By Imaan Moosa
Edited by Yumna Bodiat
We asked gynaecologist Dr Razina Patel about women's sexual and reproductive health, and what her experience is like as a healthcare worker.
Female doctors who specialised in the female reproductive organs were colloquially called ‘lady doctors’ during the 1990s, a term also used in Hollywood to characterise actors who cared for girls and women in films. The proper name for lady doctors is what we now refer to them as obstetrician-gynaecologist (OBGYN).
Fifty-four-year-old Dr Razina Patel knew she wanted to become a ‘lady doctor’ long since she can remember. Becoming a lady doctor was not a conscious decision she made at any point in her life; the desire was always there. She did not know any lady doctors personally when she was five years old, yet she attributes her inspiration to an uncle she was fond of who is a gynaecologist living in London.
She wanted to specialise in gynaecology and obstetrics because she loved working with pregnant women in particular. However, the role demands late hours and copious amounts of energy and wanting to be a hands-on mother and an OBGYN meant she had to find a way to balance both her desires.
Upon receiving her qualification in 1989 at Wits Medical School, Dr Patel did a short rotation through a research post, which consisted of majority laboratory work, as a break from in-hospital patient care. She soon realised she missed patient interaction so much that she went ahead with what she had always loved. She proceeded to do obstetrics and gynaecology and “roll with the punches”. Dr Patel got married in her fourth year of medical school and had two children while completing her specialist training in 1998.
The OBGYN and recent masters graduate in reproductive medicine and embryology (University of Valencia) answers a series of questions we posed to her about female sexual and reproductive health.
What are some of the most common illnesses and/or diseases you have found amongst South African women you have treated? What do you believe has been the largest cause of this?
Socio-economic factors such as poverty, overcrowding, absent parenting as a result of parents moving to the cities for employment, multiple sexual partners, rape, abortion, lack access to health education and medical care, malnutrition, alcohol, and domestic abuse may lead to health-related problems for girls and women.
And so the spiral begins: multiple sexual partners lead to cancer of the cervix and sexually transmitted diseases (STD) with resultant tubal blockage and infertility. Domestic abuse leads to rape and psychological illness, which can lead to unwanted pregnancies and girls being forced to drop out of school. Furthermore, lack of education may lead to feelings of worthlessness, increased sexual activity and abortions.
The wheel of poverty is perpetuated. Children come in with diseases of malnourishment; overcrowding brings diseases like tuberculosis; alcohol and drug abuse is a leading cause of physical and sexual abuse. Women, young and old, often bear the brunt of the burden of bringing up and fending for children, and double-up as victims of the indiscretions of husbands, fathers and other male figures.
How old should a young woman be to visit a gynaecologist for the first time? Is sexual activity a determinant of visiting a gynae? Why or why not?
Young women may need to visit a gynaecologist as early as eight years old if they start developing secondary sexual characteristics, i.e. pubic/underarm hair and breast bud development. This is called precocious puberty.
The aim is to halt the developmental process with medication, as it has a significant psychological, emotional and physical impact on the young child. Further, any problems with bleeding pattern or pain in a girl of appropriate age for menstruation, 11-years and older, may be the reason for her to consult with us.
Beyond this, a woman who plans to be sexually active should see us before she has her first encounter. I say ‘plans’ as it should be a well thought out, responsible decision. She will need to be given the human papillomavirus vaccine (HPV) and have a discussion on contraception and the prevention of sexually transmitted diseases. She will have to be put on a reliable form of contraception and wait the appropriate time for it and the HPV vaccine to be effective before having her sexual debut.
From then onward, we would like her to have regular pap smears (Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix (opening of the uterus or womb) or colon) to detect cancer of the cervix, which is caused by multiple sexual partners and early onset of sexual intercourse.
If a young girl has not started menstruating by age 15, she should seek help from a gynaecologist.
What is the procedure like for a first-time patient coming into your practice? What can young women expect from their visit?
Visiting a gynaecologist entails a booking, via the front desk, for a date when a woman is preferably not menstruating unless the problem is related to menstruation. If a woman has an urgent problem she should impress upon the front desk to accommodate her sooner, as regular appointments may be scheduled up to 6 weeks later.
The patient is requested to complete the required forms and produce a urine specimen prior to the consultation. If she is not sexually active, we prefer the patient comes in with a full bladder in order to do a scan of the uterus and ovaries. In this case, she will not give the urine sample before the appointment.
At the appointment, a face-to-face discussion between myself and the patient of her general medical and menstrual history, followed by a description of her main complaint is had. A complete head-to-toe examination is conducted, which may or may not include an internal vaginal examination/scan and pap smear depending on whether the young lady is sexually active or not.
Under South African law, within which timeframe are women or girls able to terminate a pregnancy? How does the procedure work?
