Barbara Nesbitt

I write this with my daughter, Hunter, sleeping peacefully on my lap. As I look down on her, I am filled with a sense of awe, and of gratitude, for her journey to us was long. Here is her story......



hen I moved to Tahoe in May of 1994, I was looking to balance my career as an ob-gyn with the pursuit of the good life -- skiing, biking, boating, gourmet meals, travel. I was not thinking about having any children to disrupt my very comfortable lifestyle. In July I met a man with the sweetest smile and the bluest eyes who, on our second date, told me how he'd always dreamed of being a dad and how he hoped at age 39, it wasn't too late. In September, he asked me to marry him and I began to think that maybe a family wasn't such a bad idea after all. 

 Jeff and I were married on a snowy Saturday in January 1995. I added maternity coverage to my health insurance that Monday -- there was a 6 month waiting period for coverage to be effective and we wanted to start our family as soon as possible. I, the successful physician, had always accomplished what I had set out to do, and was sure I'd get pregnant as soon as we tried in September 1995; besides, I was an ob-gyn, so how difficult could it be for me to get pregnant?

 As it turned out, pretty darn difficult. After 6 months of not using contraception, I started doing ovulation predictor kits. Surprise, I wasn't ovulating! I had prescribed fertility drugs such as Clomid and I'd seen my patients turned into raving lunatics by these drugs, so I opted to try alternative approaches initially. I consulted an acupuncturist who stuck me full of needles and prescribed foul tasting herbal concoctions. We also shifted my cycle so I'd ovulate when the moon was in the same phase it was when I was born! Well, my cycles became more regular, but I still wasn't pregnant.

 Being an ob-gyn, I certainly knew how to get someone to ovulate, so I prescribed Clomid for myself (now, that's a real smart move -- taking care of yourself as a patient!). Not only did it not make me a lunatic, it mellowed me out so much that Jeff asked if I could take it all the time! I conceived right away, in August of 1996. We were ecstatic! We were going to be parents! I scheduled an ultrasound in my office for 10/19/96, my husband's birthday -- I thought seeing his child on the screen would be a wonderful present. Unfortunately, what we saw was an embryonic demise -- a fetal pole but no heartbeat. We were sad, but thought we'd do better next time.

 Next time took longer than we thought. I resumed the Clomid in December but didn't conceive until the 4th cycle, in March 1997, after an IUI. It was strange -- obviously I couldn't do the IUI myself (I had my partner do that), but I brought the sperm sample from home, prepped it myself and set the room up so Lauren could do the insemination. 14 days later I had a positive pregnancy test. This time, I knew from the start something wasn't right. I kept telling Jeff not to get too excited. We drew progesterone levels (excellent) and HCG levels. The HCG levels barely rose appropriately, and an ultrasound soon thereafter confirmed what I'd known all along --this was another blighted ovum. 

 At this point I took advantage of being a doctor and began the workup for repeated miscarriages. Jeff and I had chromosome analysis done (both normal) and I had an anti-phospholipid panel done; although the initial screening tests were normal, a more extensive panel revealed a very minor elevation in anticardiolipin, an elevation that should not have been clinically significant. At this point I decide it was crazy to continue treating myself, so I saw a reproductive endocrinologist. He felt that my lab tests were inconclusive, but he said a very wise thing to me when I asked if I should take the aspirin and heparin injections that are the treatment for anti-phospholipid syndrome; he said, "if you do the treatment and you have a miscarriage again, how will you feel?" -- my answer, "devastated, of course." Then he said, "and if you don't do the treatment and you miscarry?" and I answered, "devastated, and guilty, because I didn't do everything possible." 

 I was emotionally a wreck after the second miscarriage. I felt I was a double failure -- as a woman and as an ob-gyn (I mean, I helped women get pregnant and I delivered babies every week and I couldn't even do it myself???). I joined the multiple miscarriage e-mail support group. I told my story on the Women's Health Forum at obgyn.net. The support I got helped me through a very difficult time, as did the understanding that I wasn't alone in my suffering, that many other women out there had been through worse and many had gone on to have a child. Jeff was incredible; he held me when I cried and told me he would be behind me 100% whatever decisions I made about trying again or not. It took me 6 months to get up the courage to resume infertility treatments.

 This time, with the guidance of my RE, we did a combination of Clomid and Pergonal; again my partner did the IUI. No luck. We took a vacation, then came back and started a Pergonal cycle. I was giving myself Pergonal shots in my hips (ever the doctor, I gave myself the shots rather than having my husband do it -- besides he HATES needles!) and heparin injection in my abdomen twice a day; I was black and blue. This time we decided to have the RE do the insemination. For the first time I didn't prep the sperm and for the first time Jeff was actually I the room for the actual insemination. The karma must have been better, for this time worked. As we were driving back to Tahoe, I turned to Jeff and said, "we just conceived".

 I knew, just KNEW with all my being, that we were having a girl. I had thought the two miscarriages I had were boys. I had a brother who died when I was 4 and he was 3, and I had always thought that I should have a boy to take away some of the pain of my parent's loss; I had told Jeff early on in our relationship that if we ever had a son I would name him Timothy after my brother. I know now that you can't force a spirit to come to you, that any son I have will not be my brother and I cannot make up for his loss. I was told there was a little girl spirit hanging around me, and I just had to let go to allow her in (our dear Barbara Nesbitt was one person who told me long before I became pregnant with Hunter that I would have a daughter). Now I knew she was here, and I hoped, here to stay.

 Being an ob-gyn is not always an advantage -- too much knowledge leads to neurosis, and I was definitely neurotic throughout the entire pregnancy. First I worried about miscarriage, then about incompetent cervix, then about preterm labor, then, finally, about stillbirth. I was taking 81mg aspirin a day and injecting heparin twice a day from ovulation through 36 weeks. We did ultrasounds weekly until 12 weeks. I had CVS done at 11 weeks due to my age (38 at delivery), which confirmed what I already knew -- we were having a girl (BTW, Jeff lost a $50 bet on that one!) and, at least from a chromosomal standpoint, she was fine. We did weekly ultrasounds to check my cervix from 18 - 24 weeks (after I checked myself and thought my cervix was shortening -- I told you I made myself nuts!). After that, it was monthly ultrasounds to follow growth, then weekly again from 36 weeks to check amniotic fluid. This child had more pictures taken before birth than the average supermodel has in an entire career!

 I threw up every day for 6 weeks in the first trimester and thanked God every time; to me it was a sign of a healthy pregnancy and I was grateful for every reminder that she was okay. I felt her move for the first time at 19 weeks, and almost wrecked the car calling Jeff to tell him. I got varicose veins, but just got in the habit of putting on support hose every morning. I was constipated from the progesterone I took for the first 12 weeks, and from the pressure of the growing uterus for the next 27. I got up every 2 hours throughout the night to empty my bladder. Despite all that, I never felt better. I rejoiced in all the signs of pregnancy and I glowed. My husband told me every day how beautiful I was. I loved being pregnant. 

