The uterus, also known as the womb, has not been so friendly to me this summer. Last week it turned inside out (inverted) after the delivery of a baby and, despite my best efforts, managed to bleed out almost the entire blood volume of the patient. A few months earlier a patient hemorrhaged after the delivery of her baby and as a last resort we needed to remove her uterus to save her life. A small uterine polyp I removed from an elderly patient carries the diagnosis of an aggressive cancer and she needs a hysterectomy. Another elderly patient presented with complete prolapse of her uterus and vagina and had been walking around for 20 years with 6 inches of tissue protruding from her vagina. But what is amazing to me is that the uterus does its’ job so perfectly the majority of the time. Babies grow in this organ for 9 months as it slowly increases in size tenfold, it contracts efficiently to expel the child and then immediately decreases in size by 50% to control bleeding. And you can use it again….and again….and again.
Although post-partum hemorrhage is one of the leading causes of maternal mortality in the developing world, very few women in this country die due to bleeding. Quick availability of safe blood, the majority of deliveries in a hospital with an operating room available and prophylactic use of medications that help to contract the uterus all contribute to this statistic.
When the uterus is not working to help grow a baby, it gives women their monthly menses. That means that every 26-30 days we are financing the feminine hygiene industry. Primates (us and monkeys), bats and the elephant shrew are the only members of the animal kingdom that have a menses – a great Trivial pursuit fact. Many animals reabsorb menstruation when there is not a fertilized egg. I want to know who decided that women needed to fall into the first category. Llamas and camels are known as induced ovulators and only ovulate when intercourse happens. Just think – no PMS and you wouldn’t need to worry about your menses if you weren’t sexually active. That would probably be the best birth control method ever!
Because we walk on two legs, gravity works against us when it comes to body parts falling out. Uterine prolapse has risk factors – obesity, multiple vaginal deliveries, chronic cough, smoking and genetics – most of which we have control over. The genetics component has intrigued me as I seldom see prolapse when I am in Haiti, despite women having 8-10 children, but the rate of prolapse in Central America is much higher with women having an equal number of children and performing much of the same physical labor.
Uterine cancer is becoming an epidemic in this country due to an increase in the most common risk factors. Post menopausal women who are obese, diabetic and hypertensive are at greatest risk. This describes all too many of my patients. We are just starting to see the tip of the iceberg as the baby-boomers move into this time of their lives. When diagnosed early, usually due to post menopausal bleeding, uterine cancer is highly curable with surgery.
We are requiring a lot more of our uterus now than we ever have before. In biblical times, women often didn’t start menstruating until their late teens and soon thereafter became pregnant. For the next 10-15 years they were either pregnant or breastfeeding and then usually died by their late 30’s to early 40’s. A typical woman probably only had 12 periods in her lifetime, rather than 12 menses a year. Prolapse, uterine and ovarian cancer were unheard of. Postpartum hemorrhage killed women quickly and frequently.
I am hoping that all of the uteri that I encounter the remainder of this summer behave themselves, whether it be related to childbirth or aging.