of factors are responsible for this:

• Aseptic technique has reduced the risk of infection.

•  We have powerful antibiotics should infection occur.

•  There has been a tendency to administer antibiotics at the time of surgery to reduce infection.

•  Anaesthetics are administered by highly trained and skilled doctors.

•  Surgical techniques have become ever more refined.

•  Blood-cross matching and transfusion is refined and remarkably safe.

• One of my colleagues has family in the United States. His grandson required circumcision under general anaesthetic. The family were presented with a ten page document listing all the possible complications of this relatively simple surgical procedure. The final statement was that no guarantee could be given that the child would survive! The document had to be taken home before signing to demonstrate that adequate time had been allocated. The family were required to sign a statement that they had read and understood the document before the hospital would agree to the operation. We have not reached quite such a degree of medico-legal caution in the UK but we seem to be proceeding in that direction.

• Every choice in life is a matter of balancing the advantages and the disadvantages. Frequently, the advantages of surgery clearly outweigh a conservative approach. Appendicitis or life-threatening bleeding are obvious examples. The decision to operate for the majority of operations, however, is influenced by the severity of symptoms. In gynaecology, laparoscopy to assess pelvic pain (Q23.24), hysterectomy (hysterectomy) for heavy periods (Q24.19) and pelvic floor repair for vaginal prolapse (Q30.6) are examples. If you have a recurring pain that does not require even a paracetamol tablet it is unlikely that you will require an operation to determine the cause or remove the source of the pain – the risks of surgery are likely to be greater than the possible benefits. If your periods are limiting your enjoyment of life, your family is complete, and other treatments are not helping, the benefits of hysterectomy are likely to outweigh the risks.

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
  Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment

Q 4. 8 I have a phobia about blood tests. What should I do?

• You are not alone: nobody enjoys having a blood test. First, let your doctor know, as it may be possible to reduce the number of tests that are requested. If you find the pain of the needle distressing applying a skin local anaesthetic such as Amethocaine 4% (Ametop) about 30 minutes before sampling will solve the problem for you. Let the person, who is taking the test, know about your fears, as they will have lots of experience with this problem.

Q 4. 9 What is pelvic ultrasound?

• Ultrasound was introduced into clinical medicine in the late 1950’s. We currently use equipment called real-time scanners, which provide a continuous moving picture. A transducer emits very high frequency sound waves, which are reflected back from surfaces (Figure 4.1). The reflected beam is detected and can be seen on a monitor screen. Ultrasound is safe, cost effective, non-invasive and an accurate technique for evaluating the internal reproductive organs in gynaecology and the fetus during pregnancy. Many gynaecological and early pregnancy ultrasound examinations are undertaken with a small vaginal transducer, which can be placed close to the uterus and ovaries: this is known as a transvaginal or internal scan.

• Ultrasound examination can demonstrate structural abnormalities such as fibroids and ovarian cysts. For patients with infertility problems, ultrasound provides information on oocyte (egg) development and in IVF the eggs are collected under direct ultrasound visualisation (Q10.24). Ultrasound may provide reassurance about the endometrium in patients with postmenopausal bleeding reducing the requirement for invasive investigation of the uterus (Q 26.17). Breast ultrasound examination has a role to play in screening women under the age of 40 and also supplements mammography (Q32.35).

• In pregnancy, ultrasound provides:

•  essential information on the dating of the pregnancy.

•  assessment of bleeding in early pregnancy.

•  detection of ectopic pregnancy.

•  early detection of multiple pregnancy.

•  assistance in the diagnosis of some congenital foetal abnormalities including:

•  Down’s syndrome.

• The spina bifida group.

•  Heart.

•  Skeleton.

•  an indication of the site of the placenta and the growth rate of the fetus in later pregnancy.

• Forty years of experience with ultrasound in pregnancy has shown that it is remarkably safe.

Q 4. 10 What are CAT and MRI scans?

