15 Oddments
There is a great deal of difference between a good doctor and a bad doctor but very little difference between a good doctor and no doctor at all.
Benjamin Franklin
On 22 April 1992, hearing nothing from Women's Health, I telephoned the Marie Stopes clinic in London. I was put in touch with the nurse there. She very considerately told me that as I was all of 43 I had left it too late to be sprawning and might as well be mutilated. Obviously a medical lackey, she saw no point in old hags retaining any part of their reproductive system.
Marie Stopes herself was a 37 year old virgin when she wrote the first sex manual, called Married Love, and 44 when she gave birth to her first, and only, child. However the Stopes clinic appeared to be mainly concerned, like Stopes herself, with birth control and especially with preventing dull but fertile plebs from swamping the intelligent middle classes with their hordes of moronic offspring.
In May 1992 I read of a surgeon who had been performing resection of fibroids so I wrote to him. The letter I received in reply came from a doctor at a London Colposcopy clinic. It went:-
Dear Mrs Nomark
In reply to your recent enquiry to Mr Pfaff regarding endoscopic treatment of fibroids I can confirm that some uterine fibroids are indeed amenable to this form of surgical excision. Not all fibroids however can be treated in this manner. It is restricted mainly to fibroids filling the uterine cavity in those women whose uterine size is relatively normal. Prior to a decision as to whether you are indeed a candidate for this operation, hysteroscopic examination of the uterine cavity is required to assess the size and site of your uterine fibroids and a pelvic ultrasound scan examination is needed to confirm that the fibroids can be safely resected.
I apologise for the paucity of this information but one cannot be certain whether you are indeed a candidate for this surgery without consultation and examination. Should you wish to be seen in this unit please do not hesitate to ask your General Practitioner for referral. We do see people from outside our unit and would most probably be able to give you a definite answer following one consultation.
Yours sincerely
Staff Doctor
I thought the doctors answer was as full as possible and as my womb at 23 weeks size was nothing like normal it seemed very unlikely that the unit could help. But I thought I'd ask about GnRH-a treatment to shrink the fibroid(s) anyway. The rely was dated 2 July 1992 and said that:-
Further to your recent letter regarding endoscopic treatment of uterine fibroids, prior to treatment an assessment must be made of both the size of the submucous fibroid as well as the size and distortion of the uterine cavity. On the whole submucous fibroids of up to 3 cm may be safely resected. However an assessment of the actual overall size of the uterus must be made because more often than not multiple fibroids are present at other sites in the myometrium and on the other uterine surface. Generally endoscopic treatment, either resection of fibroids or removal of the endometrium is only contemplated in a normal size uterus although treatment on occasion may be undertaken in a larger uterus possibly in size consistent with a 12-14 week gestation. This however is not a general rule and depends on the clinician's opinion. GnRH-a are used in this country to shrink uterine fibroids prior to endoscopic surgery. It is well known that GnRH-a shrink fibroids by as much as 30%. However once the treatment is stopped fibroid growth returns unabated. GnRH-a are therefore not used for long term treatment of fibroids especially in view of their known side effects causing post-menopausal symptoms and definite osteoporosis, softening of the bones.
I hope this further information is helpful to you but I would also like to stress once again that this is for your information only. I am unable to determine whether this treatment is suitable for you without examination and further investigation such as hysteroscopic examination of the uterine cavity and pelvic ultrasound scanning. Please let us know should you wish to be seen in this unit.
Yours sincerely
Staff Doctor
It was quite obvious that with a womb size more than twice that of their upper limit that treatment would not have been possible by the clinic. The fibroid was later found to be not submucous in type so resection would not have been possible anyway.
I was rather puzzled by the doctors insistence that this information was for me only. It sounded as though he didn't want it generally known that the NHS was wasting expensive drugs shrinking down fibroids before resection instead of just whipping the womb out.
I later tried to find out when exactly I had been prescribed drugs and wrote to the local pharmacy on 8 April 1993 .
Dear Mrs Lint
I have recently been trying to get my medical information. However I have found my extremely brief computer record lists only a couple of smear tests and does not have the drug record that I would have expected given their automated prescription printing.
I believe that I was given a prescription between March and May 1990, which would almost certainly have been filled at your pharmacy. Could you tell me if there is any way of checking what prescriptions, if any, were filled for me during this period.
As it is now three years ago I realise that records may have been destroyed but am hoping that they are still in existence.
Yours sincerely
Pamela Nomark
She wrote on the 26 April:-
Dear Mrs Nomark
Thank you for your letter of 8th inst.
I apologise for my lateness of reply. I do have records going back beyond 1990 in some cases but they are not full and complete as that was the introduction for patient's medication records to be kept by a pharmacy.
I no longer have the old computer to access these archived records, but even if I did I'm afraid that they might not be complete enough at that early stage of record-taking.
I do apologise for this loophole that would have appeared to occur in your files but am afraid that I cannot access information that far back.
Yours sincerely
Mrs R A Lint
Surely, I thought, my drug record couldn't have just disappeared off the surface of the globe. There must be a record in some government department, somewhere. So on 30 April 1993 I wrote to the Royal Pharmaceutical Society of Great Britain.
