Experts in minimally invasive gynecology can be viewed here discussing one of four pelvic health conditions. They were interviewed in November of 2008 by Elizabeth Battaglino Cahill, Executive Director of the National Women’s Health Resource Center. Hear what they had to say about the most common pelvic health conditions and their approach to treatment.
Abnormal Uterine Bleeding
William Parker, M.D.
University of California, Los Angeles
Santa Monica, CA Download Transcript | View Transcript
Fibroids
Linda D. Bradley, M.D.
Vice Chair of Obstetrics, Gynecology and Women’s Health Institute
Cleveland Clinic
Cleveland, OH Download Transcript | View Transcript
Incontinence
Neeraj Kohli, M.D., MBA
Director, Division of Urogynecology
Brigham Women’s Hospital
Assistant Professor
Harvard Medical School
Boston, MA Download Transcript | View Transcript
Pelvic Organ Prolapse
Vincent Lucente, M.D., MBA
Medical Director
The Institute for Female Pelvic Health Medicine
Allentown, PA Download Transcript | View Transcript
Transcripts
Transcript of video with Dr. Bradley Discussing Fibroids Experts in minimally invasive gynecology talk with Elizabeth Battaglino Cahill, RN, Executive Director of the National Women's Health Resource Center, in November 2008.
Dr. Bradley, what exactly are fibroids?
Fibroids are the most common, benign, non-cancerous growth within the uterus in women. Mostly occurring during the reproductive years.
How does a woman know if she is at risk for fibroids?
Well actually all women are at risk for fibroids. Approximately 75 to 80% of women have fibroids. It's more common the older the patient becomes. More common if it runs in your family and more common if the woman is of African descent.
How does a woman know if she has fibroids?
Well the good news is that only 50% of women actually have symptoms. So the other 50% may have symptoms that lead her to see a physician and those symptoms might be things like abnormal bleeding, abdominal pressure, severe menstrual cramping, pain with intercourse, maybe a cosmetic effect where a fibroid, which is the muscle of the uterus gets thicker such as the woman has a protuberance of her abdomen or even difficulty becoming pregnant. And then lastly, sometimes pressure symptoms where she is urinating frequently or even having symptoms like constipation. So it's a constellation of these symptoms that often drive a patient to see a physician. But as I mentioned, the best news is that most women who have them have no symptoms.
Can you develop fibroids at any age and do they change with age?
Actually most women develop fibroids in their twenties, thirties and forties. Very rarely in the teen years and virtually no evidence of growth once a woman enters menopause. So, again, it tends to be during the reproductive years. If I had to choose an age, I'd say between 25 and 45 are the most common times women will present with symptoms.
Do they ever get smaller on their own and/or do fibroids just go away?
That's the best news about getting older is that they do get smaller. I always tell my patients we diagnose it by, most often by ultrasound, so even if someone gets to be 105, we'll see the imprint or the footprint of fibroids but the symptoms won't be there. So generally after age 50, while they may have the fibroids, they shrink in size and then the symptoms go away.
What are the options available for treating fibroids?
I think it's important for women to know that there are many options. But fibroids are unique and one of a kind. And so the treatment options depend upon the patient's age, her desire for fertility but most importantly remember the size and the location of fibroids. I like to usually explain to my patients that the uterus has three components. The most inside is where baby lives. And if a fibroid is located only in that region the approach might be hysteroscopic where there's no incisions made in the abdomen. If it is in the muscle of the uterus, then it may be approached laparoscopically, also with something called mini-laparotomy or tradition open surgery. Once in a while fibroids can just be also removed vaginally, depending on if they're in that location. So size, number, location would dictate how a physician approaches the treatment. There are some fibroids that are as small as a walnut. There are others that are as large as a watermelon. So, again, we have to look at so many different things in terms of techniques. When possible, however, if the patient meets the inclusion criteria for a minimally invasive procedure, we strongly urge women to look for those options.
Can these treatments be done on an outpatient basis?
There are some procedures like a hysteroscopy that can be done as an outpatient procedure where the procedure takes about an hour and the patient is usually home about three hours after surgery and able to get back to work within a day. Then there's laparoscopic procedures that also allow patients to either go home that day or the next day. And then the traditional myomectomy, which is done abdominally, would keep a patient in the hospital on the average in the U.S. about two days and a recovery of about four weeks. So, again, it's hard to give one answer because there's such a variety and ways that fibroids look and so we have to look at the whole patient before we can say. But you're right, there are times we can do things where they go home the same day.
