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Dr. Neil B. Rosenshein, Medical Director, The Weinberg Center for Women's Health and Medicine.

Dr. Neil B. Rosenshein, Medical Director Of Mercy's Weinberg Center For Women's Health And Medicine, Leads “Women's Health: Concepts And Controversies” Conference In Downtown Baltimore

Baltimore, MD — For more than 10 years, Dr. Neil B. Rosenshein, Medical Director of The Weinberg Center for Women's Health and Medicine at Mercy and Director of The Gynecology Center at Mercy, has led a conference for physicians and other medical professionals throughout the region regarding women's health care issues.

On Sat., Oct. 25th, 2008, Dr. Rosenshein served as Course Director for "WOMEN'S HEALTH: CONCEPTS & CONTROVERSIES" at the Baltimore Hyatt Regency Hotel.

Speakers included doctors and surgeons from Mercy's medical staff as well as guest speakers Ira R. Horowitz, M.D., S.M., of the Emory University School of Medicine and Stanley A. Gall, M.D. of the University of Louisville.

Here is an overview of the topics and notes from each physician’s presentations:

Is Urodynamic Testing Necessary? (Marcella L. Roenneburg, MD, Urogynecology, Mercy)

What is Urodynamic testing? It’s a series of tests to evaluate the filling, storage and emptying phases of micturition, i.e. the act of urinating.

Urodynamic testing can be single or multichannel. Regards the latter, multichannel testing may entail a look at

Uroflow (emptying phase)
Cystometrogram (CMG) which tests filling and storage of urine in the bladder
Valsalva Leak Point Pressure (VLPP), also regards storage
Pressure Flow (emptying phase)
Urethral Pressure Profile (UPP), storage
The “Q-tip” test, to determine mobility and storage
EMG
Cystouresthroscopy
And video urodynamics

Who needs urodynamic testing?

More than 50 percent of women in the community over the age of 45. Even a woman with a healthy system can have issues. About 20 to 50 percent of women have encountered urinary incontinence.

What the risk factors?

• Age, typically becomes more a problem as we age.
• Ethnicity: Caucasian women, for example, have more problems with prolapse than do African-American women. Looking at prevalence by race, whites have urinary stress incontinence at a rate of 39% versus 27% for blacks and 24% for Hispanics. Overactive bladder appears in 16% of blacks and 19% of whites. “It’s true for men as well, but men have less incontinence.”
• Other factors include obesity, parity and hysterectomy,

“So how do you decrease your risk? Don’t be white! Only have C-sections and normalize your weight.”

A large percentage of bariatric surgery patients, at least half, become dry as they lose weight.

The cost of dealing with urinary incontinence in the U.S. (2000) was $32.1 billion. 70 percent of that is for “routine care,” i.e. pads, laundry, etc. More people are actually in nursing facilities due to urinary incontinence issues than due to dementia. 76% of the costs due to UI are for women.

What are the symptoms of overactive bladder?

• Frequency
• Urgency
• Urge Incontinence
• Triggers such as running water, changing position, even “putting the key in your front door.”

Before beginning therapy for overactive bladder, first
Write up a patient history
Conduct a physical examination
Conduct a urinalysis
Take a urine culture and sensitivity test
Measure residual urine

Overactive bladder therapies include timing the amount of times you need to void (every two hours?), avoiding bladder irritants like soda, coffee; do pelvic floor therapy and use anticholinergic medications.

What are the indications that the patient requires multichannel Urodynamic studies?

Patient continues to retain urine after voiding.
Urge incontinence is not responsive therapy
Nocturnal enuresis (urinating at night) is not responsive to therapy
Frequency of urination, urgency and pain syndromes also not responsive to therapy.

“Looking at the urodynamic studies, a drop in the urethra pressure is the initiating event before incontinence occurs.”

“Genuine stress incontinence is where there’s an involuntary loss of urine occurring during physical exertion.”

What’s needed prior to beginning therapy for stress incontinence?

• take patient’s history
• conduct physical exam
• conduct urinalysis
• take urine culture/sensitivity
• measure residual urine
• gauge bladder capacity and voiding frequency
• positive cough stress test
• “Q-tip” test

Urinary Stress Incontinence can be diagnosed without multichannel urodynamic testing when there is

• Predominant complaint of stress incontinence
• Positive stress test
• Post void residual urine volume of no more than 50 ml
• Functional bladder capacity of at least 400 ml as determined by a completed 24 hour frequency/volume voiding diary

“In cases of Urodynamic-proven stress incontinence, it is TWICE as likely to have a positive outcome after surgery.”