Dear Sir
I have recently been trying to get my medical information. However I have found my extremely brief computer record lists only a couple of smear tests and does not have the drug record that I would have expected given their automated prescription printing.
I know that at least two prescriptions I was given in 1991-2 were not recorded in my GP records and would like to know just how much of what drugs I have consumed over the at least the last 3, preferably 8, years. I wrote to the local pharmacist, who filled most of my prescriptions, but have been told that her records are incomplete and due to new computer equipment she cannot access the old records she does have.
As professional pharmacists I am sure that you know where this information is likely to be kept and am hoping that you can advise me on how to obtain it.
Yours sincerely
Pamela Nomark
The reply of 14 June said:-
Dear Ms Nomark
Thank you for your letter requesting information on medical records and I apologise for the delay in replying.
The answer to your question is that there is only one complete source of your medical history including any drug treatment and that is with the records held by your general practitioner.
Although more pharmacists are beginning to maintain medication histories of their patients there is no statutory requirement for this, and as it is a relatively new undertaking the pharmacy may not have the records as far back as you require. Additionally pharmacy maintained records will always have the problem of possibly being incomplete. Since the patient is free to have medication dispensed at any pharmacy of their choice, the record of that dispensing will not go to the pharmacy they may usually use and so the records at both dispensing sites will be incomplete. Thus I am afraid only your general practitioner can help you in this matter.
I hope this is of use to you.
Yours sincerely
A C Gibbons
Senior Information Pharmacist
As I was getting nowhere I decide to write again to Mr Gilt of the NHS and did so on 14 June 1993 .
Dear Mr Gilt
I am trying to find out what drugs I have been prescribed and when, over the last 3, preferably 8, years.
I wrote to the local pharmacy, who filled my prescriptions, but the chemist wrote that not only were her records incomplete but the computer system had been changed and earlier records were now not accessible. As you were very helpful when I was trying to find out about health record access earlier I am writing to you to ask if there is any way I can get a list of the times when I have been prescribed drugs from the NHS?
Yours sincerely
Pamela Nomark
Mr Gilt's reply was not as informative as his previous letters.
Dear Ms Nomark
Thank you for your recent letter requesting information on those items prescribed to you on the NHS.
As it is your GP who prescribes any medication you require you should perhaps approach your surgery to request access to your records.
My letters to you dated 23 December 1992 and 11 January 1993 outlined how you can request access under the Access to Health Records Act 1990. I attach copies for your conveniences.
I hope this is helpful.
Yours sincerely
STEVE GILT
Health Care Division
On 4 September 1993 I wrote...
Dear Mr Gilt
Thank you for your letter of 12 August. I have seen my medical records and besides being illegible they are also incomplete as neither of the last 2 prescriptions I had there are recorded. How many others were omitted I do not know.
For some years prescriptions had been issued with a counterfoil showing the present item(s) and the last time they were ordered. I had hoped that the computer record would show a complete listing but, as you can see from the enclosed copy, it shows absolutely nothing.
I wrote to the pharmacist at the local chemist where virtually all my prescriptions were filled and enclose a copy of her reply.
For 10 years my prescriptions were all made out to the same name, at the same address, from the same GP, at the same practice and filled by the same pharmacy. The vast majority, and the only ones I am interested in, were for inhalers of ventolin, salbutamol or becloforte so there is even a great deal of uniformity in prescription details. Yet it seems extremely difficult to get a listing of them.
I should like to know whether my prescription details still exist anywhere in the NHS records and if so how I can find them.
Also I had 2 outpatient appointments at the local hospital. The person I saw on the second occasion wrote a letter to my GP but apparently made no clinic notes. I thought that notes were supposed to be taken at every clinic appointment can you tell me if this is correct? Or if clinic notes are, in fact, optional.
Yours sincerely
Pamela Nomark
Mr Gilt reply of 29 September was almost a carbon copy of his previous one.
Dear Ms Nomark
Thank you for your further letter of 4 September requesting information on those items prescribed to you on the NHS.
My earlier letters of 12 August 1993, 11 January 1993 and 23 December 1992 explained the procedures for obtaining access to your health records. I am afraid I cannot add anything to these. I can only suggest you approach your GP again for the information you require.
I am sorry I cannot help further.
Yours sincerely
STEVE GILT
Health Care Division
Mr Gilt had not only disregarded my statement that my practice notes were incomplete but had totally ignored my query regarding outpatients appointments. It seemed that Mr Gilt knew nothing about anything except the Access to Health Records Act.
And was no longer inviting me to write again if I needed further advice.
