OBG Management

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In her February 2017 article, Lucia DiVenere interviewed the current and incoming ACOG Presidents, Drs. Thomas Gellhaus and Haywood Brown. The Presidents called for advocacy on behalf of the “melting pot” of women’s health specialists and subspecialists. “We cannot sit on the sidelines and expect others to speak for us,” said Dr. Gellhaus. “If we are not part of the solution, then we need to cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms.”

Answer the poll below:

[polldaddy:9703185]

Click here to view Lucia DiVenere’s article
'What lies ahead for women’s health? Challenges and opportunities as ACOG and US leadership transition'

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In her February 2017 article, Lucia DiVenere interviewed the current and incoming ACOG Presidents, Drs. Thomas Gellhaus and Haywood Brown. The Presidents called for advocacy on behalf of the “melting pot” of women’s health specialists and subspecialists. “We cannot sit on the sidelines and expect others to speak for us,” said Dr. Gellhaus. “If we are not part of the solution, then we need to cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms.”

Answer the poll below:

[polldaddy:9703185]

Click here to view Lucia DiVenere’s article
'What lies ahead for women’s health? Challenges and opportunities as ACOG and US leadership transition'

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In her February 2017 article, Lucia DiVenere interviewed the current and incoming ACOG Presidents, Drs. Thomas Gellhaus and Haywood Brown. The Presidents called for advocacy on behalf of the “melting pot” of women’s health specialists and subspecialists. “We cannot sit on the sidelines and expect others to speak for us,” said Dr. Gellhaus. “If we are not part of the solution, then we need to cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms.”

Answer the poll below:

[polldaddy:9703185]

Click here to view Lucia DiVenere’s article
'What lies ahead for women’s health? Challenges and opportunities as ACOG and US leadership transition'

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Using the Rotterdam criteria, the diagnosis of polycystic ovary syndrome (PCOS) is made in the presence of 2 of the following 3 criteria¹:

1. oligo-ovulation or anovulation
2. hyperandrogenism manifested by the presence of either hirsutism or elevated hormone levels (including serum testosterone androstenedione and/or dehydroepiandrosterone sulfate)
3. ultrasonography evidence of multifollicular ovaries (≥12 follicles with a diameter of 2 mm to 9 mm in one or both ovaries; FIGURE) or ovarian stromal volume of 10 mL or more.

Illustration: Kimberly Martens for OBG Management

Among reproductive-age women, the prevalence of PCOS has been reported to range from 8% to 13% for different populations.² Most clinicians initiate treatment for PCOS with oral estrogen−progestin (OEP) monotherapy. OEP treatment has many beneficial hormonal effects, including:

• a resulting decrease in pituitary luteinizing hormone (LH) secretion, which decreases ovarian androgen production
• an increase in liver production of sex hormone−binding globulin (SHBG), which decreases free testosterone levels
• protection against the development of endometrial hyperplasia
• induction of regular uterine withdrawal bleeding.

However, OEP therapy neither improves metabolic indices (insulin sensitivity and visceral fat secretion of adipokines) nor blocks androgen action in the skin.

Dual medical treatment for PCOS can address the issues that monotherapy cannot and, along with providing guidance on improving diet and exercise, many experts support the initial therapy of PCOS with dual medical therapy (OEP plus metformin or spironolactone).

Advantages of OEP plus metformin

For many women with PCOS, the syndrome is characterized by abnormalities in both the reproductive (increase in LH secretion) and metabolic (insulin resistance and increased adipokines) systems. OEP monotherapy does not improve the metabolic abnormalities of PCOS. Combination treatment with both OEP plus metformin, along with diet and exercise, can best treat these combined abnormalities.

Data support dual therapy with metformin. In one small, randomized trial in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater reduction in serum androstenedione and a greater increase in SHBG than OEP monotherapy.³ In addition, weight loss and a reduction in waist-to-hip ratio only occurred in the OEP plus metformin group.³ In another small randomized study in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater decrease in free androgen index than OEP monotherapy.⁴

In my clinical opinion, women who may best benefit from OEP plus metformin therapy have one of the following factors indicating the presence of insulin resistance⁵:

• body mass index >30 kg/m²
• waist-to-hip ratio ≥0.85
• waist circumference >35 in (89 cm)
• acanthosis nigricans
• personal history of gestational diabetes
• family history of type 2 diabetes mellitus (T2DM) in a first-degree relative
• diagnosis of the metabolic syndrome.

My preferred treatment approach

Metformin is a low cost and safe treatment for metabolic dysfunction due to insulin resistance and excess adipokines. I often start PCOS treatment for my patients with an OEP plus metformin extended release (XR) 750 mg with dinner. If the patient tolerates this dose, I increase the dose to metformin XR 1,500 mg with dinner.

Adverse effects. The most common side effects of metformin are gastrointestinal, including abdominal discomfort, flatulence, borborygmi, diarrhea, and nausea. Metformin reduces serum vitamin B12 levels by 5% to 10%; therefore, ensuring adequate vitamin B12 intake (2.6 µg daily) is helpful.⁶ Although metformin does reduce vitamin B12 levels, there is no strong relationship between metformin and anemia or peripheral neuropathy.⁷ Lactic acidosis is a rare complication of ­metformin.

Beneficial effects. In the treatment of PCOS, metformin may have many beneficial effects, including⁸:

• decrease in insulin resistance
• decrease in harmful adipokines
• reduction in visceral fat
• reduction in the incidence of T2DM.

OEP plus spironolactone

Many women with PCOS have increased LH secretion and increased androgen activity in the skin due to increased 5-alpha reductase enzyme activity, which catalyzes the conversion of testosterone to the powerful intracellular androgen dihydrotestosterone.⁹ Women with PCOS may present with a chief problem report of hirsutism, acne, or female androgenetic alopecia. OEP plus spironolactone may be an optimal initial treatment for women with a dominant dermatologic manifestation of PCOS. OEP treatment results in a decrease in pituitary LH secretion and ovarian androgen production. Spironolactone adds to this therapeutic effect by blocking androgen action in the skin.

The data on dual therapy with spironolactone. Many dermatologists recommend spironolactone in combination with cosmetic measures for the treatment of acne, but there are only a few randomized trials that demonstrate its efficacy.¹⁰ In one trial spironolactone was demonstrated to be superior to placebo for the treatment of inflammatory acne.¹⁰ Authors of multiple randomized trials report that the antiandrogens, spironolactone, or finasteride are superior to metformin to treat hirsutism.¹¹ In addition, a few small trials report that spironolactone plus OEP is superior to either OEP or metformin monotherapy for hirsutism.¹¹ Clinical trials of spironolactone for hirsutism have been rated as “low quality” and additional controlled trials of OEP monotherapy versus OEP plus spironolactone are ­warranted.¹²

My preferred treatment approach

Spironolactone is effective in the treatment of hirsutism at doses ranging from 50 mg to 200 mg daily. I ­routinely use a dose of spironolactone 100 mg daily because this dose is near of the top of the dose-response curve and has few adverse effects (such as intermittent uterine bleeding or spotting). With spironolactone monotherapy at a dose of 200 mg, irregular uterine bleeding or spotting is common, but concomitant treatment with an OEP tends to minimize this side effect. In my practice I rarely have patients report irregular uterine bleeding or spotting with the combination treatment of an OEP and spironolactone­ 100 mg ­daily.

Contraindications. Spironolactone should not be given to women with renal insufficiency because it can cause hyperkalemia. However, it is not necessary to check potassium levels in young women taking spironolactone with normal creatinine levels.¹³

Triple therapy: OEP plus metformin plus spironolactone

Some experts strongly recommend the initial treatment of PCOS in adolescents and young women with triple therapy: OEP plus an insulin sensitizer plus an antiandrogen.¹⁴ This recommendation is based in part on the observation that OEP monotherapy may be associated with an increase in circulating adipokines and visceral fat mass as determined by dual-energy x-ray absorptiometry.¹⁵ By contrast, triple treatment with an OEP plus metformin plus an antiandrogen is associated with a decrease in circulating adipokines and visceral fat mass.

What is the best progestin for PCOS?

Any OEP is better than no OEP, regardless of the progestin used to treat the PCOS because ethinyl estradiol plus any synthetic progestin suppresses pituitary secretion of LH and decreases ovarian androgen production. However, for the treatment of acne, using a progestin that is less androgenic may be ­beneficial.¹⁶

In one study, 2,147 consecutive women who were taking a contraceptive and presented for treatment of acne were asked if their contraceptive had a positive impact on their acne. The percentage of women reporting that their contraceptive significantly improved their acne ranged from 26% for those taking drospirenone-ethinyl estradiol (EE) to 1% for those taking the etonogestrel subdermal implant (FIGURE).¹⁶ The US Food and Drug Administration has approved 4 OEP contraceptives for the treatment of acne (TABLE). The OEPs with drospirenone, norgestimate, desogestrel, or norethindrone acetate may be optimal choices for the treatment of acne caused by PCOS.

The bottom line

PCOS is a common endocrine disorder treated primarily by obstetricians-gynecologists. Among adolescents and young women with PCOS chief problem reports include irregular menses, hirsutism, obesity, acne, and infertility. Among mid-life women the presentation of PCOS often evolves into chronic medical problems, including obesity, metabolic syndrome, hyperlipidemia, hypertension, T2DM, cardiovascular disease, and endometrial cancer.^17–19 To optimally treat the multiple pathophysiologic disorders manifested in PCOS, I recommend initial dual medical therapy with an OEP plus metformin or an OEP plus spironolactone.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Using the Rotterdam criteria, the diagnosis of polycystic ovary syndrome (PCOS) is made in the presence of 2 of the following 3 criteria¹:

1. oligo-ovulation or anovulation
2. hyperandrogenism manifested by the presence of either hirsutism or elevated hormone levels (including serum testosterone androstenedione and/or dehydroepiandrosterone sulfate)
3. ultrasonography evidence of multifollicular ovaries (≥12 follicles with a diameter of 2 mm to 9 mm in one or both ovaries; FIGURE) or ovarian stromal volume of 10 mL or more.

Illustration: Kimberly Martens for OBG Management

Among reproductive-age women, the prevalence of PCOS has been reported to range from 8% to 13% for different populations.² Most clinicians initiate treatment for PCOS with oral estrogen−progestin (OEP) monotherapy. OEP treatment has many beneficial hormonal effects, including:

• a resulting decrease in pituitary luteinizing hormone (LH) secretion, which decreases ovarian androgen production
• an increase in liver production of sex hormone−binding globulin (SHBG), which decreases free testosterone levels
• protection against the development of endometrial hyperplasia
• induction of regular uterine withdrawal bleeding.

However, OEP therapy neither improves metabolic indices (insulin sensitivity and visceral fat secretion of adipokines) nor blocks androgen action in the skin.

Dual medical treatment for PCOS can address the issues that monotherapy cannot and, along with providing guidance on improving diet and exercise, many experts support the initial therapy of PCOS with dual medical therapy (OEP plus metformin or spironolactone).

Advantages of OEP plus metformin

For many women with PCOS, the syndrome is characterized by abnormalities in both the reproductive (increase in LH secretion) and metabolic (insulin resistance and increased adipokines) systems. OEP monotherapy does not improve the metabolic abnormalities of PCOS. Combination treatment with both OEP plus metformin, along with diet and exercise, can best treat these combined abnormalities.

