My gynaecologist advises a hysterectomy because my fibroids have grown since I started on hormone therapy fourteen months ago. What should I do?

Fibroids only need to be treated if they are causing symptoms such as heavy or painful periods, abdominal pain, or difficulty with bowel or bladder function. Treatment is also necessary if there is any suspicion that a fibroid is turning into cancer, as indicated by its rapid growth. This is a rare occurrence, affecting only about one woman in every 800 with fibroids. If your fibroids are growing but are not causing any of the symptoms mentioned or are not suspected of becoming cancerous, then treatment is not necessary. If you are nevertheless concerned about their growth, you should consider whether you can do without hormone therapy or whether an alternative type of hormone therapy is worth trying.

Do I really need a hysterectomy?

If you are uncertain you should seek a second opinion by consulting another specialist or asking your general practitioner for advice and for another referral. Don’t be steamrolled into making a decision. It is extremely important that you are satisfied you have all the necessary information and expert advice needed before proceeding.

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Those who are sceptical about the importance of nutrition in pre-conceptual care argue that there are many cultures where the women are living through famine and yet we see them on the television with babies. They conclude that the lack of nourishment is not affecting their fertility.

However, studies have shown that in fact the babies are not born to the most undernourished women (as they are infertile) but to those whose intake is marginal, and the unfortunate outcome is sick babies. A number of studies have looked at fertility and what happens to babies when food is in short supply. During the short but terrible Dutch famine of 1944-5, right at the end of the Second World War, it was found that the timing of malnutrition was crucial. Women who conceived or were in the early part of their pregnancy when the famine struck had many more babies who died around the time of birth than women who were in the later part of a pregnancy when the food shortages happened.

This finding ties in with those on the effects of alcohol during pregnancy which is more damaging in the first 12 weeks. During the Dutch food shortage half the women of childbearing age lost their periods (i.e. became temporarily infertile). There was also an increase in stillbirths for those babies conceived during the food shortage.

Appallingly, there was also an increase in malformations among the babies born nine months after the Dutch hunger winter. These babies were conceived during the worst of the food shortage, and the impact seemed to continue in those women who conceived four months after the shortage was over. The implication is that they were still suffering the effects of malnutrition. This provides further evidence to support having a Four-Month Preconception Plan, to get the maximum benefit for fertility and the health of the baby.

Nature is extremely clever. At a time of food shortage, when the woman does not even have enough nutrients to nourish itself, it stands to reason that she cannot nourish a baby properly. So, in extreme cases of famine, the body shuts down its reproductive function, in order to avoid risking the baby’s health. The reproductive system is the only system we do not need to survive. In a time of literally life and death, the body channels its resources away from the reproductive system to other areas of greater need. As soon as the food supply is plentiful, periods return and fertility is often restored as soon as the first month, but an epidemic of miscarriages can often then follow.

Poor maternal nutrition during the most sensitive period of the baby’s development may produce lifelong changes in physiology and structure. And the most rapid cell division is taking place before most women know they are pregnant. The brain, heart and other major organs develop in the first month. When the placenta takes over, around the twelfth week of pregnancy, it can extract the nutrients from the mother’s blood for the baby. So, in the later stages of pregnancy, the mother could be nutritionally deficient and yet the baby would not suffer, unless the mother was severely malnourished. In mothers who subsequently gave birth to low birth weight babies, 43 out of 44 nutrients measured in the mothers were significantly below those of mothers whose babies fell in the normal range.

Unfortunately, and astonishingly, the UK ranks alongside Albania as having one of the worst statistics in Europe for producing seriously underweight babies according to the World Health Organization. As many as 7 per cent of babies in England and Wales are classed as ‘low birth weight’, which puts them more at risk of stillbirth, mental handicap, dying within a month, blindness, deafness, cerebral palsy and autism.

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The two side effects that are most difficult are hot flashes and the changes in sexuality. The frequency, intensity, and duration of hot flashes vary a lot from person to person. Some of us have only an occasional “warm flash,” while others of us drip with sweat. It is impossible to predict how many, how bad, and how long. You will become accustomed to your own rhythms of hot flashes, and you will find some strategies that help. They seem to be worse at night, at times of stress, and when the temperature is high. If you don’t already have air-conditioning in your bedroom, this might be a time to consider buying a unit.

The sexual side effects of menopause are also variable. The two general areas of change are in libido and vaginal dryness or elasticity. It is easy to blame these changes on the sudden loss of estrogen, and that, no doubt, is a big part of the problem. There are other contributing factors unique to women going through breast cancer. It is hard to feel sexy and desirable when you are bald, tired, and perhaps nauseated. The blows to your self-image and sense of womanliness are strong. Some women also feel assaulted by the many medical exams, all of which seem to involve breast exams. As much as you may love your partner, there may be times when you just do not want anyone else to touch you.

Changes in libido can happen suddenly or gradually. You may find that you have difficulty reaching orgasm or even that the previously erogenous zones of your body seem to have turned to wood. The same stroking or touching that used to feel wonderful may feel like nothing. In Hester’s groups, women are relieved to learn that they are not alone with these feelings. It is ironic that at a time when you may long for closeness and emotional comforting, you are uninterested in sex. The best way to manage is to talk honestly with your partner about what you are or are not feeling, reassure him or her that this is not about love and that it likely will get better in time. Most women have a slow and gradual improvement in response after treatment ends. The unfortunate truth is that you may never be quite as sexually sensitive as you were before. We hope, if that is the case, that the enrichment of your emotional relationships by virtue of what you are going through may provide some compensation. Many couples find that their love for each other is enhanced in ways never before imagined.

