Dr. Parker's Fibroids Blog

Effect of Surgical Volume on Outcomes

January 8, 2013 – 8:30 am

Authors: Wallenstein MR, Ananth CV, Kim JH, Burke WM, Hershman DL, Lewin SN, Neugut AI, Lu YS, Herzog TJ, Wright JD.

Study from: Columbia University College of Physicians and Surgeons, New York,

Journal: Obstetrics and Gynecology. 2012;119:709-16.

Problem: Studies from other surgical specialties show that surgeons who regularly perform operations have better results than those who perform surgery less often. This issue has not been studied for laparoscopic surgery for gynecologic procedures.

Study: The authors examined the hospital records of 124,615 patients who underwent laparoscopic hysterectomy from 2000 to 2010. The influence of surgeon and hospital volume on complication rates and costs was examined.

Results: Low-volume surgeons had a complication rate of 6.2% while the rate for high-volume surgeons was 4.2% (one-third lower). Complications during surgery, medical complications, long hospital stays and blood transfusion rates were less frequent for high-volume surgeons.

Women operated on at hospitals that did laparoscopic procedures frequently were 18% less likely to experience a complication than hospitals that did the procedures infrequently. The cost of surgery was $867 lower for high-volume surgeons than for low-volume surgeons.

Authors’ Conclusions: Performance of laparoscopic surgery by high-volume surgeons and at high-volume hospitals is associated with a reduction in complications and lower costs.

Dr. Parker’s Comments:

Unfortunately, this study deals with laparoscopic hysterectomy rather than the uterine-conserving procedure laparoscopic myomectomy, but the results should be the same for all advanced laparoscopic procedures. As demonstrated for chess masters, virtuoso musicians and airline pilots, it takes thousands of hours of experience to gain expertise. Surgical experience accumulates over years and results get better when procedures are performed on a regular basis. Determining the skill and experience of a surgeon is vital information for you to have. Some questions you should ask any doctor who you might consider to perform your surgery:

1) How many of this specific surgical procedures does the doctor perform a month?

2) How many of these procedures has he or she performed on women with conditions or problems like yours?

3) How many complications have occurred with this doctor’s surgeries, and what kind of complications were they?

You can see more about this topic here: Questions Everyone Should Ask Their Doctor Before Surgery

It is your body and your health and you have a right to ask these questions.

By webmaster | Posted in Recent Fibroid Research | Tagged hysterectomy, laparoscopic hysterectomy, Laparoscopic Surgery, surgeon experience levels, surgeon skill, surgeon skill levels, surgical experience | Comments (0)

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Complication Rates and Effectiveness of Uterine Artery Embolization

November 21, 2012 – 9:09 am

Title: Complication Rates and Effectiveness of Uterine Artery Embolization in the Treatment of Symptomatic Leiomyomas: A Systematic Review and Meta-Analysis

Journal: American Journal of Roentgenology, 2012; volume 199, pages 1153-1163.

Authors: Sundeep S. Toor, Arash Jaberi, D. Blair Macdonald, Mathew D. F. McInnes, Mark E. Schweitzer and Pasteur Rasuli.

Study from: Department of Medical Imaging, Ottawa Hospital, Ontario, Canada.

Problem: Many studies of uterine artery embolization include small numbers of women and conclusions are difficult to make. A “meta-analysis” combines the results of many studies and analyzes them together in order to improve the accuracy of the conclusions.

Study: The study determined the rates of complications, need for other treatment after UAE and the rate of success of uterine artery embolization (UAE) for the treatment of fibroids.

Results: Fifty-four published studies were analyzed including 8,159 patients. Women were followed anywhere from 3 months to 5 years after UAE in the various studies. There were no reported deaths in these studies. Major complications occurred in 3% of women, including serious infection in 2%. About 1% of women needed a hysterectomy to treat complications of UAE. Four percent of women had permanent loss of menstrual periods. Every year after UAE, 5% of women needed either a repeat UAE, a myomectomy or a hysterectomy due to failure of UAE to help symptoms. Most of the failures occurred in the first 2 years after UAE. About 3% of women needed to be readmitted to the hospital. Other complications included passing fibroid tissue through the vagina after UAE (5%). Fewer complications occurred in recent studies than in the early studies of UAE as techniques have improved. UAE was successful for 78% to 90% of women.

Authors’ Conclusions: UAE is an effective procedure for treatment of symptomatic uterine fibroids with a low rate of major complications, supporting its use as an alternative to hysterectomy.