In December 1996, the Choice of Termination of Pregnancy act gave women of any age the right to an abortion. The timing of the abortion was stipulated to be before 12 weeks of pregnancy, but exceptions were made to allow for extensions to the first 20 weeks of the pregnancy.
As much as this law facilitates ease of access to a termination of pregnancy, it was not meant to take the place of contraception. When poverty and overcrowding, lack of education regarding bodily functions, cultural demands and inadequate access to medical care combine, the result is high numbers of unplanned and unwanted pregnancies.
This law does not do justice to the people caught in this predicament if it does not mandate health education, reliable contraception, surveillance of compliance, improvement of access to healthcare and safety for a young woman who is victims of sexual abuse or rape in the home and work environment prior to termination.
The termination of the pregnancy is by no means the end of the woman’s torment. It has to be accompanied by adequate and thorough psychological and emotional support before, during and after the procedure.
Additionally, the background circumstances that led to her unwanted pregnancy deserves more attention than they seem to have been given since the law was passed.
What is endometriosis and how does it affect women? How is endometriosis treated and/or managed? What can women do who feel they may have symptoms?
Endometriosis is a condition where tissue similar to the inner lining of the uterus (called the endometrium) grows on the outer surface of the uterus, the fallopian tubes, the ovary, the bladder and even the bowel. It is fed by our female hormones and therefore, it is an ongoing condition and progressively goes from stage one to stage four overtime.
It can produce typical symptoms or none at all. The symptoms can be painful periods, pain during intercourse, heavy bleeding and infertility. Not every woman with these symptoms will have endometriosis, and those without may still have it.
Endometriosis can be best seen with the naked eye using a scope that is inserted via the belly button into the abdomen under general anaesthetic. This is called a laparoscopy. During this procedure, a diagnosis can be made and the treatment given at the same time.
Endometriosis is a particular kind of cyst on the ovary, which shows up on an ultrasound scan of the abdomen and pelvis only if it has been growing on the ovary. In this case, laparoscopy is still needed to treat the condition by removing the lesions and clearing away as much of the disease as possible. Certain medications are given to the patient to chemically control the disease until she is ready to have her family.
If a woman feels she may have endometriosis, she should present herself to a gynaecologist immediately.
Can you please explain what polycystic ovarian syndrome is. What is the age group of affected women?
Polycystic Ovarian Syndrome (PCOS) is a condition that is mostly seen in teenagers and women of childbearing age. It is a hormonal imbalance characterised by some of the following: irregular periods, – usually far apart or absent – heavy periods if they come after a long time, acne, excess hair growth in unwanted areas, weight gain, and difficulty falling pregnant.
It often occurs in young girls who have a family history of high blood pressure, diabetes, high cholesterol and heart attacks. These women themselves also have high cholesterol and high insulin levels no matter what age they are at. They are prone to develop high blood pressure, heart disease and diabetes later on in life.
The answer lies in women taking responsibility for their health and being instrumental in changing their lives. Lifestyle changes are imperative: weight loss; consulting a dietician and learning about and eating low GI and low-fat foods; doing regular exercise; drinking adequate amounts of fluid while cutting out sugary drinks. All these in moderate and sustainable amounts will change the course of a woman’s future and positively influence the future of generations to come.
The metabolism of the unborn child is undeniably affected by the diet of the mother, and generation after generation can be trapped in this unhealthy spiral unless we take heed. If we control weight, insulin levels drop, ovulation can become more regular making menses predictable and spontaneous conception possible.
Skin and hair problems can become more manageable. Sometimes help in the form of medication is still needed to restore the hormonal balance in women, but lifestyle changes facilitate medication to work better.
What is your personal experience delivering babies as a doctor, woman and mother?
It is an extreme sadness; the kind that wrenches every ounce of courage from my soul realising that something I took for granted is now possibly never going to happen.
As a child growing up, even if you know you are not the brightest kid in the class and will not be the aeronautical engineer, Picasso or Bach, you know you are always going to be able to be called mum or dad. That is God-given. Nobody needs to have a certificate to do that.
In fact, you are taught to be careful because children can come looking for you, so you take precautions while you finish college and until you find the person you want to share this amazing experience and responsibility with.
Now it is running away from you and the harder you chase it, the more elusive it becomes to the point where you believe – you convince yourself – that if you are not good enough to do ‘this’, then you're not good enough to do anything at all!
Blaming each other, the universe or genetics will not make it easier. People all around you keep falling pregnant and giving birth and you have to be happy for them. Your younger sister-in-law, the school friend who became the next Picasso; some people get it all! Why can’t you have a simple pregnancy? Is it too much to ask?
