Blame it on Abel, who blogged his vasectomy, and Janet, who blogged her mammogram. Also blame Drugmonkey and Physioprof, who along with Abel, Janet, and others encouraged me to Blog My D&C. Yep. So here goes.
It all started innocently enough back in May with my annual exam. First appointment. My nurse practitioner was bothered by my history: no periods since September 2006, followed by the sudden surprise! of brief bleeding episodes in February and mid-May. Various doctors of mine have been debating as to whether I am in menopause, or I just have screwed up hormone levels that need to be straightened out. The nurse practitioner is on the menopause side, and so the two bleeding episodes, from her point of view, warranted taking a uterine biopsy.
Note to readers: If anyone ever wants to biopsy your uterus and says "It doesn't hurt much, just a little cramping," do NOT believe them. Insist on some sort of sedative. Though I was told that it would be just "mildly uncomfortable" with "maybe a little cramping", I nearly elevated off the table from the astonishingly intense pain (followed by cramping on and off the rest of the day). And it was all for naught; she was unable to obtain a biopsy sample. She decided not to proceed with the exam any further at that point. She ordered a vaginal ultrasound to get a look at the condition of the uterus, and asked me to come back for the exam after getting the ultrasound.
So I scheduled the ultrasound (second appointment), which was uncomfortable but not painful, and then returned for the exam and to discuss the results. Third appointment. The results showed some thickening of the uterine lining, and she recommended a D&C, or dilation and curettage, which would be performed by a gynecologist on staff I'd yet to meet. (This site has a great description of D&C, reasons for having one, etc.)
I set an appointment with him (fourth appointment), and we discussed my history and the ultrasound results. Together we concluded that a D&C was the prudent course of action. He explained that the procedure would involve dilation of the cervix to allow entry into the uterus with various implements, including a camera that would let him take a look at everything (hysteroscopy). I would be sedated, and he promised that recovery would not be bad at all - "just a little cramping and some spotting of blood". Naturally, I was suspicious of this!
There was, of course, a pre-op appointment (fifth appointment). A very reassuring nurse took my history, list of meds, and allergies. She decided she needed to get an EKG on me because of some other stuff in my medical history, just to be safe; it was fine. Then it was time to draw blood. Sadly, my veins did not wish to cooperate. In fact, they had gone into hiding. She called in the lab technician, who draws blood all day long; she also could not find any veins. She finally drew blood from a spot on the inside of my arm about three inches below my elbow. Do not let anyone do this to you, especially if you take Plavix. Otherwise, you will end up, as I did, with a two-inch long, one-inch wide, garish purple bruise. They advised me to drink plenty of water the day before the procedure, to help beef up the recalcitrant veins.
Interestingly, I was not asked to stop taking Plavix before the procedure. Apparently the risk of extensive bleeding is slight compared to the risk of going without the Plavix for protection against stroke.
Pre-op instructions included nothing to eat or drink after midnight, take morning meds with a minimal sip of water, remove all jewelry including piercings, and wear loose clothing. I found it both funny and sad that women had to be told not to wear high heels. Who would want to walk around on high heels after having someone poke around inside your uterus? Apparently, enough women do, that an admonishment against this behavior needs to be included in the pre-op instructions. Another pre-op instruction was the requirement to have someone to drive me home, and stay with me for 24 hours following the procedure. The sedation would include a combination of three drugs: propofol, versed, and fentanyl. Sedation, amnesia, analgesia. That works for me!
I was told to report to outpatient surgery at 6:30 a.m. The very nice pre-op nurse had scheduled me first in the day to minimize my fasting time, so as to also minimize the chances of triggering a migraine from going without food for too long. Yes, she was a migraine sufferer, too. If you are a migraine sufferer and have to fast for a procedure, don't wait for a kind nurse to help you out; ask for your procedure to be scheduled as early as possible.
I got up at 5 a.m. to shower and at the last minute decided to shave my legs, too. Didn't want anyone in the operating room gossiping about those hairy-legged feminists. Mr. Z and I were at the outpatient surgery waiting room at 6:15 a.m., which was a mistake. Being early gave me extra time to work up the anxiety I was experiencing. They really should have someone to greet you at the door who says, "Welcome to the outpatient surgery waiting room; here's your valium!" I registered, with photo ID and insurance card, and was informed that my insurance required a $150 copay upfront. Good thing Mr. Z had his wallet with him because I had not brought mine, seeing as how they instructed me to leave all valuables at home. What would you do if a neighbor or friend had brought you the hospital? Ask them to pay for you? There had been a message left on my phone the previous day from someone at the hospital "regarding your insurance". Too bad they didn't call me till 4:30 pm on the day before surgery, and I didn't get the message in time to call them back. The person didn't say anything about copay. Perhaps they could have included that info in the phone message? Just sayin'.