Data support dual therapy with metformin. In one small, randomized trial in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater reduction in serum androstenedione and a greater increase in SHBG than OEP monotherapy.³ In addition, weight loss and a reduction in waist-to-hip ratio only occurred in the OEP plus metformin group.³ In another small randomized study in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater decrease in free androgen index than OEP monotherapy.⁴

In my clinical opinion, women who may best benefit from OEP plus metformin therapy have one of the following factors indicating the presence of insulin resistance⁵:

• body mass index >30 kg/m²
• waist-to-hip ratio ≥0.85
• waist circumference >35 in (89 cm)
• acanthosis nigricans
• personal history of gestational diabetes
• family history of type 2 diabetes mellitus (T2DM) in a first-degree relative
• diagnosis of the metabolic syndrome.

My preferred treatment approach

Metformin is a low cost and safe treatment for metabolic dysfunction due to insulin resistance and excess adipokines. I often start PCOS treatment for my patients with an OEP plus metformin extended release (XR) 750 mg with dinner. If the patient tolerates this dose, I increase the dose to metformin XR 1,500 mg with dinner.

Adverse effects. The most common side effects of metformin are gastrointestinal, including abdominal discomfort, flatulence, borborygmi, diarrhea, and nausea. Metformin reduces serum vitamin B12 levels by 5% to 10%; therefore, ensuring adequate vitamin B12 intake (2.6 µg daily) is helpful.⁶ Although metformin does reduce vitamin B12 levels, there is no strong relationship between metformin and anemia or peripheral neuropathy.⁷ Lactic acidosis is a rare complication of ­metformin.

Beneficial effects. In the treatment of PCOS, metformin may have many beneficial effects, including⁸:

• decrease in insulin resistance
• decrease in harmful adipokines
• reduction in visceral fat
• reduction in the incidence of T2DM.

OEP plus spironolactone

Many women with PCOS have increased LH secretion and increased androgen activity in the skin due to increased 5-alpha reductase enzyme activity, which catalyzes the conversion of testosterone to the powerful intracellular androgen dihydrotestosterone.⁹ Women with PCOS may present with a chief problem report of hirsutism, acne, or female androgenetic alopecia. OEP plus spironolactone may be an optimal initial treatment for women with a dominant dermatologic manifestation of PCOS. OEP treatment results in a decrease in pituitary LH secretion and ovarian androgen production. Spironolactone adds to this therapeutic effect by blocking androgen action in the skin.

The data on dual therapy with spironolactone. Many dermatologists recommend spironolactone in combination with cosmetic measures for the treatment of acne, but there are only a few randomized trials that demonstrate its efficacy.¹⁰ In one trial spironolactone was demonstrated to be superior to placebo for the treatment of inflammatory acne.¹⁰ Authors of multiple randomized trials report that the antiandrogens, spironolactone, or finasteride are superior to metformin to treat hirsutism.¹¹ In addition, a few small trials report that spironolactone plus OEP is superior to either OEP or metformin monotherapy for hirsutism.¹¹ Clinical trials of spironolactone for hirsutism have been rated as “low quality” and additional controlled trials of OEP monotherapy versus OEP plus spironolactone are ­warranted.¹²

My preferred treatment approach

Spironolactone is effective in the treatment of hirsutism at doses ranging from 50 mg to 200 mg daily. I ­routinely use a dose of spironolactone 100 mg daily because this dose is near of the top of the dose-response curve and has few adverse effects (such as intermittent uterine bleeding or spotting). With spironolactone monotherapy at a dose of 200 mg, irregular uterine bleeding or spotting is common, but concomitant treatment with an OEP tends to minimize this side effect. In my practice I rarely have patients report irregular uterine bleeding or spotting with the combination treatment of an OEP and spironolactone­ 100 mg ­daily.

Contraindications. Spironolactone should not be given to women with renal insufficiency because it can cause hyperkalemia. However, it is not necessary to check potassium levels in young women taking spironolactone with normal creatinine levels.¹³

Triple therapy: OEP plus metformin plus spironolactone

Some experts strongly recommend the initial treatment of PCOS in adolescents and young women with triple therapy: OEP plus an insulin sensitizer plus an antiandrogen.¹⁴ This recommendation is based in part on the observation that OEP monotherapy may be associated with an increase in circulating adipokines and visceral fat mass as determined by dual-energy x-ray absorptiometry.¹⁵ By contrast, triple treatment with an OEP plus metformin plus an antiandrogen is associated with a decrease in circulating adipokines and visceral fat mass.

What is the best progestin for PCOS?

Any OEP is better than no OEP, regardless of the progestin used to treat the PCOS because ethinyl estradiol plus any synthetic progestin suppresses pituitary secretion of LH and decreases ovarian androgen production. However, for the treatment of acne, using a progestin that is less androgenic may be ­beneficial.¹⁶

In one study, 2,147 consecutive women who were taking a contraceptive and presented for treatment of acne were asked if their contraceptive had a positive impact on their acne. The percentage of women reporting that their contraceptive significantly improved their acne ranged from 26% for those taking drospirenone-ethinyl estradiol (EE) to 1% for those taking the etonogestrel subdermal implant (FIGURE).¹⁶ The US Food and Drug Administration has approved 4 OEP contraceptives for the treatment of acne (TABLE). The OEPs with drospirenone, norgestimate, desogestrel, or norethindrone acetate may be optimal choices for the treatment of acne caused by PCOS.

The bottom line

PCOS is a common endocrine disorder treated primarily by obstetricians-gynecologists. Among adolescents and young women with PCOS chief problem reports include irregular menses, hirsutism, obesity, acne, and infertility. Among mid-life women the presentation of PCOS often evolves into chronic medical problems, including obesity, metabolic syndrome, hyperlipidemia, hypertension, T2DM, cardiovascular disease, and endometrial cancer.^17–19 To optimally treat the multiple pathophysiologic disorders manifested in PCOS, I recommend initial dual medical therapy with an OEP plus metformin or an OEP plus spironolactone.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Using the Rotterdam criteria, the diagnosis of polycystic ovary syndrome (PCOS) is made in the presence of 2 of the following 3 criteria¹:

1. oligo-ovulation or anovulation
2. hyperandrogenism manifested by the presence of either hirsutism or elevated hormone levels (including serum testosterone androstenedione and/or dehydroepiandrosterone sulfate)
3. ultrasonography evidence of multifollicular ovaries (≥12 follicles with a diameter of 2 mm to 9 mm in one or both ovaries; FIGURE) or ovarian stromal volume of 10 mL or more.

Illustration: Kimberly Martens for OBG Management

Among reproductive-age women, the prevalence of PCOS has been reported to range from 8% to 13% for different populations.² Most clinicians initiate treatment for PCOS with oral estrogen−progestin (OEP) monotherapy. OEP treatment has many beneficial hormonal effects, including:

• a resulting decrease in pituitary luteinizing hormone (LH) secretion, which decreases ovarian androgen production
• an increase in liver production of sex hormone−binding globulin (SHBG), which decreases free testosterone levels
• protection against the development of endometrial hyperplasia
• induction of regular uterine withdrawal bleeding.

However, OEP therapy neither improves metabolic indices (insulin sensitivity and visceral fat secretion of adipokines) nor blocks androgen action in the skin.

Dual medical treatment for PCOS can address the issues that monotherapy cannot and, along with providing guidance on improving diet and exercise, many experts support the initial therapy of PCOS with dual medical therapy (OEP plus metformin or spironolactone).

Advantages of OEP plus metformin

For many women with PCOS, the syndrome is characterized by abnormalities in both the reproductive (increase in LH secretion) and metabolic (insulin resistance and increased adipokines) systems. OEP monotherapy does not improve the metabolic abnormalities of PCOS. Combination treatment with both OEP plus metformin, along with diet and exercise, can best treat these combined abnormalities.

Data support dual therapy with metformin. In one small, randomized trial in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater reduction in serum androstenedione and a greater increase in SHBG than OEP monotherapy.³ In addition, weight loss and a reduction in waist-to-hip ratio only occurred in the OEP plus metformin group.³ In another small randomized study in women with PCOS, OEP plus metformin (1,500 mg daily) resulted in a greater decrease in free androgen index than OEP monotherapy.⁴

In my clinical opinion, women who may best benefit from OEP plus metformin therapy have one of the following factors indicating the presence of insulin resistance⁵:

• body mass index >30 kg/m²
• waist-to-hip ratio ≥0.85
• waist circumference >35 in (89 cm)
• acanthosis nigricans
• personal history of gestational diabetes
• family history of type 2 diabetes mellitus (T2DM) in a first-degree relative
• diagnosis of the metabolic syndrome.

My preferred treatment approach

Metformin is a low cost and safe treatment for metabolic dysfunction due to insulin resistance and excess adipokines. I often start PCOS treatment for my patients with an OEP plus metformin extended release (XR) 750 mg with dinner. If the patient tolerates this dose, I increase the dose to metformin XR 1,500 mg with dinner.

Adverse effects. The most common side effects of metformin are gastrointestinal, including abdominal discomfort, flatulence, borborygmi, diarrhea, and nausea. Metformin reduces serum vitamin B12 levels by 5% to 10%; therefore, ensuring adequate vitamin B12 intake (2.6 µg daily) is helpful.⁶ Although metformin does reduce vitamin B12 levels, there is no strong relationship between metformin and anemia or peripheral neuropathy.⁷ Lactic acidosis is a rare complication of ­metformin.

Beneficial effects. In the treatment of PCOS, metformin may have many beneficial effects, including⁸:

• decrease in insulin resistance
• decrease in harmful adipokines
• reduction in visceral fat
• reduction in the incidence of T2DM.

OEP plus spironolactone

Many women with PCOS have increased LH secretion and increased androgen activity in the skin due to increased 5-alpha reductase enzyme activity, which catalyzes the conversion of testosterone to the powerful intracellular androgen dihydrotestosterone.⁹ Women with PCOS may present with a chief problem report of hirsutism, acne, or female androgenetic alopecia. OEP plus spironolactone may be an optimal initial treatment for women with a dominant dermatologic manifestation of PCOS. OEP treatment results in a decrease in pituitary LH secretion and ovarian androgen production. Spironolactone adds to this therapeutic effect by blocking androgen action in the skin.

The data on dual therapy with spironolactone. Many dermatologists recommend spironolactone in combination with cosmetic measures for the treatment of acne, but there are only a few randomized trials that demonstrate its efficacy.¹⁰ In one trial spironolactone was demonstrated to be superior to placebo for the treatment of inflammatory acne.¹⁰ Authors of multiple randomized trials report that the antiandrogens, spironolactone, or finasteride are superior to metformin to treat hirsutism.¹¹ In addition, a few small trials report that spironolactone plus OEP is superior to either OEP or metformin monotherapy for hirsutism.¹¹ Clinical trials of spironolactone for hirsutism have been rated as “low quality” and additional controlled trials of OEP monotherapy versus OEP plus spironolactone are ­warranted.¹²

My preferred treatment approach

Spironolactone is effective in the treatment of hirsutism at doses ranging from 50 mg to 200 mg daily. I ­routinely use a dose of spironolactone 100 mg daily because this dose is near of the top of the dose-response curve and has few adverse effects (such as intermittent uterine bleeding or spotting). With spironolactone monotherapy at a dose of 200 mg, irregular uterine bleeding or spotting is common, but concomitant treatment with an OEP tends to minimize this side effect. In my practice I rarely have patients report irregular uterine bleeding or spotting with the combination treatment of an OEP and spironolactone­ 100 mg ­daily.

