Amy Rosenman, MD

Obesity: to treat, or not to treat: that is the question? Recently I read a column in the 

 in which some ob/gyns in South Florida reported that they turned away obese patients-15 practices of the 105 polled stated that they had established a weight “cut-off” starting at 200 pounds. In the interest of transparency I must admit that I would have problems finding a doctor under these circumstances as I am 5′ 10.5″ and over these physicians’ set weight limit. As a woman of size I happen to attract possibly more than my share of large patients, for which I have no regrets.

Some of the physicians interviewed in the article said the main reason for the established cut-off was that obese patients are high risk and have more complications. Isn’t this also true in patients with multiple births, diabetes, or seizures as well as those who are underweight, very young, or very old? Obstetric and gynecologic care is not elective or cosmetic. Therefore, it is up to those of us who are educated and trained to care for all women, of any size or any shape, with any disability or any comorbidity. I am surprised that it isn’t illegal to discriminate on the basis of size.

Another doctor quoted in the article stated that he did not want to have to get a consult if the patient developed a complication. Why not? I request consults whenever I am in a situation that requires expertise I do not possess. This is what doctors do. We take care of women until we find we are not capable of solving a problem, and then we get help. If we can care for a patient with brittle diabetes, an unusual infection, or a bowel obstruction (I could go on and on . . .), why not care for a patient who is overweight? Denying access to a class of women (ie, large women) is discriminatory, insulting, and bad medicine.

There are many ways to easily accommodate larger women. In my office I have a variety of specula-some are extra long and narrow, some are extra long and wide-and I can see what I need to without any problem. I also have a couple of electrical tables and some mechanical tables, all of which can accommodate most women. If someone is not ambulatory or is more than 400 pounds, making accommodations in an office setting may be more difficult, but seeing women up to 350 pounds is manageable in my office. We have extra long instruments for cervical biopsies and other office procedures. Sometimes I will have the patient lift her knees to her chest to give better access to the perineum. Our reception area has a very sturdy sofa without arms along three walls and several armchairs that are strong and can accommodate most sizes. They were purchased with this in mind.

No patient should ever be sent away from a medical office due to her size. I find that the open attitude in my practice about this has encouraged many women to take better care of themselves, to start exercise programs to improve their fitness, and to consider healthier eating patterns. They are certainly relieved that we are neither preachy nor judgmental. They follow up better and are very loyal patients.

Doctors are here to treat all patients, not to cherry pick the “easy ones.” Let’s get back to why we took that oath and chose medicine as a profession: to care for those who need us.

Articles

Obesity: to treat, or not to treat: that is the question? Recently I read a column in the Florida Sun Sentinel in which some ob/gyns in South Florida reported that they turned away obese patients-15 practices of the 105 polled stated that they had established a weight “cut-off” starting at 200 pounds. In the interest of transparency I must admit that I would have problems finding a doctor under these circumstances as I am 5′ 10.5″ and over these physicians’ set weight limit.

Obesity: To Treat, or Not to Treat?

  “I’m Barbara Nesbitt, I’m the editor of OBGYN.net and I’m at AUGS in  Florida.  It’s beautiful here.  That’s the American Urogynecological  Society and I have the pleasure and privilege of sitting with Dr. Amy  Rosenman, who is a partner with someone we have all known for years, Dr.  William Parker.  We are going to discuss their new book, The  Incontinence Solution.  We are going to have the book on the  urogynecology and the women’s page and you will be able to read chapters  from it and purchase it just like you can with Dr Parker’s first book, A  Gynecologist’s Second Opinion.  Welcome, Dr Rosenman, it’s a pleasure  to have you here and a pleasure to have you also be a member of the  UroGynecological Editorial Advisory Board on OBGYN.net.”
 
 

  “Thank you very much.  The pleasure is all mine.”
 
