Andrew Brill, MD

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Coverage of the 37th Annual Global Congress on Minimally Invasive Gynecology

What women should ask when going into surgery

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     reporting from the International Congress of Gynecologic Endoscopy. We're     talking to Dr. Andrew Brill, Professor of Obstetrics and Gynecology and     Director of Gynecologic Endoscopy at the University of Illinois, in Chicago,     and Dr. Paul Indman, on the Clinical Faculty at Sanford University, and also     in private practice in Los Gatos, California. Thank you for being here with     us gentlemen. What are we going to talk about today?"
     
     

 "I think we     both would like to talk about the options available to women who have been     advised they need a hysterectomy for abnormal uterine bleeding."
     
     

 "I think     that's especially important considering at this meeting of the AAGL there     are many new options being presented. I think it's important for women to     understand that some of these methods may be great advances and some may     not. Some have been thoroughly tested, some of the methods aren't tested. I     guess the question that I would throw out is - "How does a woman     evaluate what is real and what is frankly hype?"
     
     

 "A good     question, because we certainly hear a lot when we turn on our television     sets, and we watch Oprah Winfrey. We find out that there's all kind of     things out there, and we should be checking them out or there's terrible     horror stories of people who tried things. What do you think, Dr. Brill -     how do you evaluate this?"
     
     

 "Where as     the availability of information is at it's all time greatest today because     of the media and because of the availability of the World Wide Web, of     course, the great danger in accessing information is being unable to     differentiate between quality and just reports. I don't think the consumer     really is prepared to do that. So ultimately the only way to get at the     heart of reality when it comes to any of these methods is to face-to-face     ask your physician - what is the evidence, was this a studied procedure, is     this not experimental, has it been approved for use, and is there any     literature either dispensed by the company or dispensed in the general     medical literature that's available for them to review so they for     themselves can see is this is a method that is truly evidence based?"
     
     

 "What would     you like to add to that, Dr. Indman?"
     
     

 "I think     it's also important not to forget the basics because most women who have     abnormal bleeding can be handled with simple methods often that don't     require surgery or any fancy techniques at all. And the first question is     why is someone bleeding? This can be evaluated by determining whether or not     she's ovulating - there's simple methods to determine that. Is there a     problem with the uterus? An ultrasound which is looking in the uterus with a     hysteroscope is a basic simple procedure. We want to know is there something     that requires surgical treatment? In addition, when we're talking about     women that come to see me with abnormal bleeding - many of them are managed     with birth control pills or simple anti-inflammatory type medicines and     don't need any surgery at all. So it's only the minority of women that need     surgery, let alone these new procedures."
     
     

 "I would     completely agree with Paul. Anyone who considers a surgical option for     abnormal bleeding should have either failed an adequate trial of medicines     or should for some health reason be unable to tolerate them because this     method can be effective in the majority of women who otherwise don't have     any significant abnormalities of their uterus."
     
     

 "So are     there red flags a woman should be aware of when they go to a physician if     the solution goes right to hysterectomy or right to some type of a surgical     option? Should that alert them to, maybe, get a second opinion?"
     
     

 "Definitely     they need to know what's going on, and I know there are fortunately unusual     but extreme examples of people making an appointment and they're offered a     procedure before they're ever seen. Believe it or not - this does happen.     Certainly anyone who offers a solution without finding out the problem is     somewhat suspect. Let's take this one step further now, let's say someone     has been evaluated and has tried medical management, and it just doesn't     work - it fails. Then the question is - is a hysterectomy reasonable or     should there be alternatives? There are lots of myths about hysterectomy,     and certainly hysterectomy can have side effects, it's major surgery. On the     other hand, many women do well, and I think it's important not to dismiss     hysterectomy as being an evil thing that in itself is politically incorrect.     I think if there's simple alternatives that are less invasive I certainly     would much rather have a less invasive alternative, mostly because it's less     invasive. Andy, why don't you talk about some of the newer things that we've     seen here, the different endometrial ablation techniques?"
     
