PREGNANCY AFTER CANCER TREATMENT BY FIGO

 Introduction

There has been a rise in the incidence of cancer in reproductive-age men and women. This could be attributed to a rise in obesity and more exposure to various carcinogens. Approximately two million reproductive-age women between the ages of 15 to 49 years are diagnosed with cancer annually.  In 2022, the most common cancer types encountered were breast (32.8%), thyroid (15.1%), uterine cervical (12.5%), ovarian (4.4%), colorectal (4.3%), and lung (3.1%). The most common cancer types reported in pediatric populations include leukemia (53%), central nervous system tumors (22%), and neuroblastoma (9%). Cancer treatments include surgery, chemotherapy, and radiotherapy;  there are emerging therapies such as immunotherapy as well.  Cancer and its treatment profoundly affect fertility, resulting in significantly reduced pregnancy rates among survivors. Garg et al. reported that only 17.4% of cancer survivors had at least one subsequent live birth compared with 21.7% of age- matched controls, with an incidence rate ratio (IRR) of 0.69 across all cancer types. 

preconception

It is the natural desire of many women who have completed their cancer treatment to experience motherhood. Many factors need to be discussed to make this journey as safe as possible for the mother and the fetus. It is important to ensure that the women are in remission for 1 to 2 years. They should be provided with a reliable and safe contraceptive during this time. Women should be aware of the increased risk of cancer recurrence when stopping treatments such as tamoxifen in estrogen receptor-positive cancers before pregnancy. 

Women should be screened for mental health problems after going through the trauma and anxiety in the process of cancer treatment, and living with the pressure of possible cancer recurrence in the future. Women who have undergone adjuvant chemotherapy should be aware of the toxicity of these agents on their vital organs such as the liver, kidney, or heart. And the relevant checks need to be done in the preconception period. 

pregnancy and post-partum

Pregnant women with a history of cancer treatment should be managed in a consultant-led unit with maternal and fetal specialists. Screening for pre-eclampsia, aneuploidy, and gestational diabetes should be carried out on women. It is recommended to prescribe aspirin to reduce the risk. Serial fetal surveillance should be offered in the third trimester. Studies show that women with a history of cancer or previous pelvic surgery are at increased risk of caesarean delivery, but no increased risk of assisted delivery. In women with BRCA 1 or BRCA 2 mutations who have completed their families and are undergoing a caesarean section, a bilateral salpingo-oophorectomy can be offered to reduce their lifetime cancer risk. 

The history of cancer treatment in the post-partum period does not require the addition of LMWH, unless there is active malignancy or other factors that increase the thrombo-embolic risk. The oncology follow-up of women in the postpartum period is similar to that of non-pregnant patients. Adjuvant hormone therapy such as tamoxifen may be resumed 2 weeks after delivery, and breastfeeding will be contraindicated in this setting. 

Conclusion 

Obtain a detailed history of a past cancer diagnosis, associated treatments, and complications of treatment. Where possible, obtain appropriate screening for common complications such as cardiac, pulmonary, renal, hepatic, and endocrine toxicities. Screening may include cardiac auscultation, electrocardiogram, and lung function testing such as spirometry. If there are concerns for potential cancer- related cardiac dysfunction, such as cardiomyopathy, it is advisable to obtain assessment by an obstetric physician or obstetrical provider with appropriate expertise.  If possible, advise patients to wait 1–2 years after completing their cancer treatment before becoming pregnant.  Provide advice on nutrition, folic acid supplementation, and a healthy lifestyle for pregnancy and for the long term after pregnancy. Support breastfeeding in women without contraindications. Begin low- dose aspirin prophylaxis for patients at risk for gestational hypertension. 

THE GRAPES OF WRATH

 I am visiting South Africa with my daughter and staying with the in-laws. It's alright, but there is no unlimited wifi in Granny’s house. Johannesburg is a big cosmopolitan city, every suburb is kilometers from another one, and having a car makes getting around pretty easy. I went to visit my friend who teaches in a high school nearby. I visited her and asked if she had any books for me to read to kill time. I picked two books, one of which was a book by an author named John Steinbeck. It looked quite worn out and old, and I assumed it was perhaps written by one of the local South African authors. 

