4 Dr Amicable
The GP must choose according to whether a surgeon is kind and sympathetic; whose wounds heal; who will give a fair opinion; who will be able to get the patient into a nice hospital, within a reasonable time. If the GP has done her/his homework, fine...
And if there is any doubt as to the necessity for hysterectomy, send the patient to a consultant gynaecologist who is not just going to whip it all out on principle. Gynaecologist.
Hysterectomy - The Positive Recovery Plan by Nikki Henriques & Ann Dickson.
Before I saw my new GP, Dr Amicable, I wrote to her relating not only my dissatisfaction with my previous doctor but the painfully personal reason why I was totally against hysterectomy.
Dear Dr Amicable
I have recently changed doctors and have an appointment to see you on Wednesday at 4.20 pm. As I may become upset and incoherent I am writing to you now about my medical condition.
I am reprinting some of the letter I have written to my former GP as I think it explains what I feel about the present situation.
After printing over a page of my letter to Craft-Tort I continued:-
I saw him on March 10 because I had a vaginal discharge and on March 12 he discovered that my womb was very enlarged. My lower abdomen ached for four days afterwards, possibly due to nervous twitches.
The gynaecologist I saw, Mrs Languid, made some sympathetic sounds and arranged for an ultrasound scan. But when I went back an the 16 April she left it to an unnamed personage I shall refer to as Jack Ketch to tell me that my enlarged fibrous uterus should be excised. He also expected me to be delighted at the idea of mutilation.
I have heard since that many women do not mind the mutilation - even prefer it to bleeding and pain. I am apparently considered eccentric, at the least, for not wanting it. I think my reaction may have been unusually extreme due to an unmentioned expectation, which I have never been able to speak of, even to my closest kin, of a child of my own. I was the eldest of nine children and always assumed that some day Prince Charming would appear on the scene and I would have a beautiful baby. I didn't care if Charming immediately had a heart attack, so long as I had the baby. But years passed and my nieces and nephews appeared but I rarely went out, never established any sexual relationships and so never conceived. But as long as I bled it could still happen. And then this happened. If I had made it up to the menopause I would still grieve the final passing of my chance of maternity but it would be a natural death. To be told that I must lose it - not through a malignant growth but because of benign fibrous lumps appears to me like a murder of hope. And I am expected to sign the death warrant.
Mr Shaw in his 'Textbook of Operative Gynaecology', 1977, believed there should be "no arbitrary age limit to myomectomy before menopause if the patient expresses a strong disinclination to hysterectomy." The present opinion regarding hysterectomy as expressed in Barnes & Chamberlain's 'Lecture Notes on Gynaecology' appears to be "This is the most satisfactory treatment and is the operation of choice in women over 40 years." The surgeon's choice, of course. The choice of the woman of 40+ is like it or lump it.
I lumped it.
Jack Ketch declared that myomectomy was no good - fibroids only come back. And further:-
Didn't I know 1 in 200 turns cancerous.
That the fibroids could start degenerating, filling me with necrotic masses.
The womb could prolapse.
When I changed my mind Jack would be ready with his Knife.
In the meantime I should continue taking the iron tablets, as of course I would continue bleeding heavily.
Perhaps he was just being helpful.
It may be that this would have happened anyway but I had a smear test on the 6 March when any significant womb enlargement would surely have been noticed. And fibroids are supposed to be slow growing. These appear to be swelling like some kind of grotesque parody of pregnancy. I can't help thinking that if my anaemia had been treated instead of being left for years my condition would not have deteriorated so quickly. At the very least it is reasonable to assume that having sub standard blood is certainly not going to help any medical condition. Moreover periodical checks should have detected the swelling.
I do know that the total amount of treatment or investigation that I have received consists of some feeling and prodding in the last six weeks and an ultrasound scan. Even the iron tablets I finally got myself from Boots.
This last month has been horrendous. I have been unable to forget this threat for more than ten minutes, unable to settle. unable to concentrate, subject to depressions, weeping spells and odd aches. Found my sleep disturbed. Lost more than a stone in weight.