 By the middle of November, at 37 weeks, I really began to worry about stillbirth. Jeff did too. A friend of ours, and a patient of mine, had a history eerily similar to mine (same age, husband same age as Jeff, 2 miscarriages, mild anti-phospholipid syndrome), who had a stillbirth 8 days from her due date; I was in the first trimester at the time and was devastated. We were so afraid that same thing would happen to us. I was already doing twice weekly NSTs and weekly amniotic fluid volume checks. Jeff wanted me to deliver the baby -- now. My cervix was only 1cm at 38 weeks, but she was engaged. We decided if I hadn't gone into labor by 12/1, at 39 weeks, I'd be induced. We tried everything to get labor to start -- spicy dinners, taking Jeff's 10 year old beat up pickup with lousy shocks down bumpy roads, cutting down a Christmas tree, driving off the Hill (people in the mountains think the altitude change will start labor), sex, and even cross country skiing -- uphill! 

 I was admitted to the hospital on 12/1/98 at 6:15 AM. I was 1cm (still!) and 60% effaced. Patty, the nurse finishing her shift, placed Cytotec into my vagina to ripen my cervix. Normally, we admit patients in the evening for Cytotec, but I didn't want to keep my partner up by delivering in the middle of the night! After the mandatory bedrest and monitoring after the Cytotec was placed, I got up and played Minesweeper on the nursing station computer! I sent Jeff to work as I was feeling so good and knew it could be a long day and night. The contractions were every 3 minutes, but weren't bad at all. I received an additional dose of Cytotec at 11:00 and was 3 cm. I had had a positive strep culture during the pregnancy, so an i.v. was started shortly thereafter to administer antibiotics. I was still feeling great and even ate a veggie burger for lunch. By 2:00 I was getting uncomfortable and asked Jeff to come back; the contractions were every 1 - 2 minutes but I was still walking the halls and I still thought I could do labor without medication, but I needed my back rubbed. Jan, my labor nurse, checked me and I was 4-5 cm. Lauren came in after office hours, around 6:00, and I was barely 5 cm. She ruptured membranes -- lots of clear fluid --but I could see she was thinking I was making slow progress and might end up with a c-section. As an obstetrician, those same thoughts were in my head as well. 

 After the membranes were ruptured, the contractions really increased in intensity. I had also started retching -- no veggie burger reruns though! It was time for an epidural, the hell with unmedicated childbirth! Here's another example of it not always being an advantage to be an ob-gyn while one is pregnant: throughout my pregnancy, everyone -- from the RE I saw in order to conceive, to my partners, to the perinatologist who monitored growth, to my nurse -- always asked what I wanted to do and the anesthesiologist was no exception. When I asked her whether she wanted me sitting up or laying on my side to get the epidural, she asked me how I was more comfortable; well, the contractions were horrendous when I lay down, so I naturally opted for sitting. Despite the fact that I had gained only 18 pounds the entire pregnancy and my back was very easy to feel, she had a hard time getting the epidural in -- the interspinous spaces were just too tight. She tried for 45 minutes and I looked like a pincushion before she did what she would have done with any other patient from the start -- had me turn on my side. She popped the epidural in in no time flat and I was soon comfortable (and when it came time to take the epidural catheter out later, I had to be on my side -- it wouldn't come out with me sitting). I remember turning to Jan, my labor nurse, while I was trying to get on my side and telling her, "I'm in transition and I'm losing it!!" Jan was wonderful at helping me through that most difficult time (Jeff, quite wisely, had stepped out of the room for the epidural; remember he HATES needles). The epidural was the weirdest feeling -- I kept poking my legs and laughing because I couldn't feel them, although I could wiggle my toes.

 Shortly after the epidural was in place I began to feel pressure, but I didn't say anything because I was enjoying being comfortable. Lauren had left to say goodnight to her 2 kids and we all thought it would be a while longer. The pressure continued to build and I began to feel an urge to push; I asked Jan, who had stayed past her shift, to check me -- I was fully dilated and +1 station! Jan didn't want me to push until Lauren got back to the hospital, and I was still comfortable, so I was happy to oblige. Once I started pushing, it took about 45 minutes. Hunter began to have drops in her heart rate down to the 60s, so on went the oxygen mask. Lauren was about to use the vacuum when her heart rate went up and stayed up. I pushed a while longer, then Lauren asked if I cared whether she cut an episiotomy --the only thing I cared about was having a healthy baby! -- so she did. Two pushes later, at 9:41 PM on 12/1/98, Hunter Katherine Shanahan Turney, all 5 pounds 13 ounces and 19 inches of her, slipped into the world. Daddy Jeff was too excited to cut the cord, all he wanted to do was look at his beautiful daughter (besides, he doesn't like blood and all involved agreed it was pretty darn amazing that he was able to be there for the delivery)

 After a few whiffs of oxygen to perk her up, Hunter was placed on my chest, skin to skin. I put her to the breast and she latched on right away -- good thing one of us knew what she was doing! She was incredibly alert and just looked around. There was wisdom of the ages in her eyes. She was perfect. We were blessed.

 And are blessed. Hunter is almost 6 weeks old now and is the most wonderful, beautiful, smart and talented baby on earth. She has a cry that can shatter windows and a smile to rival the sun. Her skin is like cashmere and her eyes are the color of the sky. She has the hands of a concert pianist and her feet -- well, lets just say she'll be in no danger of tipping over once she starts walking!! She is an angel and the embodiment of all that is right and beautiful and precious in this world. She is our little girl, and we love her more than mere words can express.

Articles

I write this with my daughter, Hunter, sleeping peacefully on my lap. As I look down on her, I am filled with a sense of awe, and of gratitude, for her journey to us was long. Here is her story......

An Obstetrician Becomes a Mommy: The Story of Hunter's Birth



 We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner for age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LA VH was 144 minutes and for TAH 98 minutes, a significant difference (p <0.005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436-mg meperidine during their hospital stay, significantly more than the 197mg used by the LAVH group (p <0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p <0.00 1). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p <0.005). By the sixth postoperative week, the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.

 Dr. Carter is Assistant Clinical Professor, Department of Obstetrics and Gynecology. University of California College of Medicine, Irvine, California. Dr. Ryoo is Chairman of the Department of Obstetrics and Gynecology, and Ms. Katz is a member of the nursing staff of Kaiser Permanente Hospital, Panorama City, California.

 The Endo GIA was used successfully for laparoscopic hysterectomy in a 42-year-old woman for the treatment of pelvic pain and endometriosis in 1990. The first seven women to undergo laparoscopic-assisted vaginal hysterectomy (LAVH) in Italy experienced rapid recuperation, and the authors concluded that the procedure was a reasonable alternative to total abdominal hysterectomy (TAH). 2 We evaluated the two procedures on a case control basis for length of - operation, blood loss as estimated by the surgeon drop in hemoglobin in the 24 hours after surgery, drug use to control postoperative pain, length of hospital stay, and pain and activity levels in the immediate postoperative period to week 6.