It had been over a decade since I read a big fiction novel. The story takes place in the United States in the 1930s. I found the book extremely descriptive. The first hundred pages describe the situation of the Joad family on their farm and home. Tom Joad, who had served in prison, is released, and he comes to his hometown and finds that his family is forced to leave their home and their land, due to poor weather conditions. It showed the feeling of loss, uncertainty, sorrow, and hope for the future. Tom Joad later becomes a favourite character in the story.

I loved how the story described their situation and the road trip to California. They had hopes and dreams to find a better home and better jobs. They meet several different people on their road trip. And it all describes the situation in the States with other people struggling to make a living. They finally reach California, and their expectations are shattered. It was shocking to see how the family struggled to find work, and how difficult it was for Ma Joad to buy bread, coffee, or sugar and put food on the table every day. Ma Joad's role became more prominent once the family settled in California, and struggled day to day. 

Throughout the book, the Joad family and thousands of other Dust Bowl refugees face systemic cruelty in California. They are starved, underpaid, and treated with hostility by powerful landowners who want to keep wages low.

Steinbeck uses the metaphor of grapes growing heavy and fermenting to describe how individual misery transforms into a powerful, collective rage. In Chapter 25, he explicitly lays out this imagery:

"...and in the eyes of the people there is the failure; and in the eyes of the hungry there is a growing wrath. In the souls of the people the grapes of wrath are filling and growing heavy, growing heavy for the vintage."

At its core, the book is powered by its characters—particularly the resilient Ma Joad and the volatile, evolving Tom Joad. Through their eyes, Steinbeck transforms a massive historical crisis into an intimate family tragedy. The Joad's lose their home, their dignity, and family members along the way, yet they refuse to lose their humanity. It is significant how in the most difficult times the migrant families help each other. 

Steinbeck brilliantly alternates between descriptive chapters of the Joad's' specific journey and broader, journalistic chapters that describe the forces at play: corporate greed, the banking system, and the collective plight of thousands of displaced. 

What makes the book truly unforgettable is its transition from despair to defiance. The "wrath" of the title isn't just destructive anger; it is a righteous, unifying force. Steinbeck argues that when individuals look past their own survival and realize they are part of a larger human collective, they become impossible to defeat. This book really touched me, in one of the vulnerable stages of my life, and I am glad I came across this beautiful piece of literature. 

THE BUCKET LIST

 When I was a little girl, I used to look at my mother’s miserable life and think to myself that I would do better when I grew up. She had a hard time raising us with my dad being constantly overseas. Money was always scarce, and everything was a mission, from school pick-ups to homework. Every now and then, her in-laws would visit from another province and add to her misery and exhaustion. She was not loved or cared for; she did not have much autonomy. I don't remember her being able to spoil herself. She became more and more overweight, antisocial, and depressed. I am hoping I will be able to keep my sanity at this point in my life, keep going, and be a hot and confident mama for my little daughter.  I have been reading a lot of books and watching a lot of movies. I came across a movie called The Bucket List starring Morgan Freeman and Jack Nicholson. Just watching these great actors having a conversation on screen is the most amazing thing ever. They are diagnosed with advanced cancer and are exploring their end-of-life options. Jack Nicholson is the rich guy with the terrible attitude and the money, organizing a lot of travelling and great experiences. Morgan helps him get in touch with his inner soul and become a better human. 

I have summarised their adventures below:

• Witness something truly majestic: They try to accomplish this by visiting the Himalayas, but the view is completely blocked by a heavy storm. Later, Edward realizes a different kind of majesty at the end of the film.

• Help a complete stranger for a common good: This was one of Carter’s deeply personal goals.

• Laugh until I cry: They achieve this in a hilarious, light-hearted hospital scene later in the movie when Carter explains the incredibly bizarre (and disgusting) truth about Edward’s beloved, ultra-expensive "Kopi Luwak" coffee beans.

• Drive a Shelby Mustang: They rent out a racetrack and aggressively drag-race vintage sports cars.

• Skydive: This is the very first thing they do after leaving the hospital, featuring a terrified Carter and a thrilled Edward jumping out of an airplane.

