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Authors: Natalie Angier

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subject, some attacking the so-called hysterectomy industry, others offering practical, gal-heart to gal-heart advice for women who are contemplating the procedure. The issue sets off a brushfire of fury not quite as much as abortion, perhaps; nobody's calling anybody murderer, or holding up bloody pictures of excavated uteri, but people cry and pronounce and trade spitballs over it all the same. If you look into the issue in detail, you'll probably conclude, as I did, that surprise it isn't amenable to glib synopsis. There is no blanket solution, no simple explanation for why such a major operation is so routine. It would be nice to have one sovereign demon to heap blame on, one wicked Dr. Yes who hates women and wants to disembowel them all, but no such monster can be found, not under rock or bog, not in the codices of patriarchy, not wrapped around the caduceus of mainstream medicine.
Part of the explanation for the frequency of hysterectomies lies with the organ itself. As we have noted, the uterus is extraordinarily labile. It expands to comical dimensions during pregnancy. Its lining thickens and thins hundreds of times in a lifetime. As a result, it can end up a garden for aberrant formations turnipy fibroids, mushroom-stemmed polyps, adhesions, windblown fragments of endometrium. Nobody knows what causes fibroids or why so many women have them. Diet may play a minor role. Our diets are too high in fat, and fat stimulates excess estrogen output, and estrogen helps make fibroids grow. But even lean, healthy vegetarians get fibroids, so fat takes us only so far. Some women are genetically predisposed to them. Fibroids run in families, and black women are more susceptible to them than women of other races are. Maybe estrogen-like chemicals in the environment are partly to blame. Whatever the reasons, the uterus is prone to local disturbances, and that is a fact rather than a conspiracy. Moreover, for a large number of women, menstrual bleeding gets considerably heavier in the forties, either because of the presence of fibroids or because of hormonal fluctuations preceding menopause. The midlife uterus runs off at the mouth, and that too is a fact.
How we respond to disturbances and changes in the body's status quo is another, far more subjective matter. Few women who start to bleed heavily in their forties after twenty-five years of moderate periods are aware that many of their peers are navigating the same floodwaters and that heavy bleeding in the premenopausal years is in fact normal.

 

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Instead the woman thinks, This is disgusting, I'm hemorrhaging, I'll turn anemic, there must be something wrong, help! And she seeks help from a gynecologist and so exposes herself to the medical customs and opinions prevailing in her region. If she lives in a hip, eggheaded city where doctors, because of personal conviction or fear of lawsuits, steer away from heavy-handed procedures, she may be told, Wait it out, eat liver and iron pills, this too shall pass. If she lives in a small midwestern town as yet unruffled by activist winds, she may, in that initial doctor visit, be taking her first step toward total uterine eradication. Doctors are creatures of habit, and hysterectomies are a hoary surgeon's habit. They are simple to perform, and they are the surest cure for excess uterine bleeding. "For the people who do these things, it's a nice, comfortable way of life," says Ivan Strausz, the author of the book
You Don't Need a Hysterectomy
and a New York gynecologist of the scalpels-off persuasion. "The gynecologists are not always intellectually motivated to do the right thing. They go along and do what they've been doing all along."
In truth, any time a woman visits a doctor she risks intervention. Which brings us to the intriguing question of why European women have far fewer hysterectomies than Americans do. The issue has not been studied systematically. Some give it a sociocultural spin, pinning it to divergent attitudes toward aging. For Americans, the designation of our continent as the New World is less a detail of history than a directive in perpetuity, and even baby boomers, for all their numerical clout, have done little to improve the image of the non-new beyond making plastic surgery more socially acceptable. Catherine Deneuve, the great beauty whose face has probably sold more bottles of perfume than that of any other woman in history, said to an interviewer that it was hard getting old in any country, but unbearable in the United States. If a middle-aged woman in America is thought to be washed up and vaguely embarrassing, we can't expect that much respect will be accorded to any of her individual, overripe parts.
Maybe but there's a more interesting possibility. Nora Coffey, the founder of the organization Hysterectomy Education Resource Services, or HERS, who is among the most zealous opponents of hysterectomies, suggested to me that European women keep their organs by keeping to themselves. Quite simply, they don't visit the doctor as often as we