Contraindications. Spironolactone should not be given to women with renal insufficiency because it can cause hyperkalemia. However, it is not necessary to check potassium levels in young women taking spironolactone with normal creatinine levels.¹³

Triple therapy: OEP plus metformin plus spironolactone

Some experts strongly recommend the initial treatment of PCOS in adolescents and young women with triple therapy: OEP plus an insulin sensitizer plus an antiandrogen.¹⁴ This recommendation is based in part on the observation that OEP monotherapy may be associated with an increase in circulating adipokines and visceral fat mass as determined by dual-energy x-ray absorptiometry.¹⁵ By contrast, triple treatment with an OEP plus metformin plus an antiandrogen is associated with a decrease in circulating adipokines and visceral fat mass.

What is the best progestin for PCOS?

Any OEP is better than no OEP, regardless of the progestin used to treat the PCOS because ethinyl estradiol plus any synthetic progestin suppresses pituitary secretion of LH and decreases ovarian androgen production. However, for the treatment of acne, using a progestin that is less androgenic may be ­beneficial.¹⁶

In one study, 2,147 consecutive women who were taking a contraceptive and presented for treatment of acne were asked if their contraceptive had a positive impact on their acne. The percentage of women reporting that their contraceptive significantly improved their acne ranged from 26% for those taking drospirenone-ethinyl estradiol (EE) to 1% for those taking the etonogestrel subdermal implant (FIGURE).¹⁶ The US Food and Drug Administration has approved 4 OEP contraceptives for the treatment of acne (TABLE). The OEPs with drospirenone, norgestimate, desogestrel, or norethindrone acetate may be optimal choices for the treatment of acne caused by PCOS.

The bottom line

PCOS is a common endocrine disorder treated primarily by obstetricians-gynecologists. Among adolescents and young women with PCOS chief problem reports include irregular menses, hirsutism, obesity, acne, and infertility. Among mid-life women the presentation of PCOS often evolves into chronic medical problems, including obesity, metabolic syndrome, hyperlipidemia, hypertension, T2DM, cardiovascular disease, and endometrial cancer.^17–19 To optimally treat the multiple pathophysiologic disorders manifested in PCOS, I recommend initial dual medical therapy with an OEP plus metformin or an OEP plus spironolactone.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Care of women with pelvic floor disorders, primarily urinary incontinence and POP, involves:

• assessing the patient’s symptoms and determining how bothersome they are
• educating the patient about her condition and the options for treatment
• initiating treatment with the most conservative and least invasive therapies.

Safe treatments include PFMT and pessaries, and both can be effective. However, since approximately 25% of women experience one or more pelvic floor disorders during their life, surgical repair of these disorders is common. The lifetime risk of surgery for stress urinary incontinence (SUI) or POP is 20%,¹ and one-third of patients will undergo reoperation for the same condition. Midurethral mesh slings are the gold standard for surgical management of SUI.² Use of transvaginal mesh for primary prolapse repairs, however, is associated with challenging adverse effects, and its use should be reserved for carefully selected patients.

Data from 3 recent studies contribute to our evidence base on various treatments for pelvic floor disorders.

Details of the studies

PFMT for secondary prevention of POP. In a study conducted in the United Kingdom and New Zealand, Hagen and colleagues randomly assigned 414 women with POP, with or without symptoms, to an intervention group or a control group. The women had previously participated in a longitudinal study of postpartum pelvic floor function. Participants in the intervention group (n = 207) received 5 formal sessions of PFMT over 16 weeks, followed by Pilates-based classes focused on pelvic floor exercises; those in the control group (n = 207) received an informational leaflet about prolapse and lifestyle. The primary outcome was self-reported prolapse symptoms, assessed with the POP Symptom Score (POP-SS) at 2 years.

At study end, the mean (SD) POP-SS score in the intervention group was 3.2 (3.4), compared with a mean (SD) score of 4.2 (4.4) in the control group (adjusted mean difference, −1.01; 95% confidence interval [CI], −1.70 to −0.33; P = .004).

Investigators’ interpretation. The researchers concluded that the participants in the PFMT group had a small but significant—and clinically important—decrease in prolapse symptoms.

The PROSPECT study: Standard versus augmented surgical repair. In a multicenter trial in the United Kingdom by Glazener and associates, 1,352 women with symptomatic POP were randomly allocated to surgical repair with native tissue alone (standard repair) or to standard surgical repair augmented either with polypropylene mesh or with biological graft. The primary outcomes were participant-reported prolapse symptoms (assessed with POP-SS) and prolapse-related quality of life scores; these were measured at 1 year and at 2 years.

One year after surgery, failure rates (defined as prolapse beyond the hymen) were similar in all groups (range, 14%–18%); serious adverse events were also similar in all surgical groups (range, 6%–10%). Overall, 6% of women underwent reoperation for recurrent symptoms. Among women randomly assigned to repair with mesh, 12% to 14% experienced mesh-related adverse events; three-quarters of these women ultimately required surgical excision of the mesh.

Study takeaway. Thus, in terms of effectiveness, quality of life, and adverse effects, augmentation of a vaginal surgical repair with either mesh or graft material did not improve the outcomes of women with POP.

Adverse events after surgical procedures for pelvic floor disorders. In Scotland, Morling and colleagues performed a retrospective observational cohort study of first-time surgeries for SUI (mesh or colposuspension; 16,660 procedures) and prolapse (mesh or native tissue; 18,986 procedures).

After 5 years of follow-up, women who underwent midurethral mesh sling placement or colposuspension had similar rates of repeat surgery for recurrent SUI (adjusted incidence rate ratio, 0.90; 95% CI, 0.73–1.11). Use of mesh slings was associated with fewer immediate complications (adjusted relative risk, 0.44; 95% CI, 0.36–0.55) compared with nonmesh surgery.

Among women who underwent surgery for prolapse, those who had anterior and posterior repair with mesh experienced higher late complication rates than those who underwent native tissue repair. Risk for subsequent prolapse repair was similar with mesh and native-tissue procedures.

Authors’ commentary. The researchers noted that their data support the use of mesh procedures for incontinence but additional research on longer-term outcomes would be useful. However, for prolapse repair, the study results do not decidedly favor any one vault repair procedure.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Care of women with pelvic floor disorders, primarily urinary incontinence and POP, involves:

• assessing the patient’s symptoms and determining how bothersome they are
• educating the patient about her condition and the options for treatment
• initiating treatment with the most conservative and least invasive therapies.

Safe treatments include PFMT and pessaries, and both can be effective. However, since approximately 25% of women experience one or more pelvic floor disorders during their life, surgical repair of these disorders is common. The lifetime risk of surgery for stress urinary incontinence (SUI) or POP is 20%,¹ and one-third of patients will undergo reoperation for the same condition. Midurethral mesh slings are the gold standard for surgical management of SUI.² Use of transvaginal mesh for primary prolapse repairs, however, is associated with challenging adverse effects, and its use should be reserved for carefully selected patients.

Data from 3 recent studies contribute to our evidence base on various treatments for pelvic floor disorders.

Details of the studies

PFMT for secondary prevention of POP. In a study conducted in the United Kingdom and New Zealand, Hagen and colleagues randomly assigned 414 women with POP, with or without symptoms, to an intervention group or a control group. The women had previously participated in a longitudinal study of postpartum pelvic floor function. Participants in the intervention group (n = 207) received 5 formal sessions of PFMT over 16 weeks, followed by Pilates-based classes focused on pelvic floor exercises; those in the control group (n = 207) received an informational leaflet about prolapse and lifestyle. The primary outcome was self-reported prolapse symptoms, assessed with the POP Symptom Score (POP-SS) at 2 years.

At study end, the mean (SD) POP-SS score in the intervention group was 3.2 (3.4), compared with a mean (SD) score of 4.2 (4.4) in the control group (adjusted mean difference, −1.01; 95% confidence interval [CI], −1.70 to −0.33; P = .004).

Investigators’ interpretation. The researchers concluded that the participants in the PFMT group had a small but significant—and clinically important—decrease in prolapse symptoms.

The PROSPECT study: Standard versus augmented surgical repair. In a multicenter trial in the United Kingdom by Glazener and associates, 1,352 women with symptomatic POP were randomly allocated to surgical repair with native tissue alone (standard repair) or to standard surgical repair augmented either with polypropylene mesh or with biological graft. The primary outcomes were participant-reported prolapse symptoms (assessed with POP-SS) and prolapse-related quality of life scores; these were measured at 1 year and at 2 years.

One year after surgery, failure rates (defined as prolapse beyond the hymen) were similar in all groups (range, 14%–18%); serious adverse events were also similar in all surgical groups (range, 6%–10%). Overall, 6% of women underwent reoperation for recurrent symptoms. Among women randomly assigned to repair with mesh, 12% to 14% experienced mesh-related adverse events; three-quarters of these women ultimately required surgical excision of the mesh.

Study takeaway. Thus, in terms of effectiveness, quality of life, and adverse effects, augmentation of a vaginal surgical repair with either mesh or graft material did not improve the outcomes of women with POP.

Adverse events after surgical procedures for pelvic floor disorders. In Scotland, Morling and colleagues performed a retrospective observational cohort study of first-time surgeries for SUI (mesh or colposuspension; 16,660 procedures) and prolapse (mesh or native tissue; 18,986 procedures).

After 5 years of follow-up, women who underwent midurethral mesh sling placement or colposuspension had similar rates of repeat surgery for recurrent SUI (adjusted incidence rate ratio, 0.90; 95% CI, 0.73–1.11). Use of mesh slings was associated with fewer immediate complications (adjusted relative risk, 0.44; 95% CI, 0.36–0.55) compared with nonmesh surgery.

Among women who underwent surgery for prolapse, those who had anterior and posterior repair with mesh experienced higher late complication rates than those who underwent native tissue repair. Risk for subsequent prolapse repair was similar with mesh and native-tissue procedures.

Authors’ commentary. The researchers noted that their data support the use of mesh procedures for incontinence but additional research on longer-term outcomes would be useful. However, for prolapse repair, the study results do not decidedly favor any one vault repair procedure.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Care of women with pelvic floor disorders, primarily urinary incontinence and POP, involves:

• assessing the patient’s symptoms and determining how bothersome they are
• educating the patient about her condition and the options for treatment
• initiating treatment with the most conservative and least invasive therapies.

Safe treatments include PFMT and pessaries, and both can be effective. However, since approximately 25% of women experience one or more pelvic floor disorders during their life, surgical repair of these disorders is common. The lifetime risk of surgery for stress urinary incontinence (SUI) or POP is 20%,¹ and one-third of patients will undergo reoperation for the same condition. Midurethral mesh slings are the gold standard for surgical management of SUI.² Use of transvaginal mesh for primary prolapse repairs, however, is associated with challenging adverse effects, and its use should be reserved for carefully selected patients.

Data from 3 recent studies contribute to our evidence base on various treatments for pelvic floor disorders.

Details of the studies

PFMT for secondary prevention of POP. In a study conducted in the United Kingdom and New Zealand, Hagen and colleagues randomly assigned 414 women with POP, with or without symptoms, to an intervention group or a control group. The women had previously participated in a longitudinal study of postpartum pelvic floor function. Participants in the intervention group (n = 207) received 5 formal sessions of PFMT over 16 weeks, followed by Pilates-based classes focused on pelvic floor exercises; those in the control group (n = 207) received an informational leaflet about prolapse and lifestyle. The primary outcome was self-reported prolapse symptoms, assessed with the POP Symptom Score (POP-SS) at 2 years.

At study end, the mean (SD) POP-SS score in the intervention group was 3.2 (3.4), compared with a mean (SD) score of 4.2 (4.4) in the control group (adjusted mean difference, −1.01; 95% confidence interval [CI], −1.70 to −0.33; P = .004).

