Enduring the Unseen: Resilience Through Uterine Fibroids and an Ectopic Pregnancy

Noor is a 49-year-old mother of four whose life and motherhood have been profoundly shaped by her experiences with uterine fibroids and its complications. Throughout the many years that I have known Noor, I bore witness to her tribulations. Although uterine fibroids and ectopic pregnancies are not uncommon, Noor’s story combining the two is unique. It sheds light on the serious consequences of untreated conditions that can accumulate to become deadly— from a small fibroid to an ectopic pregnancy. 

Ectopic pregnancies and uterine fibroids can both severely impact health. According to the Cleveland Clinic, uterine fibroids, also known as leiomyomas, are non-cancerous growths that vary in size and location, and in their early stages, they often do not cause symptoms [1]. Uterine fibroids are also very common; “about 20% to 80% of women develop uterine fibroids by the time they reach the age of 50” [2]. In contrast, only 1-2% of conceptions in the US are ectopic pregnancies [3]. Mayo Clinic defines ectopic pregnancy as an abnormal implantation of the fertilized egg outside the uterus, with the most common location being on the fallopian tube. The Cleveland Clinic notes that ectopic pregnancies pose risks such as rupture, internal bleeding, and infertility, while untreated fibroids can lead to severe anemia, complications during pregnancy, and chronic pain [1] making ectopic pregnancies great mimickers. Current research suggests that while fibroids do not directly cause ectopic pregnancies, they may increase the risk by altering the structure or function of the uterus and fallopian tubes. Noor’s story depicts an instance of a direct connection between the two conditions. 

Noor first learned about her uterine fibroid condition during her second pregnancy at 27. While breastfeeding her first child, Dina, and expecting her second, Rana, a routine checkup revealed the presence of small uterine fibroids. Noor’s OB-GYN reassured her that the fibroids were harmless and required no immediate treatment, allowing her to focus on her family.

Five years later, Noor was planning for a third child. She then began experiencing heavy menstrual bleeding, also known as menorrhagia, a common symptom of fibroids. Other symptoms of fibroids include pelvic pressure or pain, frequent urination, and difficulty emptying the bladder [4]. Noor was busy balancing work and family life, so she delayed seeking care until her symptoms became unmanageable. When Noor finally visited a doctor, she was criticized for her delay in seeking help and was left feeling ashamed. Noor was  also told she would never have children anymore because of her uterine fibroids. The provider stated this to Noor as a fact, despite having performed no prior imaging or testing, and then proceeded to give Noor an injection to relieve the pain. Due to how long ago this interaction was, Noor doesn’t fully recall what was given to her. Some potential medications that might have been delivered are leuprolide acetate or medroxyprogesterone acetate, also known as Lupron Depot or Depo-Provera, respectively. They are known to reduce both the size of the uterine fibroid and improve menorrhagia by stopping the menstrual cycle during treatment [5]. This distressing interaction made Noor hesitant to seek further help, highlighting the impact provider-patient communication has on long-term health outcomes.

Two days later, Noor experienced sudden pain, dizziness, and a vibrating sensation in her lower right abdomen. Thinking her symptoms were a sign of appendicitis, she alarmingly contacted the emergency department and was advised to come in immediately from work. Noor’s doctors initially suspected appendicitis as well, but imaging revealed a pregnancy on her fallopian tube— a type of ectopic pregnancy. Tubal ectopic pregnancies can cause the fallopian tubes to burst open, resulting in lethal bleeding (Ectopic Pregnancy).  The same day, Noor underwent an emergency laparoscopic salpingostomy to remove the ectopic pregnancy and leave the fallopian tubes to heal on their own. A laparoscopic salpingostomy is a surgical procedure where a small abdominal incision is made to insert a laparoscope, a thin tube with a camera and a light, to remove the ectopic pregnancy while keeping the fallopian tube [6].  This surgical intervention needed to be done at that moment due to Noor’s menorrhagia and pain. Noor’s uterine fibroids likely disrupted normal implantation, forcing the fertilized egg to settle in a fallopian tube, rather than the uterus. She does not remember the specifics of her imaging or procedures due to the large amount of time that has passed since and the emotional and physical turmoil she had gone through at that time 

