Our Bodies, Ourselves (130 page)

Current research is focusing on identifying biomarkers—proteins in the blood that indicate the presence of cancers and how they will behave. Research is also looking at ways to keep cancer cells from reproducing, such as cutting off the blood supply to tumors and changing the genetic instructions that make them grow out of control; and developing drugs that can target cancer cells without killing healthy ones. In the foreseeable future, further work in these areas should result in more individualized and effective treatments—and perhaps even a cure. Participating in research such as comparative studies or clinical trials of new treatments is an opportunity to contribute to progress in breast cancer research and can be meaningful for some women.

The uterus (womb) is a pear-sized organ made up of muscle that sits in the lower abdomen. It is lined with endometrium, hormonally sensitive tissue designed to nourish a developing embryo. Each month that a woman doesn't conceive, this lining is shed through a menstrual period. The uterus can stretch to accommodate a growing fetus, then push the baby out and return almost to its former state. The cervix is the opening to the uterus. It protects the inside of the uterus from the outside world and then opens during labor to let a baby out.

This section covers some of the major conditions and problems we may experience with these parts of our body. For more information on the anatomy and function of the uterus and cervix, see
Chapter 1
, “Our Female Bodies.”

Fibroids are solid benign smooth-muscle tumors
*
that appear, often in groups, on the outside, inside, or within the wall of the uterus, possibly changing the size and shape of it. Many fibroids cause no problems at all, and many woman do not even know that they are present. Most women with fibroids can conceive and carry a pregnancy to term without any special treatment.

© Casserine Toussaint

A uterus without fibroids, left, and a uterus with fibroids (benign growths), right

Some fibroids, depending on size and location, can cause heavy vaginal bleeding, abdominal or back pain, urinary problems, and constipation. Sometimes they may make a woman's belly look bigger. Fibroids that bulge into the uterine cavity (submucous fibroids) may make it difficult to conceive or to sustain a full-term pregnancy. There are several way to remove fibroids—which one is best depends on the size and location of the fibroids, as well as the skills of your surgeon. In at least 10 to 50 percent of cases in which fibroids are removed, new fibroids grow. However, only about 20 percent of women will require more treatment.

About 30 percent of all women get fibroids by age thirty-five and almost 80 percent of women will have fibroids by age fifty. Black women are more likely to have them, and to get them at a younger age. The cause of fibroids is unknown. About 40 percent of fibroids will grow during pregnancy, usually within the first three months. Some researchers used to think that using oral contraceptives made fibroids grow, but this is not as clear with low-dose pills. Very rarely, taking estrogen after menopause might affect fibroids.

Fibroids may be discovered during a routine pelvic exam. Because fibroids can grow, they should be monitored. If they haven't grown any more by the time you have your next monitoring exam several months later, a yearly checkup will be enough. Ultrasound can give more definite information about the number and size of fibroids, but this is not always necessary.

If you have fibroids and abnormal bleeding, be sure to get carefully checked for other possible causes of the bleeding (see
“Abnormal Uterine Bleeding”
).

In many cases, no treatment is necessary for fibroids; this is called watchful waiting. If you are nearing menopause, the natural decline in estrogen levels at that time usually shrinks fibroids. Although many physicians recommend hysterectomy—
removal of the uterus
— as a treatment for fibroids, this is usually not necessary.

Myomectomy.
If you have excessive bleeding, pain, urinary difficulties, or problems with pregnancy, you may want to have an operation called a myomectomy to remove the fibroids. Done by a skilled practitioner, myomectomy avoids some of the problems associated with hysterectomy and poses no greater risks. Even large, multiple fibroids can be removed with a myomectomy. There are several approaches, depending on the size and location of the fibroids.

Embolization of the uterine arteries.
This procedure, performed by an interventional radiologist, cuts off blood supply to the fibroids, making them shrink. It reduces bleeding and tumor or uterus size in most women who have it done. The recovery time is typically shorter than for surgical removal of fibroids, if the procedure goes smoothly. Complications may include severe pain and fever that might require an emergency hysterectomy, damage to the uterus or other organs, and loss of ovarian function due to a constricted blood supply (this leads to premature menopause). For these reasons, this may be a risky approach for a woman who still wants to get pregnant.

Focused ultrasound surgery.
Also called focused ultrasound ablation, this is another less-invasive option, but it can be used only for smaller fibroids and is not widely available.

Other treatments.
Sometimes the drug leuprolide acetate (Lupron) is recommended to help shrink fibroids in women approaching menopause or planning to have surgery. However, Lupron has many negative effects, some of which may last many months beyond use of the drug. These include hot flashes, vaginal dryness, trouble with memory and concentration, and bone thinning. Also, after the Lupron is stopped, the fibroids can grow back.

The newest treatment, a medicated intrauterine device (IUD) called Mirena put into the uterus, can reduce bleeding and possibly enable you to avoid surgery.

Some women try to prevent or reduce fibroids by avoiding processed foods and the hormones usually found in commercial meat, dairy, and egg products, but there is no evidence that this will work. If your fibroids cause heavy bleeding, see the
self-help treatments
. Yoga exercises may ease the feelings of heaviness and pressure; some women find visualization techniques helpful, too.

