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Archive for June 18, 2017

On Hysterectomies and Hysterectomy Alternatives

Every now and then physicians have a clarifying moment that really helps to define the way we think about how to take care of our patients.  I had such a moment when I was a third year resident.

The patient was an HIV positive woman who was somewhat ill, who had problems with severe uterine bleeding.   Her workup demonstrated that she had a 3 centimeter submucosal fibroid, meaning that she had a fibroid that was inside her uterine cavity.  This type of fibroid can cause severe bleeding, and needs to be removed to resolve the problem.  She had tried a number of medical therapies, but not surprisingly they weren’t working for her.  At the time I remember thinking that she could benefit from a hysterectomy, but was worried that she wasn’t a very well woman and I wanted to do something less invasive.
I posted the patient for a hysteroscopic myomectomy, which is a procedure to remove the offending fibroid with a scope put up through the vagina and cervix, with no incisions in the abdomen.   As we didn’t have the fancy intrauterine morcellators that we now have that make these procedures much easier, it was a fairly challenging case to complete, both because it was a relatively large fibroid to tackle this way and because as a third year resident I was not highly skilled at the procedure.uterus

Ultimately, the procedure was difficult.  In fact, we were not able to complete it in a single surgery and had to come back to the OR a second day to finish it (which was not uncommon using the technology available at that time.)  In the process of the procedure, my attending physician Dr David Soper was critical of my decision to do the hysteroscopic procedure.  He asked several critical questions.  “Did she plan on future childbearing?”  The answer to this was no, as the patient was
actually quite ill with HIV related illness.  “Did she specifically desire to keep her uterus?”  The answer to this was also no.  With these two answers, he asked “So if you can do this in three hours and maybe not succeed, and she may still have bleeding issues even if you succeed, AND you could do a vaginal hysterectomy in half the time and that would have a 100% chance of solving her problem, why again are we doing this and not the vaginal hysterectomy?” (this was before the age of the laparoscopic hysterectomy.)

The reality is that I didn’t have a good answer.  The bad answer was that I had been taught to be afraid of doing hysterectomies.   I had been taught that a hysterectomy is what you do when nothing else had worked.  And there were things I hadn’t tried yet, so I didn’t do the hysterectomy that would have worked 100% of the time.

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Categories: Gynecology, Surgery
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