Behind the curtains: gynecology

I had three patients in the same room in the gyn ward who were so thematically similar it was like a Grey's Anatomy episode.

Patient 1:

-Mrs. Fertile was in the ward for bilateral tubal ligation. The reason? She's had two children while on the pill, followed by two children with an IUD. Supereggs!! On a more serious note, she suffers from pretty major depression which she relates partially to the four "unwanted" children. We joked a lot about how we could remove all her reproductive organs and she'd probably still find a way to have three more kids. I actually do believe her tubal ligation won't even slow her down. Her fetuses find a way.

Her case was such a strange contrast to the 90% of women in the ward who were there for miscarriages, ectopic pregnancies, endometrial cancer. We're used to women who are absolutely desperate to have babies and can't. We joked about it so much because it was such a welcome relief from all the bad news, but it was also a big reminder that there's only so much we can do with medicine, sometimes the fates will just have their way.

Patient 2:

Mrs. B is a middle aged woman who's had continuous very light vaginal bleeding since menopause. All tests showed that this was just benign overgrowth of the uterine walls, and there was no need for invasive treatment. We explained that we could prescribe medication that would cut back the amount of bleeding. She did a trial of the medication and it worked, she had spotting only occasionally, no intolerable side effects.

Then, she came back with a letter from her Rabbi ordaining that she must have a hysterectomy. The reason: Religious Jews practice "T'harat habayit," literally purity of the house. The couple must refrain from contact for the entire duration of the woman's period and seven additional days after that. So every time a woman bleeds, she effectively cannot touch her husband for 12-14 days. In Mrs. B's case, because she didn't know when she was going to have spotting, she was risking "impurity" every time she was with her husband because she might have bleeding during the act.

It's actually very logical, from a religious perspective, for her to have the operation. From a medical perspective, I see a woman going through a major and unnecessary surgery for an, in my opinion, antiquated religious practice. The surgery turned out to be rather unpleasant and complicated and it felt so. . . just unnecessary to me. On the other hand, it will probably improve the quality of her life dramatically.

Summary: I'm ambiguous on this one. I suppose I have to come down in favor of treating the entire patient, so in this case, the surgical option was the one that improves her life the most and therefore the best treatment. As you, darling readers, will come to realize, I'm just generally strongly in favor of the least invasive treatment possible, so it's hard for me to endorse surgery for no real medical indication. Moving on. ..

Patient 3:

Ms. H, a 41 year old Bedouin unmarried virgin with major uterine tumors that were causing her life-threatening bleeding. The absolute best option for her was a complete hysterectomy. The complication? She still hopes to be married and an infertile woman has no chance of securing a husband. Even though she has very little hope of securing a husband, or having a healthy child if she does, at the age of 41.

Another interesting complication to her care is that it is very very important that her virginity be maintained, which means absolutely no vaginal exams of any type, including transvaginal ultrasound.

In the end we did a fertility-sparing myectomy, just removing as much of the tumors as possible without damaging the uterus. Again, a complicated surgery. Again, I feel that we did the best we could given her circumstance, but I don't know that I can say it was the best possible care from a medical perspective.


These things come up all the time, I'll write more about the prenatal diagnosis stuff we encounter later this week. The one thing this always highlights for me is the difference between a competent doctor, one who would offer the best possible medical care, and an excellent doctor, who realizes that sometimes the best medical care isn't the best patient care. It's a fine line.