Fibroids and Hysterectomies used to go together like Rogers and Hammerstein. Not anymore. If your physician recommends removing your uterus as the most effective treatment for severe fibroids without first considering less invasive therapies, start singing another tune and get a second opinion!
Fibroids and Hysterectomies used to go together like Rogers and Hammerstein. Not anymore. If your physician recommends removing your uterus as the most effective treatment for severe fibroids without first considering less invasive therapies, start singing another tune and get a second opinion!
Just ten years ago, chances are you would find yourself in the hospital undergoing major surgery to treat pelvic pain or abnormal uterine bleeding caused by your fibroids. And while a hysterectomy is associated with a low death rate, this procedure is no joke. In addition to the lengthy hospital stay and recovery period at home, there’s at least a 30% complication rate and serious issues regarding a woman’s sexuality and quality of life once the uterus is removed.
The trend is moving away from treating fibroids with hysterectomies, but fibroids remain the number one reason for performing hysterectomies in the U.S. According to the National Center for Health Statistics, approximately 600,000 hysterectomies are performed each year and 60% are due to uterine fibroids. The bottom line: most women with uterine fibroids do not need a hysterectomy.
Even among physicians, the indications for hysterectomies are vague at best. And studies published in top medical journals estimate that 20 to 40% of hysterectomies cannot be justified on any established criteria.
Unfortunately, because there have been so many advances in a short period of time, not every doctor is knowledgeable about or qualified to perform the latest, less invasive alternatives to the hysterectomy. You really have to do your homework and learn what your options are. Remember, fibroids are not cancerous and you don’t have to rush into anything.
How should you manage your fibroids then? Depending on the severity of your symptoms and where you are in life (do you want to have children?) there are different approaches you and your doctor can consider.
It may be that you don’t have any symptoms. Fewer than half of the women who have fibroids ever experience any symptoms at all. Most women don’t even know they have fibroids until their physician feels them during a routine pelvic exam. If you fall into this category, all you probably have to do is watch to see that they don’t grow in size Doctors call this "expectant management".
If you are approaching menopause (most women stop having their period around age 51), you may not have to do much either. These estrogen-loving growths tend to shrink as the supply of estrogen in our bodies dwindles with middle age.
On the other hand, your uterine fibroid(s) may be causing you a great deal of discomfort, pain and embarrassment. Abdominal and lower back pain (one third of patients), alarmingly heavy menstrual bleeding ( one third of patients), and frequent urination or constipation are not easy to live with. Now, managing your fibroids becomes an important quality of life issue.
The following article will give you background information about uterine fibroids; why you probably don’t need a hysterectomy and what you can do to manage them if they are creating problems for you. Learn more about hormone therapy, myomectomy, endometrial ablation, myolysis, uterine artery embolization, and minimally invasive surgery if a hysterectomy is absolutely necessary.
Take the Fibroid Quiz and test your knowledge base. Check out the Expert Interview with Fancis L. Hutchins, M.D., a nationally recognized fibroid expert. There’s also a Questions For My Doctor Checklist that you may find useful.
The following questions touch on a variety of fibroid concerns. Find out what you know and what you would like to learn more about.
T/F 1. Fibroids are the most common reason that hysterectomies are performed in the United States.
T/F 2. Women with fibroids have a greater risk of getting ovarian cancer later in life.
T/F 3. The severity of your symptoms and the size of your fibroid(s) are related.
T/F 4. If your mother or sisters have fibroids, there’s a good chance that you have a fibroid(s) as well.
T/F 6. Medical treatments such as GnRH analogues are effective in curing fibroids.
T/F 7. Fibroids can cause extremely heavy periods and severe menstrual cramps.
If you are like most women, your annual visit to the gynecologist is right up there with shopping for a bathing suit. And you certainly don’t want to hear that you have something growing inside of you the size of an apple seed, a lemon or a grapefruit! (Traditionally doctors have compared the size of their patients’ fibroids to fruit, but medically speaking your doctor will compare them to the size of the uterus as it expands in size during pregnancy. For example, your doctor may tell you that your fibroid(s) has enlarged your uterus to the size it would be if your were eight weeks’ pregnant, 16 weeks’ pregnant or more).
If your doctor has found a uterine fibroid during a routine pelvic exam, do not be alarmed. Fibroid tumors -- dense balls of muscle that form on or inside the uterus - are benign (non-cancerous).