How do different treatments for fibroids affect a woman's fertility?What should a woman who wants to have children do?
Well if the patient wants to have kids and is having no symptoms from the fibroids, in general we do not recommend any treatment whatsoever. If she's trying to get pregnant, we try to determine whether the fibroids are impinging or blocking the fallopian tubes or if they're in the compartment, the space where baby would live. So no symptoms, no treatment. And if they are having symptoms, then again we have to really individualize the type of surgery that a patient might have.
If a woman thinks she has fibroids, who should she talk to?
I think if a patient is having symptoms she should speak with her gynecologist. That's going to be the first best step. Of if she is seeing a healthcare provider like a nurse practitioner or a midwife. So basically a healthcare provider and then once she is seen we often like to confirm the concern about fibroids, with usually doing an ultrasound.
Lots of women have seen the same gynecologist for many years but their doctor might not offer all of the latest treatments for fibroids. How does a woman know if she should seek a second opinion?
A second opinion should be sought I think certainly if a patient wants to have children and her only option being given is a hysterectomy. So I think you want kids and your doctor says hysterectomy the odds of your needing that are very, very low and I would say in those situations most certainly look for a second opinion. When you're looking for a second opinion so that tests are not repeated, take a copy of your Pap smear with you, take a copy of your ultrasound report and maybe the last two or three-year office visit notes to see if that fibroid has grown. Or if a patient is told that they need open surgery, traditional surgery, I think it's a good idea to get a second opinion to see whether that is actually what's necessary. There are times that minimally invasive surgery can't be done but more times than not again a hysteroscopy or a laparoscopic approach would be something that a patient might be able to have.
If a woman with fibroids does need a hysterectomy, is a laparoscopic hysterectomy ever an option?
Yes. laparoscopic hysterectomy is an option. We look at the surgeon's skills. But again, getting back to the size of the uterus, the number of fibroids and the location. But I think working with a physician that has all skill sets, traditional surgical skills, laparoscopic, vaginal, hysteroscopic and an additional skill, sometimes even to prevent surgery at all would be the use of something called uterine fibroid emobolization or uterine artery embolization, which is a totally non-surgical procedure that in women who do not want children can also be offered. So it's a totally non-invasive surgically invasive procedure that can be done.
What does it mean to women's healthcare that the number of hysterectomies performed each year has pretty much remained the same for the last 25 years and that the dominant type of hysterectomy used is the oldest procedure, the open abdominal hysterectomy?
Well I think it speaks volumes of a need for change. So I think that physicians need more training. Our training programs such our residencies and internships need to begin to teach physicians about new alternatives. Patients also should look at maybe sometimes medical therapies or other non-surgical approaches. For some women they've come in demanding that they have hysterectomy. And some women are not willing to wait for alternatives. I tell my patients that medicine is not like McDonald's, meaning that sometimes we need to try things, we need to give it time to look at medical therapy, to take notes to journal, those kinds of things. And then not make a rapid decision for a surgical approach.
Thank you very much, Dr. Bradley.
Thank you.
Dr. Kohli, what is stress urinary incontinence or SUI?
Stress urinary incontinence is a condition where a woman has urinary leakage with generally different types of activities. So typically a woman will come to you and complain of stress incontinence with coughing, sneezing, exercising, laughing, lifting, those types of activities. And it's actually an anatomic condition, which typically results from poor support of the bladder neck. And this is in contrast to urge incontinence or overactive bladder, which is typically a condition where a woman comes in and says I urinate frequently, either day or night and I can't make it to the bathroom in time. So stress incontinence is typically more related to activity as opposed to urge incontinence.
Is there any risk factors for stress urinary incontinence?
That's controversial. One of the things that we've traditionally thought about was childbirth and so as women have children, specifically vaginal deliveries, that there may be some disruption of the supports of the bladder neck resulting in stress incontinence. Some of the recent data is suggesting that in younger women that may be the case but in older women, even if they had Caesarean sections, that is not necessarily the case and so it suggests that certain events associated with time and aging may also contribute. And that may include menopause. It may include just weakening of the tissues as you get older. It may include neurologic conditions, which increase chronic constipation. And then also as a lot of women get older they get a little heavier so weight can actually contribute to this as well.
How common is it?
Very common and in fact more common than most people would think and most patients don't discuss it. But now it's getting to the point where more people are being more vocal because it is such a quality of life issue and people are realizing that their doctors are talking about as well as the fact that there are many treatment options for it. So it may range anywhere from 20 to 50% of women, depending on their age.
