Monday, December 16, 2013

Guest Blogger: Day 8

Dr. Terri-Ann Bennett, writing from Korle Bu Teaching Hospital in Accra, Ghana. She contemplates some of the differences in obstetrics between the US and Ghana, and encounters her first DOA patient: Day 8

Guest Blogger: Terri-Ann Bennett

Dr. Terri-Ann Bennett, a chief resident in Obstetrics & Gynecology at NYU, went to Ghana recently and had her own blog. It was insightful and well-written, and I want to share it here.

Here is her first post, in which she reviews her first few days on service at Korle Bu Teaching Hospital: The Introduction

Tuesday, July 9, 2013

How To Clean Your Vag

This post is going to be exactly what it sounds like. If that grosses you out, click to somewhere else.

In the office, I get a lot of questions about how to clean "down there." There are a lot of cultural influences that lead us to think of vaginas as unclean. Feminine hygiene products are marketed to women in a way that lead us to assume that we are inherently unclean. So many religions and cultures have mythology surrounding menstruation and women's bodies that imply a contamination or lack of cleanliness. Meanwhile, where are the testicular hygiene products?

Many of my patients come in thinking that any discharge means they have bacterial vaginosis (BV), a bacterial overgrowth that can lead to odor. While BV does exist, in my opinion* it is wildly overdiagnosed and overtreated, especially given that its presence has almost no spontaneous adverse consquences**. It can be very annoying, but it's not dangerous. It's not like Chlamydia, or HIV. It's not even as painful as a yeast infection. If you have BV or think you do, it's important to confirm it with a doctor, and not just assume you need antibiotics over and over. Those antibiotics can actually lead to a yeast infection, so be cautious.

First, a terminology clarification:
The outside female genitalia is called the vulva. The inside female genitalia is called the vagina. So even though we use vagina as a general term to refer to the entire female genitalia, the medical term only refers to the inside.

So what is the truth about the cleanliness of vaginas? 
First of all, yes, the vagina is full of bacteria. It needs to have that bacteria in order to stay healthy - they are the "good" bacteria. When you eliminate the bacteria (by taking antibiotics, for example), that allows overgrowth of other things, like yeast. Yeast can exist in the vagina, but when they grow too much, they can cause itching, burning, pain with sex, redness, or odor. There are certain bacteria that shouldn't be in the vagina - like Chlamydia (a sexually transmitted infection), or E. coli (a bacteria found in stool). Another bacteria that can exist in the vagina, Group B Strep (GBS), does nothing to the woman, but can cause a serious infection in infants, so if a pregnant woman has it, we give her Penicillin in labor to get rid of it before the baby comes out.

Should you clean your vagina?
Bottom line: not really. Most women have a small amount of daily mucous discharge. That discharge is produced by glands in the vagina. That mucous traps any untoward elements, and pushes them out. That's why the vagina is "self-cleaning." An increase in the amount of discharge isn't very concerning - usually it is related to the hormonal cycle, or random chance. A change in the color of the discharge can sometimes come with an infection, so you should see your doctor in that case. But using a douche doesn't really help. It pushes things up when you really want things to come down. And what is up? Your uterus and cervix. If there is anything dangerous in the vagina, you would be pushing it up toward your uterus, and potentially your fallopian tubes. That means that if there is "bad" bacteria in there, like Chlamydia or Gonorrhea, that bacteria would then be pushed upward into a sterile area, and cause Pelvic Inflammatory Disease, which can cause tubal scarring and infertility.

Should you clean your vulva?
Yes, this is OK. The vulva are on the outside, and so have the tougher external skin that covers most of our bodies. However, I have found that the vulvar skin, being hidden from the outside world most of the time, is more sensitive than the skin on your arms or legs. It can often become very irritated by shaving/waxing, or the detergent in soap, which strips off the natural oils. This can cause a vulvar dermatitis, which can be extremely itchy, and looks like dry patches of a lighter color than the rest of the skin. When this happens, I advise women to stop using soap or removing hair at least temporarily, and I usually prescribe a cream to help with inflammation. If you think you have vulvar dermatitis,  see your gynecologist. If you want to stop using soap on the vulva, I recommend washing with water and a washcloth. This can remove the dirt/discharge without irritating the sensitive vulvar skin.

Should you shave your vulva?
Meh. You can, if you want to, but stop if it causes problems. Hair removal pulls the hair from the shaft, and can introduce bacteria into the hair follicle. When this happens, a woman can get folliculitis, which looks like a small pimple, and is painful. If this happens, I advise women to stop hair removal at least in that area. It's important to remember that hair removal is entirely cosmetic, and has no medical benefits, so if it's causing irritation, it's time to stop, at least temporarily. Not every culture thinks women should be hairless.
One potential alternative is trimming the hair instead. This can avoid the folliculitis complication while still feeling neat/clean.