Polyps are a focal buildup of the uterine lining. Sometime benign polyps can grow in the uterine lining and cause a woman to have heavy periods or bleeding between periods. Once they are diagnosed—usually by ultrasound, and sometimes by a procedure with a thin fiberoptic instrument called a hysteroscope—they are typically easy to remove. Removal is usually recommended because of the small risk (fewer than 3 out of 100 polyps) that they may be precancerous, and to treat abnormal bleeding.

The endometrium can also become hyperplastic owing to abnormal growth of the endometrial cells. This condition can cause abnormal uterine bleeding, especially in women who are not ovulating regularly or who are taking estrogen without progesterone (or a progesterone-like substance like a progestin). While endometrial hyperplasia is benign, another condition called atypical endometrial hyperplasia can be a precursor of cancer of the lining of the uterus (endometrial cancer). In this circumstance, a hysterectomy is sometimes recommended to prevent the development of uterine cancer. Benign endometrial hyperplasia may be treated with high-dose progesterone, depending on the woman's age or intention to become pregnant, or with the Mirena IUD, which contains a progestin.

Endometrial cancer is the most common pelvic cancer, affecting fourteen out of every ten thousand women yearly. Most women with this cancer are over fifty and past menopause; 10 percent are still menstruating. If you are heavy for your size, take synthetic estrogen without a progestogen, or have diabetes, high blood pressure, or a hormone imbalance that combines high estrogen levels with infrequent ovulation, your risk of uterine cancer is increased.

During the early 1970s, there was a sharp rise in the incidence of uterine cancer because of estrogens prescribed for menopausal women without any additional progestogen (progestin or progesterone) to reduce the chances of endometrial hyperplasia. Taking progestogens usually prevents the development of this condition in women taking estrogen.

Bleeding (including light staining) after menopause is the most common symptom of uterine cancer. However, most women who bleed do not have cancer. For women who are still menstruating, increased menstrual flow and bleeding between periods may be the only symptoms. Unfortunately, the Pap test, while effective at detecting cervical cancer, is not reliable for detecting uterine cancer. If you have the above symptoms, your medical practitioner will probably recommend an aspiration or endometrial biopsy to sample the uterine lining—this is a simple office procedure. In some cases, a dilation and curettage (D&C) is preferred (performed with intravenous sedation or general anesthesia). Make sure that you have discussed the risks and benefits of these alternatives before making a decision.

Because endometrial cancer appears to be influenced by factors such as obesity, hypertension, and diabetes, controlling these conditions with self-help methods may prevent this type of cancer from developing. Exercise and a healthy diet with plenty of fruits and vegetables is the best strategy.

When uterine cancer is found early, the success rate of conventional treatments is very high. Medical treatment for uterine cancer includes surgery, radiation, and chemotherapy. There is wide disagreement about which is best. Outside the United States, radiation is used frequently with good results. Hysterectomy is the most common treatment in the United States. Follow-up radiation after surgery is possible if the tumor was large, if it is found or suspected to have spread to the lymph nodes, or if cellular
changes suggest a fast-growing tumor. Hysterectomy can often be done laparoscopically. If the cancer comes back after one of these treatments, progestogen treatment may help slow it down.

Heavy menstrual bleeding (which may include clots of blood) or bleeding happening outside the normal cyclic menstruation is referred to as abnormal uterine bleeding (AUB). AUB is a common gynecological problem, but its causes can be tricky to diagnose. The most likely cause of AUB for any woman depends on whether she is premenopausal, perimenopausal (near menopause), or postmenopausal.

Some causes of AUB include hormonal imbalances, pregnancy, the use of hormonal contraceptives (birth control pills or Depo-Provera, for instance), fibroids, endometrial polyps, infection, and, more rarely, precancerous or cancerous growths. Infrequently, bleeding that seems to be coming from the vagina may actually come from the urinary tract or gastrointestinal tract. For severe bleeding without an obvious explanation, ask to be screened for von Willebrand disease, especially if you have a history of other
bleeding problems
.

Fibroids can cause heavy, longer periods, sometimes with cramping and clots. More commonly, this occurs when the fibroids are submucosal and impinge on the uterine lining. Such periods are usually not irregular.

In addition to being a sign of a possible physical problem, heavy and/or irregular bleeding is a nuisance. It can also result in anemia from low iron and thus cause fatigue. Sometimes, heavy and prolonged bleeding may be part of the normal transition to menopause.

During perimenopause (the transition to menopause), new and different bleeding patterns are common. That makes it hard to decide when the menstrual cycle is normal and when there is a problem. The amount of blood flow may vary from month to month. Women sometimes skip their period for a few months, and then have regular periods again. However, if you are experiencing many episodes of irregular bleeding as described in the box above, it could be a sign of a medical problem that should be addressed.

Women who take hormone therapy may experience normal or abnormal uterine bleeding.
You should understand what pattern is expected with your hormone prescription and contact your health care provider if your bleeding is different from what you've been told to expect.