Can SUI happen to all women of any age?
Clearly. And in my practice in fact the youngest patient who has opted for a surgical correction was 24 and my oldest was 94. So there's a huge range and I think a lot of young patients feel very embarrassed talking to their physicians because they feel well this is something that only happens to older patients and that's clearly not the case. But every woman is going to have a different risk factor and some women may present with it earlier on.
How can women avoid SUI?
Well I think one of the things they can do is pelvic floor exercises. I think that's very important. And I think a lot of women don't consider pelvic floor exercises until they're symptomatic and at that point it becomes much more difficult to treat with exercises but it can sometimes help the progression. In prevention, I think doing the Kegel exercises is important, for many different reasons, including stress incontinence. Also looking at anything that would cause chronic Valsalva or straining. So chronic constipation, jobs where they are doing a lot of heavy lifting, and those types of things, chronic cough and then weight loss is, again, another thing to help prevent stress incontinence.
If a woman thinks she has SUI should she see a specialist?
I think it really depends on how much it bothers her. I have some women who leak ten times a day and they learn to live with it and they're okay with that. There are others who leak once a month and they think it's the worse thing in the world. At the end of the day I think it depends on how much does it bother you, and how much of it is making an impact on your daily life. The good news at this point is the diagnosis and the treatment for most types of incontinence, especially stress incontinence, is very straightforward and is really trickling down to everybody from the specialist to the general OB/GYN and even to the primary care physician.
How is stress urinary incontinence treated?
Well there's a whole range of treatments and I think the misconception that most women have is that (a) it's normal part of aging, (b) there aren't good treatments and (c) if there are treatments they're fraught with complications. And all of those are untrue. If the incontinence is mild, it really can be treated with pelvic floor exercises and there are even physical therapists who specialize in this condition. And so spending time with a physical therapist can help greatly. In other cases there are options for surgery and the surgery has progressed over the last decade to a simple outpatient procedure which can be performed in 15 or 20 minutes. And that was what I offered my 95 year-old and I would have never offered a patient that old a surgery because of the other complications including anesthesia but the surgeries have really progressed with great success and very good safety.
What are the risks associated with the surgical procedures?
Well I think with any type of surgery there's always the risk of anesthetic risks as well as bleeding and infection. But most of these are minimized because it is such a short procedure. These procedures involve making a small incision in the vagina and then passing a trocar connected to a little piece of mesh that sits underneath the bladder neck and stabilizes the bladder neck. So there are risks including the mesh, which include exposure, infection, pain with intercourse. There are also risks with passing of the trocars, which include injury to the adjacent organs but many of those risks are very, very low, especially in experienced hands.
You just mentioned mesh and we know there's been some debate around the safety of surgical mesh in the body. What should women know about surgical mesh?
Well I think when we talk about mesh it's a very broad category. And clearly the different ways of using mesh are associated with different risks and benefits. The TVT or TOT surgical procedure, which is specifically for incontinence, involves a very small piece of mesh, which is 1 cm wide by about 10 to 12 cm long. And there have been over a million procedures done in a very short time over the last decade worldwide. And the real risk of that mesh placement in terms of exposure, infection or pelvic pain or pain on intercourse is really less than 1%. So it's a very, very safe use of mesh. That's very different than using the large pieces of mesh for prolapse repairs or other parts of pelvic surgery, which may have a very different risk/benefit ratio.
When a woman decides to have a sling procedure, what questions should she ask her doctor about his or her experiences as well as the procedure itself?
I think that's a difficult question to answer because there are a lot of generalists who are very good surgeons and there may also be specialists who aren't very good surgeons. And I think it's important for a patient to ask their physician do you have any specialized training in this. How many of these do you do on a regular basis? What are your surgical success and complication rates? Too often physicians will quote what the literature or the data is and surgery is very specific in terms of those numbers and it's always better that the doctor knows his or her own rates. I also think you should ask, if we have complications who would you send me to? And when the doctor says I would take care of those complications myself, that further reassures the patient that this is a doctor who is experienced and possibly one of the best people in their area.
According to the National Association for Incontinence women spend more on sanitary products for incontinence than menstruation. Why do you think this is the case and what needs to happen to get more women to seek treatment?
