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What Is Endometrial Ablation?

Monday, March 31st, 2014

Endometrial ablation is a procedure in which a layer of the uterine lining is permanently removed in order to reduce or stop abnormal bleeding. The procedure is performed only on women who do not wish to have any more children. In some cases, it is performed in place of a hysterectomy.

The techniques used to perform endometrial ablation vary and include electrocautery, radiofrequency, cryoablation, and hydrothermal procedures, among others. The procedure is performed on women who are experiencing abnormal bleeding (bleeding between periods) or menorrhagia (prolonged or extremely heavy periods). Abnormal bleeding can be so severe in some cases that daily life is interrupted and some women may even develop anemia.

Reasons for abnormal bleeding and menorrhagia include hormone disorders or imbalances, fibroid tumors, polyps, or endometrial cancer. However, as stated earlier, the lining of the uterus is destroyed during ablation and is no longer able to function normally; therefore, bleeding is significantly lessened or even stopped entirely, and it is important to know that the woman also will no longer be able to become pregnant.

Endometrial ablation carries the same risks as any surgical procedure, including infection, bleeding, perforation of the uterine wall, or complications due to medication sensitivities the patient is not aware of (or neglects to inform the doctor of). In addition, women with certain medical conditions should not have this procedure, and these include vaginal infections, cervical infections, pelvic inflammatory disease, weakness of the uterine muscle, abnormal shape or structure of the uterus, and having an IUD in place, among others. In my health book, “Inside Information for Women”, I discuss this technique under “Resectoscopy”.  Endometrial ablation with cautery via a resectoscope or any other modality is a little tricky if the patient ultimately is found to have uterine cancer.  Why?  Because all the evidence regarding the extent of the disease (cancer) is burned away and the physician will have difficulty in staging the cancer, which is important in formulating the best management for a patient with uterine cancer. 

If your doctor and you decide that endometrial ablation may be right for you, your doctor should explain the procedure to you thoroughly and give you a chance to ask any questions you have. If you are to have a procedure that requires general anesthesia, you will be asked not to eat or drink before the procedure, most likely for at least eight hours or after midnight the night before. Be sure to tell your doctor if you may be pregnant, are allergic to any medications, or are taking any prescription drugs or herbal supplements.

Your procedure may take place in a hospital or in your doctor’s office on an outpatient basis. Recovery will depend on the type of anesthesia and the type of ablation used. In general, you can expect to need to wear a sanitary pad for a few days after the procedure, as bleeding during this time is normal. Also for the first few days, you may experience cramping, frequent urination, nausea, and/or vomiting.

Your doctor will probably instruct you not to use tampons, douche, or have sex for at least a few days. Usually restrictions on other activities are also necessary, such as heavy lifting and strenuous exercise. Let your doctor know if you experience fever, chills, severe pain, difficulty urinating, excessive bleeding, or foul-smelling discharge.

This information applies in general to most ablation procedures, but because each woman and situation is unique, the most important thing to remember is to follow your doctor’s specific instructions, and ask any questions you may have.

– Yvonne S. Thornton, M. D., M. P. H.

Pros and Cons of Robotic Surgery

Monday, March 3rd, 2014

If you need surgery, you are likely to be presented with the option of robotic surgery. This means that instead of the surgeon working on you directly with his hands, he or she will manipulate a set of robotic arms with surgical instruments attached from a console. Should you go along with this, or should you question the practice?

It would be understandable if you were hesitant. Thanks to the media’s love of a good horror story, most people have heard of instances where patients were accidentally injured – or worse – during robotic surgery. Even the American College of Obstetricians and Gynecologists maintains that robotic surgery is neither the best nor the most cost-effective approach to hysterectomy.

Does this mean that you should flatly reject robotic surgery? Not necessarily. Like any surgical instrument, a robot is as good as the surgeon using it. Furthermore, every patient profile is different. There are a number of considerations for anyone making a choice about robotic surgery.

In 2000, there were (worldwide) only 1,000 robotic surgeries. Last year, there were 450,000. Proponents of the practice say its benefits are responsible for its rising popularity. Less blood loss, less need for pain medication post-surgery, and shorter hospital stays are among these benefits, along with smaller scars (which is also a benefit of laparoscopic surgery). Robotic procedures are less taxing for surgeons, who don’t need to bend over an operating table, but instead, can sit at a console viewing the surgical field on a screen.

