Academic OB/GYN

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.

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.

To some extent, these ideas were for good reasons.   When I was in training, at least 75% of hysterectomies were performed via open laparotomy, with most of the remainder being performed vaginally.  Laparoscopic hysterectomies were really just beginning and were rare.

Since most hysterectomies at that time were performed open, most hysterectomies involved a long recovery, often 6 to 8 weeks for the woman to get back full function.  Along with this, complication rates were 3-5%, with at least 2-3% risk of urinary tract injury.  These types of injuries could substantially increase recovery time, and in some cases there could be long term issues.   And over a training period where one saw a few complications in high risk patients,  one became afraid to do a hysterectomy unless it was absolutely necessary.

So around this time, we started to see a lot of ‘hysterectomy alternatives’, like uterine ablation procedures and hysteroscopic procedures.  The argument was that we could achieve the effect of a hysterectomy without the big incision, long surgical time, and potential complciations. This were great innovations that did indeed allow some women who would otherwise have had hysterectomies to instead have a less involved procedure that they would recover from much quicker.

Uterine ablation was developed to burn the lining of the uterus, leading to dramatically decreased bleeding over time.  There were a number of different technologies that came along, including radiofrequency energy devices, hot water circulating devices, microwave devices, and cryo devices.  In the end, they were all similar, in that they caused necrosis of the endometrium and over time dramatically reduced bleeding.  In a way these were an advance, but they weren’t perfect.  Studies demonstrated that of women who had ablation procedures who otherwise might have had a hysterectomies, at least 20% go on to have hysterectomies within 5 years.  My experience over time was that while these procedures did work for many women, I also saw quite a few that developed pain in the uterus over time (the so-called Post Ablation Syndrome).  But in a world where hysterectomies were mostly 6-8 week recovery procedures they still made sense to try in many women.

Hysteroscopic procedures to remove fibroids could also be effective in some women.  This is what I was doing in the patient I mentioned, and for her it did eventually work.  When I was training these procedures were technically challenging to do effectively, but over time newer technology has made them much easier.

Over the late 90s and early 2000s, these procedures were very popular, and replaced or at least delayed lot of hysterectomies.   And today, the idea that you should try something like this before you proceed with a hysterectomy is still quite prevalent, and many physician still push uterine preserving procedures over hysterectomies.

I think this needs to change.  This is not because these procedures were not good ideas when they came on the market, but because they thing they are an alternative to has changed.

In our practice, we are able to do nearly 100% of hysterectomies in an outpatient environment through very small incisions, including cases that many physicians would do via open surgery.  So essentially, rather than going to sleep in an outpatient surgery center to have an ablation, with a  80% chance of having the problem resolved for 2-3 years, you can go to sleep in the same outpatient surgery center and have a 100% chance of having the problem resolved for the rest of one’s life.

At the same time, complication rates for hysterectomies have gone down dramatically in the hands of high volume expert surgeons.  We recently presented our 11 year practice history of outpatient hysterectomies with almost 1,100 cases with only 4 complications, three of which were managed during surgery with same day discharge.  In this series only 1 patient was converted to an open case and transferred to a hospital.  These data demonstrate that in the hands of expert high volume surgeons, the outpatient setting is a safe and effective environment for hysterectomy, and that nearly 100% of cases can be completed with same day discharge.  At the same time, we had a 98% rate of patients feeling satisfied or very satisfied with their experience, far better than scores reporting in hospitals.  Furthermore, from an actual cost point of view, we actually spend less money performing a laparoscopic hysterectomy mostly with reusable instruments that you would spend using an expensive disposable uterine ablation device.

At the same time, high volume surgeons have become very very good at doing hysterectomies via laparoscopy, even cases that seem like they need to be done via an open incision because of previous surgeries or very large uterine fibroids. It turns out that with the great optics we have with modern laparoscopes and great vessel sealing technology, we can do almost any hysterectomy laparoscopically, and with almost no blood loss.  In my practice we have done many cases where the uterus was over 1 kg in size, and sometimes much larger than that, still through very small incisions.

So given this experience, one has to look at hysterectomy in a different light then we looked at it 20 years ago.  Its a far easier procedure for the woman now, costs in the outpatient environment are quite low, and complications are quite rare in expert hands.   Given all of this, we have to see it not as the thing you do if nothing else works, but as something that can be chosen as the first option if that is what a woman is looking for.

So if we aren’t going to consider a hysterectomy to the thing you do at the end of everything else not working, what should be the criteria for choosing one?

1. The woman needs to have a problem that would be solved with a hysterectomy.  Usually this means significant bleeding issues associated with a structural issue with the uterus like fibroids or adenomyosis.  In some cases it can be for pelvic pain, but these cases usually also involve other treatment such as resection of endometriosis.

2. The woman needs to be done using her uterus, meaning she is done having babies.   If a woman wants a first kid or more kids and wants to have them in her own uterus, a hysterectomy is not an option.

3. The woman has to not be emotionally attached to her uterus.   From a scientific point of view a uterus is a bag of muscle to carry a baby in.  But we also have to understand and respect that some women have a underlying desire to preserve their uterus.  So in those cases we pursue other treatments such as myomectomy, ablation, or medical therapies.

What I have found over the years as gynecologic surgeon is that many women fit these criteria easily.  And often, they come to me after seeing other physicians who were hesitant to perform the hysterectomy they want.  In these cases, I often agree to do it, and generally don’t try to talk them out of it.  Because in my experience, I have never had happier patients than the ones that chose to rid themselves of whatever problem their uterus is causing them.

We used to look at a hysterectomy as the end of the road, after everything else has failed.  Now we should look at it as a path that can be chosen at many points along the road, and even as the first thing in some cases.

And so now, after a fellowship and almost 15 years of experience in high volume gynecologic surgery, I could better take care of that patient from my training days that was such a challenge at that time.  If she wanted a hysteroscopic myomectomy and to preserve her uterus, I now have the skills to do that far better than I did then.  But also now I would just offer her a hysterectomy if that what she wanted.  She would be 100% solved of the problem forever, and would have gone home from the surgery the same day and nearly 100% recovered in 2 weeks or less.  And for a lot of my patients, that’s exactly what they want.

Dr. Nicholas Fogelson is a gynecologic surgeon in practice in Portland, OR at Pearl Women’s Center, a center of excellence for minimally invasive gynecologic surgery and endometriosis care.  Call 503-771-1883 to schedule a consultation, or contact Dr. Fogelson directly at drfogelson@gmail.com.

** Would also like to add this – if someone is looking to stop bleeding issues and wants to do something really non-invasive, a progesterone IUD is a great option, and works as well if not better than a surgical ablation procedure.  And unlike an ablation, its totally reversible if the results aren’t what the woman wants.  AND its 100% covered by insurance without costs.  So why are people doing surgical ablations again?

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR.  Call 503-715-1377 for clinical consultation.  http://www.nwendometriosis.com