I think we've done a poor job educating patients on what the options are and I don't think they realize how effective and how safe they are. Clearly that's changed over the last decade and I think we're now catching up with the physician education as it comes around but now we have to work on patient education. And a lot of my practice is really built on word of mouth. Patients come in they had a great experience they never thought it could be so easy, and now they feel very liberated and they like to talk about it at parties and shopping trips and with their own family members. And then all of a sudden there's more education. I'm hoping that over the next decade we'll have a more structured education, not only in terms of patients but also in physicians who understand the risks and benefits and can offer these treatments to their patients.
Thank you very much.
It was my pleasure, thank you.
What is pelvic organ prolapse?
Pelvic organ prolapse is a term we use to describe a condition in which the organs of the female pelvis have become displaced. They're out of their normal position. Normally there's connective tissue, sort of like ligaments that you have in your elbows and knees that hold the pelvic organs, mostly the vagina primarily in a normal place. And do to a combination of factors, a lot of being it aging and childbearing, these supportive structures are disrupted, torn and disrupted. Now what was holding the vagina in place is again no longer continuous and the vagina begins to move, sag, protrude and whatever word you want to use, they're mechanically displaced. And because the opening of the vagina is sort of the weakest area then everything begins to bulge towards that opening. But interestingly a lot of women are confused when they hear I have a dropped bladder. Because it really isn't the bladder that has dropped. What has dropped is the vagina. The vagina supplies support to both the bladder above it and the rectum below. And when women begin to have prolapse they start to have sensations of pressure, fullness, something bulging down there in the vagina and that is what we refer to, sort of globally, as a pelvic organ prolapse condition.
How common is pelvic organ prolapse?
We look at how many women prevalence and how common it is, it's sort of a difficult thing to determine because it's hard to draw a line where exactly does the beginning of the condition start. Because if it's not really symptomatic and it's a little bit of mild changes and support like we see in our bodies as we look in the mirror as the years click by when does that become truly abnormal. So because of that definition it sort of moves around. I think probably the best way to get a handle on it is look at well how many women actually wind up being treated for the condition. Because the time when a woman decides well I'm going to have treatment for it and that treatment lifetime risk is around 11 to 12% when some of the studies have looked at surgical risk for the treatment of pelvic organ prolapse. It's a number we don't really know. We do know we're only seeing the tip of the iceberg. A lot of the conditions are misdiagnosed or under diagnosed.
What are the risk factors for pelvic organ prolapse?
That's a great question. When we look at risk factors like a lot of things it's multifactorial. A lot of it goes into it. There's been great work that's been done very recently by Dr. Norton and her group looking at genetics and really identifying chromosome #9 genetic factors. Some great work has been done by Peter Sand and his group looking at twins. Taking women that are genetically matched and look at these twin sisters and see who gets prolapse and who doesn't. And in those twin studies showing that the obstetrical factors very much come into play and in genetically matched women. So it's multi-factorial but I would say the big two in that equation is it can be environmental, chronic lifting, heavy straining but the big two are going to be genetics and then obstetrical experience and then finally the thing that tends to level the playing field and that's the aging phenomena.
Can pelvic organ prolapse happen to a woman at any age?
We look at age in terms of onset. Again, that's a difficult thing to pin down. It tends to happen with older women but, yes, I've seen women very young develop pelvic organ prolapse. Usually, most commonly after a fairly traumatic vaginal delivery. It's even been reported in young women in the Air Force who don't open their chute correctly and have a very traumatic vertical deceleration as they hit the ground, mechanically overcoming their support of the prolapse. So it really can happen at any age depending on the situation but it most commonly tends to be in older women say average range being in their sixties.
Is it easy for a doctor to miss prolapse during a routine office visit?
It's very easy to miss. I think the most common reason that it is missed is the most common positioning during a pelvic exam is for the woman to lay flat in a supine position. And really that's really suboptimum. The really magnified the force is to the pelvis a woman should be upright, preferably even standing. But at least upright sitting position and bearing down creating some force to sort of demonstrate how the prolapse exists as their up during the day and walking about and having a vigorous day. In fact commonly if a woman describes a situation that I really don't see on exam, even on examining them in an upright bearing down position and it's an early morning exam I'll say you know what you need to come back on another day at the end of the office hours, late in the day when they've been up all day long. Unless you're, again, going to sort of replicate those situations you're going to miss it more often than not.
When should a woman tell her doctor if she suspects pelvic organ prolapse?