Dr. Parker’s Comments: The results of this study of more than 8,000 women who had UAE are very reassuring. 80-90% of women are satisfied with UAE. Also, the risk of having a major complication from UAE is lower than for hysterectomy. However, the need for readmission to the hospital after UAE or the need for another fibroid treatment is greater than the rates for hysterectomy.

By webmaster | Posted in Recent Fibroid Research | Tagged complications, hysterectomy, infection, major complications, menstrual cycle, menstrual periods, myomectomy, periods, UAE, uterine artery embolization | Comments (0)

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Following Myomectomy, the Uterus is not Swiss Cheese!

June 25, 2012 – 8:30 am

Many gynecologists tell women that, after a myomectomy, their uterus will look like Swiss Cheese and there will be nothing left to put back together. So, they say, it is best for you to have a hysterectomy. Often, when I see women for a second or third or……opinion, I am often asked, “if you take out all my fibroids, will there be anything left of my uterus”?

After 35 years of practice and, for the past 20 years performing 2-3 myomectomies (laparoscopic or abdominal) a week, I have never seen a uterus that did not heal and return to normal size after surgery. I considered doing my own study to prove this point, but found a study that proved the point for me.

A Japanese study had been designed to monitor how long it takes to have the incisions in the uterus heal after abdominal myomectomies using MRI to calculate uterine volumes (very accurately). They were trying to figure out how soon to recommend that women try to get pregnant after myomectomy (answer – 3 months).

As part of the study they looked at the uterine wounds, but they also measured the volume of the healing uterus with MRI at 3, 6 and 12 months. Three months after surgery, the swelling of the uterus was mostly gone. When I compared the published uterine volume numbers with other studies that measured normal uterine size, they were the equivalent.

Fibroids start as a single cell and then produce collagen and other proteins that make the cells swell. As fibroids grow, they push away the normal muscle. A good analogy: when an onion grows in the ground, it pushes away and compresses the dirt around it, but does not destroy the dirt. Likewise, fibroids push away the normal muscle, but do not destroy it. So, when fibroids are removed with myomectomy, all the normal muscle is still there and can be sutured back together. When the uterus heals after surgery, it looks like a normal uterus.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged healing uterus after myomectomy, hysterectomy or myomectomy, uterus after myomectomy | Comments (0)

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How Soon Can You Get Pregnant after a Myomectomy?

June 18, 2012 – 8:30 am

I often get asked this question, “how soon after my myomectomy can we start trying to get pregnant”? Along the way in my training and ever since, I have heard all kinds of answers from my professors and colleagues:“women need to wait a year” ; “six months”; “three months”; “two months”. None of these answers were based on scientific studies, they were just opinions.

A few years ago there was a study that helped me answer this question. The study was conducted at three hospitals in Japan, where the authors performed a pelvic MRI before and then 6, 12, 24 and 52 weeks after abdominal myomectomies. In addition to the standard MRI, they also injected contrast solution into the women’s veins (which shows up in blood vessels) to see when blood flow in the healing uterine muscle wall was back to normal.

What they found was that all women had healing of the uterine lining area and return to a normal uterine size at around 12 weeks. Also, 12 of the 14 women (86%) had normal blood flow to the uterine muscle by 12 weeks.

Based on this study, it appears that women can start trying to get pregnant three months after myomectomy. Even for the rare patient who heals a bit more slowly, the healing should be complete by the time the uterus starts to grow with the pregnancy. I hope you find this a helpful answer to this frequent question.

Bill Parker, MD

Reference

Tsuji S, Takahashi K, Imaoka I, Sugimura K, Miyazaki K, Noda Y. MRI Evaluation of the Uterine Structure after Myomectomy. Gynecologic and Obstetric Investigation. 2006;61:106–110.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroids and pregnancy, MRI, myomectomy and pregnancy, uterus after myomectomy | Comments (0)

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This is Why the Medical Literature is Confusing!

April 18, 2012 – 8:41 am

Adverse obstetric outcomes associated with sonographically identified large uterine fibroids.

Authors: Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, Puscheck EE, Diamond MP.

From: Wayne State University, Detroit, Michigan

Journal: Fertility Sterility. 2012 Jan;97:107-10

Problem: Studies show mixed results about whether fibroids affect pregnancy or delivery. Many studies are poorly conducted leading to confusion.

Study: To determine if large uterine fibroids (greater than 5 cm in diameter) effect pregnancy and delivery.

Results: Compared to women with no fibroids, women with large fibroids (>5 cm) delivered earlier (38.6 weeks vs. 36.5 weeks). Early rupture of membranes, and early delivery were also more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. The amount of bleeding after giving birth was more in the large fibroid group (2 cups vs. 2¾ cups), and more women needed a blood transfusion (1% vs. 12%). Please read my comments below…..

