Fibroids

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…

The Stand

“So, do you have a stand on that, then?” She was smartly dressed in jeans and what looked to be an expensive white silk blouse and divided her eyes between my face and a little notebook in her lap. Whenever I said something she liked, she would scribble furiously and noisily in it. Otherwise it was silent -a non-attributable form of media manipulation? The noise amused me more than anything.

“I thought we’d already established that I like to hear what the patient is saying and then try to diagnose…” -I thought I’d sprinkle a few medical terms at her- “… what it is that she is trying to tell me.” I stared at her silent notebook and then added: “There’s more to conversation than words.” Her face took on the look of a dog that hears a noise it can’t locate. I could tell I was losing her. “You know: tone of voice, cadence of speech, body language…”

Her expression softened, and there were a few cursory scratches of pencil on paper. “A bit wish-washy. I’m trying to get at what you actually believe.” She said the word as if there were discrepancies in my answers so far.

“I believe…” –I thought I’d italicize the word as well- “…that it’s important to understand what my patient believes -read between her lines, if you will.”

“Her lines?”

Well, that metaphor was lost on her. “The lines, then.” Silence: pen gripped tightly but motionless, eyes fixed, breath held. More was expected: an addendum. “I mean that sometimes a person says one thing , but actually means something else that they’re afraid to say… Or maybe haven’t really decided what they think.”

Her brow crinkled -rather cute,  I thought. “But you’re the doctor! Wouldn’t you have an opinion on what she was telling you?”

I took a deep breath but tried to disguise it in case that would somehow get translated into pencil scratches. “If I knew what she was telling me, I suppose it might help me to direct my subsequent questions more appropriately…”

“But,” she interrupted, pencil at the ready, “let’s say the woman has already come in to see you with… a situation…” I suspect she thought she was being sensitive with that choice of words. Politically neutral. “Wouldn’t that in itself give you the information you need?”

I shifted into my bland I’m-not-sure-what-you-mean mode that I often find helpful in the office. “Information, yes; solution, no.”

“But…”

I’m still not sure why I had agree to be interviewed. Not really. Superficially I suppose it was because one of my colleagues was doing abortions and had a recent complication with the procedure -through no fault of his own, I might add. The woman had tried to self-induce a termination of her pregnancy, failed, become seriously infected, and then sought medical help from my colleague. He performed his job admirably and saved her life through his own skill and knowledge, but someone had leaked the ‘complication’ to the press and the whole event had been misconstrued. So perhaps I’d wanted to set things straight. But that’s not what this journalist saw as her mission. I suspect she actually wanted to know the opinion of a gynaecologist who worked in an ostensibly Catholic hospital.

I’d tried to dissuade her from that approach at the start, but to no avail. Now I was becoming a little annoyed at her persistence. But if the truth be recognized, it was her agenda that bothered me the most. I put on my best doctor smile and sat back in my chair. “Perhaps it might be a good time for you to be more specific. What is the question that you are leading up to?” Somewhere inside I blushed at my ending the sentence with a preposition and wondered if that might be one of the few sentences that she would quote in her article.

She gripped the pencil tightly; I could see the bones in her hand standing at attention just under her skin. “Doctor, you work at a Catholic hospital, do you not?” I nodded, but it was one of her conditions for the interview in the first place. “What do you think of abortions, then?”

My smile continued without interruption. I knew that was what she wanted, and had expected it at the beginning. And yet the question, at least for me, was irrelevant: where I work does not determine what I think. And what I think does not interfere with how I manage a patient with a problem. The journalist was staring at me, pencil poised, a subsequent question rolling around in her mouth just waiting for my answer. “Would you care to contextualize that?” I said, knowing full well she would have no idea what I meant.

“Pardon me?”

I crossed my arms and leaned forward on the desk that I had been careful to sit behind at the start of the interview. “You asked me what I thought of abortion. You might as well have asked me what I thought of fibroids…”

“I… I don’t see…”

“No, you don’t do you? Well let me put things into context for you, then. Abortions? I wish they were unnecessary. But then I also wish that people only became pregnant when they chose. And if they chose. In life, things happen, and not always for the best. I don’t much approve of smoking either, but that doesn’t mean that if a person were to become ill because they smoked I wouldn’t try my best to help them. Or in my own field, if they were to develop chlamydia or gonorrhea that I wouldn’t help them because they hadn’t used a condom, or maybe adhered to my own person moral preferences.

“Am I an ethical relativist? You might better ask me if I am a doctor. If you were to walk through that door looking for help, my first question would not be whether we had the same belief systems or the same cultural norms. No, it would be what can I do to help you? In other words, how are you suffering? And if I asked you about your sexual practices, or preferences it would not be to criticize, but to help in the diagnosis and treatment of the condition for which you had sought my help.”

“Are you Pro-Choice then?” I could see the words forming on her lips before she uttered them.

“We all have choices and I respect that. It’s not for me to interfere; I am not the person who has to make them. But I prefer to think of myself as Pro-Help… Perhaps I am the sounding board that helps you to make the Choice for yourself.”

With that she tucked her pencil and the notebook in a little shoulder bag and stood up. She sighed deeply and demonstrably. I had wasted fifteen or twenty minutes of her time. Now she was going to have to find another doctor to interview, I supposed. I stood up and extended my hand to shake, but she took it somewhat reluctantly, I think. “I’m sorry you decided not to commit yourself, doctor.”

I’m assuming it was a subtle put-down, but I allowed my smile to dance a moment longer on my face until I tucked it carefully away. “Actually, I think I did,” I said, and ushered her out of the room.