Uterus
Uterus It expands. It contracts. And part of it rebuilds itself every month.
No, it''''s not the economy.
We''''re talking about a body part that''''s located above the knees and below the breasts and--hint, hint--guys don''''t have one.
It''''s the part that yields the monthly menstrual blood and lower abdominal cramps that can send women (or their partners) to the round-the-clock-convenience store at midnight in search of tampons and Midol.
It''''s also the part that makes women groan in pain during childbirth and moan in ecstasy during lovemaking.
Unfortunately, this part of the body can develop benign growths, bleeding problems, infections and cancer.
Yes, all these things, and more, the uterus can do. The more you know about how it works and what the problems are, the better you will be able to make the decisions that affect the health of your uterus.
An Ever-Changing Organ
The uterus is an incredibly dynamic organ, says Alvin F. Goldfarb, M.D., professor of obstetrics and gynecology at Jefferson Medical College of Thomas Jefferson University in Philadelphia. It changes each month as a woman''''s body goes through the different phases of her menstrual cycle.
But there''''s more. The uterus is also capable of the amazing transformations that occur during pregnancy.
Before a woman has her first baby, the total size of the uterus is about the equivalent of a small clenched fist. Located above the vagina, behind the bladder and in front of the rectum, the organ consists of a whirl of overlapping muscular tissue. These are the muscles that contract during a woman''''s menstrual cycle and when she has an orgasm. When a woman is in labor, these muscles help deliver the baby.
Within this muscular wall is an internal clear area called the endometrial cavity. Before a woman ever has a child, this cavity is less than an inch wide and an inch in length. It is lined with specialized material called endometrial cells. These cells are replaced daily under the influence of the hormones that the ovaries produce.
Branching off from the top of the uterus are the fallopian tubes. The ovaries are also attached to the uterus with ligaments that help hold them in place. The lower portion of the uterus narrows to form the cervical canal and cervix, which extend down into the vagina.
Major Expansion
Stimulated by the sex hormones estrogen and progesterone, the uterine lining of a reproductive-age woman builds up and prepares itself for a potential pregnancy.
If the traveling egg doesn''''t get fertilized, there is a sharp plunge in the production of hormones. The uterine lining stops proliferating and sheds. It is the shedding process that creates menstrual blood.
If pregnancy does occur, the fertilized egg implants itself in the uterine lining and starts to grow. The muscular walls of the uterus stretch and enlarge, much the way a balloon expands when inflated with air. That one-inch cavity in the uterus expands until it can hold a six- to ten-pound baby.
Then, during childbirth, the muscular walls of the uterus expand and contract. This motion is what propels the fetus out of the uterus, through the cervix and vagina and into the outside world.
Fibroids: The Common Problem
As early as their mid-thirties or forties, women may get fibroids, says J. Victor Reyniak, M.D., director of reproductive surgery at Mount Sinai Medical Center in New York City. Fibroids are the most common type of benign tumor.
While some fibroids, particularly the ones that grow into the uterine cavity, cause bleeding and discomfort, others produce no symp
Fibroids may develop in many areas in and around the uterus--sometimes obstructing the fallopian tube, projecting into the uterine cavity or even protruding through the cervix. |
toms at all, according to Dr. Reyniak. The symptomless ones don''''t have to be removed. But if the fibroids produce bleeding, pain and pressure--and have grown to the size of a grapefruit--they should be taken out. Researchers don''''t fully understand what causes fibroids. But "there is a genetic predisposition," says Dr. Reyniak. So if your mother has fibroids, there is a strong likelihood that you may develop them, too.
Reading the Bleeding
While fibroids are one possible cause of heavy bleeding, there could be some other uterus-related problem. If you are in your thirties or forties and have heavy bleeding, your doctor should check you for an ectopic pregnancy or miscarriage as well as fibroids, says Dr. Reyniak.
What about the other extreme--very light bleeding or none at all?
Lack of bleeding could be caused by anovulation, or the failure to ovulate, according to Dr. Goldfarb. Anovulation might result from some kind of imbalance in your endocrine system. Other causes could be a big change in weight or even heavy-duty stress. (Lack of bleeding might not be related to the uterus, however: Some women stop bleeding because of polycystic ovarian syndrome, a condition in which multiple cysts form inside the ovaries.) Whenever your bleeding is unusually heavy or light, consult your doctor.
The Chance of Cancer
The very word cancer is scary--there is no denying it--and many women worry about the chances of uterine or endometrial cancer. These are the cancers that occur either in some part of the uterus or in the endometrium, the uterine lining. There are several different types of cancer that can appear in this area, according to William Hoskins, M.D., chief of the gynecology service at the Memorial Sloan Kettering Cancer Center in New York City.
