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Contemporary Challenges in Gynecology

Presented by The Weinberg Center for Women’s Health & Medicine at Mercy on Saturday, October 28, 2006

“Contemporary Challenges in Gynecology” provided on overview of current clinical challenges in women’s health care. It addressed topics for the practicing gynecologist, obstetrician/gynecologist, primary care physician, and allied health professional. Topics included breast health, cervical cancer, dealing with the difficult patient, alternative medicine, endometrial cancer, HPV vaccination, obesity challenges, urologic injuries in gynecology, and common case dilemmas

The conference was held Saturday, October 28th, 2006 at the Baltimore Marriott Waterfront Hotel under the auspices of Mercy Medical Center and The Weinberg Center for Women’s Health and Medicine. Dr. Neil B. Rosenshein, director of the Weinberg Center, led the course.

Managing the Difficult Patient; Identifying the Litigious Patient
Speaker: Maureen E. Burke, RN, MSN
Clinical Risk Management Consultant, RCM&D Insurance Brokers
Risk Manager, Inova Health System, Falls Church Virginia
Ms. Burke noted her background as a ER nurse and in risk management: “All behavior has meaning.”

“What do you want from your visits today, what are your expectations?” These are questions every physician should ask of their patients. Typically problems arise with patients who feel their expectations were not met. “They wanted something and they didn’t get it.”

It’s important to be emotionally supportive of patients who are grieving, anxious frightened or depressed and to “attempt to stay on schedule.”

“Avoid criticizing other providers!”—This gives the patient an opening for litigation.

Remain objective and humble; send a written summary of patient’s visit to the patient’s PCP (primary care physician). “If there are multiple physicians involved in the patient’s care, be sure someone is managing their case…if everyone is ‘hands off,’ patients can fall through the cracks.”

Make sure your staff and answer service aren’t rude, and never guarantee an outcome.

Regarding the “difficult patient. One sixth of the patient population qualifies as difficult.

“Your success and your patient’s success is dependant on your interaction.”

The When and Why Patients Become Difficult…30-50 years ago, the patient-physician relationship was informal. “The doctor delivered babies and may have accepted eggs as payment for the delivery.” The use of managed care has fragmented patient’s care; patients may see multiple doctors; patients are now more informed through the internet and various television medical programs.

What causes a patient to become difficult? Anxiety, illness, inappropriate expectations, have they been “labeled” by physicians and family, do they have a generally critical approach to things, and a high need for information.

“Today’s patients make informed decisions and often seek out alternative medicine.”

The attributes of the difficult patient include acting helpless, being demanding, violating rules, failing to cooperate with the rules of the office, hostility, depression, anger, violence, non-compliance.

Problems can arise when the patient’s personal characteristics come into conflict with the beliefs and values of the health care team.

“Physicians will have their own value system. They may not like dealing with substance abuser or the very obese. Female patients can be particularly difficult as their emotions can be more intense. It’s important that physicians not pass moral judgments on their patients.”

Watch out for the patient’s transference, i.e. you or your staff reminds them of someone from their past—remember, “this is not about us.”

Similarly, patients can evoke negative emotions in physicians. If the physician is a “type A” personality, a more “laid back” patient may seem troublesome. There is “counter transference,” where the “patient reminds YOU of someone!”

Have a conversation with the patient and family. Remember you can’t take care of everything; but you can help identify something that you can help with; mediate and make compromise.

The Difficult Patient—Management Techniques

Don’t take the patient’s behavior personally. Identify any conflict that has originated with you, your staff and the hospital staff. Foster the patient’s sense of control by offering CHOICES—“it’s all about control.”

Set firm limits for patients and provide consistent rules and expectations. Remain objective—if not, you may miss vital information that could lead to problems “down the road.”

Ensure a safe environment; install a panic button where you can alert police and/or security. And “only as a last resort, consider dismissing the patient from your practice. Keep written notes about any incidents that may occur; you will have 30 days to find a referral for the patient to a new doctor.”

