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OBGYN.net Conference CoverageFrom American Institute of Ultrasound in MedicineSan Antonio, Texas - March, 1999
Dr. Pamela Yoder: "We're at the 43rd annual meeting of the American Institute of Ultrasound in Medicine in San Antonio, Texas. Dr. Steven Goldstein has agreed to speak with us about issues related to imaging of a woman's uterus, ovaries, breasts, and the treatment and avoidance of treatment by use of ultrasound imaging."
Dr. Steven R. Goldstein: "Ultrasound is a tremendous modality, and with the introduction of transvaginal probes about a decade ago, the ability to image the ovary and uterus in such close proximity, well, it's as if you're doing ultrasound through a low-power microscope. We're seeing detail that you literally could not see with your naked eye if you were looking at it, holding it in your hand at arm's length, and squinting at it. This tremendous detail has really revolutionized the application of ultrasound in the practice of gynecology. One of the areas I think is most exciting, and that I've done the most work in, is staying out of the operating room with women with abnormal uterine bleeding, and it's specifically perimenopausal women, mainly between thirty-five and menopause. You cannot go from having regular ovulatory cycles every twenty-eight or thirty days to being menopausal without going through a transition when you don't ovulate on a regular basis. When you don't ovulate, you don't make progesterone, and when you don't make progesterone if the estrogen level is relatively constant, the endometrial lining will be stable, and women can go five, six, or seven weeks without bleeding. Then they will usually present and be evaluated, and often when they're not pregnant they're given medicine to bring their period on for gestational agents. But the same physiology of not ovulating, if the estrogen level fluctuates, will re-stabilize the lining of the uterus and these women can bleed seventeen, twenty-one, or fourteen days. When that happens two or three times in a row, over the last sixty years in this country you got a D&C, hysteroscopy, endometrial biopsy, or some sort of sampling because the gynecologists always felt the need to exclude some form of pathology - polyps, hyperplasia, pre-cancers, cancers, or fibroids. When none of that is present, then they're left with the diagnosis of what we call, by exclusion, 'hormone imbalance,' which is nothing but dysfunctional uterine bleeding. So if we could reliably diagnose lack of significant pathology, polyps, pre-cancers, or cancers non-invasively with ultrasound or some fluid enhanced ultrasound - which is what we want to discuss - then many, many women can avoid having any kind of endometrial sampling, D& C procedures, and the like. The work that I presented today and that we have been talking about now for quite some time suggests we can use ultrasound to measure endometrial thickness. The concept that's important is that it needs to be done just as the bleeding episode has ended, when the lining of the uterus is going to be as thin as it's going to be all month long. So if it's the last day or two of staining but the tissue has mostly passed, or the first day, two, three, or four after the bleeding has ended, a thin, distinct endometrial echo on ultrasound is uniformly associated with lack of significant tissue. If for some reason you can't see a good echo on ultrasound, or if it is not a thin echo, then we put about 10 to 20 cc's, or a tablespoon, of sterile saline into the uterine cavity while we're doing the sonogram. The way we put that in is through a catheter that literally looks like a piece of spaghetti before you cook it. It is an absolutely painless procedure and can be done by your physician himself or herself at the time of a no-blood exam. If it shows that there is no anatomic abnormality, then the bleeding can be treated hormonally because the bleeding is, in fact, hormonal."
Dr. Pamela Yoder: "So a woman can come in and have this study done rather than having an endometrial biopsy?"
Dr. Steven R. Goldstein: "Absolutely. In fact, I had a nurse in day surgery recently say to me, 'Dr. Goldstein, how come all your patients have something?' Makes you a little paranoid at first, but I said, 'what do you mean?' She said, 'you know, today you did two D&C's and both women had polyps, and last week you're here and one woman had a polyp and one woman had a fibroid, but they always have something. When the other doctors come, sometimes they have something but a lot of times they don't.' I told the nurse, 'that's because you never see the people who have nothing. We are able to diagnose the lack of a polyp or a fibroid with ultrasound and some fluid upstairs instead of coming to the operating room.'"
Dr. Pamela Yoder: "Now, you're a general gynecologist, trained especially in ultrasound?"