Investigators’ interpretation. The researchers concluded that the participants in the PFMT group had a small but significant—and clinically important—decrease in prolapse symptoms.

The PROSPECT study: Standard versus augmented surgical repair. In a multicenter trial in the United Kingdom by Glazener and associates, 1,352 women with symptomatic POP were randomly allocated to surgical repair with native tissue alone (standard repair) or to standard surgical repair augmented either with polypropylene mesh or with biological graft. The primary outcomes were participant-reported prolapse symptoms (assessed with POP-SS) and prolapse-related quality of life scores; these were measured at 1 year and at 2 years.

One year after surgery, failure rates (defined as prolapse beyond the hymen) were similar in all groups (range, 14%–18%); serious adverse events were also similar in all surgical groups (range, 6%–10%). Overall, 6% of women underwent reoperation for recurrent symptoms. Among women randomly assigned to repair with mesh, 12% to 14% experienced mesh-related adverse events; three-quarters of these women ultimately required surgical excision of the mesh.

Study takeaway. Thus, in terms of effectiveness, quality of life, and adverse effects, augmentation of a vaginal surgical repair with either mesh or graft material did not improve the outcomes of women with POP.

Adverse events after surgical procedures for pelvic floor disorders. In Scotland, Morling and colleagues performed a retrospective observational cohort study of first-time surgeries for SUI (mesh or colposuspension; 16,660 procedures) and prolapse (mesh or native tissue; 18,986 procedures).

After 5 years of follow-up, women who underwent midurethral mesh sling placement or colposuspension had similar rates of repeat surgery for recurrent SUI (adjusted incidence rate ratio, 0.90; 95% CI, 0.73–1.11). Use of mesh slings was associated with fewer immediate complications (adjusted relative risk, 0.44; 95% CI, 0.36–0.55) compared with nonmesh surgery.

Among women who underwent surgery for prolapse, those who had anterior and posterior repair with mesh experienced higher late complication rates than those who underwent native tissue repair. Risk for subsequent prolapse repair was similar with mesh and native-tissue procedures.

Authors’ commentary. The researchers noted that their data support the use of mesh procedures for incontinence but additional research on longer-term outcomes would be useful. However, for prolapse repair, the study results do not decidedly favor any one vault repair procedure.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

CASE Woman with fibroids seeks alternative to hysterectomy

A 42-year-old woman (G2P2) presents to the office for evaluation of heavy menstrual bleeding and known uterine fibroids. Physical examination reveals a 16-week-sized uterus, and ultrasonography shows at least 6 fibroids, 2 of which impinge on the uterine cavity. She does not want to have any more children, but she wishes to avoid a hysterectomy.

Abdominal myomectomy: A good option for many women

Abdominal myomectomy is an underutilized procedure. With fibroids as the indication for surgery, 197,000 hysterectomies were performed in the United States in 2010, compared with approximately 40,000 myomectomies.^1,2 Moreover, the rates of both laparoscopic and abdominal myomectomy have decreased following the controversial morcellation advisory issued by the US Food and Drug Administration.³

The differences in the hysterectomy and myomectomy rates might be explained by the many myths ascribed to myomectomy. Such myths include the beliefs that myomectomy, when compared with hysterectomy, is associated with greater risk of visceral injury, more blood loss, poor uterine healing, and high risk of fibroid recurrence, and that myomectomy is unlikely to improve patient symptoms.

Studies show, however, that these beliefs are wrong. The risk of needing treatment for new fibroid growth following myomectomy is low.⁴ Hysterectomy, compared with myomectomy for similar size uteri, is actually associated with a greater risk of injury to the bowel, bladder, and ureters and with a greater risk of operative hemorrhage. Furthermore, hysterectomy (without oophorectomy) can be associated with early menopause in approximately 10% of women, while myomectomy does not alter ovarian hormones. (See “7 Myomectomy myths debunked,” which appeared in the February 2017 issue of OBG Management.) Another myth debunked: Fibroids do not “degenerate” into leiomyosarcomas, and the risk of leiomyosarcoma in premenopausal women with presumed uterine fibroids is extremely low.^5,6

For women who have serious medical problems (severe anemia, ureteral obstruction) due to uterine fibroids, surgery usually is necessary. In addition, women may request surgery for fibroid-associated quality-of-life concerns, such as heavy menstrual bleeding, infertility, pelvic pressure, urinary frequency, or incontinence. In one prospective study, the authors found that when women were assessed 6 months after undergoing myomectomy, 75% reported experiencing a significant decrease in bothersome symptoms.⁷

Myomectomy may be considered even for women with large uterine fibroids who desire uterine conservation. In a systematic review of the perioperative morbidity associated with abdominal myomectomy compared with abdominal hysterectomy for fibroids, which included 1,520 women with uterine size up to 16 to 18 weeks, no difference was found in major morbidity rates.⁸ Investigators who studied 91 women with uterine size ranging from 16 to 36 weeks who underwent abdominal myomectomy reported 1 bowel injury, 1 bladder injury, and 1 reoperation for bowel obstruction; no women had conversion to hysterectomy.⁹

Since ObGyn residency training emphasizes hysterectomy techniques, many residents receive only limited exposure to myomectomy procedures. Increased exposure to and comfort with myomectomy surgical technique would encourage more gynecologists to offer this option to their patients who desire uterine conservation, including those who do not desire future childbearing.

Imaging techniques are essential in the preoperative evaluation

For women with fibroid-related symptoms who desire surgery with uterine preservation, determining the myomectomy approach (abdominal, laparoscopic/robotic, hysteroscopic) depends on accurate assessment of the size, number, and position of the fibroids. If abdominal myomectomy is planned because of uterine size, the presence of numerous fibroids, or patient choice, transvaginal/transabdominal ultrasonography usually is adequate for anticipating what will be found during surgery. Sonography is readily available and is the least costly imaging technique that can help differentiate fibroids from other pelvic pathology. Although small fibroids may not be seen on sonography, they can be palpated and removed at the time of open surgery.

If submucous fibroids need to be better defined, saline-infusion sonography can be performed. However, if laparoscopic/robotic myomectomy (which precludes accurate palpation during surgery) is being considered, magnetic resonance imaging (MRI) allows the best assessment of the size, number, and position of the fibroids.¹⁰ When adenomyosis is considered in the differential diagnosis, MRI is an accurate way to determine its presence and helps in planning the best surgical procedure and approach.

Correct anemia before surgery

Women with fibroids may have anemia requiring correction before surgery to reduce the need for intraoperative or postoperative blood transfusion. Mild iron deficiency anemia can be treated prior to surgery with oral elemental iron 150 to 200 mg per day. Vitamin C 1,000 mg per day helps to increase intestinal iron absorption. Three weeks of treatment with oral iron can increase hemoglobin concentration by 2 g/dL.

For more severe anemia or rapid correction of anemia, intravenous (IV) iron sucrose infusions, 200 mg infused over 2 hours and given 3 times per week for 3 weeks, can increase hemoglobin by 3 g/dL.¹¹ In our ObGyn practice, hematologists manage iron infusions.

Read about abdominal incision technique

Abdominal incision technique

Even a large uterus with multiple fibroids usually can be managed through use of a transverse lower abdominal incision. Prior to reaching the lateral borders of the rectus abdominis, curve the fascial incision cephalad to avoid injury to the ileoinguinal nerves (FIGURE 1). Detaching the midline rectus fascia (linea alba) from the anterior abdominal wall, starting at the pubic symphysis and continuing up to the umbilicus, frees the rectus muscles and allows them to be easily separated (see VIDEO 1). Since fascia is not elastic, these 2 steps are important to allow more room to deliver the uterus through the incision.

Illustration: Marcia Hartsock for OBG Management

Delivery of the uterus through the incision isolates the surgical field from the bowel, bladder, ureters, and pelvic nerves. Once the uterus is delivered, inspect and palpate it for fibroids. Identify the fundus and the position of the uterine cavity by locating both uterine cornua and imagining a straight line between them. It may be necessary to explore the endometrial cavity to look for and remove submucous fibroids. Then plan the necessary uterine incisions for removing all fibroids (see VIDEO 2).

Read about managing blood loss

4 approaches to managing intraoperative blood loss

In my practice, we employ misoprostol, tranexamic acid, vasopressin, and a uterine and ovarian vessel tourniquet to manage intraoperative blood loss.¹² Although no data exist to show that using these methods together is advantageous, they have different mechanisms of action and no negative interactions.

Misoprostol 400 μg inserted vaginally 2 hours before surgery induces myometrial contraction and compression of the uterine vessels. This agent can reduce blood loss by 98 mL per case.¹²

Tranexamic acid, an antifibrinolytic, is given IV piggyback at the start of surgery at a dose of 10 mg/kg; it can reduce blood loss by 243 mL per case.¹²

Vasopressin 20 U in 100 mL normal saline, injected below the vascular pseudocapsule, causes vasoconstriction of capillaries and small arterioles and venules and can reduce blood loss by 246 mL per case.¹² Intravascular injection should be avoided because rare cases of bradycardia and cardiovascular collapse have been reported.¹³ Using vasopressin to decrease blood loss during myomectomy is an off-label use of this drug.

Place a tourniquet around the lower uterine segment, including the infundibular pelvic ligaments. Tourniquet use is the most effective way to decrease blood loss during myomectomy, since it can reduce blood loss by 1,870 mL.¹² For women who wish to preserve fertility, take care to ensure that the tourniquet does not compromise the tubes. For women who are certain they do not want to preserve fertility, discuss the possibility of performing bilateral salpingectomy to decrease the risk of subsequent tubal (“ovarian”) cancer.

Some surgeons incise the broad ligaments bilaterally and pass the tourniquet through the broad ligaments to avoid compromising blood flow to the ovaries. Occluding the utero- ovarian ligaments with bulldog clamps to control collateral blood flow from the ovarian artery has been described, but the clamps can tear these often enlarged and fragile uterine veins during manipulation of the uterus. Release the tourniquet every 15 to 30 minutes to allow reperfusion of the ovaries. In women with ovarian torsion lasting hours to days, the ovary has been found to resist hypoxia and recover function.¹⁴ Antral follicle counts of detorsed and contralateral normal ovaries following a mean of 13 hours of hypoxia are similar 3 months following detorsion.¹⁵

Consider blood salvage. For women with multiple or very large fibroids, consider using a salvage-type autologous blood transfusion device, which has been shown to reduce the need for heterologous blood transfusion.¹⁶ This device suctions blood from the operative field, mixes it with heparinized saline, and stores the blood in a canister (FIGURE 2). If the patient requires blood reinfusion, the stored blood is washed with saline, filtered, centrifuged, and given back to the patient intravenously. Blood salvage, or cell salvage, avoids the risks of infection and transfusion reaction, and the oxygen transport capacity of salvaged red blood cells is equal to or better than that of stored allogeneic red cells.

Used with permission.

Additional surgical considerations

Previous teaching suggested that proper placement of the uterine incisions was an important factor in limiting blood loss. Some authors suggested that vertical uterine incisions would avoid injury to the ascending uterine vessels should inadvertent extension of the incision occur. Other authors proposed horizontal uterine incisions to avoid severing the arcuate vessels that branch off from the ascending uterine arteries and run transversely across the uterus. However, since fibroids distort the normal vascular architecture, it is not possible to entirely avoid severing vessels in the myometrium (FIGURE 3).¹⁷ Uterine incisions can therefore be made as needed based on the position of the fibroids and the need to avoid inadvertent extension to the ascending uterine vessels or cornua.¹⁷

Used with permission.