Why DON’T people sue? “Few actually file lawsuits—why? It’s related to how the doctor and institution handle the event. Is there open disclosure, honesty, is the patient treated with respect?” One third of litigants will sue if given a reason and another third will sue “no matter what.”

“It’s interesting that patients and families will remember EXACT conversations. It’s easier for them versus the thousands of conversations you have had with patients.”

When people do sue, it is because of how they are treated, outside influences of family and friends and even attorney’s advertisements.

Identifying the Litigious Patient

--patient with many symptoms (hypochondriac)…you may lose objectivity given the patient’s tendency to “cry wolf”
--patients who have suffered trauma, have abandonment issues
--the narcissistic patient, who seek perfection, can’t accept a bad outcome and need to blame the physician for the “imperfection”
--patients who have sued physicians before (you may wish to obtain a legal history from your patient)
--the “doctor shopper,” one who goes from doctor to doctor and doesn’t maintain a relationship with any one physician
--the “high risk family”

“And we are doing this to ourselves---27% of people who call lawyers do so following input from another health care provider.”

Why sue?

--doctor has deserted them 32%
--devaluation of patient/family 29%
--communication issues, poor delivery of information 26% (“so work on your bedside manner”)
--failure to see patient/family’s perspective 13%

“99% of the time patient’s claim to sue in order to prevent a similar event from happening to someone else.” They believe there is a “lack of honesty, lack of apology…they didn’t get what they needed.”

Other main themes for patients who sue are a desire to be compensated and a belief in accountability—“our society is into punishing doctors for making mistakes…we expect perfection.”

Physicians’ attitudes and poor communications constitute 69% of why patients sue.

“The biggest problem with communication is the illusion that it’s been accomplished.”—Shaw

Keep in mind that an apology is NOT considered an admission of guilt and can’t be used against you in court—SORRY does NOT admit negligence.

Follow-up is very important when dealing with patients—document your conversations, make sure informed consent is adequate.

Resolution of Claims…49.5% of claims against OB/GYN are dropped; those that do go to court, OB/GYNs win 81% of the time. The length of time from occurrence to close in these matters is FOUR years. 13% of claims that 7 or more years to resolve, and this “shows up on your record and hurts your ability to get insurance.”

Remember, informed consent, disclosure and communicate are key.

Lawrence J. Cheskin, M.D., FACP
Associate Profess of International Health (Human Nutrition) with the Johns Hopkins Bloomberg School of Public Health
OBESITY: The #1 Preventable Problem in Gynecology?
Gynecologists are now the “first line of treatment” in identifying obesity as it disproportionately effects women and their ability to do something about it due to social pressures.

Two-thirds of U.S. adults are overweight or obese. Severe obesity is rising faster than mild obesity, doubling in the past 10 years.

25% of children and adolescents are overweight and may have shorter life expectancy than the previous generation, more than any other time in history.

Obesity lowers life expectancy “by at least several years” and obesity together with smoking lowers life expectancy by 13 years, so if you would normally live to 75, you’re dead at 62. And worse, young women who smoke are continuing to do so out of fear that giving it up will cause them to gain weight.

Four out of the eight top reasons for death are obesity related: CHD, cancer, stroke and diabetes.

Diabetes has the biggest association to BMI (Body Mass Index) as “you can never be too thin relative to your risk of diabetes,” though the one plus of being overweight seems to be a decrease in problems with hip fractures and bone density/osteoporosis.

You lower your risk of death by 20% by stopping obesity. Obesity has overtaken smoking as the number one preventable cause of death.

Direct and indirect costs due to obesity cost us $117 billion each year—that’s 9% of all U.S. health care costs.

Obesity is “the easiest diagnosis you’ll ever make.” Men with a waist of over 40 inches, and for women, over 35 inches, have abdominal obesity.

Evaluation of obesity includes a weight history; pregnancies, menstrual disorders; diet history; history of other complications such as gallbladder disease, CVD, DM, OA; and changes in physical activity level. Other issues include “sleep apnea, which is becoming increasingly more common,” drugs, family history, endocrine issues, and smoking status.

