221. Sign of the Times

Not an uncommon request: "Can I have [procedure x] done before I lose insurance at the end of the month?"  The frequency (and emotional urgency) of such requests will surely increase.

Last week Maria asked for a hysterectomy.  She had breast cancer several years ago, her treatment including surgery and chemotherapy.  She received a standard 5 year course of tamoxifen, a drug that blocks estrogen receptors in the breast (her cancer was accelerated by estrogen) but paradoxically stimulates estrogen receptors in the uterine lining, increasing the risk of uterine cancer.

So, she asks, why not just take out the uterus, an organ that now serves no health purpose and carries the risk of cancer?  I acknowledged that although a hysterectomy would remove the threat of uterine cancer, the risk of uterine cancer is low even with taxoxifen, and usually easy to detect--bleeding occurs at pre-cancer stage and she has experienced no bleeding. Furthermore, she is now a couple of years beyond the final tamoxifen dose.

Then consider the potential complications of a hysterectomy such as injury to the bladder or bowel, infection life-threatening blood loss.

Maria returns to her original concern:  "I may not have insurance when and if I experience signs of cancer.

We end up planning an ultrasound (assuming it can be performed in the two weeks remaining on her insurance), which can show signs of hyperplasia (the pre-cancer stage).