In April 1993 I also wrote to the BBC program "Watchdog" and told them about fibroids and their treatment and my experience of the medical profession. I finished with:-
The Patient's Charter states that I had the right :-
to be given a clear explanation of any treatment proposed including any risks and any alternatives, before I decide whether I will agree to the treatment. This did not happen. I was told that I should have a total abdominal hysterectomy and when I was not too pleased asked "Why would I want a fibroid womb" as if it was something of no importance or value. The risks of hysterectomy were not mentioned and when I mentioned myomectomy, an operation performed over a century ago, it was sneeringly dismissed as "no good. They (fibroids) only come back". This does not accord with Monaghan's assertion that the results of myomectomy are "excellent" but fits in very well with a picture of a male dominated profession, willing to offer conservative surgery only to women whose owners want to breed from them. If you think I sound cross - you're dead right. Hell hath no fury like a woman scorned and I feel that my reproductive system has been well and truly scorned. As consumer experts I would like to know whether you agree that my alleged rights under the Charter have been ignored. And what should I do about it. I should say that I have already complained to the chief executive of the NHS on the 8 December about records I was not given. As I heard nothing I wrote again in January this year and received a note saying a full reply would be sent as soon as possible. It is now 5 months since I complained. Presumably the "full and prompt written reply" mentioned in the Charter is still snailing its way through the bureaucracy.
The male chauvinist attitude is so pervasive that some women accept the male view of their organs and unquestioningly agree to their mutilation. I should like all women with fibroids to know that conservative treatment IS possible "in almost all cases". All they have to do is dump their hysterectomist and find an experienced restorative surgeon -which they will probably find a difficult exercise. If they still decide on hysterectomy (and some will) they deserve osteoporosis, though if they're lucky the cardiovascular disease will get them first.
Yours sincerely
Pamela Nomark
There was no reply. Watchdog was busy hassling the health stores, who were selling dangerous products of far less toxicity than those dispensed by the official drug pushers. Perhaps it was not keen to criticize the official health mongers. Or perhaps it is staffed by male chauvinists who see nothing amiss in widespread female mutilation.
I think I was wrong on one point though.
Nobody deserves osteoporosis.
My next letter, on 12 April, was to a Mr Sheldon of the Department of Health Project at Leeds University.
Dear Mr Sheldon
You appeared some time ago on "The Pulse" and spoke on entrenched practices among medics which are blindly followed and never questioned.
I told him what I had read on hysterectomy and fibroids and finished :-
Personally after seeing my second hysterectomist's assistant in July last year I was so negatively impressed that I went to see a herbalist. When I saw the God herself I was not surprised at her "what you need is a hysterectomy" attitude and chose to continue taking the herbal medicine. It has not reduced the lump but at least I am not subjected to pressure to get mutilated.
I have come to the conclusion that the logical thing to do is write to the secretary of the RCOG and ask him to explain the situation. No doubt he has a good line in evasive claptrap.
If you have any comments, personal knowledge or advice I should love to hear it. I am decidedly short on input. The lower echelons of the National Hysterectomy Service, like my GP, know naught and the gynaecologists ar'nt saying.
Yours sincerely
Pamela Nomark
There was no response.
In June there was a television program called "First Sex" which was supposed to be about and for women. At the end they asked if anybody had views on what they would like programs about. On 21 June I wrote.
Dear Ms
Well you can guess what I wrote about, quoting Dr Goldfarb's book. I concluded :-
I feel that women should be warned that when they go to see a NHS gynaecologist they don't see a person who will try to resolve their problems but one who will do their utmost to rip out as much of their reproductive system as possible. And leave them to cope with the problems it brings.
If you feel that this subject is too trivial for your program I should be obliged if you would send a note to that effect. I enclose a s.a.e.
Yours sincerely
Pamela Nomark
In spite of my stamped addressed envelope there was no reply but there were no further editions of the program either so I suppose it had not gone down too well.
I thought that a project organised by the Workers Educational Association would be interested in the medical facts I had come across so on 16 June 1993 I wrote to them.
Dear WEA
I saw some of your womens health material in the local college and decided to write to you about my health.
I was found to have a large (about 23 week size) fibroid mass a year ago and since then the medical profession has done nothing except try to mutilate me with hysterectomy.
And I told her about what I had read regarding fibroids, hysterectomy and myomectomy and about my medical experiences, finishing with:-
What sort of profession is it where consultants are unhappy with basic
conservative surgery, practised for over a century?
I feel that the male chauvinist attitude is so pervasive that many women accept the male view of their organs and unquestioningly agree to their mutilation. I should like all women with fibroids to know that conservative treatment IS possible "in almost every patient".
Yours sincerely
Pamela Nomark
The reply was dated 29 October 1993, four months later.
Dear Pamela
Thank you for sending me all your information re fibroids.
I'm sorry you have had such a difficult time with it all. Did you take up a complaint with your local Community Health Council?
I cannot make good use of the considerable information you have sent, so I have forwarded it to Woman's Health in London as they may be better able to use it.
Apologies for not being able to get back to you sooner on this.
With best wishes
Linda Pappe
Well I'd already exchanged words with Woman's Health. I was pretty pissed off when I wrote to Ms Pappe on 2 November 1993.
Dear Ms Pappe
Thank you for your letter of 29 October, in reply to my communication of 16 June.
I am sorry that the WEA's Health Education for Women does not include informing females of the true facts concerning fibroids and the medical mutilation of women. I find it alarming that approximately 25,000 women are routinely mutilated every year when nearly every one could be treated with conservative surgery.
