8 Have You Been Dunn?

	All too often, doctors and patients choose hysterectomy to resolve 	problems, incorrectly assuming that pelvic surgery has no negative 	consequences. But surgery to remove the uterus is not a mild or innocuous 	procedure.
	Hysterectomy: Before and After by Dr W C Cutler

On 3 November 1993 I saw Dr Dunn. He had a student with him. She spent much of the time leafing through my medical notes. I wondered what she made of my letter to Miss Godly.
Dr Dunn started badly by saying, "You haven't started Zoladex?" Well he had my notes he should have known.
Both he and his student had an external grope of the lump. I felt that I was there as a specimen for his pupil to study.
He did not do an internal examination. Another black mark. As Dr Dally puts it in Women Under the Knife, "In medicine today an essential procedure in most serious disease is the physical examination... Once this is accepted it becomes clear that in gynaecological disorder a vaginal examination is essential". Miss Godly had never examined me because she had already decided what my treatment should be on the basis of my birthdate. The Professor, who seriously considered all surgical options, did do a pelvic examination. I therefore concluded that Dr Dunn was not at all interested in performing conservative surgery - or at least not on me.
He went on about iron levels. I told him that I had given blood only six weeks previously and my haemoglobin level had been 13.5. He still insisted that I should have blood and biochemistry tests. This reminded me strongly of Dr Amicable did nothing but send me for blood tests and attempt to get me fixed. Another bad mark.
Then Dr Dunn said that since I didn't have severe symptoms I didn't need surgery.
I nearly fell off my chair. It had been known for the last 18 months that I had a growth the size of a modest melon, heavy bleeding and a persistent vaginal discharge. It was gynaecological dogma that growths less than half the size of mine with no symptoms whatsoever necessitated surgery. Two supposed experts that both declared that my condition warranted not merely surgery but mutilation. Since they had delivered this opinion I had been found to have pressure effects on both kidneys and the Professor had obviously thought that surgery was needed.
But Dr Dunn didn't agree.
I gave the doctor a chart I had kept of my menstrual cycle and also produced a sample of menstrual flow. I had the strange impression that he probably insisted that his student disposed of it, fearing that if he touched it his beer, or should that be his vintage port, would be curdled. Perhaps this was a little fanciful.
I would have liked to have known the actual blood content of my menstrual flow, it would have given me a more acurate idea of much blood I was losing a month, but it was too much to expect that the NHS would have considered measuring its haemoglobin content.
I also gave the doctor a copy of my letter from Dr Goldfarb. This produced the only genuine reaction I have seen from a medic. He was most indignant, saying that Goldfarb was only after money (do British medics operate merely because they love mutilating women?), he couldn't possibly say that he could certainly do a myomectomy. There was always the possibility of having to do a hysterectomy. Yet Professor Tizzy had said that he could not remember having to convert a myomectomy to a hysterectomy - it was so uncommon, Coltart and Smart wrote that "Hysterectomy is rarely necessary" and Lui and Lachelin's Gynecology agreed that myomectomy "only rarely needs to be replaced by hysterectomy." I found Dr Dunn's attitude suspiciously negative and awarded him a further 2 black marks.
In the latest edition of Bonney's Gynaecological Surgery Monaghan states that, "By the use of the clamp devised by Bonney, myomectomy can be performed on an almost bloodless uterus, so that not only can the operator work as deliberately as he chooses, but also, if in the end he should find it impossible to terminate the myomectomy satisfactorily, the patient, having lost little or no blood is in a perfectly good condition for hysterectomy." That is if you choke off the the womb blood supply any hysterectomy done is chosen by the operator and not necessary because of blood loss since the patient cannot lose excessive amounts of blood. But then this is only Monaghan's opinion and other operators dislike clamping. And perhaps if blood vessels have been cut but not sealed there may be heavy blood loss when the womb clamp is released. What is interesting is that the patient is to lose her womb if it doesn't come up to the surgeon's idea of satisfactory, i.e. capable of sustaining a pregnancy (whether that is what the patient wants or not).
Dr Dunn wrote in my medical notes "see photocopy letter re Laparoscopic Myomectomy "no problems" !"
He wrote that day to my new GP:-

Dear Dr Fearless

Pamela Nomark
As you will know I have been asked by Professor Tizzy to take over this patient's care since he has recently retired.
I saw this patient today. Symptomatically she remains quite well, although her periods are heavy she is not apparently becoming anaemic. The uterine size remains the same. I have arranged for her electrolytes and haemoglobin to be checked today and a further scan to be done in 4 month's time.
I made it clear that should this patient wish to proceed with a myomectomy I would be more than happy to do so following suppression of menstruation with Zoladex.
Best wishes

Yours sincerely
DR P DUNN
Consultant Gynaecologist

I made another appointment for March 1994, had blood taken and then went to made an appointment for an ultrasound scan. Dr Dunn had said to make the scan appointment earlier on day I was to see him but when I went to the radiology department I was told that I couldn't possibly reserve time on a particular day - even if I did give 4 months notice. The receptionist took my card and told me I would be sent an appointment. This came a month later and was for a week before my gynaecology appointment, thus ensuring that I would have to traipse the 50 mile round trip twice instead of just once. When the Professor wanted a scan doing within the week he got it, when a patient makes an appointment 4 months notice is not sufficient to get a time convenient for her.
Still at least it would be the Department of Health and Social Security who paid for all the travelling backwards and forwards. I was so depressed that 2 days later I wrote to the Women's Endoscopic Laser Foundation, based at South Cleveland Hospital.
 