Drugs associated with weight gain include steroids (BCPs, HRT), tricyclic antidepressants; pheonthiazines, lithium, antihistamines, sulonylureas, insuline, beta blockers and thiazides.

Genetics is important. Children of obese parents when adopted seem to still have a high rate of obesity themselves even if adopted parents do not.

Regarding childhood onset obesity; the first five years of life are not predictive; only 21% of a cohort of obese individuals 36-years-old were obese children but 80% become overweight adults.

Treatments for obesity: diet alone has a “dismal long term outcome…58% gain back weight even with diet, exercise and behavior modification.”

What drives food choice? “Taste, cost, convenience.”

Portion size of food has been growing since the 1970s. Marketplace portions now exceed standard serving sizes by a factor of 2 to 8.

Diet composition and satiety, what foods satisfy best. Protein tops the charts followed by complex carbohydrates, simply carbohydrates, fats and ethanol (ethanol may stimulate further food intake; liquids are less satisfying than solids).

“You can eat 10 cubes of cheese and be full versus eating a whole bowl of fruit to be full—but the cheese cubes have 1,000 calories, much more than the fruit.”

“There is no naturally occurring high fiber, fatty food. Fat doesn’t mix well with fiber or water.”

The body can’t store protein or carbs, but fat is highly storable—“you have unlimited storage” for fat. Fat constitutes about 38% of our daily diet, versus 32% in 1911.

Meal patterns—Gorgers vs. Nibblers: actually eating 5-7 smaller meals during the day is more effective re: weight management than those who eat 1-2 meals per day. “The body has a powerful mechanism to prevent weight loss.”

Types of physical activity—non-exercise activity thermogenesis or NEAT, i.e. incidental activity and fidgeting, can result in burning 800 or more calories per day. Exercise is particularly good for maintaining weight after losing weight.

You would need to cut 500-750 calories a day to lose a single pound of fat per week.

Aspartame actually not effective, the body compensates for it; “the energy compensation is nearly complete in the majority of studies.”

Why do we eat? Due to habit, as a stress reliever, reward, boredom, as a social facilitator, love, and “the mountain…like Everest, because it’s there.”

Women often eat due to boredom and loneliness; social settings increase food intake as we tend to eat 40% more than when we eat alone.

Pharmacotherapy for obesity: Phentermine (the phen in Fen-Phen) achieved a weight loss in patients of 8.1%. Other drugs (off label use for obesity) include Topimax, Zonisamide and Rimonabant, a cannabinoid receptor antagonist.

Surgical therapy for obesity—warranted in cases of patients with BMI of 40+ who have failed non-surgical therapies. Gastric bypass surgery makes the patient “food intolerant.”

“We have to teach patients to read labels. A muffin may say it is 100 calories and fat free, but the serving size states ‘one third of a muffin.’ A 20 ounce juice pack says 100 calories per serving, but it is 2 ½ servings.

“The Obesigenic Environment”—we subsidize foods that make us fat; health foods cost more than fatty foods. Patients don’t come in for obesity prevention/evaluation or for other screening tests because they have body image issues and “due to messages sent by doctors.” Patients feel uncomfortable and doctors fail to follow through. “Most doctors have a feeling of inability to effective treat obesity.”

21% of doctors say they don’t want to do a pelvic exam on an obese patient; 2% are uncomfortable examining a very attractive patient and no doctors were uncomfortable about examining thin patients.

Is obesity preventable? Yes and no…In theory, if you shave just 50 calories a day, add a 20 minute walk, you can lose 5 pounds a year—but we compensate for these changes.

We should see more changes in our schools. “Before we would have physical education every day. Today it’s once a week maybe and students often ‘just watch.’”