• Computed tomography (Computer Assisted Tomography – CAT scan) requires a combination of a special x-ray machine and a computer. The computer stores a series of ‘cuts’ and a series of pictures can be produced at varying levels of the body part that has been x-rayed. It can be beneficial in the assessment of gynaecological tumours.

• Magnetic resonance imaging (MRI) is a non-invasive technique that provides images of body structures. Before entering an MRI scanner, the patient must remove all metallic objects including jewellery and watches. A powerful electromagnet causes the nuclei of atoms (particularly hydrogen in water molecules) to align magnetically. Radio waves are used to detect the position of these atoms and these are analysed by computer. Bones do not hamper the picture so the technique is particularly helpful for looking inside the skull. In gynaecology, MRI may provide a detailed assessment of the pituitary gland (Q6.10).

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
  Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment

Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?

• It is routine practice for doctors involved in your care to communicate with each other usually by letter. If you are seeing more than one specialist for different problems, they are likely to keep each other informed to ensure that you receive the optimum treatment.

Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?

• Most hospital consultants lead a team of doctors. Whilst in an ideal world you would see your consultant at every visit, in practice this is unlikely to happen. Other members of the consultant’s team review your records before they see you and they know your consultant’s plans for your management. Specialist doctors in training (senior house officers and registrars) may move from one consultant team to another every few months. Whenever medically appropriate, your consultant is consulted for advice.

• It is no longer possible for the busy gynaecologist to undertake personally every aspect of your care. The specialist nurse can be trained to undertake many tasks including monitoring agreed protocols, undertaking some investigations such as post-coital tests (Q 9.22) and performing some treatments such as introducing hormone implants (Q 28.6). The specialist nurse may have more time to counsel patients particularly about treatment protocols as well as other issues. Radiologists, ultrasonographers, embryologists and trained counsellors often have an essential input. Specialists welcome the presence of these skilled professionals in the team, as it ensures that their patients benefit fully from modern investigation and treatment.

Q 4. 13 What is known about emotion?

• Whilst scientific studies have shed light on the physical aspects of the body’s functions, including reproduction, emotional aspects can only ever be understood in an abstract fashion. Perhaps we should accept, without reservation, that emotions, including “love”, whether at the level experienced by sexual partners or between mother and child, are best left shrouded in mystery rather than being the subject of minute dissection by scientists.

Q 4. 14 Could my emotional problems be of hormonal origin?

• Your reproductive hormones (Q2.9) control your fertility and sexuality. Many of the emotional problems that confront women relate to concerns about sexuality and fertility, the second and third of the major driving forces in our lives – the first is “self-esteem”. Premenstrual syndrome is characterised by symptoms associated with the cyclical changes in hormone levels (Q25.1).
• Depression often follows childbirth and this could be related either to changes in hormone levels or in responsibilities. Many women have emotional changes around the time of the menopause (Q26.12).

• Whenever there is a chance that hormones may provide benefit a trial of treatment may be appropriate although it is difficult to predict how much of your symptoms will respond.

Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?

• When it comes to expressing feelings associated with hormonal disturbance or infertility, patients and those caring for them have understandable apprehension. It is self-evident that those in medical, nursing and associated professions, are caring people. We share in the anxieties and sadness of our patients as well as their joys. The professional way in which we try to solve the problems of our patients should not be seen as lack of caring.

Q 4. 16 How much information do patients want about their condition?

• Every patient has the right to as much information as he or she requires. The objective of this book is to provide relevant information to assist patients with gynaecological problems. For some the information provided will seem too much whilst others may require more. It is impossible to achieve the right balance for everyone.

• I was once invited to spend an afternoon (three hours) teaching a group of medical students the basics of about a third of gynaecological issues. The subjects included benign ovarian tumours, fibroids, heavy periods, vaginal prolapse, urinary incontinence and vaginal discharge. Twenty minutes was allocated to each subject. My slide collection provided a bank of teaching material and I prepared a further twenty slides to cover any gaps.

