Female Anatomy

December 14, 2007

Uterine Fibroids: Fiboids and Fireballs of the Uterus

Fibroids of the uterus (womb) are mere overgrowths of the normal uterine muscle and fibrous tissue. Their proper medical name is leiomyoma--singular, leiomyomata--plural. Possibly as many as 40% of all women may develop them, but usually they cause no problems. They're not cancerous, but they can nevertheless cause problems merely by their size if they were to grow too big.

They can, for instance, grow big enough to cause obstructions in the urinary tract, causing kidney damage or frequent kidney infections; or exert pressure against the bladder, giving a woman the false feeling that she needs to urinate; or against the rectum, causing the feeling of constipation. Their size can also cause the uterus to weigh more, this drag creating pelvic heaviness and back pain. Urinary incontinence can result from a heavier uterus jolting with that much more of a kick with a sneeze or cough, this very action suddenly puckering open the urinary sphincter which lies above the mouth of the womb.

At Charity Hospital, the patient slang for fibroid was "fireball." Although an obvious malapropism, it's not too far from it's pathological description, a glistening layered ball sitting apparently randomly in the body of the uterus. A leading cause for hysterectomy, it's not usually the size alone that pushes a woman to consider surgery. It's the bleeding.

Fibroids, also called leiomyomata, are tough and fibrous, as their name suggests. Because of this, they occupy space in the uterus where normal uterine tissue should be. Normal uterine tissue is designed to contract, that is, squinch down to decrease its surface area as much as possible so that there won't be as much real estate to bleed with a period. A large fibroid, or numerous smaller ones, makes all of this clamping down unsuccessful, causing heavier (and therefore crampier) periods that last longer, sometimes as long as eight to ten days. It's only a matter of time before a woman's quality of life deteriorates, and if she is finished her family she'll wonder whether hysterectomy might be the way to go. It just might be.

But not so fast. There are alternatives, of course, and these must certainly be considered. Myomectomy is a surgical procedure wherein just the fibroids are removed, leaving the uterus intact. This is an important alternative, especially for women who want more children. Fibroid shrinking drugs are now available. They can't be used forever, but they can perhaps be used temporarily before menopause, because after menopause, fibroids tend to shrink on their own.

Hysteroscopy is a procedure in which a lighted scope is passed through the mouth of the womb to identify any small fibroids that may be bulging into the uterine cavity and which may be available by this techique to be "scooped out" with an electrocautery.

Besides the discomfort described above, fibroids pose problems with women of childbearing age. They can bulge over the openings of the tubes, effectively blocking them and leading to infertility. They can compete for space with the developing fetus, which can make miscarriage or abnormal presentations of the baby more likely. They can also act as a foreign body, making the uterus more irritible, putting a patient at risk for premature labor. But I suppose the biggest risk to a woman with fibroids is from abnormal bleeding.

Fibroids are a fairly easy diagnosis to make, using ultrasound and a regular office pelvic exam. Even so, other causes of abnormal bleeding must be ruled out, like polyps or cancer. Once that is done, the possibility of real danger must be assessed. If a patient is anemic, this is usually an indication to act. And whether a patient chooses myomectomy, fibroid shrinking drugs, or hysterectomy, she should consider that the worst scenario would be an emergency hysterectomy if she were to land in an emergency room in shock from vaginal hemorrhage, a case I get from time to time.

True, for the most part this type of melodrama is rare. But fibroids should be respected. Usually, they're stable and just mind their own business causing no symptoms at all. With ultrasound they can be measured and safely followed. At any one time I'm following dozens of women every six months who have had stable, innocent fibroids for years. But there are the others, and a gynecologist and a patient must carefully consider the management, be it observation or something more aggressive.

 

Contemplating the Navel

 

Omphaloskepsis is a word you won't find in all dictionaries.

It refers to the practice of meditating while contemplating one's navel. I would venture to say there aren't many omphaloskeptics in your county or parish, unless of course there's some subculture you're not aware of.