Authors’ Conclusions: Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.

Dr. Parker’s Comments: This is not a good study and will mislead many doctors and their patients into unnecessary fear about fibroids and pregnancy. This is an extremely small number of women, 95 in each group, and the women with fibroids bigger than 5cm was much smaller (42). It is almost impossible to do statistical analysis with such small groups and the conclusions are likely to be meaningless. My own feeling is that this paper should never have been published and I am in the process of writing a letter to the editor to discuss the problems with the paper.

Compare the current study with a much better study by Stout published in 2010 (reference below). That study included 2,058 pregnant women who had fibroids and compared them with 61,989 pregnant women without fibroids. Stout reported very small (less than 2%) differences for the pregnancies: placenta previa (placenta located low in the uterus), placental abruption (placenta separating from the uterus early), ruptured membranes, and early birth before 34 weeks. Again, the differences were ALL LESS THAN 2%. (OB GYN 2010;116:1056). For more about this the Stout study see this prior blog post: Fibroids (leiomyomas) at routine second-trimester ultrasound examination and adverse obstetric outcomes.

Also, in the current study, other risk factors for early delivery, bleeding or other problems during pregnancy (maternal age, smoking, alcohol use, diabetes, high blood pressure, previous early birth, vaginal bleeding during pregnancy) were not factored in, but these risks were factored in to the Stout study. This is a major problem with the study and, in my mind, undermines most of the findings.

While the risk of having a blood transfusion was clearly much higher for women with large fibroids, the authors do not tell us why the transfusions were done. In the past few years, doctors have been more diligent about avoiding transfusions unless blood counts get very low (less than 7 hemoglobin) and I doubt this trend was followed in this study.

Although the Stout study found that women with large fibroids (larger than 5 cm) did have a higher risk of fetal death, this occurred rarely (2% of women with large fibroids) but we are not told the causes. So, it is hard to understand why this would be true.

It is very hard to read medical articles, or even read the lay press interpretation of medical articles. All authors (me included) try to make their research sound as important as they can. You really need to pay attention to the details, have a healthy skepticism and ask lots of questions.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroids and delivery, fibroids and early delivery, fibroids and pregnancy, large fibroids and pregnancy, placenta previa, placental abruption | Comments (0)

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New Oral Medication Tested for Fibroids

March 27, 2012 – 8:03 am

Title: Ulipristal Acetate versus Placebo for Fibroid Treatment before Surgery

Journal: New England Journal of Medicine, February, 2012

Authors: Donnez J, Tatarchuk T, Bouchard P, and others

Study from: Brussels, Russia, France, Romania, Hungary, Switzerland, England

Problem: There are no currently effective and safe pills for treatment of uterine fibroid symptoms.

Study: Women with heavy bleeding due to fibroids were randomly assigned to take either ulipristal, a medication that blocks progesterone’s effect on fibroids, or a placebo. Ulipristal does not lower estrogen production by the ovary and is not associated with hot flashes, vaginal dryness or other menopausal symptoms like previously tested treatments.

Results: After 13 weeks, bleeding was controlled in 91% of women taking ulipristal compared with only 19% of women taking a placebo. In addition, fibroid size decreased 21%. Side effects of hot flashes, vaginal dryness, headaches or breast tenderness were no more common with ulipristal than with placebo.

Authors’ Conclusions: Treatment with ulipristal for 13 weeks controlled excessive bleeding due to fibroids and reduced fibroid size.

Dr. Parker’s Comments: It would be a major treatment breakthrough if there were an oral medication, without side-effects, to effectively decrease heavy bleeding and decrease fibroid size. So far, medications have either not been effective (progesterone), or they have had bothersome side-effects (Lupron), or they have had negative effects on the uterus (Asoprisnil, Mefipristone).

This study shows ulipristal can help with bleeding and help shrink fibroids, but the final word is not in yet. All of the progesterone blocking drugs tested so far have caused thickening of the uterine lining cells and some have even caused pre-cancerous cells to develop. Although based on the way ulipristal works, this is much less likely to happen with ulipristal, a longer test of the medication will be necessary to know if it is safe for sure. This drug is currently available in the US as Ella 1 as an emergency contraceptive pill. However, it requires a prescription and costs about $50 per day! I imagine ulipristal is unlikely to be approved by the FDA for treatment of fibroids until the longer studies are finished. But, it may be something that really adds to the treatment options we have for women with fibroids.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged Asoprisnil, Ella 1, fibroids and Lupron, lupron, mefipristone, Oral Medication for Fibroids, side effects, Ulipristal, Ulipristal for fibroids | Comments (0)

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Dr. Parker recognized as one of America’s Most Compassionate Doctors

March 12, 2012 – 8:48 am

Dr. Parker thanks all of his patients for this wonderful honor:

2/23/12

Dear Dr. Parker:

Congratulations! You have once again been recognized as one of America’s Most Compassionate Doctors.