Dr. Steven R. Goldstein: "I am a full Professor of Obstetrics and Gynecology at NYU, and in my clinical practice I practice all aspects of obstetrics and gynecology. My academic interests have been in ultrasound in women. When vaginal probes came out, I became more involved in gynecologic ultrasound, opposed to obstetrical and the peri- and post-menopausal patient. Actually, when you sit down and talk to peri-menopausal patients who have some of these irregular bleeding abnormalities, you'll also find out that there is a flood gate of psycho-social symptoms that seem to go along with that era of time - mood swings, sleep disturbances, memory lapses, the inability to concentrate, free-floating anxiety, the feeling that something's happening here, not being on top of your game, etc. For many women this is long before their first hot flash. My patients are pretty savvy, and by the time they have hot flashes and a dry vagina, they know what's going on. But sometimes these symptoms, which may be subtle or not so subtle in some people, can manifest themselves up to a decade beforehand. I can't tell you the number of patients who've gone to the doctor and said, 'could I be beginning my changes?' Someone sends out a blood test on an estrogen level that comes back in a pre-menopausal range, and they're told 'no, you're not, this isn't hormonal. You're just stressed, your husband had an affair, your youngest is going to college, or you didn't get the promotion you deserve - try this Prozac.' When in reality, I believe that for a significant number of women the fluctuation of levels of unopposed estrogen in this transitional phase is the culprit for a significant portion of how they feel. The treatment for this dysfunctional bleeding and a lot of this irregularity, in my mind, is an ultra-low dose birth control pills. They're designed specifically for women in their forties who turn off their own ovarian estrogen production and instead substitute a very low dose of estrogen and progesterone all month long, often giving women back a sense of equilibrium and also solving the abnormal bleeding problem."
Dr. Pamela Yoder: "So if a woman comes to you in her early forties and is having problems with sleep, irregular periods, light periods, or some mood or behavioral changes, would you recommend that?"
Dr. Steven R. Goldstein: "In women who are non-smokers, there is excellent reason for them to consider a trial of low-dose birth control pills. I feel very confident about it, and there's a lot of overlap. I mean, I have some of those symptoms, and I don't make any estrogen. So clearly this is not all estrogen-related, but I can tell you this: whatever portion of a particular patient component is hormonal, you can take that off the table by suppressing her cycle. I've stopped calling these birth control pills. I now refer to them as cycle regulators, because you just can't take a forty-three year old woman who's had her tubes tied and say 'I'm going to put you on birth control pills.' It's not for contraception, it's for cycle regulation."
Dr. Pamela Yoder: "Some people who have had hormonal treatment for augmentation or replacement have noticed some changes in their breasts, for example."
Dr. Steven R. Goldstein: "That's a very interesting and astute point, and you use a good word, which is augmentation. There are many physicians, obstetricians, gynecologists, and family practice physicians who don't seem to understand how to use hormones in the perimenopausal woman. Perimenopausal women are making estrogen often in very fluctuating amounts, and in fact, some work done recently showed that perimenopausal women may actually make more estrogen in an atonic, unopposed fashion. At the very end, when you get the hot flashes and dry vagina, there are low estrogen levels, but I believe it's the fluctuation earlier in the perimenopause, so if you simply give these women estrogen, it's just your fluctuation plus. And I've seen some incredibly high levels of estrogen in women who were given traditional estrogen supplements. The key to the low-dose birth control pills is that they suppress ovarian function. It turns off your own estrogen and substitutes a small regular amount all month long, which goes together with people's fear of breast cancer. Let me be more specific. Women are afraid of breast cancer and women believe, and it may be true, that estrogen promotes breast cancer. I don't think it induces breast cancer, but I think long-term estrogen probably does promote breast cancer somewhat. So if you take a post-menopausal woman who is making virtually no estrogen and you give her hormone replacement therapy, clearly, she's going to have more estrogen to her breasts then if she does not take it. That's easy for patients to understand, and that's why many patients are fearful of hormone replacement therapies in spite of its benefits. The perimenopausal woman to whom you offer birth control pills is reluctant to take this because she thinks she's adding more hormones to her body, and to her breasts. She often doesn't realize what I think needs to get across, and this is that those pills, by suppressing her own ovarian function, are now turning off what she makes and substituting 20 micrograms of ethinyl estradiol, which may in fact offer less risk to her breasts in the long run than what she's already making on her own. Think about it... There are really no good studies on what the equivalent dose is, but if you look at the observational studies, women who took birth control pills years ago in college ten or twenty-five years ago have no increased risk of breast cancer. The pills those women took contained 50 and 80 micrograms of estrogen, and the pills we're using now are 20 micrograms. That's anywhere from one quarter to forty percent of the estrogen that woman were on in the past, and those women who took the pills in the past have no increase in breast cancer. Perhaps with this low dose, in ten or fifteen years we'll find that these women actually had less of a risk for breast cancer. There's good scientific evidence that they have less ovarian cancer - eighty-five percent of ovarian tumors are of the capsule of the ovary that bursts and repairs and bursts and repairs with each ovulation. For every year you suppress ovulation, you take birth control pills, and you have a ten-percent reduction in ovarian cancer. So there are tremendous benefits to women who are non-smokers in their forties for being on cycle suppression/cycle regulation. They never have the mood cycles or psychological symptoms that we were describing caused by the fluctuating hormones. Let's face it, some of them may be depressed, and some men are depressed, but for a lot of women, a significant portion of how they feel is related to fluctuating levels of estrogen. So if you're on these pills, you don't have a cycle. It's now stable all month long, so that's a benefit, and you're at less risk for ovarian cancer - that's scientifically proven. In fact, the hypothesis here is that it may be better for your breasts than the estrogen your own body makes."