Fibroid anatomy and vascularity. Fibroids are entirely encased within the dense blood supply of a pseudocapsule (FIGURE 4),¹⁸ and no distinct “vascular pedicle” exists at the base of the fibroid.¹⁹ It is therefore important to extend the uterine incisions down through the entire pseudocapsule until the fibroid is clearly visible. This will identify a less vascular surgical plane, which is deeper than commonly recognized. Once the fibroid is reached, the pseudocapsule can be “wiped away” using a dry laparotomy sponge (see VIDEO 3). Staying under the pseudocapsule reduces bleeding and may preserve the tissue growth factors and neurotransmitters that are thought to promote wound healing.²⁰

Used with permission.

Adhesion prevention. Limiting the number of uterine incisions has been suggested as a way to reduce the risk of postoperative pelvic adhesions. To extract fibroids that are distant from an incision, however, tunnels must be created within the myometrium, and this makes hemostasis within these defects difficult. In that blood increases the risk of adhesion formation, tunneling may be counterproductive. If tunneling incisions are avoided and hemostasis is secured immediately, the risk of adhesion formation should be lessened.

Therefore, make incisions directly over the fibroids. Remove only easily accessed fibroids and promptly close the defects to secure hemostasis. Multiple uterine incisions may be needed; adhesion barriers may help limit adhesion formation.²¹

On final removal of the tourniquet, carefully inspect for bleeding and perform any necessary re-suturing. We place a pain pump (ON-Q* Pain Relief System, Halyard Health, Inc) for pain management and close the abdominal incision in the standard manner.

Read about postoperative care

Postoperative care: Manage pain, restore function

The pain pump infuser, attached to one soaker catheter above and one below the fascia, provides continuous infusion of bupivacaine to the incision at 4 mL per hour for 4 days. The pain pump greatly reduces the need for postoperative opioids.²² Use of a patient-controlled analgesia pump, with its associated adverse effects (sedation, need for oxygen saturation monitoring, slowing of bowel function) can thus be avoided. The patient’s residual pain is controlled with oral oxycodone or hydrocodone and scheduled nonsteroidal anti-inflammatory drugs.

In my practice, we use an enhanced recovery after surgery (ERAS) protocol designed to reduce postoperative surgical stress and expedite a return to baseline physiologic body functions.²³ Excellent well-researched, evidence-based studies support the effectiveness of ERAS in gynecologic and general surgery procedures.²⁴

Pre-emptive, preoperative analgesia (gabapentin and celecoxib) and end-of-case IV acetaminophen are given to reduce the inflammatory response and the need for postoperative opioids. Once it is confirmed that the patient is hemodynamically stable, add ketorolac 30 mg IV every 6 hours on postoperative day 1. Nausea and vomiting prophylaxis includes ondansetron and dexamethasone at the end of surgery, avoidance of bowel edema with restriction of intraoperative and postoperative fluids (euvolemia), early oral feeding, and gum chewing. On the evening of surgery, the urinary catheter is removed to reduce the risk of bladder infection and facilitate ambulation. Encourage sitting at the bedside and early ambulation starting the evening of surgery to reduce risk of thromboembolism and to avoid skeletal muscle weakness and postoperative fatigue.

Most women are able to be discharged on postoperative day 2. They return to the office on postoperative day 5 for removal of the pain pump.

CASE Continued: Fibroids removed via abdominal myomectomy

We performed an abdominal myomectomy through a Pfannenstiel incision. Nine fibroids—3 of which were not seen on MRI—ranging in size from 1 to 7 cm were removed. Intravaginal misoprostol, IV tranexamic acid, subserosal vasopressin, and a uterine vessel tourniquet limited the intraoperative blood loss to 225 mL. After surgery, a pain pump and ERAS protocol allowed the patient to be discharged on postoperative day 2, and she returned to the office on day 5 for removal of the pain pump. Oral pain medication was continued on an as-needed basis.

Acknowledgement

The author would like to thank Stanley West, MD, for generously teaching him the surgical techniques for performing abdominal myomectomy.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

CASE Woman with fibroids seeks alternative to hysterectomy

A 42-year-old woman (G2P2) presents to the office for evaluation of heavy menstrual bleeding and known uterine fibroids. Physical examination reveals a 16-week-sized uterus, and ultrasonography shows at least 6 fibroids, 2 of which impinge on the uterine cavity. She does not want to have any more children, but she wishes to avoid a hysterectomy.

Abdominal myomectomy: A good option for many women

Abdominal myomectomy is an underutilized procedure. With fibroids as the indication for surgery, 197,000 hysterectomies were performed in the United States in 2010, compared with approximately 40,000 myomectomies.^1,2 Moreover, the rates of both laparoscopic and abdominal myomectomy have decreased following the controversial morcellation advisory issued by the US Food and Drug Administration.³

The differences in the hysterectomy and myomectomy rates might be explained by the many myths ascribed to myomectomy. Such myths include the beliefs that myomectomy, when compared with hysterectomy, is associated with greater risk of visceral injury, more blood loss, poor uterine healing, and high risk of fibroid recurrence, and that myomectomy is unlikely to improve patient symptoms.

Studies show, however, that these beliefs are wrong. The risk of needing treatment for new fibroid growth following myomectomy is low.⁴ Hysterectomy, compared with myomectomy for similar size uteri, is actually associated with a greater risk of injury to the bowel, bladder, and ureters and with a greater risk of operative hemorrhage. Furthermore, hysterectomy (without oophorectomy) can be associated with early menopause in approximately 10% of women, while myomectomy does not alter ovarian hormones. (See “7 Myomectomy myths debunked,” which appeared in the February 2017 issue of OBG Management.) Another myth debunked: Fibroids do not “degenerate” into leiomyosarcomas, and the risk of leiomyosarcoma in premenopausal women with presumed uterine fibroids is extremely low.^5,6

For women who have serious medical problems (severe anemia, ureteral obstruction) due to uterine fibroids, surgery usually is necessary. In addition, women may request surgery for fibroid-associated quality-of-life concerns, such as heavy menstrual bleeding, infertility, pelvic pressure, urinary frequency, or incontinence. In one prospective study, the authors found that when women were assessed 6 months after undergoing myomectomy, 75% reported experiencing a significant decrease in bothersome symptoms.⁷

Myomectomy may be considered even for women with large uterine fibroids who desire uterine conservation. In a systematic review of the perioperative morbidity associated with abdominal myomectomy compared with abdominal hysterectomy for fibroids, which included 1,520 women with uterine size up to 16 to 18 weeks, no difference was found in major morbidity rates.⁸ Investigators who studied 91 women with uterine size ranging from 16 to 36 weeks who underwent abdominal myomectomy reported 1 bowel injury, 1 bladder injury, and 1 reoperation for bowel obstruction; no women had conversion to hysterectomy.⁹

Since ObGyn residency training emphasizes hysterectomy techniques, many residents receive only limited exposure to myomectomy procedures. Increased exposure to and comfort with myomectomy surgical technique would encourage more gynecologists to offer this option to their patients who desire uterine conservation, including those who do not desire future childbearing.

Imaging techniques are essential in the preoperative evaluation

For women with fibroid-related symptoms who desire surgery with uterine preservation, determining the myomectomy approach (abdominal, laparoscopic/robotic, hysteroscopic) depends on accurate assessment of the size, number, and position of the fibroids. If abdominal myomectomy is planned because of uterine size, the presence of numerous fibroids, or patient choice, transvaginal/transabdominal ultrasonography usually is adequate for anticipating what will be found during surgery. Sonography is readily available and is the least costly imaging technique that can help differentiate fibroids from other pelvic pathology. Although small fibroids may not be seen on sonography, they can be palpated and removed at the time of open surgery.

If submucous fibroids need to be better defined, saline-infusion sonography can be performed. However, if laparoscopic/robotic myomectomy (which precludes accurate palpation during surgery) is being considered, magnetic resonance imaging (MRI) allows the best assessment of the size, number, and position of the fibroids.¹⁰ When adenomyosis is considered in the differential diagnosis, MRI is an accurate way to determine its presence and helps in planning the best surgical procedure and approach.

Correct anemia before surgery

Women with fibroids may have anemia requiring correction before surgery to reduce the need for intraoperative or postoperative blood transfusion. Mild iron deficiency anemia can be treated prior to surgery with oral elemental iron 150 to 200 mg per day. Vitamin C 1,000 mg per day helps to increase intestinal iron absorption. Three weeks of treatment with oral iron can increase hemoglobin concentration by 2 g/dL.

For more severe anemia or rapid correction of anemia, intravenous (IV) iron sucrose infusions, 200 mg infused over 2 hours and given 3 times per week for 3 weeks, can increase hemoglobin by 3 g/dL.¹¹ In our ObGyn practice, hematologists manage iron infusions.

Read about abdominal incision technique

Abdominal incision technique

Even a large uterus with multiple fibroids usually can be managed through use of a transverse lower abdominal incision. Prior to reaching the lateral borders of the rectus abdominis, curve the fascial incision cephalad to avoid injury to the ileoinguinal nerves (FIGURE 1). Detaching the midline rectus fascia (linea alba) from the anterior abdominal wall, starting at the pubic symphysis and continuing up to the umbilicus, frees the rectus muscles and allows them to be easily separated (see VIDEO 1). Since fascia is not elastic, these 2 steps are important to allow more room to deliver the uterus through the incision.

Illustration: Marcia Hartsock for OBG Management

Delivery of the uterus through the incision isolates the surgical field from the bowel, bladder, ureters, and pelvic nerves. Once the uterus is delivered, inspect and palpate it for fibroids. Identify the fundus and the position of the uterine cavity by locating both uterine cornua and imagining a straight line between them. It may be necessary to explore the endometrial cavity to look for and remove submucous fibroids. Then plan the necessary uterine incisions for removing all fibroids (see VIDEO 2).

Read about managing blood loss

4 approaches to managing intraoperative blood loss

In my practice, we employ misoprostol, tranexamic acid, vasopressin, and a uterine and ovarian vessel tourniquet to manage intraoperative blood loss.¹² Although no data exist to show that using these methods together is advantageous, they have different mechanisms of action and no negative interactions.

Misoprostol 400 μg inserted vaginally 2 hours before surgery induces myometrial contraction and compression of the uterine vessels. This agent can reduce blood loss by 98 mL per case.¹²

Tranexamic acid, an antifibrinolytic, is given IV piggyback at the start of surgery at a dose of 10 mg/kg; it can reduce blood loss by 243 mL per case.¹²

Vasopressin 20 U in 100 mL normal saline, injected below the vascular pseudocapsule, causes vasoconstriction of capillaries and small arterioles and venules and can reduce blood loss by 246 mL per case.¹² Intravascular injection should be avoided because rare cases of bradycardia and cardiovascular collapse have been reported.¹³ Using vasopressin to decrease blood loss during myomectomy is an off-label use of this drug.

Place a tourniquet around the lower uterine segment, including the infundibular pelvic ligaments. Tourniquet use is the most effective way to decrease blood loss during myomectomy, since it can reduce blood loss by 1,870 mL.¹² For women who wish to preserve fertility, take care to ensure that the tourniquet does not compromise the tubes. For women who are certain they do not want to preserve fertility, discuss the possibility of performing bilateral salpingectomy to decrease the risk of subsequent tubal (“ovarian”) cancer.