What should you do for the occasional itch?
If you are having persistent itch or pain, you can try an over-the-counter yeast cream, or see a gynecologist. But if you get the occasional itch down there, and you are pretty sure it's nothing, I recommend a cream like Vagisil (or its generic alternative "Vaginal Anti-Itch Cream"). It has a pain reliever and a soothing ointment, and can take care of the occasional itch, or pain from folliculitis. If it doesn't help, see a doctor.

How do you know if you need to see a doctor?
Occasional mild symptoms, like itching or odor, can arise with changes in cycle, especially around the time of menses. Something that does away quickly on its own, especially once your period is over, is usually no big deal. Symptoms that are severe, or that are constant and persistent, mean that you should be evaluated by a doctor.

These recommendations are not hard and fast rules. They're just my attempt to answer questions that it seems like all women have. Feel free to leave questions in the comments section, and I'll try to address them.

*This is my opinion, based on my professional experience, not a scientific statement. Others would disagree with me, but they can write their own damn blog.

**BV has been associated with some negative outcomes, like preterm birth or infection after surgery, but attempts at prevention and treatment have been mixed or have often failed, and it's unclear whether it's a cause or an association.

Monday, May 27, 2013

Guest blogger: Full Of Hot, Dusty Air

The last blog entry by Dr. Katy Rivlin as she prepares to leave Ghana. Many thanks to Katy for sharing her experiences in Ghana. Stay tuned - I plan to have more residents blogging in the future.

5/24 -->  Full of hot, dusty air
    I’m packing to leave, just watched my last Ghanaian uterus extracted from an abdomen and gave a pile of NYU scrubs to Parker and Henry. I picked up my dress from Constance (definitely gonna wear it to my next garden party/wedding/Kentucky Derby) and made a salad of all the leftovers in Sari’s fridge which may have involved tuna fish and beans.
    Along with my dress, I had a pair of patterned pants with a drawstring made for Ari. I envision them also at the Kentucky Derby, or perhaps when he meets with an important client at his law firm. Constance surprised me with a matching shirt. She asked me again who it was for and I told her “It is for the man I am going to marry”.
“Ah” said Comfort (Constance’s co-seamstress), “But is he a tough man?”
“Umm, yes” I said, Constance and Comfort both nodding approvingly.
“But not too tough” I added.
We all three laughed hard. Surely any woman can agree on the value of a not too tough man.
    On my last day in the Family Planning Unit, I listened to a lecture on abortion put on by a few senior medical students. While abortion is technically only legal here if a certified health care provider decides that the maternal or fetal life is at risk, Emmanuel says they interpret that law very liberally, at least at Korle Bu.
     I watched this big group of medical students (not Ob-Gyn residents mind you, just plain old medical students) passing around manual vacuum aspirators, or suction devices used for early abortion, and cheering every time they did it right. I listened to them debate the perfect combination of medications for a medical abortion. The attending doctor gave a moving talk about the horrors of septic abortion (something they see frequently here in Ghana) and he praised cytotec, a medication for abortion that is now cheap and easy to get on the black market. This has completely changed the face of illegal abortion here in Ghana. “Thank God for cytotec” he said. Never thought I’d hear God and cytotec used in the same sentence.
    I can’t imagine an equivalent scenario in the US, even at a place like NYU and certainly not at the University of Mississippi where I went to medical school. We tiptoe around abortion, we apologize for it, we neglect to teach it. With septic abortion a thing of the past in the US, we’ve forgotten what it means. And don’t blame religion, because believe me, Ghanaians are as fiercely evangelical as any bible belter worth his spurs.  It’s funny how things go in circles.
    One more bucket shower, one more semi toilet flush, one more mouthful of dirt on the car ride to the airport. Thank you Sari, plastic chair lady, Dr. Ades, Maala, bleating sheep-goat Paka-Parker, bean maker lady,  Korle Bu Teaching Hospital, Emmanuel and his family, thank you Ghana. You’ve breathed your hot, dusty air into me and I hope to have it with me always.

Sunday, May 26, 2013

Guest blogger: If you like pina coladas and other speculations on death

Dr. Katy Rivlin feeling morbid in Accra, Ghana.

