for Janice Stain, M.D.
He is moving brusquely about the house, opening this closet and that, gathering his personal belongings. Clothes mostly, but also a few magazines and cookbooks, cutesie figurines and trinkets I have known him to collect over the twenty-four years that we have been together. It’s a predictably warm Fourth of July in Fresno, the air conditioning blowing its labored breath through the vents of the house by ten o’clock in the morning. Our fifteen-year-old daughter, Maya, focuses on the SAT prep that is her mission this summer and will be again this time next year. Cyrus, two years her junior, remains in his room, peering into his cell phone, most likely reading articles about global transfers of soccer players from one club to another. I feel the absence of my brother, who took a week off from his work at Google in order to be here for my surgery a month ago–a hysterectomy to remove uterine fibroids. My mother will remain until I am fully recovered. Her own fibroids shrank with menopause many years ago. Now she occupies the white vinyl armchair in the family room as she writes, clench-jawed, about the possibility of leaving Pakistan permanently and beginning life afresh in California in her seventies.
This summer I have made it my business to read in the formal living room where Maya studies at least four hours every day. I look forward to this peace, this enforced rest. In a little while Cyrus will tire of his cell phone scrolling and move to the piano bench in his room. Then his renderings of a Beethoven rondo will waft down the hallway, and I will hold the moment, cup it in the hollow of memory, against the day when both he and Maya will be gone. Holding it, I will drift off to sleep on the red couch—I, who, in able-bodied arrogance, had scorned naps. But today I am distracted, not by my convalescing body but by the sounds of things being dropped into cardboard boxes and the periodic slap of the packaging tape sealing them shut. They are the sounds of the finally purposeful presence of my husband preparing to move out.
How do you drop twenty-four years into a box and seal it?
It’s possible that twenty-four years ago I already had the uterine fibroids.
Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. . . . Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. . . .As many as 3 out of 4 women have uterine fibroids sometime during their lives, but most are unaware of them because they often cause no symptoms. – Mayo Clinic
So, not only are most women oblivious of the fibroids they carry, but nobody knows why they happen or what a woman might do to prevent them. Genetics matter; a mother or sister with fibroids puts you at greater risk. And black women are more likely to get them–larger growths, more numerous, and at a younger age. My own fibroids first became a concern in 1999 when we lived in Taunton, Massachusetts, and I conceived Maya. One fibroid in particular, towards the bottom left of my pelvic cavity, had acquired the size of the proverbial tennis ball. While the fibroids didn’t cause a miscarriage in either of my pregnancies, they did obstruct my babies’ movements enough to keep them from turning head down, in the cephalic position. Breech babies who did not have space enough to respond to the manual guidance of “external cephalic versions,” Maya and Cyrus’s only way out into life was via caesareans. Maya, in the last weeks before birth, had been sitting on her feet like an amateur Buddha, to emerge from the womb with her right foot perpendicular to her leg. Luckily, her foot straightened itself out in a few weeks, as the doctor had said it would. In Cyrus’s time I opted for the caesarean without subjecting myself to the vain discomfort of an attempted version.
Then in 2005, when my children were five and three years old, I got so tired that moving a few feet took enormous effort, and conversation required more breath than I had to spare. It was not something I expected my husband or anyone else to really notice. That summer, on the eve of my birthday, I dreamed that I longed to lie down and be allowed to die–gradually, as in a bloodletting–but I couldn’t because Cyrus needed my attention. It turned out that I had a severe iron deficiency. Whereas the normal hemoglobin range for women is 12-15 grams per deciliter, mine had fallen to 7. I didn’t know then that such low hemoglobin levels can lead to heart attacks. That fact came to light eight years later when my father died; his last email to his children, sent from Pakistan a day before his death, mentioned that his hemoglobin level had dropped to 7. I was younger and luckier than my father. But though fibroids are technically “benign tumors,” in my case they were agents of malicious blood loss until my doctor in Taunton finally thought to put me on the birth-control pill. While the pill curbed my symptoms and arrested the bleeding, the fibroids themselves, with wry medical irony, thrived on the estrogen and progesterone in it. Yet I deferred the surgery year after year for all the wrong reasons: because I was too busy, unfocused, and afraid.
I’ve learned that a single uterus can sport a variety of these benign tumors: from the most common intramural fibroid that grows within the muscular uterus wall to the subserosal that flourishes on the outer wall, to the least common submucosal that develops just under the mucous membrane or lining and, in some internet images, resembles the outline of a toddler’s head hiding under a rug. Then there’s the pedunculated fibroid that sprouts bizarrely on a stalk, within the uterus wall or outside it. Its descriptions are often macabre: A fibroid that hangs by a stalk inside or outside the uterus . . . can trigger pain by twisting on its stalk and cutting off its blood supply (Mayo Clinic). So it blossoms on a stalk like a flower but is neither benign nor beautiful in its sadomasochistic twists. My fibroids, twelve to fifteen in number, were mostly intramural. By the time of the hysterectomy, the largest of these was ten centimeters in diameter, heavily calcified, and, according to the pathology report I later saw, showed “ischemic-type necrosis,” meaning that its blood supply had been cut off, causing it to degenerate. The multiple fibroids would chafe against my uterus lining and resulted in such bloodletting that I became acutely anemic.