Some surgeons incise the broad ligaments bilaterally and pass the tourniquet through the broad ligaments to avoid compromising blood flow to the ovaries. Occluding the utero- ovarian ligaments with bulldog clamps to control collateral blood flow from the ovarian artery has been described, but the clamps can tear these often enlarged and fragile uterine veins during manipulation of the uterus. Release the tourniquet every 15 to 30 minutes to allow reperfusion of the ovaries. In women with ovarian torsion lasting hours to days, the ovary has been found to resist hypoxia and recover function.¹⁴ Antral follicle counts of detorsed and contralateral normal ovaries following a mean of 13 hours of hypoxia are similar 3 months following detorsion.¹⁵

Consider blood salvage. For women with multiple or very large fibroids, consider using a salvage-type autologous blood transfusion device, which has been shown to reduce the need for heterologous blood transfusion.¹⁶ This device suctions blood from the operative field, mixes it with heparinized saline, and stores the blood in a canister (FIGURE 2). If the patient requires blood reinfusion, the stored blood is washed with saline, filtered, centrifuged, and given back to the patient intravenously. Blood salvage, or cell salvage, avoids the risks of infection and transfusion reaction, and the oxygen transport capacity of salvaged red blood cells is equal to or better than that of stored allogeneic red cells.

Used with permission.

Additional surgical considerations

Previous teaching suggested that proper placement of the uterine incisions was an important factor in limiting blood loss. Some authors suggested that vertical uterine incisions would avoid injury to the ascending uterine vessels should inadvertent extension of the incision occur. Other authors proposed horizontal uterine incisions to avoid severing the arcuate vessels that branch off from the ascending uterine arteries and run transversely across the uterus. However, since fibroids distort the normal vascular architecture, it is not possible to entirely avoid severing vessels in the myometrium (FIGURE 3).¹⁷ Uterine incisions can therefore be made as needed based on the position of the fibroids and the need to avoid inadvertent extension to the ascending uterine vessels or cornua.¹⁷

Used with permission.

Fibroid anatomy and vascularity. Fibroids are entirely encased within the dense blood supply of a pseudocapsule (FIGURE 4),¹⁸ and no distinct “vascular pedicle” exists at the base of the fibroid.¹⁹ It is therefore important to extend the uterine incisions down through the entire pseudocapsule until the fibroid is clearly visible. This will identify a less vascular surgical plane, which is deeper than commonly recognized. Once the fibroid is reached, the pseudocapsule can be “wiped away” using a dry laparotomy sponge (see VIDEO 3). Staying under the pseudocapsule reduces bleeding and may preserve the tissue growth factors and neurotransmitters that are thought to promote wound healing.²⁰

Used with permission.

Adhesion prevention. Limiting the number of uterine incisions has been suggested as a way to reduce the risk of postoperative pelvic adhesions. To extract fibroids that are distant from an incision, however, tunnels must be created within the myometrium, and this makes hemostasis within these defects difficult. In that blood increases the risk of adhesion formation, tunneling may be counterproductive. If tunneling incisions are avoided and hemostasis is secured immediately, the risk of adhesion formation should be lessened.

Therefore, make incisions directly over the fibroids. Remove only easily accessed fibroids and promptly close the defects to secure hemostasis. Multiple uterine incisions may be needed; adhesion barriers may help limit adhesion formation.²¹

On final removal of the tourniquet, carefully inspect for bleeding and perform any necessary re-suturing. We place a pain pump (ON-Q* Pain Relief System, Halyard Health, Inc) for pain management and close the abdominal incision in the standard manner.

Read about postoperative care

Postoperative care: Manage pain, restore function

The pain pump infuser, attached to one soaker catheter above and one below the fascia, provides continuous infusion of bupivacaine to the incision at 4 mL per hour for 4 days. The pain pump greatly reduces the need for postoperative opioids.²² Use of a patient-controlled analgesia pump, with its associated adverse effects (sedation, need for oxygen saturation monitoring, slowing of bowel function) can thus be avoided. The patient’s residual pain is controlled with oral oxycodone or hydrocodone and scheduled nonsteroidal anti-inflammatory drugs.

In my practice, we use an enhanced recovery after surgery (ERAS) protocol designed to reduce postoperative surgical stress and expedite a return to baseline physiologic body functions.²³ Excellent well-researched, evidence-based studies support the effectiveness of ERAS in gynecologic and general surgery procedures.²⁴

Pre-emptive, preoperative analgesia (gabapentin and celecoxib) and end-of-case IV acetaminophen are given to reduce the inflammatory response and the need for postoperative opioids. Once it is confirmed that the patient is hemodynamically stable, add ketorolac 30 mg IV every 6 hours on postoperative day 1. Nausea and vomiting prophylaxis includes ondansetron and dexamethasone at the end of surgery, avoidance of bowel edema with restriction of intraoperative and postoperative fluids (euvolemia), early oral feeding, and gum chewing. On the evening of surgery, the urinary catheter is removed to reduce the risk of bladder infection and facilitate ambulation. Encourage sitting at the bedside and early ambulation starting the evening of surgery to reduce risk of thromboembolism and to avoid skeletal muscle weakness and postoperative fatigue.

Most women are able to be discharged on postoperative day 2. They return to the office on postoperative day 5 for removal of the pain pump.

CASE Continued: Fibroids removed via abdominal myomectomy

We performed an abdominal myomectomy through a Pfannenstiel incision. Nine fibroids—3 of which were not seen on MRI—ranging in size from 1 to 7 cm were removed. Intravaginal misoprostol, IV tranexamic acid, subserosal vasopressin, and a uterine vessel tourniquet limited the intraoperative blood loss to 225 mL. After surgery, a pain pump and ERAS protocol allowed the patient to be discharged on postoperative day 2, and she returned to the office on day 5 for removal of the pain pump. Oral pain medication was continued on an as-needed basis.

Acknowledgement

The author would like to thank Stanley West, MD, for generously teaching him the surgical techniques for performing abdominal myomectomy.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

CASE Woman with fibroids seeks alternative to hysterectomy

A 42-year-old woman (G2P2) presents to the office for evaluation of heavy menstrual bleeding and known uterine fibroids. Physical examination reveals a 16-week-sized uterus, and ultrasonography shows at least 6 fibroids, 2 of which impinge on the uterine cavity. She does not want to have any more children, but she wishes to avoid a hysterectomy.

Abdominal myomectomy: A good option for many women

Abdominal myomectomy is an underutilized procedure. With fibroids as the indication for surgery, 197,000 hysterectomies were performed in the United States in 2010, compared with approximately 40,000 myomectomies.^1,2 Moreover, the rates of both laparoscopic and abdominal myomectomy have decreased following the controversial morcellation advisory issued by the US Food and Drug Administration.³

The differences in the hysterectomy and myomectomy rates might be explained by the many myths ascribed to myomectomy. Such myths include the beliefs that myomectomy, when compared with hysterectomy, is associated with greater risk of visceral injury, more blood loss, poor uterine healing, and high risk of fibroid recurrence, and that myomectomy is unlikely to improve patient symptoms.

Studies show, however, that these beliefs are wrong. The risk of needing treatment for new fibroid growth following myomectomy is low.⁴ Hysterectomy, compared with myomectomy for similar size uteri, is actually associated with a greater risk of injury to the bowel, bladder, and ureters and with a greater risk of operative hemorrhage. Furthermore, hysterectomy (without oophorectomy) can be associated with early menopause in approximately 10% of women, while myomectomy does not alter ovarian hormones. (See “7 Myomectomy myths debunked,” which appeared in the February 2017 issue of OBG Management.) Another myth debunked: Fibroids do not “degenerate” into leiomyosarcomas, and the risk of leiomyosarcoma in premenopausal women with presumed uterine fibroids is extremely low.^5,6

For women who have serious medical problems (severe anemia, ureteral obstruction) due to uterine fibroids, surgery usually is necessary. In addition, women may request surgery for fibroid-associated quality-of-life concerns, such as heavy menstrual bleeding, infertility, pelvic pressure, urinary frequency, or incontinence. In one prospective study, the authors found that when women were assessed 6 months after undergoing myomectomy, 75% reported experiencing a significant decrease in bothersome symptoms.⁷

Myomectomy may be considered even for women with large uterine fibroids who desire uterine conservation. In a systematic review of the perioperative morbidity associated with abdominal myomectomy compared with abdominal hysterectomy for fibroids, which included 1,520 women with uterine size up to 16 to 18 weeks, no difference was found in major morbidity rates.⁸ Investigators who studied 91 women with uterine size ranging from 16 to 36 weeks who underwent abdominal myomectomy reported 1 bowel injury, 1 bladder injury, and 1 reoperation for bowel obstruction; no women had conversion to hysterectomy.⁹

Since ObGyn residency training emphasizes hysterectomy techniques, many residents receive only limited exposure to myomectomy procedures. Increased exposure to and comfort with myomectomy surgical technique would encourage more gynecologists to offer this option to their patients who desire uterine conservation, including those who do not desire future childbearing.

Imaging techniques are essential in the preoperative evaluation

For women with fibroid-related symptoms who desire surgery with uterine preservation, determining the myomectomy approach (abdominal, laparoscopic/robotic, hysteroscopic) depends on accurate assessment of the size, number, and position of the fibroids. If abdominal myomectomy is planned because of uterine size, the presence of numerous fibroids, or patient choice, transvaginal/transabdominal ultrasonography usually is adequate for anticipating what will be found during surgery. Sonography is readily available and is the least costly imaging technique that can help differentiate fibroids from other pelvic pathology. Although small fibroids may not be seen on sonography, they can be palpated and removed at the time of open surgery.

If submucous fibroids need to be better defined, saline-infusion sonography can be performed. However, if laparoscopic/robotic myomectomy (which precludes accurate palpation during surgery) is being considered, magnetic resonance imaging (MRI) allows the best assessment of the size, number, and position of the fibroids.¹⁰ When adenomyosis is considered in the differential diagnosis, MRI is an accurate way to determine its presence and helps in planning the best surgical procedure and approach.

Correct anemia before surgery

Women with fibroids may have anemia requiring correction before surgery to reduce the need for intraoperative or postoperative blood transfusion. Mild iron deficiency anemia can be treated prior to surgery with oral elemental iron 150 to 200 mg per day. Vitamin C 1,000 mg per day helps to increase intestinal iron absorption. Three weeks of treatment with oral iron can increase hemoglobin concentration by 2 g/dL.

For more severe anemia or rapid correction of anemia, intravenous (IV) iron sucrose infusions, 200 mg infused over 2 hours and given 3 times per week for 3 weeks, can increase hemoglobin by 3 g/dL.¹¹ In our ObGyn practice, hematologists manage iron infusions.

Read about abdominal incision technique

Abdominal incision technique

Even a large uterus with multiple fibroids usually can be managed through use of a transverse lower abdominal incision. Prior to reaching the lateral borders of the rectus abdominis, curve the fascial incision cephalad to avoid injury to the ileoinguinal nerves (FIGURE 1). Detaching the midline rectus fascia (linea alba) from the anterior abdominal wall, starting at the pubic symphysis and continuing up to the umbilicus, frees the rectus muscles and allows them to be easily separated (see VIDEO 1). Since fascia is not elastic, these 2 steps are important to allow more room to deliver the uterus through the incision.

Illustration: Marcia Hartsock for OBG Management

Delivery of the uterus through the incision isolates the surgical field from the bowel, bladder, ureters, and pelvic nerves. Once the uterus is delivered, inspect and palpate it for fibroids. Identify the fundus and the position of the uterine cavity by locating both uterine cornua and imagining a straight line between them. It may be necessary to explore the endometrial cavity to look for and remove submucous fibroids. Then plan the necessary uterine incisions for removing all fibroids (see VIDEO 2).

