Unexpected

A pathology and a decision not to be a mother

I had recently returned to my home country, Colombia (with two “o”s) – after a year working towards a master’s degree at the marvellous and deeply missed city of Edinburgh. I had some abdominal discomfort the day before, and after years of very painful ovulations and menstrual periods, I attributed it to a menstrual-hormonal cause and did not worry too much. As part of a jobless transition period, I was indulging myself in a mid-morning late sleep when the pain began to turn sharper and its intensity increased. Soon, nausea and malaise followed and some hours later, pain localized precisely at the right lower abdominal quadrant and moving became quite painful. The medically-trained part of my brain sent an alarm: Acute abdomen alert! So, I decided to visit the emergency department.

I knew most of the staff at the private hospital I decided to go to, I had trained there for six years as a general physician and many of my friends and classmates were either working or completing further medical training there. The emergency department was surprisingly not crowded so I was admitted quickly and shared my symptoms with one of the on-call physicians. After a full medical history, we agreed that the best option was an abdominal ultrasound followed by a consultation with the on-call general surgeon. After the ultrasound (which actually showed an image of a swollen appendix), the surgeon (previously my teacher and now my attending general surgeon), the radiologist, the emergency department physician, and I all agreed on an acute appendicitis diagnosis and prepared for a laparoscopic surgery. Again, operating rooms were not very busy and I was taken swiftly to surgery.

I woke up and immediately looked at the clock at the recovery area. More than three hours had passed and I immediately thought something had gone wrong during surgery (why would an every-day procedure like a laparoscopic appendectomy take so long?). My thoughts were confirmed when a nurse approached and told me that the surgeon would soon be there to “talk to me and explain something”. I reassured myself thinking that it could not be that bad since from what I could see and feel the planned laparoscopy had not turned into a huge laparotomy, and waited for my surgery teacher. He soon showed up accompanied by another physician who I did not recognise, both male. He introduced him as the on-call gynaecologist and the explanation took place. This is when things start to turn wild…not so smooth and proper anymore.

My (previous teacher) surgeon explained that he had introduced the laparoscopic camera and was surprised by the amount of blood and bloody tissue he found inside my abdominal cavity; he realised that it was more than just an ordinary case of acute appendicitis and called the gynaecologist on what he thought could be a case of endometriosis.

Although I must state that more than 6 years have passed and my memories can be blurred, the explanation did not go that smooth. It was more like, “So I went into what we all thought was a simple case of appendicitis and I found a pool of blood, you were full of blood…and I thought it was just appendicitis”. Well, I, your patient, thought so too and I didn’t consciously decide to bleed internally only to spoil your day. WE all, the emergency department physician, the radiologist, the surgeon and myself – all trained in medicine – had missed it. And, well, it is nobody’s fault as medicine can sometimes be tricky. However, he could have not blamed me for having an unexpectedly different pathology.

Anyway, the surgeon and gynaecologist continued to briefly explain the surgical procedure and the gynaecologist mentioned that he would visit me later at the hospital room because he had some more information to give me. Still with some anaesthesia in my system, I fell back asleep for a little longer. I got transferred from the surgery recovery area to a private room and was given some long-awaited food. I received my mobile phone, talked to my parents and friends who had received and shared some information on my condition, and turned on the television to wait for the gynaecologist.

He entered my room and had quite a severe and concerned expression. He seemed uneasy and worried, but I thought that he was just tired. He started to tell me that he had “bad news, and was very sorry that any young woman had to go through this situation”, and proceeded to explain that my case really seemed like endometriosis – although it had to be confirmed through the samples he had taken and sent to the pathology laboratory – and hesitantly mentioned that “he was very sorry, but that he had had to remove part of my left ovary that was compromised with endometrial tissue, but that he had done so in a way that preserved the rest of the ovary”. He continued by mentioning that “no young woman with a bright future like me should face such an issue and, again, he was very sorry, but that I was very likely unable to bear children”, he stopped, looked away for a second, and began to mention that there were “multiple options available to me to try and become pregnant after the surgery had completely healed”.

He was surprised by my smile and my laughter and even seemed shocked when I assured him that it was great news since I had never wanted to be a mother and had long ago decided and informed others that I was not going to have any children, endometriosis or not.

So, for those interested, the medical side of the story ends well with no complications and not too much pain after the surgery. The endometriosis diagnosis was confirmed (including a large chunk of tissue attached to my appendix that was fully removed by the surgeon during the procedure after all) but I have had regular gynaecological controls and ultrasounds and all seems well to date.

Now, the side of the story I feel particularly impacted by is how social expectations and patriarchal structures permeate opinions, decisions, and the way we treat others, and that this happens in medical practice as well. Why did the surgeon think that it was fine to blame a female patient (physician or not) for having an unexpected diagnosis, particularly one that is unique to female anatomy and physiology? If the unexpected diagnosis had turned out to be something else that could affect males, would the reaction be the same? Would a male patient be blamed for having an unexpected pathology?

Moreover, why are we taught from an early age that all women must have children? And to do so when they are young? Especially when they have a “bright future”? Why are people from multiple backgrounds, including medicine, surprised, shocked, and even infuriated when they encounter a woman who has freely made the decision not to have children? Why do we feel the need to push them to “reconsider their womanhood” by going through assisted-fertilization processes or to adopt, even if they state that they do not want to? I personally believe that we all – men, women, others – are entitled to an opinion and to freely make the decisions we consider best for ourselves – as long as we do not harm others – even if these decisions go against what is widely believed and socially endorsed.

This is not intended to be offensive or inconsiderate towards any person who wants to become pregnant, who desires to be a parent, and who might be having a very hard time because of a fertility or medical problem, which I know and acknowledge that can be indeed very painful and very difficult to deal with (Both of my sisters wanted to be mothers and both of them had fertility issues. Only our brother was able to have biological children and one of my sisters adopted my wonderful youngest nephew 26 years ago).

I cannot help but wonder how things would have gone if the surgeon and gynaecologist were women. Would a female-surgeon have blamed me for having endometriosis instead of acute appendicitis? Would a female gynaecologist have removed my left ovary completely, instead of just the affected portion, to make sure all ectopic endometrial tissue was gone? I have also thought about discussing with the female gynaecologist I chose to have all follow-ups with the possibility of having my ovaries, fallopian tubes, and uterus removed next time I have to undergo endometriosis surgery, but I’m scared of how this can be received by the general health-care community that would have to be involved.

Story by Mariana, Colombia