I enclose a copy of the introduction to Felicity Smart's book "Fibroids", published this year. As a health writer she knew the true facts about fibroids but the hacker she saw attempted to railroad her into unnecessary mutilation. Though a professional writer she states that she found it difficult to explain that she didn't want to be mutilated. I wonder how ordinary plebs manage to communicate their disquiet in such situations? She finally managed to get decent medical attention though having friends who put her in touch with one of the few gynaecologists with any respect for the female reproductive system. I wonder how many plebs have friends who include gynaecology professors among their acquaintances? Just what hysterectomy can do for you is found in the book by Naomi Stokes entitled "The Castrated Woman: What your doctor won't tell you about hysterectomy". Mrs Stokes found this information by bitter personal experience and would like other women not to have it. My local library finally got a copy of her book from Nottingham. Not the sort of book most libraries want pleb women to have access to?
But then plebs breed like flies anyway. Perhaps it's best that they should be fixed as quickly as possible. Go repairing their reproductive systems instead of extirpating them and they might be multiplying in their forties, instead of coping with the ovarian failure and depressive after-effects of hysterectomy.
Yours sincerely
Pamela Nomark
I was not surprised to hear nothing from Mrs Pappe.
On 16 July 1993, in an attempt to discover just how anaemic a woman has to be to be actively informed of the fact, I wrote to the Royal College of General Practitioners and the Royal College of Pathologists.
Dear Sir
Some time ago I saw my GP because I had a craving for ice which a magazine article described as sometimes symptomatic of iron deficiency anaemia. I did not return to the surgery to ask for the result and six months after the test I found that the haemoglobin level had been recorded as 9.0 g per dl, well below the WHO lower limit for non-pregnant females of 11.0 g per dl.
My GP says that he wrote "make appointment" on the blood report and I should have returned to ask for the results. He says that as professional footballers have been able to function with Haemoglobin levels of only 50% he didn't feel that my clinical condition obliged him to go to the trouble of actively informing me that I was, and had been for 2 years, anaemic.
Can you tell me to what level must a patient's haemoglobin fall before they should be actively informed of their anaemic state? 40%? 30%?
And if GP's are not going to bother informing patients of results unless they are grossly abnormal wouldn't it make better sense to send the result direct to the patient?
Yours sincerely
Pamela Nomark
The Royal College of Pathologists replied on 26 July.
Dear Ms Nomark
Thank you for your letter which has been forwarded to me. The College cannot reply on individual cases such as you describe. As you are unhappy with the explanation of your anaemia I suggest that you ask your GP for a second opinion with a Haematologist locally, who would then be able to go into your case in full and explain to you the exact situation of your blood.
I do hope this line of action is satisfactory.
Yours sincerely
A J Bellingham
Vice President
I was well aware of the situation of my blood. It was in my veins and I was quite happy to leave it there. What I had written about was my GP neglect of my blood result but the Vice President was either deliberately ignoring this or was as thick as pig shit.
The Royal College of General Practitioners wrote on 30 July 1993.
Dear Pamela
Thank you very much in writing to The Royal College of General Practitioners, and I'm sorry you do seem to have had a problem recently.
The Royal College of General Practitioners does not give advice to individual patients, as we are a College that deals with standards, education and training in general for groups of general practitioners.
I am sure however, that if you discussed it further with your general practitioner that they will be able to explain this for you.
With all good wishes.
Yours sincerely
L Moya pp
Dr M McBride
Voluntary organisations tended to be informal and use Christian names. I found this a bit disconcerting as I hate being addressed on first name terms by people I don't know. I suspect that they're either being tritely insincere or condescending. Perhaps it's just my suspicious nature. And I am much more suspicious when my correspondent is not a volunteer. I wondered how Dr McBride would like being addressed as "Dear Mollie". Perhaps she was a genuinely outgoing and friendly person but I had deep reservations and on 14 August I wrote back to her.
Dear Dr McBride
Thank you for your letter of 30 July. I am happy to hear that there are standards set for general practice. Could you tell me what the desirable response should be if a blood test result is found to have a haemoglobin level of 9.0 g/dl. Is it to wait for the patient to return and ask specifically for their blood results? And how long should the blood results be allowed to lie on file and ignored for? Indefinitely?
At what level of anaemia should a patient be actively informed that they are below par in the iron department?
Also isn't it true that iron deficiency anaemia is a symptom of underlying illness rather than a complaint in itself? I believe that cancerous growths of the gut may be responsible for iron deficiency anaemia. In such a situation wouldn't a delay of 6 months in investigating the cause of the anaemia prove quite possibly lethal?
How do your standards deal with these factors?
Yours sincerely
Pamela Nomark
Mollie wrote back on 9 September. This time she addressed me as :-
Dear Ms Nomark
Thank you for your letter 14 August asking a number of questions relating to a finding of anaemia in a patient. As I indicated in my letter to you of 30 July the Royal College of General Practitioners is not able to give you advice to individual patients. At that time I suggested that you discussed the matter further with your general practitioner and I am afraid that I can only reiterated that advice to you.
I am sorry that I can not reply in a more helpful fashion to your questions.
Yours sincerely
Dr M McBride
The Royal College of General Practitioners had a fortieth anniversity in 1992 and on the envelope was their logo with the words "Knowledge with Compassion". Whatever knowledge they had they were keeping strictly to themselves.