Dear Sir/Madam 
 
I am 45 years old and 20 months ago was found to have a large abdominal mass. I have been to 2 hysterectomists who both wanted to mutilate me and later saw Professor Tizzy (now retired) who had a detailed ultrasound scan done, a copy of which I enclose.  
I wrote to H A Goldfarb, the co-author of The No-Hysterectomy Option: Your body, Your Choice and enclose his reply. As I am on Income Support I do not have the odd ?20,OO0 to spare. 
As far as I can make out laparoscopic removal of myomas up to 10 cm across, which I calculate to be no more than 500 cc volume, is possible.  The volume of my myoma is about 1200 cc and a reduction of at least 60% would be necessary for laparoscopy to be possible. Myoma shrinkage with GnRH-a seems to be extremely variable and I have read of a 571 cc fibroid totally regressing, but the average is only 40-50%. Also degenerated fibroids tend to be resistant to treatment and this myoma has an area of calcification.  
Laser myolysis is mentioned in Felicity Smart's book "Fibroids", where she says that it is used in addition to drug treatment, but gives no details so I have no idea of the volume reduction which could be expected from it. 
I have hypermenorrhoea, which has not changed significantly in the last 4 years, and became anaemic but have found that intermittent iron treatment maintains my haemoglobin levels. From weighing my menses (sheet enclosed) I calculate that I lose a minimum of 120 to over 200 mls of blood a month. I have had a persistent leucorrhea for the last 2 years, due presumably to pelvic congestion but it is light to very light and non-offensive. I have no symptoms from the mild bilateral hydronephrosis revealed by the scan. 
As the British National Formulary records the basic net price of Zoladex as ?125.40 a shot I can see that preservative treatment of my ancient womb would be far more expensive than the cheap, quick routine hysterectomy so beloved of the medical fraternity.
However I AM NOT HAVING A HYSTERECTOMY. I am not having a cheap (and hazardous) mulation for the convenience of the NHS purse. In fact I want the least traumatic possible solution. I should like to know if my myoma is too large to be dealt with by WEL as there would be no point in fighting my latest GP for a referral if you could not treat it. 
 
Yours sincerely 
Pamela Nomark 
 
The reply was dated 1 December:-

Dear Ms Nomark

Thank you for your letter of November and I apologise for not having replied sooner but I have been out of the country for some time. Your letter interests me in that you are obviously adamant that you do not want hysterectomy. I can quite understand this unwillingness and indeed here at the WEL Foundation we like to offer women as many alternatives to hysterectomy as is medically possible.
Unfortunately as you know, it is currently still not possible to remove any size of uterine fibroid laparoscopically. In light of this fact a fibroid of at least 14 week size is not possible, regardless of the use of Gusserilin. I therefore cannot perform a minimally invasive for your condition, however I wish you the very best of luck in the future.

Yours sincerely
Ray Garry
Consultant Gynaecologist
Medical Director.

If he could understand a woman's unwillingness to be mutilated why did he find my disinclination for butchery so interesting? Because I was too old to still want to keep a reproductive system? I got the impression that he was a castrator, as are the majority of medics, and would have agreed with J Studd that women over the age of 40 should all have their gonads replaced by Organon's excellent hormonal products.
The reduction produced by Zoladex (chemical name goserelin, not Gusserilin) could have been enough to bring the myoma below the maximum size. Nobody can tell in advance what the effect will be. And I later read of Nezhat et al removing by laparoscopy fibroids as big as 15 cms, though they seem to use extremely sophisticated machinery, which is doubtless not available anywhere in the UK. If you want to get your large fibroids removed without trauma Atlanta, Georgia, is the place to be. Dr Goldfarb would have tried it but the WEL Foundation would only take on patients whose fibroids were already small enough to easily treat laparoscopically. And nothing was said about what myolysis could do.
A 1995 journal article on 600 endometrial ablations performed by Mr Garry showed that he experienced few complications when razing womb linings, though as he wouldn't operate on any womb over 12 weeks in size or with fibroids more than 2 cms in diameter he also seems to avoid difficult cases.
I reread their glossy brochure. The WEL Foundation accepts all major medical insurance schemes as well as personal and company cheques. It also takes NHS patients as long as either the GP practice or the local health authorities agree in advance to foot the bill. Although the Foundation treats more NHS than private patients I would be prepared to bet 2 ovaries and 1 womb that the percentage of private patients getting laparoscopic surgery is far higher than the percentage of NHS patients.
You want less traumatic treatment - you pay for it.