 

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do. They reserve the delightful experience for times of real illness. We Americans patronize the health-care profession even when we're healthy. It's part of our chirpy wellness mindset. Women in particular are habituated to regular doctor visits, through the sacred annual gynecological checkup. We go in for a Pap smear, and we go in for a pelvic palpation: everything still in there? We think of this as wise preventive medicine, but doctors can't help themselves. They look for blemishes and portents. They seek the anomalous. And when they find a deviance from the norm, whatever the norm may be, of course they must tell the patient about it. They may counsel no action for the nonce beyond watchful waiting, but it's too late: the egg of worry has hatched. Now the woman will wonder, Is it getting worse? Could it be the reason that I'm feeling fatigued, crampy, not quite divine?
I can vouch for the insidious power of anomaly revealed. During one of my prenatal sonograms, which were being done to scan my fetus for any deviances she had to offer, I was told, You have fibroids.
The primal fear response set in; all systems seized. Is that a problem? I asked. Are they big? Can they harm the baby? Can they cause a miscarriage?
Oh, no, no, no, the sonographers assured me. There are just two, and they're small, maybe a couple of centimeters long. They're in the wall of the uterus.
Oh, I said. So what am I supposed to do?
Nothing, they replied. We just thought you should know. They may grow during pregnancy, or they may not. They may grow afterward, or they may not.
And if they do?
You may feel them. They may hurt. Or they may not. No need to worry. We just thought you should know.
So now I know I have fibroids. So now whenever I feel a twinge in my lower abdomen, the uh-oh routine growls in my head. They're getting bigger! They're taking over! I think of Hope Phillips's ropy purple fibroid, dwarfing the uterus in which it sprouted. I think of the largest fibroid on record, a mass that weighed 143 pounds when it was removed from a woman in 1888. Not surprisingly, the woman died soon after surgery. My fears are never enough to send me out for a fibroid audit, though. I'm better than a European; I'm the daughter of a Christian

 

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Scientist. Years after my father abandoned the church, he retained its distaste for doctors, and I absorbed his phobia. (I won't promote the Angier philosophy too exuberantly, though. When a suspicious mole first appeared on my father's back, he refused to see a doctor until it had grown to the size of a silver dollar, at which point it was diagnosed as malignant melanoma and removed but too late. A cancer that is eminently curable in its early stages instead had the chance to spread to my father's brain. He died of the metastasis at the age of fifty-one.)
In fact, it's possible that our sisters overseas do not have it right after all. Dr. Joanna M. Cain, of the Pennsylvania State University Medical School, has suggested that more women in Europe might choose to have a hysterectomy if the option were made available to them. Could it be that Europe's rate of the surgery is too low, rather than that ours is too high? It's easy to denounce hysterectomies, she says, and to bewail their frequency, and to argue that women are being misled by hidebound, greedy surgeons. But is it not an insult to women to assume naiveté and gullibility? If a woman spends years in pain and discomfort, sick and bleeding and consumed with the six inches of body between bellybutton and crotch, says Cain, who is she or anybody else to counsel, Oh, no, you mustn't have a hysterectomy. Under no circumstances should you have a hysterectomy. "We don't validate women's pain enough," Cain says. "We underestimate pain, we belittle it, and we undertreat it."
Women get tired of being harangued. I spoke with many intelligent women who had done their homework. They were assiduous and enlightened medical consumers who read everything they could find on hysterectomies. They knew their options, and most had tried other procedures before settling on a hysterectomy. The one thing they resented was the self-righteousness of the wards of the womb. They complained about being made to feel weak and ashamed for their decision. They argued that anti-hysterectomy fever is another example of reductionism and idolatry, of defining a woman by her high holy uterus. It is rank paternalism, they said, the worse for coming from sororal mouths. If a person had an appendectomy, they said, would she be chastised for failure to respect her appendix?
Many of the women said they felt better than ever after a hysterectomy. They felt lighter, freer the uterus had kept them in chains, and now at last they could wander. Now they hoped to help keep others

 