But this last few days I have felt better. I have felt as I imagine a sexually harassed child must who has finally told her tormentor "No". What a commendation for modern medical science. But what a profession that offers the same treatment for women's trouble in 1992 as they were given in 1838, though admittedly with a much greater chance of surviving it.
Hysterectomy may be good for your health (provided you are not one of the about 0.07% death rate) but it can sure play havoc with your psyche.
Yours sincerely
P Nomark
She seemed a very sympathetic woman but said that I'd have to think of my long term health. After all with the menopause I'd want Hormone Replacement Therapy and that would stimulate my fibroids1. She sent me for another blood test. It was 11.0 and had increased more than two points in a fortnight.
One of my brothers had given me a diary for Christmas but I rarely wrote anything down, though I started recording times when I went for appointments or got letters. However on this day I wrote "Went to see Amicable at 4.20 pm. I think she's in favour of hysterectomy". I should have taken more notice of my first impression.
It was perfectly correct.
Dr Amicable's notes said:-
gnae referral large fibroid uterus
Hyst. suggested by Mrs Languid
Ms Nomark is not in favour of this
she wants to know about different options
- Formally complaining about previous GP
Two days later I went for the introductory health check at the practice. When I had been waiting for three quarters of an hour I saw the receptionist. I had somehow been omitted from their list. I was not impressed by their incompetence.
On 5 May Dr Amicable felt the lump and pronounced it the biggest she had ever seen. I was rather surprised when she measured it with a tape measure, somehow it didn't seem very scientific, especially since it had become so mobile. She said that she would refer me to a gynaecologist at the Royal, Miss Godly.
Dr Amicable's letter to Miss Godly dated 18 May 1992 went:-
Dear Miss Godly
Thank you for seeing Pamela who presents a difficult problem and we are really asking for a second opinion. Pamela has just recently registered with the Practice after being unhappy with the care of her previous GP. A brief summary of her history is as follows:
She has a 3 year history of menorrhagia. In September 1991 she was found to be anaemic with an iron deficiency picture, although she wasn't actually informed of the result until February2. In February or March 1992 she was found by her previous Doctor to have a large fibroid uterus and was seen by Mrs Languid. Ultrasound scan confirmed the mass to be a large fibroid uterus which has now extending just beyond the level of the umbilicus. No ovarian masses were seen on the scan.
Hysterectomy was suggested to Miss Nomark, she is very reluctant to accept this. She is very angry that her problem wasn't spotted earlier and she feels that other treatment should be tried first. She has read extensively on the subject and she wishes to discuss further the possibility of myomectomy or hormonal treatment to shrink the fibroids. I have discussed this at length with her and explained that hysterectomy is possibly the only option available, but she would still like to have a second opinion. I would be grateful if you could see and advise.
Yours sincerely
DR P M AMICABLE
I remember no such discussion at length. Dr Amicable knew less about myomectomy than I did. But she was well aware of the standard medical response to female trouble. In spite of what I had written to her she wrote to Miss Godly virtually asking her just to see me and order me to have a hysterectomy.
I did more research at the library and sent Dr Amicable a some Medline abstracts and a copy of a report by Adamson on a conference about GnRH-a therapy.
Before seeing Dr Amicable on 18 June I sent her a very long letter:-
Menstrual Loss
The WHRRIC says that some women quite normally lose a pint of blood a month. I reckon that I lost about 400g of fluid last period. Allowing 50% for non blood this still leaves a flow of at least 150 mls. I S Fraser (American Journal of Obstetrics and Gynaecology 1990 May 162 (5) 1264-9) defines the upper limit of normal menstrual loss as 60-80 mls, 60-120 mls as moderately heavy and over 120 mls as heavy.
He also says "A high proportion of woman in this study did not want a hysterectomy." So I'm nothing like unique.
