She’s 37, and, at 5-feet-7 and 160 pounds, not as thin as she’d like. So when her new boyfriend suggested liposuction and agreed to foot the $6,500 bill, she agreed.

“I was slightly insulted,” says the woman, a graphic artist from Roxbury. But her boyfriend had had the same surgery and she wanted to be able to tuck in her blouses again.

Besides, she figured, this was a gift she’d have forever, “as long I don’t die through this surgery, which is not likely.”

She’s right. In the vast majority of cases, liposuction, in which fatty tissue is literally sucked out of the body through hollow tubes under anesthesia, isn’t lethal.

But the procedure — the fastest growing, most popular form of cosmetic surgery, now performed on 177,000 people a year — isn’t as benign as many people think, either.

It’s especially risky if it’s done in a doctor’s office, if the doctor is not properly trained and certified, if he removes too much fat, or if he pumps in too much “tumescent fluid” to control bleeding and then fails to control for potentially fatal fluid overload.

Consider:

• On March 17, 1997, a 47-year-old California woman died at the Irvine Medical Center after a massive procedure: 10 1/2 hours of liposuction on her legs, hips, thighs, buttocks, knees, and arms, plus a face lift. Her plastic surgeon gave her too much tumescent fluid, an administrative law judge ruled.
• On June 22, 1996, a 43-year-old California woman went in for “lunchtime lipo” in Los Angeles and was “dead soon after dinner,” as one magazine put it. Her operation was done in an office by an obstetrician-gynecologist who hadn’t even completed a two-weekend course, said the Medical Board of California.
• On Jan. 13, 1998, a 51-year-old Florida man died after a 10-hour office procedure that included liposuction and penile enlargement. Afterward, he was left in the care of a night nurse. He died of valvular heart disease due to diet drugs and “complications of plastic surgery,” the autopsy found.

These cases, while rare given how common liposuction is, are undoubtedly the tip of an iceberg, though how big an iceberg is tough to determine because death certificates may mention surgery or cardiac arrest, but usually not liposuction per se.

But concern is growing, both among doctors, who are in fierce competition for patients, and among consumers.

Dr. Mark Gorney, executive vice president for The Doctors Company in Napa, Calif., a large doctor-owned malpractice carrier, asked plastic surgeons across the country to report fatal outcomes following liposuction to him. Over an 18-month period in 1997 and 1998, 69 were reported, and he says others think the true figure may be closer to 100.

Dr. Jack Bruner, a California plastic surgeon, thinks those numbers are too high. He believes liposuction caused 60 to 100 fatalities over five years, not 18 months. Still, the California cases were “pretty spectacular deaths, so we decided we’d better take a look,” acknowledges Bruner, who is head of a liposuction task force organized by the American Society of Plastic and Reconstructive Surgeons in 1997.

The issue galvanized California Assemblyman Martin Gallegos, who filed a bill this month to require reporting of liposuction deaths and tighter controls on office procedures.

In Florida, too, the medical board is considering rule changes that would limit office-based liposuction to four hours or less and the amount of fat removed to 2 liters (about two quarts) or less per procedure.

Even in states like Massachusetts, where there have been no reported complaints, Alexander Fleming, executive director of the Board of Registration in Medicine, says there is growing concern as economic pressures nudge more doctors, some with minimal training, to do liposuction.

In the right hands, the procedure is straightforward. The doctor inserts a tube called a cannula through a tiny slit in the skin. He then moves the tube around, causing fat cells to “explode and loosen up,” says Dr. Leonard Miller, a Brookline plastic surgeon. Increasingly, doctors use ultrasound as well to break up the fat before it is suctioned out. Typically, doctors make several tiny incisions in the areas of the body to be liposuctioned.

Though the procedure is “blind,” Miller says, “you can feel where you are.” And as long as the cannula is kept away from major organs (including the intestines, which may be punctured if the patient has an undiagnosed hernia), it works.

To maintain the benefits, though, you have to watch your diet and exercise. You’re unlikely to re-gain pounds in the areas that were liposuctioned because there are fewer fat cells there to store fat. But if you overeat, you will gain weight in areas of the body that were not liposuctioned.

In some ways, it’s safer than it was a decade ago, thanks to refinement by dermatologists of the “tumescent fluid” or “super-wet” technique, which involves injecting liters of fluid into the area from which fat is to be removed.

The fluid contains salt water plus epinephrine (adrenalin), which constricts blood vessels and reduces bleeding. It also contains lidocaine, an anesthetic, which produces enough pain control that a patient may not need general anesthesia.

Adding fluid has enabled doctors to increase the amount of fat they remove because there’s less bleeding and the fat is more liquified. Some doctors now remove as much as 20 pounds of fat and fluid at a time.

But there are serious drawbacks, too. “If you keep putting in liters and liters of lidocaine and epinephrine,” says Miller, “the drugs can cause toxic reactions, including respiratory arrest, cardiac arrhythmias, and convulsions.”

And while some fluid is suctioned back out with the fat, most is absorbed into blood vessels. The result, especially if patients are given intravenous fluids as well, can be congestive heart failure and pulmonary edema (fluid in the lungs), both of which can be fatal.

Last fall, Dr. Rod J. Rohrich, chairman of plastic surgery at Southwestern Medical Center in Dallas, told a national plastic surgery meeting that “careful management of fluids is essential to avoid complications in liposuction.”

“This is real surgery,” he says. “That’s why it’s dangerous when doctors who aren’t trained in large-volume fluid management do this procedure. That’s also why patients should be healthy to start with.”

In general, the plastic surgeons’ society says, patients “should be aware that lipoplasty to remove more than five liters [about 11 pounds] of fat and fluid requires a high level of surgical skill and a provision for prolonged monitoring after the procedure.”

Translated, this means “you probably shouldn’t have more than five liters of fat and fluid removed unless you will be monitored by nurses post-operatively for 24 hours in an accredited health care facility or hospital,” says Rohrich. It’s probably also wise not to have more than 20 to 25 pounds of fat and fluid removed even in a hospital, he adds.

Dr. George Hruza, a dermatologist who runs the cutaneous surgery center at Barnes Jewish Hospital in St. Louis, agrees, especially for liposuction in a doctor’s office. He suggests not removing more than nine pounds of fat and fluids in procedures done in an office or outpatient surgery center.

The Roxbury woman, who had her three-hour operation under general anesthesia at New England Baptist Hospital, had 5 1/2 liters of fat and fluid removed from her abdomen, inner and outer thighs, hips, love-handles, and back.

Three weeks later, she was feeling great. She misses the “softness” of her old belly, she says. But she’s thrilled to be ready to wear a slinky dress.

Sidebar: To obntain more information on cosmetic surgery:

If you’re in the market for liposuction, it pays to do your homework. The competition among doctors for your business is intense, and insurance doesn’t pay for this cosmetic surgery.

Legally, anyone with an MD can do liposuction. It’s usually done by plastic surgeons or dermatologists, though sometimes by gynecologists and ear-nose-and-throat surgeons.

What counts more than the doctor’s specialty, though, is his or her training and certification — and these vary widely.

Ask if your doctor is board certified, and if so, by which board. There are 24 boards recognized by the American Board of Medical Specialties, and only one (the American Board of Plastic Surgery) certifies doctors in plastic surgery. If your doctor isn’t certified by one of these boards, though, it doesn’t automatically mean he or she is poorly trained, but it’s a reason to ask more questions. Even if you do use a plastic surgeon, it pays to ask about specific training because they do not all specialize in liposuction.

