78 year old Mildred presented with an abnormal vaginal discharge. Premenopausal vaginal glands are active,yielding a white mucoid discharge, but after the menopause these glands become less active, so the normal would be a scant discharge or none at all. The malodor bothered Mildred the most. The exam was normal as were the lab evaluation of obtained samples.
When I advised her of these results by email, she replied:
"Thank you for the follow up. I guess I will continue to be a water waster and enjoy lots of showers and baths. I wish there was something else to do. I've been comfortable with my body most of my life. This whole adventure has been miserable, embarrassing and depressing."
Although science appears to support an "old people smell," this is unlikely to be what's happening here. After all, OPS exists in the nose of the beholder, not the beholden.
Thursday, January 22, 2015
Sunday, January 4, 2015
184. Ivan the Terrible
I meet 40 year old Mariya for the first time just a week before her scheduled repeat cesarean (she's has three prior cesarean deliveries, a number that puts her at risk for significant intraoperative complications).
I note that there have been previous discussions regarding a tubal ligation, but as I try to confirm that, it is clear that Mariya wants a tubal ligation but her husband Anatoly does not. We've doing okay up to now he says, a generous use of "we." I suggest that a final decision can be made the day of surgery.
Delivery date arrives, no tubal ligation he says. She's silent. Surgery went well but post-op there's another difference of opinion. He wants to name the newborn Peter, but Mariya and her 17 year old daughter prefer Luke.
When I see her the next morning, Anatoly tells me, I think we'll end up with Peter.
I note that there have been previous discussions regarding a tubal ligation, but as I try to confirm that, it is clear that Mariya wants a tubal ligation but her husband Anatoly does not. We've doing okay up to now he says, a generous use of "we." I suggest that a final decision can be made the day of surgery.
Delivery date arrives, no tubal ligation he says. She's silent. Surgery went well but post-op there's another difference of opinion. He wants to name the newborn Peter, but Mariya and her 17 year old daughter prefer Luke.
When I see her the next morning, Anatoly tells me, I think we'll end up with Peter.
Friday, January 2, 2015
183. What Would Cicero Do?
Understandably, my exam room explanations have undergone countless iterations and though perhaps smooth, may sound a little too polished, too rote.
For example, today 66 year old Sandra expresses concern about painful intercourse, and I explain that this is common due to menopausal changes: decreased estrogen leaves the vaginal surface dry, irritable, and less flexible. I start to encourage her to consider a vaginal estrogen preparation, when she starts to interrupt me, but I won't let her, my prepared speech is too near it's conclusion to allow distractions, and concludes with the observation that the estrogen has no systemic side effects because it doesn't enter the circulation
When I finish she resumes her objection. It seems that a few years ago she tried a vaginal estrogen and within a few hours experienced breast tenderness, a clear indication of systemic absorption. Furthermore her mother died of breast cancer, increasing her wariness about any form of estrogen.
I quickly backtrack, learning again that my primary role is not to provide fluent, persuasive explanations, but to listen, to guide the discussion with questions such as, is there a family history of beast or cancer, or have you used any hormone preparations in the past?
For example, today 66 year old Sandra expresses concern about painful intercourse, and I explain that this is common due to menopausal changes: decreased estrogen leaves the vaginal surface dry, irritable, and less flexible. I start to encourage her to consider a vaginal estrogen preparation, when she starts to interrupt me, but I won't let her, my prepared speech is too near it's conclusion to allow distractions, and concludes with the observation that the estrogen has no systemic side effects because it doesn't enter the circulation
When I finish she resumes her objection. It seems that a few years ago she tried a vaginal estrogen and within a few hours experienced breast tenderness, a clear indication of systemic absorption. Furthermore her mother died of breast cancer, increasing her wariness about any form of estrogen.
I quickly backtrack, learning again that my primary role is not to provide fluent, persuasive explanations, but to listen, to guide the discussion with questions such as, is there a family history of beast or cancer, or have you used any hormone preparations in the past?
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