 

 “Thank you.  Tell  me what brought about writing this book and, also, perhaps first off you  can fill in the audience on how you and Dr Parker got together on all  of this many, many years ago.”
 
 

  “Bill Parker and I  have been colleagues and partners in medical practice for the last 23  years.  We met when we were mere children.
 
 I developed an interest in urogynecology over the last 15 years as he  was developing his interest in laparoscopic surgery and some five, six  years into that process, we realized we should merge our interests and  focus on laparoscopic approaches to urogynecologic problems.  In that  realm, we were teaching a fellowship at Harbour UCLA and he became a lot  more active in urogynecology and decided that he should write a book  because he had already successfully written A Gynecologist’s Second  Opinion and that we should collaborate on it.  As I have mentioned to  others, it’s harder than birthing a baby, but we did collaborate and  write this book with the goal of educating patients.  It is a resource  for patients where, in the privacy and comfort of their own home, they  can learn a lot about the conditions of incontinence and prolapse,  conditions that have been embarrassing in the past, conditions that  really do not have a lot written about them in the lay literature.   There was a need and we tried to meet that need.”
 
 

 “Well, I like the  part here that says, “answers for women of all ages,” because I think we  often think of women later in life having problems with incontinence or  a prolapsed bladder and we think that’s just part of aging.  But it is  not true.  It is not part of aging.  It is part of something that  happens to them at certain ages.  But young women have problems, too.”
 
 

  “The interesting  part is, although it is more common as we age, it is not a normal part  of aging.  The vast majority of older women do not have incontinence and  prolapse.  But as we age, we have a greater likelihood of having those  problems.  But you are absolutely right:  the problems go way back to  the beginning of our reproductive years.  They are related to birth  injury and we do address that in this book.  There are other problems of  younger women related to sexual function, issues they are not likely to  feel comfortable bringing up unless they understand that there is a  relationship and that there are solutions.”
 
 

 “We talked before  we came on camera about the fact that this is probably the one area of  women’s health that women are the most shy about bringing up with their  physicians.  They will talk about all or many things but, for some  reason, they just don’t want to talk about the fact that they have a  problem, say, leaking urine, and you can’t get it out of them unless  they bring it up.”
 
 

  “Actually, you  can get it out of them easily if you ask.  But, as a group of  physicians, we have not done our best to make patients comfortable to  give us this information.  They need to understand in the way the  question is asked that it’s a common problem but, more importantly, that  there are solutions.  Nobody wants to tell you about an intimate,  difficult problem for which you are going to say, sorry, you’re going to  have to live with it.  A lot of women make that assumption because  their doctors have not asked about it.  I guess there’s nothing you can  do about it so I have to live with it.  We are trying to bring it out of  the darkness and say if you ask and if you ask enough people, if that  first doctor does not know about it or does not give you a solution,  there are solutions.  Pursue it.”
 
 

 “Because we did do  an interview about the fact that women should go to someone like you,  who is a specialist in this particular area.  You do not want to  necessarily go to someone who just delivers babies all the time.  So now  we have a woman in a gynecological urologist’s office.  What are the  options she has?  She’s been diagnosed, she has a problem with  incontinence or prolapse.  What are some of the options she might hear  from you?”
 
 

  “Basically, the  options depend very much on the specifics of the problem.  We pride  ourselves on being able to specifically identify what kind of  incontinence, what is the cause and there are certain evaluation  processes that we go through.  It has to do with a discussion of the  history, we go through a specific physical examination.  Sometimes it  requires more advanced studies where we do pressure-flow computerized  studies, which are painless, by the way.  Patients worry about advanced  studies, but they are completely painless.  My mother had them done at  one point and her response was, I’d rather be at the beach, but it  didn’t hurt at all.”
 