     

 "I would     like to preface it by saying that it's very important that one is able to     differentiate which symptoms can be helped by what particular techniques.     And when it comes to abnormal bleeding unto itself, surely non-hysterectomy     alternatives should be explored and can be very effective once medicine has     been failed. If a woman, however, suffers from discomfort with sex, pressure     on her bladder, significant pain, let's say from an abnormally large uterus     because she has fibroid tumors, or other abnormalities - then one has to be     a little more suspicious about alternate therapies being helpful for those     particular symptoms. So up front it's very important for a woman to decide     what is it that she wishes to accomplish with whatever therapy she chooses.     That is why hysterectomy does have its role, and we do have to state     emphatically that hysterectomy is the final solution. It is the only     solution that is not temporary, and in no way, I think that Paul and I     advocate this as a solution but a woman must keep this in mind that it is     the final solution to the difficulty."
     
     

 "I think     it's the only solution that has a guarantee. I think there are alternatives     that many times are final. Let's look at one alternative - endometrial     ablation, that's destroying or removing the lining of the uterus. I did the     first endometrial ablation in northern California, and that was in 1985.     Many women had gone into menopause, and that was the final solution, and     they never had any further bleeding problems. However, it doesn't come with     a guarantee, it's a patch. It's a patch that may hold or it may not hold and     there are advantages and disadvantages. Recently there have been some new     endometrial ablation devices that simplify the technique of doing that.     There are two balloons, one is approved by the Food and Drug Administration,     another has tentative approval and will be available shortly."
     
     

 "What are     the names of those?"
     
     

 "The     balloon that's approved now is the Gynecare ThermaChoice. The VestaBlate     System should be released within several months."
     
     

 "Are there     significant differences even at that level of granularity with balloon     technology?"
     
     

 "The     technology or the methodology is different if you were to say how do the     balloons actually destroy the lining of the uterus, which we call "endometrium."     In the hot water balloon you actually have warmth which is transferred to     the surface of the uterus, and secondarily it heats up. And in a particular     case of VestaBlate with the electrical balloon, here you'd have electricity     flowing through the surface of the uterus, which unto itself secondarily     will heat it. So the mechanism is different but the end effect is the     same."
     
     

 "It's the     same for the patient. So it's more of a choice, is it Dr. Indman, for the     physician of how they feel more comfortable operating or what do you     think?"
     
     

 "The two     balloons have more similarities than differences. The most important thing     is that any of the balloon ablation devices as opposed to - I'm going to     back up. Normally when we do an ablation we will look inside the uterus and     apply energy either with a laser or more recently - electricity to remove,     and under direct vision we are seeing what we are doing. This is a way of     applying energy to the inside of the uterus, and so we can't see what we are     doing. About one-third of women that I see would be good candidates for this     because the other two-thirds have fibroid tumors, polyps, or other growths     that need to be removed anyway."
     
     

 "Now there     are two studies each comparing the balloon to conventional hysteroscopic     surgery. The failures rates - and these are well done studies - are the     same. However, the number of women that had no bleeding at all was double in     the Vesta group as opposed to the ThermaChoice group. Is that an important     difference - probably not. Now we have to realize that endometrial ablation     is a procedure to treat heavy bleeding. A successful ablation means a woman     no longer has heavy bleeding so if someone's in the bathroom for two days     every hour soaking through, wearing diapers, and now has normal periods - we     consider that a successful ablation. If someone says - "I don't want a     spot of blood" - then don't even consider an ablation."
     
     

 "I would     like to add something to what Paul had to say, and it's in context of what     balloon ablation technology brings really to the table of alternatives to     hysterectomy for abnormal uterine bleeding. Despite the fact that     hysteroscopy which is a telescopic sort of gold standard method of heating     the endometrium or endometrial ablation has been around for a number of     years. And you've heard that Dr. Indman was one of the first innovators with     this technique many years ago - it has not, and I can emphatically say - not     taken off in this country. Now it's beyond the conversation here for us to     conjecture all the reasons why it hasn't taken off but they surely are     complex, and there are a number of them. What's important is that since the     technology hasn't taken off that it has not been made available as an     alternative to most women in this country who have abnormal uterine     bleeding. So the balloon technology itself because it's much less skill     intensive and much easier to use now, opens up the ability to have an     endometrial ablation in an office or practice that historically may not have     offered that option because the physician for one reason or another was not     comfortable with the hysteroscopic alternative."
     