If your doctor is not a plastic surgeon, you should ask how much post-graduate training he or she has had in liposuction, and be wary of anyone who’s only been trained at weekend workshops.

In general, ask your doctor how many liposuction procedures he or she has done, what the possible complications are, what kind of anesthesia you’ll get, and where the surgery will be done. You probably shouldn’t have more than five liters of fat and fluid removed unless you will be monitored by nurses post-operatively for 24 hours in an accredited health care facility or hospital. If you do have surgery outside a hosptial, ask what the procedures are if there’s an emergency.

You should also call the board that licenses doctors in your state and ask if there have been any complaints or disciplinary actions against the doctor.

For more information:

There are several ways to verify your doctor’s credentials and training.

Nationwide, you may telephone the American Board of Medical Specialties; 1-800-776-2378. You may also call your state doctor licensing board.

In Massachusetts, the Board of Registration in Medicine can be reached at 617-727-0773.

On the Web, you can visit: www.docboard.org  or www.certifieddoctor.org

Sixteen years ago, Doris Laird, a humanities professor at Florida Agricultural and Mechanical University in Tallahassee, developed a benign brain tumor the size of an orange.

She had surgery — an operation that took 22 1/2 hours. It worked, or so she thought. But four years later, the tumor, a meningioma, was back. She had more surgery; 12 hours this time. Six years ago, it came back again, growing so much it threatened her vision — and her life. She had another 12-hour operation.

In 1994, Laird began taking RU486, the French abortion pill that is not approved for use in this country, on a “compassionate use” basis. There is preliminary evidence that the drug, which blocks the hormone progesterone, also slows the growth of meningioma. In Laird’s case, she says, it “stopped my tumor completely from growing.”

There’s also evidence that RU486 may be useful for a number of other medical problems, including fibroid tumors of the uterus; endometriosis (benign growths of tissue from the lining of the uterus; and Cushing’s Syndrome, a disorder of the pituitary gland.

To get RU486 on a compassionate use basis, Laird, like other patients in the same predicament, had to get an American doctor to prove to the US Food and Drug Administration that she had a serious disease that might respond to the drug. The doctor then arranged with the small French company that sells RU486 in Europe to send it free to her here.

Though cumbersome, this arrangement worked well enough for a while. But in a troubling example of the way politics can sometimes get in the way of legitimate medical needs, it all fell apart this summer when Exelgyn, the French company that in 1997 was given rights to RU486 by the original manufacturer, Roussel Uclaf, balked.

“We are ready to sell the tablets at cost, $5 a tablet,” says the company spokeswoman, Catherine Euvrard. “We are trying to find a US-based organization which is responsible enough to understand that it is up to a US organization to take care of US citizens, not to a tiny French company. I cannot tell you more.”

Laird would have been willing to pay, but like an estimated 25 to 30 other patients in similar straits, she has been caught in a web of red tape and abortion politics.

In 1996, RU486 was deemed “approvable” by the FDA as an abortion pill, but it has not been finally approved and cannot yet be marketed here. (Once approved, RU486, also known as mifepristone, could legally be used “off-label” for other medical purposes such as brain tumors.)

The New York-based Population Council, a nonprofit research group, has had the US rights to RU486 since 1994, but the company it licensed to actually produce and market the drug in the United States, the Danco Group in New York, is still in the process of arranging for manufacturing and distribution.

Danco, says spokeswoman Heather O’Neill, expects to make it available in the US “sometime next year.”

Jennifer Jackman, director of policy and research for the Feminist Majority Foundation, a Virginia-based national women’s rights group trying to bring RU486 to this country, says the “whole compassionate use thing has been a casualty of anti-abortion politics.” She adds that “plans are being worked out to provide it. I can’t be more specific.”

The National Right to Life Committee, prominent in the fight against abortion and RU486, did not return repeated calls.

Sandra Waldman, spokeswoman for the Population Council, echoes that. For two years, the council provided RU486 on a compassionate use basis to 24 patients from a supply it had obtained for research purposes, but that supply has been exhausted.

Waldman adds that the council is “very aware” of the supply problem. “Plans are being worked out for a strategy to handle current and new cases of compassionate use,” she says. “I can’t say more. An announcement will be made soon by the people involved. It isn’t all worked out.”

It certainly isn’t. In theory, patients like Laird could try to buy RU486 from doctors in Europe, where it is sold legally. But even in Europe, the drug is tightly controlled and is generally available only for abortions.

Even if they succeeded in buying RU486 in Europe, patients fear it would be confiscated if they tried to bring it into this country. The FDA allows importation of limited quantities of unapproved drugs for personal use in life-threatening situations. Recently, after consulting with its lawyer, the agency said it would “consider” allowing patients with meningioma to import a three-month supply. But patients worry because an “import alert” the FDA imposed in 1990 forbidding the import of RU486 for abortion purposes is still in effect.

For patients in whom RU486 does seem to slow brain tumor growth, there is great frustration that politics limits their options — even among those who once called themselves opposed to abortion.

Laird, who says her husband “lives on the Internet trying to solve this for me,” says she is “generally against” abortion. But she adds, “I can’t be against its being made legal. We’re talking about my sight and my life. It’s become very personal.”

It’s personal, too, for Anne McGinnis Breen, a Tucson woman who is 51 and had her first meningioma surgery at 39. She is a “practicing Catholic, married for 30 years, with three children. I don’t consider myself a feminist.”

But six years ago, her tumor recurred. “I am convinced,” she says, “that if I could have had this medication after that first craniotomy, I would not have had this recurrence.”

She has been on RU486 for two years — she has a small supply left — and according to the brain scans she gets every four months, her tumor has stopped growing. “Believe me,” she says, “I’m a radical now.”

Lyle R. Groshel of Virginia Beach, Va., echoes that. He won’t state his position on abortion.His wife’s meningioma has been treated with radiation, but if it grows back, “her only option is to find a drug that may stop the growth,” he wrote in an impassioned e-mail.

“I find it reprehensible that our government can prevent the importation or production of RU486 for use by people with meningioma.”

 

SIDEBAR

How RU486 does its job

 

RU486 works by blocking progesterone, a hormone needed for pregnancy. In combination with another drug, misoprostol, RU486 induces miscarriage. Taken alone within 72 hours of unprotected sex, it works as an emergency contraceptive.

The reason it may work on meningiomas — rare, noncancerous brain tumors that strike about 4,000 people a year — is that many of these tumors are also driven by progesterone, and blocking progesterone may slow the tumor. Surgery often works, but the tumors can regrow.

Because of its progesterone-blocking action, RU486 may also help control endometriosis (abnormal growth of uterine tissue outside the uterus) and fibroids, benign uterine tumors.

Through another mechanism, blocking of the hormone cortisol, RU486 may help treat Cushing’s syndrome, a hormonal abnormality.

So far, the data supporting the use of RU486 for brain tumors are preliminary. In 1991, California researchers reported in the Journal of Neurosurgery that they tried RU486 in 14 people with inoperable meningiomas, and five responded well.

That may sound unimpressive, but it’s “very encouraging,” says Dr. Daniel Karp, director of cancer clinical research at Beth Israel Deaconess Medical Center in Boston.

So encouraging, in fact, that the National Cancer Institute set up a placebo-controlled, multicenter study involving 200 meningioma patients. That study ended in July and results are not yet ready, says Karp, who was one of the investigators.