 Of the 81 women (32 TAH, 49 LAVH) who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, at the two study sites (Kaiser Foundation Hospital, Panorama City, CA; Mission Hospital Regional Medical Center, Mission Viejo, CA), 38 were selected for inclusion in this study, 19 undergoing each operation. Inclusion criteria were that patients be matched in a case control manner for age, weight, diagnosis, and uterine weight, and that they be candidates for TAH.

 All 19 LAVHs were performed by one surgeon to ensure uniformity and familiarity with the procedure. Abdominal hysterectomies were performed in the standard manner using similar techniques.

 Patients with fibroid uterus in the LAVH group underwent therapy with a gonadotropin-releasing hormone analog (depot leuprolide; TAP Pharmaceuticals. Deerfield, IL), resulting in a 40% to 60% reduction in uterine volume from initiation of therapy to surgery. The LAVH was performed by placing one 10-mm cannula infraumbilically and two 12-mm cannulas in the lower quadrant approximately 6 cm above the pubic rami, lateral to the inferior epigastric arteries. A 5-mm cannula was placed 4 cm above the pubis in the midline. A ZUMI catheter (Zinnanti Surgical Instruments, Chatsworth, CA) was placed in the uterus for uterine manipulation.

 In each case, the round ligaments were treated with bipolar coagulation  and transected with the contact-tip neodymium:yttrium-aluminum-gEtrnet (Nd:YAG ) laser (Surgical Laser Technology, Oak Ridge, PA) with a GRP6  sapphire-tip scalpel. The anterior leaf of the broad ligament was similarly transected. The bladder flap was  then developed by placing 4 x 8-cm gauze on a ring forceps into the vagina and elevating the vaginal apex so that  the bladder could be taken down over the apex by sharp and blunt dissection. The bladder pillars were coagulated  with bipolar electrocoagulation and transected with a GRP6 probe. The perivesicle and perivaginal spaces were then  developed. Windows were created using a right-angle dissector. The Endo-GIA linear stapler was used to transect the  infundibulopelvic or utero-ovarian ligaments according to an earlier decision to remove or preserve the ovaries.

 Using contralateral placement of the linear stapler, a very close approximation of the uterine body and cervix and vagina was obtained, and the ascending branch of the uterine artery was transected. The anterior and posterior colpotomy incisions were opened with the laser. The cardinal ligaments were cross-clamped, divided, and suture ligated from below, with the final vaginal cuff closure also being accomplished from below. Once the vaginal cuff was closed, the peritoneal cavity was insufflated, inspected laparoscopically for hemostasis, and irrigated with warm lactated Ringer's solution. Throughout the procedure and at the final look, bleeders were coagulated with the argon beam coagulator (Birtcher Medical Systems, Irvine, CA). The bladder was drained with a Foley catheter, and no vaginal packing was used postoperatively.

 In the TAH group, 25 procedures were performed: 14 women had bilateral and 1 unilateral salpingo-oophorectomies. 1 had an appendectomy. 2 had lysis of pelvic adhesions, and 7 were treated for endometriosis. In the LAVH group. 24 procedures were performed: 7 patients had bilateral and 5 unilateral salpingo- oophorectomies. 7 had lysis of adhesions, 1 had a repair of bilateral hernia, and 4 were treated for endometriosis.

 After a brief stay in the recovery room, the patients were transferred to the wards. They were discharged when they were able to void, pass flatus and tolerate oral agents to control pain. Discharge criteria were the same for both groups.

 Operating time, blood loss as estimated by the surgeon, and intraoperative complications were recorded. Hemoglobin levels in blood drawn the morning after the procedure were compared with preoperative levels. Pain control was assessed by aggregate intramuscular narcotic use on all hospital days.

 Pain levels were assessed by patient interviews 1, 3, 7, 14, and 21 days, and 6 weeks postoperatively. The women rated their pain on a 10-point scale from 1 -no pain to 10 unbearable pain. Their activity levels were assessed by interviews 1, 3, 7, 14, 21 days, and 6 weeks postoperatively, with 1 extremely limited activity and 10 no limits on activity. The data on pain and activity were analyzed by Wilcoxon's signed rank test. The rest of the data were analyzed by two-tailed Student's t test.






 All patients were operated on for a primary diagnosis of severe, disabling pelvic pain. As shown in Table 1, demographics and pathologic diagnoses in the two groups were closely matched.

TABLE 1. Patient Demographics and Pathologic Diagnoses

a Two-tailed Student t test.
 b The primary diagnosis for all patients was pelvic pain
 NS = not significant at p <0.1

Surgeries were successfully completed in the proposed manner in all patients. The mean operating time for LAVH was 46 minutes longer than for TAH, a significant difference (p <0.005). The estimated blood loss for those who underwent LAVH was not significantly different than that for women having TAH.

The drug requirement to control pain during hospitalization after TAH was almost double that after LAVH (p <0.001). The mean length of hospital stay was significantly shorter after LAVH (2.135 days) than after TAH (3.54 days) (p <0.005) (Table 2).

Table 2. Length of Time in Surgery, Blood Loss, Hemoglobin Drop, Meperidine Use, 
 and Length of Stay.

a Two-tailed Student's t test.
 b As estimated by the surgeon.
 S= significant at p < 0.005; NS = not significant at p< 0.1


Postoperative complications in the TAH group were one woman with mild fever and atelectasis, three with hemoglobin below 10g/dl, and two with urinary tract infections. In the LAVH group. one woman had mild fever with atelectasis and two had anemia with hemoglobin below 10g/dl; no patients were affected by urinary tract infections. No patients required transfusions of nonautologous blood.

Pain levels are shown in Table 3 and Figure 1. Patients undergoing LAVH reported a significantly lower level of pain than those having TAH on days 7,14, and 21 (p <0.05). The difference in postoperative activity level achieved statistical significance on day 7. This difference became more pronounced at day 14, when it was 9.2 for LAVH and only 6.4 for TAH (p <0.005) (Table 4, Figure 2). By day 21 women in the LAVH group reported an activity level of 9.6, where-as those in the TAH group reported only 7.9 (p <0.005). At 6 weeks, the levels were 9.95 and 8.5, respectively (p <0.005). Another way of comparing this is to note that the former women felt more fully recovered at 2 weeks than the latter did at 6 weeks.

a Wilcoxon's signed rank test.
 Ten-point activity scale: 1 = no pain, 10 = unbearable pain.
 S = significant at p < 0.005; NS = not significant at p <0.01

a Wilcoxon's signed rank test.
 Ten-point activity scale: 1 = extremely limited activity, 10 = no limits on activity
 S = significant at p < 0.005; NS = not significant at p <0.01

Figures 1 & 2 match data points in Tables 3 & 4



In 1992, a minimum complication rate, less postoperative analgesia, faster recovery, and shorter hospital stay were reported for the first 75 consecutive cases of LAVH than for abdominal or vaginal hysterectomy.