Tracy W. Gaudet, M.D., FACOG
Assistant Professor, Department of Obstetrics and Gynecology, Duke Center for Integrative Medicine, Duke University Medical Center
Complementary Medicine in Gynecology
Categories of complementary medicine—alternative or complementary now refers to anything not taught in U.S. medical schools or offered in U.S. hospitals and “ranges from botanics to crystal gazing,” and includes nutritional supplements, herbals, physical manipulation therapy like work by chiropractors and massage; hypnosis and stress reducing therapies; Reiki therapy, “healing touch,” magnets; and those that are based on complete systems like acupuncture and homeotherapies.

Complementary/Alternative Medicine (CAM) use in the U.S. According to research reported in the New England Journal of Medicine (1990 survey), about 34% were using unconventional therapies with 425 million CAM related visits (vs. 388 million primary care physician visits_

72% are not telling their doctors that they are using CAM. This can be dangerous as in the case of the patient who is using estrogenics (botanicals that have an estrogen effect) and you are prescribing HRT (hormone replacement therapy).

75% of Americans have, at some point, used CAM according to a CDC (Centers for Disease Control) study, and an increasing number are using prayer specifically for health concerns.

“The goal should always be to have the best practice of medicine—not just CAM or just mainstream medicine, not two isolated worlds.”

Integrative Medicine: recognizes that good medicine must always be based on good science that is inquiry driven and open to new paradigms.

Therapeutic Opportunities: decreased harm of interventions; treatment for conditions when conventional medicine fails; decreased cost and improve outcomes; non-invasive approaches.

Therapeutic Challenges: huge market demand, lack of regulation (what’s in the bottle may not match up to what’s on the label), lack of education (in terms of CAM vs. conventional medicine, “each side knows little about the other”); refusal to be open to proven conventional therapies; lack of integration

“You often have health food clerks handing out medical/health care advice.”

Women are the primary users of alternative medicine for issues relative of menopause, puberty, pregnancy, and birth control. Women more often than not see the gynecologist not for disease, but for “life transitions.”

The best integrative medicine approaches are for dysmennorhea and PMS, chronic pelvic pain, obstetrical care, surgery, infertility and menopause. The best evidence of effectiveness can be found with botanicals, oriental medicine (e.g. acupuncture), and mind-body approaches

Consider botanicals. 25% of prescription drugs are plant-based, and 60% of over the counter (OTC) drugs come from plants. While botanicals may be regulated as dietary supplements in the U.S., they should be thought of as drugs.

The Dietary Supplement Health and Education Act of 1994 (DSHEA) made it legal to make claims relative to a supplement’s effect on the body’s structure or function or a person’s well-being WITHOUT referring to the FDA. These products are easy to recognize as they are typically marked, “This product is not intended to diagnose, treat, cure or prevent any disease.” With botanicals, “we not even know what the active ingredient is and there may be multiple active ingredients.”

Visit www.consumerlab.com for information from independent lab evaluation of products and their quality.

Regarding Acupuncture. A NIH (National Institutes of Health) Consensus Conference on Acupuncture in 1997, stated there was “proven efficacy” relative to the effect of acupuncture for post-operative and chemotherapy nausea and vomiting, also for post-operative dental pain.

“Data for acupuncture are as strong as those for many accepted Western medical therapies.”

One challenge is the concept of acupuncture as being “foreign, with Chi and energy meridians…the fact that an acupuncture point at the lateral aspect of the foot connects with the visual cortex of the brain.” However, using MRI, when a light was shone on the eye and the acupuncture point made in the lateral aspect of the foot, the MRI indicated the equivalent activity of the visual cortex in both cases.

As for mind-body approaches such a hypnosis, there are cases of patient’s undergoing a c-section without anesthesia, other than hypnosis. The “proposed mechanism of action is decreased CNS adrenergic tone.” There’s a probable wide range of health benefits of the relax-response effect, positively impacting hypertension, arrhythmias, chronic pain, insomnia, anxiety, and PMS.