Read about managing blood loss

4 approaches to managing intraoperative blood loss

In my practice, we employ misoprostol, tranexamic acid, vasopressin, and a uterine and ovarian vessel tourniquet to manage intraoperative blood loss.¹² Although no data exist to show that using these methods together is advantageous, they have different mechanisms of action and no negative interactions.

Misoprostol 400 μg inserted vaginally 2 hours before surgery induces myometrial contraction and compression of the uterine vessels. This agent can reduce blood loss by 98 mL per case.¹²

Tranexamic acid, an antifibrinolytic, is given IV piggyback at the start of surgery at a dose of 10 mg/kg; it can reduce blood loss by 243 mL per case.¹²

Vasopressin 20 U in 100 mL normal saline, injected below the vascular pseudocapsule, causes vasoconstriction of capillaries and small arterioles and venules and can reduce blood loss by 246 mL per case.¹² Intravascular injection should be avoided because rare cases of bradycardia and cardiovascular collapse have been reported.¹³ Using vasopressin to decrease blood loss during myomectomy is an off-label use of this drug.

Place a tourniquet around the lower uterine segment, including the infundibular pelvic ligaments. Tourniquet use is the most effective way to decrease blood loss during myomectomy, since it can reduce blood loss by 1,870 mL.¹² For women who wish to preserve fertility, take care to ensure that the tourniquet does not compromise the tubes. For women who are certain they do not want to preserve fertility, discuss the possibility of performing bilateral salpingectomy to decrease the risk of subsequent tubal (“ovarian”) cancer.

Some surgeons incise the broad ligaments bilaterally and pass the tourniquet through the broad ligaments to avoid compromising blood flow to the ovaries. Occluding the utero- ovarian ligaments with bulldog clamps to control collateral blood flow from the ovarian artery has been described, but the clamps can tear these often enlarged and fragile uterine veins during manipulation of the uterus. Release the tourniquet every 15 to 30 minutes to allow reperfusion of the ovaries. In women with ovarian torsion lasting hours to days, the ovary has been found to resist hypoxia and recover function.¹⁴ Antral follicle counts of detorsed and contralateral normal ovaries following a mean of 13 hours of hypoxia are similar 3 months following detorsion.¹⁵

Consider blood salvage. For women with multiple or very large fibroids, consider using a salvage-type autologous blood transfusion device, which has been shown to reduce the need for heterologous blood transfusion.¹⁶ This device suctions blood from the operative field, mixes it with heparinized saline, and stores the blood in a canister (FIGURE 2). If the patient requires blood reinfusion, the stored blood is washed with saline, filtered, centrifuged, and given back to the patient intravenously. Blood salvage, or cell salvage, avoids the risks of infection and transfusion reaction, and the oxygen transport capacity of salvaged red blood cells is equal to or better than that of stored allogeneic red cells.

Used with permission.

Additional surgical considerations

Previous teaching suggested that proper placement of the uterine incisions was an important factor in limiting blood loss. Some authors suggested that vertical uterine incisions would avoid injury to the ascending uterine vessels should inadvertent extension of the incision occur. Other authors proposed horizontal uterine incisions to avoid severing the arcuate vessels that branch off from the ascending uterine arteries and run transversely across the uterus. However, since fibroids distort the normal vascular architecture, it is not possible to entirely avoid severing vessels in the myometrium (FIGURE 3).¹⁷ Uterine incisions can therefore be made as needed based on the position of the fibroids and the need to avoid inadvertent extension to the ascending uterine vessels or cornua.¹⁷

Used with permission.

Fibroid anatomy and vascularity. Fibroids are entirely encased within the dense blood supply of a pseudocapsule (FIGURE 4),¹⁸ and no distinct “vascular pedicle” exists at the base of the fibroid.¹⁹ It is therefore important to extend the uterine incisions down through the entire pseudocapsule until the fibroid is clearly visible. This will identify a less vascular surgical plane, which is deeper than commonly recognized. Once the fibroid is reached, the pseudocapsule can be “wiped away” using a dry laparotomy sponge (see VIDEO 3). Staying under the pseudocapsule reduces bleeding and may preserve the tissue growth factors and neurotransmitters that are thought to promote wound healing.²⁰

Used with permission.

Adhesion prevention. Limiting the number of uterine incisions has been suggested as a way to reduce the risk of postoperative pelvic adhesions. To extract fibroids that are distant from an incision, however, tunnels must be created within the myometrium, and this makes hemostasis within these defects difficult. In that blood increases the risk of adhesion formation, tunneling may be counterproductive. If tunneling incisions are avoided and hemostasis is secured immediately, the risk of adhesion formation should be lessened.

Therefore, make incisions directly over the fibroids. Remove only easily accessed fibroids and promptly close the defects to secure hemostasis. Multiple uterine incisions may be needed; adhesion barriers may help limit adhesion formation.²¹

On final removal of the tourniquet, carefully inspect for bleeding and perform any necessary re-suturing. We place a pain pump (ON-Q* Pain Relief System, Halyard Health, Inc) for pain management and close the abdominal incision in the standard manner.

Read about postoperative care

Postoperative care: Manage pain, restore function

The pain pump infuser, attached to one soaker catheter above and one below the fascia, provides continuous infusion of bupivacaine to the incision at 4 mL per hour for 4 days. The pain pump greatly reduces the need for postoperative opioids.²² Use of a patient-controlled analgesia pump, with its associated adverse effects (sedation, need for oxygen saturation monitoring, slowing of bowel function) can thus be avoided. The patient’s residual pain is controlled with oral oxycodone or hydrocodone and scheduled nonsteroidal anti-inflammatory drugs.

In my practice, we use an enhanced recovery after surgery (ERAS) protocol designed to reduce postoperative surgical stress and expedite a return to baseline physiologic body functions.²³ Excellent well-researched, evidence-based studies support the effectiveness of ERAS in gynecologic and general surgery procedures.²⁴

Pre-emptive, preoperative analgesia (gabapentin and celecoxib) and end-of-case IV acetaminophen are given to reduce the inflammatory response and the need for postoperative opioids. Once it is confirmed that the patient is hemodynamically stable, add ketorolac 30 mg IV every 6 hours on postoperative day 1. Nausea and vomiting prophylaxis includes ondansetron and dexamethasone at the end of surgery, avoidance of bowel edema with restriction of intraoperative and postoperative fluids (euvolemia), early oral feeding, and gum chewing. On the evening of surgery, the urinary catheter is removed to reduce the risk of bladder infection and facilitate ambulation. Encourage sitting at the bedside and early ambulation starting the evening of surgery to reduce risk of thromboembolism and to avoid skeletal muscle weakness and postoperative fatigue.

Most women are able to be discharged on postoperative day 2. They return to the office on postoperative day 5 for removal of the pain pump.

CASE Continued: Fibroids removed via abdominal myomectomy

We performed an abdominal myomectomy through a Pfannenstiel incision. Nine fibroids—3 of which were not seen on MRI—ranging in size from 1 to 7 cm were removed. Intravaginal misoprostol, IV tranexamic acid, subserosal vasopressin, and a uterine vessel tourniquet limited the intraoperative blood loss to 225 mL. After surgery, a pain pump and ERAS protocol allowed the patient to be discharged on postoperative day 2, and she returned to the office on day 5 for removal of the pain pump. Oral pain medication was continued on an as-needed basis.

Acknowledgement

The author would like to thank Stanley West, MD, for generously teaching him the surgical techniques for performing abdominal myomectomy.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Click here to download the PDF

Click here to download the PDF

Click here to download the PDF

Two issues of emerging importance are being addressed in the literature: caring for patients with obesity and the concept of delivering value-based care. Value-based care does not mean providing the cheapest care; “value” places importance on quality as well as cost. In this Update, we present 3 practices that the evidence says will deliver value:

• endometrial biopsy in all obese women. Although performing more endometrial biopsies in younger women with a body mass index (BMI) in the obese range will not be less expensive initially, the procedure’s value likely will be in early diagnosis, which hopefully will translate to eventual health care system savings.
• use of the levonorgestrel-releasing intrauterine device (LNG-IUD) in obese patients experiencing abnormal uterine bleeding (AUB). This practice appears to add value in the context of AUB.
• performance of routine diagnostic hysteroscopy in the office setting. We should reconsider our current habits and traditions of performing routine diagnostic hysteroscopy in the operating room (OR) as we move toward providing value-based care.

Read about obesity as a risk factor for endometrial hyperplasia

Endometrial sampling and obesity: Forget the "age 45" rule 

Wise MR, Gill P, Lensen S, Thompson JM, Farquhar CM. Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women. Am J Obstet Gynecol. 2016;215(5):598.e1-e8.

How do we bring more value to our patients with AUB? We are well aware that heavy menstrual bleeding places a burden on many women; AUB affects 30% of those of reproductive age. The condition often results in lost workdays and diminished quality of life. It also is associated with significant cost expenditures for hygiene products. It is important not only to bring value to women with heavy menstrual bleeding but also to consider our increasingly expensive health care system.

Obesity is a significant problem that likely will increase the number of women presenting with AUB to ObGyns. Recent studies from New Zealand--which has 33% of its population classified as obese--have provided valuable information.¹

Photo: Shutterstock

Obesity is a risk factor for endometrial hyperplasia

In a large retrospective cohort study, Wise and colleagues analyzed data from 916 premenopausal women referred for AUB who had an endometrial biopsy from 2008 to 2014. The setting was a single large urban secondary women's health service in New Zealand. This study challenges the concept of age-related biopsy guidelines.

Of the 916 women, half were obese. Almost 5% of the women had complex endometrial hyperplasia with atypia or cancer. This incidence had risen from 3% in the years 1995 to 1997, likely due to the rising incidence of obesity. Women with a BMI ≥30 kg/m2 were 4 times more likely to develop complex hyperplasia or cancer than normal-weight women.

Other factors associated with an increased risk for complex hyperplasia or cancer were nulliparity (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.25-5.05), anemia (OR, 2.38; 95% CI, 1.25-4.56), and a thickened endometrium on ultrasonography (defined as >12 mm; OR, 4.04; 95% CI, 1.69-9.65). Age was not a significant risk factor in this group.  

Read about using LNG-IUD to treat AUB in obese women

Small study shows LNG-IUD is effective for treating heavy menstrual bleeding in obese patients

Shaw V, Vandal AC, Coomarasamy C, Ekeroma AJ. The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding. Aust N Z J Obstet Gynaecol. 2016;56(6):619-623.

In another recent study from New Zealand, researchers set out to assess the efficacy of the LNG-IUD for the treatment of heavy menstrual bleeding in obese women. This study is important because there are very few studies of the LNG-IUD in the obese population, and none that have studied quality-of-life measures. 

Shaw and colleagues conducted the prospective observational study at a tertiary teaching hospital. Twenty obese (BMI >30 kg/m2) women with heavy menstrual bleeding agreed to treatment with an LNG-IUD, and 14 completed the study (2 had a device expulsion, 1 had a device removed for pain, and 1 had a device removed for infection; 2 were lost to follow-up). The women were aged 27 to 52 years (median, 40.5 years), and their BMI ranged from 30 to 68 kg/m2 (median, 40.6 kg/m2). At recruitment, 6 months, and 12 months, participants completed the Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart--2 validated tools.

Photo: Shutterstock

Compared with baseline Pictorial Bleeding Assessment scores, the authors found the LNG-IUD to be effective in 73.2% (95% CI, 55.3%-83.9%) of women at 6 months and in 92.8% (95% CI, 80.0%-97.4%) of women at 12 months. Taking into consideration device failures, including removed and expelled LNG-IUDs (which occurred in 4 women, or 20%, in the intent-to-treat analysis), the actual efficacy rate was 67%. Similarly, there was significant improvement at 6 and 12 months in Menstrual Impact Questionnaire scores for social activities, work performance, tiredness, productivity, hygiene,  and depression.