Even if RU486 is not a magic bullet for meningioma, “the results of the study need to be looked at — these patients are not surgically treatable,” adds Dr. John Erban, chief of hematology and oncology at New England Medical Center in Boston and another investigator in the meningioma study.

Carol Rose, a Harvard-trained lawyer from Melrose, was pregnant with her first child two years ago when her health plan pulled a switch.

She was in the exam room, waiting for her female doctor when a male doctor walked in. She’s not anti-men, or anti-doctor, but this guy was a bad match. “I had a bunch of questions,” she says. “He said, `I have limited time.’ I felt so dehumanized and medicalized that I left.”

When she turned to Leslie Ludka, a nurse-midwife who heads the midwifery program at Brigham and Women’s Hospital, she discovered “the best of both worlds” — someone with time to answer questions, yet backed by doctors at a major hospital.

When the big day came, says Rose, Ludka was great. “When the pain was at its peak, I said, `I’m not sure I can do this.’ She said, `The pain will not get worse than it is right now.’ ” It didn’t. Rose had a drug-free delivery, just as she had hoped.

Midwifery — the art of helping a woman through childbirth — is as low-tech as mother’s milk, as ancient as womankind. But until recently, it had been squeezed out of the birthing room by doctors and their gadgets, much as death has been hustled out of homes and into hospitals.

That is changing — 6.5 percent of American babies are now delivered by midwives, usually in hospitals, compared to 1 percent in 1975. And this could be good news for babies.

A study published in May by the National Center for Health Statistics found babies delivered by certified nurse-midwives were less likely to die than those delivered by doctors.

The study, by researchers Marian MacDorman and Gopal Singh, looked at all singleton babies delivered vaginally in the United States in 1991 at 35 to 43 weeks of gestation — roughly full term. (The study did not look at multiple births or Caesareans, which account for about one quarter of all births.)

Of the 2.8 million births studied, the team focused on about 1 million: a sampling of doctor-attended births (850,000) and all 153,194 births at-tended by certified nurse-midwives.

The results were striking:

– After controlling for socioeconomic and medical risk factors, the infant mortality rate — death during the first year — was 19 percent lower for certified nurse-midwives than for physicians.

– The death rate in the first 28 days — was 33 percent lower. – And the risk of low birthweight infants was 31 percent lower.

Some doctors, among them Dr. Michael Greene, director of maternal-fetal medicine at Massachusetts General Hospital, suspect that the midwives’ better track record may be due to their having patients who were “healthier to begin with.”

Dr. Fredric Frigoletto, chief of obstetrics at MGH and a past president of the American College of Obstetricians and Gynecologists, agrees. This study has “significant limitations,” he says, because it’s not clear “how patients found themselves in the midwife or doctor cohort.”

Statistician MacDorman agrees that any study like hers based on data from birth certificates can’t control for all factors, but she notes that since her study deliberately left out multiple births, preterm births and Caesarean deliveries, the women were comparable in that they all had normal deliveries.

Furthermore, her study showed that midwives were more likely than doctors to care for women at higher socioeconomic risk — black women, American Indians, teenagers, women with three or more previous births, unmarried women, those with less than a high school education and those with late or no prenatal care.

The doctors were somewhat more likely to have medically difficult cases, she says, but “the differences were small.”

So if there’s magic in midwifery, what is it? Midwives say it’s time and support — during prenatal visits and labor.

One study cited by MacDorman found certified nurse-midwives spent an average of 49.3 minutes on the first visit — versus 29.8 minutes for doctors. Subsequent visits averaged 29.3 minutes for midwives, against 14.6 minutes for doctors.

Frigoletto counters that if you add up the time the doctor, the nurse and the nurse’s assistant spend with each patient, “the total visit might be just as long.”

Unlike doctors, most midwives stay with the woman — not just nearby — for the duration. This allows quick action if the baby’s heart rate soars or plummets. If low-tech remedies such as having the woman change position or drink fluids don’t help, the midwife can then call in the doctor.

Often, the combination of massage, position changes, breathing exercises and moral support do the trick, though Frigoletto warns there’s little data linking these interventions with birth outcomes.

Midwives believe they have economics on their side, too. A 1996 study of 1,000 patients showed that hospital charges for midwife births were 21 percent lower than those for doctors, perhaps because they’re less likely to use interventions such as electronic fetal monitors and to do procedures such as episiotomies (surgical cuts to enlarge the vaginal opening).

Though midwives, like doctors, can use painkilling medications and drugs such as oxytocin (Pitocin) to induce or speed up labor, they do so sparingly lest they trigger a vicious circle: Painkillers may slow labor, which means a woman may need oxytocin, which causes more pain, which may necessitate more painkillers.

“There’s some truth to that” scenario, says Frigoletto. But usually, the need for drugs depends on the individual and how many previous births she’s had. He adds that doctors, like midwives, are cautious about using drugs too early in labor.

And midwives have some time-honored tricks up their sleeves. Instead of using forceps, midwives often ask a woman to stand and rock her hips or squat to free a stuck baby. They also may use nipple stimulation, which can help a woman’s body release its own natural oxytocin.

“What was nice,” Rose says of her son’s birth two years ago, was having “all the advantages of a midwife, yet if something went wrong, there was a doctor on call and a neonatal intensive care unit 30 seconds away.”

So nice, in fact, that Rose and her husband asked Ludka to deliver their second child, who arrived last month — with the help of another midwife at the Brigham. Ludka was fast asleep — she’d been delivering a baby the whole night before.

SIDEBAR 1:

Some nations cite lower death rates

Long a staple of medical care in other countries, midwifery is growing steadily in the United States.

In 1975, only 1 percent of American babies were delivered by midwives, according to government statistics. By 1991, it was up to 4.4 percent; by 1996, 6.5 percent.

Worldwide, the use of midwives is often associated with lower infant mortality, says Lisa Paine, head of maternal and child health at the Boston University School of Public Health.

In most countries that are “ahead of us in infant mortality rates, there is greater reliance on care provided by midwives,” she says.

But interpreting such data can be tricky, warns Dr. Fredric Frigoletto, chief of obstetrics at Massachusetts General Hospital. Neonatal mortality (deaths in the first month of life) are a big contributor toward infant mortality (deaths in the first year). The United States counts deaths of premature and low birthweight infants as neonatal deaths, but some countries might not count them at all, which skews the statistics, he says.

Still, the apparent link between reliance on midwives and low infant mortality is intriguing. In Britain, about 70 percent of births are attended by midwives and the infant mortality rate is 6.1 per 1,000 — versus 7.8 per 1,000 in the United States, says Paine. In the Netherlands, where nearly half of all births are attended by midwives, the rate is 5.2.

In Canada, midwifery is less common than in the United States, but the infant mortality rate is lower (6.0), for unclear reasons.

Japan, whose infant mortality rate is the world’s lowest (3.8 per 1,000), is facing a potential midwife shortage. Many of Japan’s midwives are over 65, and it’s not clear there will be enough younger midwives to take their place.

In the United States, there are now an estimated 5,500 certified nurse-midwives, according to the American College of Nurse-Midwives, an advocacy and lobbying group in Washington, D.C.

