By Stefanie Weiss
Special to The Washington Post
Tuesday, October 2, 2007
In my dream, I'm Sigourney Weaver in "Alien" -- tough, brassy and fit, fighting a hideous extraterrestrial parasite that could invade my body and burst from my midsection at any moment. In real life, I'm a 49-year-old nonprofit employee, semi-tough, semi-brassy and semi-fit, fighting a humongous uterine fibroid, fearful of having my mother's hysterectomy, and full of creeping doubts about the entire gyno-industrial complex.
It all started years ago with one small and harmless fibroid, or benign tumor, discovered during a regular exam. "Lots of women have fibroids," often the size of grapes, my gynecologist assured me. "Yours is the size of a plum -- no big deal. We'll just watch it over time."
I should have known that anything ending in "roid" -- asteroid, hemorrhoid, fibroid -- wasn't going to be good, but I was prepared to make the best of it. I'd learned to ignore the fruits of my womb (one surly teenage boy); I could learn to ignore a piece of fruit in my womb.
Except that the plum, over time, grew into an orange, then a grapefruit, a cantaloupe, and eventually, a honeydew melon. Last year, my gynecologist took off the (latex) gloves. "Your uterus is now the size of a 16-week pregnancy," she said. "It's time for a hysterectomy."
Words ending in "ectomy" aren't good, either. Thirty years ago, my mother had a hysterectomy for nasty fibroids. She got the full treatment: a six-inch abdominal incision, narcotics for the pain, hormones for the menopause that surgeons induced by taking her ovaries out at the same time, a four-day hospital stay and an arduous eight-week recovery.
"Isn't there some easier way?" I asked my doctor.
"Not for fibroids as large as yours," she answered.
It turns out she was wrong. I did some research, got a second opinion and let a year pass. When I could no longer lie on my stomach without feeling like a seal balancing on a rock, I had a supracervical laparoscopic hysterectomy. A surgeon removed my uterus -- then the size of a 20-week pregnancy -- through a quarter-inch hole near my belly button, leaving my ovaries and cervix intact.
I stayed in the hospital one night and felt crummy and uncomfortable for a weekend. After that I felt great -- no pain, no pills (not even aspirin), no stitches that had to come out, no bleeding or itching, no problems walking, climbing stairs, eating, sleeping or eliminating. At the two-week mark, I was back to work full time and easing back into my exercise routine.
Women have been passing basketball-size babies through very small holes for a long time, and, as it turns out, gynecologists have been doing minimally invasive hysterectomies for more than 15 years. But the operations haven't exactly caught on.
In 2004, according to the American College of Obstetricians and Gynecologists, 617,000 American women had hysterectomies. Three-fourths of them were done the old-fashioned way, through large abdominal incisions like my mom's. Only a quarter were done in minimally invasive ways -- either through a vaginal incision (look, ma, no scar!), via laparoscopy, like mine, or in a procedure that combines the two.
Got a gallbladder or an appendix that needs to come out? A knee that needs a tuneup? It's all laparoscopic these days. But if your uterus is on the chopping block, you're not likely to be on the cutting edge, at least when it comes to surgical options.Incentive Lacking
What's going on here? First of all, fellow feminists, put down your copies of "Our Bodies, Ourselves." It's not sexism. I spoke with five experienced gynecologic surgeons from across the country, and here's what I found.
Removing large parts through small holes isn't easy. John George, director of gynecologic endoscopy at Washington Hospital Center, did my three-hour laparoscopic hysterectomy. He's been doing the procedure since 1991 and explained it to me.
Simply speaking, George starts by inserting a telescope through the belly button or, in the case of large uteri like mine, just above it. A camera attached to the telescope projects the image of the internal organs onto a TV monitor.
George inserts other tools (the ones that cut, burn and shred) through two or three other tiny holes. Gas is blown into the body cavity to expand the area and allow the surgeon some room to maneuver.
Seeing what the camera sees on a monitor, George cuts the uterus away from its blood supply and its tethers until it's just floating in there, connected to nothing. Then he inserts a cylindrical morcellator -- something like a miniature circular saw with a very sharp, rotating blade at the tip. The blade cuts the uterus into long strips. Then George uses a pincer to pull them out.