I think as soon as possible. I think the sooner a woman shares with a physician that she's having some changes in her sensations in her pelvis, like something doesn't feel right, something feels like it's out of position or I've got pressure more towards the end of the day a fullness, a bulging, any kind of symptomatology even if it's soft it ought to be brought to the physician's attention because that's going to begin at least having some dialogue and education about what can we do now at the very early signs to hopefully prevent progression. Are there changes in lifestyle activities that you should avoid? Should we do something about your pelvic floor muscles because like the rest of our body, the muscles are more important in support than the connective tissue. Our collagen, elastin and fibrin, the things that come together that make ligament like support structures are stabilizing support structures. But the thing that gives you the moment to moment dynamic support responding to what we're doing are the muscles. And there's a big group of muscles in the bottom of a female pelvis and a lot of women are familiar with the term of a Kegel exercise trying to actively squeeze those muscles. And I think earlier on when women begin to discuss symptoms with their physician they can begin to make some positive changes that hopefully stop the progression of it and hopefully even avoid a surgical intervention.
How can a woman avoid pelvic organ prolapse?
I don't know if you can truly avoid it. I think if it's sort of genetically there and you live long enough it may be in the cards. But I definitely think that you can do things to minimize the risk. One of those is to be very open and candid with your obstetrician about labor and delivery. Everything from their viewpoints on episiotomy with a lot of literature now supporting that an episiotomy is more harmful than it is beneficial in the majority of cases and how the episiotomy is performed. How vigorous should we pursue this Holy Grail of a vaginal delivery. Because if we start really looking at caring for a woman over her entire lifetime, versus the episodic care of being 29 and pregnant and should be via C-section or vaginal delivery, that maybe the morbidity associated with a C-section is actually less than the morbidity of reconstructive pelvic surgery when you're 60. Until physicians start thinking about that, women actually need to help catalyze that conversation as well and saying I'm concerned about my pelvic health. My mother had prolapse or incontinence and my sister did. I want to talk about, especially going into a pregnancy, as well as after the first delivery and talk about well was there damage during that delivery and how do we consider that going forward. So I think there are definite things you can do to minimize it. One of which is going to be really carefully considering your obstetrical experience in terms of managing the labor with your physician.
So it's also important to examine your family history too?
Well absolutely and especially, just like a lot of things, first-degree relatives are going to be the most predictive. And then other, again, factors. Smoking is a big factor. Obesity is a big factor. Chronic, heavy straining and lift so environmental, whether it's an occupation or even another medical condition like allergies with vigorous, violent coughing or sneezing repetitively. So there are a lot of things that you can definitely begin to do to manage your lifestyle, manage your co-morbidities such obesity, which is a tremendous problem in our population. But a lot of things that women can do to minimize, can they truly avoid it by paying attention to all those, that's an interesting question but I think it's hard to predict.
What types of treatments are there for pelvic organ prolapse?
If you look at treatments, and again I don't consider observation only a treatment and some people early on opt for that. It really using a supportive device into the vagina that is placed, it's called a pessary. Kind of a strange name. But it can be placed and removed and sort of worn like you would wear a knee brace. Put it on and take it off. And we encourage women who may want to use that as a first start or as a temporary device until they want to have more definitive surgery to buy themselves some time, whether it be on their work life schedule or just watching the surgical technology evolve. And you know surgery keeps getting better and the techniques and some of the implants we're using keep getting better than maybe it's best to hold off for a couple of years using a conservative modality like a pessary. It's a great option. And then honestly the other option is a surgical treatment to correct the defects in pelvic support and re-establish the normal anatomy of the pelvis.
How successful are repairs for the pelvic organ prolapse?
In terms of success, it really depends what type of repair has been done. I guess it's probably easiest to group them into traditional endogenous tissue suture repair, which means the doctor uses your own body's tissues and a series of stitches or sutures to reattach the vagina to the pelvis and actually what we call plicate and it actually means just taking muscle and bringing it together and sort of plicating it over. Sort of a tucking of tissue and oversewing a bit. And that, unfortunately, and evidence shows that it's really not that successful, especially over time. So if you follow those patients over time, approximately 30 to 40% of them will fail over time. So it's not very good numbers when tissue, endogenous tissue, your own tissue and suture only. And that what has really driven and inspired a lot of physicians to start looking elsewhere for another way to improve the durability of the surgery. And that has lead to the concept of augmenting that repair with an implant. And that implant can either be a biologic implant or it can be a synthetic implant. And as we look at the evidence on how those surgeries are doing, it's starting to look fairly clearly, although the data is not robust, and it's not long-term, but there's some great comparative trials, meaning looking at one group of women versus another. And the ones that are using a synthetic, permanent synthetic material, especially kind of designed for this use, we learned a lot from the hernia world but the material has to be designed for this use and be very safely implemented and is really starting to show some promising results. How long? Yet to be determined but if you look over a period of a year or two, relatively short, the permanent materials are outperforming the traditional surgery without an implant by a significant margin.