Certified nurse-midwives — nurses who have taken accredited midwifery training and have passed a national certification exam — are licensed in all 50 states. In addition, there are several thousand lay midwives. They are not licensed in Massachusetts and many other states. But in some cases, they have passed a different exam and may be certified by the National Association for the Registry of Midwives, in which case they’re called CPMs: certified professional midwives.

In some states, CPMs are allowed to deliver babies in hospitals, but in most states, they’re not; they deliver babies at home and in birth centers.

Despite the growth in midwifery, there are “not enough midwives to meet the demand,” says Judy Norsigian, program director of the Boston Women’s Health Book Collective, the women’s health group that wrote self-help book “Our Bodies, Ourselves.”

SIDEBAR 2:

To learn more

For more information, try:

• American College of Nurse-Midwives, 202-728-9860 or 888-643-9433 to find a midwife near you. On the web, it’s www.midwife.org

• Midwives Alliance of North America, 888-923-6262

• Massachusetts Midwives Alliance, 508-376-8201

• Massachusetts Friends of Midwives, 1 800-WITH-YOU (1 800 948 4968).

SIDEBAR 3:

A GROWING PHENOMENON

PLEASE SEE MICROFILM FOR CHART DATA

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To listen to Lisette Mancini, a 40-year old Walpole audiologist and mother of three, you might be tempted to conclude that thyroid troubles are a blessing.

Years ago, as a student at Boston College, her metabolism was cranked so high she “flew through school because I had so much time to study. I never slept. I was never tired,” she recalls. She got all A’s, carried a double major, and did an honors thesis.

Sure, she was always hungry. But that meant she could eat three dinners a night and not get fat. She was always hot, but she’d just open the window and wear T-shirts while her roommate bundled up.

But this was no blessing. Mancini’s heart raced even when she lay down. Her periods were erratic. She was elated one minute, catatonic the next. Her skin was so greasy she needed two showers a day — but she never worried about any of it, like millions of others whose thyroid problems creep up on them.

Finally diagnosed with hyperthyroidism, she had surgery to remove most of the butterfly-shaped gland in her neck that was producing too much thyroid hormone, which is crucial for basic metabolism. The tiny bits left supplied normal levels — and she was fine for years.

But then, like many women, she developed problems from too little thyroid after her first pregnancy. Now she had hypothyroidism and felt like “a total zombie.”

Mancini’s problems may seem extreme, but the trouble she — and some of her doctors — had in spotting the warning signs is so common that the American College of Physicians and the American Society of Internal Medicine recently issued new guidelines calling for thyroid screening for all women over 50.

The American Association of Clinical Endocrinologists, who specialize in hormone problems, goes even further. Since 1995, that group has urged not just screening but treatment for patients whose thyroid tests are abnormal, even if they have no symptoms, says Dr. Stanley Feld of Dallas, a past president.

An estimated 11 million Americans, many of them women over 50, have hypothyroidism, or an underactive thyroid, which results in fatigue, forgetfulness, depression, chilliness, weight gain, elevated cholesterol and goiter, an enlarged thyroid gland. Many more people are never diagnosed because the symptoms are chalked up to aging or “the blues.”

Another 2 million Americans, many of them women aged 20 to 40, have hyperthyroidism, or an overactive thyroid, which causes nervousness, weight loss, intolerance to heat and goiter.

Hyperthyroidism is also often underdiagnosed, especially in older people with subtle symptoms, says Dr. Mark Helfand, an internist at Oregon Health Sciences University in Portland.

Both hypothyroidism and hyperthyroidism can result from a misguided attack by the body’s immune cells and antibodies on the thyroid gland — in the first case, inhibiting or destroying the gland, in the second, kicking it into high gear.

With hypothyroidism, the most common cause is an auto-immune syndrome called Hashimoto’s thyroiditis, which often runs in families; with hyperthyroidism, the most common cause is an auto-immune condition called Graves’ disease, which also tends to run in families, though here, too, not everyone with a family history of thyroid troubles is at risk.

The screening now widely recommended is a blood test for TSH, or thyroid stimulating hormone, which is made by the pituitary gland. When the pituitary senses the body is not making enough thyroid hormone, TSH levels rise, signalling the thyroid gland to make more. The test picks up minute fluctuations in TSH.

If your TSH is abnormal, doctors add another test to detect blood levels of thyroid hormone itself. It’s a clear sign you need treatment for hypothyroidism if your TSH is elevated and your thyroid hormone levels are low. You need treatment for hyperthyroidism if the reverse is true — low TSH and high thyroid hormone levels.

Where things get tricky is with “subclinical” disease, particularly hypothyroidism — when TSH is elevated but thyroid hormone is normal, says Dr. Robert D. Utiger, an endocrinologist and deputy editor of the New England Journal of Medicine.

Many specialists, Feld among them, recommend treatment even for subclinical disease because patients with subtle symptoms often feel better.

But the data are “unimpressive,” says Utiger. According to the American College of Physicians, studies of people who have subclinical disease and symptoms are inconclusive, and people with no symptoms have not been shown to benefit from treatment.

Complicating things is the fact that patients who deny symptoms may have them nevertheless, says Dr. John C. Morris, a Mayo Clinic endocrinologist, though this may only become clear when the doctor asks more questions.

“It’s a subtle thing,” adds Feld. “You don’t wake up one day” with hypothyroidism. “You get a little bit that way, then a little more.”

The treatment for hypothyroidism is straightforward, and “great, provided you need it,” says Helfand. Thyroid supplements — chiefly, levothyroxine (which comes in generic form and in brands such as Synthroid or Levoxyl,) are safe, effective and cheap — about $20 for a three-month supply.

The catch is that doses have to be monitored lest you go from having too little thyroid hormone to too much, which can lead to osteoporosis and increased risk of a heart rhythm abnormality called atrial fibrillation.

Like hypothyroidism, hyperthyroidism can also appear in subclinical form. But it, too, is readily treatable.

One treatment is radioactive iodine (a one-time capsule) to shrink the thyroid gland. This does not seem to cause cancer, thyroid specialists say, though many patients are leery.

An alternative is the drugs Tapazole or PTU (propylthiouracil) that block production of thyroid hormone.

Yet another is surgery to remove the thyroid gland, or most of it, though this can be difficult to do without disrupting the adjacent glands that control calcium metabolism.

In many cases, once an overactive thyroid problem is treated, you will end up with hypothyroidism, which means you’ll need to take a thyroid hormone replacement drug.

Recently, there’s been growing concern that iodine deficiency in the American diet may increase the risk of thyroid problems, especially during pregnancy, says Dr. Reed Larsen, chief of the thyroid division at Brigham and Women’s Hospital in Boston.

The thyroid gland makes hormone from iodine, which is present in many foods, including salt and fish. But a recent government study of urine samples showed that between 1974 and 1994, the proportion of Americans deficient in iodine has grown from 2.4 percent to 11.7 percent. Iodine deficiency in pregnant women has also grown — from 1 percent to 7 percent.

“We thought we had cured this by putting iodine in salt,” Larsen says. It’s unclear why this deficiency is growing, but some suspect that people are using less salt and that iodine is used less often as a preservative in bread.

Pregnant women, especially if they have an auto-immune disease, should be especially alert to thyroid problems. In many women, stored thyroid hormone spills into the blood as soon as pregnancy is over, causing hyperthyroidism. After several weeks, the pituitary gland signals the thyroid gland to cut production of the hormone, which then can trigger hypothyroidism.