But some feel that robotic surgery does not offer significant benefits beyond those of laparoscopic or other types of surgery, and that the “wow” factor is one of the real reasons robotic surgery is catching on. In our love affair with new technology, it’s possible we have a tendency to move ahead too fast without enough standardized evaluation. To be sure, any new medical technology requires proper patient selection as well as a full explanation of all options and their risks and benefits for informed decision making.

What Does All of this Mean for You?

The wisest approach for a patient who needs surgery is to make sure to get an explanation from the surgeon about possible procedures, including what to expect in the postoperative period. The surgeon should also explain why he or she feels that a particular method is the best option in an individual patient’s case. There is no one-size-fits-all when it comes to surgery.

Another consideration is the cost of the surgery. Robotic procedures tend to cost more, but the patient may end up spending less overall. The need for longer hospital stays and pain medications is potentially lower with robotic surgery, and patients might have a lower chance of being readmitted for complications, all things which can lower a patient’s total costs.

For now, robotic surgery appears safe and effective, but it remains just one of the options available to patients. Ask your surgeon about his or her experience with any procedure he or she wants to use, and about complications that have arisen in the past. Remember that the right choice will be different for different people, so talk to your doctor, and let his or her expertise and experience guide you to make the right informed choice for your unique situation.

– Yvonne S. Thornton, M. D., M. P. H.

Myomas – Also (Wrongly) Known as Fibroids

Thursday, November 7th, 2013

As widely used as the term “fibroids” is, it is, in fact, a misnomer. “Myoma or myomas”  is the proper name for these tumors of the uterine muscle.

Myomas can be many different sizes and are typically hard and rubbery. They grow slowly and can occur at any time in any woman. 25 percent of all women have myomas, while 50 percent of black women do. Fortunately, many of these myomas are small and require no treatment. There can be just one or dozens in one uterus, and each one can be smaller than a pea or as large as a cantaloupe – or anywhere in between.

If your doctor tells you that you have a myoma, there are some questions you should be prepared to ask. You’ll want to know how big it is, how many of them there are, and where in the uterus they are located. Furthermore, you’ll want to discuss any symptoms it may be causing. A diagnosis of myomas often leads to hysterectomy, but sometimes this is an unnecessary overreaction, so talk to your doctor about possible other treatments, or whether treatment is needed at all.

For example, at menopause, myomas often shrink. This is because they are largely dependent on estrogen, so when estrogen output dwindles, myomas shrivel. They may not disappear completely, but if they are small enough and not causing symptoms, then there is often no reason to treat them.

However, some myomas can cause troublesome symptoms such as pain, irregular heavy bleeding, frequent urination, or problems with defecation caused by pressure on the colon. Another problem with myomas is that they can be hard to distinguish from ovarian cysts and tumors. Because they are slow-growing, though, it’s usually fine to monitor their growth through repeated examinations. If they stay the same size over time, this is a good sign. However, a growing myoma is a concern that requires some type of follow-up, usually exploratory surgery.

If a myoma needs to be removed, there are still different options for women and their doctors to explore. A myomectomy isolates and removes each myoma, while a hysterectomy removes the entire uterus. A woman who wants to preserve her ability to have children may opt for a myomectomy, but she should realize that this operation is difficult and complications are likely, so if she is older or certain that she does not want to have more children, then a hysterectomy is a much safer, simpler option.

There are new alternative treatments for myomas that are not recommended for women who still want to have children, because their newness calls into question the wisdom of recommending them; you can find more information about these treatments in my book, Inside Information for Women. But the fact remains that hysterectomy is the safe, rational course of action for myomas in women who do not want any more kids. Therefore, if you are symptomatic, menopausal and/or have completed your family, your  gynecologist may offer the definitive treatment of hysterectomy.

– Yvonne S. Thornton, M. D., M. P. H.

The Risk of Cellulitis and Infections After Hysterectomies

Monday, June 3rd, 2013

There is no doubt that a hysterectomy can be a traumatic experience for women. In fact, it is one of the most invasive surgeries that most women will face over the course of their lives. The immediate effects of a hysterectomy are far reaching.  The psychological effects of a hysterectomy can be devastating. Even women who do not plan on having any more children may experience difficulty coping with this kind of surgery.

Unfortunately, there are other risks associated with hysterectomies, and these risks can make it even more frightening for some women who are facing the surgery. Cellulitis and SSIs (surgical site infections), can cause complications after surgery for women. These issues can delay healing time, and can lead to other psychological effects as women cope with the cellulitis or SSI in addition to the effects of the surgery.