• Kiss the most beautiful girl in the world: Edward originally scoffs at this, assuming it means a supermodel. At the end of the film, after reconciling with his estranged daughter, he hugs his young granddaughter and kisses her on the cheek, finally crossing it off.

• Go to the Pyramids/See the Great Sphinx: They sit on top of the Pyramids of Giza, discussing life, faith, and Egyptian myths about the afterlife.

Additional Global Milestones (Seen in the Travel Montage)

While they don't read every item aloud, their journey across the globe checks off several massive travel goals:

• Go on an African Safari (Shot in Tanzania)

• Ride a motorcycle on the Great Wall of China

• Visit the Taj Mahal in India

• Dine at Chevre d'Or in France

This movie really got me thinking about my life and my priorities. What are the things I genuinely want to do? It would have been easier if I could have made friends with someone like Jack Nicholson, who would have funded my dreams and ambitions. Perhaps it would be easier to think about your bucket list when you have stage four cancer, and you do not need to save for retirement or leave money for your kids.  We are focusing on the smaller check goals and then to bigger long term goals in this bucket list. 

1. Blasting on eating out with family in a sit-down restaurant!

2. Buy my little girl a bicycle, I hope she plays with it, and does not disappoint me

3. Send my review article for publication to that stupid and expensive journal

4.  Book and travel to whatever conference I want to 

5. Have a spa day and a whole-body massage

6. Go and visit my home country if the political situation allows. I cannot think about any other travel destination until I make it home, eat at a fancy local restaurant…go to grandma’s house where I was born and raised…and go through all my sentimental items. 

7. Have a Mamma Mia, ABBA theme birthday party, with a live band playing! full of dancing, singing, laughter, and fun.

BREAST CANCER SCREENING

 I recently attended a webinar on breast cancer screening, presented by a radiologist. It had a lot of new information on screening guidelines for women. As an OBGYN I am not equipped with clear guidelines to inform the reproductive age patients about their breast cancer risk and screening intervals. Breast cancer screening is focused on identifying malignancies in asymptomatic women to detect disease at an early, highly treatable stage. While the clinical utility of early detection is universally acknowledged, specific screening protocols, modalities, and initiation ages vary slightly across international and regional guidelines.

Mammography remains the gold standard for population-based screening and the only modality clinically proven to reduce breast cancer mortality. Mammography employs low-dose X-ray imaging to visualize architectural distortions, microcalcifications, and soft tissue masses.

Increasingly preferred over conventional 2D mammography, particularly for dense breast tissue, 3D mammography reduces recall rates and improves the detection of invasive cancers by capturing multiple cross-sectional images.

Other modalities are utilized for specific clinical indications and are not recommended as standalone screening tools for average-risk individuals:

Breast Ultrasound: Primarily used to evaluate palpable masses or targeted findings on a mammogram. It serves as a supplemental screening tool in women with dense breast tissue (BI-RADS C or D), where dense parenchymal tissue can mask small lesions on an X-ray.

Magnetic Resonance Imaging (MRI): Utilizes intravenous gadolinium contrast to detect neoangiogenesis associated with malignancy. It features high sensitivity but lower specificity, and is reserved for high-risk screening algorithms.

Screening schedules are strictly dictated by an individual’s risk category, typically determined using validated risk assessment models.  Tyrer-Cuzick is a software risk calculator that can identify high-risk women who may require annual screening. 

I went and reviewed my mammogram report again, which made more sense to me, realizing that I have type C breast density. which explains why radiologists are required to supplement their screening with an ultrasound. 

Most average-risk women have no personal history of breast cancer, no family history, and no genetic mutations. 

Defined as women with a calculated lifetime risk of breast cancer greater than 20%, a known pathogenic germline mutation (e.g., BRAC1, BRCA2, TP53, PTEN), an untested first-degree relative with a mutation, or a history of therapeutic chest radiation (e.g., for Hodgkin lymphoma) received between the ages of 10 and 30. This category of high-risk patients requires combined annual screening mammography and annual contrast-enhanced breast MRI. The screening typically begins at age 25 to 30, or 10 years earlier than the youngest affected first-degree relative (but generally not before age 25 for MRI and age 30 for mammography due to radiation sensitivity of young breast tissue).