What are the complications associated with the surgery?
The complications associated with the surgery are the traditional ones that you have any time that you go and to have a surgical intervention. First of all there can be an infection at the operative site because the surgical incision disrupts your normal host protection for bacteria and they can invade the surgical wounds. So there's always infection with any surgery. And of course there can be bleeding that's not desired and creating even maybe a transfusion situation if there is excessive bleeding. Then there's also the risk of injury to surrounding, adjacent organs. So when someone is operating on your vagina, the bladder next to it or the rectum could be injured during that. So there's always a risk of infection, bleeding, and injury. But when it comes to restorative surgery, which is different than taking out your appendix. When you take out your appendix, it's not coming back. But if I restore torn tissue in your body, whether it the rotator cuff in your shoulder or the torn ligaments in your pelvis, you can tear them again. So there's the risk of recurrence. So those risks are out there regardless if you have an implant of not. Once you start using an implant then the actual implant and the graph brings a new set of risks to the patient. And those have gotten a lot of attention. The FDA just recently this month in October of 2008, the FDA issued a notification of safety to physicians, making them more aware of the reports they've been receiving about probably the biggest area is erosion. That means that material has moved through the vaginal lining is now exposed. Or the other one is that the material is creating pain in the pelvis that is fairly refractory to treatment. So it's pain and obviously it's going to be most commonly with intercourse because that's when the vagina has the most mechanical strain put to it during intercourse. So pain with intercourse and erosion are the ones that are really being highlighted as having a slightly higher incident with using implants. And there lies the challenge of new surgeries, new innovations and surgical expertise in putting them in properly and safely.
If necessary, can the mesh ever be removed?
It can. It's difficult. I have taken mesh out that other physicians have placed in that was bothering the patient. That's very tedious. When I lecture I always say it takes 40 minutes to put one in and four hours to take one out. It's a very, very tedious procedure to remove the mesh. And we really can't get it out in its entirety. Some of the arms sort of are used to support the mesh, these arms wrap over and around the bones of the pelvis and through the muscles and they provide a holding force early on into the tissue grows into the mesh. So we can't get those arms out but they also tend not to be the troubled part of the mesh. It's the center body of the mesh that really is juxtaposed to the vaginal walls. We can remove it but it's tedious and it takes some skill.
How important is the skill of the surgeon in pelvic organ prolapse repair?
I would say it's critically important. And that's a big challenge, I think for the medical community. Because as innovation comes around and engineers are thinking about how to help with surgical approaches to things like wear and tear on our bodies. We're literally outliving our bodies. We're outliving our knees. We're outliving our joints. Women are outliving the supportive elements of their pelvis. So, yes, if you tear your ligament really bad when you're 18 or your knee, the doctors are going to repair that. If you do the same injury if your 80 and you have a bad knee, their most likely going to replace the knee. And so this replacement is a phenomena of aging and as engineers start to help surgeons with that there's definitely the technical aspects of how to properly place it. And how do you learn that if you're no longer a resident in a hospital setting with this controlled environment in that sort of apprentice style learning. So it is difficult and unfortunately physicians very often in kind of a desperation to try to help the patients and try to learn these new things, we really haven't gotten the experience broadly to do that. I think it's critical that patients find out what is the surgeon's experience and skill set with doing these new surgeries. Quite simply you just can ask. How many have you done? How many years have you been performing it? And ask them what are their results. I was lecturing just the other day and saying when you speak to your patients, and it's actually spelled out in the FDA, that you should discuss with patients the risks and quantify them for the patient. So you should be quoting the patient, what is your infection rate? Not what is reported in the literature by other physicians but you should be following your patients and you should know what your infection rate, you should know what your erosion rate and be able to share them with a patient and then patients will basically write them down and then call another physician immediately and look around a little bit. It's always amazing that people will comparatively shop for their automobiles or appliances and maybe which hotel they're staying in but they don't really do any comparative shopping for which physician will be doing the surgery, which is disappointing.
