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In this episode, Shirin Towfigh, a surgeon and hernia specialist, delves into the often-overlooked issue of hernias, particularly in women. The discussion highlights the challenges patients face when dealing with chronic pelvic pain and undiagnosed hernias. From gender disparities in diagnosis to the latest advancements in surgical treatment, this conversation emphasizes the importance of proper diagnosis, patient advocacy, and raising awareness about hernia-related conditions.
Shirin Towfigh is a surgeon and hernia specialist.
She discusses the KevinMD article, “Ignored and misdiagnosed: the truth about hernias in women.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Shirin Towfigh. She’s a surgeon and hernia specialist. Today’s KevinMD article is “Ignored and misdiagnosed: the truth about hernias in women.” Shirin, welcome to the show.
Shirin Towfigh: Thank you so much, Kevin. It’s my pleasure. I listen to your show.
Kevin Pho: Oh, I appreciate it. And where are you based out of?
Shirin Towfigh: I’m based out of Beverly Hills, and I have the Beverly Hills Hernia Center.
Kevin Pho: Well, all right. So how long have you been a hernia specialist, and tell us what a typical day is like.
Shirin Towfigh: Sure. So I’m a general surgeon, and I started my practice in 2002, and I’ve been exclusively doing hernia since 2008. So my typical day is seeing patients with hernia related complaints. About 80 percent of my practice is revisional, or someone’s had a complication.
I also am a little bit of a curious person, so many patients are sent to me because no one can figure out why they have abdominal pains or groin pains or pelvic pain, and then I try and figure it out, tell the doctors what to do. And then I enjoy those puzzle solving situations.
Kevin Pho: So what made you specifically focus on hernias as a career?
Shirin Towfigh: You know, everyone asks me that, first of all, especially patients, sometimes because I’m female, they’re like, why did you, how did you get into this? So it definitely did not sprout early. My goal was to be a laparoscopic surgeon, that was my first job. But I started inheriting patients that had very complex hernias, and I noticed I need a little bit more education on it and to learn more.
And I was really interested in it once I got to learning it through the American Hernia Society. I got to rub shoulders with people that I learned from in the books, like Shouldice was there, Amid was there, Condon was there. These are all people, Nyhus and Condon have a great book on hernias. So all the people that I read about were at this meeting, and I was really inspired.
And I was the only female at the meeting, so I had just graduated, they already came up to me and said, hey, would you like to be an editor for our hernia journal, we’ve never had a female before. I was like, absolutely. So it kind of started like that. They’re very loving and inclusive, interested in seeing younger people. Now I’m kind of one of the older people in the society, but it’s nice to see that. What I really enjoy right now, more and more people are enjoying, and it’s becoming a bona fide subspecialty within general surgery.
Kevin Pho: So we’re going to talk about your article a little bit, but let me ask this question. What would you say is the biggest misperception or misconception about hernias that we should know about?
Shirin Towfigh: That it’s just a hernia. That is the worst. We say all the time, oh, it’s just a hernia. So surgeons for sure don’t typically spend a lot of time and energy perfecting their knowledge and their surgical technique for hernia repair, and it’s not really considered a very fancy or sexy part of general surgery.
And other specialists, gynecologists, urologists, other doctors that may, even like general medicine doctors, they may not understand the importance of diagnosing a hernia. Because maybe it’s a female, oh, women don’t get hernia, some people feel. Or it’s not a big hernia so it can’t be the cause of your problem, maybe it’s all in your head. There’s a lot of misconceptions about what a hernia is, who can get it, and then what’s the best next plan of care.
Kevin Pho: All right, so you’re going to talk more about that in your KevinMD article titled “Ignored and misdiagnosed: the truth about hernias in women.” So tell us what led you to write this article, and then go into the article for those who didn’t get a chance to read it.