Regarding the treatment of dysmenorrheal and PMS…Omega 3 fatty acids have been found to have many health benefits, and can be found in cold water fish like cod, salmon, mackerel and sardines. Flax seeds, one tablespoon, also a factor (high in fiber). Vitamins and minerals, recommend 900-1200 mgs of calcium per day; those who took calcium at this level were found to experience an improvement of mood, less water retention and lesser food cravings (a 48% decrease vs. 30%). Magnesium is also effective in abating some PMS symptoms at 200-400 mgs; Vitamin B6 at 50mg per day resulted in less pain, depression, mastalgia, but at levels over 100mg, there were “neurological symptoms.”

Chasteberry is another botanical found to have some positive impact on dysmenorrheal and PMS. In a study of 178 women with a mean age of 36 years, found a decrease in irritability, anger, headache, mood alteration, breast fullness and bloating (likely chasteberry decreases prolactin secretions).

In a pilot trial for St. John’s Wort, found a significant reduction of all PMS symptoms, 50%, in 2/3rds of women in the study, but it may negatively impact the efficacy of birth control pills.

The research for the efficacy of acupuncture for dysmenorrheal is “promising, but further research is needed.”

Can acupuncture improve fertility? A study reported in Fertility and Sterility medical journal found in a study of 160 patients receiving invitro fertilization (IVF) and acupuncture, 25 minutes of acupuncture therapy pre and post embryo-transfer, pregnancy rates achieved were 43% with acupuncture, 26% without.

Can mind-body treatments, group psychological interventions, play a role in aiding fertility? Fertility and Sterility medical journal also reports that those in a 10-session cognitive behavior group, vs. those in a support group vs those just receiving “routine care” achieved pregnancy at a rates of 55%, 54% vs. 20%. “This is a low-risk, low-cost intervention to raise the rate of pregnancy.”

Can acupuncture relieve menopause symptoms? Hot flashes were found to decrease significantly.

Acupuncture in breast cancer patients, regarding a pilot study of patients treated with tamoxifen, with acupuncture patients were found to enjoy improvement in anxiety, depression and somatic and vasomotor symptoms; libido was not modified.

Mind/body techniques for menopause—hypnosis was found to reduce hot flashes and improved quality of life.

Regarding botanicals and their use in combating menopause symptoms, “the strongest evidence is for Black Cohosh which is “not estrogenic, versus Red Clover, which is very estrogenic.” One most be wary regarding obtaining botanicals as “people who market these want to create proprietary blends” so you may be getting something that has other items mixed in that you don’t want or need.

Concerning CAM and surgical patients…looking at cases of cesarean section using acupuncture for anesthesia (23 provinces, 1975-80 and 1981-87; more than 40,000 cases), enjoyed “success rates of 92 and 99 percent, with blood pressure, heart rate, RR, all stable throughout.

There are ways to integrate acupuncture with traditional medicine; consider use of “relief bands,” a band worn on the wrist which applies acupuncture pressure on a key point designed to reduce nausea and vomiting “and there is a fair amount of evidence that there is a reduction in nausea and vomiting by wearing these bands.” Oriental medicine was found to help prevent post-operative nausea and vomiting and was more effective than placebo.

The use of pre-operative acupuncture reduced the need for supplemental morphine by 50%; post operative nausea and vomiting reduced by 30%; cortisol and epinephrine reduced by 30%. Simply put, “relaxed patients pre-op do better.”

It doesn’t cost much to provide acupuncture bands or headsets with relaxation tapes.

There’s evidence that these CAM measures “even decreased patient blood loss.”

“The greatest barrier to discovery is not ignorance, but the illusion of knowledge.”—David Borstein

Should you see a CAM practitioner or a conventional physician with CAM training? The latter physician usually requires no more than 200-300 hours of CAM training, but for the “non-doctor licensed acupuncturist, they require 2,500-3,000 hours of training.”

Ira R. Horowitz, M.D., SM, FACOG, FACS
Willaford Ransom Leach Professor in Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Emory University School of Medicine
Urinary Tract Injuries
“Does everyone need a cystoscopy?”