You Should Know:
1. Uterine fibroids are extremely common. For some unknown reason, this tumor is at least three times more common in black women than in the general population.
2. Chances are you will never experience any symptoms.
3. Uterine fibroids are benign and women with them are not predisposed to ovarian cancer.
4. When you reach menopause (around age 51), these estrogen-dependent tumors stop growing and often decrease in size as the estrogen supply diminishes with the onset of menopause.
5. Just because you have a fibroid(s), it does not mean you need to have a hysterectomy. Be certain to ask your doctor about expectant management (wait and watch approach), medical therapy (typically drugs to control bleeding and shrink the fibroid), procedures that remove only the fibroid but leave the uterus intact, and newer, less-invasive surgical procedures such as laparoscopy, hysteroscopy and uterine artery embolization.
What is a uterine fibroid?
Uterine fibroids (Leiomyomata) are benign overgrowths of muscle and connective tissue. Of all the growths in the female pelvis, uterine fibroids are the most common. Between 25 percent and 50 percent of all women eventually develop fibroids.
Fibroids will vary greatly in size and number, as well as location. They can be as tiny as an apple seed (1 - 2 mm) or as large as a watermelon (30 cm). Some will grow directly on the inside or outside of the uterus, and some protrude from the uterus on a stem-like base.
Women in their 30s and 40s are most likely to have fibroids and African American women are at least three times more likely than other women to develop them.
What causes fibroids?
While no one knows for certain what causes fibroids, it seems that the female hormone estrogen is a key factor in fueling their growth. During pregnancy, when there are high levels of estrogen in the body, fibroids sometimes grow larger. During menopause, when estrogen levels drop off, fibroids tend to shrink and become less problematic.
How do I know for certain that I have fibroids?
More often than not, you won’t know you have a fibroid until your physician feels it manually during a pelvic exam. There are several tests to confirm the diagnosis.
Ultrasound - a wand-like instrument is moved across the surface of the abdomen and sound waves create an image of the pelvic organs on a monitor.
Laparoscopy - a thin telescope - like instrument is inserted through a small cut just below or through the navel that enables your physician to see inside your abdomen.
Hysterosalpingogram - an x-ray procedure which involves injecting dye into the uterus and the fallopian tubes to highlight irregularities in their size and shape.
Hysteroscopy - a thin telescope-like instrument is inserted through your vagina and cervix and then into the uterus, allowing your doctor to check for growths and abnormalities.
Fibroids At A Glance
There is no single management plan that is right for every woman. It is especially important that you and your doctor agree on a treatment plan that is individualized for your specific situation.
Deciding how to treat your fibroids can be confusing. Before considering any treatment, you need to discuss with your doctor (1) the severity of your symptoms and (2) whether or not you are planning to have children. Then, you and your doctor can choose from:
Ten years ago, if you were diagnosed with fibroids and experiencing severe pelvic pain or abnormal bleeding (especially during your period) chances are you would have been advised to undergo a hysterectomy.
Today, we know that a hysterectomy is not the only option for treating troublesome uterine fibroids. And with the advent of improved tools for medical and surgical therapy, women have more options then ever.
It is very important, however, to find a doctor who is specially trained and experienced in performing the newer, less-invasive techniques.
If the newer procedures are safer and less traumatic, why are so many hysterectomies still performed each year to treat fibroids?
Many practicing surgeons are unfamiliar and uncomfortable with the newer technologies. They feel they can perform the hysterectomy more safely than less invasive procedures which are difficult to master without sufficient training. Some research also suggests that a "fee for service" system has rewarded gynecologists for performing as many surgeries as possible.
Before agreeing to any surgery, ask your doctor about his/her training and the number and type of procedures they do each month.
If you are not experiencing any symptoms from your fibroid(s), deciding how to manage them is straightforward. There really isn’t anything much you have to do. Your doctor will probably check your fibroid from time to time to see if it has changed in size. And your physician may request an ultrasound - a technology that uses sound waves to create a picture of the pelvic organs on a monitor - to get a baseline picture of your fibroid or to more accurately measure any changes in size. Ultrasounds are also helpful when there is a question in discerning whether a growth is indeed a benign uterine fibroid, or instead, a potentially serious ovarian tumor.
What should I ask my doctor if we are "watching" my fibroids?
Don’t treat fibroids based on size alone.