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from going through the prolonged misery that they suffered. They wanted to remove the stigma of the surgery. Again and again in the course of my reporting I heard variations on the line "The one thing I'm sorry about is that I didn't do it sooner!"
We come back to the matter of choices, wonderful choices. Isn't it grand to live in a world that promotes "choices"? A woman should be allowed to choose a hysterectomy without being made to feel guilty or diminished. That is easy to say and to advocate. At the same time, a choice has meaning only if it is freely and knowingly embraced, with all the risks, benefits, and alternatives honestly arrayed before the chooser. Such a state of enlightenment is difficult for anybody to achieve, and we are talking about the necessity of its being achieved half a million times a year. For example, let's return to the matter of fibroids. Doctors in big, hip cities generally will assure a woman with asymptomatic fibroids that nothing needs to be done, everybody has them, the growths recede with menopause, and so on, all of which is true. But if the woman is passing such large clots of bloody tissue that she is becoming ill, or if she is in terrible pain, then the fibroids must be treated, at which point even the most urbane doctors can give bum advice. A woman who still plans to bear children is counseled to have a myomectomy, the removal of the fibroids alone. But for the woman who is past having or desiring progeny, the myomectomy option is presented in terms so dire it might as well be plastered with a skull and crossbones. The woman is told that a myomectomy is much riskier and bloodier than a hysterectomy, with a higher rate of postsurgical complications and infections. I interviewed dozens of women in their forties and early fifties who sought help for their fibroids and were told hysterectomy, period. When they asked about a myomectomy, their doctors argued against it. But is a myomectomy really as bloody and dangerous as it's portrayed? In many cases, the fibroids that give a woman difficulty can be removed hysteroscopically, through a tube like a periscope that is threaded up the vagina and into the uterus. The doctor inserts a tool into the hysteroscope and then shells out the offending tumors, chipping away at them until only their husks remain. This sort of hysteroscopic myomectomy can be done in an office and does not even count as true surgery, let alone as a bloody horror show. Yet few women hear of the option, one reason being that it requires a skillfulness not all gynecologists command. If your doctor

 

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has no experience with hysteroscopic myomectomies, find one who does; the procedure is the best first-line attack against symptomatic fibroids.
Even when the fibroids are inaccessible to hysteroscopic scoop-out, they can be removed abdominally, by opening the uterus, cutting out the fibroids, and sewing the uterus back up again. Now we're talking about major surgery, but if you research the medical literature, you'll find that abdominal myomectomies compare favorably with hysterectomies in factors such as blood loss, postsurgical complications and infections, and healing time. I observed an abdominal myomectomy performed at Bryn Mawr Hospital by Dr. Michael Toaff, who specializes in the procedure, and it was surprisingly clean. The woman sacrificed perhaps twenty or thirty cubic centimeters of blood, no more than she would have for a few routine blood tests. She, as well as many others I talked with who had similar operations, recovered in a couple of weeks and felt exhilarated, liberated, resuscitated from the dead just the way women say they feel after a hysterectomy.
Ah, but doctors can always retort, You may be fine for now, but remember,
fibroids grow back
. Then what will you do, Lady Womb-Keeper? Have another myomectomy? Or accept the hysterectomy at last? In fact, while it's true that a woman who has fibroids is prone to fibroids, the great majority of the tumors will give no trouble at all, so that even if a new fibroid does appear in the wake of a myomectomy, it will likely be meaningless, the way most fibroids are. Just because one fibroid caused you misery doesn't mean your next one will. Nonetheless, accepted verities are hard to shatter, and the purported dangers and futility of a myomectomy continue to influence physicians' attitudes and thus the advice they give to their patients. Yes, women should have "choices," including a hysterectomy, but it's hard to choose wisely when the best items on the menu have been edited out beforehand.
To assert our choices freely, we need stronger tongues for ourselves, of course, to proclaim what we must about our bodies and our desires, but also for our doctors, so they can hold those tongues in check rather than say thoughtless, callous things. For better or worse, we often feel meek when we visit doctors. They are like our parents, and they can hurt us too easily. Doctors should never tell patients that they are beyond needing a uterus, that the uterus is "just a sack, whaddya want it

 

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