So during the last week I have spent a few days in one of the village health post within Nepal. I was surprised at the lack of patients that I saw in this health post. May this had something to do with the remote location of the centre itself, a mere 5 minute walk from something that vaguely resembled a track. Considering the house I was staying in was a 30 minute hike from the road, this health post was pretty accessible for rural Nepal, despite the fact I thought one wrong step climbing up to the health post would put me in hospital let alone someone that was unwell.
The only interesting patient that I did see at my time at the health camp was a woman presenting with vaginal bleeding, a para 2 patient (has had 2 children previously), the doctor at the health post seemed to suspect a uterine prolapse. I was not convinced as the only uterine prolapse I had seen was immediately post child birth and resulted in a major postpartum bleed. This patient looked far too well for that, anaemic I grant you but not by any stretch on deaths door. We decided to use a speculum to look at the cervix to check for prolapse. To my surprise this was a metal Cusco speculum, that resembled the one that my flatmates and I had at our house as an antique. No prolapse was seen and her bleeding was put down to menorrhagia. She was simply treated with B12 and folate tablets to address the anaemia, I can see the logic but this didn’t quite fit for me seeing as the anaemia was probably due to blood loss (giving a normocytic anaemia) rather than a B12 deficiency (macrocytic anaemia). Obviously, no blood tests were available therefore this couldn’t be clarified.
Menorrhagia usually has no causative abnormalities, so treatment is directed at treating the symptoms, the contraceptive pill is usually first line, with medications such as transexamic acid also an option. Transexamic acid prevents the degradation of fibrin which forms when the clotting process is activated. It prevents plasminogen converting to plasmin which degrades fibrin, to normally keep the clotting process in balance. However, in menorrhagia where the bleeding is excessive it prevents the breakdown of the clot and therefore decreases the bleeding. Actual abnormalities that cause menorrhagia that need to be excluded are fibroids (benign tumours in the endometrium of the uterus), clotting disorders, endometrial cancer, endometriosis (where there is endometrial tissue that lies outside of the uterus) and pelvic inflammatory disease.
The lack of access to healthcare within Nepal because more apparent to me from just being within the country and doing activities outside the hospital. From seeing patients being stretchered to hospitals by family members, hospitals being a 4 day hike away, to talking to helicopter pilots over there. When patients needed transfer from their village to hospital another option from carrying them to the hospital or hopefully closer would be a road, was for the whole village to club together to hire a helicopter to transport the patient to hospital. The part that really shocked me about this was the helicopter was unmanned except for the pilot and even then the pilot was medically untrained so if anything happened during the flight there was no one to intervene, the pilot just had to get to the hospital as quickly as they could.
My whole experience within Nepal has been incredibly eye opening and an extraordinary experience. It has really shown me, although many people often complain, how lucky we are to have a healthcare system that works amazing well especially in comparison.