Treating patients, not just the disease, is what you excel at, and your patients appreciate the kindness you have dispensed along with your medical care.

While physicians generally receive positive feedback from their patients, only a select few receive praise about the compassion that accompanied their care. In fact, of the nation’s 720,000 active physicians, less than 3% were accorded this honor by their patients in 2011.

The Compassionate Doctor certification is part of Patients’ Choice recognition program, where patients rate and vote for their favorite doctors.

Congratulations once again on this outstanding distinction.

Sincerely,

Erika Boyer
Vice President, Consumer Research

PatientsChoice

By Bill Parker, MD | Posted in Announcements | Comments (0)

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America’s Top Doctors

February 6, 2012 – 9:04 am

Dr. William Parker has been selected again for the new edition of Castle Connolly’s America’s Top Doctors, for expertise in:

Gynecology (ObGyn)

Dr. Parker has also been selected as a Top Doctor in the following Special Expertise Categories:

Gynecologic Surgery
Laparoscopic Surgery
Hysteroscopic Surgery
Uterine Fibroids

Dr. Parker is the only gynecologist in the country who is listed in all four of these categories.

Castle Connolly’s Top Doctors™ selection process begins with surveys of thousands of physicians and other healthcare professionals and asks them to identify excellent doctors in every specialty in their region and throughout the nation. Initially, they surveyed over 230,000 of the nation’s leading medical specialists, department chairs, residency program directors, vice presidents of medical affairs and presidents of the nation’s leading medical centers and specialty hospitals.

In partnership with US News and World Report, the Castle Connolly physician-led research team carefully reviews the credentials of every physician being considered for inclusion. The review includes scrutiny of medical education, training, hospital appointments, administrative posts, professional achievements, and malpractice and disciplinary history. Doctors cannot pay to be listed in any Castle Connolly guide to top doctors.

By Bill Parker, MD | Posted in Announcements | Tagged America’s Top Doctors, Castle Connolly's Top Doctors, Gynecologic Surgery, Hysteroscopic Surgery, Laparoscopic Surgery, Uterine Fibroids | Comments (0)

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Hysterectomy Improves Sexual Response? Addressing a Crucial Omission in the Literature

January 24, 2012 – 8:30 am

Journal: The Journal of Minimally Invasive Gynecology, Volume 18, Pages 288-295, May 2011

Authors: Barry R. Komisaruk, Eleni Frangos, Beverly Whipple

Study from: University of Medicine and Dentistry of New Jersey

Problem: The prevailing view in the medical literature is that hysterectomy improves the quality of life. This is based on claims that hysterectomy relieves painful intercourse and abnormal bleeding and improves sexual response. Because hysterectomy requires cutting the sensory nerves that supply the cervix and uterus, it is surprising that the reports of negative effects on sexual response are so limited. However, almost all articles report that some women find that hysterectomy is detrimental to their sexual response. It is likely that the degree to which a woman’s sexual response and pleasure are affected by hysterectomy depends not only on which nerves were severed by the surgery, but also the genital regions whose stimulation the woman enjoys for eliciting sexual response.

Study: A review of the medical literature regarding female sexual response and the effects of hysterectomy on sexual response.

Results:

While most women report improvement of sexual functioning after hysterectomy, this may be the result of relief of symptoms after removal of a diseased uterus, such as vaginal bleeding and pain with intercourse.
Hysterectomy may eliminate anxiety about cancer risk (uterine, cervix, ovarian) and unwanted pregnancy.
Multiple factors may be related to the negative effects of hysterectomy on sexual response including:
1. For some women, uterine contractions are an important aspect of orgasm and hysterectomy eliminates this sexual response.
2. Scar tissue at the top of the vagina (when the cervix is removed) may make intercourse difficult because the top of the vagina is less elastic.
3. Internal scarring or nerve damage may cause pain or may interfere with feeling sexual pleasure.
4. Surgical removal of some of the vaginal wall may result in decreased vaginal blood flow, which may decrease sexual arousal and the possibility of multiple orgasms.
The vagina and cervix have a plentiful nerve supply. The hypogastric nerves come from the uterus and cervix, the pelvic nerves come from the vagina and the pudendal nerves come from the clitoris, labia majora, and labia minora. The ilioinguinal and genitofemoral nerves come from the mons pubis, labia, and vulvar skin.