What is it about the navel that intrigues us? Barbara Eden couldn't show hers. Belly dancers adorn theirs. Shirley McClain chains herself to out-of-body experiences from hers, or so she says. (Earth to Shirley, Earth to Shirley...) Bikinis expose them, rings pierce them, and lint collects in them. So why on Earth would I write about belly buttons in the first place? Is it because I ran out of every other conceivable medical subject there is to write about?

Not to worry. There's an endless array of bumps, protuberances, pits, and orifices on the human body to keep me well stocked for years. An immediate consideration for me in justifying today's subject is that doctors use them surgically to place their laparoscopes. Also, the exciting new research in using cord blood as a source of stem cells for cancer patients hints at a brave new world in transplants. But that's where my own omphaloskepsis would stop had I not had children who asked me about their own navels.

A child's questions are extremely important on many levels, because besides simply requesting information, a child goes right for the heart of the matter. This often stimulates us to look at things in ways other than just the practical. Within every child's questions are inquiries into philosophies as well. A child seeks to get at the center of an issue. Not just What is a navel? but Why is there a navel?

We are a centrophilic species. Throughout history we have sought the centers of everything. The ancient geocentric scientists saw our world as the center of the universe. Then the heliocentrics correctly saw the sun as the center of our solar system, and many were persecuted for their theories. We are comfortable with centers. Even our two eyes, spaced well enough apart on our faces to give us true stereoscopic vision, align the two fields to create a central point for our gaze. We walk and run and somersault using our centers of gravity. And our center-seeking ways in some fashion emphasize the navel.

Adam and Eve were missing two things we all have--Original Sin and belly buttons. The navel is nothing more than a scar, after all. But what was there before this skin scarred over makes our whole existence possible. Through this portal both life and nurturing flowed from our mothers. Two arteries and a vein exchanged nutrients and oxygen for us during the pregnancies that safely delivered us into the air-breathing world. The cutting of the cord at birth is more than symbolic, for it challenges us to survive within our own machinery. The stump that remains withers, until we're left with what seems like the body's only joke--the belly button.

The fascia is a tough fibrous tissue that is the main supporting layer of the abdomen. It's really the thing that holds our organs inside. The carnivores among us will encounter fascia as grizzle on steaks. A weakening of this layer is a hernia, which emphasizes its importance. During our development in the womb, there's a separation in the fascia at the navel, for the umbilical vessels need a way out and in while the umbilical cord's in operation. After birth when the navel remains, there is a small hole left which is technically a hernia as well. It is a point of weakness in our bellies we all are aware of. Whether we realize it or not. Of course, unless you're an omphaloskeptic, you probably haven't ever stopped to contemplate it.

(Wake up and smell the lint!)

Consider this: We're comfortable braving the elements of this world with these shells we occupy. We can throw our back to an onslaught, we can stiffen our abdominal muscles and invite your best shot, but just don't poke your finger in our navels as hard as you can. That would hurt bad. Somewhere, somehow, deep in the recesses of our brains lies a vague sense of physical vulnerability, and the navel is one of the places that is connected to that area. We are all able to close our eyes and with pin-point precision bring our index fingers straight to our navels. Why? The navel, the belly button, the umbilicus--all are words that describe a center of our physical bodies.

An answer to my children about it involves the medical descriptions of how the arteries and vein in the umbilical cord flow this way and that, and then at birth when we become air breathing, lung-inflated beings, the flow alters, the portal there shutting down, the heart adjusting to a different type of circulation, and we're on our own. But this answer is incomplete, because we really do have a center.

We were all connected to our mothers, and they to their mothers, and so on all the way back. We are all wired. We are all "on line," with our connections intact to the first people. The lines drawn on paper that make up a family tree can easily be envisioned as cords of life, all inserting into navels down the page. The field of genealogy is learning the way to untangle and draw umbilical cords. Looked at that way, there's a certain beauty to a navel, whether it's an innee or an outee, as we are tethered snugly to our species. But I still don't know why Barbara Eden couldn't show hers.

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