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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

Why Healthcare in America is So Expensive Part 2 – Surgical Equipment

February 27, 2017 5 comments

With this essay we embark on a journey through the world of medical cost.   In my last essay, I argued that while our government struggles to create a system that pays for the healthcare system we have, the true problem is the outrageou
s cost of that system, not how we pay for it.

Today, we will examine the surgical equipment industry, and how expensive i
nnovation and technology is valued over actual contribution to patient outcomes, and how every incentive exists to make medical equipment as expensive as possible.

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A few years ago, I was involved in a project with a number of students from Georgia Tech’s biomedical engineering department.   I had an idea to solve a basic problem in laparoscopic surgery, and these students were charged with cSurgical-Instruments-11.jpg
reating a prototype solution to the idea.  We came up with an elegant solution to an issue that occurred in every laparoscopic surgery in this country, and eventually the students presented this idea as their senior project for their degrees.

Subsequently, I approached my University’s Technology Transfer department (the group that helps faculty to commercialize their ideas.)  We went through a process of idea disclosure with the hope that the University would help me to bring this idea to market.  In the end, though, it fizzled.    They said they weren’t interested in developing the idea.  So I approached several industry groups.   Again, no interest.  Over time I talked with three different groups that develops ideas, and no one was interested.

The kicker of all of this is that the lack if industry interest had nothing to do with the utility of my invention.  In fact, all parties agreed that the idea was great and the solution was elegant.  They also agreed that they could imagine the device in practice.   The problem wasn’t that the device wasn’t a good one, it was that the device was too simple, and too inexpensive to manufacture.  I had imagined a device that would probably cost about 5 dollars in every surgical pack.  In the end, the development market had little interest in such a device, given what it costs to develop bring a device to market and the likely payout at the end.  This thing actually saved money in time and in replacement of more expensive equipment already in use in the OR.   But what I found out was that there wasn’t much interest in devices that causes industry to make less money.

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Thoughts on Hemodynamic Instability, Laparoscopy, and Ectopic Pregnancies

As a young physician, I was taught that when a patient presents with a ruptured ectopic pregnancy and was hemodynamically unstable, the corimagesrect course was to perform a laparotomy for immediate control of the bleeding.  At that time (around the year 2000), complex laparoscopy was not really in wide practice, a
nd a physician who suggested that they could control bleeding laparoscopically as quickly as they could via laparotomy would have been met with skepticism.  In some cases, a physician suggesting a laparoscopic approach to the problem might be blocked by the atten

ding anesthesiologist, who often holds veto power over certain surgical decisions.  The idea was that the bleeding needs to be stopped quickly, and the way to do that is a laparotomy.

But over time, our ability to do things quickly and effectively via laparoscopy has changed, and I think our understanding of hemodynamic instability in young women has changed as well.

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The Important of Estrogen Replacement after Surgical and Natural Menopause

November 11, 2016 2 comments

Last night the Portland OB/GYN Society, of which I am the current president, had the honor of hosting Dr Philip Sarrel to speak on the important topic of replacing estrogen in women who have experienced surgical menopause at an early age.   His talk was fantastic, and illustrated the extreme importance of replacing estrogen in any woman who has experienced an unnatural loss of estrogen early in her life, and the ongoing benefit of estrogen replacement after menopause as well.   I encourage you to review this video, which describes the findings of his research and his point of view, which I entirely agree with.

What was truly striking to me was the number of women who have had their ovaries removed at an early age.  It saddens me, as I know that in many cases this is because of pelvic pain and endometriosis.  While oophorectomy often does improve and in some cases even eliminate endometriosis pain, with proper resection of the the disease we can often achieve substantial and even complete pain relief while preserving ovarian function.

This is definitely worth a watch.

Categories: Gynecology, Uncategorized

Birth Control Pills and Depression

October 7, 2016 1 comment

This week a study was published in JAMA Psychology drawing a connection between the use of birth control pills and depression.   This was picked up in the popular press, and briefly we were hearing about it in the news and radio.  I first heard about on my way to work listening to NPR.   The message I got was that a study was just published that showed  a link between the use of birth control pills and the development of new depression.

photolibrary_rf_photo_of_birth_control_pillsToday I read the actual paper that led to this media frenzy, and not surprisingly the media got it at least partially wrong.