Query
Lui & Lachelin Practical Gynaecology 1989
"A rapid increase in uteral size indicates degeneration or malignancy."
Assuming my haemoglobin level has returned to normal during April it rose from about 8.4 to over 12 g/dl - an increase of about 50%. During April my womb also increased, swelling forward, with tender spots and aching. Was this a direct result of improved blood quality? I can find nothing relating increased haemoglobin content to increasing fibroid size, though it sounds sensible to me.
In the few accounts I have read most fibroids were detected by about 12 week size and took years to grow to 20 week size. If mine are so big now why didn't the smear clinic nurse notice them 2 years ago. And if they weren't big enough to detect then they have they grown so fast?
Also if I have been losing only 0.1 g HB dl/month (from the fall between September 1991 and April 1992) then it has taken 5 years for my Hb level to fall so low. And at less than 1 mg Fe loss/day it would take 3 years to drain the iron reserves. Can this anaemia have been developing for 8 years?
I should like to know what, if anything, has been established about the condition of my uterus. How many fibroids are there? How big are they? What type are they? How long have they been growing? Are they growing unusually rapidly? What is unusually rapidly? Are they degenerating, or malignant? Would anybody know pre-postmortem if they were? From what I've read they wouldn't.
Or are these questions not addressed since the procedure for a woman over forty, in fact for most women, is fibroids detected, hysterectomy first - fibroid investigation afterwards. It certainly seems that way to me.
So far I have been told merely that I have a fibroid womb. I suspected that over two years ago though I had no idea just how much trouble fibroids could cause since it is always stressed that they are BENIGN lumps. So why are so many women mutilated because of them? Or am I illogically rejecting a perfectly satisfactory answer to "female trouble" which will bring about a vast improvement to my health? I did some reading.
Hysterectomy
If hysterectomy is such a wonderful cure with benefits of freedom from periods and the threat of uterine cancer why are there so many hysterectomy support groups,leaflets telling you it's "nothing these days" and telephone "help" lines on "coping with hysterectomy"?3
The Operation
Stephen Fulder How to Survive Medical Treatment
States that in the US only 1 in 5 hysterectomies is fully clinically justified. The US rate is twice that of the UK but unless British women are more unhealthy than American this still means only 2 in 5 British operations are justified.
Even in the medical profession there are those who are not happy with the vast numbers of hysterectomies performed.
Mirriam Stoppard Woman to Woman
"The decision to have a hysterectomy should never be taken lightly and it should only be performed as treatment for a life-threatening disease."
Miller in 1946 wrote in the American Journal of Obstetrics and Gynaecology on "Hysterectomy: Therapeutic necessity or surgical racket?" He claimed that 33% of hysterectomies were carried out in the absence of pathological findings and inferred that some were performed because of the complaints of emotionally disturbed patients.
If they weren't disturbed beforehand they were afterwards.
Barker (British Medical Journal 1968 2 91-95) studying 729 women from Dundee who had either hysterectomy or cholecystectomy4 found that a significantly higher proportion of the hysterectomised women were referred to a psychiatrist after the operation. This was particularly evident in those who had not been referred to psychiatry previously.
Others insist that it is only a few women who react badly to hysterectomy but where any consideration is given to patients at all the message is that this is something most women feel very negative about.
Goldfarb HA (Obstetrics & Gynaecology 1990 Nov 5 (Pt 1) 833-5
A review of 35 endometrial ablation cases finishes:
"The additional benefit of the procedure is the avoidance of hysterectomy and postsurgical complications as well as the psychological consequences of a hysterectomy."
Boto (British J of Hospital Medicine 1990 August 44 (2) 93-9) says :-
"Hysterectomy for benign but intractable menorrhagia is the major surgical procedure performed upon women in middle life. Many of them approach the operation with considerable dread fearing both the physical effects of the surgery and what they perceive as an attack on their sexual status. Certainly unwanted physical and psychological sequelae are not uncommon..
