February 11th, 2009
I am 46 years old. History of fibroids. Married with three teenage children. Husband does not want any more children. I do, but don’t have the energy for another small one. I am in moderate constant pain from the fibroids. It’s like walking around with a dull ache inside my abdomen. I also have painful ovulations. My doctor told me today that a hysterectomy is my only alternative as I already had fibroid surgery five years ago. Are there any other options for me? A hysterectomy seems so final. Thanks!
Ann
ANSWER:
Thank you for your question. It is often stated that after a myomectomy the only choice is hysterectomy, but this is not the case. I have on several occasions performed a second or even a third myomectomy for patients either eager to get pregnant, possibly ambivalent about getting pregnant, or just wanting to keep the uterus they came into this world with intact. There are studies showing that myomectomy is not surgically riskier than hysterectomy, is not associated with greater blood loss than hysterectomy, and only in very rare instances can result in very good outcomes. There are rare cases of fibromatosis (where the uterus has over 100 tiny fibroids) that are not very successful, but this condition is not common. Since fibroids are benign and since they stop growing at menopause and actually shrink, I would recommend another myomectomy to any woman not ready or interested in hysterectomy. The benefits of hysterectomy are that no further fibroids can grow, there will be no further menstrual bleeding at all, and estrogen replacement if desired will not need to be balanced with progesterone. Still, if uterine preservation is necessary or desirable, myomectomy is the way to go.
There are other options for fibroids if bleeding is the problem such as resectoscope myomectomy and ablation but this will not treat the pain. There are drugs that put you into temporary menopause and stop the growth and bleeding of fibroids, but not always the pain.
If you cannot find a doctor to take care of this near you, we have many patients who come for care here in Santa Monica from all over the country. Best of luck in your quest.
Amy Rosenman, MD
Tags: fibroids, hysterectomy, myomectomy
Posted in Answers to Patient Questions | No Comments »
February 10th, 2009
Today I had a most interesting conversation with a new patient about the merits of mesh repairs for prolapse. Her research had alarmed her that there was limited long term information available on the new mesh repairs, especially the new kits that place the mesh through vaginal incisions. She said something that struck me as insightful. She said “If there is a significant risk of erosion of the mesh, or marrowing and discomfort in the vagina I would rather have the prolapse!”
Coincidentally I attended a discussion of mesh with the director of Urogynecology at UCLA. I had the privilege of training him as a resident and fellow. He reviewed the literature on vaginal mesh repairs and concluded that the patient must be openly consented for all the possible complications we are now aware of. He agreed that it takes at least 3 years on the market for new materials to be properly evaluated for long term safety. We are now at the 3 plus year mark and we are learning that the placement of vaginal mesh has some complications. I have decided that I will not use these mesh kits for repairs the first time, that I may only use them if a previous repair has failed requiring re-operation. This is just a small sub-group of patients.
In my experience I have seen several women who had this mesh placed elsewhere and then had complications. They were uncomfortable and in many cases I had to remove part or most of the mesh. It is quite difficult to remove all the mesh because it grows into the surrounding tissue. These women were uncomfortable with either pelvic pain, discharge and bleeding or all of these symptoms. Each of them said if they had understood the risks they would not have proceeded with the mesh. For the first (or a primary) repair it is usually advisable to use the native tissue and perform the least invasive surgery possible. In my hands that is a transvaginal hysteropexy or colpopexy ( uterine or vaginal suspension through the vagina) or a laparoscopic vaginal suspension if the woman has already had a hysterectomy. These procedures have good success, in the 80% range, and if there is a recurrence, it rarely requires another surgery, and if it does, we may have more information about mesh repairs by then.
At this time I will reserve my judgement and stick to native tissue repairs in most circumstances especially since the FDA (Federal Drug Administration) which regulates medical and surgical devices issued a warning about vaginal mesh last November 2008 pointing out that there are more mesh related complications than originally expected. Most of these are mesh exposures in the vagina and pain with intercourse. The erosion rate was in the 10 – 13% range. I agree with the above patient, I would rather have prolapse, or try a procedure without those particular risks, even if it had slightly more recurrences.
Tags: mesh, prolapse
Posted in prolapse | No Comments »
January 21st, 2009
In the past 3 days I have been asked by at 21 year old, a 24 year old and a 32 year old woman if it is possible she could have prolapse. One of these women had a five month old baby but the other two had never been pregnant. Although it is not too common, it can happen that the support in the pelvic area is less than it should be and the uterus, bladder and rectum can sag a bit and possibly bulge at the vaginal opening. If the prolapse is not severe, Kegel exercises are helpful in reducing the bulge, especiallyif there is not any birth trauma. If the bulge is significant it is helpful to use a device in the vagina to support the pelvic organs such as a pessary, a diaphragm-like object that gives extra support to the uterus, bladder and rectum. The pessary is not felt, can be placed by the woman herself and is removed every night for hygiene and to allow for sexual intercourse.
There is a relatively new device on the market called a Colpexin which is ideal for younger women. It is a spherical firm ball that is used to give added support to the pelvic organs by placing it in the vagina. Kegel exercises are performed with it in place and it increases the effectiveness of the Kegels with a mild biofeedback letting you know to contract the correct pelvic floor muscles. It can be fit by a urogynecologist in the office and costs under $150 for the device.
If you plan to have children, definitive surgical repair should be put off until you are finished with pregnancies. When this is not possible and surgical repair is a necessity, cesarean birth is usually recommended to avoid disruption of the previously repaired area.
There are some risk factors to prolapse at any age: childbirth trauma is top of the list but after this are heredity, vocations that increase pelvic pressure (like parachuting), use of steroids that weaken tissue, other medical conditions that weaken tissue.
Tags: birth trauma, Colpexin, Kegel exercise, pessary, prolapse, prolapse doctor, prolapse without pregnancy, proplapse, vaginal bulge, vaginal bulge in young woman, young woman with prolapse
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January 17th, 2009
I was seeing one of my favorite people this morning, a 17 year old high school senior who asked me “when should I have my first Pap smear?” This is an area of evolving understanding. On my website there is some information about Cervical Cancer vaccine that discusses some of this BUT… What we understand now is that cervical cancer is caused by the HPV virus, that vaccine can prevent 80% of these transmitted viruses but not all. We still need annual pap smears IF we are sexually active. It is recommended to start pap smear testing on all women within 3 years of the beginning of intercourse or by age 21. Condoms are still recommended to reduce sexually transmitted infections (STI) and screening for these other infections is still recommended along with a breast and pelvic exam yearly. Most teenagers do not need pap smears unless they are sexually active before age 16, but they do need check-ups for birth control and STI screening if they are sexually active. Good gynecologic care will preserve fertility and good health, it is well worth it.
Tags: Gardisil, HPV cervical cancer vaccine, Pap Smears, sexually transmitted infections
Posted in College Corner | No Comments »
January 17th, 2009
Today I will begin blogging and answering your questions on a regular basis. Please feel free to ask any questions on the material on my website or other questions pertaining to women’s health.
Tags: gynecology, questions, women's health
Posted in Uncategorized | No Comments »