• These days it is not only the students who are evaluated. A few months after the teaching session I received a summary of the student assessments of that afternoon. Reassuringly, there were some students who were entirely happy with the content and presentation. A few felt that too much ground had been covered and they had difficulty making adequate notes. Others, however, suggested that all the areas I had covered could have been found in standard textbooks and that rather than attempting a teaching session on basic issues, they would have preferred to have heard about current controversy and debate.

• Most patients, although not all, are keen to receive information. There remains some professional belief that the information that doctors provide for their patients is easily understood and remembered. There is, however, a wealth of literature to the contrary. Patients may forget information given to them even within a short time of leaving the consulting room. Thirty years ago, one study reported that not one patient remembered everything, and, on average, less than half the information was recalled.

• When information packages are given to patients to take away with them their subsequent recall is enhanced. Information leaflets are the most frequently provided aids to memory although some clinics offer audiocassettes, videocassettes and even computer assisted programs. Information which helps patients understand their medical problems and treatment has been proven to reduce suffering, improve compliance with treatment, promote early and successful recovery and increase patient satisfaction. For some years the author has provided information leaflets.
• For the preparation of these leaflets, a list was made of the most frequent questions that patients ask and my typical answers.

• A medical textbook has many references to the original sources of information and opinions, usually articles in medical journals or books. Doctors and nurses appreciate that there may be variation in opinion as to the significance of information and views on the best approach to solving problems just as artists have there own characteristic techniques for producing a picture.
• It is often tempting for patients to believe that there is always a simple and immediate explanation for their problems and a guaranteed, uncomplicated remedy that could be administered once to provide a perfect cure. The medical profession would always wish to oblige but we are all too aware of current limitations.

Q 4. 17 Will the doctor listen to my views on how my problems should be managed?

• If you understand your options and request an approved treatment, it is reasonable for your doctor to agree provided that this treatment is available locally. There are occasions when a patient requests a treatment but the doctor has misgivings and may feel unhappy to proceed with it.

• Patients’ expectations are increasing as a result of media coverage and political involvement (such as ‘The Patient’s Charter’). Despite our best endeavours, there are times when patient satisfaction seems less than we, as doctors, would have anticipated. Physicians have an absolute responsibility to assist their patients to the best of their ability but success can only be accomplished in partnership with our patients; we cannot insist on patients accepting our advice.

• The partnership between patient and doctor is a special one. Both share the desire to see you safely through your problems in a caring and efficient manner. It is clearly not a partnership of two equals pooling resources such as two doctors sharing a practice. Ultimately, only you are in a position to know how much your condition is affecting you and how far you wish to pursue investigation and treatment. Furthermore, however much you read on the subject, it is your doctor who has had the appropriate extensive background education, who has seen many patients with similar problems to yours and who continues to keep abreast of current advances and their limitations.

• High quality physician-patient communication lies at the heart of medical practice. The medical profession has always acted in the best interests of its patients. For previous generations, it was accepted that the doctors were the experts and decisions made by them should be accepted without question. Patients were effectively shielded from the decision making process. In an ever-increasing way, patients have appropriately taken a more active role, and perhaps the ideal is reached when the relationship becomes one of partnership (Figure 4.1).

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
  Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment

Q 4. 18 How do doctors decide on the best treatment?

• When your doctor has recorded the history, examination findings and investigation results it would be unusual if there was only one problem to be resolved. Sometimes the combination will point in the direction of a specific treatment: for example, if there are heavy periods, the uterus is enlarged by fibroids and a patient wishes to be sterilised, hysterectomy would be an obvious choice. More often, the problems to be resolved do not lead to a common pathway. An example would be a combination of moderate premenstrual syndrome (Q25.1) and vulval warts (Q31.2). Here two separate lines of treatment are required.

Q 4. 19 How do doctors decide on the best hormone treatment?