So - goodbye to Mr. Z and back into the prep room or whatever it is called. My anxiety level went up another notch, but a very nice nurse soothed me a bit. Off with all the clothes, on with two of those lovely hospital gowns - the first with the opening to the back, second with the opening to the front, like a bathrobe. Tres chic. And a pair of those fab hospital slipper socks, with the non-skid treads on the bottom. Upside: warm toes. Downside: no one gets to see my pedicure.
The very nice nurse spoke calmly and slowly to me, explaining that the anesthesiologist would come see me and then the doctor, and then I would go into the surgery room. The anesthesiologist flounced over to my corner, apparently bored and angry. She spoke so fast I could only understand every third word or so. Her obvious lack of interest in communicating with me and apparent disdain for her required task frightened me into silence. I was not happy that this was the person who would be in charge of my breathing, but I felt powerless. She was there for maybe a minute and then was gone. I was angry with her for being such a jerk, and angry with myself for not having the nerve to ask her to slow down so I could understand her. I mean, even if I hadn't been mentally impaired by anxiety it would still have been impossible to catch anything she said.
Next the doctor came to speak with me, and he was all that the anesthesiologist was not: calm, friendly, reassuring, he spoke slowly and asked if I had any questions. And waited for me to think of questions. He asked for my permission to talk to Mr. Z after the procedure, and then asked if I wanted a copy of any photos he might take during the procedure. Photos? Ooh, yes please!
Then suddenly it was time to go into the operating room, and my anxiety level spiked. There were four or five people in the room; I can't tell you what they all did as I was too anxious to take note, but they were very, very, very kind people. They were aware of my family history - I have a brother who, thirty years ago, was ruined during a routine hernia operation when he was not given enough oxygen; he's been in a nursing home ever since. The people in this operating room offered their sympathy, and reassured me. They told me that the whole time I would be sedated, blood pressure, oxygen level, and heart rate all would be constantly monitored.
Before I got on the table in the operating room, I had to take off the "bathrobe" gown, leaving only the one that opens in the back. Then I had to lay down on my bare back with the gown just covering me. The table had a hole right about where your butt would go - I had to position my butt right at the edge of this hole. I didn't see any stirrups but I'm presuming they had to be there somewhere. Someone strapped a large belt over my waist, and my arms were taken to either side. At this point, as in my appendectomy and gallbladder surgeries, it felt weirdly like being put on a cross. Maybe that's just a peculiarly Catholic anxiety? One arm is devoted to monitoring equipment, I think, and the other goes for the iv. The whole setup leaves one feeling particularly vulnerable. By now I was shaking with anxiety, and tears were leaking out the corners of my eyes. One of those nice people took the edge of blanket covering me and gently wiped my eyes. That little gesture meant a great deal to me. The first prick of the needle in my hand burned - a local anesthetic, I was told - and then I felt something cool and it's a bit uncomfortable, and then...
...hello! It's the recovery room! w00t! I'm still alive! And not brain-damaged! Whoa, but those are some mighty unpleasant cramps.
A nurse brought something that looked like a pool float, several long tubular sections joined together. She placed it on me and draped a blanket over top - soothing warmth all over. I think I heard someone say they inflate the pool float-y things with the hot air from a blow dryer, but possibly I just dreamed that in the drug haze. My thanks to whoever engineered that rig - it's very relaxing. Also, they gave me percocet (after a little ginger ale and a few crackers). Cramps, begone!
Here is what I missed thanks to the sedation:
Dilation (the first step): While grasping the cervix with a clamp, the doctor will pass a thin, flexible piece of metal called a sound to determine the depth and angle of the uterus. These measurements allow the doctor to know how far into the uterus the curette can be safely inserted. The usual method of dilation is to insert a thin, smooth metal rod gently along the vaginal canal and up into the tiny cervical opening. The rod is left in place for a moment, then withdrawn and replaced by a slightly larger rod. This process is repeated until the cervix has expanded to about the width of a finger. This method takes about 10 minutes...
