Dan Braun, MD

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   “I’m Togas Tulandi, and I’m Professor of Obstetrics and Gynecology and  Milton Leong Chair in Reproductive Medicine at McGill University.  I  have with me Dr. Alan DeCherney who is Professor and Chair of Obstetrics  and Gynecology at UCLA.  Dr. Cherney is the keynote speaker of the ISGE  meeting this morning.  Alan, could you describe your thoughts about the  future treatment of myomectomy?”
       
       

   “Myolysis, of course, is the last thing we did discuss as a  controversial area.  I think that the only thing that’s on the horizon  is treating these with high intensity ultrasound with a transabdominal  approach.”
       
       

 “I have  done myolysis in two or three patients, and I also did second look  laparoscopy.  They were full of adhesions so I stopped doing it.  Tell  me about this ultrasound treatment of myomas, Alan.”
       
       

 “I don’t  really know about it.  I think at the American Colleague meeting people  are going to be talking about it.  I think that’s where the concept will  be released and they’ll be encounter groups talk about it but,  basically, I know very little about it at this point.”
       
       

 “How about uterine artery embolization and the risk of premature menopause?”
       
       

 “Of  course, that’s been described because of the occasional breaking off of  some of the embolizing material into the ovary so I think that’s a risk  that has to be explained to the patient.  I think it’s a small risk but  it definitely is there and of course there have been embolization  material that’s been broken off and gone to the kidney as well.”
       
       

 “So what you’re saying is the best treatment is still laparotomy-myomectomy?”
       
       

 “I think  for abdominal myomas the best treatment is abdominal myomectomy.  I  think in certain cases in certain surgeon’s hands a laparoscopic  myomectomy is a good technique.  The one technique that has made the  most impact and I think is most important is the treatment of  intracavitary myomas with a hysteroscopic approach.”
       
       

 “What’s your cut off point in terms of the size?”
       
       

 “If you  mean for intracavitary - I don’t have a cut off.  If I put them on Depo  Lupron and shrink them down so that they’re not at the internal os so  that I have a decent operative field, I’ll do them.  If it’s into the  internal       os, of course, I can’t do them because I can’t get a good  visualization of the fibroids.”
       
       

 “I don’t think there is any point anyway.  How about the submucous myoma with a large intramural component?”
       
       

 “I think  that probably those don’t represent a problem and should be left alone  unless you can document that that’s the cause of that patient’s  bleeding.  If it’s just kind of slightly bulging into the endometrium, I  usually don’t think that that’s a problem but they’re easy to treat and  they’re easy to shave down because you only have to shave down a small  portion to get below the level of the endometrium so normal endometrium  can grow over them.”
       
       

 “So you shave it until it is level with the rest of the endometrium?”
       
       

 “How often does it come back?”
       
       

 “I don’t  think that fibroids grow to recreate a sphere.  I think if you truncate  them they stay truncated.  I think what happens in those when they recur  is that the muscle squeezes the fibroid, the intramural part, back into  the uterus over time so it’s not really a recurrence, it’s just that  the muscle kind of works it in, it’s not really growing.”
       
       

 “Often when  we are doing the procedure, when we pull out the scope and put it back  in, the fibroid is extending more into the cavity because of uterine  contraction.  Do you find that?”
       
       

 “Yes, I think that’s true and that’s really the same phenomena.”
       
       

 “Dr.  DeCherney, is there anything else you want to add for the future of  treatment of myomas?  Do you think there is anything else on the  horizon?”
       
       

 “No,  except the use of hormonal treatment in order to shrink them other than  Depo       Lupron, and utilizing serums or some other hormonal treatment to  shrink them but, of course, that will only be temporary as long as the  patient is on them.”
       
       

 “There is a  new treatment - progesterone receptor modulator, I think it’s still on  an investigational basis at the moment.  Have you tried that?”
       
       

 “No,  actually I haven’t used the selective progesterone receptor modulators;  I’ve been to a conference on them.  As I said today, fibroids are  responsive to both estrogen and progesterone so I think that blocking  one receptor is not going to be particularly helpful.”
       
       

 “Thank you very much, Dr. DeCherney.”     

Articles

OBGYN.net Conference CoverageFrom ISGE 2001 Congress - Chicago, Illinois, 2001

Future Treatment of Myomectomy

OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Recurrent Pregnancy Loss

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       "My name is Howard Carp and I'm from the University of Tel Aviv. I'm       sitting this evening with Bruno Lunenfeld, a noted professor at Bar-Ilan       University just outside of Tel Aviv, Togas Tulandi, who's Professor of       Obstetrics and Gynecology at McGill University in Montreal, and Alan       DeCherney, Professor of Obstetrics and Gynecology at the University of       California, Los Angeles. They've been discussing some of the sessions,       which have gone on here today. Professors Tulandi and DeCherney, I       understand that you were speaking about some of the controversies       surrounding ectopic pregnancy. Could you please tell us some of the       controversies which came up for discussion and the things which were       discussed at the meeting?"
       