5/23 --> If you like pina coladas and other speculations on death

    Drunk again, this time Sari, Maala and I commemorated my last night in Accra at Labadi Beach Hotel, a swanky obruni heavy spot with a pool, sweet cocktails, and food not cooked in palm oil. No yams, no rice, no beans. Aside from the buzzing mosquitoes and the High Life band, I could have been in Miami. 
    In my revery I started to think (and blab) about death in Ghana and death in the US (who wouldn’t over a couple of ice-cold pina coladas??) Sari tells stories of family members blessing her and kissing her when she decides to withdraw care from a patient in the emergency room and the stillbirth I saw delivered on labor and delivery lay alongside its mother for hours, both of them lodged between rows and rows of healthy, newborn babies. I’ve already mentioned the open aired coffin markets on the drive to Cape Coast, and while I never got to visit it, I read in Sari’s guidebook to Ghana about Kane Kwei Carpentry where you can be fitted for the fantasy coffin of your choosing, with shapes like airplanes, whales, boats, birds, even uteruses. 
    It feels unnecessary to provide the US counterpoints, but good luck finding a uterus coffin worth its salt south of the Mason Dixon. My point is that people die here in Ghana. A lot. We die in the US too, but man it drives us (and our doctors) nuts. I’m not saying let's learn to die from the Ghanians, I’m just saying a uterus coffin might be a start. 
    Ok ok, it’s enough already. Either the malaria has set in or I have dysentery of the brain. To bed!

Friday, May 24, 2013

Guest blogger: Any way you want to tie it

Dr. Katy Rivlin writing from Accra, Ghana

5/22 --> Any way you want to tie it

    In the mornings, I awake to the sound of a traveling saleswoman from the North (Sari says you can tell by her accent). She cries “plaaaaaaastic chairs, PLAAAAAASTIC CHAIRS!!!” The metal worker beats out his offerings with a wooden stick on a wooden box, and the shoe repair man has a little metal clanger. The goat (who turned out to be a sheep) has gone to a better place and bleats to me no more. 
    In the family planning unit this morning we did a tubal ligation. It’s a surgery that I’ve only done laparoscopically in the US, so using a mini abdominal incision was new to me. Only later in the case when I jabbed my finger into the woman’s abdomen to fish out her fallopian tube did I realize she had nothing but local anesthesia and some IV sedation. Geeeeze!!  It’s a whole different skill set here: low cost, fast surgery, as gently as you can. Turns out there’s a special instrument other than your finger that you can use to snag the tube. My apologies to you and your peritoneal cavity Madame. 
    After work, Emmanuel drove me out to a suburb of Accra to meet his family and to see the house they just built. His oldest daughter, Ama is 15 and away at secondary school, but his son Naana is only 5 and came with us to dinner. We ate Chinese food spiced Ghanaian style, talked about the contested election here, Chinese immigrants and how to lose weight. Well, I think we did. The conversation was half Twi and half English so as usual, I did a lot of smiling and eyeball crossing. When Emmanuel’s wife packed me off at the end of the night, she made sure I had a half gallon of strawberry ice cream to take with me. 
    In other news, I think Maala has finally gotten her sea legs. She told me a story about the water and electricity running out at her house (a fancy gated expat community with AC and running water). It happened right as she was taking her post call shower, and “my hair was full of lather” (don’t forget, she’s British). With no other water around she resorted to rinsing her hair out with mouth wash. All day today her scalp was tingling. Bravo Maala, this makes my bucket showers seem like a Carnival Cruise. 

Thursday, May 23, 2013

Guest blogger: Duty

5/21--> Duty

Last night was my “duty” night or 24 hour shift. Well, sort of. There was a random 3 hour break in the middle of the day in which Sari took Maala and I fabric shopping and then to Constance the seamstress.  She works from a wooden shack in the middle of a field and has a steady inflow of obruni doctors coming to her thanks to Sari. Maala played it safe with a light blue fabric covered in tiny blue flowers, I went for a very African yellow, orange and black print that will bring tears to your eyes. I hope my dress has lots of ruffles. 
    With rounds in the morning and Ob clinic in the afternoon (two patients and two doctors to a room, pelvic exams and all) we didn’t get to L&D until 5pm. Sign out involved the outgoing resident telling Parker about all the patients on the floor (this one, she delivered, this one, she has imminent eclampsia, this one, she has a stillbirth, this one, she is for an elective c-section for a bad obstetrical history) and then leaving. Not much to go on.
    Other than the heat, the lack of water for scrubbing (someone pours it over your hands for you before a c-section), and the colorful fabric sheets that each patient brings for herself and to wrap her baby,  L&D in Ghana is quite similar to L&D in the States. Babies come, some from the vagina, some from the abdomen. Sometimes women bleed and you try to stop it, sometimes their blood pressure gets really high and you try to stop it. Lucky for us in the States, there is never a magnesium shortage and we always have IV antihypertensives. I guess that’s a difference too. 
    I tried to teach Maala cervical exams and how to rupture membranes with limited success. They use a Kocher clamp to rupture here (in other words, a heavy metal instrument with wooly mammoth like teeth) which I think left Maala more traumatized than the non flushing toilets.  We spent the whole night doing c-section after c-section, until everyone got tired of it and went to sleep. Then we woke up and did some more.
Finally Emmanuel sent me home to “take a bath” and I am to be back for a Family Planning meeting this morning. I think I’m getting too intolerably pungent for anyone to stand anymore.