     

 "And that's     an advantage and a disadvantage. I have some real concerns because the     technique is so simple to do that anyone can do it. It's essential to be     sure that any woman considering it is an appropriate candidate, if there's     anything precancerous, it absolutely should not be done. So you need a     physician who is comfortable in ruling out anything precancerous. One of the     greatest predictors of failure of an endometrial ablation is something     called "adenomyosis." Adeno means glands, when the glands of the     lining of the uterus invade the muscles it's called "adenomyosis."     So you have trapped glands in the muscle, they make blood, that blood is     trapped. That causes extreme pain, and when endometrial ablations fail     that's generally why. So it's very important to be as sure as you can that     there's not a lot of adenomyosis before doing an ablation because it simply     isn't going to work. A woman's going to wind up with a hysterectomy very     shortly thereafter so although technically these balloon procedures are     simple to do, the evaluation requires great skill, and it should be done     before a woman considers any treatment for abnormal bleeding."
     
     

 "I would     reiterate that someone who is skilled in the routine gynecologic care of     women is comfortable with surgical techniques should be the one who performs     endometrial ablations regardless of what kind of technology is used."
     
     

 "I'm going     down to my doctor in Austin, Texas - we'll use this as an example - and I'll     be having this problem. What should I expect - does anyone want to address     this? Since we're trying to help women evaluate this technology, what should     she expect to happen that will tell her things are going well, and what     should be the indications that things aren't going well, as far as if     someone that isn't qualified or some of the things you've said? How do I     transfer that as a woman, to my own care?"
     
     

 "It's very     difficult for a patient to evaluate a physician, I think there's certain     minimums. I think an evaluation of abnormal bleeding is the first step that     I use is - which is a vaginal ultrasound. I feel strongly that the physician     doing the initial evaluation should be doing the scan, if not - I would     wonder why. I think you want to make sure your physician is very familiar     with hysteroscopy. Until very recently, I would say that hysteroscopy should     be done in an office setting always because it's very simple to do and     inexpensive - it should not be uncomfortable. Very recently some insurance     companies have not been reimbursing physicians for their supplies, saying,     "Doc, you pay for all your supplies or not." As a result, we may     have to bring simple office procedures into the hospital setting even though     it will cost them thousands of dollars more, that's their choice. At any     rate, I think you want a physician who's familiar in hysteroscopy and has     done a lot of it. I think your physician should be able to discuss the     advantages and disadvantages of all of the methods of treatment available.     Hopefully, your physician has had some experience with them, even though the     balloon is new enough to where it is unlikely anyone will have had much     experience, and that they're familiar with other techniques of evaluating     bleeding like hysteroscopy. The balloon is the simple method but there     should also be other methods available in case that's not appropriate."
     
     

 "Do you     agree with this, Dr. Brill?"
     
     

 "I do, and I     think it's possible through local inquiry and contacting women's groups in     empowering ones self with the media and the web to find out locally what     persons have experience treating patients with alternative therapies for     abnormal uterine bleeding."
     
     

 "Also, I     imagine that a woman should be aware if she's being told as you said,     earlier in the interview - one choice, right up front, very early without     any of these diagnostic tools - that's the number one reason you should then     get a second opinion, is it?"
     
     

 "I would     rather put it this way, I think every woman should seek a physician who is     going to include them in the process of decision. In order to be included in     the process of decision one has to be presented with the options, the     benefits, and the risks of each option. That person should be allowed to     consider these in the context of their own life and their own desires, and     come to her own decision as to what she wishes. This is the kind of process     I think a patient should pursue in a physician's office."
     
     

 "That's very     good information. I think with the empowerment of that information a woman     could go in, evaluate the situation, evaluate her relationship with the     physician, and decide if she's moving in the right direction. I really     appreciate you both taking the time to share that with the women on 

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsAtlanta, Georgia, November, 1998

Author | Andrew Brill, MD

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