“People can predict stress incontinence, but urodynamics gives you a much bigger view of the patient’s situation.”

Indications for Multichannel Urodynamic Studies includes

• Complicated history
• Stress incontinence before surgical correction
• Urinary incontinence after surgery for stress incontinence
• Pre-Operative evaluation prior to surgical repair of prolapse
• Urinary retention
• Lower urinary tract dysfunction after pelvic radiation or radical pelvic surgery
• Neurologic disorders
• Continuous leakage
• Suspected voiding difficulties

“There remains no clear consensus as to whether urodynamic testing enhances surgical outcomes of stress urinary incontinence. However, urodynamic testing may provide prognostic information about risks of voiding dysfunction or urge-related leakage after surgery.”

“People with stress incontinence considering surgery should have urodynamic studies for what we DON’T see.”

“The FDA is making a cautionary announcement to physicians and patients regarding mesh sling surgery. In about 1,000 cases of mesh sling surgery, there has been erosion in three years. Physicians must counsel their patients about the risks before surgery. Check the FDA website for more details.”

Genetic Susceptibility to Cancer--BRCA Testing: Who & When (Kathy J. Helzlsouer, MD, MHS, Director, Prevention & Research Center, Mercy Medical Center)

Determining risk…Take a family history (genes and exposures track in families). “History is the key.”

“Genes and environment are passed down. Note the patient’s personal exposure as they may have received radiation treatments for acne, patients with scoliosis have had multiple X-rays, so it’s not always just the genes.”

“Take a cancer family history”

• Obtain at least a 3-generation pedigree (“That’s patient, children, parents, grandparents, aunts and uncles…”)

“And don’t just check the women. You have to think about Dad too, look at BOTH sides of the family.”

• Ask about all individuals in the family and record the following:
• Age at cancer diagnosis, age at and cause of death
• Distinguish primary from metastatic sites
• Precursor lesions, bilateral multiple cancers
• Pertinent prophylactic surgeries
• Associated congenital abnormalities
• Record ethnicity and race

How much breast and ovarian cancer is hereditary? Between 5-10 percent.

“Was the liver cancer a primary tumor? We’re doing a better job of colon cancer screening which means we’re finding multiple polyps before they become cancer. The patient might not have a history of ovarian cancer, but you note that all her sisters had hysterectomies at early ages. And not that some ethnic groups are at higher risk. Family history changes over time, so you need to keep checking a patient’s history.”

“Ten percent of all cancers have a hereditary component. Even lung cancer has been found to have a familial component. In families with incidence of breast cancer only, have found BRCA 1 & 2 mutation 50 percent of the time. However, there are other genetic syndromes that we currently can’t test for,” such as the Li-Fraumeni, Cowden, Peutz-Jeghers and Ataxia-telangiectasia genetic disorders.

“Ovarian cancer may be part of several cancer family syndromes.”

Regards the causes of hereditary susceptibility of ovarian cancer, BRCA-1 mutation appears 75%, versus 15% for BRCA-2.

BRCA-1 and BRCA-2 associated cancers: lifetime risks

• breast cancer, 40-85% (often at an early age of onset)
• contralateral breast cancer, 40-60%
• ovarian cancer, 15-40%

In men with the mutation, the risk of breast cancer is elevated and some studies suggest that the risk of prostate and pancreatic cancer are also elevated.

When to suspect Hereditary Cancer Syndrome…

• cancer in two or more close relatives (on same side of family)
• early age at diagnosis
• multiple primary tumors in the same individual
• bilateral or multiple rare cancers
• constellation of tumors consistent with specific cancer syndrome (e.g. breast and ovary)
• evidence of autosomal dominant transmission with multiple affected generations and the presence of congenital anomalies or syndrome associated benign lesions

What clinical decisions do women need to make who are at risk for breast or ovarian cancer?

• Breast cancer chemoprevention therapy with tamoxifen, raloxifene
• MRI in addition to mammography
• Screening for ovarian cancer
• Risk reducing surgeries such as breast, hysterectomy, oophorectomy (removal of the ovaries)

How to interpret a negative result. “Concerning a negative genetic test, does not always mean that cancer susceptibility is not a factor. 50% where inheritance is suspected are negative on the BRCA-1&2 test. Sometimes other syndromes are at play, not yet discovered.”

“You can have more than one mutation.” Noted recent case of a family that had both Cowden’s syndrome and a BRCA2 mutation.