“You go from palpitations and fretfulness, which you think is because you’ve just had a baby. . .to feeling dragged out and tired, which you say is because you just had a baby,” says Feld, adding that doctors overlook the possibility of thyroid problems for the same reasons.

The bottom line, whether you’re young or old, female or male, recently pregnant or not, is that if you feel inexplicably tired — or wired — talk to your doctor. And ask about a TSH test.

For years, millions of Americans with arthritis have been caught in a troublesome trap.

If they don’t take medication, they often suffer severe pain and life-wrecking disability. Yet if they do, they risk worrisome side effects. Some drugs, like methotrexate and high dose prednisone, can suppress the immune system. Others — notably painkillers like aspirin, Anacin, Advil, Motrin IB and others — can cause stomach ulcers and bleeding.

Every year, in fact, more than 60,000 Americans are hospitalized with complications from prescription and over-the-counter painkillers known as NSAIDS (pronounced EN-SAIDS), or non-steroidal anti-inflammatory drugs; thousands die.

But this grim picture could soon change dramatically, thanks to four drugs that are expected to be in drugstores soon: Arava, Enbrel, Celebra and Vioxx.

“In the last two decades, there hasn’t been any time like this, with four new drugs that appear to be very effective and very safe,” says Dr. Arthur Weaver, director of clinical research at the Arthritis Center of Nebraska and past president of the American College of Rheumatology.

These are “very exciting times,” adds Dr. Michael Schiff, medical director of clinical research at the Denver Arthritis Clinic, who calls two of the drugs “breakthrough medications.”

“Breakthrough” is a word researchers don’t use lightly, but it may be justified — though longterm side effects are still unknown.

Take Enbrel, the first arthritis drug in a relatively new class of compounds called biological response modifiers, which rev up or damp down specific components of the immune system.

Less than two weeks ago, an FDA advisory panel unanimously recommended approval of Enbrel for people with rheumatoid arthritis who have not improved on other treatments. The Food and Drug Administration usually follows the recommendations of its panels, and a decision is expected soon.

In rheumatoid arthritis, which affects 2 million Americans, an unknown factor — perhaps a virus — causes the immune system in genetically susceptible people to attack the synovium, a layer of cells that lines the joints. The result is chronic inflammation, pain, stiffness and joint destruction.

An additional 20 million Americans suffer from osteoarthritis, caused by wear and tear on joints.

A major culprit in many cases of arthritis is a natural substance called TNF-alpha, or tumor necrosis factor, that enters cells through a special receptor and helps promote inflammation. Enbrel, an injectable drug made by Immunex Corp. that has been studied in more than 1,000 patients, acts as a decoy receptor, mopping up TNF before it can enter cells, says Dr. Lee S. Simon, a rheumatologist at Beth Israel Deaconess Medical Center in Boston.

(Another drug that blocks TNF, Remicade, has already been approved by the FDA — for Crohn’s disease. But that means doctors can prescribe it for other problems, and evidence suggests it can help people with rheumatoid arthritis.)

Even more exciting, says Dr. Michael Weinblatt, director of clinical rheumatology at Brigham and Women’s Hospital, is Arava, made by Hoechst Marion Roussel. Following studies in 2,200 patients, it was approved by the FDA on Sept. 11.

Like the drug methotrexate, Arava actually modifies disease progression in rheumatoid arthritis. Taken orally, it inhibits pyrimidine, a building block of DNA. This affects immune cells called T cells, reducing inflammation in the synovium.

Promising though they are, nobody knows yet what the longterm side effects of Enbrel and Arava might be, warns Dr. Doyt Conn, medical director of the Atlanta-based Arthritis Foundation.

And then there are the new “super aspirin” drugs called Cox-2 inhibitors: Celebra, by Searle, and Vioxx, by Merck, as well as others in the pipeline. In late August, the FDA agreed to a fast-track review of Celebra, which means it could be approved in early 1999; Merck plans to file for approval late this year.

Unlike Enbrel and Arava, the Cox-2 inhibitors are aimed primarily at people with osteoarthritis, though they may be used, with other drugs, for rheumatoid arthritis, too.

In arthritis, it’s not just TNF that drives inflammation, but often other natural chemicals as well, notably the prostaglandins, which trigger those all-too-familiar symptoms: pain, swelling, redness and heat.

Prostaglandins are made in cells under the direction of an enzyme called Cox, or cyclooxygenase, and many painkillers work by blocking this enzyme. But it turns out that there is not just one Cox enzyme, as scientists used to think, but at least two. Cox-1 releases “good” prostaglandins that protect the stomach and kidneys. Cox-2, made primarily by cells at the site of an inflammation, releases “bad” prostaglandins that further drive inflammation.

The reason NSAIDs are a mixed blessing is that they work against both Cox enzymes, blocking both the bad and the good prostaglandins.

The new Cox-2 drugs block only the bad prostaglandins, which means they “hold the promise of being as effective as the old NSAIDs in managing pain and inflammation without the same side effects,” says Conn of the Arthritis Foundation.

So far, Celebra has been studied in trials of nearly 13,000 people. One of them was Rich Dillon, a 53-year old firefighter from Lincoln, Neb. who gave up long games of raquetball because of osteoarthritis in his knees. Celebra, he says, “makes a great difference,” and he can play short games again.

It appears to be living up to its billing as a stomach-friendly painkiller. In one study, notes Simon of Beth Israel, no one taking Celebra (a twice-a-day pill) developed an ulcer, but 19 percent of those taking a prescription form of naproxen, an NSAID, did.

Vioxx, a once-a-day pill tested so far in studies involving 9,000 people worldwide, appears to be even more potent than Celebra at blocking Cox-2, though it may also increase edema, or swelling.

In addition to these drugs, the FDA next month is expected to consider expanded use of a blood-filtering device called Prosorba that removes antibodies that contribute to inflammation.

Financially, the combined impact of the new arthritis drugs is expected to be “huge,” says Maryann Quinn, an industry analyst at BT Alex. Brown, Inc. in New York. Celebra alone could do $500 million in sales in 1999, she says.

The drugs will be expensive — an estimated $3,000 to $4,000 a year for Arava, $6,000 to $8,000 a year for Enbrel, for instance.

And the Cox-2 drugs in particular will help treat symptoms, but probably won’t alter the underlying course of disease.

Still, this slew of new drugs could finally bring safe relief to millions. It’s been years, says Weinblatt of the Brigham, “since we’ve had such promising therapies.”

SIDEBAR:

Help for Alzheimer’s?

It’s not just arthritis sufferers who may benefit from the new Cox-2 inhibitor drugs, but people with cancer and Alzheimer’s disease as well.

In recent years, 14 studies have shown that NSAIDs — drugs like Anacin, Advil, Nuprin, and others — can slow progression of Alzheimer’s disease by 30 to 50 percent, says Dr. Clifford Saper, chief of neurology at Beth Israel Deaconess Medical Center in Boston.

That’s probably because inflammation, well-known as a culprit in arthritis, plays a role in Alzheimer’s, too. As parts of the brain become clogged with deposits of a protein called beta-amyloid, inflammation often develops around these sites.

The NSAIDs probably slow progression of Alzheimer’s by blocking so-called Cox enzymes, which promote inflammation. But the NSAIDs have a major drawback: They often cause ulcers by causing changes in the stomach lining. By contrast, the new Cox-2 drugs block inflammation just as well as the old NSAIDs, but are far gentler on the stomach.