Probably in a strongbox with their compassion.
On 13 July I had written to the National Osteoporosis Society.
Dear Sir
Re: Hysterectomy and HRT Booklet
While I found this booklet very interesting there are a few facts it omits. Hysterectomy is associated with a number of unpleasant effects listed in "The No-Hysterectomy Option; Your body Your choice" by Goldfarb and J Greif, published by John Wiley & Sons ISBN 0-471-51615-5 Preface "..the notion that a hysterectomy is a relatively risk-free panacea for the woman who is troubled by a gynecologic problem.... Nothing could be farther from the truth. All major surgery is fraught with complications. Hysterectomy is no exception, sometimes resulting in: hemorrhage, urinary tract trauma, intestinal injuries, posthysterectomy depression, sexual dysfunction, early ovarian failure, heart disease and osteoporosis....."
I would recommend that women read the facts from Dr Goldfarb before having any surgery.
You also do not mention the fact that women who have been surgically castrated have later developed a cancer indistinguishable from ovarian cancer. It would seem that if a cancer has your name removing its primary target organs will not necessarily thwart it. Osteoporosis has become a major health hazard. Especially in the USA, well known for its high rate of female mutilation. Is this significant? How common is osteoporosis in third world countries which don't have the luxury of "elective" hysterectomies? I have never noticed deformed old Africans on TV but perhaps they exist.
The avoidance of unnecessary hysterectomies would seem to be a good idea. As the enclosed sheets show a myomectomy can be performed "in almost all patients". Perhaps this should be "the operation of choice "for fibroid women, if not out of consideration for their feelings then perhaps out of concern for their bones.
You also do not mention alternative therapies for menstrual problems. Vitamin A treatment or herbalism is sometimes effective for heavy bleeding. Homeopathy or acupuncture can both help. All of these therapies are much less damaging than conventional medical treatment and may prevent surgery. They at least deserve trying before proceeding to irreversible amputation.
Yours sincerely
Pamela Nomark
The reply, dated 27 July, said:-
Dear Ms Nomark
Thank you for your letter commenting on the Hysterectomy & HRT booklet. I think you raise some interesting points and there are certainly hysterectomies that are performed unnecessarily or without proper recognition of the emotional or physical effects that can follow. The National Osteoporosis Society has been concerned off course by the increase in osteoporosis and hysterectomies are significant because it is known that women become oestrogen deficient with conservation of their ovaries.
With reference to your comment about lack of osteoporosis in the third world, there are of course many factors here. Black people have a higher average bone mass than white people and are less prone to osteoporosis. It is also known that weight-bearing exercise will also reduce the risk. Also women with a shorter life expectancy probably do not live to experience the effects of the menopause to the same extent.
I do hear from women who have had a lot of help from complimentary therapies and perhaps a future revision of our booklet should also mention alternatives to conventional treatment. I wonder if you have seen the recent Virago publication "Hysterectomy and the Alternatives" by Jan Clark 1993, it may be of interest to you.
Best wishes
Yours sincerely
Sarah Leyland
Nurse Advisor
I wrote back on the 27 August 1993.
Dear Ms Leyland
Thank you for your letter of 28 July. I have reserved a copy of the book you mentioned from the local library. I have recently been reading a book called What Every Woman Should Know About Hysterectomy by W Gifford Jones Ltd, written in 1977. Although it seems very dated, and the author far too willing to castrate women, some of what he says is quite interesting. The economic basis of widespread female mutilation and castration is quite clearly set out and accompanied by warning case studies. Also operative dabbling by family doctors seems to lead to quite a lot of substandard surgery in the USA. I've noticed before that the hysterectomy mortality rates seem higher in America than here.
I have also read the following on page 22 of Avoiding Osteoporosis by Dr A Dixon & Dr A Woolf "Some women have to have their ovaries removed because of disease. For them, all the usual post menopausal problems are likely to come on quite severely, and most doctors would consider it almost unethical not to offer treatment with hormone replacement therapy. However what is not always realised is that this should be continued for many years, possibly until age 60 or more, if the almost inevitable osteoporosis is also to be avoided." I also read that P Fogarty in the Ulster Med J vol 60 no2 Oct 9 pg 172 surveyed gynaecologists in Ulster and found of 43 replies:- 72% performed prophylatic castration and 10% used oestradiol implants at the time of surgery, 57% prescribed hormone replacement for premenstrual women, 33% only prescribed if the patient became symptomatic.
As far as I can make out this means that according to doctors Dixon and Woolf 33% of castrated women in Ulster are being left to "almost inevitable osteoporosis" unless they return complaining of symptoms. I find this alarming.
Even when HRT can be taken it seems to be associated with hazards and inadequacies - like not providing the androgens that the ovaries normally produce even after menopause. The enclosed article by J J Kabukoba on HRT by implant shows that of 38 women returning with menopausal symptoms only 3 had hormone levels in the menopausal range and 9 had excessively high oestrogen levels. As Kabukoba says, if very high oestrogen levels were found at the time of reimplantation what on earth are the peak levels like? And what effect do these huge levels of circulating hormone have on the patients?
I remain convinced that the best way to take your hormones is by ovarian production and anything that disturbs this should be a last resort.