A very short hospitalization was reported for 72 patients in 1992,~ and 215 subsequent laparoscopic hysterectomies required an average operating time of 114 minutes and a mean hospital stay of 1.21 days.

At 1 week after surgery the majority of these women were permitted to drive and resume normal, non-strenuous physical activity.

In a comparison of LAVH with standard vaginal hysterectomy in a prospective study of 56 patients,

the LAVH group had a longer operating time (120 vs 65 mm). The clinical outcomes were similar for both groups, including a 12-hour hospital stay. The mean hospital charge for LAVH was $3000 more than for vaginal hysterectomy.

Perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomies were compared in 10 women undergoing LAVH and 10 undergoing TAH.

Surgery time was 160 versus 102 minutes, length of hospital stay 2.4 versus 4.4 days, and recovery time 3 versus 5 weeks, respectively. The laparoscopic Doderlein hysterectomy compared favorably with standard abdominal hysterectomy in 167 procedures.

Postoperative recovery times and pain levels were assessed in 37 patients with a primary complaint of pelvic pain and diagnoses of fibroid uterus, adenomyosis, and severe endometriosis who underwent LAVH.

Women reported an activity level of 8.7 on a scale of 1 to 10 (10 no limits on activity) by postoperative day 14. In another study those undergoing abdominal hysterectomy had a mean uterine weight of 418 g compared with 150 g for those undergoing LAVH.

The hospital stay after abdominal hysterectomy was 4.5 days and after LAVH 2.5 days. Hospital costs were $10,511 and $12,814, respectively, a difference of $2303.

Women who underwent vaginal hysterectomy experienced significantly fewer complications than those who had undergone TAH in one study.

The major finding was that the overall complication rate after TAH was 70% higher than that after vaginal hysterectomy, although the morbidity associated with both procedures was appreciable.

Women in our study who underwent LAVH had a shorter hospitalization but longer operating room time than those having TAH. They also experienced a much more rapid recuperation and much quicker return to normal activities. The primary advantage of TAH is clearly the shorter operating time; the primary advantages of LAVH are shorter hospitalization, reduced requirement for drugs to control postoperative pain, and faster return to normal activities.

An important public policy issue now confronts us. As it is currently performed, LAVH is more expensive than TAH. The issue is whether the benefits of shorter convalescence and faster return to the work force, shorter hospitalization, and less need for narcotics for postoperative pain outweigh the disadvantage of the higher cost. If total health care system costs are evaluated, the short-term disability costs of 2 weeks of recovery after laparoscopic hysterectomy should be compared with disability costs of 6 to 8 weeks of recovery after abdominal hysterectomy. The woman who returns to work 4 to 6 weeks earlier is producing.

For LAVH to be, economically viable compared with TAH, savings in disability costs and the increased contribution to the gross domestic product must offset the increased health care costs. In the current system, insurance companies and hospitals do not share in these benefits, only the costs. The economic impact of laparoscopic surgery must take into account both the cost to the hospital and insurance payors and these productivity and social issues. Insurance is based on a risk pool whereby the cost of a premium is based on the cost of treatment, not the ability of the subscriber to return to work. An economic and social cost-benefit analysis must be performed before decisions are made to modify or judge a procedure that provides substantial benefits to the patient.

Laparoscopic versus open cholecystectomy was discussed in 1991 by the medical director of Blue Cross/Blue Shield of South Carolina.

He stated that hospital charges for the former were 14% higher, surgeon fees were 25% higher, and the anesthesia professional charges were 34% higher than for the latter, resulting in a 25% average higher cost for laparoscopy despite a 63% reduction in hospital days. These matters must be addressed, together with the development of methods to improve efficiency, to shorten the length of surgery time by using partial vaginal approaches, and to reduce the cost of instruments required for the procedure. Without a resolution to these problems, LAVH may not be a viable option for the health care consumer of the future.

In this case control study LAVH resulted in a significantly shorter hospital stay, with a much more rapid return to normal activities, than TAH. The drug requirement to control pain and the level of pain patients experienced were also significantly less. Blood loss was not different for the two procedures.

Although LAVH took on average 46 minutes longer to perform, women in that group were able to leave the hospital in an average of 2.1 days and return to normal activity by 2 weeks, thus demonstrating significant advantages over TAH for both patients and the health care system. If 80% of patients scheduled for abdominal hysterectomy undergo LAVH, the average reduction of hospital stay of 1.5 days would save more than half a million hospital days over 1 year.

The impact on the workforce is equally important. Allowing women to return to employment in 2 weeks rather than 8 weeks will result in more than 16 million more days spent in productive work. This translates into equally important savings in disability insurance.

Since its introduction in 1989, continued improvement of techniques will likely progress rapidly so that LAVH will be performed on an outpatient basis for many women, and will result in shorter recovery time.

Thus the increased operating room time of approximately 46 minutes is significantly outweighed by the benefits available with widespread application of this procedure.

1. Nezhat C, Nezhat F, Silfen SL: Laparoscopic hysterectomy and bilateral salpingo-oophorectomy using Multifire GIA surgical stapler. J Gynecol Surg 6:287-288, 1990

2. Minelli L, Angiolillo M, Caione C, et al: Laparoscopically assisted vaginal hysterectomy. Endoscopy 23:64-66, 1991

3. Padial JG, Sotolongo J, Casey MJ, et al: Laparoscopy assisted vaginal hysterectomy: Report of 75 consecutive cases. J Gynecol Surg 8:81-85, 1992

4. Liu CY: Laparoscopic hysterectomy: A review of 72 cases. J Reprod Med 37(4):351-354, 1992

5. Liu CY: Laparoscopic hysterectomy: Report of 215 cases. Gynaecol Endosc 1:73-77, 1992

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels.

Laparoscopic-Assisted Vaginal Hysterectomy

Barbara Nesbitt, Executive Editor of MediSpecialty.com with 

, otohns.net                 Facial Plastics and Reconstructive Surgery                 Advisory Board Member


                 *requires RealPlayer - 

   "Hi, I'm Barbara Nesbitt, and I'm here in Washington, D.C. at the  Academy Conference with Dr. Miller who is in private practice in New  York and also Assistant Professor."
         
         

  "That's right, at the New York University School of Medicine."
         
         

  "In  talking to him a few minutes ago, one of the things that I also found  out was he is among a group of physicians that are involved in the         Face to Face program, that's the program for women that have  been severely damaged."
         
         

  "From domestic violence."
         
         

  "Tell me about it, how you got involved, and what do you do?"
         
         

  "The  American Academy of Facial Plastic and Reconstructive Surgery has an         affiliation with the National Coalition Against Domestic  Violence whereby individuals who are victims of domestic violence, once  they've proceeded through a full program regiment of the rehabilitation,  are eligible for receiving pro-bono facial plastic surgery work for  some of the physical scars that they have acquired while in the abusive  relationship."
         