In summary, a family history is a “critical part of the medical history.” Note the “red flags” for a genetic counseling referral:

• Early age of onset
• Multiple relative/generations (same side)
• Combinations of cancers (breast ovarian, colon/endometrial)
• Multiple primary cancers

“Clinical management does impact high risk individuals. What you discover may make the difference between whether a patient requires a lumpectomy versus a radical bilateral mastectomy.”

Breast MRI: How to Apply (Dalliah M. Black, M.D., Hoffberger Breast Center at Mercy)

Recently, news of actress’ Christina Applegate’s breast cancer that was identified by MRI has increased patient interest in MRI.

Mammography is the current screening imaging modality shown to reduce breast cancer mortality, but with limitations in sensitivity and specificity.

Over the past five years, technologic advances have increased the use of MRI, but there is little long-term outcome or survival data currently available to support the effectiveness of using breast MRI.

In using breast MRI, what’s involved?

• Gadolinium contrast
• Signal intensity is more important than time
• Lesion morphology versus size
• Menstrual cycle (best to have MRI at least one week after the patient’s period)
• Equipment

“Be sure to discuss the patient’s background with the radiologist” as it is helpful in conducting review of the MRI scan.

How does MRI screening compare to mammography and ultrasound?

MRI finds 1.5-3 times the number of cancers.
MRI also yields 3.-4.5 times as many FALSE positive biopsies
“There’s no proof of the benefit of MRI, even though it is thought to be the case.”
“The best combination is to have MRI and a mammogram.”

The American Cancer Society recommendations for MRI screening in addition to Mammography are:

• In cases of patients who are BRCA mutation carriers
• First degree relative of a BRCA carrier
• Patients with a lifetime risk of breast cancer of 20-25% (mainly based on family history)
• Patients who have had central chest radiation
• Genetic syndromes like Li-Fraumeni and Cowden

If the patient has a life time risk of breast cancer of 15-20 percent, has lobular carcinoma in situ, atypical ductal or lobular hyperplasia, extremely dense breast tissue, or in cases of women with a personal history of breast cancer, these items alone are not sufficient evidence for an MRI screening. There’s either insufficient evidence or no data that MRI is beneficial.

“MRI can be used in following patients currently in treatment for breast cancer.”

“What MRI misses is likely to be a ductal carcinoma in situ (DCIS) {Ductal carcinoma in situ. A precancerous condition characterized by the clonal proliferation of malignant-looking cells in the lining of a breast without evidence of spread outside the duct to other tissues in the breast or outside the breast. DCIS is clearly the precursor (forerunner) of invasive breast cancer.}

“A negative breast MRI cannot obviate the need for tissue diagnosis in a patient with a suspicious mammogram, ultrasound or clinical exam.”

MRI Limitations:
A false negative rate of 4-12%. False positive lead to an increase in excised tissue and unnecessary mastectomy.
Cost/availability/interpretation issues. “MRI may cost $2,000 or more.”
“Also, MRIs don’t ‘carry’ well,” i.e. don’t do well when patients have on disks, etc.

“If you’re going to order a breast MRI, prepare the patient. Explain false positives versus true positives. Some patients may simply be followed, while others may be biopsied.”

Fertility, Pregnancy, and Inflammatory Bowel Disease (Mary L. Harris, M.D., Institute for Digestive Health & Liver Disease, Mercy)

Ulcerative colitis is typically limited to the colon while Crohn’s Disease may affect any part of the GI tract.

The influence of genetics is greater in cases of Crohn’s Disease (CD) and Ulcerative colitis (UC).

Questions commonly asked by IBD (Inflammatory Bowel Disease) patients…

• How will my IBD impact my sexual health?
• Is this inherited? Will I pass this along to my children?
• Will my IBD impact my ability to have children?
• How will my IBD affect my pregnancy?
• Can I take my IBD medications when I’m trying to conceive? When I’m pregnant?
• Will my IBD impact how I deliver? Vaginally, C-section?
• Will I be able to breast feed?

Sexual Health
IBD patients have body image problems related to weight loss/weight gain and growth retardation; hirsutism (body hair growth), fistulae or perineal disease and stoma surgery.

“IBD patients may have difficulties in establishing social relationships given their concerns about how their IBD impacts their sexual health. They fear having impaired sexual function, such as impotence or even fear of fecal incontinence.”

Inheritance
The strongest predictor for developing IBD is a family history. If both parents have IBD, the child’s risk of the disease is 35-50 percent.