Just because your fibroid is large does not necessarily mean it will give you any or more trouble, compared to one of smaller size. Too often in the past doctors would recommend a hysterectomy (surgery to remove the entire uterus) based on concerns that fibroids could potentially obstruct the bowel or other nearby organs. In reality, this is rarely the case.
Experts also warn against rushing into treatment because your fibroid changes size rapidly. Just because a fibroid grows larger over time is no reason alone to remove it. Also, remember that fibroids by nature progressively increase in size until menopause, when the body stops producing estrogen and fibroids tend to shrink on their own.
Warning: Increasing uterine size in the postmenopausal woman does warrant immediate attention by a gynecologist or other physician trained in this area. This diagnosis does suggest a cancerous tumor may be present and you don’t want to waste any time.
If you’ve had to run out of a room with your sweater around your waist to hide your blood-stained pants, or if you have to miss a day of work each month because of painful menstrual cramps, you don’t have to take it anymore. Depending on the severity of your fibroid symptoms and whether or not you have completed childbearing, you will want to look into these treatment options.
Drug Therapy - Synthetic hormones are prescribed which can decrease the size of the uterus and the fibroid. The drugs can be prescribed alone or in conjunction with a surgical procedure to shrink fibroids prior to surgery.
Myomectomy - This is a surgical procedure, but it is a less "radical" approach to treating fibroids, than a hysterectomy. Fibroids are cut away, but the uterus is preserved meaning you can still have children. Traditionally, this procedure involved an abdominal incision and several days in the hospital. Today, depending on the size and location of the fibroid, your doctor can also remove the fibroid using less invasive procedures like hysteroscopy and laparoscopy. In most cases, these can be done on an outpatient basis or overnight stay, but there are still some risks involved. Generally, the risks are lower and the recovery is easier than traditional surgery. During a hysteroscopic myomectomy a thin telescope-like instrument is inserted through your vagina and cervix into the uterus. Special surgical tools are fitted to the hysteroscope to remove the fibroids. During a laparoscopic myomectomy a thin telescope-like instrument is inserted through a small cut just below or through the navel that enables your physician to see inside your abdomen. Very thin surgical tools are are used in conjunction with the laparoscope to remove the fibroids.
Myolysis - This is typically used for fibroids near the uterine surface. Using medications to shrink the fibroids first, your doctor performs this laparoscopic procedure which involves using an electrical needle to destroy the blood vessels feeding the fibroids. Eventually, the fibroids shrink and occasionally may even disappear.
Endometrial Ablation - This is helpful for excessive bleeding. In this procedure, the endometrial lining (the tissue that makes up the inner lining of the uterine wall) of the uterus is destroyed and it is generally no longer possible to have children. Originally, surgeons used a YAG laser to destroy the lining, but that technique has been replaced in most centers in favor of a safer one done through an operating hysteroscope (resectoscope) fitted with a special tools known as rollerballs, rollerbarrels, resecting loops and vaportrodes that allows your doctor to destroy the lining. There is also a fairly new, experimental type of ablation technique known as uterine balloon therapy. A balloon catheter is inserted into the uterus, where the balloon is filled with a sterilized liquid. Then, a heating element raises the liquid temperature and the lining of the uterus is destroyed or ablated. Considered safer than previous methods that use lasers or electrocautery to ablate the endometrium, this procedure is still being tested. There is also no guarantee that bleeding will not recur.
Uterine artery embolization - Used to treat excessive bleeding due to fibroids. Blood flow to the fibroid is blocked, causing the fibroid to shrink and die. During this low-risk procedure, an interventional radiologist (a specialized physician who uses x-rays or other imaging techniques to place needles or catheters in different areas of the body, to evaluate and/or treat a variety of conditions in a minimally invasive fashion) inserts a catheter through a small incision in the groin, threading it into the femoral artery (major artery supplying blood to the leg) and then up to the uterine artery (main artery supplying the uterus). Plastic sand-sized particles are injected into the catheter. These fine particles lodge in tiny blood vessels, cutting off blood flow to the fibroids.
Hysterectomy - A surgical procedure to remove the entire uterus. Although there is a move away from hysterectomy to treat fibroids, for a small percentage of women it may be the best choice. You need to be certain that your doctor is recommending this procedure for the right reasons and not because he/she is unfamiliar with the newer, less invasive techniques that are now available.