- Pathology. A quantitative deficiency of the hemoglobin, often accompanied by a reduced number of red blood cells and causing pallor, weakness, and breathlessness.
- a lack of power, vigor, vitality, or colorfulness.
What I hadn’t realized a decade ago was that my marriage, too, had begun its long, anemic decline. The symptoms were so subtle as to go undetected. We were different to begin with–in age, race, religious background, politics, priorities, and temperament–but thought we could overwhelm the odds.. In the mid-1990s we were also at different stages of our very different careers: while I wrote my dissertation in American literature and braved the whims of academia as an adjunct professor, his leasing company still employed several people. But he captained a ship that had once sailed with the rising tides and now drifted only half-aware of the shoals that would sink it before we even married. Then with two children born twenty-one months apart, it was easy to see ourselves as just getting through the daily tasks to do our best as parents. How eagerly we–I?–blamed these pressures and held on to the hazy thought that we would get beyond them to a day when we could bring each other into focus again. In the meantime, if we weren’t going to the movies or to dinner together, we explained it to ourselves as lack of money or babysitter rather than lack of inclination. That the marriage might have paled before the children were even born–that is a possibility I am allowing myself to register only now, in this act of writing. The mind conspires to not see. It’s only now as my fingertip retraces the thread of time and fumbles its way back to the spool that I detect the silent, stealthy unraveling. But who can account for the death of a love or the disappearance of a former self? Who can see an invisible hemorrhaging?
I wish I could identify the benign tumors that drained the lifeblood from my marriage. The enemy within the walls, or hiding against it, or stalking on the outside, biding its time until one suicidal twist cuts off its own blood supply and, in bitter anguish, it strangles itself and the marriage. The marriage a uterus, full of the possibility of life–indeed delivering on its promise until one day a sudden clap of clarity reveals that it has outlived its purposefulness, that the thought of its surgical removal is more welcome to both parties than the prospect of bearing the burden it has become.
Or had the marriage itself become a benign tumor? A fibroid pressing against vital organs, distorting the shape of the uterus on which it preys, and gradually robbing the entire body of red-blooded vitality. Our growing habit of inattention has taken distinct forms: mine an easy immersion in children and students; his the constant busy work in the house, the exacting perfectionism in small things, even as he ignores the financial precipice toward which we are edging; the brooding at the dinner table with eyes closed as the children chatter. When did my shoulders learn to relax with his absence, like a tide receding, every third weekend when he visits his mother in Carmel?
Carmel, that fairytale setting for weddings, including ours almost nineteen years ago.
I think now of his relationship with other things and seek clues to the mystery of our story there. The Pace Arrow motorhome he drove alone, devoted and determined, across the continent when we moved to Fresno in 2006, the 38-foot vehicle already eighteen years old and clambering breathlessly as he coaxed it over the Rockies and the Sierras. Once in Fresno, it was parked in storage and never seen again. Dues paid faithfully every month for near nine years; the joy of it forgotten.
And then his equivocal relationship with the yard: at once a passion, an escape, and a life sentence with hard labor. No thanks he says to the gardeners who maintain our neighbors’ homes. Hours poured into work that is never complete, yet all the trees left untended. The palm that sold me on the house in Fresno so overburdened that it hangs threateningly over the children’s heads in the pool. Voluntary oaks shoot up in the front yard; oleanders rise jarringly amidst the junipers. The olive tree near the entrance, into whose outstretched and welcoming arms my four- and six-year-olds had run at first sight of their new home, still standing, its limbs now gnawed away by termites. But its roots grow powerful beneath the ground we tread, and treacherous–undulating the surface in concrete waves that reach for Maya’s bedroom. A few feet away, a young Japanese maple threads its trunk through the wrought iron gate, one of its thicker branches resting against the house and a crack spreading like a sardonic smile on the inside of the arched wall overhead. It is a landscape both cared for and neglected, loved and resented.
Was that a separation in 2003 when I took three-year-old Maya and one-year-old Cyrus with me to Pakistan for an open-ended stay? To give him time to find employment and me a chance to escape the Iraq War fervor in America–in my own home, in fact–and make memories with my parents, so we said. We talked on the phone twice a week over what turned into five months, his note cards supplementing our scattered conversations at regular intervals. He even visited us in Karachi for a week. But if either of us said I miss you, I have forgotten it.
A mystery, too, when precisely cards and flowers languished into bloodless rituals. Each year before our anniversary there I am, staring blankly at the offerings in the Target aisle. He goes for the cute and funny, but I strain for the right tone. Valentine’s Day matters less–a manufactured holiday that marginalizes most people. But he will have card and flowers for me, as he will for the children and for his mother, the cards bearing similar cheery messages in his unique, oversized handwriting that quickly covers the space.