         

  "You said pro-bono, everybody knows pro-bono means that these physicians are doing it for free."
         
         

  "And  something that I found really good was we're talking about the leading,  top notch - yourself obviously included - facial plastic surgeons that  are doing this."
         
         

  "That's  absolutely right.  Patients have to have been screened by a social  worker and demonstrated a variety of criteria, for example, making sure  that they are out of the abusive relationship for
         quite some time, and when a woman has finally been able to  remove herself from that abusive relationship and she's back on her feet  and actively seeking care because, unfortunately, one of the reasons  why women remain in the abusive relationship is that they financially  cannot survive without the abuser so once they're secure financially..."
         
         

  "So  somebody tells them they'll get some training, they're going to get a  job, they'll get an apartment, and they get a new identity. If a woman  watches this on OBGYN.net or otohns.net and they know of somebody maybe  in their family, in their neighborhood, or even perhaps themselves,  where is the first place that they should contact to get involved in  having this help?"
         
         

  "They  should call the 800 number, and the 800 number is 842-4546.  They'll  then be contacted by either the National Coalition Against Domestic  Violence or a representatives of the         

 American Academy of Facial Plastic and Reconstructive         Surgery

  "Thank you very, very much. "
         
         

  "My pleasure, thank you."
         
         

otohns.net Conference CoverageAnnual Meeting of the AAO-HNSF and Oto Expo Washington, D.C - 2000

Face To Face Program for Victims of Domestic Violence

Karen Abbott, MD and Barbara Nesbitt: "My breast cancer survival story"

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

My breast cancer survival story

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 "Hello.       I'm Dr. Jim Carter from Mission Viejo, California, and I'm here at the       International Pelvic Pain Society meeting in Connecticut with John Slocumb,       M.D., who is at the University of Colorado and is Director of their pelvic       pain program. John, I can remember my earliest times visiting with you       when you were in Mexico. I went into your facility, and you were doing       trigger point injections or injections for treatment of chronic pain as       part of a landmark study that you published on abdominal wall myofascial       syndrome and pelvic pain related to this condition. Could you describe       your work for us?"
       
       

 "Jim,       that was a fascinating period of time for me, in that in the mid- to       late-70's, I found the patients in whom I was performing this standard       therapy of chronic pelvic pain - total hysterectomy - had the same       identical pain afterwards. There would be a period of six weeks to a       couple of months in which the pain would be gone; the patient would be       most thankful. The pain was cured only to have the exact same sensation       return in spite of the absence of the uterus and the ovaries in many       cases. This raised a question about what was actually hurting, and being a       gynecologist, of course, we always focus on the uterus and the       reproductive tissues. This obviously wasn't the case, there was a more       complex mechanism involved. So the first attempt that I tried to look at       was to actually identify what hurt. The initial approach was to take a       needle and some local anesthetic and place the needle where the patient       said the pain was, go deep enough to reproduce it with a needle, and then       block it and see what happened to the pain. And lo and behold, the major       focus in over 90% of the patients was a layer of fascia in the wall of the       abdomen. So by placing the needle over the area where the patient provided       to identify her painful area, place the needle over the skin of the       abdomen, penetrate a matter of a ½" - 1", the patient would       suddenly jump and say, "That's my pain!" This identified a       tissue source but not necessarily mechanism. A way to confirm that was       then to inject a local anesthetic into these tender areas or so called       "trigger areas," and then have the patient walk out of the room       saying, "This is the first time my pains been gone in years."       The source of the pain, the wall of the abdomen, really did not indicate       why I was there; there was nothing wrong with the wall of the abdomen but       this corresponded neurologically to the referral area of internal organs.       So we can actually map out these referral fascial layers of the wall of       the abdomen and their associated referral areas. The lateral areas of the       abdomen indicated referral from the ureter and lateral aspects of the       bladder, the central layer of the abdomen referral from the bladder and       the uterus itself, the mons pubis area referral from the trigon of the       bladder; so that in this mapping we could identify the real and somatic       mechanisms of this manufactured pain."
       
       

 "I       recall that, in fact, it was in '79-'80 that I visited you, and that's       when you were at the University of New Mexico and then later at the       University of Colorado you continued that work looking for the source and       also continuing the mapping. Now you've also found that these injections       work if they were done intravaginally - into the muscle and fascia layers       of the levator ani and the obturator internus. Can you describe for us       then the technique that you use for those type of trigger points?"
       
       

 "Here       again, the crucial issue is to identify the actual focus or trigger area.       The finger sometimes, certainly two fingers in the vagina and one in the       abdomen, was too blunt in approach to identify very focal areas of       neuropathy or focal areas of pain. Also noted was that a focal area of       pain, particularly in the scar tissue of the top of the vagina after       hysterectomy or in the tissue around the levator sling, can produce       surrounding referral so that the patient has multiple areas of pain on       exam but this is not necessarily the cause. So one can use a small Q-tip       or the back end of a large text of swab to just systematically go through       these very sensitive tissues and find a focus that seems to be a central       sharp stabbing area with firm pains to the other areas. Then again using       the block technique to identify that as a source (blocking one area takes       away pain in multiple areas) is very helpful. So, the levator sling can       focal trigger areas in the vulvar area, and in my experience, the worst       area is the paracervical area before a hysterectomy or the scar tissue of       the vaginal cuff after a hysterectomy. These occur to be neuromas,       occasionally we can find a little foci of endometriosis, but clearly the       scar tissue seems to embellish the sensation, spreading it to other areas       and becoming a major focus. These patients on pelvic exam have a lot of       pain with insertion of the speculum, certainly with the bimanual, and       certainly with a history of significant sharp pain with intercourse."
       
       

 "So the       technique that you employ is to use the back side of the Q-tip to palpate       with a very small focus rather than using even one or two fingers to       palpate those areas to identify an area where the individual gives you a       report of the pain that they're experiencing. Then to focus on that to see       if you can remove that pain with an injection, and identify that that       truly is the focus. As you approach these patients and you do your       physical examination and you find the guitar string finding of the cord       with the trigger point imbedded that sometimes occurs - and I find in the       levator ani - when you inject those, do you find those generally softened       quite a bit?"
       
       

       "That's really a good point - one of the observations that you want       to make is not only is the pain gone for the duration of the local       anesthetic, but you see changes in the tissues around it. The tension in       the muscles seems to relax considerably and the decrease in tension gives       them additional pain relief. The local anesthetic may have a prolonged       affect that lasts for days and sometimes weeks because of the blocking of       a nerve reflex, indicating again a neurologic mechanism of this rather       than a focal disease in that area. Patients have learned over a period of       time that when they are threatened with a pelvic exam or intercourse that       those muscles reflexively tense and tighten - again intensifying the       sensitivity and the pain in that area. They really need to relearn to       relax, and when they do that they take away the original focal pain       mechanism by and by. So I think your observation of tension was a good way       to identify where that's coming from."
       