Surgery is not always necessary to alleviate fibroid symptoms. There are different types of drugs that can control your symptoms. Basically, these drugs are designed to shrink your fibroid and reduce bleeding. However, these drugs will not get rid of your fibroid. Fibroids can re-grow after you stop taking these medications. There are also side effects associated with the drugs that you will want to discuss with your doctor.
Progestins are female hormones. Excessive bleeding , known as menorrhagia (pronounced men-o-raj-ia) can be controlled with this class of medications. Medroxy-progesterone acetate and Megestrol are commonly prescribed Progestins.
One of the newer and most promising group of drugs being used are synthetic hormones known as gonadotropin-releasing analogues (GnRH Analogues). Acting like hormones which occur naturally in our bodies, these "look-alikes" reduce blood flow to the uterus and in turn to individual tumors. The end result is a decrease in the overall size of both the uterus and the tumor. Lupron Depo is a commonly prescribed drug.
Some physicians are prescribing GnRH agonists prior to surgery to shrink large fibroids, making it easier to remove them. In some cases, where a small fibroid is thought to be interfering with fertility, physicians will suggest a course of GnRH to shrink the fibroid in order to increase the chances of conception.
There is a down side to GnRH agonists: the results achieved with GnRH agonists are temporary. Current studies show that within four to six months following the drug therapy, tumors will regrow to their original size. Also, because the GnRH agonist is suppressing estrogen, women will experience side effects similar to those associated with menopause, such as mild hot flashes, vaginal dryness, mood swings and increased risk for osteoporosis (weakening of the bone). GnRH agonists are generally used for 6 months are less to minimize the risk of osteoporosis.
During this procedure your doctor will remove your fibroid(s), leaving the uterus intact. This approach preserves the possibility of continued childbearing and is typically easier to recover from than a traditional hysterectomy.
There are several ways that a fibroid can be removed during a myomectomy. Depending on the location and size of your fibroid, you doctor will recommend either an abdominal (traditional) myomectomy, hysteroscopic myomectomy or laparoscopic myomectomy.
Abdominal or Traditional Myomectomy
During an abdominal myomectomy, your doctor removes only the fibroid(s), leaving the uterus intact. An incision is made through the abdominal wall that is similar to one made with a hysterectomy.
In the past, myomectomy was considered to be a more difficult procedure than a hysterectomy. It took longer and there was a greater risk of blood loss associated with the procedure. A growing number of researchers today believe that it is for this reason that so many unnecessary hysterectomies are still being performed; doctors who have not trained to perform myomectomies simply find it easier to do a hysterectomy. However, myomectomies are now considered just as safe, or safer than a hysterectomy in the hands of an experienced surgeon.
Before committing to any surgery, ask your doctor about his/her training and the number and type of procedures they do each month.
Will my fibroids return after a myomectomy?
Having a myomectomy does not guarantee that your fibroid problems are over for good. Fibroids reappear in about 30% of women. There’s also a small chance that the procedure will cause internal scarring that can interfere with your ability to become pregnant, but this is generally not the case.
Ask your doctor how you should expect to feel after the procedure. Keep in mind that an abdominal myomectomy is still major surgery and it will take some time to recover.
If your fibroid(s) protrudes into the cavity of the uterus, this variation of a traditional myomectomy may be a good option for you. In this outpatient procedure, an abdominal incision is avoided making the recovery easier. The surgeon inserts a hysteroscope - a thin telescope-like instrument that can be fitted with special surgical tools - through the vagina and into the uterine cavity to remove the fibroid.
If your fibroid is located on the outside of the uterus, your surgeon may also be able to get to the fibroid without making a large incision in the abdomen. During this outpatient, or overnight stay procedure, the surgeon will insert a thin tube through a small incision just below or through the navel. The laparoscope - a thin-telescope like instrument - is place through this tube to look at the contents of the abdomen and pelvis, in this case specifically looking for the fibroid(s). While the surgeon views the inside of the abdomen, he/she guides other tubes into the sides of the lower abdomen. The lower abdominal tubes are fitted with long and thin specialized surgical instruments that are used to remove the fibroid(s).
Adjuncts to Myomectomy
Myomectomy via the hysteroscope (through the vagina) or the laparoscope (through the navel) are associated with a faster recovery than with a traditional myomectomy that involves an abdominal incision. There are also several techniques that have been developed to make it easier to perform the less invasive hysteroscopic and laparoscopic myomectomies.