On 2 March I went for my second ultrasound scan. While in the waiting area an asian man, woman and child appeared along with a middle-aged white woman who gave me the impression of being some sort of social worker. They had come from antenatal to book an ultrasound scan. The receptionist demanded their paperwork. If you didn't have the correct form you didn't get an appointment. They didn't have it. The social worker type went off to try to get something sorted while the asian woman rested in the waiting area. When the older woman came back with a rather irate white coat the receptionist went into servile mode. If doctor wanted the woman scanned then of course she could have an appointment, even if she didn't have the proper form.
This time I was scanned by a radiographer only on what looked like the inferior equipment, which produced fuzzier pictures. I wondered if I was actually still regularly producing eggs, as after their thirties women are supposed to be less fertile because eggs are not produced in some of their menstrual cycles. I asked the operator if she could see a corpus luteum, the yellow, secretory body that the ruptured egg follicle turns into. By about 7 days after ovulation, that is about day 22 (just the day I was on), the corpus luteum is so large that it forms almost half the mass of the ovary. She went on about not seeing any cysts and the follicles having ruptured. Not only could she not distinguish a corpus luteum from ordinary ovarian tissue - she didn't appear to know what it was.
However when I had seen Dr Rimmer I had been on day 19 and she had recorded that the ovaries contained small follicles, but had not mentioned a corpus luteum so perhaps it could only be distinquished with very good equipment -or perhaps none were being formed. 
The radiographer said that I had a large fibroid and that she could see the womb lining deflected forwards by it. She could also see several other areas that she identified as fibroids. This I found extremely surprising. My large, solitary, fibroid sitting on top of the womb had somehow changed position and slipped down behind the womb cavity and had been joined by several smaller friends. As fibroids are slow growing the only way these could have grown from undetectable to moderately large in less than 8 months would have been by being malignant. I just didn't believe it.
And what about the fluid on my kidneys? Well you had to have be a doctor to do a kidney scan and Dr Dunn had only put down "pelvic scan" so that was all I was getting. Perhaps the doctor was going estimate the water damage to my kidneys with a divining rod when I saw him. Or perhaps he didn't think it of any importance.
I had written a letter requesting a copy of the ultrasound report and gave it to the radiographer. She didn't know what to do with it and she said she would pass it on to the doctor.
As I left I noticed that the asian family was still in the waiting area.

When I saw Dr Dunn a week later, on 9 March, he had another female student. Dr Dunn didn't have the latest ultrasound report and when it was eventually unearthed he only glanced at it and threw it aside. There was, of course, no copy for me. He said absolutely nothing about the blood and biochemistry tests done.
The student had to have a grope of the mass. Well they have to learn by practising on patients, and you can't allow them to use private patients. Dr Dunn apparently expected me to parrot my menstrual problems for the benefit of the student. I did not feel like performing and was unco-operative. I had related my history, I had written it all down and it was in the notes. And I didn't have the notes. The medical professionals did. Why couldn't they read them occasionally? I felt like an exhibit again. And became very sullen.
No I wasn't happy with the lump and if it wasn't going to get any smaller I wanted it removing. He got the surgery book and wrote me down for June 13. He went on (again) about maybe having to do a hysterectomy. I told him I didn't want a general anaesthetic. He would not be happy operating on a conscious patient. Well I was not at all happy at the idea of being unconscious while somebody I didn't trust an inch sliced open my body. I was sullenly silent. He said I would have to see the anaesthetist.
Dr Dunn wrote "Accepts = MYOMECTOMY =" in the medical notes.
What about GnRH-a treatment? He wrote out a prescription for Zoladex and told me to get it from the pharmacy and come back and knock on the examining room door. There was a queue at the pharmacy and it was some time before I got back to the out patients waiting room. I knocked several times on the examining room door and eventually a nurse appeared from somewhere, took the Zoldex off me and told me to wait again. Some 10 minutes later she showed me to a different room where a young apprentice doctor had a grope of the lump and stuck a needle into my belly fat.
Zoladex produces an initial rise in oestrogen before a fall to menopausal levels. If the first implant is given in the second half of the menstrual cycle then the oestrogen fall co-incides with the expected menstrual period and no more bleeding follows. If it is given in the early days of the cycle the normal period is followed by a further oestrogen withdrawal bleed as the Zoladex takes effect.
I was on the last day of my cycle and the period that started the next day was followed 16 days after the injection by a withdrawal bleed that lasted more than a week. There was no attempt to time Zoladex treatment to avoid withdrawal bleeding and I was not asked what day of the cycle I was on.
I had kept a copy of the hospitals record request form and anticipating unco-operation with my request for a copy of the ultrasound I had brought it with me along with a self addressed envelope. I filled in the form asking for the ultrasound report and any letter to Professor Tizzy from the Brook practice from September 1993 and left it at the hospital.
Again feeling depressed and very distrustful and uncertain about what I should do, on 14 March 1994 I wrote once more to the US.