IBD and Fertility/Women’s Issues
In cases of UC, women experience a normal fertility rate overall. In CD, pelvic inflammation can decrease fertility. Voluntary childlessness is typically higher in IBD patients.

Disease Activity in Pregnancy
Education, planning, nutritional assessment is required
Folic acid should be taken before conception
Maintenance activity in treating IBD should be continued and flareups should be actively treated
“The disease activity is more dangerous than most drugs taken for treatment of IBD.”

How safe are IBD medications taken during pregnancy?

Oral and topical mesalamine, Sulfasalazine, Ciprofloxacin, metronidazole (after first trimester), and Corticosterioids are safe; there is limited data as to the safety of Azathioprine, 6-Mercaptopurine, Cyclosoporine and Infliximab; CONTRAINDICATED are Methotrexate, Thalidomide, Diphenoxylate, Doxycycline and Tetracycline.

If you’re going to do surgery on an IBD patient, avoid the first trimester of pregnancy, “that’s when you’ll have the highest risk of pregnancy complications. The third trimester offers technical challenges and the chance of a premature delivery. The second trimester is generally regarded as the ‘safest’ period for surgery.”

Impact of IBD on Pregnancy Outcomes
IBD can be associated with low birth weight, premature delivery, small for infant’s gestational age, some increase in spontaneous abortions in CD when there is active disease in the first trimester. Typically, adverse outcomes are due to disease activity. Inactive IBD has little impact on pregnancy.

Typically we see an increased rate of C-sections among IBD patients due to such issues as

• Fetal distress
• Preeclampsia
• Breech birth
• Cephalopelvic disproportion
• Maladvancement of labor
• The advice of the surgeon/obstetrician
• Patient preference

What drugs are safe to take for IBD during breastfeeding?

Oral and topical mesalamine, Sulfasalazine and Corticosteroids are safe; there is limited data regarding Azathioprine, 6-Mercaptopurine and Infliximab; but is CONTRAINDICATED for Methotrexate, Thalidomide, Cyclosporine, Ciprofloxacin and Metronidazole.

To best manage pregnancy in patients with IBD, have early and adequate prenatal care. Assess the patient’s nutrition, is it adequate? If there is low maternal weight gain you risk a lagging in fetal growth. Assess fetal well-being via ultrasound. The OB and IBD physicians should work closely together.

In Summary

• Fertility is affected in post-surgical UC and in active Crohn’s Disease.
• There is NO increase in adverse outcomes with nonactive IBD.
• Active disease at conception increases the risk of an adverse outcome.
• The majority of medications for IBD are SAFE in pregnancy.

“A good, reliable set of bowels is more important than brains.”—Josh Billings

Cardiovascular Disease Prevention in Women: Should Every Woman Be on Aspirin? (Mark M. Applefeld, M.D., Cardiology, Mercy)

1899 Aspirin became commercially available.

In a 1956 study of 8,000 obese patients, most with “poor diets,” taking 300-600mg of aspirin daily, in a 7-year followup discovered NO cases of cerebral thrombosis or coronary thrombosis.

Cardiovascular Disease in Women: What’s the Big Deal Anyway?

Atherothrombotic disease – CAD, Stroke – is the LEADING CAUSE OF MORBIDITY AND MORTALITY in women in the United States.

CAD causes 500,000 deaths annually, more than in men, and more than the next seven causes of death in women. The clinical manifestations of heart disease are seen 10 years later in women than in men. Within the first year of the initial recognized MI (heart attack), more women than men die (38 to 25%).

“In the 1990s, the issue of gender bias in trials regards women began gaining attention. 18 years later, women are still under-represented.”

“The benefits of aspirin for secondary prevention in men and women, 80-325 mg., to reduce cardiovascular risk are well established.”

There are six primary prevention trials of aspirin benefit, but of those six trials, only one featured all women.

The Women’s Health Initiative study of 39,876 women older than age 45 with NO prior cardiovascular disease in a random trial, 100 mg of aspirin every other day versus placebo. Findings indicated that aspirin reduced the risk of Ischemic Stroke by 24%, but NO effect on the risk of a fatal or nonfatal MI (heart attack) in women less than 65 years of age.

“Routine use of aspirin in healthy women under the age of 65 is NOT recommended to prevent MI, but may be considered when benefit of ischemic stroke prevention likely to outweigh adverse effects (such as GI bleeding) of aspirin,” the WHI study concluded.