Hysteroscopy and curettage (the second step): After dilation, your doctor holds the vagina open again with the speculum. The doctor may also reach into the cervix with a tiny spoon to obtain a specimen of the cervical lining. At this point, the hysteroscope is usually inserted into the uterus so that the doctor may look at the inside of the uterus. The doctor may see fibroids, polyps, or overgrowths of the endometrium. At that time, instruments may be inserted through the hysteroscope and biopsy, or removal, of these things may be accomplished.
The doctor will now place a slightly longer and larger curette through the dilated cervix and up into the uterus. This is a metal loop on the end of a long, thin handle. With steady, gentle strokes, the doctor will scrape or suction the uterine wall. This tissue is sent to the lab for analysis. When the curettage is completed, the instruments are removed.
Here's one of the pictures from my hysteroscopy. Don't ask me to interpret for you.
I can't remember how long it was before they decided I could move from the bed in the recovery room, to a chair, or what the decision was based on, but pretty soon I was in the hospital version of a Barcalounger. They gave me pads to sop up the blood but surprisingly (to me) there really wasn't any blood flow. Before I got dressed, the nurse gave me a wet towel to clean myself; there apparently was a fair amount of blood on me from the procedure, but I wasn't bleeding. Mr. Z was brought in to hear the post-op instructions since I obviously couldn't be trusted to remember them. Then he went out to bring the car around to the exit, I got wheeled out to meet him, and we were on our way home. It was 10 a.m.
Most of the rest of the day was spent lying around in a foggy post-sedation haze, while Mr. Z brought me this and that to eat, generally fussed over me, and kept asking me if I needed anything. Mr. Z rawks. I experienced some uncomfortable cramping throughout the day, but it was not intolerable. They sent me home with percocet for post-operative pain, and it was certainly adequate. Though I was told I might have bleeding which could be heavy, and could last up to two weeks, I have barely spotted. The recovery has been much easier than I expected. The doctor told me, and Mr. Z, that "everything looked good" and that he did not see anything of concern.
I have a follow-up appointment with the doctor in a week, at which time I assume I'll hear about any biopsy results. This will be the sixth appointment in this saga, plus the procedure day itself. It is obvious that attending to your health takes serious amounts of time. How would a woman with a full-time job and very limited vacation or sick leave manage six appointments and a whole day off for the procedure, just to deal with ONE health issue?
Post-op instructions included no heavy lifting for two weeks, and no douching, intercourse, or tampons for two weeks. I specifically asked about gardening and was told "no" for at least the next week or so. So of course, it rained like hell last night, blowing out the heat and humidity we'd been stuck with for days, leaving us with a day of perfect weather, and garden soil loosened by the rain, just begging to be weeded. By the time I can get back to the garden the weeds will be knee high and the soil baked dry again, I'm sure. I was casting longing looks at the garden all morning. Then, after what I thought was some relatively minor physical activity, I experienced another bout of cramping, so I decided against sneaking out to weed the garden without telling Mr. Z. I do not like being kept out of my garden. I will be glad when this time is over.
And that's it! Now I am officially one of those people who shares every intimate detail of their lives with total strangers on the internet. You know, just like I promised myself I would never do. If you had asked me, when I first took up blogging, whether I'd be posting pictures of the inside of my uterus on my blog, I'm pretty sure I'd have answered "what the hell are you talking about?" And yet, here we are. Just don't tell my mom.
A side note on women and gynecological procedures:
Many women are survivors of sexual abuse or sexual assault. For them, even routine gynecological exams can be a traumatic experience. A procedure like a D&C, which places one in an even more vulnerable state, can be even more difficult to undergo. It's important to be able to communicate openly with your health care provider about your history. A good gynecologist will talk with you about your fears and explore ways to reduce anxiety. These can include simple techniques like making sure that the health care provider tells you explicitly everything that he or she will do at each step before proceeding, and checking in with you periodically to see how you are doing. If you find it difficult to advocate for yourself in this way, you may want to take a trusted friend with you to your exam. Most gynecologists these days are aware that sexual abuse and sexual assault are all-too-common experiences for women, and that they can affect a woman's ability to tolerate exams and procedures. But if you run into someone who is not sympathetic, don't just put up with it, or worse, avoid taking care of your health because of it. Find a new doctor.