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May 13, 2013

Womb to Grow

Author Affiliations

Author Affiliation: Ms Mu is a medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland.

JAMA Intern Med. 2013;173(9):729. doi:10.1001/jamainternmed.2013.313

I first met Emily during my third year of medical school, and she deeply impressed upon me that in matters of the womb, patient wishes define when less is more. Emily was a 33-year-old woman (gravida 0, para 0) admitted for fever and right flank pain lasting several weeks. Emily's diagnosis was initially elusive. She had received a full course of antibiotics to treat suspected pyelonephritis. However, when her pain, leukocytosis, and fever persisted, we searched for another source of infection. A transvaginal ultrasound examination ultimately revealed extensive endometriosis and 2 large cystic masses in the right ovary that were the likely source of her infection.

Peeling a sticker

Emily's treatment came down to surgery. Dr G, the attending gynecologic surgeon, carefully explained the possible outcomes. If the infection were isolated to a cyst, a simple cystectomy would be sufficient. However, the endometriosis appeared to be invading Emily's pelvic wall, ovaries, and uterus. Definitive treatment of such extensive disease could require a bilateral salpingo-oophorectomy and hysterectomy.

“Taking out endometriosis is like peeling off a sticker,” Dr G said. “If there is endometriosis involving the uterus, it will be hard to get it all; there's a chance that some will remain, and the pain will recur.”

Aggressive surgery would be more effective in treating widespread endometriosis in the long run, but to Emily it meant eliminating any chance of bearing her own children.

“If you have to take my ovary, take it—it has caused me enough pain,” Emily murmured. “But I don't want to lose my uterus. I’m not ready for that.”

Dr G assured Emily we would make every effort to preserve her left ovary and uterus. Unfortunately, there was no way of knowing the full scope of Emily's current disease and infection prior to surgery. Emily nodded. Trust. It is the greatest compliment we can receive from our patients.

More than a uterus

According to anatomy books, the uterus is an organ where fertilized eggs can implant and grow for approximately 40 weeks. For Emily, the uterus embodied the essence of womanhood. I had admittedly given little thought to the uterus prior to meeting Emily. Never before had I wondered about this superpower bestowed upon women—a womb with the remarkable ability to create life. Within its fleshy confines lies hope of persistence, a promise of posterity. Emily held tightly to these notions in refusing more aggressive surgery, willing to accept relapsing pain for the hope of fertility. To her, less treatment meant more than we could imagine.

For which we labor

The morning of the surgery, Emily's burst of hair refused to be tamed by a blue bouffant cap, every curl echoing a vibrant life outside of operating rooms and hospital gowns.

During the operation, we were immediately faced with entangled bowels adherent to a massive ovarian cyst on her right ovary. The ovarian cyst was so large and septated that it spanned her entire abdomen. Happily, we found that the left ovary and uterus were grossly normal. As we concentrated on removing the right ovary, dusky foul smelling brown fluid leaked out of the cyst, confirming the source of infection.

Following the operation, Dr G and I met with Emily's family to report the surgery had gone smoothly. We were able to remove the localized source of infection and preserve Emily's uterus and left ovary as she wished. However, in all operations we must remain vigilant for possible infection and adequate pain control. In Emily's case, less aggressive surgery also meant a considerable chance of disease recurrence. While she retained the ability to have children, she would likely require treatment for endometriosis in the future, and pregnancy might be difficult to achieve without assistance.

As we walked back to clinic, I thought about how Emily embodied the principle of “less is more.” Less treatment necessitates more patient-physician communication, more understanding of patient preferences, and more patient-centered goal setting. Personalizing care compels us to become more compassionate and cautious physicians.

It would certainly be a long journey ahead. But for now, I smiled. I knew that when Emily awoke, she would be surrounded by family. And most of all, she would have her beloved uterus and a world of possibility.

Four weeks later, Emily was recovering well, finished her course of antibiotics, and had begun to do some light yoga.

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Article Information

Correspondence: Ms Mu, Johns Hopkins University School of Medicine, 733 N Broadway, Ste 137, Baltimore, MD 21205-2196 (emu1@jhmi.edu).

Published Online: March 18, 2013. doi:10.1001/jamainternmed.2013.313

Conflict of Interest Disclosures: None reported.

Additional Contributions: Isabel Green, MD, and Nancy A. Hueppchen, MD, generously offered their expertise and guidance during the writing of the manuscript and throughout medical school.