Gonadotropin Releasing Hormone Analogues (GnRH Analogues) are synthetic hormones that can be taken prior to surgery to reduce the size of the fibroids and make them easier to remove.
A small amount of a substance known as Vasopressin (an agent that constricts vessels) can be injected into the uterus during surgery, shrinking the blood vessels and thereby reducing the amount of bleeding.
Devices such as electrosurgical instruments (tools that can cut and coagulate with the aid of electricity), lasers, and others can be used as cutting tools instead of a scalpel or scissors. They decrease the amount of bleeding while cutting into the uterus or around the fibroids.
The Dreaded Hysterectomy (It’s Not Your Destiny)
Ten years ago, chances are your doctor would recommend treating your symptomatic fibroids with major surgery - the dreaded hysterectomy - to remove the entire uterus. It was almost like a right of passage into the Golden Years. This is no longer the case. Don’t let anyone tell you that you have no choice but to face a hysterectomy as part of being a woman or a woman with fibroids (you’d be surprised how many women are made to feel foolish for trying to avoid a hysterectomy even today).
As the number of safer, less invasive treatments continues to grow, hysterectomy should be at the bottom of your list. Unfortunately, because there have been so many advances in a short period of time, not every doctor is knowledgeable about or qualified to perform these newer techniques. You really have to do your homework and learn what your options are. Then, find a doctor who feels comfortable with and does a lot of the newer techniques.
How do I know if I really need a hysterectomy?
If you are considering a hysterectomy to treat fibroids, you probably don't need to have a hysterectomy at all. Talk to your doctor about trying drug therapy or other less invasive surgical procedures first. Get a second and even a third opinion. You need to be convinced that a hysterectomy is absolutely the best solution for you.
Supracervical Hysterectomy Through the Laparoscope
You may be surprised to learn that not every hysterectomy requires an abdominal incision. In some cases, it is possible for your doctor to do what is known as a supracervical hysterectomy through the laparoscope (a thin telescope-like instrument inserted through a small cut just below or through the navel). In this procedure, the surgeon removes only the top part of the uterus, leaving the cervix intact. The recovery is shorter than one with an abdominal incision and there is less risk of complications. This type of hysterectomy is extremely popular in Europe and will probably become more popular in the United States as well. A recent study in Scandinavia compared women who had supracervical hysterectomies with those who had a total (the cervix is removed) hysterectomies in terms of sexual dysfunction after the procedure. They found that there were less complaints when the cervix was not disturbed.
A Mini-History of Hysterectomies
The original hysterectomy involved an abdominal incision (there were no laparoscopes at the time) but it was a supracervical hysterectomy - doctors only removed the top of the uterus and left the fallopian tubes, ovaries and the cervix intact. Then, in the 1930s, doctors became concerned when they noticed there were large numbers of women, some who had hysterectomies, who were dying of cervical cancer. The response: surgeons started doing what is known as a total hysterectomy to remove the cervix as well. This is a longer operation, associated with more blood loss and more complications to the urinary tract and the intestines. Today, we understand that every woman, whether she has had a hysterectomy or not, has a very low risk of developing invasive cancer of the cervix as long as she has a routine pap smear. With the advent of the pap smear and the laparoscope, supracervical hysterectomies may have a resurgence.
In the simplest terms, fibroids grow old and then they die (as the estrogen in a woman’s body decreases with age). This latest treatment option just speeds up the process of degeneration. (To find an Interventional Radiologist near you, or more about UAE visit http://www.scvir.org/) Doctors cut off blood flow to the fibroids using angiography -- a low-risk radiologic procedure which does not require major surgery or anesthesia. To date, this procedure is only recommended for women with heavy bleeding due to fibroids and the results are overwhelmingly successful.
Your gynecologist is not trained to do this procedure. You will be referred to a specially trained radiologist known as an interventional radiologist. During the procedure, the doctor inserts a catheter through a small incision in the groin, into the femoral artery (major artery supplying blood to the leg) and up to the uterine artery (artery supplying the major blood supply to the uterus). Plastic sand-sized particles are injected into the catheter. These fine particles lodge in tiny blood vessels, cutting off blood flow to the fibroids.