After this ordeal, Noor was advised to find a new OBGYN. Her new provider, Dr. Nawal El Khalidi, assessed Noor and determined that she needed to remove her fibroids surgically. After further assessment, Dr. Khalidi also diagnosed Noor with severe anemia, as her hemoglobin levels were dangerously low at 4 g/dL. Normal levels for women range from 12 to 16 g/dL [8], and levels as low as Noor’s are extremely dangerous. 

Dr Khalidi exclaimed, “How are you even standing right now?!”

Before the emergency salpingostomy, Noor consistently showed up to work even when she was dizzy, extremely exhausted, and experiencing severe menorrhagia. “I thought that I was normal, but no one told me that this could be serious,” Noor said carefully. 

After months of trying to stabilize Noor’s hemoglobin levels to no avail, Dr. Khalidi recommended iron supplements and an injection to temporarily halt her menstrual cycle.  This would allow her hemoglobin levels to stabilize over six months. Although Noor doesn’t recall the details of the injection, it is a standard treatment to pause heavy bleeding and allow the body to recover [1]. Some possible injections are the same as those used by the earlier provider, such as Lupron Depot or Depo-Provera. 

Once her hemoglobin levels improved, Noor underwent an abdominal myomectomy, a surgical procedure where a horizontal incision is made in the lower abdomen to remove fibroids while preserving the uterus [4]. During the surgery, Dr. Khalidi observed many fibroids that were relatively larger in size, explaining the excruciating pain that Noor was feeling. Imaging was taken to ensure that her fallopian tubes remained intact, preserving her fertility, as Noor really wanted to have more children of her own. Noor described the imaging as “colorful imaging.” This likely could have been a type of hysterosalpingography, an X-ray dye test that allows providers to visualize if there are any fallopian tube blockages (“Hysterosalpingogram”). 

Shortly after the surgery, Noor conceived her third child, Lee. Due to her myomectomy, she delivered Lee via a Cesarean section (C-section). A C-section involves making a horizontal incision in the lower abdomen to deliver the baby surgically, and it is often recommended after uterine surgeries to reduce the risk of complications that may arise during vaginal delivery (“C-Section”). Noor later gave birth to her fourth child, Layla, also via C-section.

Years later, in 2016, Noor and her family relocated to the United States. By 2018, her symptoms returned, including heavy bleeding, painful cramps, and blood clots. “They weren’t any normal clots; they were terrifying.” 

This pushed Noor to seek care at a free clinic, as she had just immigrated and had no health insurance. After examination, the clinic advised her to go to the emergency department, stating that her condition was quite dangerous. Noor went, despite being afraid to go to the emergency department in a new country— especially because she primarily spoke Arabic with some English,  The emergency department conducted an ultrasound, revealing the re-emergence of uterine fibroids, a common occurrence when the uterus remains inactive [1]. The emergency department doctors rushed her to get ready for surgery, which made Noor feel uneasy and worried. Her hemoglobin levels again were critically low. However, Noor was discharged without having done the surgery after hours of waiting. She was confused and anxious. “Why would they let me go when they made me think that my condition is urgent? It turns out that it was because I didn't have insurance.”

Months later, with insurance, Noor saw an OBGYN in the US for the first time. Noor was made aware by the new OBGYN that she most likely needed to get some surgical intervention. However, her time with the provider was cut short as the OBGYN retired soon after. Noor then started doubting whether these fibroids were now cancerous due to their aggressive nature. Fortunately, the head of the OBGYN department assured her that her symptoms were not of a cancerous nature. Hearing that after having the doubts simmer in her mind for a while was quite reassuring for Noor. At the time, she was far away from any family because she was in a new country, and she did not speak the language, making her increasingly anxious about her health and wellbeing.   