BUT…Was the issue of aspirin resistance taken into consideration with tis study. Women have been found to have 2-3X higher rate of aspirin resistance than men—was the dose amount of aspirin in the WHI study TOO LOW? Aspirin’s efficacy can also be affected by drug interactions and patient pre-existing conditions like diabetes.

Secondary prevention trials of the effects of aspirin (British Medical Journal, 2002) note the effects of aspirin are similar in men and women. Aspirin decreases the risk of fatal and nonfata MI to comparable degree in men (19%) and women (25%) as well as stroke in men (17%) and women (22%).

Classification of cardiovascular risk factors in women:

Women considered “HIGH RISK” have established disease, diabetes, AAA (abdominal aortic aneurysm) or chronic renal disease.

INTERMEDIATE RISK—coronary calcification, carotid stenosis; family history, more than one risk factor.

LOWER RISK—sedentary lifestyle, hyperlipidemia (LDL cholesesterol of mg/dl) and subclinical vascular disease (breast arterial calcifications that may appear on a mammogram).

To assess women’s cardiovascular risk, conduct a lipid panel; CT scan for coronary artery calcifications (issue is, scans pick up only on hardened calcifications, not noncalcified plaque).

Looking at the long term prognosis of coronary artery calcification, approximately 25,000 in the study, about half women, found that “as calcifications rose, heart disease death goes up.”

How to treat? The benefits of using statin therapies decline with decreasing baseline LDL cholesterol level. Statins do reduce soft cholesterol levels and inflammation.

Potential of Vitamin E still being examined, doesn’t seem to be very useful initially and could actually be harmful in the long-term.

Osteoporosis Treatment: Weekly, Monthly, Yearly (Errol H. Rushovich, M.D., Director, The Center for Bone Health/Division of Endocrinology, Mercy)

What is osteoporosis? A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

Osteoporotic fractures increase with age. There are 600,000 verterbral fractures each year, accounting for 27% of all fractures for those over age 50. Hip fractures, 300,000 per year and these increase over the age of 75.

The most common secondary causes for low bone mass include endocrine disorders (e.g. hypogonadism, hyperthyroidism, hyperparathyroidism, Vitamin D insufficiency/deficiency), gastrointestinal disorders (e.g. Celiac Disease, inflammatory bowel disease; also cirrhosis); and bone marrow disorders (leukemia and lymphoma, multiple myeloma).

Other secondary causes for low bone mass include connective tissue disorders (rheumatoid arthritis), renal disorders, and medications that can cause bone loss (including chemotherapy and immunosuppressive agents, corticosteroids, excess thyroid hormone, heparin, antiepileptic drugs, aromatase inhibitors).

There is now a “Fracture Risk Calculator” that became available online in 2008.

What drug options are available for osteoporosis?
“First line therapy remains bisphosphonates.”
Bisophosphonates (e.g. Fosamax, Actone, Boniva, Reclast)
SERMs (Raloxifene/Evista)
Nasal Calcitonin
Parathyroid Hormone

Fosamax, Actonel, Reclast and Forteo (Teriparatide) have all been shown to reduce spine and hip fractures. Boniva, Miacalcin/Raloxifene and Miacalcin/Nasal Calcitonin effective for spine ONLY.

“Evidence to date is insufficient to determine whether one bisphosphonate is superior to another with the exception that Boniva does not reduce nonvertebral fracture.”

“Use bisophosphonates interchangeably but stay away from Boniva for hip fractures.”

Regarding intermittent dosing and side effects. Side effects include gastrointestinal, adverse renal effects, hypocalcemia, musculoskeletal pain, osteoneocrosis of the jaw, atrial fibrillation, etc.

“Patients prefer intermittent dosing by 76%. Adherence to taking medication is easier, adaptable to one’s lifestyle, but compliance and persistence is poor with ALL dose schedules. IV dosing annually may be advantageous.”

Regards costs, Alendronate is “about $100 a year, something to consider when other drugs may cost over $1,000 per year.”

How often should you conduct a bone density scan? As a general screening, once every two years; if following a patient, every 1-2 years.

HIV Testing in the 19-64 Year Old Female (Stanley A. Gall, M.D., University of Louisville)

HIV screening is now recommended for patients in all healthcare settings after notification that the testing will be done (patient may opt-out, refuse the test; persons at high risk for HIV infection should be screened at least annually).

“HIV screening will ultimately become a regular part of your panel.”

Separate written consent for HIV testing should be required, a general medical consent should be sufficient. Prevention counseling should not be required with HIV diagnostic testing.