With colleagues at other centers, Saper is testing several hundred people with mild Alzheimer’s, giving some Celebra, a new Cox-2 inhibitor, and others a dummy pill. After six months, researchers will re-test all participants to see whether Celebra slows progression of the dementia.

The Cox-2 inhibitors may also lower the incidence of colon cancer, says Dr. Jerome Groopman, chief of experimental medicine at Beth Israel. Several studies in the last decade have shown that NSAIDs can reduce the risk of colon cancer by 50 percent.

Colon cancer often arises after a two-step process. In the first step, a gene mutation leads to high levels of the Cox-2 enxyme, which results in growths called polyps. Another mutation then causes the polyps to become cancerous.

In mice, Celebra seems to block formation of polyps, thus stopping cancer before it starts. Studies are underway to see if the drug can prevent colon cancer in people at high risk. Someday, “we may be able to exploit this for people with already-established tumors,” Groopman says.

For more information, you may call the Arthritis Foundation at 1-800-283-7800, or contact them on the Net at www.arthritis.org.

Women, at least in America, outlive men by six years.

So how, then, do you account for this:

Women are five times as likely as men to get migraines and osteoporosis, two to three times as likely to get seriously depressed, and much more likely to get diseases like lupus, rheumatoid arthritis and scleroderma, in which the immune system attacks the body’s own organs.

Women are also more susceptible to damage from tobacco and alcohol. In men and women of equal size who consume equal amounts of alcohol, blood levels are higher in women because they metabolize alcohol differently.

Certain biological basics differ, too. Women’s hearts beat faster. And food travels more slowly through women’s intestines, which may explain why they have more constipation and slightly more colon cancer. Women also respond differently to pain and to some anesthetics.

Granted, men fall prey to heart disease earlier in life than women, and they suffer more than their share of cluster headaches and violent deaths, especially when they’re young. But the enigma remains.

How can females — and for that matter, female mammals in general — outlive males, yet have such a disproportionate share of some diseases? Beyond the obvious Adam and Eve stuff, in other words, how do women’s and men’s bodies differ, and how important are these differences to health and medicine?

That’s exactly what researchers in a new field, gender-specific medicine, are trying to find out — a quest with potentially life-saving consequences, because women and men not only get certain diseases at different rates but often have different symptoms for the same disease.

Heart disease, for instance, is the number one killer of both men and women, though women on average get it 10 years later in life because they are protected until menopause, in part by the hormone estrogen.

But unlike men, women often don’t experience the “classic” heart attack symptoms: feeling as if there’s “an elephant on their chest,” or pain radiating down their arms, says Dr. Marianne J. Legato, director of the Partnership for Women’s Health at Columbia University College of Physicians and Surgeons.

Instead, many women, perhaps 15 to 20 percent, feel pain in the upper abdomen and have nausea, sweating and shortness of breath, says Legato, a pioneer in gender-specific medicine. Unless doctors are alert, women’s heart attacks may be dismissed as stomach aches and their breathlessness, as anxiety.

Sex hormones, and the ways they influence immune reactions, metabolism, and other functions, are one major factor in gender differences.

Osteoporosis, for instance, is clearly tied to low levels of estrogen, which is produced by the ovaries and keeps bones strong. The risk of osteoporosis rises steeply at menopause as estrogen levels decline.

Men have less osteoporosis largely because they continue to produce testosterone (which the body converts to estrogen) at a comparatively steady rate throughout life, notes Dr. Andrea Dunaif, chief of the Division of Women’s Health at Brigham and Women’s Hospital.

And it’s not just bones that respond. Receptors for estrogen, androgens and other hormones are scattered throughout the body, and researchers are just beginning to understand why, says Dr. JoAnn Manson, an endocrinologist at Brigham and Women’s and a principal investigator of the Women’s Health Initiative, an ongoing nationwide study of older women.

Perhaps the most puzzling gender differences are those in the immune system, most notably in auto-immune diseases that occur when immune cells and antibodies attack the body’s own tissues. Here, too, some researchers suspect a hormone connection.

“About 90 percent of auto-immune diseases occur more often in women than men,” says Dr. Robert Lahita, chief of rheumatology at St. Luke’s-Roosevelt Hospital in New York.

Women are nine times more likely to get systemic lupus erythematosus, three to four times more likely to get rheumatoid arthritis, four times more likely to get scleroderma, and two to three times more likely to get multiple sclerosis.

Both men and women make so-called TH1 cytokines, which promote inflammation and production of immune cells, as well TH2 cytokines, which stimulate antibodies. Estrogen may trigger extra production of some TH2 cytokines and may also inhibit cells that suppress inflammation, which would contribute to auto-immune disease, Lahita says.

But precisely how hormones influence cytokine production is a matter of debate — and intense research, much of it focused on pregnancy, a time when both hormones and the immune system play out a fascinating and perplexing script.

During pregnancy, levels of estrogen and another hormone, progesterone, are high. But if high estrogen were the sole reason women get more auto-immune diseases than men, you’d think that all that pregnancy would make auto-immune diseases worse. And that isn’t so.

In fact, some auto-immune diseases, like rheumatoid arthritis, actually go into remission, while others, like lupus, do not, notes Dr. J. Lee Nelson, a rheumatologist at Fred Hutchinson Cancer Center in Seattle.

Multiple sclerosis also gets better in some women during pregnancy, but often gets worse again after delivery.

What is clear is that evolution has deemed it important to make these immune shifts in pregnancy — probably for the survival of both mother and fetus.

That’s because some cells from the fetus inevitably cross the placenta and wind up in the mother’s bloodstream. If the mother’s immune system reacted too strongly to these fetal cells, which are half “foreign” because of the father’s DNA, she would reject the fetus, Nelson notes. This means her immune system must become “tolerant” of this foreign tissue. Yet the mother’s immune system can’t become too quiescent or she would come down with endless infections.

Teasing apart the intricate hormonal and immunological shifts during pregnancy has implications not just for women with auto-immune diseases, but for a basic understanding of how gender influences biology.

“Research on women, and the changes in sex hormones at menopause and during pregnancy, has already resulted in a whole new understanding of the importance of these hormones to the functioning of all systems in the body, from brain to skin,” says Legato.

But many questions remain. The big one is why, given the burden of so many gender-specific diseases, do women still live longer than men?

That’s “the great puzzle,” says Wanda Jones, deputy assistant secretary for women’s health at the Department of Health and Human Services.

“And if we understood that better, maybe we could help men live longer.'”

SIDEBAR:

Reconciling differences

Confronting gender-specific medicine:

• If you’re a woman, ask your doctor if that means you should take a different dose of drugs than the package label says and whether you should expect different side effects.
• Remember that alcohol has a more potent effect on women than on men and, cigarette for cigarette, tobacco is more deadly for women, too, not to mention more addictive.
• When you read results from a study done on men, ask your doctor if the results apply to women as well. And vice versa.
• If you’re a woman at risk for heart attack, remember that your symptoms may not be exactly like men’s chest pain, but may be pain in the upper abdomen, nausea, and shortness of breath.
• The need for vitamins and minerals — including supplements — varies by gender, too. In general, adults need 1,000 milligrams a day of calcium, but postmenopausal women need 1,500 a day unless they’re taking estrogen. Men rarely need iron supplements, but menstruating women may. Women of childbearing age may also need 400 micrograms a day of folic acid.
• Migraine headaches, acne, panic attacks, and seizures often get worse just before menstruation. A diabetic woman’s need for insulin may increase at this time, too.
• If you’re a man with heart disease, make sure you’re not being given overly aggressive treatment. Women sometimes get treatment that’s not aggressive enough, but men are sometimes treated too aggressively — with clot-busting drugs, bypass surgery, and other interventions. So ask your doctor.