Implementing a screening program requires a balanced evaluation of its epidemiological advantages against potential diagnostic complications.

The benefits include

• Significant reduction in breast cancer-specific mortality.

• Increased likelihood of identifying early-stage disease (Stage 0 or I), allowing for breast-conserving surgery rather than mastectomy and lowering the necessity for aggressive adjuvant systemic chemotherapy.

As with any screening test, there may be false positive results, which may lead to unnecessary health care costs, psychological distress, and tissue biopsies. 

This made me a bit worried to know that high breast density decreases mammographic sensitivity and independently increases breast cancer risk. Clinical practice increasingly incorporates mandatory reporting of breast density to guide decisions regarding supplemental screening.

Routine physical examination alone is no longer recommended as a primary standalone screening method due to a lack of clear mortality benefit; clinicians emphasize "breast self-awareness." Patients should remain familiar with their baseline breast topography and promptly report clinical changes, such as skin tethering, nipple retraction, or new focal asymmetry.
 

WE ALL KNOW HOW THIS ENDS

 This was the title of the latest book I have read. It really touched my heart. As a doctor, we aim to keep patients alive, and, most importantly, in my profession as an obstetrician, we assist women in giving birth. This book has a great number of topics that are not discussed in everyday life and are often avoided. These are topics around death, the end of life, funerals, and dealing with grief. We are mostly unprepared and unable to plan accordingly. In all these affairs, the presence of an end-of-life doula becomes handy. The author Anna Lyons points out tips to help people who are interested in this profession to step into this path. Tips such as working in a hospice or as a healthcare assistant, and she introduces several useful websites and links.

Training as an end-of-life doula teaches us that death is a normal and natural part of life, dying is still living, and death is a transition. She points out that a good doula listens to her clients and asks all the important questions. They remember all the important facts, and at the same time maintain confidentiality. They are not there to be your friend, judge, or impose their own beliefs, or befriend you. 

Throughout the book, there were numerous stories of death and loss and how the family members handled it, from stillbirth to death in the COVID pandemic, or loss of a small child who had been unwell from birth. There were some interesting reads about various funeral plans. It really got me thinking about how I have not really bothered to plan my own funeral. I am of muslim faith, and most of the time, the family does the burial the following day after the death, the body is washed and wrapped in a white cloth, and buried with no coffin. Sometimes I feel like a cremation would be a better option, but I am fearful to make such drastic decisions. 

My first experience with the death of a family member was in 2008, when my great-grandmother was transferred to a specialist cardiology hospital after collapsing in a nursing home. I was a curious medical student then. She was taken for a pacemaker insertion, but the procedure failed, and she was transferred to the ward, intubated, while someone was giving breaths through the ambu bag. She demised the following day. My uncle and I were there all along. I unfortunately missed the burial due to my duties and classes.  Grandpa, whom I have always loved more than my parents, passed away in August 2018. I got the news of his passing while driving to work. I cried in the car, wiped the tears and went to work. I am crying now as I am typing… I flew back home for the 40th, and my family and I went to his grave, mourned, cried, and paid our respects. I have a small picture frame of him, looking handsome in a tie and suit, on my parents’ wedding day. I talk to him most of the time, especially when I am sad with my medical work, and things are not going well. He was so proud of me when I made it to medical school.

Towards the end of the book, I came across Dr Liz O’Riordan’s story. She was a qualified breast surgeon who was diagnosed with stage 3 breast cancer. She has had two episodes of local cancer recurrence. She is an author and, through multiple social media channels, educates the public on cancer awareness and her own personal experience with cancer treatment. She is open about how her cancer treatment caused her to lose her career as a surgeon and her ability to have children. I was extremely touched by her resilience and her extraordinary work. 

No matter what happens in life, we all know that death is the one true inevitability. There is nothing more certain in this world than our mortality. 

