Medical Examiner

The Only Certainty in Reproductive Health Is Uncertainty

Lena Dunham’s painful essay about her hysterectomy should remind us that medicine is highly individual and often outside of our control.

Lena Dunham.
Lena Dunham. Photo illustration by Slate. Photos by Amanda Edwards/WireImage/Getty Images and Thinkstock.

On Valentine’s Day this year, Vogue published an essay by Lena Dunham about her experience of choosing to undergo hysterectomy for treatment of chronic pelvic pain and endometriosis. As a gynecologist, I am grateful whenever celebrities publish articles about their reproductive health. Whether it’s Angelina Jolie writing about BRCA or Chrissy Teigen writing about her postpartum depression, these women, whose lives and bodies are already the focus of incredible public scrutiny, are laying bare one of the most private and vulnerable aspects of their life—all for the sake of raising awareness about a medical condition they share with other women.

They also tend to receive a hefty amount criticism for doing so. Dunham’s piece certainly did, which is unsurprising, since her story highlights some of the most uncomfortable themes that I’ve encountered as a women’s health care provider—namely, the issues around reproductive self-determination and the capacity for informed consent. Even more illustrative is the media response to her article: There are the opinion pieces questioning her choice, seeking to challenge or verify the medical facts of her decision. (As a gynecologist specializing in chronic pelvic pain, I understand this impulse, because I similarly couldn’t help but wonder whether Dunham’s physician had accurately diagnosed the causes of her pelvic pain, or appropriately counseled her about options for fertility-sparing treatment.) And there are the meta-articles criticizing other articles for questioning her choice, citing this as another example of society imposing its opinions upon an individual woman’s decisions regarding her body.

At the core of the impulse to question Dunham’s choice is the myth that if women just try hard enough, they can achieve reproductive self-determination. We all want to believe that Lena Dunham has the ability to conceive and carry the pregnancy that she eloquently describes herself as having always dreamed of. We all want to believe that she has a right to parent the biologic children that she desires. But in the fight for women’s reproductive freedom, in our efforts to remove external constraints on women’s reproductive choices, we have forgotten the one internal constraint over which even medicine is often powerless: biology.

If there’s one thing that I’ve learned from my training as an OB-GYN, it’s to respect the capricious, at times cruel nature of reproductive biology. You could have the healthiest lifestyle possible, wait until the reasonable age of 30 to start a family, face the cruel struggle of infertility, spend lots of money attempting pregnancy through in vitro fertilization while facing medical side effects and surgical risks—and you could be completely unsuccessful. You could lose both of your fallopian tubes to ectopic pregnancy, experience scarring from pelvic infection or endometriosis and not be able to afford assisted reproductive technologies to attempt pregnancy. You could undergo a myomectomy to remove fibroids that were impairing your fertility, only to end up with a hysterectomy performed to stanch life-threatening bleeding. You could successfully get pregnant, carry until term, and be diagnosed with in utero fetal demise upon arrival to the hospital for a scheduled induction of labor. You could successfully deliver your first child, then hemorrhage and require cesarean hysterectomy, eliminating your chance of growing the family that you and your partner had hoped for. I have comforted women suffering through each of these scenarios, trying to reconcile her long-standing belief that she had control over her reproduction with the reality imposed by her biology.

When medicine can overcome the constraints of biology, it is often at great, even prohibitive cost. Dunham talks in her article about having preserved her ovaries, and her continued hope for a biological child. Her article doesn’t go into details, but the only medical option currently available in this scenario is in vitro fertilization with use of a gestational carrier: the use of medications to stimulate Dunham’s ovaries to make eggs, retrieval of eggs through a procedure requiring anesthesia, creation of embryos in a laboratory, and implantation of an embryo into another woman’s uterus. Average cost of an IVF cycle in the United States is $12,400, with multiple cycles often being necessary to achieve live birth, and the use of a gestational carrier further increases costs and introduces legal complications. Insurance coverage of assisted reproductive technology is an area of huge disparity in American health care. Dunham may be able to afford this process, but most young women considering hysterectomy for debilitating pelvic pain cannot.

When it comes to reproductive decisions, perhaps the most challenging part is accepting that the control we crave is out of reach. While physicians strive to counsel patients with the best information about their individual risk factors and predilection for disease, the truth is that none of us has a crystal ball. We simply cannot know whether a certain reproductive outcome will happen, or whether a change in behavior will result in a specific reproductive outcome. No physician can say for sure whether Lena Dunham would have ever achieved a successful pregnancy if she had chosen a different path.

For young women with chronic pelvic pain, considering hysterectomy as a treatment involves weighing the hope for future children against the hope for pain relief. GYN surgeons are especially careful when counseling patients in this scenario. In her article, Dunham correctly summarizes, “They don’t contemplate this request lightly, doctors.” Physician-patient conversations about chronic pain are especially challenging, as pain can be a mind-altering experience. The urgency to resolve one’s pain can distort how a person thinks and makes lasting decisions about the future, including about surgery that will irreversibly end a woman’s ability to have children. As a surgeon, I need to feel confident that my patients are consenting to surgery from a place of resolve and deep understanding of the risks, benefits, and alternatives to the procedure: This is the foundation of informed consent.

If you are in your 20s or early 30s and are confident that you desire a hysterectomy or sterilization procedure, I am happy to perform that surgery for you, as long as we are able to discuss the alternatives and reach a decision through a process of informed consent. I may feel that an alternative procedure would be a better option for you—a presacral neurectomy, for example—and I will let you know as much, but at the end of the day it’s your choice. So long as you have listened to my counseling and considered the alternatives, I can be confident that I have obtained your informed consent for the procedure, which is my ethical obligation.

Working as an obstetrician-gynecologist, I’ve experienced both the joy and the suffering brought to women by their reproductive biology. I’ve experienced the miracle of birth hundreds of times over. It remains a miracle, because I know how tenuous it is: all the things that had to go right over the course of that woman’s life, over the course of that pregnancy. Until that baby is out and breathing room air, there’s no guarantee of success. OB-GYNs are sometimes maligned for disregarding the birth plans of expectant mothers arriving in labor and delivery. But it’s not that we don’t think you should have exactly the birth that you want, it’s that we recognize it as hubris to expect that you or your physician can guarantee this.

Any conversation about women’s health and health care is complicated by social, socioeconomic, political, and religious considerations—this is one of the greatest challenges of working as an OB-GYN. It is also something that imbues the work with great meaning. Every conversation with a patient should begin with the cultural context surrounding her sexuality or fertility. In the process of communicating detailed medical facts about a patient’s health and her options for management, the OB-GYN must clarify that individual patient’s individual reproductive values and goals, then counsel toward the outcome best suited to fulfilling these. It is hard to get it right, thanks to the 15- and 30-minute clinic time slots afforded by the modern health system, or the urgency demanded by an unstable patient bleeding internally from a ruptured ectopic pregnancy. But it is perhaps hardest to get it right because many times, there are simply no good answers. So before you judge Lena Dunham, yourself, or anybody else for the decisions they have made about their reproductive health, remember—we have influence, but not control over our biology. We can hope for the best, but we can’t expect it.