Yours sincerely
Pamela Nomark
Recently a study of rural Maya was undertaken as these women become menopausal earlier than American women but suffered neither from menopausal symptoms nor osteoporosis. It was thought that they might have higher oestrogen levels. However on investigation it was found that although none of the observed women suffered hot flushes (found in 60-80% of Americans) their oestrogen and testosterone levels were the same as those of American women. And although bone measurements showed bone demineralisation few old women had histories of osteoporotic fractures.
It was thought that a calcium rich diet combined with plenty of exercise was what kept their bones healthy.
A 1986 study measuring fitness by maximum oxygen consumption found that higher oxygen consumption was associated with denser spine and hip bones. And a recent report showed that premenopausal women who exercised daily for a year showed an increase of 3% in bone density. Fat people have strong bones and although they have increased blood levels of active oestrogen this does not account completely for their increased bone strength. Could it be due to the sheer physical effort involved in carrying around excess weight? In the weightless conditions of space travel bones lose mineral at an alarming rate and in the more sedendary west osteoporosis is increasing amongst men as well as women. It would seem that "use it or lose it" applies to bones and the way to prevent bone loss is to keep active and make sure you don't indulge in behaviour which will impair your bones. Like risking ovarian damage by having a hysterectomy.
In November 1993 I wrote to Felicity Smart, author of the book "Fibroids".
Dear Ms Smart
I found your book on fibroids very interesting. No wonder I found the medical profession obscenely eager to amputate my womb. Since it affords no respect for a womb in its thirties there was no chance of any consideration being shown to my 43 year old organ.
However I noticed the usual lack of information about the true effects of hysterectomy, so graphically described by the founder of HERS in the enclosed newspaper article. Though it must be admitted that her symptoms were so severe because she was also castrated.
Also you refer to ovarian failure after hysterectomy as "a myth". This it certainly is not. Jan Clark's book "Hysterectomy and the Alternatives" describes, on page 75, the case of Adeline from Swindon who had a hysterectomy at the age of 34 and spent the next 3 years depressed. When she finally found that her ovaries were no longer functioning (thanks to a woman's magazine - not the medical profession) she had lost 2 inches in height.
As early as 1977 Dr Gifford-Jones stated in his book "What every woman should know about Hysterectomy", "Furthermore, during a hysterectomy, the ovarian blood supply is always impaired to some extent." And he should know - he did lots of them.
Siddle found that the age at menopause was significantly lower for hysterectomised women and the risk appeared to be non uniform. His work is quoted in the Osteoporosis Society booklet on Hysterectomy and HRT. I also enclose an abstract of Semm's report of ovarian deficiency following not only hysterectomy but also sterilisation and the abstract of another paper showing that hysterectomised women have more severe menopausal complaints. Naturally because of the high incidence of ovarian damage from surgery and the "residual ovary syndrome".
I find the other paper by Semm very interesting. The professor is apparently coring out the lining of the cervix to maintain the "transvaginal sexual sensations of the patient" although every book printed for the masses will tell them that amputation of the cervix will make no difference to them.
I hope further editions of your book will not contain this inaccuracy. Perhaps one day a book will be published which really does tell women what they should know about hysterectomy.
Yours sincerely
Pamela Nomark
Ms Smart sent me a short letter on 11 November telling me that she had passed my criticism regarding ovarian failure to her collaborator and on 16 December sent a longer letter:-
Dear Ms Nomark
I said I would write again regarding ovarian failure after hysterectomy when I had spoken to Professor Campbell, who has only recently returned from a lecture tour abroad.
The literature on this subject is vast and certainly not unanimous. Specialists, such as Professor Campbell, will back their own findings. He has provided the enclosed study which supports his view.
His reaction to the case of 34-year-old Adeline from Swindon was to wonder whether her ovaries were in fact removed during her hysterectomy without it being clear to her. You will see that on pg 57-8 of our book we advise women to be certain they understand exactly what will be done during a hysterectomy. Diagnosing a lack of oestrogen afterwards is not proof that failed ovaries are present. One anecdotal case, though interesting, does not in itself constitute scientific evidence.
Finally, I would like to stress that the purpose of our book is to emphasise the treatment options open to most women with fibroids - and that hysterectomy can usually be avoided, if that is what the woman wants. Professor Campbell himself regards it as a treatment of last resort. As his patient, I had every confidence in him, which is why I subsequently wrote the book with his help.
I wish you health and happiness, especially at this season.
Yours sincerely
Felicity Smart
I should have found the suggestion that a supposedly well qualified surgeon would rip out the ovaries of a 34 year old woman without telling her and leave her to develop her "almost certain osteoporosis", as Dr Dixon put it, quite shocking. But I didn't. And Adeline's case was, of course, only the most extreme of many.
Siddle's estimate of 25% premature ovarian failure after hysterectomy is accepted by the National Osteoporosis Society in their booklet on Hysterectomy and HRT. The Medical Advisory Board of the NOS includes 5 professors and over 10 medical doctors. A dozen doctors and professors comprise the Council of Management. Presumably they all accept Siddle's figures, which are widely quoted.