Dear Dr Friedman

I wrote to you in December 1992, when I was trying to find out why I should be condemned to the barbarity of hysterectomy with no attempt made to conserve my womb merely because I was over 40 years old.
After reading around the subject (Mendelsohn, Stokes, Scully, the HERS Foundation) I now feel sure that this is because medicine is run by a bunch of male chauvinists who have no respect for any organ they don't personally need.
Weingold in that great tome Principles and Practice of Clinical Gynecology, by Weingold, Kase and Gershenson, is dead set against women retaining their reproductive systems after the age of 35 and writes, "Generally, myomectomy is the applicable procedure in the patient desiring further childbearing and under the age of 35.
Beyond that age the patient should be made aware of the possible need for repeat surgery for recurred myomas and should be carefully counselled in order to be certain that an informed consent is obtained.
For the patient who has completed her family and who has symptoms or uterine size equivalent to that of a 12 week gestation hysterectomy is the procedure of choice."
As I've noticed before (frequently over the last 2 years) the "choice" is that of the surgeon. The little woman is not asked if she feels that her womb is of any importance or use to her. And although the older woman is LESS likely to have further fibroid problems after myomectomy, since she has fewer menstrual years left, she is MORE likely to be mutilated, since the medical profession regards the womb as being there only to carry their children. As they generally react with abhorence at the idea of older mothers all older women with womb problems must of course have their organs excised - all of their organs. I find it very interesting that women are subjected to "prophylactic" castrations galore when there is no such thing as a "prophylactic" prostatectomy, even though the prostate is only a gland, much easier to excise and causes twice as many cancer deaths as do the ovaries. Not to mention the fact that castrated women are now dying from abdominal cancer indistinguishable from ovarian cancer.
Weingold also stated that, that "Myomas should be removed when their conglomerate size exceeds that of a 12 week gestation", obviously a tad smaller than my present lump and "Hydronephrosis is a clear indication for surgery". Besides agreeing with Reiter that women should not be routinely mutilated because of asymptomatic myoma your article in the Am J Obs Gy last March stated that "stable, asymptomatic hydroureter does not increase the likelihood of urinary tract infection or renal damage and should not be considered an absolute indication for surgical intervention".
Since I last wrote my 23 week mass has increased to 25 weeks or so and I enclose a copy of the detailed ultrasound it took me a year to get out of the NHS. Professor Tizzy, who ordered the scan, seemed to think the hydronephrosis significant enough to warrant surgery but since he retired his successor feels that since I don't have much in the way of symptoms I don't need surgery.
I found this surprising since more than a year previously, and before 
hydronephrosis had been discovered, 2 female gynaecologists and their assistants, had all declared that I should be mutilated.

After writing about how they had all tried to get me fixed I related my bleeding and leucorrhea and continued by quoting from the doctor's article:-

But "If the fibroid uterus causes symptoms, the severity and impact of the symptoms on a woman's quality of life should be the primary factors involved in a decision about the need for and urgency of surgical intervention" are my symptoms severe enough to require surgery? How severe is severe? How significant is mild bilateral hydronephrosis? How significant is a melon sized myoma?
This month another ultrasound was done but I haven't yet managed to tear a copy from the system. Apparently the mass has increased in size to 16 x 16 
x 11 cms and the radiographer noticed more than 1 fibroid. A renal scan was not done since the present medic did not ask for it. He is apparently totally unconcerned by mild hydronephrosis and feels no need to monitor it, though he did have blood electrolytes done 4 months ago.
Being single and fundal (according to Dr Rimmer) I don't see how the fibroid could be easier to remove, and in fact Prof Tizzy stated that its removal should be "technically easy". But both times that I have seen Tizzy's successor he has been going on about maybe having to do a hysterectomy not a myomectomy because of blood loss at operation. No-one tells the hordes of women hysterectomised every year that there is about a 25% chance of their operation causing premature ovarian failure, that they may lose their sex life or that complications are frequent. Yet he stresses the low possiblity of heavy operative blood losses requiring hysterectomy. Frankly I find this highly suspicious. Also both times I saw him he had a student in tow and I felt like a specimen on exhibition. This made me even more sullen, bad tempered and uncommunicative.
I have absolutely no desire to be cut at all. I can't say that I feel happy about permanently carrying a melon sized growth around in my belly but as I don't have any pains and I am no longer anaemic perhaps there is no need for surgery. But..
I am not likely to become menopausal for more than five years and this lump is not only already a fairly considerable size and growing but also degenerating, with signs of calcification. If it's going to grow and degenerate and become refractory to menopausal shrinkage then I'm faced with a situation which is not only going to get increasingly worse but leaving it may reduce the effectiveness of GnRH-a therapy.
As you seem to be the most experienced user of GnRH-a therapy can you tell me if I am being unnecessarily alarmed. Or is calcification a bad sign?
As you may have gathered neither my reading nor my personal experience has inspired the faintest trust in the medical profession. I have had to fight and ferret for every scrap of information from my own medical files. And if it hadn't been for the 1990 Access to Information Act I wouldn't have got anything at all.
And what I have read in gynaecology textbooks does not accord with many experiences of mutilated women and their hysterectomy aftereffects.
I still keep coming up with the same basic facts that myomectomy can be done in nearly all cases and the reason it is not is apparently based solely on the victim's date of birth. I have written to several people about this, including Weingold, and I don't even get an answer. This I regard as extremely significant. And in the absence of any justification for the wholesale, determined uterine amputations performed on uninformed females I can only conclude that my worst suspicions are perfectly correct.
I hope you find the scan interesting. 

