I sometimes prefer to call them leiomyomas -it’s more descriptive of a condition that involves muscle cells- or even fibromas. I said this by way of beginning an explanation to a patient who was sent to me for them; she looked at me as if I had just sworn at her -belittled her condition. I hadn’t meant to…
“Hiding behind medical words, doc?” she said, unsuccessfully attempting a smile.
I suppose I was. Her mother had endured a hysterectomy for fibroids, her sister had developed them and was booked for surgery, and a recent ultrasound had discovered several 3-4 cm. nodules in her own uterus. Now I was trying to fool her with new words: a different type of fibroid that maybe you didn’t have to remove. She’d looked them up, and talked with her family, and now was convinced that hers needed fixing too.
Not too long ago, that’s what you did with fibroids: you either removed the fibroids, or the organ that carried them. Period. They were clearly abnormal and shouldn’t be there in the first place. They pushed on things inside the abdomen, could grow really large -and, oh yes, they made you bleed. No, hemorrhage! End of story. And besides, for Marlene, it was a family tradition, a rite of passage into the next phase of womanhood: after the kids, the hysterectomy.
She seemed disappointed when I told her they were quite small, and that their location made it unlikely that they were contributing significantly to her heavy periods.
“Then why are my periods all over the map and heavy like this? When I was younger, they hardly showed.”
I tried to put fibroids into some perspective for her. “Well, first of all, fibroids are really very common. Up to 30% of caucasian women at thirty years of age have fibroids. That’s how I remember it,” I said, smiling, and dotted my pen on a diagram of a uterus I keep on my desk to illustrate the size they might be at that age. “And in some populations, genetics probably plays a big role and the figure might be as high as 50%.” She became all eyes.
“Fibroids are usually very sensitive to estrogen and so they tend to grow more rapidly in a woman’s mid to late forties when they get a lot of unopposed estrogen -estrogen that’s not being opposed by progesterone…” I could see I was losing her. “You’re what..?” I snuck a look at the chart. “Forty-eight?”
Her brow wrinkled. “Forty seven, doc.”
“Well, when you were twenty-seven, you probably ovulated each month and then your ovary would produce progesterone and…”
Her hands slipped onto the desk in front of her and she leaned over it and stared at me. “Doc, I’m not here to talk about what my ovary does or used to do. I’m here to talk about what my fibroids are doing now!”
She had a point.
“And more particularly, what you are going to do about my fibroids!”
“Well, I don’t think that…”
“My sister’s fibroids are small, too and she’s getting them out.” She sat back for a moment, convinced she’d scored a point. “She’s two years older than me and she’s got six.” Her face took on the determined look of someone dealing with a small child. “How many have I got?”
I looked at the ultrasound report her family doctor had sent along with the consultation request. “It just says ‘multiple fibroids, the largest of which is three centimetres in diameter. They all appear to be intramural in position with no submucosal component.’ They usually only describe the biggest ones, because sometimes the others are too numerous to count.”
Her expression showed some interest. “Sub what?”
I showed her on the diagram that a submucosal fibroid juts into the lining cells of the uterine cavity. “They tend to be more of a cause for heavy periods than the ones that are growing in the middle of the muscle of the wall: that’s probably because they create an increased surface area where more endometrial cells can grow.” It seemed a good argument to me. “So your fibroids are small and not sticking into the uterine cavity.” I drew what I hoped was a convincing fibroid in the muscle wall, careful to keep it a decent distance from the lining cells in case she wanted to argue about surface areas.
“But I got a lot of ’em doc,” she said, almost proudly. “My sister only has six and she’s getting a hysterectomy.”
“Well,” I said, stalling for time -I could see the writing on the wall already. “There are other things we can do for fibroids…”
Her arms suddenly appeared across her chest as she pretended to listen politely. It was what you had to do at a doctor’s office sometimes. “Like what?” she said with her mouth, while her eyes dared me to find something acceptable to her and her family.
“Like embolization: cutting off the blood supply to the fibroids so they shrink down by about…”
But she was shaking her head vehemently. “Doesn’t sound natural!”
“Well, if we could get you to menopause without surgery that would be really natural -given that you have no symptoms except a recent onset of heavy periods, and there are…”
“No symptoms? What would you know about symptoms, doc?” she said, giving what she could see of me above the desk a critical once-over and rising to her feet. “I can see I’m wasting my time here,” she muttered, gathering up her belongings from where she had scattered them on the floor beside her chair. “I knew I shoulda gone to a woman!”
“Marlene,” I said to her back as I rose to see her to the door. “I was merely suggesting that there are options with fibroids; they don’t all have to end up being removed.”
She turned to face me, and I could see the muscles of her jaw twitching. I had obviously crossed some sort of threshold. “Doctor,” she said coldly, “Despite your age, you still haven’t learned when options are needed, and when they’re…” She paused to consider the word. “…Unnecessary and insulting. If I’d wanted a choice, I would have asked you!” And with that, she turned and walked out.
I’ve thought about this a lot and I’m still not certain whether she was right. For a choice to be truly that, shouldn’t it be made from a list of things that might also work -an informed choice, in other words? Wouldn’t it be irresponsible of me as a doctor merely to accede to the initial wishes without explaining what else is available?
It would be easier, I’ll admit, but I doubt if I could sleep at night…