Skovlund et al reported the following

“A total of 1 061 997 women (mean [SD] age, 24.4 [0.001] years; mean [SD] follow-up, 6.4 [0.004] years) were included in the analysis. Compared with nonusers, users of combined oral contraceptives had an RR of first use of an antidepressant of 1.23 (95% CI, 1.22-1.25). Users of progestogen-only pills had an RR for first use of an antidepressant of 1.34 (95% CI, 1.27-1.40); users of a patch (norgestrolmin), 2.0 (95% CI, 1.76-2.18); users of a vaginal ring (etonogestrel), 1.6 (95% CI, 1.55-1.69); and users of a levonorgestrel intrauterine system, 1.4 (95% CI, 1.31-1.42). For depression diagnoses, similar or slightly lower estimates were found. The relative risks generally decreased with increasing age. Adolescents (age range, 15-19 years) using combined oral contraceptives had an RR of a first use of an antidepressant of 1.8 (95% CI, 1.75-1.84) and those using progestin-only pills, 2.2 (95% CI, 1.99-2.52). Six months after starting use of hormonal contraceptives, the RR of antidepressant use peaked at 1.4 (95% CI, 1.34-1.46). When the reference group was changed to those who never used hormonal contraception, the RR estimates for users of combined oral contraceptives increased to 1.7 (95% CI, 1.66-1.71).”

In summary, women who used birth control pills were more likely to also use antidepressants.   They concluded that women who use birth control use antidepressants more often, and thus they may be more likely to be depressed.

Here’s what I think about this.

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The Importance of Genetic Screening for Heritable Cancer Syndromes

September 6, 2016 5 comments

 

When I talk to my patients, one of the greatest concerns I hear is regarding the fear that they might get a cancer at some point in their life.  It is a very reasonable fear, as cancers of the female reproductive tract and breasts are not as rare as we might like.  Perhaps educated by Angelina Jolie’s announcement of her BRCA mutation in 2013, many women now ask me about BRCA testing.  In the past I referred to genetic counseling for this, but more recently I have become more educated on exactly who qualifies for testing, and send quite a few BRCA tests out of my office myself.

Across the board, somewhere between 1 in 8 and 1 in 10 women will get breast cancer over the course of their life, if they live to an age of 85 years old.  Fortunately cure rates are high because we have many screening methodologies that are quite effective at finding it before it has spread widely, allowing for relatively straightforward treatments that are usually curative.  These screenings include typical mammography, as well as high risk screening methodologies like breast MRI.

angelina-jolie-mastectomyOvarian cancer is far less common than breast cancer , affecting about 1 out of every 100 women, though it is also far more deadly.  While breast cancer is usually caught early enough to be cured, ovarian cancer is usually found when it is already at an advanced stage, and even with treatment significantly shortens the life of women affected by it.  We have investigated various strategies to screen for ovarian cacer, including ultrasounds and blood analyte testing (ie CA125), but to date no screening methodology has been shown to be truly useful in detecting the disease early, and unfortunately most women diagnosed eventually die from complications of the disease.

It is my impression that physician are very good at screening for breast cancer, and aware of women at high risk for ovarian cancer.   This is a good thing. What we are not  great at is identifying women who are at the highest risk of developing the disease : those that have heritable mutations such as BRCA mutation.

The most common heritable mutation for breast and ovarian cancer is BRCA 1 and 2 mutations.   BRCA 1 is present in 2-3% of the general population, in 8% of women of Ashkenazi Jewish descent, and in 4% of Hispanic women.  BRCA 2 is present in 2% of the general popuation, and in 1% of women of Ashkenazi Jewish descent, and in 3% of the African American population.

If a woman has a BRCA 1 mutation she is has a 60% chance of developing breast cancer by age 70, and a 50% chance of developing ovarian cancer.

If a woman has a BRCA 2 mutation, she has a 50 to 85% chance of developing breast cancer, and an approximately 30% chance of developing ovarian cancer.

Women that have these mutations can dramatically reduce their likelihood of dying from these cancers by doing advanced screening, and in many cases can consider removal of the potentially cancerous organs once they have completed childbearing (something brought into the mainstream awareness by Angelina Jolie a few years ago, who had a prophylactic mastectomy and oophorectomy for this reason.)

So given this important information, why are physicians not very active in ordering these tests?

The biggest reasons are two fold:  1) the tests are pretty expensive, with list prices between 2 and 4 thousand dollars depending on the lab and 2) the criteria under which these tests will be paid by insurance have been shifting in the last few years, and it has been hard to tell who will have their tests paid for and who will not.  It is not worthwhile (or cost effective) to screen every woman for BRCA, but for women of high risk is is not only useful but also cost effective.  But just how much risk is enough, and how do we quantify this and understand who will be covered for testing and who won’t?  It is this question that keeps many qualifying women from getting screened in many physician’s offices today.

Fortunately, these issues have been greatly simplified in the last two years.

In general, BRCA testing will be covered by insurance for women who meet NCCN (National Comprehensive Cancer Network) guidelines for testing, which include:

1) women who have a direct relative positive for a BRCA mutation

2) women who have breast cancer at an age less than 50

3) women who develop triple negative breast cancer at an age less than 60 (i.e. negative progesterone receptor, negative estrogen receptor, HER2 receptor negative)

4) women who have had two different breast cancers

5) women who have a first degree (ie mother / sister) who had ovarian cancer _or_ who have a second degree relative (ie grandmother / aunt ) with ovarian cancer.