Doctors refer to one type as epithelial tumors. This kind of cancer starts to grow in a part of the uterine lining called the epithelial layer, which includes the endometrium. While this type of cancer makes up 95 percent of the cancers that develop in the uterus, says Dr. Hoskins, it is not frequently seen in women ages 30 to 45. Instead, it is more common in women over 50 years of age.
The second type of cancer that can develop in the uterus is uterine sarcoma. This cancer can arise from either the lining of the uterus or from the muscular wall, Dr. Hoskins says. It represents only about 5 percent of all uterine cancers, but it is more likely to show up again after it has been removed. Fifty percent of certain types of uterine sarcomas will recur, and that''''s higher than the recurrence rate for epithelial tumors. So the chance of surviving a sarcoma is lower than the chance of surviving an epithelial tumor.
The Estrogen Factor
Because the sex hormone estrogen has a great influence over cell production within the endometrium, the hormone can play a big role in cancer that affects the cells of the uterine lining. In the past, when estrogen replacement therapy was recommended for many postmenopausal women, they would receive unopposed estrogen. But researchers learned that when only estrogen is given, a woman''''s chance of endometrial cancer would increase seven- to eightfold over what her risk would be if she took no hormone replacement therapy or if she took estrogen with progesterone, says Dr. Hoskins.
Why does progesterone help balance the equation, reducing the risk of cancer?
Lining Out
Normally, the uterine lining begins building up each month prior to ovulation. Following ovulation, progesterone is released, helping prepare the lining to receive the egg. If an egg doesn''''t arrive, the progesterone will help shed the lining. Without progesterone the endometrial lining hangs around longer--and because it doesn''''t shed properly, the risk for cancer is greater.
Today, hormone replacement therapy (HRT) will normally include progesterone as well as estrogen, unless a woman has had her uterus removed during a hysterectomy. Yet there are other factors as well that can increase your risk of endometrial cancer. Women who have been diagnosed with a condition called polycystic ovarian syndrome are at greater risk, because their bodies release estrogen but do not produce progesterone. Obese women are also at greater risk, because when a woman has a lot of fat cells, she is more likely to produce excess estrogen.
| Hysterectomy--And Other Options The exams are done, and the tests are in. You''''re sitting in your doctor''''s office listening to the verdict. Suddenly, there''''s one word that jumps out from all the rest. Hysterectomy. It zaps you like an electric shock. Your doctor''''s words become a blur as she continues talking. Something about success rates. Then she''''s asking you what you want to do. What do you do? First off, try not to panic. Hysterectomies are common, with an estimated 600,000 performed each year. In fact, they are the second most common type of surgery performed in the United States. (Cesarean section is first.) The question is, why is the major surgery performed so often? Some women advocates and members of the health profession have claimed that hysterectomies are sometimes performed unnecessarily, and some doctors agree. Is This the Way to Go? It''''s important to keep in mind that just because your doctor has recommended a hysterectomy doesn''''t mean that you necessarily have to have one. Before you make up your mind, you might want to consider the alternative methods for treating a host of gynecological problems, including fibroids, abnormal bleeding and chronic pelvic pain. "There are many medical and minor surgical alternatives to hysterectomy that should be considered prior to making your final decision," says Jack M. Lomano, M.D., director and president of the South Florida Woman''''s Center in Fort Myers, Florida. Start by asking your doctor if there are any medications that can help alleviate your problem, says J. Victor Reyniak, M.D., director of reproductive surgery at Mount Sinai Medical Center in New York City. For example, certain drugs called GnRH agonists are used to treat a host of gynecological problems. GnRH stands for gonadotropin-releasing hormone. These medications can be used to treat large fibroids. They work by depriving fibroids of the estrogen that feeds them--and when estrogen is lacking, the fibroids shrink. The GnRH medications can also be used to help stem abnormal bleeding and relieve the pain and discomfort of endometriosis and other chronic pelvic pain problems, says Dr. Reyniak. And if you''''re having painful periods or severe bleeding, be sure to ask your doctor about nonsteroidal anti-inflammatories such as Motrin and Advil, he suggests. Or you might be helped by oral contraceptives or hormone replacement therapy. You can also ask your doctor if there is another surgical option that will help your condition. For instance, large fibroids that cause pain and pressure can be treated with myomectomy, a procedure in which the fibroid alone is removed and the uterus is left in place. Before the Cut Is Made Suppose you decide to have a hysterectomy, having concluded that it''''s really your best option. There is more than one kind of procedure--and some hysterectomies are more extensive than others. Here are three different types to consider before you make a final decision. Total hysterectomy with bilateral salpingo-oophorectomy. This is the most extensive. The surgeon removes the uterus, the cervix, both ovaries and both fallopian tubes. After this type of hysterectomy, you can no longer bear children. And because you won''''t ovulate, you won''''t produce ovarian hormones. For a woman of reproductive age, the