And what answers should she be looking for in pelvic organ prolapse repair surgery?
Well like I said, the first is how many of these surgeries have you done and how long have you been performing them. And, again, the longer they've been doing it and the more surgeries they've done, again from a probability stand more likely their experience has gotten them further long in their learning curve. And once you get a sense of okay so the doctor's been doing it for a couple of years and has done, hopefully, several, someplace in the range of 50 and greater. I think my teachings on this when surgeons ask well how long is it going to take me. So you really don't become, I don't think, truly an expert at it until you've done around 50. You're kind of beyond your learning curve. So I look for 50 or beyond in the number of cases. I would like to have the physician doing it for greater than a year. A year is sort of the minimum in terms of what your long-term sort of followup with your patients. And then they ask questions like infection rate, transfusion rate, complication rate and start from there. But it's easier than you think to really get this information, either candid questioning with the physician as well as doing a little shopping on-line and looking to see has the physician done any research on this particular area. Do they lecture and teach? Do they publish and write books? Because those will tend to be the leading experts in the field and you can quickly find that, like all things today, over the Internet. And I would also caution as any time a physician has difficulty answering these questions and doesn't really quite give you a clear answer, it's time to be a little bit concerned. Thank you very much.
Dr. Parker, lots of women say that they have heavy periods. When is uterine bleeding considered to be a clinical problem?
We consider it a clinical problem, first of all if a woman herself feels like things are changing that may be a problem but the definition is a period every 21 to 35 days, usually lasting somewhere between 5 to 7 days, changing a pad or tampon no more than every 3 or 4 hours. That would be clinically considered. But if you've had very light periods your whole life and then all of a sudden there's a dramatic change, even if it doesn't necessarily meet these criteria, probably that should be discussed with the doctor.
What are the causes of abnormal uterine bleeding?
Well most people think about fibroids first but actually it's further down the line. Often it's hormonal, minor hormonal fluctuations that are pretty common. Thyroid disease can do it, either in overactive or underactive thyroid can do it. Very common and not very well understood, even among doctors, there is a blood clotting disorder called von Willebrand disease, which can cause very heavy periods. It's usually present from the first period on and I've had patients tell me I've had incredibly heavy periods from—and they expect that that's normal but in fact we found a number of women that have had blood clotting disorders. And that's important to know because if you need surgery down the line it would be important to know that. Fibroids is definitely on the list. That's a fairly common problem. And then irregular bleeding, ovarian cysts can do it, some other less common things.
How often is heavy bleeding a symptom of fibroids?
Well we know that of all the women that have hysterectomies, about 35% of them are for fibroids and the majority of that is for bleeding disorders. So I'm not sure that that number is known but that's probably close.
And how do women know that it's time to talk to their doctor about their heavy bleeding?
I think women should talk if there is a dramatic change. One of the things about bleeding is that it sometimes can sneak up on you. You bleed a little bit more this month than you did last month. And a little bit more next month. And before you know it a year and a half has gone by and you've forgotten what normal was for you a year ago or two years ago. I had one patient actually carried into my office by her husband because she couldn't stand up. And she had had just progressive heavy bleeding over a period of time. So, you don't want to wait that long. You want to discuss it early on when there's a change. If you're changing a menstrual pad every 2 hours or 1 hour, that's not normal. It should be discussed.
And can abnormal uterine bleeding happen at any age?
Yes. In young women, it's often hormonal. In the reproductive age of women, it can be any of the causes we discussed, thyroid disease, fibroids, ovarian cysts, etc. And then after the menopause it's particularly concerning because there's a possibility that it's associated with cancer or pre-cancer. I don't want to scare people about the cancer because that's actually rare but that's one of the things that needs to be ruled out. So it's important to see the doctor about that.
The report found that over one-third of all baby boomers are affected by abnormal bleeding. Do you think that one-third of 40 and 50 year olds are talking to their doctor about this?
No, I don't think they talk, they talk to their best friend and their best friend tells them what to do. And often they'll do what their friend tells them to do. They usually come to the doctor when it's already bad and it's been bad for a while. And it probably makes sense because there are a lot of things we can do to treat this now short of hysterectomy. And I think it's worth talking to the doctor earlier in the course before you get anemic, before the treatment options are limited.
What do you think is necessary to happen for more women to discuss abnormal uterine bleeding with their doctors?
Well hopefully this program and your information on your website. There have been a lot of articles in the lay press, magazine articles to try to encourage women to talk to their doctor and if they don't like the answers get a second opinion.