For more information on the subject, you might want to read “Gender-Specific Aspects of Human Biology for the Practising Physician,” by Dr. Marianne J. Legato, Futura Publishing Co., Armonk, N.Y.

Over the years, Kathy Duffy, a 38-year-old school teacher in Reading, tried many treatments for her severe incontinence — pills, injections, exercises, even “retraining” her bladder.

Everything helped some. Even so, she was always ducking out on her second graders to rush to the bathroom. She didn’t sleep much, either. The urge to urinate woke her every hour or so.

Two weeks ago, Duffy and two other women became the first patients in New England to have a new electrical device called InterStim implanted near their spines to calm bladder spasms.

For the first time in years, Duffy says, she’s sleeping five hours at a stretch, thanks to the device, which seems to slow the excessive firing of nerves to the bladder.

Urinary incontinence strikes 15 million Americans, most of them women and most, like Duffy, well under 65. Unlike Duffy, many of those whose bladders betray them suffer in shameful silence, avoiding other people lest they have an “accident.”

Luckily, researchers and venture capitalists are not so shy. In fact, convinced of the demand for something better than adult diapers, they’re racing to develop pills, plugs, and other devices to keep bladders from their dismal dripping.

Incontinence comes in two main forms — urge problems like Duffy’s, in which bladder muscles go into spasm, making it impossible to stop urine flow once it starts; and stress problems, in which weak sphincter or pelvic muscles fail to keep the bladder neck closed during sudden physical stresses like coughing, sneezing, laughing, or exercising.

It can also occur when an obstruction — usually an enlarged prostate in men — blocks urine flow, leading to overflow or urge problems.

“For every kind of incontinence, there’s a pill, or behavioral intervention, a device or an operation,” says Dr. Neil Resnick, an incontinence specialist at Brigham and Women’s Hospital. “Cure is usually possible, and usually without surgery.”

The trick is to diagnose what kind of incontinence you have — you can have more than one — and be savvy about your options.

In the past, for instance, incontinent women were often told to have a hysterectomy. But you don’t need that, says Dr. Deborah Lightner, a Mayo Clinic urologist, unless your uterus has prolapsed and is pressing on the bladder.

In fact, for most people the best bet is to start with the simplest, least invasive options.

For stress incontinence, this means Kegel exercises, in which you strengthen pelvic floor muscles, which can be damaged by giving birth. To identify these muscles, try stopping urine flow in midstream. If you can, you’ve got the right muscles. Once you’ve found them, make that same exertion 100 times a day, but not during voiding lest you retain urine.

If you can’t pinpoint those muscles on your own, go to a continence center (many hospitals have them) and ask for biofeedback training, a system of electrical sensors on patches on the skin or in the vagina or rectum that send an unmistakeable signal when you contract the right muscles.

If your problem is urge incontinence, bladder retraining can help. You try to stick to a pre-set bathroom schedule, urinating regularly before the bladder gets too full, and learning to suppress temporarily the urge to urinate.

If these simple behavioral tricks don’t help, there’s a slew of devices to control leaky bladders, most of them available by prescription. Some women, for instance, use vaginal cones, tampon-like devices held in the vagina for 15 minutes twice a day to strengthen pelvic muscles.

Others use pessaries, like Introl, that are inserted into the vagina to support the bladder neck, though these have to be carefully fitted and changed regularly. Other women prefer a product like Capsure that plugs the opening of the urethra; it stays in place by suction and is pulled out by a nipple during urination. New devices like Inflow, which is not yet approved, may be left in the urethra for as long as a month.

Soon, women may also have another option — a foam patch called Impress that’s designed to stick to the urethral opening like a tiny BandAid. Impress has been approved but has not yet been marketed for over-the-counter use.

If none of these options works, you can try collagen injections — done via a needle passed through the urethra. The collagen squeezes the side of the urethra together, slowing urine flow.

For sheer convenience, many women opt for medications rather than devices. Estrogen, for instance, can make the urethra more pliable and easier to seal and it can be taken in a variety of ways — pills, patches, vaginal cream or a vaginal ring that releases the hormone slowly.

For urge incontinence specifically, other drugs also help — including old standbys like Ditropan and newer ones like Levbid and Detrol, says Dr. David Staskin, director of the continence center at Beth Israel Deaconess Medical Center.

These drugs all block acetylcholine, a chemical secreted by nerves that tells muscles to contract. The newer verions of this medication cause fewer side effects such as dry mouth and constipation.

Tofranil, an anti-depressant that has the useful side effect of relaxing bladder spasms and tightening the sphincter, can also help, says Dr. Stanley Swierzewski, III, co-director of the Lahey Clinic continence center.

For men with incontinence caused by an enlarged prostate, drugs like Minipress, Hytrin, Cardura or Flomax that relax the urethra can be very helpful. So does shrinking the prostate itself — with a drug called Proscar, microwave therapy, or surgery.

Surgery is also an option for some women, and for those with stress incontinence two options work well. In the “suspension” procedure — done through a vaginal or abdominal incision — surgeons stitch a drooping bladder to ligaments in the pelvis. In the other, a “sling” is made for the bladder with fascia tissue from the patient or a cadaver.

In the past, surgery has not been a useful option for women with urge incontinence. But surgery to implant the InterStim “pacemaker” like Duffy should become a growing option.

The theory behind InterStim is that urge incontinence is triggered by overactive nerves called C-fibers that run from the spinal cord to the bladder. The C-fibers are believed to govern urination in babies, whose bladders empty uncontrollably. These fibers are thought to be quiescent in adults, though they can be reactivated, sometimes after back surgery or pelvic trauma.

Applying an electric current to the bladder nerves seems to shut down the C-fibers but not normal fibers, says Swierzewski, who implanted the device in Duffy and two other patients.

Other researchers are cautious. InterStim has been tried in fewer than 200 patients at about half a dozen centers, says Resnick. “The results are promising, but the number of people who’ve had the device implanted is still small.”

But Duffy needs no convincing: “I’m very pleased.”

Teresa Menz, a 34-year-old teacher from Sidney, N.Y., tried almost everything for her fibroids — benign uterine tumors that cause pain and bleeding in millions of women.

With more than 100 fibroids, Menz’s belly was as big as that of a woman 26 weeks pregnant and she hemorrhaged during every menstrual period. She tried hormone treatment for a year and had four major operations. Nothing worked.

Until last fall, when she became one of a few hundred women worldwide — and the first at North Shore Medical Center in Salem — to undergo a procedure called uterine artery embolization. Her fibroids are still growing and the treatment may have left her infertile. But at least her periods are normal now.

For years, Leslie Magier, 36, a Framingham interior decorator with a hereditary bleeding disorder called von Willebrand disease, also had such heavy periods she “couldn’t walk into someone’s house because of the fear I would bleed onto their couch,” she says.

Magier, too, took a chance on a then-experimental treatment — uterine balloon therapy — two years ago at Brigham and Women’s Hospital. She’s has been fine since, the balloon device was approved by the US Food and Drug Administration in December and the procedure is becoming available at many hospitals.