HIV screening should be included in prenatal lab panel for all pregnant women. HIV screening is recommended after the patient is notified that testing is to be done unless patients “opt out.”

In December 2004, there were 944,305 people diagnosed with AIDS; 529,113 died of AIDS that same year. The number of annual AIDS cases has declined after 1994 and stabilized, 1994-2004.

By 2002, 38-44% of all adults in the U.S. were tested for HIV; 16-22 million persons aged 18-64 are tested annually for HIV; 300,000 people “are unaware of their HIV diagnosis.”

Persons who are tested late for HIV are more likely to be Hispanic or African-Americans.

In 1985, the main goal of HIV testing was to protect the blood supply; the meaning of a positive HIV result was uncertain; there was no consensus as to whether a positive test predicted transmission to sex partners or from mother to infant.

By 1987, HIV counseling had become a higher priority. “This meant for many doctors’ offices that someone needed to be hired to provide HIV counseling so, in many cases, this never happened.”

By 2003, a movement was underway to make HIV testing a part of routine medical care on the same basis as other medical tests. In 2004, efforts were underway to simplify the HIV screening process, make it less costly, more feasible and more frequent testing of patients with symptoms. Still, “a lack of progress” remains.

“Patients are referred to HIV testing sites when you could do the test in your office. You can’t look in a person’s eyes and say, ‘you’re a low risk.’ HIV risk occurs on all socio-economic levels.”

HIV screening recommendations:

• HIV screening on patients ages 13-64
• All patients starting TB (tuberculosis) therapy
• All patients treated for STDs (sexually transmitted diseases)

Recommendations for Pregnant Women re: HIV testing

• Make HIV testing a routine component of the prenatal lab assessment
• Test should be voluntary
• No additional process or written informed consent beyond what is required for other prenatal tests
• Document if a patient declines testing
• Conduct retesting at 36 weeks of pregnancy

“In summary, screen all patients ages 13-64. Screen all pregnant patients at least once. And re-screen all high-risk patients.”

Advanced Endoscopic Surgery (Fermin F.Barrueto, MD, Chief of Endoscopy and Pelvic Reconstruction; Kevin Audlin, M.D.; Christine E. O'Connor, M.D., Mercy)

Total Laparoscopic Hysterectomy (TLH) vs. Total Abdominal Hysterectomy (TAH) – Dr. Fermin Barrueto

Hysterectomies in the US

• 600,000 hysterectomies are performed each year—it’s the 2nd most common procedure in the U.S. after cataract surgery
• Cost of greater than $5 billion

Reasons for hysterectomy include

• symptomatic uterine leiomyomas
• abnormal uterine bleeding
• pelvic endometriosis, adenomyosis
• chronic pelvic inflammatory disease
• pelvic adhesions

Why choose laparascopic versus abdominal hysterectomy? “There’s no better way to look at the pelvis than endoscopically.” Reasons include:

• Magnification of anatomy and pathology with excellent view of the deep pelvis
• Low infection rate and ileus
• Minimally invasive
• Decrease the length of surgery
• Prevention of V.V. prolapse
• Faster recovery time, more comfortable

Study of use of TLH in Finland revealed higher incidence of ureteral injury, but given the number of cases and number of trained physicians in Finland, believe a case of surgeons not experienced in performing TLH. “The role of the experience of the surgeon has to be taken into account.”

Dr. Barrueto then screened video of a TLH using the “harmonic ACE” or ultrasonic scalpel which coagulates, cuts and dissects, sealing 5mm vessels.

Narrow Band Imaging for Identification of Endometriosis—Dr. Kevin Audlin

There are no exact numbers as to what percentage of women have endometriosis since an unknown amount have no symptoms.

Estimations are that endometriosis is found in 1% of all gynecologic major surgeries and in 5-7% of all women undergoing tubal ligation. 50% of adolescents who undergo laparoscopy for pelvic pain and dysmenorrhea are believed to have endometriosis.

Endometriosis is most often diagnosed between the ages of 25-35 and is more common in whites than in Asians or African Americans. “There’s a higher association of endometriosis with taller, thinner women,” and is more prevalent in higher socioeconomic classes and women who delay pregnancy.

A survey of the Endometriosis Association noted a higher rate of autoimmune disorders among patients diagnosed with endometriosis.

How can we identify endometriosis? Narrow Band Imaging (NBI)

“NBI is a novel approach by which a narrow band wave lengths are displayed within the pelvis during laparoscopy…Higher concentrations of hemoglobin, found in the hyper-vascular implants will be visually distinct when exposed to the blue light specture.”