Yours sincerely
Pamela Nomark

Friedman's reply was dated 26 March. He said:-

Dear Ms Nomark:

I received your letter of March 14, 1994. I sympathize with your plight. From your description of your symptoms, it seems quite reasonable that you seek some treatment for your uterine symptoms. I have made it a policy not to offer advice to individuals whom I have not personally examined nor seen in the office. Thus I cannot render a specific opinion for you and your situation. If you ever plan to come to Boston, I would be happy to see you.
I wish you the best of luck in your condition.

Sincerely
Andrew J Friedman, M.D.
Chief
Division Of Reproductive Endocrinology

I could have done with less sympathy and more factual information. As far as I could make out there were few people in the world who had more practical experience of GnRH-a shrinkage of fibroids than Dr Friedman but he wouldn't make any comment on the mass. Miss Godly was not so circumspect. She had no doubts about the treatment I needed even though she had never actually examined me. At least Dr Friedman wrote back, which is more than most will do.
Though I had told the receptionist that I had no GP the hospital, on 13 March, had written to Dr Fearless, informing her that I was having Zoladex treatment. She told them I was no longer her patient, and I again confirmed that I had no GP but the hospital continued to keep the completely disinterested Dr Fearless informed of my treatment. It seems that the system is so geared to writing to GPs that it cannot stop doing so.

At the end of March I received a copy of the ultrasound scan. It was done by an unspecified radiologist and said:-

The uterus measures 16 x 16 x 10 cm. It appears to consist of a large fundal fibroid on the left measuring 8 x 8 x 6 cm and displacing the endometrium superiorly. Also to the right there is some calcification ? also fibroid. Superior to the cervix is also a smaller fibroid at 4 cm. Both ovaries seen NAD.
J. Keit

This was very much less detailed than the July scan and I didn't think it was consistent. I decided to write to Dr Dunn and ask him about it. On 21 March I reproduced the two scan reports and then asked:-

Does this mean that the previously single, 15.7 x 15.0 x 9.8 cm, fibroid has split into two? And somehow slipped down behind the endometrium? And that another fibroid has grown from undetectable to 4 cm within less than 8 months? And wouldn't such rapid growth of a fibroid be considered indicative of malignancy?
Could you tell me if this is what has happened or if I have misinterpreted the scan reports.

Yours sincerely
Pamela Nomark

On 6 April I was back at St Mary's for my second Zoladex implant. An efficient female doctor whom I later found to be the senior house officer, Dr Brisk, did the injecting before Dr Dunn appeared to say now was it myomectomy or hysterectomy you're having. I didn't know whether he had no idea who I was (and of course had never so much as glanced at my medical notes), was just trying to upset me, or thought that with a bit of prodding I might change my mind about mutilation.
I had been looking at the calendar and as I was concerned about the timing of the Zoladex treatment had written a note which I gave to the doctor. It said:-

Professor Tizzy said that surgery would be 2 weeks after the last GnRH-a treatment.
In the literature Golan et al gave the last GnRH-a treatment 1 month before surgery. Friedman et al performed myomectomy within 4 weeks of the last GnRH-a injection. A'Addato et al also recorded that myomectomy was performed within 4 weeks of their last GnRH-a treatment.
However my last Zoladex injection is due on 4 May and surgery has been scheduled for 13 June, nearly 6 weeks later.
If the reason for Zoladex treatment (expensive treatment - as I was reminded) is to reduce the uterine and myoma blood supply, and myoma size, what is the point of postphoning the slicing and hacking until the drugs's effect is fading?