As many as one-fifth of women are believed to have excessive menstrual bleeding — bleeding that lasts more than seven days or necessitates more than 10 pads a day. But until recently, both women and their doctors often ignored it.

In fact, many women never mention it, either because they’ve gotten used to becoming shut-ins every month or because they fear they’ll be told to have a hysterctomy.

In the past, those fears were often justified. Hysterectomies — done 600,000 times a year — are the second-most common operation, after Caesarean sections. And many hysterectomies — 25 percent, according to a 1993 Rand study; more than 90 percent, say some women’s advocates — may be unnecessary.

But a growing recognition of bleeding problems in women and new treatment options may soon change this mindset, starting with a research conference this weekend in Philadelphia.

The first step in treating excessive menstrual bleeding, specialists say, is to figure out exactly what’s causing it.

Often, the cause is a hormonal disturbance in which the ovary does not release an egg, which triggers irregular bleeding — light one month, heavy the next, says Dr. Brian Walsh, chief of surgical gynecology at the Brigham.

Other times, it’s fibroids, which affect one-third of women and can cause heavy bleeding during and between periods.

Occasionally, it’s that the lining of the uterus (the endometrium) grows into the uterine wall. And sometimes, as in Magier’s case, the cause is von Willebrand disease, a genetic defect that’s less well-known, but more common than hemophilia.

Von Willebrand disease affects at least 3 million men and women — versus 20,000 (mostly men) for hemophilia, according to figures from the Centers for Disease Control and Prevention to be presented at this weekend’s conference.

And while both men and women with von Willebrand have severe nosebleeds and bruise easily, women have an extra problem — heavy menstrual periods, says Dr. Jeanne Lusher, a Wayne State University hematologist and co-organizer of the conference, which is being sponsored by the National Hemophilia Foundation.

Once the cause of heavy bleeding is identified, the next step is to choose among the growing treatment possibilities.

If the problem is hormonal disturbance, for instance, the solution is hormonal — birth control pills to regulate periods if you’re young and don’t smoke, progesterone pills for two weeks a month if you’re older or smoke.

If the problem is von Willebrand disease, injections — or a relatively new nasal spray — of DDAVP (1-deamino-8-D-arginine-vasopressin) often help, as do transfusions in some cases.

Surgery, of course, is the right solution for some women, but that doesn’t have to mean a traditional hysterectomy, which takes four to six weeks to recover from. Today, many hysterectomies can be done vaginally and recovery takes two to four weeks. Some women also take a hormone called Depo-Lupron before surgery to shrink the uterus to allow vaginal removal.

Another alternative is ablation, or destruction, of the lining of the uterus. This is a deeper procedure than a D & C (dilation and curettage), which removes only the surface of the lining and reduces excessive bleeding for only a few cycles.

Ablation, which usually stops excessive bleeding or at least makes it lighter, is often done with a “rollerball,” a kind of electrified paint brush passed repeatedly over the endometrium.

“If you don’t want a hysterectomy and want normal bleeding,” this may be an answer, says Dr. Alan Penzias, a gynecologist at Beth Israel Deaconess Medical Center.

But the fluid (glycine) used to inflate the uterus during this procedure can cause electrolyte imblances, warns Dr. John Petrozza , a reproductive endocrinologist at the New England Medical Center. Ablation is also likely to cause infertility.

And because the rollerball demands considerable skill, some surgeons are now turning to a new, easier technique that utilizes a balloon device made by Gynecare, Inc.

In this procedure, which Magier had, a balloon is inserted into the uterus and filled with water that is then heated to 188 degrees Farenheit for eight minutes.

So far, more than 125 women have had balloon therapy, says Walsh of the Brigham, who ran part of the study that led to FDA approval of the device. It takes 28 minutes, he says, versus 45 for the rollerball, and can be done under local anesthesia plus intravenous sedation.

Like any ablation technique, though, balloon therapy “destroys the endometrium by scarring it,” warns Nora Coffey , director of the HERS (Hysterectomy Educational Resources and Services) Foundation in Pennsylvania.

And because ablation is chiefly for women whose bleeding is not caused by fibroids, those who have fibroids must consider other options, like Depo-Lupron to temporarily shrink fibroids.

If surgery does seem to be the best solution for fibroids, there’s still an option to hysterectomy. Called myomectomy, it involves removing just the fibroids that protrude into the uterus, not the uterus itself. This can preserve fertility.

If the fibroids are big or numerous, the myomectomy must be done through an abdominal incision. But if they’re small or few in number, they can be removed with an instrument called a hysteroscope that is inserted vaginally. Some researchers are experimenting with freezing and thawing to remove fibroids.

The option Terera Menz chose — embolization — is still another option for fibroids. So far, it’s still rare, but “very exciting,” says Dr. Robert Mals, the interventional radiologist at North Shore Medical Center who treated her, with gynecologist Mitchell Rein.

In the procedure, a catheter is inserted into the groin and threaded up to the uterine arteries under X-ray guidance. When it reaches the blood vessels supplying the uterus, tiny particles of polyvinyl alcohol are released. This triggers a kind of heart attack in the uterus; the resulting blockage of blood flow then causes the fibroids to shrivel.

Dr. Robert L. Worthington-Kirsch, an interventional radiologist in Bala Cynwyd, Pa., who has done 186 such embolizations, says that while fibroids shrink, the uterus itself survives because of collateral blood flow. Even so, the procedure should be assumed to cause infertility.

The procedure, long used to treat hemorrhaging after childbirth, is 90 percent successful for fibroids, he says, in that women get at least some reduction in bleeding. But so far, there are few published reports and many are skeptical, including Coffey of the HERS Foundation.

“I don’t think embolization is conservative,” she says. “We are still doing these destructive things to women in the name of its being an alternative, it not being a hysterectomy.”

But Teresa Menz doesn’t see it that way at all. “I would totally recommend this over hysterectomy to women who definitely are done having children.”

SIDEBAR:

Where to learn more

Talk to your doctor about a possible bleeding disorder and tests for von Willebrand disease if:

• Your menstrual periods get progressively heavier or longer or last more than seven days, you need more than 10 pads a day or more than a super-tampon an hour, or if you pass large clots.
• You bleed heavily after surgery, including dental work.
• You have a family history of heavy bleeding.
• You get nosebleeds that demand emergency treatment.
• You bruise easily.

If you have excessive menstrual bleeding, ask about:

• Tests for anemia, and iron supplements.
• A drug called DDAVP if you have von Willebrand disease.
• Hormonal treatment, including birth control pills, to restore menstrual regularity.
• Ultrasound and other tests to see if you have fibroids. If you do, consider medications, including GnRH agonists like Depo-Lupron (a monthly injection), Synarel (a daily nasal spray) and Zoladex, capsules injected under the skin. The drugs are expensive — $300 a month or more — and bring on menopausal symptoms such as hot flashes, vaginal dryness, and bone loss.

If your doctor suggests a hysterectomy, ask about other options:

• If you choose to have your uterus removed, ask if this can be done vaginally, which can shorten recovery time.
• If the problem is fibroids, ask about a myomectomy — surgery to remove fibroids, not the uterus. This can be done vaginally or through an abdominal incision. You might also ask about uterine artery embolization.
• If bleeding is not due to fibroids, ask about endometrial ablation, including the new balloon therapy device.
• Get a second opinion or call a women’s health group such as the HERS Foundation, 610-667-7757, for more information.