 

  “They sound scary  and painful and these are not painful at all.  We have an office  procedure where we can actually look in the bladder with a flexible  telescope that does not hurt at all and we use local numbing medicines  that are not injectable, they are just local gels.  We are able to  painlessly evaluate the patient completely in the office and, if it  turns out their condition is amenable to what we call conservative  treatment, that is, non-surgical treatment, we have a complete menu of  services available for that.  It may be something as simple as fluid  control.  We have a nurse practitioner who will go over how much you  drink.  Obviously, if you drink an excessive amount, it’s got to come  out.  Maybe we need to manage the timing and the quantity.  Sometimes it  has to do with bladder retraining.  We will train the bladder to hold  more than a thimbleful, more like a cup or two, and this can be done.   We learned it when we two years old, we can learn it again when we’re 50  years old.  Not that I’m 50 years old, by the way.”
 
 

  “We have  bio-feedback services where we can retrain pelvic floor muscles.  We  also use electrical stimulation which, again, doesn’t hurt, it’s like a  tension where you feel a little tingle in the pelvic floor and it  doesn’t hurt, it just allows the pelvic muscles to contract in women who  perhaps on their own cannot figure out which muscles we are talking  about.  There are other treatments out there, things like an  electromagnetic chair, where you can just sit fully-clothed, very much  like a chair in this hotel room, and there is an electromagnetic device  underneath it that will make those muscles contract.”
 
 

  “It’s funny but  if you can do the kegels independently, we will encourage use at home  and kegels are extremely effective.  Looking at all women with  incontinence, of all types, if you do kegels religiously for six months,  70% will be dry, leaving us only with that 30% who perhaps need more.”
 
 

 “These are all  non-invasive, non-painful, with only a little training, pretty much a  do-it-yourself type of thing that you can do.”
 
 

  “They are  one-on-one and will greatly improve the outcome if you work one-on-one  with a nurse practitioner, a nurse, possibly a physical therapist.  But,  yes, they do not involve anything surgical and they are covered by most  reimbursements.”
 
 

 “The next phase is probably not as invasive as complete surgery, but is there another phase in there?”
 
 

  “There are  minimally invasive approaches now to certain forms of incontinence and  the next step up would be something like an injection, a collagen  injection or a Durasphere injection.  These injections are done through a cystoscope.  As I mentioned, we do cystoscopy in the office.  These  injections could be done in some doctors’ offices.  We happen to use a surgi-centre because it’s a special scope, not because it’s painful.   It’s done again with the local gel and little bit of sedation.  Patients  go home the same day.  Our oldest patient was 97 years old and she did  phenomenally.  It changed her life.  It allowed her to go out and do  things again.  Patients of all health can do that.  You do not need to  be an able-bodied, well person to have collagen injections.”
 
 

 “When it is more  advanced than that, we are here at this conference where they have all  kinds of procedures that are surgical procedures mostly.  What is that  level?”
 
 

  “The next level  would be minimally invasive surgery where cuts in the realm of half an  inch or less are made.  One in the vagina and two just above the pelvic  bone, they are each about a quarter of an inch.  Through these small  openings, needles pass a small piece of nylon-like tape and these  procedures come, as you mentioned, in many varieties.  There is a  tension-free vaginal tape and there is a spark procedure.  About five  different companies make a variation, but they all come down to the same  thing:  a gentle sling of nylon-like material under the urethra that is  held in place by tissue friction, very gently, it does not elevate.   Then, when the patient stands up, it’s a backboard so that when they  cough or sneeze and those muscles in the abdomen contract, it just gives  a little gentle tension to that tape that is in place so that during  those kinds of activities you do not leak.”
 
 

 “If I was to have  this, what would I expect as the time in hospital and how long before I  am back to living my normal life?  How painful?”
 
 

 “I am really glad  you asked.  Painful during - this does require an anesthetic.  It has  been described with a local anesthetic, but I think it requires like an  epidermal or a short general anesthetic.  But this is an out-patient  procedure.  Patients will go home the same day.  They will have  soreness, maybe a little bruising, in the area around the pelvic bone.”
 