BEACH DAY

 

I have been in the city of Sligo since September 2025, and only last week I managed to go and check out the Strandhill beach. It was the perfect combination of me being on leave and in the mood, and the weather being agreeable. I got into the S2 bus and told the driver I was going to Strandhill for the first time, and he pointed out that the beach is on the last stop. It was a 30-minute bus ride. I enjoyed exploring the rest of the city. I was so excited to see the blue sea, the blue sky, and hear the sound of the waves. It was extremely serene. I sat on the nearest bench and enjoyed the scenery. I had packed a sandwich for breakfast, and having a meal with a view was very enjoyable. I took a walk down to the other side of the beach, passed the pebbles, and reached the sand. There was a surfing class in progress. It was quite cold and windy to even think about walking on the sand barefoot. The first thing that came to my mind was how my 3-year-old daughter would enjoy this beach day. 

She is a lovely child, and she has learnt to walk the streets at my pace and catch the public transport; she even has a sense of direction. For example, when we go towards the public library, she gets excited and runs ahead. We try to play inside the house, draw, and do various things, but somehow we end up spending hours in front of the screens. I try to organize outings for the weekends and spend quality time with my daughter. She enjoys playing with her doll, bunny, and other stuffed animals. She has a set of cups and plastic cupcakes where we have pretend tea parties. We enjoy drawing and painting. I can't wait for her to finally figure out how to colour objects individually. She goes crazy for the K-POP demons and sings and dances with them. Her speech has been a bit delayed, but she is slowly getting there. Only now she is making simple sentences such as I want to sleep, I want food, etc. Her favourite foods are toast with butter, chocolate of course, fruits, chicken, meat, fish, and chips. The other day, I made rice and tuna, and she completely omitted eating the rice and finished the tuna. 

She has coped very well with our immigration to Ireland. She finally started preschool in February 2026, after 5 months at home. She was not worried about getting in the transport lady’s car and going to her new school. She enjoys playing with other children. Even though she is a girl, she likes playing with cars and dinosaurs. When we moved to the new house with no bathtub, I was wondering how I could convince her to enjoy the shower. We succeeded with a bucket of foamy water and some toys, and she enjoyed playing in the shower. Potty training has not been consistent, and she still has a nappy on most days. But we have had successful days with the pants staying dry. 

Finally, on a sunny Sunday, we made our way to the beach. It was a pleasant bus ride. She understands the sea now and was even pointing out the baby sharks to mommy! We had lots of snacks while enjoying the view, plus feeding the birds and the seagulls. She would get very excited to see the dogs being walked, and would greet all of them. She did very well walking on the pebbles, and we found a lovely spot to play with the sand. I am looking forward to making more memories with my baby girl. 

LA LA LANAD

 

I have been on leave lately. I have enjoyed watching several movies, reading, creating art, doing crochet, and going for long walks when my little baby is in school. The other night, I opened Netflix, and I saw the movie La La Land come up. I am shocked to see that a decade has passed since it was released. It felt like yesterday. I cried a lot while watching that movie, shockingly more than while watching Hamnet. I know how passionate I felt when I first watched it in 2017. I was obsessed with the story, with the music, and all the dancing scenes. Playing that soundtrack in my car would really take me to La La Land while driving to work. I was passionate about life, about my work, and about the future. 

It was before the COVID pandemic, when life had different ways, and I  think most of us are not fully recovered from the pandemic trauma, and the post-pandemic price hikes and inflation. Before the pandemic, my plane tickets to home were booked 6 months in advance, and it was something to look forward to. I was constantly exploring new restaurants and places to eat out, shop, and meet people. My immigration to Ireland in 2025 is my first international travel since 2019. It does not count as a vacation; it was a painful immigration. I am the most minimal person right now when it comes to shopping. Buying clothes only when necessary, in solid and neutral colours. No more retail therapy, buying a leopard print blazer, and figuring out how to match it later! The last time I ate at a  sit-down restaurant was in February in Dublin when we went to get our resident cards. 