Shirin Towfigh: Well, June is hernia awareness week, believe it or not, we have a whole month. And usually on my own social media I would say something about it in the month of June. But I am a big follower of KevinMD, and it’s a nice way to get information out there that’s kind of from the heart. So I’m like, I have so much information to share, and you can only do so much at meetings and writing articles, or we have a book even on groin pain, but people have to read that. And I felt this would be a nice audience to share my thoughts in a very concise way.
Kevin Pho: All right, tell us what the article was about for those who missed it.
Shirin Towfigh: Yeah, so I basically filled the article with as much information I can that would be relevant to the typical doctor or even patients. So understand that most people know hernias to be a bulge, and oftentimes they don’t consider it to be a painful bulge. But if you’re female, younger, thinner, don’t expect to see a bulge. They may present first with pain and not with a bulge.
Also especially in the groin, if you have pelvic pain, chronic pelvic pain, there are a lot of atypical signs of hernias that are due to the hernia and not due to something else. So you can have hip pain, you can have pain radiating into your inner thigh, around your lower back. All of these are symptoms of a hernia. You can have urinary frequency, pain with intercourse, pain during your menses. These are all findings that are consistent with an inguinal hernia. Bloating, nausea, these are all symptoms. You don’t have to have an obstructing hernia or a strangulating hernia to have these symptoms.
So what happens is, patients typically women, typically younger people, go to their doctor with these vague symptoms. Yeah, I got this like lower abdominal pain or pelvic pain. If you’re female you get sent to the gynecologist and they treat you for endometriosis, ovarian cysts, because a lot of your pain is not like your typical bulge in the groin.
Whereas I’m hoping that people who treat patients with pelvic pain not to dismiss hernia, because hernia is probably the most common reason for the pelvic pain, because it’s so much more common than all these other diagnoses I told you about.
Kevin Pho: Well, specifically in women, you mentioned younger women. What other risk factors do women have to worry about that puts them at risk for hernias?
Shirin Towfigh: Good question. So hernias do run in the family, it’s very genetic based. If you have a female in your family with a hernia, you’re more likely to have a hernia than if you have a male in the family. So it is also sex based in some manner.
Then there’s lifestyles. So obese patients, chronic cough, constipation, anything that requires straining. If you have an enlarged prostate or you’re straining to urinate, those are all risk factors for getting hernias. Nicotine use has been associated with worsening collagen and may accelerate your hernia, shouldn’t cause a hernia. Obesity again, if you have a tendency towards a hernia, being obese may also make it more likely for you to accelerate development of your hernia.
Kevin Pho: And when you say younger women in particular, what particular age groups are most at risk?
Shirin Towfigh: You know, hernia in general is a disease of the older population statistically. But what happens is, when you’re younger people don’t think about hernias as much, and so they dismiss some of your pelvic pain complaints as gynecologic. Or if they can’t figure out why it’s gynecologic, then it must be in your head.
So my concern is that women are being dismissed and being given this chronic pelvic pain diagnosis, which is kind of like anything can be chronic pelvic pain. Whereas if they’re just diagnosed with a hernia and you treat the hernia, that’s a cure.
And our studies have shown that women have about a two-year delay in diagnosis compared to men. They’re more likely to be on narcotics preoperatively than men prior to their hernia repair, and they are much more likely to have a better outcome with less chronic pain from their hernia repair than men. So think of hernias when you think of pelvic pain.
Kevin Pho: So in the exam room, and as you and my listeners know, I’m an internal medicine primary care physician, so if I have a female in my exam room exhibiting some of the symptoms that you describe, and because I’m hearing you and I’m thinking of hernia now, and clinically like you said they don’t have that stereotypical bulge associated with hernias, what would be the next step? Would it be some type of imaging study, any type of physical exam findings that could elucidate that? What would be the next step?
Shirin Towfigh: Absolutely. So examine your patient standing, because the gravity will help elucidate a larger hernia. If you don’t see a bulge, then palpate the inguinal canal, and that’s basically a line from the anterior superior iliac spine down to the pubis. Along that line, if there’s any fullness or tenderness, that’s a very, very sensitive finding for an inguinal hernia.