Longer term problems are accelerated ovarian failure with attendant cardiovascular disease, osteoporosis and psychosexual dysfunction
(Centrewell 1981, Siddle et al 1987)."
And not just psychosexual effects either according to:-
Leon Zussman et al (Am J Obs 1981 140 725)
"Recent studies conducted in the UK show that 33% to 43% of women report a decrease in sexual response after hysterectomy-oophorectomy (oophorectomy is castration)."
Zussman et al suggest both hormonal changes and anatomical changes are responsible.
Utian found after hysterectomy "a high incidence of decreased or absent libido....irrespective or whether the ovaries had been removed or not". Ovaries, both pre and post menopausal, produce androgen which enhances libido in women.
Asch and Greenblatt state that post menopausal ovaries are not senescent and "incretory function is maintained at least a dozen or more years after the onset of menopause. Oestrogen replacement may counteract menopausal symptoms but it does not restore libido."
One woman said she no longer enjoyed sex because she "felt just dead up inside."
I bet this effect is not mentioned on the jolly "misinformation" lines. Perhaps hysterectomy should have a government health warning.
"This operation can seriously injure your orgasm."
Easterday C L et al Obs & Gyn 1983 62 203-21
Half to a quarter of all women who undergo hysterectomy develop some morbidity, with fever and haemorrhage the most common types. Late sequelae may include the residual ovary syndrome, depression, and an increased risk of cardiovascular disease.
Finally the ultimate "complication". More than 600 women in the US die each year from hysterectomy or its side effects.
Am J Obs Gyn 162 (6) 1451
Hysterectomy - a medical legal perspective 1975-85
73% of obstetrician-gynecologists have had at least one professional liability suit filed against them. Of the 87 cases reviewed 4 of the 5 deaths were preventable. Of the 15 alleged unnecessary hysterectomies 7 were paid - 2 each receiving $250,000. Easterday states that hysterectomies have declined in the US between 1975 and 1980 while in the UK they have risen from 57,830 in 1979 to 66,470 in 1985. Perhaps what we need to reduce the figures in the UK is a few malpractice suits.
Neuwirth R S (Am J Obs Gy 1976 126)
Excision of submucous fibroids with hysteroscopic control
Case number 4 - a 64 year old had a D & C and cervical polypectomy and then a D & C and pedunculated submucous fibroid 3 x 3 x 5 cm removed.
She was long past the menopause but presumably still didn't want a prophylactic gutting of her reproductive system.
The Operated
Suzie Hayman Hysterectomy
"I can't describe the feelings of horror, of desolation almost, that hit me when he said "It'll have to come out, Mrs B ". What was so awful was that he quite obviously thought I was being silly to feel upset."
Many doctors will treat this organ as if it were an appendix - a useless redundant piece of tissue you no longer need or want.....You're only an emotional woman and he (doctor) knows best.
The following account is from the WHRRIC's fibroid leaflet. It was so interesting I have reproduced it in full.
"The GP told me that I'd have to have a hysterectomy. The uterus was so full of fibroids that they could certainly never be removed by a myomectomy. On account of my age (37) and my reluctance to have a hysterectomy (because of childlessness), he would refer me to a specialist teaching hospital to see what they thought.
By the time I finally got to see the consultant (6 weeks later), I was extremely apprehensive. However he told me that he didn't feel an operation was indicated at the present time. An ultrasound scan confirmed that I was carrying round a useless uterus. Nevertheless, useless or not, it was still giving me no trouble at all. I was determined to fight against the hysterectomy which I felt would be so wrong for me.
(Three years later the fibroids had grown to the size of a 20 week pregnancy). The GP wrote me an angry letter saying that if I was genuinely concerned about my physical health, I would have the operation for fibroids. He added that fibroids do have complications, of which cancerous change is one, and that I was putting myself in the position of someone who is asking for the fire alarm to be checked out, whilst perfectly aware that a fire is burning unchecked in the basement and may soon burst though the floor. This put me in a panic (as I suppose he intended it to) and I did in fact agree to have a hysterectomy when I next saw the gynaecologist.