Many women may want to know if they are at risk for these kinds of issues after surgery. There are in fact multiple risk factors, as this study shows, which can include pulmonary disease, obesity, and even the lack of private insurance.  This may be concerning for some women as they go into their surgery.  Even the operating room environment in this study played a major role in whether a patient develops cellulitis (inflammation just below the skin) and a wound infection in the hospital (nosocomial).  One of my pet peeves is the wearing of O. R. scrubs as a fashion statement.  O. R. scrub attire was designed to decrease the possibility of outside contamination and not bringing it into the Operating Room.  Yet, today, you see doctors and O. R. personnel  (as well as the housekeeping personnel) wearing their “scrubs” to the food trucks outside of the hospital, wearing them home, walking and running in the street, sleeping in them.  All the while knowing that these filthy O. R. scrubs are vectors for disease and infection.  But, because everyone today is more casual, the patient has to suffer with a nosocomial infection (an infection contracted from the hospital) and needs to be treated with antibiotics or in some instances pay the ultimate price of an overwhelming, untreatable infection (such as MRSA) because someone was too lazy to change their O. R. scrubs before leaving the hospital.  Dr. Oz and other TV reality show doctors have set this unfortunate precedent by wearing their scrubs on TV, as if to make a statement that they are “real” doctors.  “Real” surgeons do not wear their scrub attire outside of the operating room, unless they are covered up with a buttoned, long, white coat.  So, the next time you see your doctor wearing scrubs outside of the Operating Room, you should call them on it.

Fortunately, the study also shows that certain precautions, such as pre-operative showers, antibiotic prophylaxis and better surgical techniques and a better operating room environment (personnel and instrumentation) can help prevent SSIs and cellulitis. It is important to figure out new ways to speed up the healing process in order to help women who have had these surgeries move on as quickly as possible—for many women, this will be one of the most traumatic experiences that they will ever go through.

– Yvonne S. Thornton, M. D., M. P. H.

Technology in Medicine: Robotic Assistance in Surgeries

Monday, May 20th, 2013

“Robots” are being used to assist in surgeries throughout the world. It sounds like something out of a movie, doesn’t it? The use of this kind of technology in medicine is raising a lot of questions for patients. Some may believe that the more technology that is used during their surgery, the better—others may have problems with the idea of a “machine” doing a lot of the work during a surgery. Doctors and surgeons are divided in much the same way, which is why studies are currently being done to assess the differences between robotic-assisted surgeries and traditional surgery methods.

In one study, women who were scheduled to receive hysterectomies were divided into two groups. One group received robotic assistance during surgery and the other did not. Researchers found that there were no significant differences in the outcomes of the surgeries—however, the robotic-assisted surgeries did take longer to complete. It may not seem like much of a finding, especially for patients, but studies like these may help ease the mind of individuals who worry about advances in medicine and whether or not they will be safe during their own surgeries or medical procedures.

Surgery—especially gynecological surgery—is becoming increasingly sophisticated, and that is good news for patients. Procedures that were once much more invasive can now be performed via laparoscopic methods, with only a few small incisions. While the outcomes at present are still very much the same for surgeries that do and do not use robotic assistance, there is a strong likelihood that in the future, as the technology advances, robotic-assisted surgeries could actually be much more advanced, and have much better postoperative outcomes compared to traditional surgical methods.

On the other hand, robotic surgery is very expensive (The DaVinci system costs 1.3 million dollars) and is labor-intensive (increased operating time), which means the patient is under anesthesia for a longer period of time, which may have serious sequelae.  All this has to be factored into the equation.  As a surgeon myself, the only advantage I see is that the surgeon gets to sit down during the entire procedure.  As a Catch-22, using robotic technology also reduces the training of young surgeons in the traditional approaches to operations, and thus the skill and “tried and true” surgical techniques are lost because they are no longer taught and performed on a daily basis.  The robot may have to be the wave of the future, by default, because surgical residents will no longer be taught how to do surgery the traditional way, and thereby fulfilling the prophesy.

The reason I find this so important to point out is to ease the minds of patients who worry about new methodologies in medicine—the simple fact is that even though surgery is growing more complex, it is also constantly improving in its ability to treat patients with a wide range of problems. While some of the newest trends in medicine may seem like science fiction more than anything else, our surgeons need to know and to be comfortable with both forms of surgery in order to have outcomes most advantageous for the patient.

– Yvonne S. Thornton, M. D., M. P. H.