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.
I recently was looking into whether or not you should place a paracervical block before placing an intrauterine device, after a particular patient had a difficult time with a placement. Over my career, I generally haven’t done so, as the vast majority of patients don’t seem to have a significant amount of pain, and the literature I have read has not been very supportive of the practice.
Today I looked at the literature again, and was a little irritated at what I found. One particular study was Mody et al, which concluded “Compared with no anesthetic, a 1% lidocaine paracervical block did not result in a statistically significant decrease in perceived pain with IUD insertion.”
So clearly most would read this and say that it doesn’t matter if you put in a paracervical block or not.
But’s here’s the kicker; the summary of their data is the following: ” Twenty-six women received the paracervical block before IUD insertion, and 24 received no local anesthesia. Groups were similar in age, parity, ethnicity, education and complications. Women who received the paracervical block reported a median VAS score of 24.0 mm with IUD insertion, and women who did not receive local anesthetic reported a median VAS score of 62.0 mm with IUD insertion; p=.09.”
So patients who got a block had pain of 2 on a scale of 2 to 10, and patinets who did not have a block had pain of 6 on the same scale. So did the paracervical block really not work?
I would say it did. What didn’t work was the study, or at least most likely so. The p value, or likelihood that the outcome was do to statistical chance alone, was 0.09. In translation, there was a 9% chance that the difference between the groups was due to chance alone, and a 91% chance that it was due to an actual effect of the paracervical block. Since we arbitrarily say that a p of 0.05 is statistically significant, the authors say that the study was negative.
But isn’t this quite misleading? It is 10 to 1 likely that the paracervical block actually made the procedure less painful, and we just didn’t reach a p of < 0.05 because there weren’t enough patients in the study to adequately separate the groups mathematically (lack of power).
P values are important, but we can’t consider them to be everything. Statistical significance is a continuous variable, not a nominal one. If we say that p=0.049 means that the study shows a difference and p=0.051 means there was no difference, we are just being foolish, and in the end quite ignorant of the actual mathematics that goes into how the p value was created.
Here’s how I would like to see such a study concluded : “Compared with no anesthetic, a 1% lidocaine paracervical block showed a strong trend towards decreasing pain with IUD insertion, that did not reach statistical significance. Further study with a greater number of patients is warranted.”
If you read their conclusion, you would probably take from that that paracervical blocks don’t work. But if you read mine, you take a different message, which is actually supported by the data, which would be “It is very likely that paracervical blocks decrease pain with IUD insertion”, which of course makes sense
Mody SK; Kiley J; Rademaker A; Gawron L; Stika C; Hammon C. Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block. Contraception. 2012; 86(6): 704-9.
As many of my readers know, I spend a fair amount of time online. I love interacting with other docs that do what I do, and even more so, I love interacting with women that have the conditions that I treat. Even though I have left academics, I am a teacher at heart, and enjoy the opportunity to pass on what I have learned when I can.
One of the biggest questions I see is about how endometriosis care is paid for.
Unlike typical care, many endometriosis physicians are not under contract with insurers for care. This creates a whole different system for payment of medical care that is confusing to many patients – so let me explain it here. Read more…
Recently I read an article by Lena Dunham, describing her life with endometriosis, treatment she has undergone, and how her life has been since. Its a very poignant article about a successful woman who has been held back by her condition, yet also a story of incredible perseverance despite tremendous barriers. Ms Dunham is a successful actress, producer, writer, and director, having created multiple films and the wildly successful (and awesome!) HBO series Girls, both as writer/director/producer and as principal actress. She is also a woman who did these things despite tremendous pain from endometriosis.
This video discusses a case involving partial thickness colonic/rectal endometriosis with severe pain with defecation. The video demonstrates dissection technique for bowel mobilization and resection of the lesion, as well as generalized intraperitoneal and retroperitoneal dissection techniques.
For clinical consultation with Dr Fogelson in Portland, OR, contact Pearl Women’s Center at 503-771-1883
This is a video describing and demonstrating technique for resection of stage I endometriosis, performed and narrated by Dr Nicholas Fogelson of Pearl Women’s Center in Portland, OR. Drs Fogelson and Rosenfield are available for clinical consultation, seeing patients from Portland, the Pacific Northwest, and around world.
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.