Presacral Neuorectomy – Dr. Christine O’Connor

Women dealing with chronic pelvic pain may see a physical therapist, psychistrist, gastroenterologist, internal medicine physician, etc., all to “try to provide normal function.”

Medical treatments include nonsteroidal anti-inflammatory drugs and opiads, Lupron, SSIs and even anticonvulsants.

Surgically, the Presacral Neurectomy is one of the described methods of surgical interruption of the pelvic nerve pathways for dysmenorrheal. It is ideally performed in combination with conservative laparoscopic treatment of endometriosis in patients with severe, central dysmenorrheal.

Presacral Neurectomy involves removal of the Lee-Frankenhauser nerve plexus.

The Pigmented Lesion: To Biopsy or Not (Craig A. Vander Kolk, M.D., Plastic & Reconstructive Surgery, Mercy)

“99% of us have pigmented lesions and the number of these increase as we age. One in six Americans will get skin cancer. The majority of these are basal cell carcinomas. Melanoma is the 8th most common cancer. One in every 1,500 born in 1935, but one in every 103 born in 1993, so the incidence has greatly increased.”

The American Cancer Society recommends a complete skin exam every 3 years for those 20-39 years of age, and once a year over the age of 40.

In diagnosing a potential skin lesion as cancerous, check its history, has there been a change in the lesion? “Keep in mind the ‘ABCD’ rule,” which is

• Assymetry
• Border & Bleeding
• Color & Change (“does the lesion look like the Chesapeake Bay?”)
• Diameter (“typically about the size of a pencil eraser”)

Types of Lesions: Nevi, Kerotosis, Cysts and Fleshy Lesions, Vascular Lesions, Miscellaneous Lesions and Malignant Lesions.

“hemangioma” is the most common benign vascular tumor, particularly common in children like “port wine stains” that can best be treated by laser.

To diagnose, biopsy, either incisional or excisional.

Scars—“A keloid is a tumor of a scar.”

“Usually you want to let scars heal on their own for the first six months. You can later treat with elastic pressure support tape, steroid injections, silicone sheeting or excision.”

Prevention? “It’s never too late” to take preventive steps:

• Avoid, cover up and use sunscreen
• Wear sunglasses
• Use Retin A, Effudex and Laser Therapy

HPV Testing: Should it be Standard? (Ira R. Horowitz, MD, SM, Emory University School of Medicine)

“Is it time to retire the Pap smear? Should HPV testing replace the Pap?”

There are 5000-8000 cervical cancer deaths each year and 14,000-16,000 new cases of cervical cnacer annual at a cost of $480 million.  Here are 2,500 new cases of HPV disease documented each year.

Cervical cancer has a racial connection with a greater incidence among Native Americans, then Hispanics, African-Americans and then whites. 

“Cervical cancer is a problem throughout the world, not just the U.S.”

Cervical Cancer Risk Factors
“HPV is the most important risk factor.”
There are 100 HPV types that infect humans

High risk group A: HPV types 16, 31, 33, 35, 52 and 58 (50% of cervical cancers will have)

High risk group C: HPV 18, 45, 39 (30% of cancers)

Cost of dealing with cervical cancer/HPV “is over $3 billion in the U.S.”

“When you look at HPV in young adults, you se it increasing,” but for those over age 30, “that’s where you see the increase in cervical cancer. 30 is that magic age.”

Vaccine Therapy in the Sexually Active Female (Stanley A. Gall, MD, University of Louisville)

Vaccine preventable STDs include
Human Papilloma Virus (HPV)
Hepatitis B Virus (HBV)
Hepatitis A  Virus (HAV)

“Hepatitis C is not yet preventable by vaccine.”

“Hepatitis B is 2nd only to tobacco among known human carcinogens.”

“HBV can survive at room temperature on environmental surfaces for seven days with up to a 160 day incubation period.”

Clinical characteristics of Vaccine Preventable Hepatitis (VPH)
HAV – symptoms are age related (no symptoms in 70% of children under age 6; symptomatic in over 70% of older children and adults; illness generally lasts less or no more than 2 months; high morbidity rate, but low mortality.
HBV – 50% of acute infections in adults are without symptoms with 5% of all HBV infections progressing to chronic infection which accounts for most of the morbidity and mortality with HBV infection

“In 2005, 33% of patients with HAV were hospitalized with annual costs between $332-580 million. 25% of those with chronic HBV infection die prematurely from liver cancer or cirrhosis. There are 1-1.25 million chronic HBV carriers in the U.S.”

