What Every Patient Should Know about Hysterectomies

About 590,000 hysterectomies are done annual in the U.S. but I would say that a vast majority of the patients don't take the time or effort to educate themselves prior to going under the knife. I want to give you some key questions to ask your doc and provide some sound education on the matter. So hopefully if you are ever in the position that you need a hysterectomy you are prepared.

First and foremost, never have surgery without first understanding exactly what will be done. I know of plenty of patients when asked about a past surgical history can not tell me whether they had 1 ovary, both ovaries, or no ovaries removed with their hysterectomy. A hysterectomy by definition is the idea of removing the uterus. Ovaries are considered to be an extra procedure that can be done in conjunction with the hysterectomy. Most patients would say that they had a partial hysterectomy because they didn't have their ovaries removed. This is incorrect. A partial hysterectomy is the idea of leaving the cervix behind. The gynecologist would call this a subtotal or supracervical hysterectomy.

There are a variety of ways to have a hysterectomy done and here are the bullet points

• Total abdominal hysterectomy: this is the original way that a hysterectomy was done.  The incision on your abdomen can be either (bikini cut, like a c-section or vertical).  Of all of the hysterectomies this is the most painful and will require the most time in the hospital directly after surgery.  In general you will be in the hospital for 2-3 days after the surgery (mostly based on how your pain tolerance).
• Vaginal hysterectomy (Gold Standard): This is considered to be the standard by which all others are compared.  ANY Gynecologist worth his/her salt should be able to perform a successful vaginal hysterectomy.  Most patients will stay overnight in the hospital and be discharged to home the next day.  Because the procedure is being done vaginally there won't be any incisions on your abdomen.
• Laparoscopic assisted Vaginal Hysterectomy (LAVH): With the assistance of a laparoscope a portion of the hysterectomy in the abdomen and the remainder is done vaginally.  Most patients will stay overnight in the hospital and be discharged to home the next day.
• Total Laparoscopic Hysterectomy (TLH):  The entire hysterectomy is done laparoscopically.  The uterus is either pulled out vaginally or morcellated (cut into small pieces and pulled out of the abdomen).  Most patients will stay overnight in the hospital and be discharged to home the next day.
• daVinci Hysterectomy: This is similar to the TLH but with superior visualization and instrument flexibility.  Most patients will stay overnight in the hospital and be discharged to home the next day.

The type of hysterectomy will be based on the size of your uterus (fibroids will make the uterus grow in size and make one type of hysterectomy over the other more difficult), prior surgically history, obesity, and most importantly the skill set of the surgeon.

FIVE Questions you should have answered prior to go into surgery:

1. Why is it necessary for me to have a hysterectomy?
• Number one cause is heavy bleeding caused by fibroids
• The presence of fibroids alone (without any symptoms) is not a reason for a hysterectomy
2. How do you plan on performing my surgery?
• As of 2013 I would consider it antiquated to have an abdominal hysterectomy under MOST situations.  Even a 20 week sized uterus (the top of your uterus can be felt at your belly button) can be safely done with the daVinci system.
3. How long will I be off work?
• With a Vaginal hysterectomy, LAVH, TLH, or daVinci you should have the quickest recovery time.
4. Will I have my ovaries removed?  Why or Why not?
• At one time it was standard procedure to have an oopherectomy done (removal of ovaries) and patient started on hormone replacement therapy right afterwards.  I counsel most of my patients to keep their ovaries.  Seldom times will I perform the hysterectomy and think that the patient MUST have their ovaries removed.
5. What should I call you about after surgery?
• No one wants complications but they do happen.  Bleeding, fever, excessive pain would definitely be something I want my patients to call about.

Thanks for reading.

Dr. Harris

Honey I've Got a Headache...Struggles with sexually intimacy

If men are from Venus and Women are from Mars no wonder couple have problems getting it on. As you might have guessed this blog is dealing with sex. I want to approach this from a physician who takes care of women. This will definitely get the conversations going which is exactly what I want to happen.

Sex has been a hurdle for some couples for years. I think that the biggest problem I have seen clinically is that of expectations. How often should a couple have sex? Is it normal to have sex four times a week or is it more normal to have sex four times a month? In my mind the answer to the question is ..... yes! The normalcy has more to do with the couples' expectation than meeting an average.

The next area that I see couples have major problems is associated with desire. For the most part...no desire leads to little or no sex. What are some of the hurdles that I have seen with my patients.

1. Hormonal changes: childbirth, menopause, medications, depression
2. Pain with sex: if it hurts every time you do something you're probably not in a rush to come back to it again.
3. Work / children: I put these together because the underlying issue is the same. Fatigue has spoiled many a romantic nights.
4. Body image: be it yours or his...sometimes the extra jiggle just ain't sexy baby.

So what do we do: C O M M U N I C A T E ! ! ! ! !