Dr Dunn wanted to know where I got the information from. It came from Medline, as he would have realised if he had read my medical notes. He said that another Zoladex injection could be given in early June. This would add another ?126 to the bill. I thought that more attention to scheduling would have been in order. There just didn't seem to have been any organisation or planning done at all.
On 9 April I received a letter, dated 31 March, which said:-

Dear Miss Nomark

Thank you for your letter of 21 March 1994. I very much doubt that the single fibroid has split in two. I have not known this happen, however, another fibroid may well have developed adjacent to the larger one. The rate of growth is not specifically indicative of malignancy and this is extremely unlikely as you are aware.
I hope that this is of help.
Best wishes

Yours sincerely
Dr P Dunn
Consultant Gynaecologist

I thought this was ridiculous and on 12 April wrote to the radiologist:-

Dear Dr Rimmer

Last July you did a scan of my fibroid womb, of which I enclose a copy. In March this year another scan was done at St Mary's and I enclose a copy of this. This second scan seems very different to me and I should like somebody to explain it to me. I wondered if the "large fundal fibroid" of July had split in two by March, but I have been told that this does not happen and that a second mass has sprouted next to the original one.
However the ultrasound of July 1992 specifically stated that the uterine mass, described as "a large, fundal fibroid", measured 15.7 x 15.0 x 9.8 cm - not much smaller than the 16 x 16 x 10 cm given as the entire uterine size by the March scan. So if that fundal fibroid is in fact the "large fundal fibroid" measured by the March radiographer as now being 8 x 8 x 6 cm then its mass has decreased from 1,200 ccs to 200 ccs, a matter of 83%, in less than 8 months. And at the same time another mass, possibly a fibroid, has materialised, complete with calcification, to occupy the space, about 1,000 ccs, vacated by the amazing shrinking fibroid. I find this truly incredible. Fibroids do not usually grow from nothing to 1,000 ccs in less than 8 months. Neither do large myoma usually shrink spontaneously by 83% - unfortunately.
The March scan also recorded that the endometrium had been displaced superiorly while your July scan could not find any encroachment on the uterine cavity. It also made no mention of any signs of smaller fibroids above the cervix.
I get the impression that the July scan was a proper detailed one while the one done in March was a rough recording on basic equipment and of very limited use except as a diagnosis. If you accept the March scan as meaning exactly what it says then there have been pretty drastic changes. If it is not to be relied on then what was the point of doing it? It seems like a waste of time, effort and money to me. And some of that time was mine.
If this is not an accurate analysis of the scan situation could you please tell me what is.

Yours sincerely
P Nomark

As there was no reply I sent another copy of this letter, by recorded delivery, on 10 May. A reply, dated 11 May and postmarked 18 May, came on 20 May.

Dear Mrs Nomark

Re: your pelvic scans.

The initial scan carried out by myself on 22 July 1993, as you know demonstrated a large, fundal fibroid. It is not unusual to follow up such fibroids if they are being managed conservatively to see how they progress and accordingly Dr Dunn, to whose care you had been transferred following Prof Tizzy's retirement, requested a follow-up scan in March after a time interval of seven months. The reason for this is that fibroids may vary in size over time.
As regards the equipment on which you were scanned, it does seem to be one of our three Acusons which are all state of the art equipment, though the one in the room in which I myself scanned you does have additional facilities, though not ones which are routinely used when visualising fibroids.
Clearly from the measurements I would agree that there seems to have been a marked change in the size of your uterine fibroid. It is also not unusual in a fibroid uterus to see additional fibroids develop and the finding of other fibroids does not surprise me after an interval of seven months. Clearly it was important to be certain that your uterus had not dramatically increased in size over that interval and as such the scan was helpful and reassuring.
I understand that Dr Dunn will be seeing you again with a view to  discussing the most appropriate form of treatment and I hope that your problem is soon resolved satisfactorily.

Yours sincerely
Dr S Rimmer
Consultant Radiologist

So the detailed scan I had had at the professor's request was unusual for fibroids which, as we all know, are routinely treated with routine mutilation requiring no further investigation. The attention paid was also unusual. An uninteresting fibroid will normally be scanned by a radiographer only, as I was at Helton.
Had there been a marked increase in the size of my womb I would have been conscious of it without the need for a scan. And I was not at all reassured by a follow-up scan that alleged that, although my actual womb size had not increased at all, fibroids were shrinking and appearing in it like night grown mushrooms, when it was well known that normal fibroids grow slowly and rarely shrink much, if at all, before the menopause. It made less sense to me than "The Jabberwocky", no matter how unsurprised Dr Rimmer was.