And then if you’re still not confident that they have a hernia, do get imaging. There’s only two good imagings you should order for patients with groin pain to rule out an inguinal hernia, especially an occult one where it’s not very obvious. One would be a hernia ultrasound, specifically have to say dynamic hernia ultrasound, because that’s a specific protocol where they will have the patient move around, do bear down, and they’ll really look for an inguinal hernia. If you order an abdominal ultrasound or anything else similar to that, it will not show a hernia most likely.
And then the other one is an MRI. So MRI pelvis, no contrast, just a straight MRI would be great. On my website we have our MRI hernia protocol, which many institutions around me are now using, which is a Valsalva MRI. So it’s a dynamic MRI looking at the pelvis. You have to order it as a soft tissue MRI, otherwise they’ll tell you about the bones and the pelvis and the sacrum and they’ll miss the fact that there’s a hernia.
Kevin Pho: And no role for CT?
Shirin Towfigh: Not very much. If it’s an obvious inguinal hernia and you want to look at contents, or if it’s a ventral hernia, abdominal wall hernia, CT scan’s very good for that. But we’ve looked at the benefit of CT scan in these occult hernias and it’s horrible.
So we found for ultrasound it’s about 50 percent true negative and 100 percent true positives. So ultrasound is great if it shows something. If it doesn’t show it, you should move on to MRI, where the sensitivity and specificity is over 90 percent. It was in the single digits for a CT scan.
Kevin Pho: So we focused more on inguinal hernias. What about umbilical hernias and abdominal wall hernias? Are they underdiagnosed in women as well?
Shirin Towfigh: Not as much. I think we appreciate that women are predominantly the ones that get umbilical hernias, pregnancy, you can see a little outie. And most ventral hernias and umbilical hernias do not need surgical attention if they’re not symptomatic.
Whereas in the groin, especially in females, you must make sure you’re not missing a femoral hernia that’s causing their groin pain, as opposed to an inguinal hernia, because that is a life-saving procedure if you address a femoral hernia in a female.
Kevin Pho: So let’s say we order that MRI or ultrasound and it confirms a diagnosis of an occult inguinal hernia. So the next step, is it a referral to a surgeon like yourself? Is there a role for conservative treatment? What should I do next?
Shirin Towfigh: So for ventral hernias, watchful waiting is considered safe for most umbilical hernias unless they’re symptomatic, in which case you should send them to a surgeon. For inguinal hernias in males, we have good studies to show that watchful waiting is considered safe for asymptomatic, so no symptoms, or minimally symptomatic inguinal hernias. And the prediction is you may have a 0.18 percent per year risk of incarceration if you do choose not to have surgery. If you do have symptoms, surgery is recommended, and about two-thirds of patients will require some type of surgery within 10 years of their diagnosis.
Women’s a different situation. We have zero studies looking at women. Of the past major seven, sorry, six randomized control trials looking at inguinal hernias, only seven women have been enrolled. Most studies have had zero women. So we don’t understand the chronology of women’s hernias.
What we do know is that women are 10 times more likely than men to have femoral hernias, and femoral hernias can kill you. So if you have an emergency from a femoral hernia you have a 5 percent chance of death, and that’s the highest risk of any hernia we ever talk about. So for women it’s very important that you rule out a femoral hernia.
Now for surgeons, that’s our role during surgery, if you take a patient to the operating room, to make sure you don’t miss a femoral hernia during your surgery, which is why laparoscopy is so great for that. However, we don’t know, there may be a role of just with imaging ruling out femoral hernia and then saying, OK, you don’t have a femoral, you have an inguinal hernia, it’s not bothering you that much, come back to me when it’s bothering you. We don’t know if that’s valid. We know that’s valid for men. There’s a group out of Michigan that’s hoping to study that and repeat the same studies that were done for males on females. And so hopefully soon, in the next couple years, we’ll have a watchful waiting trial that will enroll women.
