The following is a cross post of a blog post we wrote for the MIRI network (http://www.miriwomen.com), a network of expert gynecologic surgeons.
Nicholas Fogelson, MD, Richard Rosenfield, MD
Pearl Women’s Center, Portland, OR
- Why am I bleeding so much?
Heavy menstrual bleeding (menorrhagia) is one of the top reasons that women seek gynecologic care with us. When we consider bleeding, we have to think of two different systems that are involved – the endocrine (or hormone ) system, and the structural system, which in this case is the uterus itself.
The uterus is a muscular sac that in its normal function serves as a place to carry a pregnancy and to deliver the baby. As far as we know, that’s its only function. In order to serve that function it works in concert with the endocrine system to prepare a place for an embryo to implant and grow every month. If a pregnancy occurs, there is no bleeding that month and a pregnancy ensues. If there is no pregnancy, the bed of endometrium (uterine lining) is shed in what we know as a menstrual cycle. If a woman has normal hormonal function, and the uterus is normal in shape and contour, then in most cases she will have a relatively light and short menstrual cycle. At least that’s the way it is supposed to work! In women who are having exceedingly heavy menstrual, some part of this system is having a problem.
A woman with a normally functioning endocrine system will ovulate once a month, leading to the typical once a month menstrual cycle. Some women will have problems that lead them to have irregular ovulation, including polycystic ovarian syndrome, thyroid disorders, extremes of weight (both obesity and extreme thinness). Any one of these problems can lead to heavy or irregular menstrual cycles, because the uterus fails to receive the hormonal signals it needs to have a short and light menstrual period. When patients have these problems, there are often medical treatments that can improve their hormonal system that will in turn improve their menstrual cycles. These treatment can include birth control pills, progesterone based drugs, and in some cases insulin related drugs. Hormonal intrauterine devices can also be quite effective in controlling this type of issue.
In some cases, the hormonal system is functioning correctly, but the uterus itself can be structurally abnormal leading to heavy menstrual cycles. Fibroids are a common cause of bleeding. These are muscle tumors that are within the walls of or within the cavity of the uterus. Fibroids can cause very heavy long menstrual cycles, irregular bleeding, and in some cases can contribute to infertility or miscarriage. Another structural cause of bleeding is a condition called adenomyosis, which is common in patients who have had many children. In this condition the lining of the uterus has grown into the muscle wall of the uterus, effectively causing the women to menstruate directly in the muscle of the uterus. Women with this condition tend to have painful, heavy menstrual cycles, and often have uterine tenderness that may cause pain with intercourse. Additionally, there are some rare conditions of the uterus that are congenital (present at birth) that can cause problematic bleeding patterns.
Structural issues of the uterus can also be treated with the previously mentioned medical treatment options, though this may be less effective depending on the severity of the structural issue. Fibroids of the uterus can be removed surgically, which can be done either through an open incision or laparoscopically. A number of procedures exist to remove or burn the lining of the uterus, which in many cases can significantly decrease bleeding. This option works best in women who have uterus that are normal to mostly normal from a structural point of view. The entire uterus can also be removed (hysterectomy), which entirely eliminates bleeding. This procedure can also be open, laparoscopically, or vaginally.
Hysterectomy is a procedure that is thought of differently by women from different backgrounds. Some women want to preserve their uterus, even after childbearing, while other women absolutely giddy to be rid of the source of their bleeding. At Pearl Women’s Center we are excited to work with women with their bleeding issues and provide the treatment that best fits their needs. Both of our surgeons have extensive experience with minimally invasive techniques and can provide myomectomy and hysterectomy procedures through very small incisions and minimal downtime in the vast majority of their cases. In the last 10 years we have completed over 1000 laparoscopic hysterectomy procedures and have been a driving force on a national level in showing that these procedures can be safely performed in the outpatient surgery center setting. Our rate of conversion from laparoscopy to open procedures (having to open up) is less than 1%, compared to a national average of 10-20% depending on surgeon experience and setting.
Stay tuned for four more posts from Pearl Women’s Center in the near future!
The Pearl Women’s Center is a gynecologic surgery and aesthetic medicine practice in Portland, OR. Staffed by national expert level physicians and surgeons, the Pearl Women’s Center provides cutting edge care in a beautiful environment. Drs Rosenfield and Fogelson participate in the MIRI network and are look forward to serving new patients every day.
In my first year out of residency I practiced in Honolulu, HI. One day in my outlying clinic in Kapolei, on the west side of Oahu, I entered an exam room to find a woman crying in pain. She said she had pain in her belly wall that had been present for years and no doctor could help her or tell what was wrong with it. She said that several months after her last cesarean delivery she started to feel this hard lump on the side of her belly. Every month right before her menstrual cycle, this lump would become exceedingly painful, both at rest and even more so with any kind of pressure.