       

 "So       summarize this briefly - you do the exam with a finer instrument than our       fingers generally. You find an area where there's a focus of tenderness,       or let's say a guitar string-type area of muscle, that support we could       call the epithelial and the central very strong focus of pain, and then       you will say do an injection. Now just for those who don't do this       technique, what size needle do you use, how much do you inject and what do       you…?"
       
       

 "The       smaller the needle the better, in order to minimize the discomfort of the       injection itself, so I usually use 25's and others use even smaller - up       to 30 size needles. On the other hand, the smaller the needle, the       tendency to pass through the tissue without really reducing the pain can       be a problem as well. So what you want to do with your needle technique       is, instead of just penetrating, to very slowly move the needle with a       back and forth motion so you can get enough tissue stimulus that when you       hit the hyperpathic point, the patient is obsessed by pain. Then you're       able to stop and infiltrate adequately, and again these areas may be       pretty small but you want enough volume of local anesthetic. A weak       concentration of Marcaine would be adequate to infiltrate the area to get       the block to cover the tender area. Another question is - is this really       muscle or is this fascia? And people, of course, describe mild fascial       pain, and Janet Travell talked a lot about the mild fascial pain and       muscles with referral areas and trigger areas as being the original       researcher to describe these syndromes but much of the tissue actually is       fascia. The muscle may be more to reactive, of course, and muscle and       fascia go together. We have to really recognize that we use the needle to       identify the tissue source, and we use the block to tell where it's coming       from, and what the nerve mechanism is really is not clear. The abdominal       wall pretty clearly in my experience is fascial; there's no muscle       component to it. It's really well above the rectus muscle and the obliques;       you're really into Scarpa's fascia. Our neurometric studies reflect that       there is actually abnormal nerve energy in those areas indicating that       there is a central spinal cord mechanism which keeps these areas       hypersensitive, and then as a result of the hypersensitivity and the       feedback exacerbates the spinal cord component as well."
       
       

 "Very       good point. I know in my experience in reporting these injections for the       vaginal area, I elect to use in the fascia and levator ani obturator       internus a 30-gauge small needle, ½%-1% Lidocaine, 1-2 cc's into these       regions is frequently enough for a complete trigger point resolution in       one area. For the abdominal wall a larger needle 25, 22, and you may have       to go a little bit deeper. On the point of the trigger points, I had a       nice conversation with David Simons, who's just completed his latest       addition of the 1999 Volume 1 of Simons & Trudels Trigger Point       Manual. That is an excellent guide for the knowledge base for the       physicians and practitioners on the techniques of trigger points, not only       in our region but also for a dentist, general surgeons, and physical       therapists. It is a very, very elegant work and has an excellent       presentation. On the point that you made on these long lasting effects       that you get and the central nervous cord relationship, I know your       current work is very deep into how this mechanism is actually functioning.       Could you describe some of the current research that's undergoing for       us?"
       
       

 "Sure,       there are a couple of things that we need to recognize here that it's       really our instinct to go to where the patient says it hurts and blame       that tissue as being the cause, when actually it's the nerves feeding that       area that seem to be a interval part of this mechanism. So we blame where       it hurts rather then the source of those nerves that are creating this       hypersensitive tissue. Unfortunately, we end up doing treatments that       actually may make the area worse, like removing organs and doing that       nerve surgery to try to change that. So what our research looking at right       now is to identify what tissue hurts, what nerve pathways are involved,       and then what is an actual mechanism for that. Just to cut the discussion       short, my belief is that the origin of these dysfunctions is actually       coming from the spinal cord. The tissues we see can be unilateral, can be       a dermatome distribution, and there appears to be a very central focus       with multiple peripheral tissues from that central focus in the spinal       cord. This is why the dermatome component or the somatotome component is       critical in trying to understand it. Another frustration is that each of       us as specialists tend to look to our organs of specialty without looking       at the whole patient, the whole neurologic component to it. Therefore, we       tend to develop our own theories and treatments in a very specific for       focal organs when this is actually multiple organs involved, this is       really a culdomyopathy rather than a disease of the bladder, or the       uterus, or the ovaries, or the vulva. Once we broaden our view and broaden       our exam, we can understand these better. Research wise there's not a       whole lot done in terms of nerve transmitter dysfunction, but I think       that's where we really need to go to understand these mechanisms and       examples of vulvodynia. The focus of our observation is the redness around       the vestibula gland, and the pattern is really consistent with a nerve       transmitter altering the threshold coming from the secretions of the gland       itself. That obviously is an area where research will give us some better       insights in managing this - rather than grossly removing the whole tissue       as it seems to be recommended in some centers."
       
       

 "John,       one of the things I want to express is my appreciation to you for being       open to me, coming as this was when I was completing my medical school and       traveling and looking at what people were doing in new areas. You       pioneered and introduced this, and the fact is that you have pursued what       is causing the pain of a woman whose gynecologic organs have been removed.       And yet, you as a gynecologist saying - "Wait, the problem is still       there, I'm going to pursue this and find out" - has opened up an area       for gynecologists which we're now realizing. Our old way of examining the       patient simply is an old way, and you've been teaching us. The students at       the University of Colorado are so fortunate to have you there to give them       the insight, and the people in Colorado who get those residents into their       community because they're so well served, and as a result, hysterectomies       are not only not necessary but they know they won't solve the problem, and       in fact, the problem is coming from another source. Then this way, people       are not getting surgery, they're getting therapeutic intervention for       their problem, and as I understand it, that the injection although it only       lasts for awhile may uncouple this relationship between the central       nervous system and that peripheral stimulus. So the person might have had       a fall ten years ago, developed this problem, and what you've done is       uncouple it by doing the injection therapy so that they no longer feel the       pain. The stimulus is long gone, it's all wrapped into this circuit. Is       that a correct summation?"
       
       

 "I       think that's a very good description. That there are peripheral sensitized       tissues that normal physiologic functions such as a menstrual period or       filling of the bladder, full bladder, intercourse, sometimes orgasm can       turn the pain on; often we see it in association with ovulation. These are       normal physiologic functions, but when they occur in an area that has been       sensitized, they end up becoming a major painful experience for the       patient, and we keep blaming the event rather than the threshold involved       in these tissues. As you know, the best way we can learn about this - a       condition that is not well understood - is to listen to the patient. I       can't teach anybody anything that any patient can't teach them. As long as       we listen, believe what they say, try to explain what they're telling us       in physiologic or pathologic terminology, and if our language isn't       adequate to explain it, go back to the drawing board and find a better way       to understand it."
       
       

 "Two       things you said, one is to listen to the patient. The other thing that is       that after learning this type of exam, as Dr. Slocumb has pointed out, and       proceeding with a trial injection, that patient will say, "That's       where my pain was and now that pain is gone." Those are words I've       heard over and over again from my patients following your techniques,       following the work that you've taught me, and I really thank you."
       