Kevin Pho: And can a femoral hernia in women be differentiated on imaging?
Shirin Towfigh: On imaging, yes. On examination it can be difficult.
Kevin Pho: So in terms of repair, what’s that process like for patients?
Shirin Towfigh: Oh well, they have a lot of options. In the United States, mesh based repair tends to be the typical way to do it, but you have open, laparoscopic, or robotic approaches. You can have it with mesh, without mesh, and we have a wide range of meshes nowadays. So if you go to your general surgeon, they usually have a type of hernia repair they like to do. If you go to a hernia specialist, we tend to have more tools in our toolbox, so to speak, about different options that we can tailor to your needs.
Kevin Pho: So what kind of additional options would a hernia specialist like yourself have in contrast to a general surgeon?
Shirin Towfigh: Well, for example, if you come to me and you’re morbidly obese and you have a big scarred hernia, I’d probably err on mesh repair with robotic approach. If you’re a ballerina or a yoga instructor with a small hernia, I probably will do a small open repair with no mesh. So there’s different types of hernias. If it’s a recurrent or larger hernia, we err on thicker, stronger meshes. If it’s a more typical hernia or smaller hernia, you can err on using lighter weight meshes.
There are people with autoimmune disorders, so lupus, rheumatoid arthritis, that are potentially prone to react to the inflammatory process that a mesh involves, and they can get an autoimmune inflammatory response to it. We call that mesh implant illness, and I published on what mesh implant illness is and who’s at risk. And in our population, 80 percent of the people that had mesh implant illness had some type of autoimmune disorder themselves already. So I try to prevent use of implants in that population. But we don’t really know from a population standpoint how many people will react to mesh given that kind of personal risk factor.
Kevin Pho: And in terms of outcomes, what is the percentage of recurrence after repair?
Shirin Towfigh: Very surgeon specific. There are great population studies out of Denmark, Sweden, and Germany, which show the recurrence risk for laparoscopic repairs should be 1 to 3 percent, and for an open repair less than 5 percent. Hernia specialists should bring that number down, and bring the risk of chronic pain with repairs below that level. So that’s really what differentiates a specialist perhaps, because we tend to tailor our care.
Kevin Pho: So what do we have to look forward to on the horizon when it comes to hernia treatments over the next year or so?
Shirin Towfigh: Maybe not over the next year, I would say over the next 10 years. Hopefully more data to support evidence-based hernia repairs and hernia care for women. Hopefully better meshes. We are slowly moving away from permanent inflammatory synthetic meshes, there are hybrid meshes now.
I have a couple patents on gender based meshes. I feel that the female pelvis is very different than the male pelvis, and so our surgical technique including our mesh design should be different. So hopefully we’ll have a lot more tailoring of care to improve outcomes.
Kevin Pho: We’re talking to Shirin Towfigh. She’s a surgeon and hernia specialist. Today’s KevinMD article is “Ignored and misdiagnosed: the truth about hernias in women.” Shirin, let’s end with some of your take-home messages that you’d like to leave with the KevinMD audience.
Shirin Towfigh: Number one, it’s not just a hernia, do treat it as you would any serious disease. Number two, do your research. Most of my patients are highly educated when they come. Number three, pelvic pain is most likely not purely gynecologic, and do consider a hernia in your differential diagnosis, because that’s a very treatable way to handle groin hernias.
Number four, I don’t believe in overtreating, so watchful waiting and educating patients on risk factor adjustments, such as treating their chronic cough, constipation, or prostate enlargement, can be very helpful.
And the one thing we didn’t discuss is exercise is great, it’s protective. You can do sit-ups, push-ups, lift weights. Those are all great things and will not hurt your hernia, but may help you.
Kevin Pho: Shirin, thank you so much for sharing your expertise and perspective, and thanks again for coming on the show.
Shirin Towfigh: Thank you Kevin, it’s my pleasure.
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