Taking women’s pain seriously: the surgeon who spoke out about vaginal mesh

Speaking out made me a pariah

Elneil’s first case of extracting mesh was in 2005, a job she describes as “horrible.” “At the beginning, the women’s stories had a terrible effect. I couldn’t believe they were so badly treated,” she says. “I was surprised because when I was in Africa [where Elneil spent some of her childhood], I understood it as there were strong patriarchal societies that could explain it. In my head, England was not like that. So I got a shock because patients would say, ‘Oh, so-and-so put the mesh in.’ And I would think, ‘I know him, he’s a nice guy, why would he do this, and why would you not help her?’ I couldn’t comprehend it.”

Elneil started talking at societal and college events about the problems with mesh but found few allies. At first she was simply excluded from events, but soon the attacks became personal. She was reported to the General Medical Council multiple times, mainly by fellow urogynaecologists, the biggest implanters of mesh. “I was very upset. It felt like a war. They were saying I was removing mesh and harming patients unnecessarily.”

Elneil encountered women injured by mesh implants in 2007 while working in a clinic focused on abdominal and pelvic pain at the National Hospital for Neurology and Neurosurgery, London. “I remember examining the very first patient—she still comes to see me once every few years—and you could feel the mesh come through into the vagina. That was the beginning. You’d ask women, what surgery did you have? And they would reply, ‘Oh, I was told it was just a little tape or a ribbon.’”

Elneil says the patients that she saw had not been listened to, and their surgeons had been blind to the efficacy of the device, partly owing to the massive commercial push for mesh products. “These surgeons didn’t explain the possible complications. It was all about: ‘I’m telling you this is the right thing for you.’ They were almost 100% men.” She adds, “I also think there was a lack of understanding of how women work; that the vagina isn’t just a piece of skin. The justification was that mesh was fine for hernias. But you’re putting a piece of immobile plastic in a mobile tissue—a vagina, bladder, rectum that moves—so how is it not going to wear and tear?”

Financial incentive

Surgery that involves any form of implant operates in a huge field of commercialisation, Elneil says. “If you find one simple product that you can implant in a patient with a very common problem, you are talking serious money,” she explains. “With mesh, it started with two or three companies. And then several device companies created a version of it, cutting products in different shapes and sizes.”

As the use of mesh became mainstream, the pressure to conform was felt even in the operating theatre. Elneil recalls being pressured by a sales representative in her own operating theatre in 2006. “This representative used to just show up in my theatre and demand to know why I wasn’t putting in mesh, and why not her brand. I was at a major London teaching hospital. I could put my foot down, but it made me question whether I was doing something wrong—that’s how she made me feel.”

Other doctors, Elneil says, were offered financial incentives. “For example, they would say, ‘I'll take you on a trip to America, and we can go to show you this doctor in Denver.’ And people fell for that.”

Listening to women

Early on in her career, Elneil noticed how women were often ignored in clinical settings. Her experience of this, when working with patients with fistulas and female genital mutilation in Africa, led her to intervene on behalf of women left with chronic pain after mesh surgery. “Fistula is the worst form of traumatic childbirth outcome,” Elneil says. “It goes back to really poor obstetric care, a lack of antenatal support, and a lack of help at the very beginning of the whole journey. These women never had good care. The impact on me was phenomenal.”

Elneil also noticed that surgical trainees she met at that time had very little respect for the women they were treating. “They didn’t ask the women, ‘What do you want?’ They didn’t say, ‘How could we help?’ There was no explanation, no discussion.”

Many decades later, she gave evidence to the Cumberlege review, the scope of which included the harms of vaginal mesh, and the final recommendations of which included establishing mesh removal centres in the NHS.1 “The centre I built in London was based on the women’s vision; they wanted psychological input, they wanted physiotherapy support, they wanted options because some wanted all of the mesh removed, some of them didn’t want it removed at all, they just wanted to be monitored. We devised a really complex plan of action.”

Overhauling the specialty

On reflection, Elneil thinks that the field of urogynaecology needs to be healed in the wake of a scandal she says is similar to the one uncovered by the infected blood inquiry. The use of mesh needs to be re-evaluated, and women’s health needs an overhaul, she adds.

“The [Royal College of Obstetricians and Gynaecologists] is too safe as an institution, and it needs to rethink how it approaches women’s health; it needs an overhaul. There is a tendency not to take the bull by the horns. But you need to speak openly so you can deal with it. This is about politics with both a small and a big p,” she says.

“I feel very sorry that in obstetrics and gynaecology where we are serving the health of women, there is still a lack of understanding about what women want. More of us who work directly with women need to be at the table, as do the women themselves.”