On Valentine’s Day weekend, 2015, there happen to be no cards. For the first time in fifteen years, there are no children at home either because my family has flown them out to San Diego for Cyrus’s birthday. That Friday evening after I return from dropping our young teens off at the airport, he tells me it has been three weeks–time for his drive to Carmel. He doesn’t ask what my plans are; I don’t ask to accompany him. We kiss each other on the cheek, and I spend the weekend alone. And happy: a morning walk, an idle peek at a house for sale in the bohemian part of town, a little dancing by myself as my mother used to when I was Maya’s age.
Marriage as a benign tumor, then. It’s what one calls “baggage” in a more familiar metaphor. Over the past two decades I have learned that there is no such thing as benign baggage because, one way or another, you pay to lug it.
The fibroids I had been lugging all those years were removed in an abdominal hysterectomy. My surgeon was also my gynecologist of four years. An earth-toned African American woman of faith and grace, she has moist eyes, a deep, gentle voice, and a powerful handshake. Her small, silver-and-pearl cross gleams beneath her collar bones. Though she appears spacey at times, I am convinced that I can trust her with a knife. Perhaps I do so because she is the only doctor ever to tell me, “I like words. I like their precision.” Or perhaps I trust her because she isn’t afraid to show emotion. At my pre-op appointment I sit in her office as she peers into a computer and asks me a series of routine pre-surgery questions. Then she poses one that I’m not unexpecting:
“Are you married?” she asks.
“Eighteen and a half years,” I say. Then add: “But it’s about to end.”
Still facing the computer, she closes her eyes and takes a deep breath. In that moment she is taking in the whole likely story. When she opens her eyes again, something between sorrow and exasperation crosses her face. “I like to know,” she says.
She also tells me that my uterus has grown dramatically due to the fibroids; it is the size of a thirteen to fourteen-week pregnancy.
During the abdominal hysterectomy she cut into the very incision that was made years ago for my two caesareans. In order to rid my body of the fibroids, the uterus that had been harboring them, as it had harbored my babies, had to go, too. My cervix, ovaries, and fallopian tubes were also removed in what is called a total abdominal hysterectomy with bilateral salpingo-oophorectomy. There was no point in holding on to them. At my age these reproductive organs, simply by virtue of time, had lost their life-giver status and become potentially treacherous sources of cancer. And when the ovaries go, they take with them the woman’s primary source of estrogen, so menopause arrives immediately and unceremoniously, ready or not. After caesareans, hysterectomy is the most common form of surgery performed on women, and one in three American women have the procedure by the time they are sixty. Major surgery, demanding six to eight weeks for recovery, but routinely performed nonetheless. As in my case, the most common reason for hysterectomies is unruly fibroids–those benign tumors that three out of four women carry though they may not realize it, whose cause is unknown, and to prevent which there is nothing they can do.
For a time after the hysterectomy I am uncomfortable even when the pain has diminished. Distended stomach, lower-back ache, easier to sleep sitting up. When I lie on my back, a weight settles on me; as I try to turn on my side, I feel a movement, something shifting, and I support my drum belly with my hand.
“It’s weird to feel pregnant when you don’t have a uterus,” I say. Maya is so amused by this statement, she tweets it.
I imagine how my pelvic cavity looks without uterus, cervix, fallopian tubes, and ovaries. An empty cave? More space than the remaining organs know what to do with, but in time they will adjust to the absence of that presence that had seemed an inevitability. I wonder what has taken the place of my reproductive organs in the immediate aftermath of the hysterectomy. Gases? Fluids? The emptiness is not nothingness. Sometimes at the bottom left of my abdomen, where once I could touch the well-defined tennis ball, I feel a twinge of pain. A phantom fibroid. Will it always haunt?
Loss and hope converge in my hysterectomy. That word “womb”–a lone syllable, wistful; its long vowel shaping the mouth in a wind-blown kiss, its consonant cluster mellifluous and lingering. The womb that had held my babies, grown them in cramped quarters and brought them safely to term, is gone. All that remains of it is captured in a photograph that I had asked my doctor to take for me (not an usual request, she said). Cyrus is fascinated by the pulpy, pear-shaped mass, its tennis ball glistening. “Your first home,” I say, and he smiles.
With ovaries gone, the hormonal shock to my system has rendered me instantly menopausal. And no woman was ever as excited about this phenomenon as I. Lying in the hospital bed a night or two after the hysterectomy, I realize that I’m breaking into a sweat. Through my morphine-muddled consciousness, an exhilarating thought breaks through: Hot flashes! These must be hot flashes! I bid the moment stay. After years of blur, I am giddy with gratitude for menopause’s sudden and unequivocal arrival, for its contours sharp and bold. The womb is gone, the ovaries, too, but in one summer I have freed myself of all benign tumors. Welcome then, menopause. Welcome the clarity of this transition, the crisp outline of the end of an era. And the beginning of a new one–just my babies and me.