I can feel how different I feel now compared to 10 years ago. I used to feel young and alive, with a world full of opportunities ahead of me. I used to be excited about life and the future. Little things used to inspire me. I feel so numb these days. I do everything as a sense of duty. Get up and go to work to pay the bills, clean the house, look after my baby, and check on my parents. Work has lost its spark! That training registrar's adrenaline rush to learn something new has been replaced with burnout and defensive medicine. My husband and I have been married for 6 years now. Those good old dating days when we used to drool over each other are gone. It is a sad reality for most marriages when we hardly plan to do anything together, or dress up and go on a date for a change. In the new country, we do not have a nanny or a babysitter, so it is quite impossible to have some time with just the two of us. I guess this is what a midlife crisis looks like. After decades of hard work and juggling. 

I was hoping that with immigration to Europe, working in a more systematic and organized health care system, I would be happier and have a more balanced life. I was hoping earning a decent salary in a strong currency would give more opportunities to travel. As I am writing this blog, the world is in the middle of an energy crisis with Iran, Israel, and the US in a state of war. Following social media and the war news has become extremely exhausting. Yesterday I came across a comic cartoon of Donald Trump on Instagram,  dressed as Moses with his stick opening the Strait of Hormuz! It is an uncertain time of history, with more price hikes on fuel, flights, and groceries. No travel plans for me this year, and only saving and survival so we can pay the bills and put food on the table. 

FLOORED

 If you are a woman and you have a pelvic floor, you need to read this book, written by a pelvic physiotherapist. I am a gynaecologist, and I have always undermined pelvic physiotherapy. After having my first child, my mom started babysitting for me. By the time my baby turned 2 years old, my mother’s stress incontinence had worsened from leaking a couple of drops to being wet most of the time. Having a chronic cough wasn't helping as well. I was hunting for a urogynaecologist in town to fix the problem. I felt responsible that lifting my little baby was a possible contributing factor. A colleague recommended a urologist. We had a consultation, he suggested we start with a cystoscopy and urodynamic studies. I found the urodynamic study very invasive, and it didn't add any new information. The urologist suggested a tape, and off my mom went for surgery. We did not send Mom for any pelvic floor physiotherapy. 

You don't have to be in your 50s or sixties to have pelvic floor problems. I had one vaginal delivery, and I know my ability to hold my pee and poo is not the same as my 20s. We underutilize pelvic physio in most aspects of women’s lives. Dr Sara points out how we get all the other organs regularly checked out, and we forget about the pelvic floor until there is a prolapse or a leakage. 

As Dr Sara educates us in her book, nearly one in three women suffer from pelvic floor disorders such as painful sex, prolapse, back pain, constipation, urinary leakage, and lack of orgasms. These conditions affect women’s self-esteem and their ability to exercise or have intimate relationships. Urinary leakage alone is costing women in the USA over 20 billion dollars per year, yet most of these treatments are temporarily successful and do not address the main underlying cause, which is pelvic floor dysfunction. 

There are multiple body stretches that are instructed in the book that help, relax the pelvic floor muscles. She explains the importance of pelvic physiotherapy during pregnancy to reduce pelvic girdle pain, and improve the strength of the pelvic muscles. She explained her own birth experience going smoothly, with an intact perineum. She explained that taking time and effort with the help of her partner to give her regular perineal massages. 

The book is written in a very easy-to-read style, with a friendly tone. It explains the anatomy and physiology of female pelvic organs in simple terms that people who are not medical professionals can understand better. There is a holistic approach into how the pelvic organs and the pelvic floor function, besides doing the Kegels, such as giving us hints as  how to efficiently empty our bowels and bladder without causing tension and ongoing dysfunction. 

Read it You have ever leaked while sneezing, feel "disconnected" from your core, are preparing for birth, or are navigating menopause. It is essentially the "owner’s manual" for the female body that most of us never received in school.