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Many women will be given chemotherapy and/or hormone therapy as part of their treatment for breast cancer. Chemotherapy may be administered in conjunction with radiation or in sequence with radiation (either before or after) or independent of radiation treatments altogether. In most cases, chemotherapy is administered prophylactically or adjuvantly (to prevent a possible recurrence of the disease, not to treat known active cancer). Malignant breast tumors usually grow slowly over time, and in many cases, the tumors detected at the time the diagnosis is made have been growing for quite a while. Since some breast cancer cells have the ability to spread to other areas of the body (metastasize), chemotherapy or hormone therapy may be recommended to treat the disease systemically by killing any cells that may have traveled away from the primary tumor. When successful, this treatment will prevent recurrence of the disease.

Generally speaking, most breast cancers need to be treated both locally and systemically. Mastectomy or wide excision with radiation ace the local treatment options; they are planned to prevent a recurrence of the cancer in your breast. They do nothing, however, to treat any cancer cells that may have already escaped the tumor and gone elsewhere in your body. Although your own immune system may be effective in destroying any traveling cells, the possibility that it may not be is the rationale for chemotherapy or hormone therapy. There is strong evidence from careful scientific studies that breast cancer is a systemic disease and that even in cases of women with negative axillary lymph nodes, there may already be cancer cells somewhere else.

The real danger of breast cancer is not what occurs in your breast but what potentially could happen in other parts of your body. If the breast cancer cells spread, or metastasize, to vital organs (for example, your lungs or your liver), it is a life-threatening situation.

*53\109\8*

Another way to locate the sentinel node employs a blue dye injected at the site of the tumor. It stains the sentinel node blue. The surgeon then makes a small incision in the lower axilla and looks for the blue dye in the lymphatic channels and the lymph node. The sentinel node is then removed and sent to a pathologist, who then examines it very carefully for evidence of any breast cancer cells. If the node is negative and has no evidence of cancer cells, then no further axillary dissection is needed. However, if the sentinel node does contain cancer cells and is positive, then a traditional axillary node dissection is recommended to determine if any other lymph nodes contain cancer.

The sentinel node dissection has been tested in several major medical centers. Its accuracy is very high and reliable, and it may soon become the standard of care for most breast cancer patients. If this technique is of interest to you, ask your surgeon about it.

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For most of us, the most painful and frightening aspect of the whole breast cancer experience is associated with our children and our mothering. Whatever else we think about parenting, we assume that we will be around to give our children safe passage to adulthood. It is absolutely devastating to be confronted with the possibility that we might not be able to carry through that basic promise. Mothers of both younger and older children experience these feelings, and the sadness can be so great that we can’t find the words to express it. Women who have not yet completed their families find that they too are struggling with an enormous loss and grief as they confront the possible end of a life’s dream. For the sake of our children and our families, we must find ways to understand our powerful feelings, to communicate with one another, and to believe in the real probabilities of our long and healthy lives.

*27\109\8*

As one oncologist says to his new patients, “This is a long-term relationship.” You will be followed by all of these people for a long time, and you must feel comfortable with and trust them. Your medical oncologist will be the long-term captain of your care team, so it is especially important that you have a good relationship with him or her.

Many large hospitals have something like an interdisciplinary breast clinic. Scheduling an appointment in one of these centers, even if you don’t anticipate receiving all of your care at that hospital, can be an excellent and efficient way of gathering information. In a single visit, you will be able to meet with a surgeon, a radiation oncologist, and a medical oncologist.

Often a radiologist (who would be expert at reading mammograms and other radiographic tests) and a pathologist are also part of the team, although you probably will not meet them. The advantage to one of these clinics is that in a single day you will be able to hear from each of the treating physicians and leave with a clear recommendation and/or treatment plans. You can then decide whether to take this information back to another doctor or whether to continue your care at that facility. The disadvantage of this system is that the single day can be a long, exhausting, and stressful one.

*12\109\8*

How adenocarcinoma of the uterus develops? The lining of the uterus, the endometrium, is stimulated to grow when there are certain levels of oestrogen around. If there are regular surges of progesterone (as is usual in a normal menstrual cycle, and with use of the combined oral contraceptive pill, and combined hormone replacement therapy), the lining of the uterus changes, stops building up, and is shed in a period. If there is more oestrogen and less progesterone the endometrium can be over-stimulared, and the cells will multiply without the regular protective shedding that progesterone usually provides. ‘Unopposed oestrogen’ can cause the lining cells to multiply so frantically that they make mistakes, and develop changes, like precancer (called atypical hyperplasia) and cancer.

Women whose endometrium is exposed to more oestrogen seem to be at higher risk of developing cancer of the uterus. This includes women who have oestrogen-producing tumours (rare), women on only oestrogen for hormone replacement therapy (rarely done now, except after hysterectomy), and women who have had anovulatory menstrual cycles over a long period of time (irregular cycles, no eggs produced).

Another group at higher risk is obese women. Fatty tissue converts some of the circulating male hormones into oestrogen, especially after menopause, so obese women may be getting higher levels of oestrogen than less overweight women, putting them at risk of endometrial cancer.

Women taking combined (oestrogen and progesterone) hormone replacement therapy or the combined oral contraceptive pill seem to have a decreased risk of developing this disease.

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