Nevertheless it almost broke my heart to agree to it. All those years of periods and "being careful" were now to be for nothing. I felt extremely bad about it, yet felt that for my health's sake I ought to now go ahead with the hysterectomy, just in case complications were developing. Well meaning others told me "it's nothing these days... " "you'll be a new person afterwards..." but these were women who already had their families. How could they understand how I felt?
Possibly by postponing the operation for so long, I made it harder for myself when I finally had the hysterectomy, in that it became a bigger operation than perhaps it might have been. However I have no regrets about having delayed it. But once everyone knew it was going to be done, I felt I was under a lot of subtle (and not so subtle) pressure to get it over and done with. It's true that I now know that I have not got cancer, that I no longer look pregnant and have lost a stone in weight. But I have merely exchanged bladder frequency for bladder pain and a fat tummy for a scarred one. I don't feel a new woman or even a fitter one.
If I had known it would be quite so hard to re-adjust, I might perhaps have delayed the operation for even longer. It has only reinforced my belief that unless one's condition is life-threatening or the symptoms too much to bear it is better to put up with the symptoms, rather than submit to surgery."
An interesting phrase that "submit to surgery". The little woman finally beaten into submission by expanding benign growths and forced to accept mutilation "for the good of her physical health" though obviously not her mental health. I wonder if she got any pre-operational treatment at all, or even a second opinion.
The BMA Family Doctor
"After your hysterectomy... some women feel that they have lost part of their femininity. Your doctor will be sympathetic to such feelings and may be able to offer counselling after the operation to help you overcome depression and other difficulties."
Another half acknowledgement that hysterectomy produces depression and "other difficulties" - possibly too embarrassing to mention. I didn't notice much sympathy in the above account though.
Myomectomy
Bonney's Gynaecological Surgery
First published 1911, performed 806 myomectomies, retired 1937.
"Since cure without deformity or loss of function must ever be surgery's highest ideal the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable...
Fibroids of the uterus beyond the scope of conservative surgery are uncommon.....
The oldest patient for which we have performed myomectomy in the treatment of primary infertility was 47. She conceived shortly afterwards and gave birth at the age of 48 to a healthy son."
Shaw's Textbook of Operative Gynaecology 1977
Referring to the Bonney series of myomectomies:-
1 Greatest number of tumours removed was 225.
Shaw thinks this is excessive zeal as such a scarred endometrium would be "useless" - that is incapable of sustaining a pregnancy. But why should an individual be mutilated because an organ is not functioning fully. If the Pope had a diseased penis would it automatically be severed because it was "functionless" - and therefore not worth preserving? Moreover it would seem that the womb is not, in fact, "useless" even when it is not being "used". It is part of a dynamic system and without it ovaries can fail and libido shrivel.
2 40 tumours removed with a total weight of 21 pounds.
3 Re-occurrence rate estimated at 4%.
Shaw believes this to be a fair estimate if the operation has been thoroughly performed and obviously Bonney was thorough.
4 Mortality 1.1%.
In the pre-penicillin age this was less than the mortality rate for hysterectomy (2.4%) at London hospitals of the time.
Jeffcoate's Principles of Gynaecology edited by V R Tindall
"Myomectomy is not usually ruled out by the fibroids being large in number or size. It is relatively easy to enucleate 10-30 fibroids."
Published this year is "The Woman's Guide to Surgery" by Tim Coltart & Felicity Smart. Chapter 11 on Fibroids states that hysterectomy is usual for fibroids and then says:-
"But if you wish to have children or simply want to retain your womb, perhaps "keep your options open" these fibroids can be removed by myomectomy."
"A myomectomy can be quite straightforward."
"If the womb is much misshapen by fibroids, so that it could be extremely difficult to restore it to its normal size and function, the surgeon may want to reserve the right to do a hysterectomy if necessary." But you'll be glad to know "Hysterectomy is rarely needed, however."