       

       "We talked about which surgical approach was better, salpingoscopy or       salpingectomy, and I think that we concluded that salpingoscopy in most       incidences in a first ectopic pregnancy was better. We also discussed       whether a laparotomy or a laparoscopic approach was better, and we came up       with the conclusion that a laparoscopic approach was preferable if the       patient was stable. And last, we talked about chemotherapy and the       discussion there centered around whether a local injection or a systemic       injection was preferable. It seems that since they both have the same       outcome, the systemic treatment is better because it doesn't really       require any skill, and it doesn't have to be injected into the ectopic. So       we came up in the end with a continuum-the best way to treat a patient       fulfilling criteria of small size was first methotrexate, then a       laparoscopic approach, and last a laparotomy."
       
       

       "Do you feel that the surgical management was adequately discussed in       this session?"
       
       

       "Yes I do. Actually, the last three sessions today did cover surgical       aspects, but basically they were the sessions only looking at real       surgical aspects. So I think that if this was to cover the whole field,       perhaps a shortage was not enough coverage of some of the surgical       controversies. But perhaps that will be covered in another meeting."
       
       

       "Now Professor Tulandi, I know that you've also been discussing       surgical aspects this afternoon, but also surgical aspects of a different       nature-hysterectomy and the alternatives to hysterectomy. Could you tell       us a little about what was discussed this afternoon, please?"
       
       

       "Yes. We discussed the treatment of abnormal uterine bleeding, by       hysterectomy or other methods, and we came up with the conclusion that an       alternative to hysterectomy such as endometrial ablation has a place in       the treatment of abnormal uterine bleeding. Those talking about subtotal       or total hysterectomy were also represented, and I think we agree that       there is a place for subtotal hysterectomy, as well for benign       gynecological conditions."
       
       

"When       you were speaking about endometrial ablation, were you only speaking about       the hysteroscopic forms of ablation under direct vision, or also possibly       some of the catheter techniques, such as using heat to ablate, and so       on?"
       
       

"We       talked about both hysteroscopic techniques and non-hysteroscopic       techniques. The non-hysteroscopic techniques are microwave, balloon,       thermal balloon, and VestaBlate, which is with electrodes. It seems like       the results are often similar."
       
       

       "Were there any conclusions reached as to which may be an optimal       method of ablation, or does that still remain controversial?"
       
       

       "The hysteroscopic technique certainly works very well. It has high       efficacy, and several endometrial studies have shown that the newer       methods are as effective."
       
       

       "Thank you. Professor Lunenfeld, I understand that you touched on a       very important subject this afternoon when you talked about a cancer risk       in patients who have had ovulation inducing agents. Could you please       elaborate on the points which were discussed?"
       
       

       "You probably remember that after the Witmore paper in 1992, there       was a big problem and people were afraid that using drugs may increase       their risk of ovarian cancer. This was increased even further by the       Austin paper, which showed that patients who receive more than twelve       treatment cycles with clomiphene citrate had an accelerated risk of       ovarian cancer. We are now able to look at other studies, concentrated and       modulated by Professor Mundon, in which we collected some 130,000 women in       Israel with a mean age of patients of 52. We demonstrated very, very       clearly that there is no increased risk of ovarian cancer. Furthermore, we       were able to obtain the data from the California study, which is around       65,000 patients from 15 IVF centers and 40 physicians, and their study is       only preliminary for the time being, also. But the data on ovarian cancer       is already there. They observed no increased risk of ovarian cancer when       the patients were treated or were not treated. I think this is an       important result, although the author said at the end of the study that he       still would like to wait another ten years to see the patients after the       age of sixty. I think we can be quite comfortable today. I think this       data, at least for me, is sufficient reason not to be afraid anymore of       the relation in using drugs. We did not discuss assisted productive       techniques because the time interval between ART and ovarian cancer is too       short, for the time being. Although we were told that in approximately       three to four weeks a paper will appear in the Lancet in which the       Australians will claim there is an increased risk of breast cancer about       one year after treatment, and after ten years this risk equalizes to the       non-treated patients. So today we believe-and Dr. Carson agrees with me       fully-that this first increase after one year that comes after ART, or       after stopping contraception, may just be a group of patients who had       already harbored a tumor and where the treatment actually stimulated this       harboring tumor and brought this tumor about. Of course, when we look       after ten years, we'll disseminate this out. This is what we believe is       probably the reason, and I'd like to ask Alan if this sounds reasonable to       you?"
       
       

       "Yes. Reasonable, I agree with that. It's very much like endometrial       cancer, where the high estrogen levels are exaggerated, but it's already       present."
       
       

       "Professor Lunenfeld, this is taking the whole group of ovulation       inducing agents as a whole. Was there any difference between various sub       groups, possibly women who had had urinary menotropins, possible       menotropins based on FSH alone, or the most classical ones which also       included LH in the preparation? Was there any difference seen or was that       not looked at?"
       