When a woman is lying on her back, the region of the vagina near 12-o’clock (the “G spot”) is often the most sensitive area to physical stimulation and more likely to produce orgasm than stimulation of other regions of the vagina.

One study reported that 35% of 128 healthy women said they experience orgasm from penile stimulation of the cervix during sexual intercourse, 63% reported that they experience orgasm from vaginal stimulation, and 94% reported that they experience orgasm from clitoral stimulation.

Authors’ Conclusions: Based on the nerve supply of the clitoris, vagina, and cervix, it would not be surprising if responses to genital stimulation are decreased by hysterectomy. There is a glaring omission in the literature on the effects of hysterectomy on sexual response; women’s reports of their preferred source of genital stimulation have not been included in any studies and their sexual response may depend on whether a woman’s preferred genital site of stimulation is desensitized by hysterectomy.

Further research that considers these factors may help to reconcile the reported variability of the effects of hysterectomy on sexual response.

Dr. Parker’s Comments: For women who are considering a hysterectomy for severe adenomyosis or failure of less invasive treatment options, the issue of sexual response is important to think about. Unfortunately, there are no studies about sexual response following myomectomy or UAE.

Although some women report improvement of sexual response after a hysterectomy, this is usually related to the relief of symptoms, such as vaginal bleeding and pain with intercourse. However, some women note a change in sexual response for the worse. This article beautifully outlines the issues and describes why the medical literature about sexuality and hysterectomy has been so unhelpful for women. Not one study has asked women what they find pleasurable before surgery, or whether there is any difference in what they find pleasurable after surgery.

I have been discussing this issue with women for years and the conversation is interesting and sometimes humorous. I review the differences in pleasurable sexual response among women (stimulation of clitoris, vagina, cervix, and uterine contractions) and some women know exactly what gives them pleasure. And, some women say, “what the heck are you talking about?” The next step is a homework assignment – see what works for you before you decide on surgery.

Since fibroids or adenomyosis almost never involve the cervix and since removing the cervix does cut nerves and support ligaments to the pelvis, many women who chose to have a hysterectomy wish to leave the cervix. My feeling is, if the cervix isn’t broken, don’t fix it. Other issues regarding hysterectomy are discussed here: https://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Although not explored here, if your ovaries are removed major hormonal changes are likely to occur, which can lead to vaginal dryness and loss of vaginal elasticity. Decreased sleep quality and resultant fatigue can also influence sexuality. For women who are not an increased risk of ovarian cancer due to family history, keeping your ovaries decreases the risk of heart disease, stroke, lung cancer and osteoporosis. More about the benefits of keeping your ovaries can be found at the bottom of this page: https://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Until the proper studies are done, we will not be able to make any general conclusions about sexual response following surgery (or UAE, HIFU). However, because sexual response can be so different for different women, no matter what future studies show the questions about sexual response will always need to be considered by each woman for herself.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged cervix and sex, hysterectomy and ovary removal, hysterectomy and sex, ovaries and sex, ovary removal and sex, pain after hysterectomy, surgery and sex, uterine contractions and sex | Comments (0)

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Using MRI to Determine Surgical Treatment Options for Women with Fibroids

January 10, 2012 – 8:37 am

The utility of MRI for the surgical treatment of women with uterine fibroid tumors

Journal: American Journal of Obstetrics and Gynecology (in press, available now on-line for subscribers)

Authors: William Parker

From: UCLA School of Medicine, Los Angeles, CA.

Problem: Fibroids can usually be diagnosed by pelvic examination and ultrasound, but neither gives us exact information about the sizes, number, and positions of all fibroids present. Excellent studies show that MRI is the most accurate way to get all this information, but most gynecologists do not order MRIs or know how to interpret them.

Clinical Opinion: This article describes how MRI works, illustrates normal pelvic anatomy and the appearance of fibroids (and adenomyosis) on MRI and discusses the ways to limit the number of images and, therefore, the cost of an MRI. Three actual cases from my practice are presented to show how MRI can change the treatment options available to women with fibroids.

Authors’ (Dr. Parker’s) Conclusions: If your gynecologist is able to perform only a hysterectomy, then precise imaging of fibroids is not necessary since they will all be removed with the uterus. However, with many other treatment options now available, magnetic resonance imaging (MRI) can help tell us which options may be best. If your gynecologist does not offer the available, often less invasive, treatment options, accurate information allows you to find a gynecologist who has the skills to take care of you.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroid treatment options, fibroids, fibroids and pelvic exam, hysterectomy, magnetic resonance imaging, minimally invasive treatment options for fibroids, MRI, no hysterectomy, ultrasound | Comments (0)

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Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.