You’re seeing the wrong gynecologist: 6 red flags

As a doctor, I appreciate that I am at an advantage when I seek medical care. Knowing terminology and basic medical principles helps a lot. In addition, when you’ve been practicing medicine for a while you get a feeling from how a doctor discusses options if the care seems valid or if a second opinion is in order. Other things I look for are board certification and a doctor who explains their treatment plan in the context of recommended guidelines.

Summarizing everything that combines to make good medical care is very hard. However, from time to time I take unfortunate histories from patients or hear stories of medical misadventures from friends and I just cringe. Actually, they make me want to shout, “Your doctor did/said what?!” These are red flags, because not only are these recommendations potentially harmful, but if your doctor recommends one thing that is so flagrantly bad, well, uh, um, how can you trust the rest of their care?

So, these are six red flags that would make me stop and not pass go. They would make me get up, get dressed, and say, “Thanks but no thanks,” and walk out the door looking for a second opinion:

1. A prescription for estrogen containing birth control (pills, patch, or ring) with no inquiry about migraines. Why? Migraines with aura are an absolute contraindication to estrogen containing birth control (do to an increased risk of stroke) and if your doctor were up to date on the WHO/CDC guidelines he/she would know that. I want my doctor to be up to date on guidelines, you know?

2. Blaming pelvic pain on pelvic organ prolapse. Prolapse is not a cause of pelvic pain. It causes a bulge, it causes a feeling that something is coming out of the vagina, but it does not cause pain. Any doctor who thinks that the two are related knows nothing about prolapse and even less about pain. And if they want to operate on your prolapse to fix your pain don’t walk out of the office, run.

3. Getting booked for incontinence surgery without a bladder diary (basically measuring everything that goes in and out for 48 hours) and a post void residual (a test to make sure you are emptying your bladder correctly). This simple diary and test can distinguish people who can (and can’t be helped by surgery) as well as indicate some people who could even be worse after surgery.

4. Having concerns about pain with sex dismissed. Painful sex, called dyspareunia, is not normal. Let me repeat that: sex should not hurt. If your doctor doesn’t know that or doesn’t care, move on until you find someone who will listen to your history and do an appropriate exam. There are a multitude of medical conditions that cause painful intercourse and not one of them is, “It’s all in your head.”

5. Getting a prescription for fluconazole (Diflucan) but you also take a statin drug for high cholesterol. These two medications can interact in a fatal manner (rhabdomyolysis) and should not be given together. Especially for a routine yeast infection. In the RARE circumstances where I have a patient with yeast who can only be treated with fluconazole (it’s pretty rare, because there are other options for a yeast infection) I stop the statin, but I really prefer to use something else.

6. Being told your pelvic pain is due to pressure from fibroids. FIbroids are benign tumors of the uterine muscle and they do not cause chronic pain (sometimes when they outgrow their blood supply, they degenerate and that condition is acutely painful, but you can usually pick that up with imaging studies and it’s not chronic pain). Fibroids can cause irregular and or heavy bleeding, but they don’t cause pain. A large fibroid uterus would be 1 lb (most are much smaller, although they can certainly be bigger). If a one pound uterus caused severe daily pain how could pregnancy ever be endured? Think about it.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • http://www.facebook.com/errol.d.williamson Errol Delano Williamson

    Something odd about this blog. Opinionated lacking in humility, reeking of a young Dr. Just beginning understand medicine. Think carefully before you apply recommendation trotted out, that is why we Doctors, not robots.

    • http://twitter.com/DrJenGunter Jennifer Gunter

      So Errol, you think it’s humility to stand by and see a young woman have a stroke who should never have been on the birth control pill in the first place? Or to say nothing while women have needless prolapse surgeries? Or to be silent as you listen to women who recount the fact that for 10 years their doctors have callously told them their pain with sex is all in their head?
      Patients deserve information and they deserve to know that there are uninformed doctors practicing good medicine. Most are good, but some are not. I’ve practiced medicine for 22 years (if you’d read my blog you’d know that). You’d also know this is my writing style.

  • aelephant

    I can’t find any reports of fatal Rhabdo following the combination of Fluconazole & a Statin. Has this happened before or is the author just being an alarmist? Most sources I’ve seen do NOT consider a single dose of Fluconazole to be a contraindication to Statins. Some sources may recommend temporarily decreasing the Statin dose by 50% or otherwise limiting the exposure. This post makes it sound like if your doctor prescribes you Fluconazole & you’re taking a Statin, you are doomed.

