The menopause can be a mysterious time, although the mechanism is easily enough defined: the cessation of menses because of the lack of estrogen production by the ovary. The concept may be simple, but the ramifications and folklore that surround it less so. It has always worn its myths like a hood, obscuring the face beneath, confusing the experience like shadows on a rainy day.
Descriptions are legion, but ultimately unhelpful in dissipating the fog the definition drags with it: hot flushes, sleep disorders, irritability, worries about cognition and memory, regrets about the loss of fertility, and concerns about sexual function and desires… And although some symptoms may cross the gender divide, many -if not most- are unique to women. Unique to ovaries.
And the response to the change can be unique as well.
I hadn’t seen Elizabeth for a long time –in fact I couldn’t remember ever seeing her. Memory deficits are not the sole prerogative of the estrogen deficient –although in fairness, when I tried to look it up, it must been well over ten years since her last visit because the chart had been destroyed. The legal limit that we are required to keep records had obviously been exceeded.
She treated it as if it had only been a month or two, and greeted me with a smile usually reserved for someone who is supposed to go over some frequently-repeated test results. Someone she’d seen in the mall last week, and at a restaurant the week before. But there was a hint of suspicion in her smile.
“Elizabeth,” I said, extending my hand when I greeted her in the waiting room. “Nice to see you again,” I continued as I led her down the corridor to my office. She looked at me politely and sat down in a chair by the window across from my desk, perhaps waiting for me to reminisce.
The referral letter said only that I had seen her before and that she seemed angry about something. She was 55 years old, was on no medications, and she had some questions about the menopause. “So, what can I do for you, Elizabeth?” A rather predictable opening, I suppose, but it didn’t commit me to anything –in other words it didn’t disclose the fact that I couldn’t remember a thing about her.
She probed me with her eyes for a moment, suspecting, I think, that I didn’t recognize her. But if she was disappointed, she didn’t betray it with her face. The ghost of a smile reappeared, and her eyes relaxed enough to twinkle through her glasses.
She didn’t look the merry type, I decided. Her hair was greying and pulled back tightly in a bun. Her outfit was severe: a black, loosely hanging dress that covered her ankles but not her jewelleryless arms. She was a thin, tall woman and sat as straight as a pole in the chair, her white skin even more pallid where it met the dress.
“How will I know when I’m in the menopause?” she said suddenly, as I glanced at the computer screen searching for more clues.
I met her eyes half way, and smiled reassuringly. I hadn’t had a chance to take a history, so I had to be careful with my answer. “Well, in many women, the symptoms can be very subtle, but generally speaking, the usual tip-off is an irregularity of menstruation and eventually its cessation. And, of course, there are often hot flushes, irritability and…
Her face turned smug and her smile condescending. “But I haven’t had a period for years, doctor…” She sat back in the chair and regarded me with some ill-disguised amusement. I must have looked confused, because she sighed both audibly as well as visually –performance art. “You took my uterus out fifteen years ago…”
I did my best to retain a modicum of Aequanimitas: I tried not to blush.
“Big fibroids,” she continued, to add to my discomfort. “You said one of them was the size of a basketball… I thought you’d remember.” I was blushing now, and about to apologize, so she backed off. “It has been a long time, I suppose.”
I attempted a smile, but I think it came out as rather forced and weak. I decided I’d better take a more detailed history before I addressed her concerns. “I’m sorry, but unfortunately I no longer have your records so I’m going to have to ask you a few questions… First, are you having any symptoms of the menopause?”
She frowned a look of concern unrolled onto her face. “Why don’t you have my records? You did my surgery…” Her eyes suddenly tied me to my seat. “Suppose I developed complications?”
I started to feel defensive. “The law requires us to keep the files for only 10 years unless there is an ongoing attendance,” I said, rounding off the numbers for her. “I haven’t seen you for longer than that, and you haven’t declared any complications in that fifteen years that I know of…”
She lengthened herself to the full length of her spine and glared at me. “My complication may be the menopause, doctor!”
I tried to stay neutral. Professional. “I’m sorry, Elizabeth, why do you think that?”
Her face crinkled into a little wrinkled ball, like a piece of paper someone had crumpled before throwing it away. “You took my uterus out!” She almost spit the words at me, as if I should have known that was the problem.
I sighed in an unsuccessful attempt to duplicate her previous performance. “Did I remove your ovaries as well?” At forty, I wouldn’t have.
She stared at me wordlessly for a moment. “You did a total hysterectomy you said, doctor.” She said the last word as an insult, not as a descriptive, or an honorific title.
I smiled and realized she had not really understood what I had done. “A total hysterectomy merely refers to the act of removal of the whole uterus –the total uterus. A partial hysterectomy, on the other hand, means I’ve only taken part of it out –left the cervix, usually…” Her expression didn’t change. “I wouldn’t have taken your ovaries out at that age, because… Well, first of all because they would still have been working and producing hormones, and secondly there would have been no need to do so.”
I hoped that would mollify her, but if anything, her face crinkled into an even smaller bun. Then why haven’t I had any hot flushes, or irritability?” She could see one of my eyebrows start to raise –it’s really hard to control that- and hissed audibly at me. I think it was a hiss, but maybe she was just breathing through her teeth.
I tried to relax my expression –a Mindfulness technique. “Whether or not your uterus is present, the ovaries don’t last forever. They eventually stop producing hormones.” I realized I shouldn’t have used the word ‘last’ as soon as I said it; it just sort of slipped out.
She shook her head slowly in her anger. “You men are so insensitive about the ovaries! You just don’t know what they mean to us, do you?” I suppose it was a rhetorical question, because she continued the rant without stopping for a reply. “And I’m surprised to hear that attitude from a doctor!” She stopped talking for a moment and looked at me. “You weren’t like that back then…” The scowl returned. “And to tell you the truth, doctor, I don’t remember you like this at all…” She glanced around the office. “Not even the office.”
I was about to say something reassuring to her –like that I’d probably changed a few things in here over the years- when she suddenly stood up and wrinkled her nose. It was hard to spot in her overall expression, but I noticed it immediately. Her eyes closed briefly as if she could somehow block out everything that she didn’t like about where she found herself. And then, gathering herself up to her full six foot height, she thanked me for my time and stomped out.
You know, I still can’t remember operating on her… and I don’t think she does, either.