Let me put on the guy hat now and take off the doctor's coat. Men are simple creatures and we focus our thoughts in a compartmentalized fashion. If you need more help with the kids, washing dishes, cleaning the bathroom let your partner know. If sex is painful it may be a simple fix such as using K-Y jelly.

The crux is talk it out. Stop being quiet about your needs and hopefully you'll be having outstanding sex again.

As always I welcome your comments and questions!!


- Posted using BlogPress from my iPad

Location:Dayton, OH

Mammogram or not to mammogram

For years women have been taught the great importance of doing a breast exam on a monthly basis and the need for annual mammograms >40 years old. Well, the USPSTF (U.S. Preventative Service Task Force) just recently recommended a drastic change from the norm. The new recommendations are as follows:

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (grade C recommendation)
  


• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (grade B recommendation)
  


• The USPSTF recommends against teaching breast self-examination (BSE). (grade D recommendation)

So let me throw in my two point five, two, seven, five cents :) The argument for / against mammograms has been an issue for years. The major issue is that the number of women that need to be screened to save one life is around 2000. In addition along the way several women will have to deal with the scare of breast cancer and may have an unnecessary breast biopsy. The question... is the scare worth the life of one woman? I am convinced that if it is my wife, mother, aunt, grandmother, sister it is worth the scare.

Now it is beyond me why I, as a medical professional (in particular an OB/GYN), would choose to not teach a woman how to do her own breast exam. The fact that you have the knowledge base and are aware of what to bring to a physician's attention is key to early detection in my eyes.

Of course I will take a second to educate. Remember that the breast tissue is shaped like a tear drop. The tail points toward the arm pit (this is called the tail of Spence). The tail region and directly underneath the nipple are the high risk areas for breast cancer.

So here are my recommendations

1. Learn how to do a breast exam and do it on a monthly basis
2. In agreement with ACOG ( http://www.acog.org/from_home/Misc/uspstfResponse.cfm ) continue having your mammogram every 1-2 yrs age 40 - 49 and annually 50+ yrs

As always feel free to ask any questions.

I'm Pregnant with H1N1....Help!!

This has probably been the craziest flu season in a long time for patients and practitioners alike. In April 2009, when the first reported cases of the H1N1 novel virus hit the news I'm sure that no one could have anticipated how wide spread this problem would be.

I thought that I would make my comeback blog one that would dealt with a specific question concerning H1N1. What do you do if you are pregnant and have a confirmed diagnosis of H1N1? First lets establish the ground rules. As a physician I will suspect that a patient has the flu if they have:

• fever
• chills
• headache
• upper respiratory symptoms (cough, sore throat, running nose)
• muscle aches
• joint aches
• fatigue
• Nausea/Vomiting/Diarrhea (these symptoms are not very common with the seasonal flu)

After you have raised my suspicion I will swab your nose and send it for Influenza A &B. You may not know that the H1N1 is a variant of the Influenza A. The whole swine flu thing came from the fact that pigs can be infected by several different strains of influenza (bird, human, ducks, etc...). When you have a single host with several different viral strains a NEW (or NOVEL) strain can emerge that has not been seen before. This is part of the theory behind or 2009 flu virus.

If you are sick (see the above symptoms) the first thing to do is C A L L your OB doc. Right now ER's and Urgent care facilities are becoming a melding pot for sick patients. If your symptoms are mild and you don't have the following problems:

• Difficulty breathing
  
• Chest pain
• Persistent vomiting
  
• High fever not responding to Tylenol
• Baby moving much less or no movement

then the best thing to do is stay at home. You will need to be started on Tamiflu (this will help you fight the infection). Stay hydrated, get rest, and use Tylenol for symptom relief. If symptoms worsen and you experience the above then you must be seen quickly. We are trying to avoid pneumonia or other complications of the flu.

Handwashing is key. And if you are sneezing and coughing a lot then a face mask will probably be helpful for you to wear to decrease exposure to your family.

Breastfeeding (for the mom who has delivered) is a toss up. Thus far no one has brought any definitive proof showing that you should not breast feed your baby. The risk is that you could pass the virus to your newborn because of having an active infection. But we know that sooooo many good things are available in breast milk that not passing that on to the baby would be a crime. You can also use Tamiflu while you are breastfeeding.

Lastly, please...please...please get the H1N1 flu vaccine (the injection NOT the flu mist).

Would I give my daughter Gardasil?

Ok. This is a hot topic right now and getting plenty of press so I might as well jump on the bandwagon and throw out my two and a half cents.

Just as a little background, Gardasil hit the market in 2006 with much fanfare. The idea of vaccinating little girls and potentially little boys against high risk HPV (human papilloma virus) subtypes to prevent the sexually transmitted infection that causes cervical cancer. At one point the state of Texas had legislation heading to the books that would have made the vaccine mandatory for school-aged children.