The challenges of any hysterectomy are to avoid nicking the bladder or bowel, to minimize bleeding and to do the surgery quickly to minimize the time the patient is under anesthesia. Doing it laparoscopically means doing it with no hands inside the patient and no eye directly on the ball, so to speak.
George is low-key, even humble -- rare for a surgeon, I know -- but when pushed, he acknowledged that the procedure "takes a tremendous amount of skill and experience and confidence."
Too often, explained Stephen Young, president of the Society of Gynecologic Surgeons, "residents don't have enough time or cases to learn how to be comfortable doing advanced laparoscopic surgery."
Once out of school, most OB-GYNs, Young said, deliver babies, treat infections and handle a few hysterectomies a month or a year. To get comfortable with laparoscopic techniques, they would need to work with more-experienced surgeons who can mentor them, then do more procedures themselves.
In addition, most insurance companies pay doctors the same fee for any hysterectomy, regardless of the type of incision, so there's little economic incentive to invest the time in learning a new and difficult technique.
The Toyota dealer isn't going to tell you about the Kia, and doctors may not tell you about minimally invasive hysterectomies if they don't do them. I made a real pest of myself, calling my gynecologist several times, asking repeatedly for more options.
"I saw a study that says size of uterus isn't necessarily a reason to avoid a laparoscopic procedure," I said.
"But I don't do that kind of procedure," she replied.
"Yes, but isn't there anyone who does?"
"Yes, but most of them aren't really good at it yet."
"Okay, but is there one person in the entire Washington area who might actually be good at it?" I asked. That's when she told me about John George.Exaggerated Risk
Most gynecologists who don't do minimally invasive surgeries tell patients that " 'in my hands, the best procedure is an abdominal hysterectomy.' And that's true," explained Franklin Loffler, associate clinical professor of OB-GYN at the University of Arizona. "If they're not comfortable doing another procedure, it's not the best."
When it's time for a hysterectomy, say some experts, too many women don't go shopping. "If your family doctor told you that you have colon cancer, you are going to look for the best colorectal surgeon," said Lauren Streicher, assistant professor of OB-GYN at Northwestern University Hospital and author of "The Essential Guide to Hysterectomy."
But women usually feel comfortable with the gynecologist they've seen for years and guilty about looking around for another surgeon. "It's an established relationship, almost like a family doctor," Streicher said.
Old myths -- including the one about minimally invasive surgery being excessively risky -- die hard. Research shows that, in experienced hands, the risk of minimally invasive procedures is the same as or less than the risk of abdominal hysterectomy, Streicher said. The key, the experts I spoke with agreed, is to get several opinions and to ask a lot of questions. Then, if you decide less-invasive surgery is right for you, find a surgeon who has done hundreds of procedures.
Some hysterectomies, particularly where uterine cancer or severe endometrial scarring is involved, may always require abdominal incisions. But George says that 80 percent of the hysterectomies now done abdominally could be done laparoscopically.
"Ninety percent of the second opinions I see have been told that they are not candidates for laparoscopy, and I say they are," Streicher said. "The only one who can tell you if you are a candidate [for a particular procedure] is a doctor who does it."
A final note: Beware unrealistic expectations on the cosmetic front. I got rid of a melon and expected to drop 10 pounds and a pants size. Oh, well. Even my gigantic uterus weighed only a little over two pounds. (A normal uterus weighs just four or five ounces.) My pants fit a little better, not that most folks would notice.
Then again, before the surgery, most folks didn't ask me if I was pregnant.
"You didn't look pregnant," my sister assured me. "You just looked 49 years old."
My husband was too smart to comment.
Stefanie Weiss has written many stories on midlife health issues for Health. Comments:firstname.lastname@example.org.More Info About Hysterectomy
* "The Essential Guide to Hysterectomy," by Lauren F. Streicher (M. Evans and Co., 2004)
* Hysterectomy Resource Center, http://www.obgyn.net
* National Women's Health Information Center, http://www.womenshealth.gov
* National Women's Health Research Center, http://www.healthywomen.org
* National Uterine Fibroids Foundation, http://www.nuff.org
To find a surgeon, try:
* American Association of Gynecologic Laparoscopists, http://www.aagl.org
* American College of Obstetricians and Gynecologists, http://www.acog.org
* Society of Gynecologic Surgeons, http://www.sgsonline.org