The enclosed study involved measurements of chemicals excreted in urine which indicated the amount of circulating progesterone. A pattern of peaks indicated normal ovarian cycles. When I got a copy of the paper I noticed some interesting things about it. The women studied were picked out of 318 and those women (4) who were having one or more hot flashes a day were excluded. The selected women were those had no obvious signs of hormone trouble or any other ill health apart from headaches, allergy or asthma or joint pain. As 83 out of the 93 described their health as good or excellent it would seem that the investigators deliberately chose only the healthiest survivors of hysterectomy to study so that they could state that being mutilated does not harm your hormonal condition.
The average age at the menopause is 49-50 and a menopause under the age of 45 is usually considered early. The maximum age of the women was 44. At the ages of 40 and 43 two of them were found to exhibit no cycles at all and as they also had the uniformly low oestrogen levels associated with ovarian failure even the authors had to concede that they "may" have been postmenopausal. Another women had a slight surge that the authors interpreted as a peak. They reproduced both the prehysterectomy pattern of this woman, showing large monthy peaks, and the irregular squiggle measured 15 months after the operation. As her oestrogen output was also erratic, at the age of either 42 or 43 she was also experiencing the menopause. Another 3 women, aged 43, 44 and 33, had intervals of 62 to 83 days between peaks and the hormone measurements done in 2 of them indicated hormonal disruption.
Another item of interest is the fact that some of the women had only recently been operated on. The median time since operation was 2.6 years and a quarter had been done within the year. Hysterectomy damage may be due either directly to the operation or to the adhesions of the residual ovary syndrome, which may take some time to develop. Since Siddle found the period during which many women became menopausal to be the 2 years after hysterectomy I would regard all women during this period as still at risk.
In other words almost half of the 93 selected, healthy women were still in the danger zone for post hysterectomy ovarian failure, 2 were found to be postmenopausal and a further 4 were becoming menopausal, one of them at the age of only 33.
The authors demonstated that normal ovarian cycles follow hysterectomy in many women but they certainly did not show that hysterectomy does not cause ovarian failure. Quite the contrary. What they did show was that some women become menopausal soon after hysterectomy with no "overt signs of endocrine ... abnormalities". Presumably the apparently healthy 33 year old would soon become menopausal and possibly share Adeline's experience of osteoporosis and other unpleasant effects of early ovarian failure.
Oldenhave et al, who found that hysterectomised women suffered more severe menopauses, analysed responses from 986 hysterectomised and 5,636 normal women. They noted that from as early as 1902 there have been indications that hysterectomy causes ovarian failure. However, as I have said, I believe that a major cause of post operative ovarian failure is surgical competence, or lack of it, and it is possible that Professor Campbell's patients suffered minimal damage due to exceptional surgical expertise.
I wrote to the professor about my reservations about the validity of this study's conclusions.
There was no response.
As Ms Smart noted gynaecologists argue amongst themselves over castrating women for their own good. Dr J Studd deplores the fact that few gynaecologists in England will castrate a healthy woman under 45. He says that ovarian cysts and adhesions in the form of the residual ovarian syndrome occur in 7-20% of women after hysterectomy and calls the symptoms of an aging menstrual cycle an "ovarian cycle syndrome", increasing with age and at its worst in the few years before ovarian failure. In other words the reproductive system of the female of 40+ is just a nuisance and should be entirely excised whenever possible and replaced with HRT, which Dr Studd regards as perfectly safe and much more convenient than the natural female hormone production system. He concludes that "The woman has the ultimate choice. If she exercises what is perhaps the only worthwhile argument against prophylactic oophorectomy, namely a sentimental desire to keep her ovaries then it would be a foolish and insensitive gynaecologist who ignores this compelling argument." I'm glad that the woman is admitted to have any choice but feel that it is a very stubborn woman indeed who withstands the cocksure surgeon's pressure to dispose of her organs.
In a leaflet produced by Organon Laboratories and distributed to doctors surgeries, Dr Studd lists the symptoms of the menopause - hot flushes, thin skin, painful joints, reduced sex drive, urinary frequence, mood swings, loss of concentration, sleeplessness and depression, osteoporosis, heart attack and stroke - and describes how HRT will help with each and every one of these symptoms. Side effects, including cancer risks, are dismissed as insignificant or of short duration. There are many treatments which have been found to relieve menopausal symptoms including vitamin suppliments, evening primrose oil, increasing calcium or magnesium intake, acupuncture, exercise, herbalism, homeopathy and dietary changes. Naturally a leaflet produced by the drug industry mentions none of them.
HRT has also been touted as a treatment for irritable bowel disease. And Dr Studd is now treating depressed women with HRT. Women can throw anyway their anti-depressant drugs and stick on a hormonal drug patch. Is there anything that female hormones cannot do? Val Brown tells how the oestrogen treatment has helped her with mood swings, tiredness and sleeplessness. Of course she now has migraine instead but you don't get anything for nothing. In "The Bitter Pill" Dr Grant noted that oestrogen makes women feel happy so it's not surprising that it does counteract depression. It also brought strokes and premature death. The oestrogen levels in HRT patches are much lower but they still have unwanted side effects, like Val Brown's migraines. They also leave red marks on your bum.