MENOPAUSE MISUNDERSTOOD

 

I have moved to a first-world country now, and I see a totally different demographic of patients with new problems. Women are well educated and way more fit and active in their fifties than women in third-world countries. I came across a woman in her sixties who is still working in a law firm with a demanding job, and she was experiencing a bit of brain fog; her GP put her on HRT to improve her memory. What is the first thing that comes to our mind, in elderly women with memory loss, perhaps this could be the beginning of dementia, or the normal forgetfulness with aging. She presented to us with unscheduled vaginal bleeding and decided to stop her HRT. Her hysteroscopy, dilatation, and curettage showed uterine atrophy and no hyperplasia. She claimed the HRT did not make a difference

The most shocking thing I witnessed was a patient in her forties, who presented to the gynae clinic with an extensive psychiatric history of bipolar disease, with extensive medical treatment, previous admissions to psychiatric ward and even a session of Electroconvulsive therapy (ECT).  she was in her fourties, still menstruating, and was asking if going on HRT will improve her psychiatric condition! She was hoping she could even try to reduce or stop her psychiatric treatment. I reassured her that she has to continue her treatment with her psychiatrist. She is menstruating and not menopausal yet, and the real indication for HRT is severe hot flashes that decrease the quality of life and sleep, etc. I explored some of the side effects and the contraindications, such as a history of thromboembolic disease, stroke, ischemic heart disease, or estrogen-dependent malignancies. 

We have had an ambulatory gyneacology unit in the department since 2024. The referrals to the department are mainly women with heavy menstrual bleeding or post menopausal bleeding. Other services, such as coil insertion, are also offered. Patients have analgesia, and in cases of post menopausal bleeding or unscheduled bleeding on HRT, women are triaged to attend within 2 weeks. When women start HRT, and they experience some vaginal bleeding, we usually still classify them as post menopausal bleeding. The biggest worry in this situation is endometrial hyperplasia or malignancy. One of the non-invasive tools for this is a transvaginal ultrasound to assess the endometrial thickness. The British Menopause Society indicated that the endometrial thickness varies in women on HRT, with the higher ET limit of 7mm in women on a sequential regimen and 4 mm in women on a continuous regimen being accepted. If the endometrial thickness is increased or difficult to visualize, an urgent hysteroscopy and endometrial sampling are mandatory. 

Most clinicians offering HRT understand the importance of progestogens along with estrogen in women with a uterus. The challenge is calculating the optimal dose of an oral or vaginal progestin and ensuring patients adhere to it. 

Women with unscheduled bleeding with HRT with these major risk factors for endometrial carcinoma should be prioritized for hysteroscopy and endometrial sampling. These include: A BMI more than 40, lynch syndrome, being on HRT for more than five years, and inadequate use of progesterone. Minor risks for endometrial cancer are Diabetes, a BMI of 30-39, and a history of polycystic ovaries. 

Mirena coil is a good option to ensure a good endometrial progesterone supply without systemic side effects. We need to ensure the Mirena coil is in the correct position; if it is more than 2cm from the fundus of the uterus, it will not be protecting the endometrium. 

Using oral HRT preparations or Mirena coil as the progesterone component ensures more amenorrhea and less unscheduled vaginal bleeding. Using the fixed oral combined estrogen and progesterone ensures adequate dosing. We need to ensure our patients are up to date with their cervical smears, and if there is evidence of vaginal atrophy, to supply them with topical estrogen. 

APPRECIATION

 

I am under a lot of pressure at work, and it is affecting my mental health. It is the 8th of March, and the weather is still as frosty and cold as January, crushing my expectations that spring is near. I have downgraded my winter clothes to lighter jackets with no gloves, and I am not able to cope with the cold weather when I go out in the mornings. My baby girl started school in the middle of February, and I am having a terrible case of the flu again, after recovering from a chronic cough that lasted three months. On top of the new and difficult work environment, absenteeism has been prominent during the time colleagues were writing the Royal College exams. Not to mention the world leaders have decided to start a new war and bomb each other. With the instability in the Gulf countries, the fuel and grocery prices will go up. Here I am trying to be positive about life. and make a list of the things I am grateful for. 

I am grateful I actually have a job right now. This is the job I got so excited about last year may when I had the interview and broke the news to my parents, and started applying for a work permit, visa, and getting tickets for Ireland.  We are back to basics. We are grateful to have a job and a stable income to put food on the table. The demographic of patients has changed here; they are well taken care of, and I find it very rewarding compared to South Africa, where every day we had to save patients from critical conditions such as severe cardio-respiratory distress, sepsis, or haemorrhage. 