• In most cases this is a matter of personal preference based on experience. I sometimes feel that it is a little like a conductor arranging his orchestra. On occasion, the requirements may be obvious. For example, a pianist is needed for a piano concerto. One instrument may be quite inappropriate – bagpipes may be wonderful at Edinburgh Castle but out of place in an orchestra.
• If one part of the orchestra, such as the percussion, plays louder, the other sections will sound relatively quiet even if individually they make no changes. So it is with hormone therapy. There are more hormones in the body than there are instruments in a symphony orchestra. When introducing one hormone treatment, there will inevitably be a knock-on effect on the others.
• Frequently, the treatment may involve more than one additional hormone; the combined oral contraceptive pill has oestrogen and progestogen. Several hormones must be given in sequence for in vitro fertilisation, (Figure 10.3). Finally, one expert will prefer an arrangement by one conductor to that of another. This is a matter of personal preference. So it will be with hormone treatment – one patient may feel happier on one pill than another but that choice may not suit everyone.

Q 4. 20 How long will my hormone treatment be effective?

• Invariably only whilst it is taken. Many patients believe that there will be a treatment that will be taken once and will cure their problems indefinitely. Unfortunately, hormone treatments do not work like that. The pill, for example, provides contraception only if taken correctly. If one pill is missed or taken more than 12 hours late pregnancy could occur. If periods are not occurring (amenorrhoea Q6.1), there are a variety of hormones that could be administered but when the treatment is discontinued, the amenorrhoea is likely to return.

Q 4. 21 What are the risks of surgery?

• Surgery can be extremely effective but it is not free from risk. The risk may be small but should be balanced against the likely benefits. Complications can occur:-

•  at the time of surgery or within the first twenty-four hours (immediate),

•  during the next days or few weeks (intermediate)

•  in the long-term.

• There could be bleeding during the operation, within the first 24 hours of the operation (primary haemorrhage) requiring a return to the operating theatre or bruising or collection of blood over the next few days (secondary haemorrhage). A surgical cut results in scarring which could result in long-term discomfort. The objective of the operation may not be achieved. There may be specific recognised complications for particular operations. An example of a long-term psychological complication is regret at having been sterilised.

• Some complications are local such as:

• Wound infection.

• There is always a tiny chance of an accidental or unavoidable injury however competent and careful the surgeon may be.

• Other complications may be of a more general nature:

•  A general anaesthetic carries by itself a small risk; chest infection or breathing difficulties for example may occur.

•  A clot may occasionally form in a leg vein (deep venous thrombosis (DVT) and if it is dislodged it may travel to the lung (pulmonary embolism). The risk of this complication is increased:

• if you are overweight -if there is a history of previous thrombosis or embolism. -with more complex and time consuming surgical procedures when there is delay in post-operative mobilisation.

• The risks of surgery have fallen dramatically over the last century. A number of factors are responsible for this:

•  Aseptic technique has reduced the risk of infection.

•  We have powerful antibiotics should infection occur.

• There has been a tendency to administer antibiotics at the time of surgery to reduce infection.

•  Anaesthetics are administered by highly trained and skilled doctors.

•  Surgical techniques have become ever more refined.

• Blood-cross matching and transfusion is refined and remarkably safe.

• One of my colleagues has family in the United States. His grandson required circumcision under general anaesthetic. The family were presented with a ten page document listing all the possible complications of this relatively simple surgical procedure. The final statement was that no guarantee could be given that the child would survive! The document had to be taken home before signing to demonstrate that adequate time had been allocated. The family were required to sign a statement that they had read and understood the document before the hospital would agree to the operation. We have not reached quite such a degree of medico-legal caution in the UK but we seem to be proceeding in that direction.

• Every choice in life is a matter of balancing the advantages and the disadvantages. Frequently, the advantages of surgery clearly outweigh a conservative approach. Appendicitis or life-threatening bleeding are obvious examples. The decision to operate for the majority of operations, however, is influenced by the severity of symptoms. In gynaecology, laparoscopy to assess pelvic pain (Q23.24), hysterectomy for heavy periods (Q24.19) and pelvic floor repair for vaginal prolapse (Q30.6) are examples. If you have a recurring pain that does not require even a paracetamol tablet it is unlikely that you will require an operation to determine the cause or remove the source of the pain – the risks of surgery are likely to be greater than the possible benefits. If your periods are limiting your enjoyment of life, your family is complete, and other treatments are not helping, the benefits of hysterectomy are likely to outweigh the risks.