During a consultation with Noor’s new OBGYN,  the two had a discussion about children. However, keeping Noor’s health in mind, they decided it was best for her to proceed with surgical interventions to remove her uterus and keep the cervix intact, also known as a subtotal hysterectomy [8]. Noor’s surgery was repeatedly delayed due to the COVID-19 pandemic and provider availability. After months of waiting and on her fifth OBGYN, Noor opted for a total hysterectomy with bilateral salpingo-oophorectomy, a procedure that removed her uterus, cervix, ovaries, and fallopian tubes [8]. The surgery was complicated because of the dense scar tissue from previous abdominal operations. Due to the COVID-19 drainage on hospital resources, Noor was discharged that night after the procedure. Post-surgery, Noor experienced intestinal and bladder paralysis, requiring immediate hospitalization. Noor stayed in the hospital alone for five days trying to recover; she described that time as “dark.” he was alone, the hospital had a nasogastric tube in her to drain the fluids, which caused her discomfort, and no one shared a similar background as her, making her feel alienated. 

After recovering from the surgery, Noor was presented with hormone replacement therapy to aid with her missing ovaries. Noor declined the therapy due to her family history of breast cancer, given that research supports estrogen treatments linked to the onset of breast cancer [9].  

Noor endured many traumatic events in her journey with uterine fibroids, ectopic pregnancy, and the complications that came with that. For a while, Noor felt like she had lost her womanhood after the subtotal hysterectomy, which is a mental battle that many endure after such an invasive procedure as they enter a surgically induced menopause. Despite that, Noor found peace and kept her head high for her four children. She now feels a glimmer of hope, as she constantly prays that these 18 years of uterine issues have come to a quiet end.

Author's Note

In my UWP104F class, we were asked to interview someone to write this narrative case study. Our literature review had to align with the narrative case study’s participants. Through that class, I better understood the condition and the aspect of human struggle. The participant I interviewed is a very close relative; they endured many hurdles with their condition and their pursuit of choosing to become a mother. The goal of this narrative case study was to tell the story of Noor (a pseudonym) in chronological order, emphasizing how there was something with her condition to be dealt with every step of the way. The language of this case study is somewhat casual, as I wanted Noor to be able to read it without having too much trouble; her first language is Arabic. However, I kept in mind that I wanted her story to be told so others could understand the complications of her issues.  When looking at literature about her condition, there was not much to be found, making this story even more powerful.

References

1. Cleveland Clinic. 2024. Uterine fibroids: symptoms & treatment [Internet]. Available from: https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids

2. Office on Women’s Health. 2024. Uterine fibroids [Internet]. U.S. Department of Health and Human Services. Available from: https://www.womenshealth.gov/a-z-topics/uterine-fibroids

3. American Society for Reproductive Medicine. 2024. Ectopic pregnancy [Internet]. Available from: https://www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/ectopic-pregnancy-booklet/

4. Mayo Clinic. 2023. Uterine fibroids: diagnosis and treatment [Internet]. Available from: https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/diagnosis-treatment/drc-20354294

5. Weiser P. 2022. Lupron Depot injection: side effects, cost, dosage, and more [Internet]. Medical News Today. Available from: https://www.medicalnewstoday.com/articles/lupron-depot#alternatives

6. Mayo Clinic. 2024. Ectopic pregnancy [Internet]. Accessed 2024 Dec 3. Available from: https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-causes/syc-20372088

7. Brihi JE. 2024. Normal and abnormal complete blood count with differential [Internet]. StatPearls [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK604207/

8. NHS. 2024. What happens during a hysterectomy [Internet]. Accessed 2024 Dec 3. Available from: https://www.nhs.uk/conditions/hysterectomy/what-happens/

9. Mayo Clinic. 2024. Breast cancer: different types, different treatments [Internet]. Available from: https://www.mayoclinic.org/diseases-conditions/breast-cancer/in-depth/breast-cancer/art-20045654