    • http://twitter.com/DrJenGunter Jennifer Gunter

      There are 8 references in pubmed that describe rhabomyolysis induced by mixing statins and fluconazoles. Some are reviews and some are case reports. The infectious disease experts I have worked with over the years have always recommend stopping the statin and say the interaction is severe and can happen from a single dose. It may not be common, but I am guessing you wouldn’t want to have rhamdomyolysis and if such a serious side effect were a real risk (which it is) you would want your doctor to discuss it with you. Especially as there are other options for a yeast infection. I like to know if my medications can produce a very serious if not fatal drug-drug interaction.

      • aelephant

        A search for “rhabdomyolysis fluconazole” returns 9 results. The 1st
        result includes Amiodarone, which is itself a 3A4 inhibitor & could
        be the cause of the interaction by itself. The 2nd result seems like an
        educational hypothetical case. I’m not sure if this is a real case
        report or not. The 3rd doesn’t mention Fluconazole in the title, so I’m
        skipping it for now. The 4th looks like an actual case report, but
        doesn’t list the dose or duration of Fluconazole. If you have access to
        the full text, I’d be curious to know what it was! Was it a single 100mg
        dose? The 5th doesn’t mention Fluconazole in the title, so I’m skipping
        it as well. The 6th seems like an actual case report, but again, not
        even an Abstract available to tell me the dose or duration. If you have
        access to this one, I’d love to get the details. The 7th result looks
        like a review, not a case report. The 8th is a case report. This patient
        was on Fluconazole 400mg once daily, which is NOT the dose a
        Gynecologist will be prescribing for a yeast infection. The 9th result,
        again, is a review.

        What do we have? 3 case reports, only 1 of which gives the dose, which
        was higher than the doses used by Gynecologists since it was being given
        for fungal infection prophylaxis in the setting of Neutropenia. Like I
        said, lets take a look at the details from those other 2 case reports
        & see what we’ve got.

  • southerndoc1

    You’re seeing the wrong gynecologist: one red flag-
    Overwhelming and condescending self-righteousness, combined with an infinite capacity to retroactively condemn the actions of other physicians based on anecdotal evidence

    • http://twitter.com/DrJenGunter Jennifer Gunter

      The WHO guidelines are not anecdotal and are endorsed by ACOG and the CDC
      I am board certified in OB/GYN and pain medicine, as you are anonymous I don’t know who you are or your training, but I’m going to hazard a guess that I know more about pelvic pain than you do.
      Doing bladder surgery on a woman without a bladder diary and a post void residual is malpractice.
      Not telling your patient that a medication you are prescribing can have a serious and potentially fatal drug interaction is wrong.
      Telling a woman that her pain with sex is all in her head is not only wrong, it’s cruel.

      It is not condescending nor self-righteous to want women to have the best medical care possible.
      If you think the medical information I have presented is anecdotal then you have a gap in your education.

      • rswmd

        ‘I . . . hear stories of medical misadventures from friends and I just cringe. Actually, they make me want to shout, “Your doctor did/said what?!” ‘

        Learning the definition of “anecdotal” was definitely not a gap in my education.

        You, however, seem to have a problem with elementary reading comprehension. I didn’t dispute any of the data you referenced.

        I criticized your attitude, a criticism which is validated by your response.

        • http://twitter.com/DrJenGunter Jennifer Gunter

          You are the one who said I was condemning “the actions of other physicians based on anecdotal evidence.” You are wrong, I did not use anecdotal evidence. I was pointing that out. And now you are resulting to more insults? Awesome!

          Saying nasty things about my reading comprehension behind a mask of anonymity is laughable!

  • OldRedned

    So there you are, Dr. Jen Gunter, three comments on your above article and all in the same vein (no pun intended). It calls for your response.

    • http://twitter.com/DrJenGunter Jennifer Gunter

      My response is this post has 71 likes on Facebook and 4 negative comments that also felt the need to personalize their insults by calling me obnoxious, lacking in humility, and one may have even called me a “stereotypical bitchy female obgyn.” Three are apparently from doctors (maybe the 4th, can’t tell) and three are from people who don’t have the courage to post their reply under their real name.

      • OldRedned

        Wow, it seems you got more gentle treatment on Facebook than you have on this forum. Still, this forum is a good place to develop a thick and insensitive skin – even better that using surgical spirit. The trick is not to take it to heart.