She was absolutely distraught, and was really in my office to ask for some narcotic pain medications to treat the severe pain. So many doctors had failed to make a diagnosis on this issue that she thought it was something she would have to live with for the rest of her life.
But, that day was different, because her doctor that day had been fortunate enough to be exposed to this condition in his training. The woman had abdominal wall endometriosis that had been ignored or missed for years. I scheduled her for surgery that afternoon and by that evening she was completely cured of the problem. I asked her as she woke up whether it still hurt, and she said that she felt some pain from the surgery, but the pain from that mass was gone. It felt good to help her, and I was thankful that I had gotten training in the diagnosis and management of this condition in my residency, something that is lacking in the training of most gynecologists in this country.
Since that time, I have been fortunate to be able to help a lot of women with this condition. The first few came randomly, and to my disappointment each one had been missed by at least a few doctors before I saw them. Eventually I became known as a competent manager of this condition, along with my general expertise in endometriosis, and at that point I started to see a lot of referrals and do a significant number of surgical repairs for this problem.
Abdominal wall endometriosis is a predominantly iatrogenic condition, meaning that it is the result of something that we are doing – and that something is cesarean delivery. The vast majority of these cases are subsequent to cesarean delivery, presumably via seeding of the abdominal incision with endometrial tissue at some point during the case. We do not know exactly what are the risk factors in cesarean delivery that cause this condition, but we do know from animal models that if you take a little piece of endometrium and stick it in the fascia when you close it after surgery, abdominal wall endometriosis will result – so presumably that is what is happening.
There are a few things I think we can do to reduce the incidence of this cesarean related endometriosis. Thorough irrigation of the wound prior to closure is likely to reduce or eliminate flecks of endometrium that might implant in the abdominal wall. I also believe, based on my experience but lacking data, that closure of the parietal peritoneum will reduce the incidence of this disease. I say this because of multiple experiences where uteri are adherent to the abdominal wall contiguous with masses of abdominal wall endometriosis. In one of these cases a hysterectomy was required to entirely remove the disease.
Interestingly, people with cesarean related abdominal wall endometriosis do not necessarily have typical peritoneal endometriosis, as it is caused by direct deposit of endometrium into the abdominal wall during a surgery. However, women that have abdominal wall endometriosis who did not have prior surgery most likely do have peritoneal disease, and it is probably severe. Papers suggest that only 50% of these cases are post-surgical, but in my experience cases without prior surgery are very rare.
Abdominal wall endometriosis is a disease that is easy to diagnose if you know what the condition is and how it presents, and impossible to diagnose if you don’t. This is called availability heuristic – it is impossible to make a correct diagnosis if the disease state doesn’t exist in your brain’s medical knowledge banks.
In almost every case I have diagnosed, the patient came right out and told me they had it. Not literally of course, but rather they said the words that made the diagnosis certain. The disease presents with a hard mass that is painful at all times, but become larger and dramatically more painful prior to and during the menses. It is exquisitely tender to the touch, particularly during the most painful part of the month. With those symptoms, the diagnosis is almost certain. I can tell you that I have heard this story over and over and over, and I come right out and tell the patient what is wrong before I even look at their abdomen, and in each case it is there to be found on abdominal exam, just missed by well-intentioned people who didn’t know what to look for.
Imaging studies are useful in confirming the disease, though in my experience it is useful only to for surgical planning, as history is enough to make the diagnosis. The proper imaging should be an axial cut CT or MRI. MRI is better at showing the depth of invasion into the fascia and muscle, but either modality is adequate. If cost were an issue one could certainly get away without imaging. Some people (mostly general surgeons) will do a fine needle biopsy to confirm that it isn’t a malignant tumor, though I don’t think that is necessary and it drives up costs.
There are three things one can do with abdominal wall endometriosis, only one of which clearly leads to lasting cure of the problem.
As AWE is endometrial tissue, it will respond to high dose progestin therapy or continuous birth control pills. It will also respond to Depot-Lupron (leuprolide), and perhaps to aromatase inhibitors (eg letrozole). The upside is that these agents do work. The downside is that the patient is stuck taking them forever, or at least until menopause, and that they are not really treating the problem.
There are some recent trials that suggest efficacy in ultrasound guided injection of phenol directly into the endometrial tissue. These injections destroy whatever tissue they go into, so properly guided this probably does work. It is however something that is still in a research stage and only supported by a few recent papers (in international press.)