       

 "Thank       you. It's been a pleasure."

OBGYN.net Conference CoverageFrom IPPS - Simsbury, Connecticut - April/May, 1999

Myofascial Injection

 "Hello,       I'm Dr. Jim Carter, and I'm here in Connecticut at the International       Pelvic Pain Society meeting. With me I have R. William Stones, physician       from England, specifically University of Southampton, who has been very       busy working in this area of pelvic pain for many years and has a number       of insights into how we should approach women with chronic pelvic pain.       Welcome to Connecticut, it was a long trip, and I'm sure happy you're       here."
       
       

 "Thank       you very much Jim, it's a pleasure to be here. It's particularly       interesting to get the American angle on pelvic pain and see how it       compares to the way that things happen in Britain and Europe. I think that       some of our perspectives have been somewhat different over the years, and       it's very interesting to exchange views with colleagues."
       
       

 "Let's       start with the views from England and the area that you are in;       approaching women with chronic pelvic pain - would you describe some of       your work?"
       
       

 "Yes, I       think, probably in common with practice in the U.S., most women probably       have a laparoscopy looking for specific pathology at an early, early stage       in their investigation. But one of the problems arises when we don't find       specific pathology, and I'm sure that's your experience as well. The       question then arises - how do we explain the condition in women who have       pain but don't have specific obvious laparoscopic pathology? I think one       of the answers may well be that we haven't looked hard enough, that we       haven't done a laparoscopic evaluation that hasn't been systematic as it       should have been. But I think on the other hand, there are people even       when we do our laparoscopy very carefully that clearly don't have specific       pathology. The condition that we've really focused on quite a lot over the       last few years, and particularly under the influence of my own teacher,       Richard Beard, has been pelvic congestion syndrome - i.e. pain related to       congestion of veins in the uterus and the ovarian circulation."
       
       

 "Could       you describe what you might find on a physical examination, a radiologic       study, and a laparoscopy for your patients with pelvic pain and       congestion?"
       
       

 "Sure,       I think the classic clinical features that Richard Beard has highlighted       are really a variable nature of the pain, that symptoms are typically not       confined to one specific location, they may well shift. There's the       posture effect, particularly, that the patient's symptoms will be       exacerbated by their standing for a long time, perhaps relief by rest. I       know that Richard describes the classic occupation of the patient with       pelvic congestion as a hairdresser whose occupation makes her stand all       day attending to her clients."
       
       

 "So one       first thing to look for is in the history. A real important feature is the       occupation; a person that's standing a long time can develop this type of       pelvic congestion, kind of a venous stasis-type picture."
       
       

       "Absolutely. I suspect it's probably not the primary cause but in       somebody who has that predisposition, it's certainly an acerbating       factor."
       
       

 "And       then physical exam…"
       
       

 "Just       finishing on the symptom thing. I think the other very interesting symptom       which we don't always get unless we inquire for it specifically, is in       women who have pain with intercourse, there's pain going on after       post-coital aching. Those are symptoms that women may not volunteer during       their consultation unless we ask them specifically about it. I think that       seems to be a particular feature with pelvic congestion."
       
       

 "So       those women who have pain afterward…."
       
       

 "Going       on after intercourse."
       
       

 "That's       a common complaint that we'll hear and that may be related to this issue       of pelvic congestion."
       
       

       "Absolutely. Going on to the physical exam, I think, perhaps       tenderness typically related to the ovaries rather than the uterus or       uterine - I call ligament tenderness, but adnexal palpation by manual       palpation of the ovaries, perhaps exquisitely tender."
       
       

 "So on       the deep palpation, the physical exam, the ovarian tenderness…"
       
       

 "Yes,       the tenderness seems to be more prominent and related to the ovaries than       the uterus itself."
       
       

 "And       then your radiologic studies, could you describe those?"
       
       

 "Yes,       the technique of venography to demonstrate pelvic venous congestion is an       old technique, it's been around, I think, since the 1940's, that recently       has been used more systematically, perhaps, to try to evaluate that pelvic       congestion. The technique is actually surprisingly simple for those who       are familiar with doing hysterosalpingograms. It's really not too much       more troublesome for the patient than a hysterosalpingogram. But the       trans-myogram where a needle is inserted - just penetrating a couple of       millimeters into the myometrium, and then contrast medium injected under       fluoroscopic screening into the myometrium with some vigor. Then we can       see on the imaging the contrast medium dispersing into the pelvic veins,       and get that impression not only of the venous diameters but also of the       clearance - the venous clearance - which I think is one of the key       features of pelvic congestion - that it's dilated veins that would reduce       the rate of clearance from the pelvic veins."
       
       

 "You       inject the dye just a couple of millimeters deep into the myometrium, the       veins are dilated but they clear very slowly."
       
       

 "That's       right, you get pools of contrast medium sitting there for several minutes,       even up to ten minutes. One really wonders why those veins don't clot, the       contrast just seems to be sitting there. I think it's obviously desirable       not to be minimizing one's use of radiation, even diagnostic radiation, in       women in their reproductive years. Of course, we're talking about a       condition which is a relative feature of reproductive years, and obviously       it would be better if we could primarily rely on ultrasound."
       
       

 "Are       there ultrasound findings that can help you with this diagnosis?"
       
       

 "Yes,       we can certainly identify dilated pelvic veins, particularly, I think the       transvaginal ultrasound. I think the possible problem with transabdominal       scanning is that the full bladder that we use for our artistic window may       possibly contract some of the pelvic veins and alter their appearance, so       transvaginal is probably the ideal modality. One can easily assess       diameters using transvaginal but unfortunately it's less easy to really       assess venous clearance or venous flow because, I think, the Doppler       possibilities are really still under evaluation. So the venous flow rates       tend to be rather low, and it's difficult to get a decent Doppler shift in       order to get meaningful data."
       
       

 "Then       your findings of laparoscopy, are there any specific pearls that we could       give to the laparoscopist on what to evaluate?"
       
       

 "Anyone       who undertakes laparoscopy certainly will have seen very dilated pelvic       veins, and in the appropriate context that could be very useful. I think       the practical problem for diagnostic laparoscopy as the modality for       diagnosing pelvic congestion is, of course, we have the patient in the       head-down-tilt, and we've also distended the abdomen with gas for the       procedure which in both procedures will tend to collapse pelvic veins. I       think as some people have advocated, carrying out laparoscopy with some       degree of head-up-tilt and perhaps using a minimum of gas. But I think the       bottom line is - it's probably unrealistic to rely entirely on laparoscopy       for the diagnosis of pelvic congestion. I think we'd probably be better       off with ultrasound."
       