Q 4. 22 How long do gynaecological operations take?

• As an approximate guide, a surgeon will take less than 15 minutes for a minor operation, 15 to 30 minutes on an intermediate operation and 30 minutes or more on a major operation. To this must be added the time to induce anaesthesia and come out of the anaesthetic. Following surgery, the time spent in hospital has been reduced over recent years. The once fashionable belief that rest in bed was beneficial proved to be unfounded and actually dangerous contributing to the risks of thromboembolism (Q 4.21) and wound infection. Many minor and intermediate operations may be performed on a day case basis and patients having conventional hysterectomy (hysterectomy) can often be home within two to five days.

• After a major operation, it may take two or three weeks until you have your full strength back. It is probably wise to avoid driving for at least four weeks; insurance companies may be unhappy should a problem arise earlier. Even after a minor operation, the anaesthetic may have effects for a couple of days.

Q 4. 23 Have there been advances in gynaecological surgical treatment?

• The most significant development in recent years has been minimally invasive surgery. In the early 1970s, the laparoscope became popular as a means of evaluating the pelvic organs for investigation of symptoms such as pelvic pain and infertility. At that time research showed that the pre-operative presumed diagnosis proved to be incorrect in more than 50% of cases! Since that time, however, there have been other developments. Ultrasound (Q4.7), for example, increases our ability to evaluate the structure of the pelvic organs without surgery reducing to some degree the need for laparoscopy

• Minimally invasive surgery has been a significant development although its exact place is still under evaluation. Some gynaecologists now specialise in this form of surgery. At one time a diagnosis of an ectopic pregnancy necessitated a laparotomy to remove the tube. The patient would remain in hospital for a week and would be off work for another five weeks. We have learned from minimally invasive surgery that hospitalisation can be reduced.

• A thirty year old lady presented with a second ectopic pregnancy in her right Fallopian tube. Two years earlier she had an ectopic in the same tube. The ectopic had been removed and the tube conserved. She now wished to have the tube taken away. Through a mini-laparotomy incision (conventional surgery rather than minimally invasive) the tube was taken away. The patient went home on the second post-operative day. Two weeks later she was back at work and had recommenced swimming. It is unlikely that she would have done better with minimally invasive surgery.

• Pilots specialise in the type of plane they fly: a Concorde pilot would not be expected to fly a jumbo nor a jumbo pilot a Concorde. Similarly, the accelerating developments in gynaecology should lead to the conclusion that individual gynaecologists should confine their interests and work with others in a team to ensure that patients receive the best possible options and treatments.

Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?

• Every decision we make in our adult lives involves balancing the potential benefits against the risks. This is true when we decide the job we plan to do, choose a partner in life, how many children we wish to have and when to have them. Only you can determine how much your symptom is troubling you. If the symptom is minimal, you may elect to seek reassurance that there is no worrying cause and leave it at that. Active treatment is only required if your symptoms trouble you significantly or if the underlying disease necessitates it. If treatment is required, you have to weigh up the risks and benefits of each treatment option and choose which seems best for you.

Q 4. 25 What is the place of support groups?

• Life is about experience and sharing that experience. Many patients, as well as their families and friends, with medical conditions find they need to liaise with others with similar problems.
• There is consolation and comfort in finding that they are not alone. Some find it helpful to write or speak about their experience and others are happy to read or listen. The value of the good will and support offered by these groups cannot be underestimated. From the professional point of view, these groups are not in any way accountable for the advice that they offer.
• Nevertheless, their motives are entirely positive.

Q 4. 26 Where can I obtain more information?