result is early menopause--what doctors refer to as surgical menopause. Total, or complete, hysterectomy. The doctor removes the uterus and cervix but leaves the fallopian tubes and ovaries in place. After this procedure you will not have menstrual periods or be able to bear children, since the uterus is removed. You will ovulate, however, if you are still in your reproductive years. Your ovaries will still produce hormones that influence your health--estrogen, which affects the functions of your bones and heart, and androgen, which influences your sex drive. Supracervical hysterectomy. The ovaries and fallopian tubes are left in place, but the uterus is removed. Most of the cervix, the lower portion of the uterus, stays in place. Doctors have a reason for removing part of the cervix but leaving the rest in, according to Dr. Reyniak. The part of the cervix that is removed, called the transformation zone, is the area where cancerous cells can develop. By leaving the rest of the cervix in, the doctor ensures that a woman can still have sexual sensation in that area. In addition to different kinds of hysterectomy, there are also a number of more moderate surgical approaches. They include: Abdominal hysterectomy. The uterus is removed through an incision in the abdomen. This type of surgery is usually necessary when the uterus is too large to be removed through the vagina, says Dr. Reyniak. Vaginal hysterectomy. The uterus is removed through an incision in the vagina. This leaves no scars, since all the stitches are made internally, says Dr. Reyniak. Laparoscopic-assisted vaginal hysterectomy (LAVH). An instrument called a laparoscope is inserted through four to five small incisions in the abdomen. Through this instrument the physician cuts the ligaments that attach the uterus to the abdominal cavity. This releases the uterus, which is then removed through the vagina. LAVH is a relatively new technique. "Some doctors may be more experienced with it than others," says Dr. Lomano. Before you have LAVH, ask your doctor how many of these surgeries that she has performed; twenty or more indicates a good level of experience. |
Since abnormal vaginal bleeding is one symptom of uterine cancer, it is yet another reason to check with your doctor if your bleeding is unusual. Other symptoms include lower abdominal pain and lower back pain.
If you do have endometrial cancer, many doctors will recommend a hysterectomy. That''''s because the disease can spread to other areas of the body unless the uterus is removed. Not all hysterectomy procedures are the same, however. Doctors recommend that women be aware of and explore their different options before they decide what to do.
Protecting the Womb
With so much going on--and so many chances for problems--your uterus deserves first-class service. Here''''s how to make sure that you are doing all you can to keep it healthy and free of problems.
Get checked. To safeguard the health of her uterus, a woman should plan on having an annual exam, says Dr. Goldfarb. During a pelvic exam your doctor may be able to detect any unusual growths or masses in your uterus.
Watch for signals. "Above all, know your body," says Dr. Goldfarb. That way, if anything changes, you can consult your doctor. Any signs of unusual bleeding or pain are cause for concern, and you should let your doctor know about them.
Also, if you start missing periods and know you are not pregnant, talk to your doctor, says Dr. Goldfarb. Your ovaries may not be releasing eggs because of polycystic ovarian syndrome. Because this problem of not ovulating may increase your risk for the development of endometrial cancer, it''''s important to ask your doctor about the different medications that can induce ovulation. (If you''''re not ovulating because you are taking the Pill, you don''''t have to worry: In fact, the Pill actually protects against the development of the disease, he says.)
Of course, another possibility could be that you''''re starting menopause, which some women can experience as early as their mid-thirties.
Find the right doctor. Take the time to find a doctor you like, says Dr. Goldfarb. If you can''''t communicate with your physician, find one you can talk with openly. One way to begin the search is to ask your friends about gynecologists that they have been to and like.
Many hospitals also have physician referral services. By calling a special telephone number, you can find out what doctors are available at a particular hospital and hear comments from other patients who have seen them.
Consider the Pill. "The single most important thing that a woman can do to protect against ovarian and uterine cancer is to take birth control pills," says Dr. Hoskins. In addition to decreasing the risk of endometrial cancer, taking the Pill for five years or more will decrease the risk of ovarian cancer by 50 percent.
Watch your weight. By eating a low-fat diet and exercising, women can help prevent endometrial cancer, says Dr. Hoskins. That''''s because obesity is such a risk factor.
Be informed about HRT. If you''''ve gone through menopause and you''''re currently getting HRT, you should find out what your HRT regimen includes or ask your doctor to explain it. If you''''ve had a hysterectomy, then you''''re eligible to receive unopposed estrogen. For anyone else, however, the therapy should include progesterone as well as estrogen in order to avoid raising your risk of endometrial cancer.
Call on the experts. If you are diagnosed with cancer, see a gynecological oncologist, says Dr. Hoskins. Gynecological oncologists are the doctors who, through years of training, specialize in treating cancers of the reproductive tract. You can call the Society of Gynecological Oncologists at 1-800-444-4441 for a listing of gynecological oncologists in your area.
See also Pregnancy, Reproductive System