 

 “But there are some nice mild painkillers.”
 
 

  “They are taking  oral pain medicine, they are comfortable, they are eating normally but,  most importantly, they are urinating almost normally, maybe a little  slower than before, but they are emptying their bladders, which is a big  change from previous surgeries.  I am saying the patients do not need  to use a catheter - this is one of their biggest worries.  Am I going  home with a catheter?  No, you are not going home with a catheter.  Will  I have to insert my own catheter (self-catheterization)?  No, not with  this procedure.  Less than 5% or 10% of the patients have anything to do  with a catheter.  So that makes it very, very nice for the patient.   How long should they be off?  We advise our patients to take one to two  weeks off from work, but that may be an over-estimate because most go  back in a week.”
 
 

 “If you are in an office position or you are doing something that is not labor-intensive?”
 
 

  “We are very  specific about the limitations.  After this kind of surgery, you cannot  lift anything more than ten pounds for two months because that could  dislodge or move the sling a little bit.  Horseback riding you could  probably resume in two weeks.  Tennis, two weeks.”
 
 

 “This is a wonderful recuperative time.”
 
 

  “Patients love  this because it resolves the problem, it solves their issues without  pain and suffering and without laying them up for any amount of time.”
 
 

 “What is a rough estimate or guess be at the success rate on this?”
 
 

  “We don’t even need a rough estimate.  It’s been well-studied.  It’s in the realm of 90% success.”
 
 

  “You can’t beat  that.  It’s as good as any previous procedure ever described and better  than most, so we are really happy about that, too.  Now it’s been around  in this country since 1997 and in Europe for ten years prior so there  is enough long-term experience to feel very safe and very comfortable  with it.”
 
 

 “What we are  telling these ladies today is find the right doctor.  Go to your doctor  who, obviously if your primary care doctor is your ObGyn, talk to him, tell him you would like a referral to a  urogynecologist and they are so busy, they are happy to have you go, I  would think.”
 
 

  “Yes, and because  they cannot all provide the menu of services that are necessary.  You  do not want to get what your doctor knows, you want to get what is right  for you.  You want to get someone who is truly versed in all of the  possibilities.”
 
 

 “So you are going  to go to someone just like Dr. Amy Rosenman and she is going to take  care of your urinary problem and then you are going to go back to your  doctor you’ve gone to for many years of your life and . . .”
 
 

  “We work in  conjunction with a lot of our local physicians.  Some of them just want  to send patients for conservative treatment.  Some of them do some of  the operations, that’s fine.  We are happy to fill that gap.”
 
 

 “But if you feel you have a problem, investigate all of the areas.”
 
 

  “Investigate it,  get another opinion, the last book, A Gynecologist’s Second Opinion.  We  are really interested in patients being well-educated and we were  talking before about how the patient makes a decision.  It’s a  collaboration.  You educate yourself, you make sure your physician can  give you all the options you need and help you make the best decision  for yourself.”
 
 

 “I am in a unique  place because I have a son-in-law who is a surgeon in the town I live in  and I do nothing but associate with physicians like yourself.  I am in a  unique place because I could call you and you would help me.  But  everyone has the right to ask for and receive.”
 
 

  “Yes, and we were  hoping with this book, The Incontinence Solution, to give women the  fodder to have the discussion with their physicians.  They will go in as  educated patients, educated consumers, and be able to say, who can help  me with this, who can help me with that?  They have the information  right in front of them.”
 
 

 “Well, I thank you  very much, Dr. Rosenman, and we’ll have the book and access to chapters  and we will also have a link to your website with Dr. Parker and a way  that you can buy the book from Amazon right off of our website.”
 
 

OBGYN.net Conference CoverageFrom the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003

The Incontinence Solution

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Amy Rosenman, MD

Articles

Obesity: To Treat, or Not to Treat?

The Incontinence Solution

The Incontinence Solution Video