Everyone's life plans include parenthood! No one imagines they won't qualify! No one checks their potential marriage partner’s credentials for this very important job before signing the contract.
You can see by the way they handle kids that they will be a good mum or dad. You can see from their lineage that they are genteel folk. You might see that they are well endowed and are a pleasure to be with. But you can never know that this pleasure may have to be harnessed into a tube to give you both the privilege of parenthood.
We see many sad people in this desperate predicament every day. Try as we may, not everyone we try to help can be helped. We don't have the Midas touch – not everyone we treat gets to take a baby home with them.
We don't look for whose fault it is! We try to respectfully and kindly optimise where we find optimal function if we are lacking. We endeavour to hold your hand and your heart through this tough but amazing journey.
In science, things are not always as they seem. Sometimes we feel all is going well and we go nowhere. Other times, we can't imagine what good can come of this and one oocyte at pick-up makes one perfect embryo and one perfect pregnancy.
We never know if you will walk away disappointed after the first treatment, but we do guarantee you one thing: when you have that precious soul in your arms and you feel her soft skin and hear his sweet cry, none of what happened before will ever matter.
What are some of the complications and/or challenges you have faced delivering newborns?
Vaginal delivery versus caesarean section.
Who gets to decide? Who gets short-changed and who pays the price in health? Is vaginal delivery a soul-enriching uplifting experience or merely a means to bring forth a child into the world if indeed all things are in favour of it being safe?
It is an age-old debate I think will never be resolved. People, young and old, male and female, are of the view that doctors do caesarean sections unnecessarily and it is the patient’s responsibility to fight that decision to the end.
One must bear in mind that the gynaecologist has two patients to take care of before the baby is born and that we are sworn to the oath of ‘first do no harm’. We aim to do what’s best for our patients but we also actively guard against doing something that will harm them.
Besides following our instinct to do what’s right for the patient, we have to follow protocol and stand to be taken to task by senior colleagues, the patient and the law if we are found to be negligent.
The first aim of delivery is a healthy mummy and baby. The next is to help the mother-to-be to have a good birthing experience. The responsibility of the second aim is partly with the patient. She can make her own experience bad if she is fixed on certain ideas, for example, no pain relief, no caesarean.
Unrealistic expectations make a woman feel like a failure when she eventually has to take pain medication or have a caesarean. In fact, there is no such thing as a failure when you give birth.
The delivery of a baby is so unpredictable that when mum and baby are healthy we feel relieved. It is usually beyond the mother’s control and she can still never fault herself when she or the baby is less than perfectly healthy.
As far as the healthcare team is concerned, someone can occasionally be neglectful but for the most part, despite everyone’s good intentions and expert care, things can and do go wrong. This is why we have strong reasons for caesarean section and we cannot allow sentiment or patient preference to standing in the way of evidence-based medicine that dictates when women should have a caesarean section to deliver their baby safely and stay safe themselves.
How do you feel you empower and/or educate women through the work that you do?
I believe that the team of women who work in my reception area and on my social platforms inspire other women by our position in the arena of professional women. We also touch and inspire women when we treat them the way they deserve to be treated.
All healthcare and allied healthcare workers (e.g., nurses, physiotherapists, etc.) must be willing to and able to serve humanity with humility and kindness. To do this adequately and honour the profession, one should be going into this career for the right reason: to sacrifice yourself for the sake of your patient and to honour the trust they put in you.
People do medicine for the wrong reasons: for the status and the title, money and the perks or sometimes because they did so well at school that they were pushed into medicine by well-meaning teachers or family.
Everyone thinks it a glorified occupation. Doctors should only feel ‘glorified’ by their patients’ testimony of them. That testimony is based on whether they feel adequately treated by their doctor, not only with the correct medicine and surgery but by receiving dignity, respect, a listening ear, a kind word and genuine empathy.
Why would you recommend young girls or women to choose a career in gynaecology?
Studying to be a doctor is hard work and requires dedication more than intelligence. Specialising means that one does 10-12 years after leaving school before you are out in the workforce as a specialist doctor. Your counterparts who followed other career paths will have been working for six years already.
If you keep your family life on hold while you specialise, you may be too ‘overqualified' and also set in your ways to settle down with a partner. You can also be in turmoil about when to have your children if you are setting up your private practice.
I would say that if you want to be a doctor and you want to specialise in gynaecology, follow your heart and don’t let anything stop you. Live and love while you study. Get married if it comes to that; I did in my fourth year of medicine. Have your children and enjoy them; they give you balance and take away the monotony of work.
I had my first child after my internship before I started my specialist training. My second child came in the middle of my specialist training when I would be away from home every fourth night to do a 30-hour shift. I was either working at work or working at home, and I loved that I had both places to fuel me. Don’t wait for one to follow another – you can and must do both alongside each other.
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