The vaccine is effective against subtypes of the virus 6, 11, 16, 18. The first two are responsible for genital warts primarily whereas the last two are the major culprits behind agressive dysplasia (abnormally growing cells) and cervical cancer (the outcome if left unchecked). In 2008 there was approx. 11,000 new cases of cervical cancer. The pap smear has become one of the single most effective screening tools in modern medicine and has moved cervical cancer out of the top 3 causes of cancer related deaths for women. So the most natural step would be to try and prevent the known culprit from even getting a head start.

Now if you read my last blog about Herpes you know that it is very easy to spread STDs. It could not be any easier than with HPV. There is currently no testing for HPV in men and therefore no way to find out who is carrying the aggressive strain of the virus and stay away from him. The best way is to stay abstinent until marriage and then stay faithful to your spouse but of course this is not the way our free society views sex (sorry about the soap box...I'll put it away now).

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According to the package insert from Merck:

Serious Adverse Reactions in the Entire Study Population
A total of 237 subjects out of 25,274 total subjects (9- through 45-year-old girls and women; and 9-through 15-year-old boys) who received both GARDASIL (N = 13,686) and AAHS control (N = 11,004) orsaline placebo (N = 584) reported a serious systemic adverse reaction following any vaccination visit during the clinical trials for GARDASIL.
Out of the entire study population (25,274 subjects), only 0.05% of the reported serious systemic
adverse reactions were judged to be vaccine related by the study investigator. The most frequently reportedserious systemic adverse reactions for GARDASIL compared to AAHS control or saline placebo and regardless of causality were:
Headache [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Gastroenteritis [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Appendicitis [0.03% GARDASIL (4 cases) vs. 0.01% AAHS Control (1 case)],
Pelvic inflammatory disease [0.02% GARDASIL (3 cases) vs. 0.04% AAHS Control (4 cases)],
Urinary tract infection [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pneumonia [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pyelonephritis [0.02% GARDASIL (2 cases) vs. 0.03% AAHS Control (3 cases)],
Pulmonary embolism [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)].

Deaths in the Entire Study Population
Across the clinical studies, 24 deaths were reported in 25,274 (GARDASIL N = 13,686; AAHS Control N= 11,004, saline placebo N = 584) subjects (9- through 45-year-old girls and women; and 9- through 15-year-old boys). The events reported were consistent with events expected in healthy adolescent and adult populations. The most common cause of death was motor vehicle accident (4 subjects who received GARDASIL and 3 AAHS Control subjects), followed by overdose/suicide (2 subjects who received GARDASIL and 2 subjects who received AAHS Control), and pulmonary embolus/deep vein thrombosis (1 subject who received GARDASIL and 1 AAHS Control subject). In addition, there were 2 cases of sepsis, 1 case of pancreatic cancer, 1 case of arrhythmia, 1 case of pulmonary tuberculosis, 1 case of hyperthyroidism, 1 case of post-operative pulmonary embolism and acute renal failure, and 1 case of systemic lupus erythematosus in the group that received GARDASIL; 1 case of asphyxia, and 1 case of
acute lymphocytic leukemia in the AAHS Control; and 1 case of medulloblastoma in the saline placebo group.
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In the past year there has been much horrible press for Merck. Gardasil has been "associated with" several adverse events from painful injection sites, neurologic issues, immune disease, blood clots, pulmonary embolism, and death. I used the "quotes" because there has not been any 1:1 correlation between the vaccine and death. The CDC is standing by the statement that Gardasil is safe and the risk outweigh the benefits. To date there are approx 12,000 adverse events reported of which a few deaths have been included.

The question is does the overall good that the vaccine can bring to millions outweigh the small percentage of bad outcomes?

Well if it were my daughter I would say.... NO! Even though I truly believe that this is a giant leap forward for prevention of cervical cancer I can't, in good conscience, tell my daughter or my patients to get the vaccine.

A quiet epidemic

First of all, sorry for the delay in posting. I've been a little busy and haven't had the time to post. I thought that this would be a good topic and will definitely get you thinking.



Genital herpes is probably one of the most quiet epidemics in the U.S. to date. CDC states that that approx. 1:4 women are positive for herpes (1:8 for the men). One of the reasons that I believe that this disease continues to propagate is because there is no mandate to screen patients.



The disease is one that takes about 2 weeks to present itself after initial exposure. The problem is that only about 25% of infected patients will have the classic painful ulceration that will drive them to the doctor's office. The remainder of the patients will not have a single classic symptom. As a matter of fact the symptoms that most patients will have are similar to that of a yeast infection (women) or jock itch (men). What I have found in my office is that this is exactly what is happening on a daily basis. We have, in the past year to year and a half, started offering a full STD screening that includes herpes (Gonorrhea, Chlamydia, Trichomonas, Syphillis, Hepatitis, HIV, and Herpes). Just as an aside, if you haven't had blood testing for STD screening you probably haven't been tested for the last four diseases.