In early April I had received an appointment to be assessed by the anaesthetist on 25 April. In Understanding Anaesthesia Carrie and Simpson remark that both spinal and epidural nerve blocks could be used as the only anaesthetics for surgery and it is patient expectation which limits their use, as British people expect to be unconscious for surgery. This is not so in other countries, where general anaesthesia appears to be much less common. I gathered together this quote, some Medline abstracts on the high usage of nerve blocks for major surgery in eastern countries and an account of the removal under epidural anaesthesia of a fibroid "the size of a basketball".
I had reluctantly come to the conclusion that given the fibroid's size, its associated symptoms, its effect on my kidneys and the certainty that little short of a miracle was going to make it shrink that surgery was the only logical option. Herbalism had not made it regress, and homeopathy had not helped. I had first considered epidurals after I saw the professor but it was just an idle thought and if he had said it was best I would have settled for a general anaesthetic. I felt that I was lumbered with Dr Dunn and did not think that being operated on by a man you did not trust was a satisfactory situation but was there anywhere a gynaecologist that I could trust? And how would I find this rarity? Then there were the restrictions of the NHS which mean that you have to go to a GP to get a referral to somewhere with whom they, or the health authority, have financial contracts. I didn't want to start all over again but there was no way I was going to be out cold while somebody I positively mistrusted rummaged amongst my internal organs. Either I was in on the op or there wasn't one. I can be very indecisive but when I make my mind up I'm as stubborn as a mule.
I started accustomising myself to the idea that the surgery was going to be cancelled. And why not? Most times it is better to get things done properly than quickly. I was sure that since the discovery of the mass 2 years ago it had grown very little. It was highly unlikely to become suddenly malignant or dangerous and Dr Dunn had seemed very unconcerned about it. Perhaps I should write again to the gynaecologists' college to see if they would give me the name of a competant conservative surgeon.
And on 25 April I went off to the Out-Patients department at the Royal Hospital with my references and a medical records request form so I could, if necessary, finish the St Marys file by updating my records.
But after being weighed and measured I was seen by a very amiable doc who said that though epidurals were not common outside of birth interventions if I wanted one there was no reason why I couldn't have one.
And that was that.

When the Zoladex took effect I started getting hot flashes. Sometimes it would be my face that got hot and red but most times the flash started in the chest and spread outwards. But they weren't a problem and I knew the effect was only going to be for a few months.
I arrived early for my next appointment at St Mary's, 10 days later on 4 May. There was a plain, inconspicuous, typed letter sellotaped on the top of the reception desk, where there was little danger of its being noticed. It said that there were staff shortages due to illness and maternity leave and there would be delays. The receptionist couldn't find my notes. I sat down and about 10 minutes later a woman turned up to question me. I told her that my notes had definitely been present when I had been to the anaesthetic clinic, a ten minute walk away. When I was finally seen, more than an hour after my appointment time, by what appeared to be a very junior doctor, my notes still hadn't materialised. She had no information on me and had no idea why I was there. However as I had got the Zoladex from the pharmacy all she had to do was inject it, after telling me that of course I might suffer so much blood loss that I would have to be butchered. Then she rooted around for a plaster to put on the welling blood.
I found this constant harping on about the necessity to do a hysterectomy extremely suspicious. When Bonney could remove 40 fibroids weighing 21 pounds more than 50 years ago, before modern anaesthetics, antibiotics or blood transfusions, and without Zoladex to reduce the blood supply I found the suggestion that Dunn could not remove one (probably), easy to reach, Zoladex treated, solitary fibroid whose removal had been described as "technically easy" without a big "well we might have to do a hysterectomy" production as tantamount to an admission of incompetence.
I remembered to point out that I needed another implant to maintain my Zoladex levels. Miss Doctor said that 7 June was only slightly more than a month away. But that was the date of the preoperative clinic appointment. The operation day was nearly 6 weeks away. She gave me another prescription. She asked if the lump had reduced at all and I said that it didn't seem to be smaller but in the next few weeks it did appear to shrink somewhat. It did not rise so far up my belly in the morning but I thought this might be due to the effect Zoladex has shrinking the normal womb tissues as well as fibroids.
A week later I had a bruise as big as a 10p piece over the needle-mark on my belly. I was quite surprised to find that Miss Doctor was, in fact, not a junior doctor but a registrar.