What are the treatment options for abnormal uteerine bleeding?
So one of them would be medical therapy. And actually medications like Aleve and Motrin can often be used if they're used prior to the onset of bleeding, they will sometimes dramatically cut down heavy bleeding. So 2 or 3 tablets every 8 hours starting maybe a day before the menstrual period really will make a difference for a lot of women. Other medical therapy, hormonal therapy, birth control pills work really well. And now most women know that you can take the pill, you can actually even skip periods. Take the pill for three months in a row, have a period. Take the pill for six months in a row and have a period. And that works very well. Another form of hormonal treatment is the Mirena IUD. So progesterone containing IUD. Tiny amounts of progesterone but working locally in the tissue. Very effect. In fact, in Europe it's probably first line there because it's been shown to be so effective for bleeding. Six months of irregular bleeding but then most women have even no bleeding or very very light bleeding. That's probably underutilized in this country but utilized in Europe. And then endometrial ablation for women that have completed childbearing and have periods often can be either office procedure or certainly outpatient. No incisions, no recovery time. Patients don't believe me when I tell them this but no pain afterwards. After the procedures done they go home and take Aleve, Tylenol, Motrin for a day and that's it and go back to work in a day. Very effective, somewhere in the 90% range for abnormal bleeding. And then there's more surgical therapies. Certain a hysterectomy can be done. Myomectomy, removing fibroids when they're present. Very effective for bleeding. Hysterectomy I like to think of as a last resort because it's a bigger operation and longer recovery time, time in the hospital. But you do get the hundred percent guarantee no more bleeding.
Which surgical treatments can be performed on an outpatient basis?
The endometrial ablation can now be performed in the office with certain methodologies. There are probably 5 or 6 different ways to do it and 2 or 3 of them can be done in the office as an outpatient. Local medication and injection near the cervix, maybe some oral Valium, very effective.
And are there times when hysterectomy is the right option and when might that be?
I think hysterectomy should be a last resort. You've tried some of the simpler less invasive methods and you say you know what I've had it, I'm sick of it, I've got to get back to work, I don't want to mess with this anymore. Now most women with the simpler methods are going to have success. So now you're talking about a very very small portion of that population that's going to eventually say I'm sick of it. But I see that even in my practice. I try to be very conservative. But every once in a while a patient walks in and says I've had enough.
Lots of women have seen the same gynecologist for many years but their doctor might not offer all of the latest treatments.
How does a woman know if she should seek a second opinion?
Well I think women nowadays have a lot of avenues to educate themselves. The Internet, it has good and bad but there's a lot more good now than there used to be. Really good sites like your site. Straight, unbiased information. If somebody goes to a site and it sounds like they're selling one thing probably should go to another site. But that information is available. There are books available now. And I think you have to educate yourself, going into talk to your doctor with a list of questions. If they don't offer you ablation, let's say or Mirena, you should ask why. And hopefully they'll be honest enough to say because I don't know how to do it and if they don't know how to do it then you need to get a second opinion.
What kinds of comments from doctors are clues to women that they need a second opinion? Such as, you're just a few years from menopause, it will get better. You need a hysterectomy, no other options offered. You get a better outcome with an open abdominal hysterectomy.
Well, again, I think you have to go in knowing the information, knowing what is available and I think it's totally legitimate to ask as many questions as you need to ask. Do you do this procedure. I'm think about ablation. Do you do it? How many have you done? How many have you done in women like me? Have you had any complications? And that's totally legitimate and women need to ask their doctors those questions. And if they're not happy with the answers, time to go find another doctor.
You have published research that found women should not routinely have their ovaries removed during hysterectomy. Please tell us about that research and what women should know.
So in 2005 we published an article that was a computer model for many studies that have been done over 30 years looking at the outcomes after taking out ovaries. And what we found is when you take out your ovaries there's obviously a lower risk of ovarian cancer, which is a really frightening disease for women but it's really rare. For instance, 14,000 women die in this country every year of ovarian cancer, 450,000 women die of heart disease. And what we found is if you take out ovaries you've actually increased the risk of heart disease. So it doesn't take much change on this arm to overpower the loss of life on this one. Now we're talking about death and that's horrible no matter what but we found that if you leave ovaries women have less risk of heart disease, less risk of dying of hip fracture and incidence of hip fracture. There's some data that suggests maybe less risk of stroke. Thank you Dr. Parker.