Hysterectomy by Dr E Philly, 1987, states:-
"Myomectomy is quite a difficult operation. It calls for considerable experience and skill."
The truth would seem to be that though myomectomy does require experience and competence it is usually neither complicated nor difficult.
Hysterectomy on the other hand can presumably be performed by any barely adequate hack. And is. One of them severed both his victims ureters. She sued.
It seems that what Bonney could do nearly a century ago modern gynaecologists (or should that be hysterectomy technicians) can't do. Except for Dr Smith of Seattle, Washington, of course.
But is it significant that the patients of Bonney and Smith personally paid for their treatment and if you pay you may get a say in your treatment.
In Conclusion
Anything from 5% to 30% of myomectomy patients will subsequently have a hysterectomy.5 Some women have had two myomectomies and a hysterectomy - in the US, anyway. Do British doctors want to save patients from the risks of further surgery by not mentioning that fibroids are removable or emphasising the problems involved when myomectomy is known about? While at the same time not mentioning some of the real consequences of hysterectomy? I have seen at least two letters to womens magazines from women plunged prematurely into menopause following hysterectomy, something they were obviously not told about. Is this why myomectomy although rarely impracticable appears to be also rarely practised?
Or is it that most medics do not want to preserve useless female organs? Can it be true that surgeons - mainly men - really do resent owing their very existence to women and take every opportunity to deny this by excising every womb possible? A pessimistic view indeed but given Jack Ketch's attitude (a sneering Why would you want a fibroid womb?) I could quite easily believe it.
Or is it because they really don't have the technical skill - since myomectomy is more difficult than straightforward excision? It's so much easier just to rip everything out.6
Or is it financial? The Final Solution means the National Hysterectomy Service never having to fork out for womb treatment again, or have the expense of smear tests. Even better if the reproductive system is completely gutted. Then there's absolutely nothing left to cause any concern, or expense, whatsoever. And no extensive training or expensive equipment, like lasers necessary - just a sharp knife.
Is it convenience, competence or cash - or all of them. A conspiracy of factors all working to separate a female from her reproductive system. According to Stoppard's Patients Rights on page 367 every patient has the right to "have the most modern treatment available". Is the 1828 treatment the most modern available?
I keep thinking of the verse in Alice in Wonderland which went something like this.
I speak severely to my patient
And scold her if she refuses
For I know she could enjoy
The mutilation if she chooses
Far from offering any reassurance my reading so far would suggest that there is a worldwide male conspiracy to mutilate as many females as possible. The only contra-indication that I have had is the Checkout 92 program on prostate cancer which showed that urologists were just as inconsiderate to their patients.
P Nomark
The last sheet of my letter listed the treatments I had found for fibroids in the medical literature. Besides hysterectomy and myomectomy there was resection, which was only possible for fibroids within the womb cavity and a few experimental studies combining GnRH-a therapy (to shrink the fibroids) with added oestrogens to restore hormone levels and thus prevent the effects of oestrogen lack, like brittle bones and heart disease. The last treatment I found was rather intruiging.
In the late 1980's a drug called gestrinone, which opposes the effects of oestrogen, was used in some studies to assess its effects on endometriosis and fibroids. A Brazilian called Coutinho wrote up 6 reports between 1987 and 1990. The first patient given the drug was a young childless woman with a womb 400 cm in size, bleeding because of her fibroids. Scheduled for a hysterectomy she was given gestrinone instead. After 2 years of treatment the womb had returned to normal size and she became pregnant with twins. At the time of writing she had 5 children in 3 pregnancies. Coutinho writes that, "Surgery is the quickest and most efficient way to treat myomas though it may result in infertility7. However in many countries the appropriate technology for surgery is either unavailable or of poor quality."
In January 1977 the NY Times described the high rate (60%) of caesarean section in Brazil among women delivering in private clinics because "A substantial number of physicians in Brazil believe that the surgical delivery is the best method of childbirth - it causes no harm to the figure, it is quick, and it is a lot more profitable". It seems that surgery is available nearly anywhere in the world for those with the money to pay for it.