6) women who have two first degree relatives with breast cancer at any age

7) women who have one relative who had breast cancer at an age less than 50

Women with family histories of pancreatic cancer may also qualify, as this disease is also associated with BRCA mutation in some cases.

For women that meet these guidelines, testing should be largely covered by insurance, and in most cases are paid entirely by insurance.  One strategy for appopriate testing is to routinely refer to genetic counseling, which if easily available will lead to the patient getting excellent information and counseling prior to having a test run, if appropriate.  This strategy works great where there is readily available appointments, and with patients that are likely to follow a doctor’s recommendation to go to such a visit.  There is, however, a subset of patients that will for whatever not reason not follow a recommendation to go to a genetic counselor.  I think in many cases the concern for a heritable cancer is something that doesn’t directly influence a patient’s life, and they put addressing in on the back burner.  As such, direct testing may lead to a greater likelihood of actually testing appropriate women, and is reasonable to consider in some practices.   In the end, I think the most important thing is that physicians keeps the issue in front-of-mind, and appropriately manage patients with a strategy that makes sense for each individual patient.

In the last few years, I have begun to test far more women than I used to.   While I have only found a single woman who actually had a BRCA mutation, I have consistently found that women who are tested and are found to be negative really appreciate having had the opportunity to be tested, and feel great reassurance that they do not have the mutation, which is of value in itself.

So if you are a physician and are not considering testing appropriate patients for BRCA, make it a more prominent part of your practice, whether that be through direct testing or routine referral to genetic counseling.   If you are a woman who has a concern about your family history of breast or ovarian cancer, please ask your doctor if its appropriate for you to be tested, either directly or through referral to a genetic counselor.  Because while screening the general population for the actual cancer is important, finding the women who are at the highest risk is also an important part of care.

Dr. Fogelson practices gynecologic surgery and general gynecology at Pearl Women’s Center in Portland, OR.   He can be reached at (503) 771-1183, or http://www.pearlwomenscenter.com./

 

 

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Addenda (9/22/2016)

Not surprisingly, this post has gotten a lot of interest, mostly negatively from the genetic counseling world.   The gist is that that genetic counselors think it a terrible idea for a non-genetic counselor to order these types of tests without referring to them first, which I did suggest in the original text.

In many ways, I agree with them.   They have years of training and a deeper understanding of each potential mutation than most physicians have (absent physicians with genetics fellowships).  They also have more time to talk to patients about these issues, and thus can be more thorough in their counseling.  As such, the optimal course for patients who are considering BRCA testing, or any other genetic counseling, is to see a genetic counselor first.  Some insurers (Aetna I’m looking at you) even require it.

We must also recognize, though, that these genetic counselors see the world through a different lens than a physician that refers to them.   They see patients that come to see them and do a great job with them.  What they don’t see are the women who had discussions with their doctors about seeing genetic counselors, but that never actually came to see them.

In most cases, a concern for a heritable cancer syndrome develops because of a routine history with a thoughtful physician.   It is only the minority where a patient actually comes in with the expressed concern about a heritable cancer syndrome.   So in most cases, it is the physician who is bringing up the issue and saying “hey we should consider this issue”.  Now this consideration can be referral to a genetic counselor, or it may be considering if direct testing is appropriate.   What I know from experience, is that if I pass it off to a genetic counselor, a substantial number of patients are going to take my advice to go se them and not act on it.  After all, a genetic predisposition isn’t a sickness that a patient can feel.  If somebody has chest pain and I refer them to a cardiologist, they are going to go. But if they have a completely unseen and unfelt predisposition to some future disease, maybe they won’t.  In fact, definitely some won’t.    So the hard line everybody has to see a genetic counselor prior to testing is missing this point, in my opinion.  I think that it is entirely reasonable to ask a patient if they would like to see (or even recommend that they see) a genetic counselor, and also entirely reasonable that some patients may be tested directly.  After all, individualized care is what we do.

In the end, I think this question is a bit of a distraction, and not really the point of my article anyway.  What is important is that physicians think about this issue more.  Many physicians don’t think about it much at all, and may neither refer to a genetic counselor nor order appropriate testing.  And that is something worth trying to change.

In light of this issue, I have edited the original article a bit, as I do think it was a little too much against sending to genetic counseling, which was perhaps misguided.

Surgical Video -Ovarian Suspension for Endometriosis Resection

Dr Nicholas Fogelson of Pearl Women’s Center in Portland, OR demonstrates a technique for temporary ovarian suspension. This technique is useful for lifting the ovaries off the pelvic sidewall, exposing the area for treatment of endometriosis or other pathology.

 

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