44% of urinary tract injuries are secondary to gynecologic procedures. Ureteral trauma is the most common injury to the urinary tract. One percent of gynecologic procedures are complicated by a urinary tract injury.

Urinary tract injury accounts for 10% of all claims against OB/GYNS.

Prevention: place hysterectomy clamp close to the cervix; use downward traction; if using endovascular staples, harmonic scalpels or electrosurgical devices, be sure to check the bowel and ureter proximity.

“When in doubt, do cystoscopy, sterile milk and dye instillation!”

Should you do cystoscopy after every hysterectomy—yes, after every vaginal hysterectomy.

Sometimes it may be best to do nothing at all. In case of a pinpoint fistula, it typically will close spontaneously without the need for additional surgery…but if patient is still having symptoms after three months, take action.

Kevin A. Ault, M.D., FACOG
Associate Professor of Obstetrics and Gynecology, Emory University School of Medicine
The HPV Vaccine: Where to From Here?
Cervical cancer is caused by the human papilloma virus (HPV). Worldwide cervical cancer is a significant cause of death with 250,000 deaths annually. In the developed world, most costs associated with HPV are relative to detection and treatment of pre-malignant disease; cost in the U.S., $3 billion. In the case of abnormal pap tests in the U.S., over 10,000 cases had cancer and 300,000, dysplasia.

Of the various types of HPV, HPV 16 causes cancer in 53% of cases, HPV 18, 13% of case. Anal cancer due to HPV is now getting more attention since the case of celebrity Farrah Fawcett.

Regarding HPV infection among college-age women, “in the case of a couple hundred women in Seattle who had contacted local clinic for birth control as they were becoming sexually active, from the time of first intercourse the rise in HPV infection rose from 20 to 50 to 60% in four years.

“Just about everyone who has had sex is at risk for HPV.”

Regarding vaccine for HPV 16, involves three injections over a 6-month period, a similar dosing for treating Hepatitis B and is “well tolerated. Women drop out, one for every thousand.” In a phase II study using the quadrivalent HPV vaccine (for treating HPV 6, 11, 16 and 18), it was found to be 96% effective, with only two cases of HPV infection with the vaccine vs. 51 cases with placebo after 60 months. In a phase III study with the same vaccine, found to be “100% effective per protocol analysis.”

Question remains, how long will the vaccine last and provide protection? Will it provide protection in HIV+ women?

Looking at research in how well the vaccine is being accepted by the public…Parents want to protect their children/teens so there is “generally a high level of parent acceptance of HPV vaccine.” Vaccination of children is looked upon positively. An important factor regarding their buy-in for this or any vaccine is, “does it work?” That, and the severity of the disease in question and the doctor’s recommendation play a strong role in whether parents opt for the vaccine.

Cervical cancer, past and present: in 1930, cervical cancer number one in cancer mortality in women in the U.S. In 1941, Papnicolaou publishes his paper in the American Journal of Obstetrics and Gynecology, fathers the “Pap” test; 1950, Fletcher opens cobalt unit at MD Anderson; 2005, 500,000 cases of cervical cancer worldwide; 2006, cervical cancer vaccine introduced. “This is the vaccine prevention generation.”

ACIP recommendations for the vaccine, starting at age 11-12 years; girls get other vaccines at this time, so may be best to do “all vaccines at the same time,” even as young as age 9.

David B. Redwine, M.D., FACOG
Medical Director, Endometriosis Institute of Oregon in Bend, Oregon
Active Staff, St. Charles Medical Center, Bend, Oregon
Endometriosis: Modern concepts of pathogenesis and treatment
Excision is the only therapy proven to cure endometriosis.

Consider monopolar electroexcision which is possible with laser and scissors. Electrosurgery, monopolar, may be unsafe and shouldn’t be used at laparoscopy. Biopolar is the safest while the argon beam coagulator really isn’t appropriate for endometriosis and remains “a device looking for a use.”