I cannot put a price on the feeling of safety we have staying in Ireland. There is no constant fear of an armed robbery, hijacking, or a gun attack. I often walk to work while on a video call with my mother.  In other countries, phones go missing in public. I remember when I worked in one of the government hospitals in Johannesburg, there was an incident in ED where one of the patients started assaulting a male nurse, and another patient pulled out a gun, to defend the nurse! I love my morning and evening walks to work,  thanks to a safe community. 

We appreciate the change of seasons, and we are eagerly waiting for the beautiful spring and summer to arrive. Hoping to spend more time in nature with friends and Aryana. Most of my career and study difficulties have occurred in winter. I remember when I was in university back home, I had not submitted my research proposal, and I was in crisis before the start of the internship. I was very stressed out, while mom and Cyrus were in South Africa, every morning before going to the university, I would have an episode of crying at the breakfast table. 

I love seafood, and Ireland is a country where we can get a good supply of fish and prawns. I am in love with Salmon. My favourite meal of the week is baked salmon fillets in the oven with a healthy side of vegetables. My daughter is also a great fan of seafood and prawns. I am planning to cook more sophisticated dishes on weekends when I  have time, it is more fun and rewarding than eating out. 

I am happy that my little girl is going to day care. It was weighing on my heart all these months she was at home. hopefully the school will help her pick up more skills and learn to be more vocal. Immigration is hard, but we are slowly settling in and getting used to our new environment. I enjoy the slower pace of life in our small city. There is no hectic traffic or morning rush to day care. My husband and the transport lady take care of the day care drop off and pick up while I focus on getting to work. 

THE MONTH OF LOVE

 January has been a difficult month for me. My in-laws, who paid us a visit during Christmas, left on the 6th. I was suddenly put on back-to-back night shifts, under supervision, and heavily criticised and broken at the end of the month. I had a week of annual leave, and we attended the immigration office and came back empty-handed and irritated. We tried to make a vacation out of the Dublin trip and booked a fancy hotel, but it didn’t turn out as we had expected. I was hoping to go and visit a Persian restaurant and eat kebabs, flat bread, and Persian tea, but the visit was cancelled due to poor mood and bad weather. Work has been draining me, adjusting to the new demographic of patients, the new system, and constantly being supervised and on edge is a recipe for burnout. The negative political news from back home was the cherry on top to make this cold and dark January more and more miserable. The last blow to my mental health was my Cuban friend doctor showing up for her job in ED, after long research and chats with me since last year, and abruptly leaving after three weeks of work. I can not believe the stress I went through to find her an accommodation and help her out. 

February is the month of love and Valentine's Day. The second of February 2020 was our engagement anniversary. It was a beautiful day, and a complete surprise when he gave me the ring while I was on labour ward duty on a Sunday. We were truly in love, and what pushed him to propose was losing his aunt at the end of January. It was the year of Covid-19 pandemic, and there was no room for fussing and throwing big engagement parties. Social media makes things easy; you post a picture and a caption, and all your friends and family will know that you are engaged. We had a small court wedding and dinner later in September. Once you are in a committed relationship and have a child, things change from date night and excitement to duty. just making it from day to day. There is love everywhere, every day. The romantic love, the love of parents, and the most special thing is friendships. Our friends do not love us because they are related to us, like our parents and siblings; they are there because they want to be with us. I feel that is a genuine love. 

We had some good family time on Valentine’s weekend, with my girl and daddy. I met another South African doctor from ED for a long-awaited coffee break. It was my first time meeting someone for coffee in Ireland, and I was very excited; I felt like I was going on a first date! She was lovely, and we both knew why we left South Africa, due to its poor health infrastructure and poor job opportunities.  We knew that settling in Ireland had not been easy, leaving our family and friends behind, and adjusting to a new country is a huge challenge. There is always room to find love in a foreign land, to give love and kindness, and feel connected. This is how I felt when I met my Lebanese and Serbian friends in South Africa, and we connected instantly. This is what the world needs right now: for the people to come together regardless of their race and colour, and it was beautiful to watch Bad Bunny perform in the NFL halftime show, and remind us of all the countries there in the American continent, encourage love and togetherness.