The final intervention, which is both curative and reliable, is surgical resection of the abdominal wall disease. In my experience, complete resection of the indurated tissue in the subcutaneous space, including resection of underlying fascia if necessary, is curative of the problem. I have had only one patient who did not experience complete relief, and subsequent imaging showed that she had a satellite area of disease that was not resected in the first surgery. She was cured in a subsequent surgery to remove this additional disease.
This procedure is performed under anesthesia by opening up the old cesarean scar, identifying the endometrial implants, and resecting them. In some cases the implant is superficial enough that removal does not require entry in the rectus fascia. In other cases the disease is invasive into the fascia or even the underlying recurs muscle, requiring resecting a portion of the abdominal fascia. Small fascial defects can be closed primarily, while larger ones can require mesh reconstruction of the fascia prior to closure.
I have removed quite a number of these, and in my experience about half require some level of mesh reconstruction. There are some studies that show a much lower likelihood than that, though I suspect they had a population with less severe disease than I have seen. My criteria for mesh reconstruction is a lack of ability to reapproximate the fascia without significant tension. I have predominantly used a biologic mesh (either Strattice (porcine dermis) or Veritas (bovine pericardium)) which is reabsorbed and replaced with fibrosis over time. Some operators use a permanent mesh. Permanent mesh is likely superior for large defects, though it comes with a chance of infection requiring removal. Porcine or bovine mesh will not get infected easily (if placed in a sterile field), but there is greater risk of subsequent hernia formation. We lack any randomized trials to direct us on exactly what type of mesh we should use in this diseases state, other than the general surgery literature on general abdominal wall reconstruction.
Placement of mesh is does by a simple inlay technique. I use 2-0 PDS suture to secure the mesh. Very large defects may require underlay or component separation techniques, in which case I will involve a general surgeon in the closure.
With the placement of any biologic mesh, drainage is imperative as seroma formation is quite common without it. Drains are left in place until drainage is minimal (10-20 cc a day), which can be as long as a month. My experience with inadvertent (gets pulled out accidentally) or impatient (resident pulls it out thinking that 50cc a day was little enough) has been consistently negative, with seroma reformation being common. While patients dislike drains, they can be managed, and they are preferable to a wound that is draining clear fluid for a period of time.
If you are a physician seeing a patient with the symptoms I mention, please think about this diseases state. If you make the diagnosis you will be doing better than 90+% of people out there.
If you are a patient with these symptoms, tell your physician your own diagnosis. If they are not able to help you with it, consider visiting beautiful Portland, OR and I would be honored to help you.
Dr Fogelson practices gynecologic surgery with a specialty in pelvic pain and endometriosis at Pearl Women’s Center in Portland, OR, where he sees patients from Oregon, the northwest region, and the nation.
For more information contact us at email@example.com, or call (503) 771-1883
This month ACOG released a statement on Robotic Surgery, generally negative towards the development. They propose that robotics does not offer a proven advantage in benign gynecologic surgery, and increases cost.
Per the statement “If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.”
This morning a large cadre of minimally invasive surgeons released a statement of response, accusing ACOG of not being supportive of minimally invasive techniques and misinterpreting the data on robotics.
Here’s my take on the issue:
I am a surgeon that focuses on minimally invasive techniques and gets a lot of referrals for difficult cases. I’ve been doing robotics for about two years now, and have done enough cases (over 100) that I feel like I can make a pretty objective assessment of its utility in what I do.
As Intuitive Surgical will be happy to tell anyone that listens, robotics has quite a few advantages.
The ability of the robot to move with wrist-like motions allows laparoscopic maneuvers that are difficult if not impossible with straight stick laparoscopy. This allows one to do surgery in very small delicate areas that are much harder to address traditionally.
The vision allowed by the robot is far superior to traditional laparoscopic vision, for 4 reasons: 1) image fidelity is better than most traditional equipment 2) 3D vision allows one to see relationships between structures far better 3) the screen is so close to your face that it fills your whole field of view, creating an immersive “I am the robot” experience and 4) you control the camera and don’t have to depend on your assistant to show you what you want to see.
The ability to pass energy through both primary instruments creates a surgical flow that is difficult to match with traditional instruments. The fact that one can cauterize every surface that is cut tends to lead to bloodless surgery. This can be done traditionally as well, but its a bit more difficult to achieve the same result.
Long laparoscopic surgeries require a surgeon to stand in a way that is eventually painful to the back and legs. Robotics is quite comfortable for the surgeon, as he is sitting in a ergonomically superior position.
All of this together allows one to tackle much more difficult cases than one might have tackled with straight stick, such as stage IV endometriosis with obliterated cul-de-sacs, huge uteruses, or cases that require extensive suturing. As such, robotics has the potential to turn cases that otherwise would have been abdominal cases into laparoscopic cases.