       

 "So if       a physician sees pelvic congestion at laparoscopy, they can pretty well       say, "That's pelvic congestion." But then if they don't see it,       it still could be a significant factor. They need to look at their history       of a standing position with occupation, with the complaint of pain after       intercourse, the discomfort after intercourse, and also the physical       examination findings of tenderness in the ovarian focil area rather than       on the ovaries. Then they do the laparoscopy, if they've done the       procedure to look for the dilated veins or even at ultrasound if they see       the dilated veins, perhaps, they should simply be ready to treat."
       
       

 "What       treatment approaches are you using?"
       
       

 "I       think if we're going up the scale of invasive treatments, one would start       obviously with simply discussing the diagnosis with the patients. I tend       to discuss the diagnosis very much as one might with the diagnosis of       cerebral migraine. In other words, this is a pain of vascular origin,       which as in the case of cerebral migraine isn't associated with any       ongoing or serious progressive pathology but it does, of course, cause       pain. Thinking in terms of a migraine-like condition, I think that's a       conceptual model that patients find very useful, and that type of       explanation sometimes lead women to say, "Thank you very much, now       I've got an explanation for my pain." It helps remove the anxiety,       and they perhaps don't necessarily need specific treatments. Moving up the       scale then, of course, to people who do need specific treatment. I think       the women fully evaluated in our practice are certainly under the       leadership of Richard Beard, our treatments with ovarian suppression. One       that we know most about is using a high dose of medroxyprogesterone with a       dose for endometriosis of around 30 milligrams daily taken continuously.       That seems to be effective in reducing pain symptoms."
       
       

 "I've       also seen good reports on norethindrone of 20 milligrams, a similar       approach."
       
       

 "I       suspect there isn't any one specific route of the choice of ovarian       suppression, and similarly, the analogues will obviously will be       potentially useful."
       
       

 "The       GNRH analogues are appropriate ?."
       
       

 "Of       course, they'll be limited by each individual's side effects and the use       of addback which will obviate side effects. Then the limiting factor, of       course, becomes practicality and costs."
       
       

 "Yes,       the addback meaning the addback of .3 milligrams, say of an estradiol       agent?"
       
       

 "Yes,       and that doesn't seem to render the ovarian suppression less effective in       terms of pain relief."
       
       

 "Then       if you go into a surgical modality for treatment - what approaches are you       using?"
       
       

 "Again       the extreme, of course, would be hysterectomy and oophorectomy. I think in       women with this condition, if they have reached the end of the line, if       they are in extreme pain, and other treatments haven't been successful, it       does seem to me that treatment by hysterectomy with ovarian conservation       is not a good idea. Removing the ovaries and then continuing long-term       estrogen replacement is probably much more appropriate. If one does a       hysterectomy and conserves the ovaries, that is likely to be associated       with unknown symptoms. Of course, we are talking about young women with       this condition, and therefore, early recourse to that kind of mutilating       treatment is clearly inappropriate. This is really reserved for those with       very extreme symptoms where other treatments have failed."
       
       

 "I've       had physicians report to me that uterine suspension or uterine positioning       procedures have also been performed in those patients who are preserving       fertility and gives them a relief for a period of time until their       pregnancy. Then of course, if this condition recurs and becomes a terribly       severe condition, I know Dr. Beard demonstrated an 80% success with the       extirpation procedure, which of course you want to reserve, but it does       have to be considered in some of the worst cases. Do you have any pearls       on the diagnostic area for this rather underdiagnosed condition, because       when we're looking at laparoscopy we don't see the dilated veins       generally. So we probably missed this at our laparoscopy, our "gold       standard" of laparoscopy somewhat fails us because the positions       people are in. Could you give a pearl to the physicians who are watching       that will help alert them to being a little more open to this?"
       
       

 "The       key thing is to be aware of that diagnostic possibility from the outset.       The clinical evaluation is the diagnosis that perhaps should be formed       early on in the process of diagnosis rather than at the end when all the       investigations have proved to be negative. If we're considering if we're       asking the right questions, I think, the pearl really is to focus on the       history and the physical exam, and in a way we're half expecting our       negative laparoscopy or our observation of dilated pelvic veins."
       
       

 "So       truly, this is a place where history and physical examination, and one       additional small pearl would be as I picked up from your discussion - ask       if you send your patients to a radiologist or to an ultrasound center, and       you're not doing your ultrasound yourself, ask them to measure the caliber       of the veins. How often do we actually get a report back where they've       told us the caliber of the veins - I think very rarely."
       
       

 "Jim, I       think that's a very important point, and it's something that when one is       carrying out ultrasound scans one would assume somebody has mentioned the       possibility of looking for a vein but suddenly become obvious and       sonographers then sometimes say, "I've never seen them." Then       one says, "Well, just go and look for them." And then having       pointed them out - it's obvious. But as you say, if we don't ask about       information from our sonographers, then we won't get it."
       
       

 "Is       there a particular diameter of these veins, just to comment that they       should be looking at when they do this caliber measurement?"
       
       

 "Yes, I       think the variables to look at, perhaps, are the number of veins. I think       in some individuals would be one or two quite large veins, perhaps, more       than a centimeter in diameter but others will have very large numbers of       smaller vessels in say, the 3-5 millimeter range but they'll be very       widely distributed around both adnexa. It's really the number of vessels       and their caliber."
       
       

 "So       you're looking at ovarian veins, and you're looking at caliber, and if       it's greater than a centimeter you should be concerned. If there's one or       two that are greater than a centimeter or if you see this plexus of       ovarian veins, that's just a mass of 3-4 millimeters veins that are all       distributed - that would give you a very good hint."
       
       

 "Yes,       exactly. I think it's important to bear in mind the limitations of       ultrasound compared to venography in that it is more difficult to evaluate       venous flow and venous clearance - ultrasound can't do that. If we really       want the gold standard and that still remains transvaginal sonography."
       
       

 "I am       very thankful that you've taken the time to travel from England to the       States to give us a perspective. By the way, I'd like you to tell the       audience the opportunity they have to come to London to England to your       conference. Do you want to give us some information on that?"
       
       

       "Certainly do, Jim, thank you. On Saturday, May the 13th in the year       2000, we're having the millennial meeting of the International Pelvic Pain       Society in London in England. That's going to be a meeting held the day       before the start of the World Congress of Endometriosis. Maybe many who       are planning to come to that World Congress which starts on Sunday, the       14th of May, might like to add that to their schedule, perhaps come a day       or two earlier and can join in. We've got a very pleasant venue for the       meeting in Central London at the Royal Society of Medicine, and I'm sure       that's going to be very exciting meeting."
       
       

 "I'd       like to add - we're working out the details of this program. Dr. Stone,       I'd be very appreciative myself if you would run a work shop prior to that       on your work on the venography and the techniques that are used. Also,       we're hopeful that he's going to put together a very nice party the night       before for all of you, and a little plenary lecture, and perhaps, a       reception. So come in early, don't just plan to come in for the 13th,       we're going to have him give us a little party in London. So the 12th       would be a good day to plan for it. Thank you very much."
       
       

 "Thank       you very much, Jim."
       
       