In my experience of the NHS the treatment options usually available were mutilation or nothing. As Jack Ketch made patently clear I should come back only when I was willing to be butchered. And Miss Godly finally stated that it would not be "ethical" for her it even consider an operation like myomectomy which she did not consider "in my best interests" - and bugger what I wanted.
And Dr Goode, like Dr Craft-Tort, never even considered conservative womb treatment. She knew well that her patients either put up with the symptoms or had the mutilation.
But if Ms Smart thinks her book may result in more considerate and less destructive treatment for women I say, "Good on her" and "Bloody good luck."
She'll need it.
On 22 September 1993 Bella magazine printed a letter from a 43 year old woman. She said that she had accepted that she "needed" a hysterectomy because of fibroids but was concerned because her doctor also wanted to castrate her as well and she felt that she was too young to be starting HRT. Bella's doctor did not tell her that for almost all patients the fibroids alone can be removed regardless of their number, size or position and did not tell her to get a second opinion from a doctor who did not regard all women of 40+ as having redundant reproductive systems. He said that the gynaecologist had her interests at heart and declared that taking HRT for a decade "should be quite safe". He also said that as premature menopause may follow quite soon after hysterectomy because of damage to the ovarian blood supply she might as well be castrated anyway.
I have another cutting from the Sunday Sun. Their dubious doc, Dr Barbara, relates the tale of the unfortunate 42 year old Sara afflicted with some "very small fibroids" who "never expected to be faced with the prospect of having a hysterectomy" and whose main worry was that "the gynaecologist would want her to have a hysterectomy". Very small fibroids causing severe bleeding such as Sara was said to be experiencing are usually situated in the womb lining and can be removed vaginally by a competent gynaecologist. As Sara's womb was described as only "slightly bulky" Dr Pfaff should have been easily able to remove her fibroids. Did Dr Barbara's patient have her fibroids removed vaginally? Did she have them removed by abdominal myomectomy? Or did she have an endometrial resection to cut down or stop her bleeding? No! Sara had had a trial of "hormones", probably cheap Provera, which did no good. Dr Barbara mentioned the drugs that can reduce bleeding like Danazol, which has unpleasant side effects, gestrinone, which is quite expensive, and GnRH-agonists, which are so expensive they are usually only used preoperatively and never given for heavy bleeding. Sara was not actually offered any of these more expensive drugs and "eventually decided to plump for the hysterectomy and keep her ovaries" which Dr Barbara felt was best. Best for whom I wonder? For Sara who was apparently only given the option of either being mutilated or enduring her heavy bleeding? Or for the gynaecologist who was uninterested in conservative treatment, or even incapable of doing it, and certainly not willing to refer Sara to somebody who was?
Still searching for information I telephoned Women and Medical Practice and found, to my surprise, a woman who knew that you didn't have to have a hysterectomy just because you had fibroids. As it was expensive phoning London I wrote to her on 1 September 1993.
Dear Ms Winsome
I enclose rather a lot of stuff. I hope you are not overwhelmed with it. Some people seem to be easily overwhelmed. First is my view of the NHS, followed by my correspondence with Women's Health and Women's Health Concern. I find it grotesque that when I wrote in great distress to WHRRIC (as it was then) I received no reply, when I sent a caustic note I got an immediate reply - though of course of as little practical use as silence. I am also very suspicious of WHC. I wrote to a charity and got a note from one of the woman hackers - not on WHC stationary but from Harley Street.
Naturally their Hysterectomy leaflet makes no mention of the many unpleasant effects of hysterectomy, but puts up a few Aunt Sally "old wives tales" to demonstrate that hysterectomy is, of course, the bees knees and a good earner for Ms Bounce. Even the Endometrial Ablation leaflet goes on about women who "erroneously believe that hysterectomy will destroy their femininity, whereas concern for their future well being seems to elude them". Considering what hysterectomy can do to you these women are dead right not to want butchering. Most menstrual problems fade with the menopause, hysterectomy problems can last a lifetime.
I sent a virtual copy of my letter of December 1992 to Dr Goode, who my sister thought a woman orientated quack. I enclose a copy of her reply. The Woman's Newspaper item was sent to me from the HERS Foundation. This I find totally believable. My ultrasound reports are also enclosed.
I would like to hear some comment on the conclusions I have come to. The medical profession seems to be smugly satisfied with their little butchery. Although, as HERS states in their leaflet on hysterectomy and castration (a far cry from anything I've seen in England), the nasty effects of hysterectomy are well documented in medical journals but it is still considered "the operation of choice" by many hackers, who are apparently not qualified to do anything else. It seems amazing to think that the treatment offered women is dictated by the surgical non-competence of the hacker they are referred to, not by their medical condition, and certainly not by their own preferences, which are totally ignored.
So far I have had no real comment on anything I have written. Quacks do not feel that they have to justify established medical practice - no matter how unpleasant or inappropriate it is - and non medical women seem to think that whatever a quack says is right. Personally I keep thinking that Mengele was a doctor too.
Yours sincerely
Pamela Nomark
However Ms Winsome was of less help than Womans Health. She never even bothered to send a brief, non committal note.
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