How does electrosurgery work? Effect is either through vaporization—an active electrode, causes water to boil, cells to explode and vaporize. Coagulation is achieved by generation of heat which causes proteins to coagulate, but this does not work for for endometriosis as it will leave a crust of desiccated tissue behind as an insulator.

To perform monopolar electrosurgery safely, remember—short bursts, pull tissue away from vital structures, use shaving strokes (avoid pillowing), blunt dissection, traction/counter traction, high power density for cutting and lower power density for bleeders and use the appropriate power for the electrode size and shape.

John Albert Sampson, M.D.’s theory of the origin of endometriosis was that it was due to “reflux menstruation.” In 1921, speculated that peritoneal endometriosis was caused from leakage due to ovarian endometriosis. Further theorized that the ovary is the most common site for involvement re: origins of endometriosis, because of its proximity to the fimbriated end of the fallopian tube. However, the ovaries are not the most common site of endometriosis.

In 1922, Dr. Sampson modified his theory to say that reflux menstruation through the fallopian tubes was the mechanism for the origin of endometriosis. But consider that one out of 15 patients with peritoneal endometriosis had blocked fallopian tubes—where did that patient’s disease come from then?

Is endometriosis an autotransplant, that is the appearance of the endometrium in other areas as though transplanted? Autographs remain largely identical to the tissue of origin. Examples of autographs include skin grafts, pulmonary valve transplants and where the toe is substituted for the thumb. However, endometriosis and endometrium are dissimilar. Endometriosis and endometrium have chromosomal differences, different hormone receptors, different adhesion molecule component, cellular invasiveness, histology, morphology, etc.

Conclusion? Endometriosis is NOT an autograph.

Is endometriosis displaced endometrium? No.

How persistent is endometriosis, how often does it occur. There are some risks of recurrence but not a high risk if you remove all of the disease.

How do you judge cure? 66% were cured by laparotomy excision; 57% by laparoscopy excision.

Theories of origin: endometriosis is NOT reflux menstruation, NOT an autotranpslant (note that endometriosis can occur in males), and not caused by lymphatic spread.

If endometriosis is caused by blood, blood must travel by veins to the heart and lungs so you should see endometriosis occurring in the heart and lungs—pulmonary endometriosis “is extremely rare.”

When endometriosis occurs in males, it is typically connected to male use of estrogen therapy for prostate cancer.

Endometriosis facts: it does NOT spread geographically over time. Extreme plasticity is required, and what’s most plastic? Embryo. Endometriosis is embryologically patterned, determined at conception? At puberty, estrogen makes endometriosis symptomatic. By mid 20s, women have formed most of the endometriosis sites they will ever have.

Dwight Im, M.D., FACOG
Associate Director, The Gynecology Oncology Center, Mercy Medical Center
Adenocarcinoma in Situ/Microinvasive Cervical Cancer: Diagnosis and How Much Treatment?
Today, we see less than 10,000 cases of cervical cancer per year. Ten years ago, that figure was in excess of 13,000, so number of cervical cancer cases in the U.S. is decreasing.

Cervical cancer accounts for 2% of cancer deaths in women.

Of the 500,000 women worldwide diagnosed with cervical cancer, 288,800 will die (by comparison, that’s 9,710 women diagnosed, 3,700 deaths in the U.S.). Cervical cancer is a major issue in the Third World.

Cervical cancer symptoms include abnormal vaginal bleeding in 56% of cases, followed by pelvic pain/pressure (9%), vaginal discharge (4%), abnormal pap smear (28%).

“It is a microscopic disease, by and large, and may not have symptoms.”

Risk factors include HPV infection or other STDs; first sexual intercourse at age 16 or younger; multiple sexual partners; presence of other genital tract neoplasia; smoking, immunodeficiency or HIV positivity; poor nutrition.

“If you can see it in an exam, it is no longer a microscopic disease, which means it is later stage cervical cancer.”