One of Coutinho's studies, reported in 1989, involved 300 women, aged 18 to 53, who were treated for up to 2 years at doses of up to 15 mg a week. I was quite surprised to find that in the current British National Formulary the price of 8 capsules containing 2.5 mg each of gestrinone was £75. This means that, at current prices, the cost of treating a woman with the highest doses of the drug was over £50 a week, and over 2 years the total cost of treatment would have been nearly £6,000. But in 1990 the NHS could do a routine hysterectomy for £1,100.
So why were third world women getting such large doses of fairly expensive drugs? Well gestrinone has only recently been added to the list of drugs found fit for consumption by western women8. I wondered if the long term drug trials at up to twice the recommended dose had anything to do with the granting of licenses to compete in profitable western drug markets. And if the company provided the drug free for testing on Brazilian guinea pigs.
Perhaps, I thought, I was overly suspicious but I have seen no gestinone studies by Coutinho published after 1990.
Years later I read the following in Braithwaite's Corporate Crime in the Pharmaceutical Industry. "A greater source of resentment in the Third World than the dumping of old or unsafe drugs has been the testing of new drugs which are regarded as having risks too high for testing in developed countries."
Mr Braithwaite relates how the first large-scale clinical trials on oral contraceptives were conducted in Puerto Rico around 1953. More tests followed in Puerto Rico, Haiti and Mexico. The first major US clinical trials were conducted on women from low-income groups, 84% of whom were of Mexican extraction and 6% black. Copper containing IUDs were tested in Chile, Columbia, Iran, Korea, Taiwan and Thailand.
It is estimated that only 10% of the drugs which start clinical testing in the US become commercial products and following drug disasters, such as DES and thalidomide, western nations have demanded more extensive, and much more expensive, testing of drugs before they will register them. A study of 15 large US firms found that although before 1966 almost all of their primary testing was done in the US, by 1974 there were more first tests conducted abroad than in US. Testing under much slacker regulations in developing countries is an attractive proposition. Not only is there a large supply of dispensible, Third World guinea pigs but they do not have the means to sue global corporations for injury. Moreover the drug companies can rake in profits by registering and selling in the Third World so that even if the drug is later found to be unsafe they will have made some money out of it.
I later found that there was a 10% error in haemoglobin measurement so it would have been useless to try and estimated the rate of haemoglobin rate from the two readings of September 1991 and April 1992. Working in a chemical analytical laboratory I had come to expect more accurate assays. The only thing that could definitely be said was that I was losing iron slowly and must have been anaemic for years.
I saw Dr Amicable on the 18 June 1992. She still did not have my medical notes. She also had no answers. She suggested I give a copy of my letter to Miss Godly and sent me for another blood test. My haemoglobin level was 14.0.
1 According to A J Friedmann "Currently no data suggests that significant uterine enlargement occurs in postmenopausal women taking the doses of estrogen and progestin generally used in hormone relacement therapy".
2 In fact it was early April
3 Most of the latter seem to have been replaced by by HRT and the menopause though Dr Pat Last still had one going in 1993.
4 Removal of the gall bladder
5 This is incorrect. It was 5-30% that will have recurrence of fibroids. The average hysterectomy after myomectomy rate is 10% and remember the women least likely to require further treatment after myomectomy, those over 40 years old, are also the least likely to get one.
6 I later read Dr Goldfarb's book which said "It is true that hysterectomy is a technically less difficult operation (though not to the doctor who is accustomed to performing myomectomy)." That is if your gynaecologist is really experienced he will find a myomectomy no more difficult than a hysterectomy and will not push you into unwanted mutilation. If he's a hysterectomy technician - watch out!
7 Considering that the surgery usually, and sometimes exclusively, contemplated is hysterectomy I think "may" is understating the facts.
8 It's used to treat endometriosis and breast pain - not fibroids.