What to Expect from a Second Opinion

By Dr Graham Tronc, Graham Tronc Medical

As I go through my own endometriosis journey, I reflect on my early years.  As a doctor, one has to begin somewhere. That somewhere, is as a medical student.  As a medical student, I was particularly impressed by one special obstetrician. He has retired now of course, but his manner and empathy shaped my career.  Few, I think, start off wanting actually to be a gynaecologist! I didn’t! I started off wanting the happy life of an obstetrician. Happy mothers, happy babies, father involved etc.

But, one cannot become an obstetrician, without also being trained as a gynaecologist.

In my formative years, endometriosis was NOT the focal point of my career!  I had a busy obstetric practice (and yes, I still enjoy delivering babies), but over time I became interested, then intrigued, then obsessed to find out about this weird disease.  I wondered why one woman would have periods that were a breeze, but another would have nightmares, full of clots, flooding, pain and time off (well, everything). How come?!

Well how come!  No one really knows still, but on my journey of questioning and inquiring, I discovered three amazing people. Professor Carl Wood of Melbourne (whom I personally flew up to Brisbane and paid for him to operate on my most difficult Endometriosis cases).  Best known as the “Father of IVF” in Australia, he was also the father of the “proper treatment of Endometriosis in Australia”. He was the father; because he looked after me and taught me well.

Then there was Dr Jim Tsaltas, past President of the Gynaecological Endoscopy Society of Australia.  Jim also mentored me. Associate Professor Michael Cooper; I also flew up for two weekends, where we operated on my most difficult cases.  Three different, yet great surgeons in their own right!

And finally there was my partner, not a Doctor, but a patient, who twice in her younger years, almost bled to death (to use her own words), from two separate incidents of flooding.  A person I love, that went through hell, then went through hell again after a bowel resection (for Endometriosis) went bad. The bowel anastomosis leaked on day 3. No-ones fault. Just very difficult surgery. Surgery done by two hand-picked surgeons (hand-picked by me). My partner dodged at bullet and a colostomy! Sadly she failed to conceive in her previous marriage. So sad.

Why am I telling you this?  Because I am saddened and sickened that my medical colleagues, both GP and Specialists alike (only some of them, of course) still fail to make the diagnosis of both endometriosis and adenomyosis.  The delay in diagnosis is 9 years world-wide.

So, when I see a patient for a second opinion, I have special reason to pay attention to what they say!

When I know the patient is seeking a second opinion, (they usually tell my why they are here), the first thing I do is sit down and ask them “Tell me your story” – from the beginning and as far back as they need to go.  Sometimes it’s a long story! BUT, my job is to listen. Once I have listened, I then fill in any blanks, by asking direct questions.

Sometimes, I go right back and ask them “when was your first period and what was it like?”  Sometimes it is obvious that the Endometriosis (or adenomyosis, yes adenomyosis at a tender young age) begins in the early teenage years.  Sometimes it is later. But the story is usually the same! It is a story of relentless pain, relentless heavy periods, the sadness of pain with intercourse, the crippling pain suffered when performing a primary function like moving the bowels (and more).

When I have taken the full story, I then ask what the patient was told by her previous surgeon.Sometimes (believe it or not, the specialist gynaecologist, for whatever reason, does not even offer a laparoscopy!)  Instead, they have just “put her on the Pill”, or put in a Mirena in the office. (NB. Don’t consent to this in the office – it is painful) Hey, wait Doctor!  What is the diagnosis? What are we treating? Usually I will ask for the operative notes.  The word I don’t want to see is “Diathermy” or “Ablation” of endometriosis.  In 2018, endometriosis should always be excised! Burning it off simply burns the top off, burns only the obvious – yet there is OFTEN peripheral scarring around the central “obvious area”.

Histology (what the pathologist sees under microscope), is the next informative part of the puzzle.  There I look at where the specimen came from, BUT also the SIZE of the tissue excised. Sometimes I surgically excise peritoneum (inside skin) the size of the palm of my hand! If the specimen is only ½ cm in diameter, then if the patient has ongoing pain, it means the previous gynaecologist has EITHER only taken a biopsy, OR there is something else going on. That “something else” is often “adenomyosis” or endometriosis in the muscle of the uterus.  An MRI scan will tell me where or not adenomyosis has been missed.

Similarly, colour photos of the previous procedure will often SHOW me how much endometriosis was seen, excised (or not) and will also show me the outline, size and hopefully the texture of the uterus. Maybe, the problem is NOT endometriosis, but in fact adenomyosis (the “often” silent assassin) – a disease that is still seriously underdiagnosed.

So, once I have all that information, I am in a position to give my second opinion!





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