• There is a vast array of patient information leaflets covering all aspects of reproductive medicine. These are available from many sources including the RCOG Press (Royal College of Obstetricians and Gynaecologists) in London, the American Society for Reproductive Medicine, The Human Fertilisation and Embryology Authority, The Family Planning Association, pharmaceutical companies and a variety of support groups. Generally they are of a high standard reflecting the time, care and effort spent in their production. There are three disadvantages to be found with some of these leaflets: firstly, there is inevitably variation at least in emphasis if not necessarily in content between mass-produced leaflets and the way that individual doctors provide information: secondly, they are frequently out-of-date. Finally, the treatments discussed in the leaflet may not reflect those available locally.

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
  Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment

Q 4. 27 Are there any dangers in acquiring health information on the internet?

• There is a danger of becoming more confused than you started primarily because of the spectrum of opinion that you may find on your subject of interest. Anyone can publish on the internet and there is no filtering system to guide you on the validity of the information that you find. At the very least, you should check whether the source is backed by a qualified person or a bone fide organisation. You should also try to determine whether there is clinical trial evidence (Q33.24) to support the claims being made.

• There are some web sites that expand on the issue of quality of information obtainable on the internet.

Bibliography:

• How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. 2002 – 3549

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
  Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment

Q 4. 28 Could I have some useful Web sites?

• We live in a new age of information technology. The internet provides a rapid route of access to millions of source of information. Just fifteen years ago, when I was writing my MD thesis, it would take me several hours to find medical articles on a subject and at least a week before many of the papers became available in the library. Nowadays, courtesy of the British Medical Association and database sources such as Medline and Embase, a similar search may take just 15 seconds and the abstracts at least are available immediately.

• Many quality sites provide valuable information for patients and there is no reason why you should refrain from taking advantage of these facilities. You can even log into sources similar to the BMA Medline. At the end of most chapters of this book, a few selected Web sites have been provided, which may set you on the road to some fascinating surfing.

• The following are some general sites that include sections that cover many aspects of gynaecology:-

• General Health / Women’s Health:

• Medical Dictionaries:

• Medline

• (A search engine of several million medical papers published in all the major medical journals in the last forty years):

• Q 4. 1 Which doctor should I see?
• Q 4. 2 What are symptoms and signs?
• Q 4. 3 How can we be certain whether an abnormality that my doctor has found is the cause of my problem or an incidental finding?
• Q 4. 4 How do doctors arrive at a diagnosis?
• Q 4. 5 What does a gynaecologist do during a consultation?
• Q 4. 6 What is the purpose of the pelvic examination?
• Q 4. 7 Will a blood test to assess a hormone level provide a guide to treatment.
• Q 4. 8 I have a phobia about blood tests. What should I do?
• Q 4. 9 What is pelvic ultrasound?
• Q 4. 10 What are CAT and MRI scans?
• Q 4. 11 Will my general practitioner receive information from my specialist gynaecologist?
• Q 4. 12 Will I see the same specialist every time I attend the out-patients clinic?
• Q 4. 13 What is known about emotion.
• Q 4. 14 Could my emotional problems be of hormonal origin?
• Q 4. 15 Does my doctor understand my anxieties and concerns about my gynaecological problem?
• Q 4. 16 How much information do patients want about their condition?
• Q 4. 17 Will the doctor listen to my views on how my problems should be managed?
• Q 4. 18 How do doctors decide on the best treatment?
• Q 4. 19 How do doctors decide on the best hormone treatment?
• Q 4. 20 How long will my hormone treatment be effective?
• Q 4. 21 What are the risks of surgery?
• Q 4. 22 How long do gynaecological operations take?
• Q 4. 23 Have there been advances in gynaecological surgical treatment?
• Q 4. 24 I have been offered a choice of treatments. How can I decide which will be best for me?
• Q 4. 25 What is the place of support groups?
• Q 4. 26 Where can I obtain more information?
• Q 4. 27 Are there any dangers in acquiring health information on the internet?
• Q 4. 28 Could I have some useful Web sites?
• Women’s Health – Home Page

• Chapter 04 Diagnosis and Treatment