Dr. Pamela Yoder: "If a woman has had a hysterectomy, is she a candidate for estrogen alone, or should she be taking a combination?"
Dr. Steven R. Goldstein: "That would depend on whether she has ovarian function. These are different issues you're talking about here. If you've had a hysterectomy, there's no longer any fear of endometrial cancer, so you don't need progesterone to protect the endometrium. But if you've had a hysterectomy - which simply involves removal of the uterus - and your ovaries are still functioning, if they start to make fluctuating levels of unopposed estrogen, you may not have the bleeding irregularity that brings women to see me and try the saline effusion sonography that we were talking about. The changes in moods, sleep patterns, and concentration that may be hormonally mediated will still be present in a woman who has had a hysterectomy, but her ovaries are maintained. So that woman should still take low-dose birth control pills if her ovaries are functioning. If she's had her ovaries removed, then I think she's an excellent candidate for hormone replacement, which in her case doesn't need progesterone because the only point of the progesterone is endometrial protection against endometrial cancer."
Dr. Pamela Yoder: "There are many mid-life women that are part of the sandwich generation and have many, many hats to wear and no time for any additional causes of stress, such as surgery, in their lives. Is there an opportunity to use the ultrasound also to decrease their need for surgery if they develop an ovarian cyst, for example?"
Dr. Steven R. Goldstein: "I've spent most of my academic career working on this. Ten or fifteen years ago, if you were post-menopausal and you had an ovarian cyst that was cancerous until proven otherwise, you had an operation and they removed the uterus, tubes and ovaries. I actually published a third paper, but it had been a six-year study and, in my mind, the largest and the earliest in 1988, that suggested that simple cystic masses up to 5 cm were rarely malignant and didn't necessarily need to be removed. I would say at this point that's probably standard. If you have a smooth-wall, unilocular, simple cystic structure of an ovary that looks by its appearance to be absolutely benign, we would no longer do exploratory surgery and remove it, and I'm glad that I made that happen. There may still be some places where people remove it if the patient has a cancer phobia, but we know the incidence of malignancy in that kind of appearance cystic structure is virtually zero. If you start to look at women in general with an ultrasound, you see that 10% to 17% of women in that age group will have some form of simple cystic structure in the ovaries, but you're certainly not going to operate on all these people, especially since the incidence of malignancy is virtually zero. The same thing with fibroids - we could discuss fibroids, and I can't tell you the number of women who have hysterectomies because there are fibroids present. It's amazing how much everybody wants to explain any symptoms they have in women with fibroids on their fibroids. It often coexists. Fibroids have virtually no potential of undergoing malignant transformation, so malignancy is not the issue. If the bleeding is not a major problem and people are not anemic or troubled by the pattern of bleeding and you can see the ovaries on ultrasound, we used to think you had to take out the uterus because we couldn't feel the ovaries. Now there's ultrasound, and if you know the ovaries are normal then there's no reason to remove the uterus just because it gets to a certain size and the ovaries are no longer palpated on an exam. If you really want to extend the conversation, I think ultrasound should be part of the overall gynecologic visit. Most of the information that we're trying to establish with examining a patient at the time of her visit is objective information to the gynecologist. Is this uterus normal-sized, does it tip forward, does it tip backwards, is this a normal ovary, does this ovary have a cystic mass on it? This is all objective information, and if you have the equipment available and the know-how, you can get this information in a matter of seconds. I have seen equipment that will be to these ultrasound machines what the laptop is to the computer, today. There's no doubt in my mind that in fifteen years students are going to look at us and say, 'wait a minute, you used to feel without looking? How did you know what they had?' Just like now, when I say to a student, 'you know when I was a student, we use to listen to the baby's heart every fifteen minutes in the first stage of labor, and every five minutes in the second stage, and we didn't have monitors at all.' They look at me like, 'you didn't have a monitor!?' It's a similar kind of thing, but I think we will be seeing something like the ultrasound stethoscope, and I've seen prototypes of this. I think there will be some out by the ACOG meeting in May, all these prototypes."
Dr. Pamela Yoder: "As a woman and Director of Women's Services, I find all of this wonderful news, and I thank you for your time."
Dr. Steven R. Goldstein: "Thank you - my pleasure."