Vaccine Preventable Hepatitis (VPH) can be transmitted sexually.

There are 67.5 million people infected with an STD (e.g. Chlamydia, genital herpes, HPV or HBV).

“Vaccination is one of the most effective ways to prevent Hepatitis A and B.”

“International travelers are at higher risk of exposure to VPH.”

Why give the HPV vaccine?
There are 10,370 new cases of cervical cancer and one million new cases of genital warts.

HPV is present in virtually all cervical cancers, 99.7%.

Goal of HPV vaccine is to reduce transmission, reduce cervical cancer, reduce incidence of genital warts.

HPV vaccine is 90-98% effective.

Current recommendations for giving the HPV vaccine—girls/women ages 11-26 who have not previously been vaccinated and “this could go down to age 9.”

“HPV vaccine can be given with any other vaccine.”

Can HPV vaccine be given to someone who is immunosuppresed? “Yes, but how much response depends on how much the patient is immunosuppressed.”

In summary:
HPV causes extensive disease of the cervix, vaginal, vulva, anus, and oral pharynx.
HPV vaccine has been shown to be immunogenic, efficacious and safe
HPV vaccine prevents persistent infection and disease due to vaccine HPV types.

Endometrial Cancer: How Much Therapy? (Dwight D. Im, MD, FACOG, Co-Director, The Gynecology Center at Mercy)

There are 40,000 cases of endometrial cancer and 7,000 deaths of endometrial cancer (2008)

Risk factors include

• Hormone replacement therapy (HRT)
• Obesity
• Anovulatory cycles
• Estrogen-secreting tumors
• Age
• Late menopause
• Hypertension
• Diabetes
• Prior exposure to radiation

“There is no ideal method of screening for endometrial cancer.” However, endometrial cancer screening may be justified for:

• Post-menopausal women on unopposed exogenous estrogens
• Women with families with hereditary nonpolyposis colorectal cancer
• Premenopausal women with anovulatory cycles (PCOD)

“You should never experience a period that is bigger than your normal period.”

Endometrial cancer: signs
During the physical exam, notice

• obesity, hypertension, postmenopausal
• 35% however are not obese and not hyperestrogenic
• “abdominal exam is usually unremarkable”
• Pelvic exam—uterus may be bulky, but often not enlarged

“In the U.S. only 30% of endometrial cancer patients are surgically staged and gynecologic oncologists are consulted in only 45% of these cases.”

“By involving the gynecologic oncologist, you reduce the use of XRT (Whole-pelvis external-beam radiotherapy, or radiation treatment) and experience improved survival after staging.”

Chemotherapy is warranted in advanced or recurrent endometrial cancer. In cases of young women with endometrial cancer (under age 50), “look for Lynch syndrome,” offer genetic counseling and testing.

Should CIN (Cervical Intraepithelial Neoplasia) be Treated?* (Neil B. Rosenshein, M.D., FACOG, Mercy)* Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the potentially premalignant transformation and abnormal growth (dysplasia) of squamous cells on the surface of the cervix.

CIN is “precancerous lesions of the cervix.”

“Is there an inevitable progression from CIN 1 to CIN 3 to cancer?”

CIN is “a very slowly progressive issue, if it progresses at all.”
CIN1 progression to cancer is less than 1 percent; 5% in CIN2 and 22% in CIN3.

This year there will be 11,000 cases of invasive cervical cancer.

“If CIN was rapidly progressive, we’d have a significantly greater number of cancers.”

In the case of CIN/HPV lesions, “Most HPV lesions are transient with 75% clearing on their own in 6-18 months, and 80-90 percent clearing in 2-5 years.”

“We need better terminology. Better to classify low grade and high grade lesions.”

Low grade lesion – CIN1/Early CIN2
High grade lesion – Late CIN2/CIN3

“Should CIN be treated? Primum Non Nocere –First, do no harm. You don’t want to subject young women to unnecessary procedures.”

Best to monitor CIN; cervical cytology, colposcopy, and biopsy in expectant cases; immediate, use ablative treatment, cryotherapy or laser ablation.

Should CIN be treated? No, in cases of CIN1 and early CIN2. “There are fertility issues, pregnancy to consider.”

Should CIN be treated? Yes, in case of late CIN2, CIN3.

Special attention should be given to the immunosuppressed patient (e.g. transplant patient, HIV positive patient)

“Improper management of CIN can increase the risk of cervical cancer on the one hand, and complications from over treatment on the other.”