It takes a big man to admit he's wrong

April 1, 2012

I have been teaching gynecologic ultrasound for 25 years and espousing the virtues of saline infusion sonohysterography (SIS) for more than 20. And almost since the introduction of global endometrial ablation (GEA) devices, at various ultrasound courses and conferences, I have virtually always been asked, "What do I do with the patient who has had a global endometrial ablation and now has irregular bleeding premenopausally or any bleeding postmenopausally?"

I have been teaching gynecologic ultrasound for 25 years and espousing the virtues of saline infusion sonohysterography (SIS) for more than 20. And almost since the introduction of global endometrial ablation (GEA) devices, at various ultrasound courses and conferences, I have virtually always been asked, "What do I do with the patient who has had a prior global endometrial ablation and now has irregular bleeding premenopausally or any bleeding postmenopausally?"

I invariably used to make one of two responses. The first was: "I seem to have virtually no patients for whom to re-commend ablation. When I get done resecting myomas in patients with submucous fibroids, removing polyps in those with polyps, and treating hormonally mediated abnormal uterine bleeding medically, I seem to have very few candidates left." I also added, "If your idea of 'failed medical management' is the first episode of breakthrough bleeding on low-dose oral contraceptive pills, then you can generate a lot of surgery." The other response was: "I would be very careful about patient selection in offering GEA because all the cases referred to me to evaluate bleeding seem to have multiple adhesions, making virtually any of the usual modalities (ie, transvaginal ultrasound, SIS, suction piston biopsy, even D and C hysteroscopy), of limited value." In other words, I was extremely negative on GEA as a procedure.

But-and the point of this article is-I was wrong.

The patients sent to me because of my supposed expertise in endometrial evaluation had previously been unsuccessfully evaluated by the referring physician. I guess it was sort of "the buck stops here." Only once was I any more successful than the original frustrated healthcare provider who had made the referral.

Then I was contacted by the medical director of CooperSurgical Inc (Trumbull, Connecticut). Would I be willing to see some patients to evaluate their endometrial cavity? I was not a consultant or speaker for them or any other GEA device manufacturer, and I have a reputation as an expert in endometrial evaluation, so I agreed.

Ten patients, referred by Cooper, visited my practice. I treated them as new gynecologic patients. Cooper underwrote the cost of their SIS. The chief complaint among these patients was a desire to know the status of their endometrial cavity. Nine of them were not yet menopausal. One had drifted into menopause since her GEA procedure 3 years previous. The women ranged in age from 37 to 55 years. The time since GEA ranged from 4 months to 3 years. None were nulliparous. The 9 who were premenopausal had some monthly bleeding (ie, they were not totally amenorrheic).