There is potential to do surgeries through a single site using the robot, which is a cosmetic advantage over multiple port surgeries.
And here is the downside:
The robot is a tremendously complicated piece of equipment that requires a very skilled team to operate efficiently. Without that team, the use of the robot adds a huge layer of complexity to a surgery. With that team, it still slows things down. While one may be able to do the operative portion faster, the setup time for the room and and early part of the surgery is significant and will slow most cases down overall. A ideal team may mitigate this completely, but such a team I have never seen in an academic center.
The robot is extremely expensive, both to buy and to maintain. It costs between 1.5 and 2 million dollars, and several hundred thousand dollars a year for a service contract.
One usually needs more port sites to do robotics than traditional laparoscopy.
The robot breaks down from time to time, sometimes in the middle of a surgery. While these problems inevitably get resolved, it is a remarkably unpleasant experience for all involved. A two million dollar machine with a two hundred thousand dollar a year service contract should not break down at all.
The robot is sold and serviced by a company that does not have an objective view of their own technology. They aggressively market their product directly to patients, and even more so to the robot trained surgeons. They do not seem to see the reality of their product, which is that it is very useful for a subset of laparoscopic surgeries and a hinderance to another subset. They prefer to think about it as an improvement to all laparoscopic surgery, which it clearly is not.
My feeling is that ACOG’s statement is a response to the tremendous proliferation of robotics throughout benign gynecologic surgery without a clear evidence base to suggest that this level of use can be justified. I agree with that part. A lot of surgeons are using robotics to complete cases that could have been done via traditional laparoscopy or vaginal surgery, which is not right. The entire point of the robot was to convert open surgeries to laparoscopic surgeries, but in benign gynecology it is being used for far more than that. This drives up costs at minimal to no benefit to patients.
Some argue that robotics allows a surgeon who is not a particularly skilled laparoscopist to do more difficult laparoscopic surgeries. I think this is true, but at the same time I am not sure that is a good thing. Surgery is done best when it is done by people that do a lot of it. If one does a lot of laparoscopy, one gets good at doing a lot of things with or without the robot. At that point many mild to moderate difficulty laparoscopic surgery is most easily done without the robot.
Right now my hospital has two robots at one center and is about to buy a second at our other site. The drive to have multiple robots is because of demand for time on the robot. While this seems appropriate, I have to ask myself whether these marginal cases that justify a second machine actually cases that require robotics to be completed laparoscopically. If not, then the cost is not very justifiable.
I love working with the robot, and get a real feeling of accomplishment when I am able to complete a robotic case that I know I never would have been able to do through traditional methods without a laparotomy. I have done many of those. But having done over 100 robotic cases, a 10 week size hysterectomy done robotically does not give me that sense of accomplishment. I get that sense of accomplishment by doing that case vaginally or via traditional laparoscopic surgery, being out of the room in two hours and with far less expensive toys.
There are days when laparoscopic surgery is a breeze. The anatomy is perfect. The view is beautiful. Your assistants are thinking three steps ahead of you. In other words, the way surgery happens in your dreams
And then there are days when it isn’t going that way. The anatomy is distorted and confusing. There is bleeding that continuously distort your view. Your assistants are struggling. You are quickly becoming unhappy and want nothing more than for the surgery to be over and the patient to be well.
I have had many of both kinds of days. Over the years I have been operating, I have identified a few things that tend to have happened on the latter kind of days, and hope to pass a few of those things on. So if you find yourself struggling with laparoscopy, consider whether one of these things is going on.
This video demonstrates techniques for resecting infiltrating endometriosis, including dissection of bilateral ureters and pararectal spaces.
For consultation with Dr Fogelson please call Emory University at (404) 778-4416
Copyright 2012 Nicholas Fogelson and http://www.academicobgyn.com
This month I started a fellowship that predominantly involves taking care of women with cancer. Through surgery, chemotherapy, and other medications we do our best to cure or hold back malignancies of many kinds. In these past weeks, I have taken care of several patients who are Jehovah Witnesses, an experience that has been quite interesting.
In most cases, what religion a person subscribes to has little to no impact on their clinical outcome. We have an exception, however, when it comes to a Jehovah’s Witness with cancer. JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer. In some cases they cannot have surgery because the surgery they need is unsafe without the possibility of blood transfusion. In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression. As surgery and chemotherapy are our two best treatments, they are at a major disadvantage.
When I was a resident, I had a pretty hard opinion about this. I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me. He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not. He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor. He even arranged for attending coverage for emergent issues if need be. He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence. While this was a very hard line, I respected the boldness of it, and that he was being true to his internal values. I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.
Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.
As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.