Actually, this new technique is just a new twist on a proven procedure for treating life threatening pelvic hemorrhage related to childbirth or pelvic cancer. Historically, surgeons would block the blood flow into the uterus, but they had to make a major abdominal incision first. In many cases, this is no longer necessary. With the advances in angiography (visualizing vessels with the aid of x-ray, after the injection of a special dye), doctors can thread a thin catheter through a blood vessel to the precise site of bleeding. By injecting sand-sized plastic particles into the vessel, the bleeding can be controlled.
Can I get pregnant after undergoing uterine artery embolization?
Yes. There is no indication at the present time that a uterine artery embolization will prevent women from becoming pregnant. It is not clear, however, whether or not this procedure can actually improve a woman’s chances of fertility if she has fibroids and has been having difficulty getting pregnant.
Who should have this procedure?
This procedure is for the woman who is having problems with excessive bleeding due to fibroids. It avoids major surgery, and leaves open the option for pregnancy at a later time.
What should I ask if I am "watching" my fibroids?
What should I ask if I need to treat my fibroid symptoms?
If there were such a thing as a "fibroid king", Francis L. Hutchins, M.D. could rightfully wear that crown. A renown fibroid expert, Dr. Hutchins has developed a practice that is devoted almost entirely to treating women with fibroids. Most recently, Dr. Hutchins has been recognized in the media for his pioneering efforts in using uterine artery embolization to treat women with severe bleeding due to fibroids. A Clinical Associate Professor of Obstetrics and Gynecology at Allegheny University of the Health Sciences and Thomas Jefferson University, Dr. Hutchins is passionate when it comes to educating women about fibroids and helping them sort out the best treatment option for their particular situation. You may want to consult his website Hope For Fibroids Organization for additional fibroid information. Here’s what he had to say about fibroids during a recent interview.
When does a woman with fibroids require at hysterectomy?
Dr. Hutchins: Most women with fibroids do not need to have a hysterectomy. And I believe that we are going to see the numbers of hysterectomies performed to treat fibroid symptoms decline, as more doctors and women become aware of other effective, less-invasive treatment options. A hysterectomy to treat fibroids should be reserved for the woman who says, I’ve been burned. I’ve tried everything and I don’t want to ever have to think about my fibroids again. I want cure! If you want cure, then removal of the uterus is the answer to your problem. But, deciding to undergo a hysterectomy is a big decision and a woman needs to understand the risks associated with the surgery and other serious issues that go along with it. I only consider this when all else has failed.
How does a woman know her doctor is up to date and qualified to perform the newer techniques available to treat fibroid symptoms?
Dr. Hutchins: I think that especially because there has been a rapid expansion of treatment options in the past ten years, that it is more incumbent than usual for the woman to do her homework as best as possible get a grasp on what a full range of options are and expect that her gynecologist will be able to discuss those within the framework of what her needs are. And the woman should be able to make liberal use of second and third opinions. If someone says they can do something, that is materially different than if they say they do this particular thing. If a gynecologist is not performing myomectomies multiple times a year, then that individual is probably not skilled in that procedure and is not necessarily the best person to be performing it, especially if fertility is the issue. So, the question that should be put to the gynecologist is, How regularly do you perform this or that procedure?
Does a woman with fibroid have to worry about it turning cancerous?
Dr. Hutchins: The consensus opinion today is that a fibroid is a fibroid is a fibroid. It is absolutely unnecessary for a woman to be concerned whether or not that fibroid is a sarcoma, an extremely rare cancer that can look like a fibroid. Years ago, when I was in medical school, we were taught that a fibroid can turn into a sarcoma, but no one believes that today.
What is the greatest myth that women have about fibroids?
Dr. Hutchins: Number one is that they have to be treated at all and number two is that they are going to eventually have symptoms and require a hysterectomy.
What do women fear the most about their fibroids?
Dr. Hutchins: Most women fear they are going to need a hysterectomy. And the interesting thing about that is that many times they are criticized by their female friends for not just going on and being a woman about it. There’s that mentality: have your hysterectomy like everyone else. What’s the matter with you, you punk! I meet women all the time who are burdened with this guilt, because they are "too chicken" to have a hysterectomy. I want to change this way of thinking.
This article courtesy of EmpowerMed, an Internet-based service that empowers individuals and their families to become more active participants in the decisions that affect their health and well-being. This free service will be available in April, 1998 at www.empowermed.com. Copyright 1998 EmpowerMed, all rights reserved.