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.
This video demonstrates and discussed technique for performance of a supracervical hysterectomy in a massive fibroid uterus, 2 kilograms in size. This procedure was performed in the Pearl Surgicenter in Portland, OR by Drs. Nicholas Fogelson and Richard Rosenfield.
Please call us at 503-771-1883 for clinical consultation for any gynecologic concern, including complex laparoscopy as well as complex endometriosis management.
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
A few months ago we hit the seven year anniversary of Academic OB/GYN. And today, I found out that we have been nominated in the AAGL Oscars for “Most Innovated Social Media Platform”. This nomination was a pleasant surprise – I completely agree that we should compete for that title, but in truth it always a bit of a shock to find out that people in my field actually have seen what I have been doing here and appreciate it. Most people are afraid of social media, and seven years ago when I started this most people in medicine thought far more of the risks than any kind of benefits. Since that time, things have changed, and many doctors have created robust social media presence. Since I started, the big players have come on the bandwagon. Now we have podcasts from all the major journals, and several website podcasts as well such as medscape and so forth. But I am proud to have been one of the first ,and almost certainly the first to have significant presence in the field of OB/GYN. With that, I thought it would be fun to recall how it started, and how the journey has been for me, and for the brand of Academic OB/GYN.
I started Academic OB/GYN the summer of 2007 at the University of Hawai’i. The impetus to do so actually came from my fandom of a podcast called Diggnation, hosted by Kevin Rose and Alex Albrecht. This was a podcast done by two nerds talking about nerd topics for an hour or so, and also doing a fair bit of drinking. It came to me – wouldn’t it be great to do Diggnation for OB/GYNs? So the next week I lined up some guests, fired up Garage Band, and published the first episode of the podcast. It absolutely took off, and in its heyday we were getting over 500 downloads in the first 48 hours of a new podcast being published, and in some cases topping 5,000 downloads in the first month. In the early years the audio quality was atrocious. Some of the episodes were almost not worth listening to it was so bad. But people liked the content, and they seemed to listen anyway. The audio got better, though never really to a professional level. But the content kept coming, and listeners kept growing. I got lots of mail of appreciation and comments. In 2010 at the University of South Carolina I added Dr Paul Browne as a co-host, and it made the podcast even better. Listenership grew even further. This year we total over 102,000 downloads, over 50% of which listened to the entire podcast. Our most popular episode was an early one with Dr Roger Newman, with over 8,000 downloads, still rising today. Amazingly, new fans still download our old content, and while we haven’t published an episode in three years we still get 20-30 new downloads a day. While total numbers are very little compared to downloads of wider appeal products, for a product that really only appeals to a very narrow slice of the world, the popularity has been staggering.
“You should carry a gun Nick”, my friend told me as I started work in his abortion clinic. “We all do, and you never know when you might need it.”
It was sort of shocking advice to get so early in my medical career, that I should be arming myself in case some cuckoo bird activist chose to try to assassinate me for my choice to help women realize their reproductive freedom. I didn’t take that advice, as I didn’t grow up with firearms. Overall, they scare me, and I don’t like handling them. Perhaps this is why I was a little freaked out every time I got in the car with my friend and he unholstered his Glock and unceremoniously dropped it into the side door pocket of his truck. I worked in abortion clinics for years and never chose to carry, though. It would have been easy to get a carry license, given that I was a potential target of legitimate violence (as if that is required). But in the end it seemed really unlikely that a gun could be useful to me, even if somebody tried to kill me. And I could think of a tremendous number of ways it could be to my disadvantage to have it. So I didn’t carry.
But my friend thought differently. He imagined some kind of situation where a bad guy might come up on him and he would be John Wayne, outdrawing the perp and somehow taking him down. It always seemed a little ridiculous that this could possibly happen. The problem would be that you would have no idea who that dangerous person might be. By the time you realized who the bad guy is, you would be dead or injured at least. I can sort of imagine a firearm being useful in some kind of mass shooting situation, but for an abortion provider it wouldn’t be a mass shooting – it would be a directed assassination attempt. And that would be an entirely different situation. But my friend still thought it made sense to carry, and he did.
And wouldn’t you know it, one day he actually had a reason to use that gun, and he did. And this is what happened.