       

       "Don't forget this was a study where the patients are now 52 years       old. This was a study that was performed between 1961 and 1984, where       there was no other preparation other than the old H&G preparations. We       do not have any data yet on the newer preparations."
       
       

       "Thank you. I understand that another subject which you spoke about       was the so-called andropause, or partial androgen deficiency. Could you       elaborate on some of the points that came up in that discussion       please?"
       
       

       "Yes, I think we all agreed today that in men there is a gradual       decline of the Leydig cell function and adrenal cell function related to       dehydroepiandrosterone, not cortisol. There is a decrease in cortisol       hormone, there is an increase in melatonin, and there is a decrease in       IGF-1. That means that today, with the prolonged life span of men, they       will live about one-third of their lives in partial endocrine deficiency.       Now, if we have endocrine deficiency which is expressed by clinical signs       and proven by laboratory tests, then I believe only in these cases should       we start using replacement therapy. It has been shown quite well today       that testosterone is probably not a risk factor for cardiovascular       disease. I believe the our study team demonstrated quite elegantly that       you can reduce cardiovascular risk because you reduce visceral effect, and       that it seems quite likely that testosterone does not induce prostatic       cancer, but it may stimulate existing prostatic cancer. Therefore, the       guidelines of today suggest that, before initiating testosterone therapy,       we should have a digital examination and a PSA (prostatic specific       antigen), and if there's anything suspicious, a transrectal       ultrasonography. And we should repeat this three months after the       testosterone therapy because this could create a very early diagnosis of       cancer, should the PSA go up within three months. So I think guidelines       are being developed. We are in the very, very beginning-we are where we       were with HRT about thirty years ago."
       
       

       "Professors Lunenfeld, Tulandi, and DeCherney, thank you very       much."

OBGYN.net Conference CoverageFrom First Congress on Controversies in Obstetrics, Gynecology & Infertility Prague CZECH REPUBLIC - October, 1999

Programs Presented at the First Congress on Controversies in Obstetrics, Gynecology & Infertility

       "Welcome back to the American College of Obstetricians and       Gynecologists meeting in Philadelphia, for 1999. I'm Dr. Daniel Braun,       from Indianapolis, and sitting with me is Dr. Lance Talmage, from Toledo,       Ohio. Dr. Talmage is Chairman of District 5 of the American College of       Obstetricians and Gynecologists and as of last Saturday, past President of       the Ohio State Medical Association. Lance, could you tell us how a fellow       such as yourself, who is in private practice and very busy practicing       medicine, ends up getting to be so involved in the politics of       medicine?"
       
       

       "I think you get interested in an issue, and my bed has always been       as a patient advocate. Once you get interested, you'll find other people       who have the same interest, and then they usually ask you if you would       like to be on a board or a committee. It sort of snowballs from       there."
       
       

 "So       it's not something you really set out to do, to become district chairman,       it's just you get out there, fight for an issue, and it goes from there.       Is that right?"
       
       

       "Exactly, I think probably fifteen years ago when this all began, I       had no intention of being a district chair, president, or anything else.       It's sort of a thing that evolves because your interested, you feel that       there's a job that needs to be done, and somebody says, "Would you       like to take more responsibility to get that job done?" It evolves, I       think, very naturally."
       
       

 "How       do you find the time for that?"
       
       

       "Fortunately, my wife is very understanding, and the kids were always       a priority when they were home. Now that they've been gone for a few       years, having their own families, it's a little easier but you do       sacrifice a little bit of income, you're not in the office quite as much,       and you go where the meetings are instead of going where you want to go.       But if it's a job worth doing, it's a job worth sacrificing for, as far as       I'm concerned."
       
       

 "I       suppose the fact that you have a hard working good partner helps a little       bit too?"
       
       

       "It helps tremendously, and she's very interested. She's the       political arm of the family and helps make connections for me and makes it       a lot easier to get done what I want to do."
       
       

 "I       was actually referring to your other partner, your partner in       practice."
       
       

       "Right, they're a good partner too. Yes, they've been super and being       willing to take call for me when I'm gone, and sometimes you have to make       up call when you get back but that's ok."
       
       

 "So       in other words, it just evolves and that's the way it goes."
       
       

       "I think so, I think being interested is the key in finding that       patients do need advocacy, and they do need to be assured that they can       get good access to good quality medical care. If that's your guiding       principal, there's lots of opportunities to move up in committees,       participation, and leadership."
       
       

 "So       that would be your advice to young residents who are just finishing and       going out into practice?"
       
       

       "Yes, it would. I think even a little bit of involvement while       they're really busy early on in their practices will keep them in the net,       and then they get pretty much swept up in moving up as soon as they have       the time and the opportunity."
       
       

       "Very good. Thank you very much for being with us - we've enjoyed       it."
       
       

From ACOG - Philadelphia, Pennsylvania - May, 1999

Dan Braun, MD

Articles

Future Treatment of Myomectomy

Recurrent Pregnancy Loss

Programs Presented at the First Congress on Controversies in Obstetrics, Gynecology & Infertility

Politics in Medicine