        • http://twitter.com/wpfleischmann W.P. Fleischmann

          Just FYI: “this forum” and “on Facebook” are not actually separable, insofar as one can click a Facebook “Like” button right here at the end of the article, (below the author’s tagline and above “Related stories”)

          • OldRedned

            Thank you for the info. So much to learn, so little time.

  • Reluctantmd

    You know, there is validity to all the points you make clearly and I am giving you the benefit of the doubt when I assume you take this tone only to safeguard the welfare of patients, but come on…there is a little virtue called tact. It is not what you say, but how you say it. The tone of this piece is obnoxious. I take special offense because it reinforces the ‘bitchy female obgyn’ stereotype that I constantly have to dispel every second of my life in practice.

    • EmilyAnon

      You obviously edited this reply because the one that landed in my mailbox had you calling Dr. Gunter a “stereotypical bitchy female obgyn”. Maybe you need a lesson on the “little virtue called tact.” I think there is something non medical going on here that is threatening to the critical responders to this post.

      • http://twitter.com/DrJenGunter Jennifer Gunter

        I can’t tell by the thread who called me a “stereotypical bitchy female obgyn.” Can you clarify?

        • EmilyAnon

          Dr. G, the slur was edited out by the poster after it appeared online. But the intact version had already been mailed out to people who had subscribed to the thread earlier.
          This is the line that Reluctantmd edited out from his above comment.
          “I take special offense because it reinforces the ‘bitchy female obgyn’ stereotype that I constantly have to dispel every second of my life in practice.”
          I’m just speculating, but I think about 3 of the critical posters here are the same person

    • http://twitter.com/ekdikeo Eric B

      Obnoxious? Please identify yourself so that we may never have to visit your practice — if candidly stating facts is “obnoxious”, it would do people very good to never have to endure whatever your tone is.

    • http://twitter.com/wpfleischmann W.P. Fleischmann

      So, are you agreeing that these are “red flags” or not? Because I don’t view a red flag situation as an occasion for tact. (“You might consider slowing down, or perhaps even stopping, if it’s not too inconvenient, insofar as there is a bridge out ahead, and the though you might enjoy portions of the fall, with the lovely view of the river and all, the sudden deceleration at the end may be disappointing.”)

  • http://twitter.com/micahlef Micah LeFebvre

    You’re the coolest, Doctor Jen. :)

  • http://twitter.com/jennifershark Jennifer Shark

    Floored by some of the comments here. Clearly the anonymous commenters who seem to be afraid to stand behind their remarks have never read Dr Jen’s blog, which while snarky at times, always has a compassionate point of view, and is always up-to-date. They’ve also clearly never ready a women’s magazine which publish items in this vein all the time. If I was not a woman’s health care provider these are EXACTLY the kinds of things I’d want to know when seeking out gyn care.

    As a CNM with a fairly extensive gyn practice, I see these things all the time, and it really bothers me.– Along with the migraine thing for estrogen-containing contraception, the number of women who’ve never been taught signs of thrombosis, the very simple ACHES, astounds me. I always teach it, and if it scares them away from the method, I help them find another one that will be more acceptable. –

    We all want to do our jobs well. Anonymous name calling is cowardly, and helps no one. Solid intellectual debate is awesome, but what’s been happening here is unfortunate. If you are going to be critical, do so using your real name and constructively in order to foster real debate.

  • LastoftheZucchiniFlowers

    With the increasing availability and decreasing cost of genetic testing, patients who have migraine with aura are being tested and subsequently identified as having the autosomal dominant CADASIL Notch 3 defect, hence known to have an arteriopathy which DEFINITELY predisposes the patient to (atypical) stroke. So, while not ALL migraineurs with aura have the CADASIL gene, no migraineur should ever take estrogen. Why take the risk? That Dr. Jen’s post has incited a few tempers is a good thing. We need more feathers ruffled in our ranks today but a more scholarly battle would improve our image as opposed to defiling it which is the net effect of quarrelsome and childish internet snark.

  • StephenModesto

    ..Thank you Dr.Jen. Sure, your post was brief and reflected trends and dispositional approaches by many in health care…especially for women’s health care. The `flags’ you describe are valid concerns …Abdominal `mesh’ surgeries…a great idea in theory, but a post-op mess. Well, I copied and saved your article and will share it with others.

  • Kathy

    I have a question – if you get migraine aura without the accompanying migraine can you still take HRT?

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