73. Follow-Up

At 26 Gwen's Pap smear shows “severe dysplasia” (which means the presence of cellular changes that carry a 10-15% risk of progressing to cancer). She was referred for a gynecologic consult to confirm the diagnosis and to make recommendations for management (usually a simple office procedure that removes a button-size segment from the tip of the cervix).  She did not make an appointment.

3 months later: patient encouraged by phone to make gyn appointment. She replied that she was waiting for the new year because she had used up her deductable for the current year.

Over the course of the next 3 years, 8 more telephone calls were made from the family practice office, and three letters sent, all reminders of the importance of follow-up.  

She finally comes in for STD screening because of an abnormal discharge.  These screening tests were negative, but a Pap smear obtained at the same time diagnoses cervical cancer

Next week she  will start radiation therapy, then a radical (i.e. extensive) hysterectomy.  She may survive the cancer, but the effects of radiation and surgery will be permanent and potentially disabling

72. IUFD

Around 30 weeks, Tess hadn't felt much movement for a few days, so she came in.  No heart tones with the doppler; ultrasound confirmed IntraUterine Fetal Demise.  Labor was induced and in just a few hours she delivered a lifeless but otherwise normal appearing baby.

Now two weeks later she comes in as recommended, though "I really didn't want to come in."  I shared with her test results: no evidence of infection, a "less than 10% placental infarct," and a "true knot" in the cord but without sign of ischemia--lack of blood flow--on either side of the knot.  So we really don't know; we rarely do in this setting.

I asked her if she though she was coping okay (she shrugs), if she had people she could talk with (yes), if she wanted to talk with a counselor (no), if she was sleeping (not at all, "I keep seeing tiny coffins.")

I gave her some ambien and contraception.

71. SSKI

As an essential component of the thyroid hormone, most ingested iodide concentrates in the thyroid gland.  The same happens with inhaled iodide, as in radioactive iodide, a common by-product of nuclear fission (see nuclear bombs and nuclear plant accidents).  Anyone downwind from Japan should think about this.

One of my patients has thought about it and today asked whether she should start taking SSKI, a potassium iodide supplement.  It turns out that saturating (more or less) our bodies with SSKI makes it likely that any inhaled radioactive iodide will be excreted rather than concentrated in the thyroid gland where it can cause cancer.

I politely reassured the patient: any radiation released from the earthquake-damaged reactors in Japan would be at very low levels by the time they reached the American west coast, so no need for preventative measures such as SSKI.

That was this morning.  Tonight, I'm reconsidering my advice.

p.s. SSKI does not protect against any other radioactive danger but can mess up the body's endocrine system.

70: It's In the Air

In post 34 I described the resumption of menses 2-3 years after a natural menopause, associated with the extended stay of daughter and family.  After several months later, the daughter has moved out as planned, but menses continued.

Initially I presented evidence that pheromones (olfactory signals) may influence the timing of menses in young women.  I asked, could the same mechanism cause the return of monthly periods after menopause?

But this most unusual event may also have reflected the interplay of reproductive and stress hormones, the latter increased with the stress of a crowded house.  Another possible cause of postmenopausal bleeding is cancer.  We tested for that: negative.

After the daughter moved out, menses continued, which neither confirms or disproves my speculations.

69. Everything

Pelvic pain, the nemesis of a gyn clinic.

We all recognize stress as both a cause of and an additive factor to pain, but try to look for "physical" sources first. However, Tammy's words and body language shouted, "stress," so early on I asked, "what is going on around you?"

"Everything," she answered.  Daughter leaving home; "had it out with my partner;" no pay when not working (because of the pain), no sleep ("since my daughter was born 18 years ago").  

She knows the effect of stress; her assessment is spot-on; she just feels overwhelmed.

The medical profession with its time constraints and the insurance industry's with its limits on mental health coverage have conspired to add to her list: narcotic addiction.