The development of cervical cancer is progressive, “it’s pretty slow, in 30-70% of cases may take 10-12 years” but it can also be very swift in some cases, “in 10%, under one year for appearance of invasive cervical cancer.”

A definitive diagnosis is needed by hysterectomy specimen or conization, i.e. cone shaped biopsy from the cervix, but “stay away from ‘cone biopsy’ term.”

You decide to do a hysterectomy—but what kind? In cases of microinvasive cervical cancer, stage 1A, treatment options include simple hysterectomy, conization, radical hysterectomy and intracavitary radiation alone.

“Treatment of microinvasive cervical cancer is becoming more conservative—conization and follow the patient closely.”

Neil B. Rosenshein, M.D., FACOG
Medical Director, The Weinberg Center for Women’s Health & Medicine, Mercy Medical Center; Director, The Gynecologic Oncology Center
Oopherectomy: Is it Necessary?
Is oopherctomy necessary, i.e. the prophylactic oophorectomy, removal of benign ovaries. Currently, the rate of oophorectomy is 38% in ages 18-44, and 78% in ages 45-64. With approximately 600,000 hysterectomies performed each year, in about 300,000, the benign ovaries are removed.

Consider prophylactic oophorectomy as a risk reducing procedure for ovarian cancer—“Begin using the term Risk Reducing Salpingo-oophorectomy” or RRSO – as primary and secondary forms of prevention. May be appropriate but only in the high risk population who are those who are older, have a family history of the disease and personal history of cancer.

“Patients who have a negative family history, their risk is 1.5%, or put another way, they have a 98.5% chance they WON’T have ovarian cancer. But patients with two or more first degree relatives have a 40% chance of the disease (versus breast cancer stats, 14%).

“So unless ovarian cancer is in your family, your risk of ovarian cancer is quite low.”

Consider women who carry the BRCA 1 and 2 gene mutation—these are women to target. In these patients the incidence of ovarian cancer rises significantly starting in their 30s versus 50s for those without the mutation. If the patient has BRCA ½ and has had breast cancer, even greater risk of developing ovarian cancer.

The risk reduction of developing ovarian cancer drops 60-95% with prophylactic oophorectomy. Why not 100%? If the patient had ovarian cancer going in (occult) or it was there and not detected, and in cases of fallopian tube cancer.

“Do your pathology correctly. Never say ‘to protect her from ovarian cancer,’ but will reduce risk, never eliminate entirely.”

When should you do the procedure? Timing is important. The earlier you perform the surgery, the less risk of developing ovarian cancer. If before the age of 35, risk drops to nearly zero, while somewhat higher for age 35-50, but a more significant increase of cancer incidence over age 50. Also, with the procedure, allows a greater reduction in the risk of breast cancer.

Recommendation? For women who are BRCA-1 positive, at age 35, “that’s the time to talk about oophorectomy.” For those with BRCA-2, can consider waiting to older age and take into consideration patient’s desire to bear children.

Remember, ovarian cancer amounts for only 3% of all cancers among women, 17.1 per 100,000.

“Ovarian cancer is a rare disease.”

On the “con” side, if oophorectomy or RRSO in the premenopausal patient, that patient will now have estrogen issues and need to go on HRT. There are concerns with HRT relative to heart disease, stroke, osteoporosis and quality of life issues. Further, estrogen replacement compliance is an issue as “nobody takes their medications consistently as they should. If you had perfect compliance and removed the ovaries and gave ERT, you have longer survival than if you left the ovaries in.”

“If you do the hysterectomy and leave the ovaries, you still get a 40% reduction” in the incidence of ovarian cancer.

“Ovarian conservation as a general rule until age 65; there are benefits for long term survival.”

Conclusions: Primary RRSO in the BRCA patient is effective in reducing incidence of ovarian cancer. Secondary RRSO conveys little or no benefit in the average risk patient for ovarian cancer…plus there are positive risks of harm by surgery and estrogen replacement.

RRSO “may not be the best thing for your patient. Rethink some of the standards we have had for some time.”