On my last appointment, on 1 June, I asked about autologous blood donation - giving your own blood for use at operation if necessary. The heftly registrar, Dr Brandy, went off to telephone around and then told me that if you needed blood after myomectomy you would need a lot, up to 4 units, so there was no point in just taking one now. I would have to have been giving blood for the past 4 months to have made that much up. He went on about the blood being safe. I didn't think that relevant. If I needed a transfusion I wanted my own blood, or even some of my own blood but I wasn't going to get it. Nobody had mentioned autologous blood donation to me. Although it was supposed to be an option they obviously weren't bothering with it.
Nezhat et al wrote that all their patients were encouraged to store 1 to 2 units of blood for possible autologous transfusion but I couldn't get the NHS to take mine. I had never thought that they would want more than 1 unit of blood and I wished that I had asked about it sooner especially when I read that Dr Brandy had written:-
"On their (the Blood Transfusion Service) behalf I have reassured Miss Nomark that all blood products are now carefully screened and that although there still is a risk of infection from blood transfusion, they feel this risk is in fact extremely small."
Considering what you can get from blood it was a risk I would have rather have not taken - however small.
I later read that an estimated 0.8% of the population is infected with hepatitis C, mainly from blood contacts, and before it was monitored for, pre 1991, at least 3,000 were contaminated by blood transfusions. In a quarter of cases it can be cured by interferon treatment at ?1,500 to ?3,000 per person. I wonder what further diseases will be found to have been passed by blood transfusions in the future.
On 7 June I attended the preoperative clinic. Here I was first sent to have blood removed for testing, and later seen by the woman who had done my second injection to be quizzed again - health problems, drugs taken, smoking, last menstrual period. Last menstrual period? When I had been on menopause-inducing Zoladex for three months. The amount of mind numbing repetition is incredible. Did I have any questions? What sort of cut was going to be made - the low horizontal or the vertical. Well Dr Dunn would make his mind up about that, but it would probably be the vertical. I didn't think he would use membranes, like Gor-Tex or Interceed, to cover the cut on the womb and stop it sticking to other organs like the gut, but his assistant didn't even seem to have heard of them. In fact Fayez and Dempsey found simple Ringer's lactate to be as effective as anything else at reducing adhesions but even this does not appear to be used by the NHS.
Adhesions are caused by pelvic infections, endometriosis and operative damage. Factors which increase adhesion formation are drying of the womb surface, contact with blood, infection and contamination with talc from surgical gloves. Constant irrigation, strict control of bleeding, preventative antibiotics and talcless gloves can help to prevent adhesion formation.
Then I had to have the "Well we might have to do a hysterectomy" speech again. I pointed out that in the 3 papers I had found, covering over 340 myomectomies, the only hysterectomy was performed after a hack had removed a woman's entire womb cavity. In spite of the fact that none had Zoladex treatment to reduce blood flow none had bleeding heavy enough to justify a hysterectomy. Although dangerously heavy bleeding appears to be extremely rare it is frequently mentioned.
I baulked at the consent form which Dr Youngson considers too generous in its license to cut out anything clause. Then I'd have to see about that when I came in to hospital and in the meantime Dr Brisk had 14 women to see and was getting impatient.
Monaghan considers it restrictive and unreasonable to have to fully inform a patient of all the risks she is running and insists that surgeons should still have a "permit to do anything they think necessary" clause. Of course what a male surgeon thinks necessary and reasonable may not be what the patient feels to be necessary and reasonable and I get the feeling that although Dr Monaghan insists that patients should be informed about the treatment they are getting he does not think they should never be consulted about what treatment they would like. Though as he appears to specialise in cancers Monaghan's patients would perhaps have few treatment options. 
I returned home with what was now becoming a regular post medical encounter depression.

On the morning of Sunday, 12 June my teaching sister and her boyfriend took me to the hospital and came up to the ward with me. I kept reminding myself that I did not need surgery. I would survive without it and if I was still unhapppy after seeing Dr Dunn I could get the train home. I was very pleased with the accomodation as I had been allocated what I decided was the best bed in the house. A single room situated on a corner away from the bustle of the entrance, it had a large window with a panoramic view of a notorious city area associated with violence and drugs, vertical blinds, a shower with a tiled motif of two birds on a flowering branch and large cupboards full of vases and other oddments. I was also favorably impressed by the long visiting hours (11 am to 8 pm) and being told that I didn't have to act like an helpless inmate by immediately changing into nightware and going to bed.
Dr Dunn appeared soon after check-in time and said he was glad I had arrived on time as he had a tight schedule and was "on a knife edge", a description which I thought applied more accurately to his patients.
He had had a word with the anaesthetist, who knew that I wanted an epidural because I didn't trust gynaecologists at all. He told me that the psychologist mother of another patient had insisted on being present in theatre to ensure that her daughter's myomectomy was just that. So I wasn't the only one with suspicions. It was scarcely reassuring to find that even members of the medical profession do not trust doctors to respect either their wishes or their wombs.
I was assured that he wouldn't make a spurious excuse to whip out my womb as soon as I was on the operating table but I would just have to trust him on this as he wasn't having a patient bleed to death on him. It is extremely bad form to have a non-emergency patient expire on the operating table.
He had another feel of the lump and remarked on how mobile it was. Which cut did I want? Well as the horizontal cut is the strongest and heals best, being associated with less wound infection, that was what I preferred so that was what I was getting. Clamps and vasoconstrictor injections would be used to restrict bloodflow to the womb so there wasn't really anything else that could be done to ensure an easier operation. So I signed the consent form as it was, feeling too chicken to start crossing things out and perhaps cause more ill feeling. I now felt definitely committed to surgery and said I would also like to see the excised fibroid.
Then he blew his credibility by asking about my ovaries. Well I was keeping them of course. I was not having a distorted womb junked when it could be salvaged. So I was certainly not going to have 2 perfectly normally functioning ovaries destroyed and my entire hormonal balance thrown permanently out of balance on the vague chance of preventing ovarian cancer in the future.
The nurses were all very friendly and reassuring. The same questions were asked again, my blood pressure taken and I was labelled with the usual plastic wristband as an official ward resident. The ward notes recorded that I was first on the morning list and was, "Fanatical regarding research on myomectomy".
A fanatic - moi? Just because I wanted to know all the facts and had enough scientific education to understand them?
Surely not.