When Things Don't Go As Planned

As a clinician you want the answers and certainly your patient wants you to have them. There is total satisfaction when someone comes in and says "I have this" and you know exactly what to do. I imagine it's what makes doctors go into orthopedics and surgery. "That hurts?", I'd say. "I'll add some plates, screws, or just remove that little bit and EVERYTHING will be better".
Sadly, hormone balance can be a bit trickier.

So, when a patient is frustrated with not getting better, it seems that I am almost as frustrated at not being able to help them get better.

Sometimes, I'm frustrated at the patient, since commonly the patient forgets that they didn't do the steps that you wanted them to because of time or money or willingness.

Other times, I'm frustrated because I too, don't know why they haven't improved. It worked for other patients and should have worked for them. It makes me start to look outside of myself to see who might have a different take on this patient. Who might be able to do or see what I couldn't?

And then there are the unique patients. The ones I desperately want to help, have no idea what's wrong and don't know where in the world to send them. Any one with a cure for closed head trauma brain dysfunction in the NW, please contact me.

But, these patients that you want to help the most and who don't react the way you expected can teach you new tricks.

One of my favorite stories is about a woman who came to me trying to get pregnant.
She had tried for several years without success, was young, and didn’t have any "classic" reason to be facing infertility. BUT, she had menstrual spotting from ovulation until her period. Multiple OBGYNs had told her that that wouldn't make a difference, but physiologically, that didn't make sense to me. So, we set upon giving her progesterone. So me in my cocky way, started her on progesterone. After all, how hard could it be? We see this every day.
Well…
It did nothing.
Still spotting.
...Great! (read sarcasm here)

Next cycle - we upped the dosage and when she started to spot I doubled it! Then doubled it again!
Yup - spotting away.

Hmmm… Ok, lets try oral. (Clinically, I find that the oral progesterone may stop dysfunctional bleeding better than topical; perhaps because of the action of progesterone metabolites).
Anyone guess?
Yup, continued to spot.

Thankfully this woman was very patient with me and a few other symptoms that she had were getting better. So I changed her dosage for the next month and started her a couple of days earlier than ovulation.

SHE STILL SPOTTED.

In utter frustration for both of us, I suggested that she use one of those oral capsules and just insert it vaginally.

AND IT STOPPED!

And it continued to stay stopped at much less than 1/2 the dosage I had been using orally (200mg vaginally if you care to know).

The next month she got pregnant doing vaginal progesterone from ovulation to day 28. I kept her on it the entire first trimester. A very happy ending.

Needless to say, now I consider vaginal progesterone even when oral and topical have failed.

Anyone else care to share a success born out of failure?

Dr Alison McAllister