Indian Express
21 May 2011

Unlike hernias in men, those that afflict women are usually small, internal and rarely cause an obvious bulge. It can take years, if ever, to get the right diagnosis and correct the problem

LAURA Sweet was an active, upbeat 42–year–old sales woman living in Santa Monica, California, when the agony first started –debilitating, flaring pains in her pelvis that lasted for days and recurred periodically. The discomfort resulted in many visits to the emergency room, referrals to various specialists, wrong diagnoses and a daily cocktail of painkillers.

When one doctor’s tests revealed no explanation, Ms Sweet said, he told her she had "chronic pelvic pain and I should learn to live with it".

Her sorry tale could be repeated by countless women who had hidden abdominal hernias, a condition that most doctors –including gynaecologists and surgeons –rarely consider or know how to find.

Unlike hernias in men, which are far more common, those that afflict women are usually small and internal and rarely cause an obvious bulge.

Symptoms can be suggestive of other problems–ovarian cysts, fibroids, endometriosis or adhesions from a previous operation –but surgically correcting these conditions does not relieve the devastating pain.

"On average, women go through four prior surgeries, and some a lot more than that, before the real cause of their pain is identified," said Dr Deborah A Metzger, a gynaecologist in Los Altos, California, who specialises in chronic pelvic pain.

When a woman lies flat on the examining table, the signs and symptoms of a hernia disappear. And the usual exam, an ultrasound, rarely reveals the real problem. Lacking an accurate diagnosis, doctors often send patients to be drugged up by pain specialists and psychiatrists.

For many women with these occult, or hidden, hernias, it can take years, if ever, to get the right diagnosis and correct the problem. Women account for only 8 per cent of the hernias diagnosed, and doctors simply "don’t think hernia" when women complain of pelvic pain, Dr Metzger said in an interview.

But after 18 months of torment, Ms Sweet got lucky. A urogynaecologist she consulted at Cedars–Sinai Medical Center in Los Angeles had a hunch that a hernia might be the problem and sent Ms Sweet to a specialist in women’s hernias.

`LIKE IT NEVER HAPPENED’ AN MRI revealed not one but two inguinal hernias: small holes in a layer of muscle through which pieces of abdominal fat can protrude, pressing on nerves and causing pain. Dr Shirin Towfigh repaired them both in a four–hour laparoscopic operation.

"I was back exercising in a week and jogging 10 days later," Ms Sweet said in an interview."Now everything is fine, like it never happened."

A hernia is protrusion of tissue through the wall of a body cavity in which it is normally contained, most often an opening or weakness in the muscular wall of the abdomen.

Dr Towfigh, a general surgeon who trains other doctors in laparoscopic surgery, explained that in men hernias often involve an obvious outward protrusion. In rare instances, such hernias may entrap a piece of the intestine, causing gangrene and even death.

But while women can sometimes develop a similar hernia, they are more likely to have a hidden, internal kind that entraps abdominal fat and compresses nerves, causing intense pain. Dr Towfigh said that despite frequent misdiagnoses, the symptoms of a hernia in women are really not typical of more common gynaecological problems.

She recalled that Ms Sweet said she had experienced "burning, pinching pain shot down into her groin, leg and back. It was worse with exercise, prolonged standing, lifting, bending, coughing, laughing, going up and down stairs, straining at stool, and during her menstrual period".

In other words, anything that increases abdominal pressure, sometimes even prolonged sitting, can provoke the pain, which occurs randomly throughout the day, Dr Towfigh said.

"Women with young children can’t bend over to pick them up. It affects their marriage because sex hurts too much, and it impairs their ability to work," she said. "The pain can be severe enough to cause a woman to pass out. It can be so extreme that women are given spinal injections and spinal stimulators as well as multiple pain medications and psychiatric drugs."

When all else fails, some women resort to lying in bed to bring relief.

Dr Towfigh explained that tiny hernias are the worst. "The smaller the hole, the worse the pain," she said.

But in examining a woman, even with an MRI, "you don’t see the hole –you only see the hole when something goes through it." That may require positioning the patient to provoke the symptoms.

Dr Metzger said an abdominal exam in the standing position sometimes reveals a subtle bulge. But more often these hernias can be nei ther seen nor felt, and a correct diagnosis relies mainly on a vagi nal examination. The pelvic muscles are often tense and ten der, and the patient’s pain can be reproduced by pressure on the internal inguinal area, she said.

When a woman’s hernia is diag nosed and surgically corrected –usually by placing mesh over the hole during a laparoscopic procedure –the pain dis appears completely. "It’s so easy to fix," Dr Towfigh said.

Exercise that helps maintain healthy abdominal muscle tone can protect against hernias, she said, but "once you have the problem, exercise won’t cor rect it, though it may prevent it from getting worse."

PARTICULAR VULNERABILITY Women are also more likely than men to develop umbilical hernias, in the bellybutton, especially if they are overweight, have had multiple pregnancies or endured very long labour when delivering a baby.

The British R&B star Jamelia Niela Davis, who goes by her first name, has said she first noticed that whenever she laughed, she automatically put her hand on her stomach and could feel an odd bulge. Though she did not have much pain at first, one day she experienced "excruciating pain, as if someone had grabbed hold of my insides and was twisting them". The surgeon she consulted told her that a piece of fatty abdominal tissue was being caught in the weakened umbilical wall and that without an operation it would only get worse.

Umbilical hernias can also entrap intestines and become life–threatening. But umbilical hernias are easier to recognise than internal hernias in women.

"The bellybutton should be perfectly symmetrical," Dr Towfigh said. "If you look carefully, you can see the asymmetry caused by an umbilical hernia, when a little piece of fat pushes out through a small hole."