Now, the problem with offering testing for herpes is not the patient that comes in with problems but it is the patient who is asymptomatic. My problem has been telling a 43 year woman with no symptoms that she is positive for herpes. How does she tell her significant other, lover, husband that she is positive? When I have posed the question to some of my medical colleagues about screening the response has been, "Why open a can of worms?" For the asymptomatic patient why should she be screened for a disease process that may never cause her a single problem in her life (remember that the majority of patients will be asymptomatic)? The answer is HIV. Wait, wait, wait... I thought that we were talking about HSV (herpes)! HSV can increase any patient's susceptibility being infected with HIV. The thought is that because of the lesions the virus has a easier access.



Let's throw another wrench in the thinking. Herpes is classically understood to be classified as HSV-1 (oral) and HSV-2 (genital). It does not take a rocket scientist to understand this concept: anyone who participates in oral sex makes theirself a candidate for a outbreak of HSV-1 on their genitals. I bring this thought up because most would consider a new outbreak of herpes as a sign of infidelity of their partner. The truth is that the outbreak may be a HSV-1 or HSV-2. I adamantly oppose telling any patient that their partner has been unfaithful based on a positive test or symptoms pointing towards herpes. The reality is that the patient could have been infected with their first sexual experience.



So what's my recommendation? If you have been with one partner for the past several years and have never had a single outbreak don't run to the doctor to try and find out your status. Why?... Ignorance can be bliss in this situation. If you are positive more than likely your partner is positive and neither one of you can get more positive. What I have seen more than once is strife and fear being brought into a situtation that need not happen. Now if you are planning to hit the dating scene it would behoove you to know what you are bringing to the bedroom. For my patient's that either practice serial monogamy or that ... well don't I want them to know where they stand.



[At the risk of sounding preachy I must fall back to the biblical principal of one husband and wife concept. It's old fashioned but if you have a true covenant between the two this won't be a concern.]

New Guidelines for Pap Smears

Ok, I know that getting a pap smear is about as exciting as a root canal (personally I've never had either :), but when you go to your local gynecologist there is something new you should ask for if you are 30 or older. Ask for HPV genotyping with your pap.

HPV (human papilloma virus) made a big splash on the marketing venues with the release of the vaccine Gardasil (if you haven't been to the web site click on the link...very interactive and informative). Up until March 2009 when the FDA approve a new test the only thing that we as physicians were concerned about was the entire group of high risk strains of HPV. It is well established that the most virulent strains are 16 and 18.

The FDA approved Cervista:

Descriptions of New FDA-approved HPV DNA Tests

In March 2009 the FDA announced approval for clinical use in the U.S. of two new HPV DNA diagnostic
tests.

• One of these tests is designed to identify 14 high risk types of HPV. These include the 13 types detected by the Hybrid Capture® 2 HPV DNA Assay (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68) as well as HPV 66. This test will be marketed under the name Cervista™ HPV HR. The other test is designed to specifically detect HPV 16 and HPV 18 and will be marketed under the name Cervista™ HPV 16/18. Both tests utilize an isothermal enzymatic DNA amplification process with a fluorescent read out and both are approved for use with ThinPrep® samples. They were developed by Third Wave Technologies which was acquired in 2008 by Hologic Inc., the manufacturer of the ThinPrep® Pap test.
  

FDA Approved Indications

• The FDA-approved clinical indications for Cervista™ HPV HR are similar to those of the Hybrid Capture® 2HPV DNA Assay. These are:
  

1. To screen patients with ASC-US cervical cytology results to determine the need for referral to colposcopy.
2. Used adjunctively with cervical cytology to screen women 30 years and older to assess the presence or absence of high-risk HPV types.
   

The FDA-approved indications for the Cervista™ HPV 16/18 test are:

1. In women 30 years and older the test may be used adjunctively with the Cervista™ HPV HR test in combination with cervical cytology to assess the presence or absence of specific high-risk HPV types.
2. Used adjunctively with the Cervista™ HPV HR test in patients with ASC-US cervical cytology results, to assess the presence or absence of specific high-risk HPV types. The results of this test are not intended to prevent women from proceeding to colposcopy

Succintly put: In a low risk 30+ y/o female the new guidelines are to perform a thin prep pap accompanied by Cervista. If the patient has a negative pap and a +screening for cervista (i.e. the presence of 16 or 18) then she should have a colposcopy done to look for cervical dysplasia. Because of the genotyping we are able to pick out the women that will be at highest risk for cervical dysplasia and/or cancer.

So when you go back for your ANNUAL (put it big letters so you don't forget to call for an appointment) ask for HPV typing if you are 30 or over.