Read about doing more diagnostic hysteroscopy in the office

Is it time to abandon diagnostic hysteroscopy in the OR?

Leung S, Leyland N, Murji A. Decreasing diagnostic hysteroscopy performed in the operating room: a quality improvement initiative. J Obstet Gynaecol Can. 2016;38(4):351-356.

Diagnostic hysteroscopy: Are we stuck in the 1990s? Why are we still performing so many diagnostic hysteroscopies in the OR, thus subjecting our patients to general anesthesia and using our precious OR time? That is the question asked by a group of researchers in Canada. 

According to data from the Ontario Ministry of Health and Long Term Care, diagnostic hysteroscopy was performed 10,027 times in the 2013-2014 fiscal year. Ontario researchers designed and implemented a quality improvement initiative at their institution and successfully decreased the number of diagnostic hysteroscopies performed in their hospital by 70% from their baseline 12-month period. The improvements resulted in a savings of 78 hours of case costing, or $126,984. When these data are extrapolated to the Ontario population (in which more than  10,000 diagnostic hysteroscopies were performed), potentially 7,000 women could avoid the risk of general anesthesia and the health care system could save $11 million. 

Re-education protocol was key to reducing OR procedures

How did the researchers accomplish their results? The multifaceted intervention had  3 key components:

Staff education and review. Many surgeons were performing diagnostic hysteroscopy in the OR because that is how they were trained, and they were unaware of less invasive options. An awareness campaign was conducted by e-mail, during staff meetings, and at rounds. 

Accessible sonohysterography. This diagnostic modality was made more accessible to referring physicians in a timely manner.

Initiation of an operative hysteroscopy education program. To allow more surgeons greater comfort with office hysteroscopy, the authors instituted didactic sessions, dry and wet lab simulations, and mentorship.  

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Two issues of emerging importance are being addressed in the literature: caring for patients with obesity and the concept of delivering value-based care. Value-based care does not mean providing the cheapest care; “value” places importance on quality as well as cost. In this Update, we present 3 practices that the evidence says will deliver value:

• endometrial biopsy in all obese women. Although performing more endometrial biopsies in younger women with a body mass index (BMI) in the obese range will not be less expensive initially, the procedure’s value likely will be in early diagnosis, which hopefully will translate to eventual health care system savings.
• use of the levonorgestrel-releasing intrauterine device (LNG-IUD) in obese patients experiencing abnormal uterine bleeding (AUB). This practice appears to add value in the context of AUB.
• performance of routine diagnostic hysteroscopy in the office setting. We should reconsider our current habits and traditions of performing routine diagnostic hysteroscopy in the operating room (OR) as we move toward providing value-based care.

Read about obesity as a risk factor for endometrial hyperplasia

Endometrial sampling and obesity: Forget the "age 45" rule 

Wise MR, Gill P, Lensen S, Thompson JM, Farquhar CM. Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women. Am J Obstet Gynecol. 2016;215(5):598.e1-e8.

How do we bring more value to our patients with AUB? We are well aware that heavy menstrual bleeding places a burden on many women; AUB affects 30% of those of reproductive age. The condition often results in lost workdays and diminished quality of life. It also is associated with significant cost expenditures for hygiene products. It is important not only to bring value to women with heavy menstrual bleeding but also to consider our increasingly expensive health care system.

Obesity is a significant problem that likely will increase the number of women presenting with AUB to ObGyns. Recent studies from New Zealand--which has 33% of its population classified as obese--have provided valuable information.¹

Photo: Shutterstock

Obesity is a risk factor for endometrial hyperplasia

In a large retrospective cohort study, Wise and colleagues analyzed data from 916 premenopausal women referred for AUB who had an endometrial biopsy from 2008 to 2014. The setting was a single large urban secondary women's health service in New Zealand. This study challenges the concept of age-related biopsy guidelines.

Of the 916 women, half were obese. Almost 5% of the women had complex endometrial hyperplasia with atypia or cancer. This incidence had risen from 3% in the years 1995 to 1997, likely due to the rising incidence of obesity. Women with a BMI ≥30 kg/m2 were 4 times more likely to develop complex hyperplasia or cancer than normal-weight women.

Other factors associated with an increased risk for complex hyperplasia or cancer were nulliparity (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.25-5.05), anemia (OR, 2.38; 95% CI, 1.25-4.56), and a thickened endometrium on ultrasonography (defined as >12 mm; OR, 4.04; 95% CI, 1.69-9.65). Age was not a significant risk factor in this group.  

Read about using LNG-IUD to treat AUB in obese women

Small study shows LNG-IUD is effective for treating heavy menstrual bleeding in obese patients

Shaw V, Vandal AC, Coomarasamy C, Ekeroma AJ. The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding. Aust N Z J Obstet Gynaecol. 2016;56(6):619-623.

In another recent study from New Zealand, researchers set out to assess the efficacy of the LNG-IUD for the treatment of heavy menstrual bleeding in obese women. This study is important because there are very few studies of the LNG-IUD in the obese population, and none that have studied quality-of-life measures. 

Shaw and colleagues conducted the prospective observational study at a tertiary teaching hospital. Twenty obese (BMI >30 kg/m2) women with heavy menstrual bleeding agreed to treatment with an LNG-IUD, and 14 completed the study (2 had a device expulsion, 1 had a device removed for pain, and 1 had a device removed for infection; 2 were lost to follow-up). The women were aged 27 to 52 years (median, 40.5 years), and their BMI ranged from 30 to 68 kg/m2 (median, 40.6 kg/m2). At recruitment, 6 months, and 12 months, participants completed the Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart--2 validated tools.

Photo: Shutterstock

Compared with baseline Pictorial Bleeding Assessment scores, the authors found the LNG-IUD to be effective in 73.2% (95% CI, 55.3%-83.9%) of women at 6 months and in 92.8% (95% CI, 80.0%-97.4%) of women at 12 months. Taking into consideration device failures, including removed and expelled LNG-IUDs (which occurred in 4 women, or 20%, in the intent-to-treat analysis), the actual efficacy rate was 67%. Similarly, there was significant improvement at 6 and 12 months in Menstrual Impact Questionnaire scores for social activities, work performance, tiredness, productivity, hygiene,  and depression.

Read about doing more diagnostic hysteroscopy in the office

Is it time to abandon diagnostic hysteroscopy in the OR?

Leung S, Leyland N, Murji A. Decreasing diagnostic hysteroscopy performed in the operating room: a quality improvement initiative. J Obstet Gynaecol Can. 2016;38(4):351-356.

Diagnostic hysteroscopy: Are we stuck in the 1990s? Why are we still performing so many diagnostic hysteroscopies in the OR, thus subjecting our patients to general anesthesia and using our precious OR time? That is the question asked by a group of researchers in Canada. 

According to data from the Ontario Ministry of Health and Long Term Care, diagnostic hysteroscopy was performed 10,027 times in the 2013-2014 fiscal year. Ontario researchers designed and implemented a quality improvement initiative at their institution and successfully decreased the number of diagnostic hysteroscopies performed in their hospital by 70% from their baseline 12-month period. The improvements resulted in a savings of 78 hours of case costing, or $126,984. When these data are extrapolated to the Ontario population (in which more than  10,000 diagnostic hysteroscopies were performed), potentially 7,000 women could avoid the risk of general anesthesia and the health care system could save $11 million. 

Re-education protocol was key to reducing OR procedures

How did the researchers accomplish their results? The multifaceted intervention had  3 key components:

Staff education and review. Many surgeons were performing diagnostic hysteroscopy in the OR because that is how they were trained, and they were unaware of less invasive options. An awareness campaign was conducted by e-mail, during staff meetings, and at rounds. 

Accessible sonohysterography. This diagnostic modality was made more accessible to referring physicians in a timely manner.

Initiation of an operative hysteroscopy education program. To allow more surgeons greater comfort with office hysteroscopy, the authors instituted didactic sessions, dry and wet lab simulations, and mentorship.  

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Two issues of emerging importance are being addressed in the literature: caring for patients with obesity and the concept of delivering value-based care. Value-based care does not mean providing the cheapest care; “value” places importance on quality as well as cost. In this Update, we present 3 practices that the evidence says will deliver value:

• endometrial biopsy in all obese women. Although performing more endometrial biopsies in younger women with a body mass index (BMI) in the obese range will not be less expensive initially, the procedure’s value likely will be in early diagnosis, which hopefully will translate to eventual health care system savings.
• use of the levonorgestrel-releasing intrauterine device (LNG-IUD) in obese patients experiencing abnormal uterine bleeding (AUB). This practice appears to add value in the context of AUB.
• performance of routine diagnostic hysteroscopy in the office setting. We should reconsider our current habits and traditions of performing routine diagnostic hysteroscopy in the operating room (OR) as we move toward providing value-based care.

Read about obesity as a risk factor for endometrial hyperplasia

Endometrial sampling and obesity: Forget the "age 45" rule 

Wise MR, Gill P, Lensen S, Thompson JM, Farquhar CM. Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women. Am J Obstet Gynecol. 2016;215(5):598.e1-e8.

How do we bring more value to our patients with AUB? We are well aware that heavy menstrual bleeding places a burden on many women; AUB affects 30% of those of reproductive age. The condition often results in lost workdays and diminished quality of life. It also is associated with significant cost expenditures for hygiene products. It is important not only to bring value to women with heavy menstrual bleeding but also to consider our increasingly expensive health care system.

Obesity is a significant problem that likely will increase the number of women presenting with AUB to ObGyns. Recent studies from New Zealand--which has 33% of its population classified as obese--have provided valuable information.¹

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Obesity is a risk factor for endometrial hyperplasia

In a large retrospective cohort study, Wise and colleagues analyzed data from 916 premenopausal women referred for AUB who had an endometrial biopsy from 2008 to 2014. The setting was a single large urban secondary women's health service in New Zealand. This study challenges the concept of age-related biopsy guidelines.

Of the 916 women, half were obese. Almost 5% of the women had complex endometrial hyperplasia with atypia or cancer. This incidence had risen from 3% in the years 1995 to 1997, likely due to the rising incidence of obesity. Women with a BMI ≥30 kg/m2 were 4 times more likely to develop complex hyperplasia or cancer than normal-weight women.

Other factors associated with an increased risk for complex hyperplasia or cancer were nulliparity (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.25-5.05), anemia (OR, 2.38; 95% CI, 1.25-4.56), and a thickened endometrium on ultrasonography (defined as >12 mm; OR, 4.04; 95% CI, 1.69-9.65). Age was not a significant risk factor in this group.  

Read about using LNG-IUD to treat AUB in obese women

Small study shows LNG-IUD is effective for treating heavy menstrual bleeding in obese patients

Shaw V, Vandal AC, Coomarasamy C, Ekeroma AJ. The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding. Aust N Z J Obstet Gynaecol. 2016;56(6):619-623.

In another recent study from New Zealand, researchers set out to assess the efficacy of the LNG-IUD for the treatment of heavy menstrual bleeding in obese women. This study is important because there are very few studies of the LNG-IUD in the obese population, and none that have studied quality-of-life measures. 

Shaw and colleagues conducted the prospective observational study at a tertiary teaching hospital. Twenty obese (BMI >30 kg/m2) women with heavy menstrual bleeding agreed to treatment with an LNG-IUD, and 14 completed the study (2 had a device expulsion, 1 had a device removed for pain, and 1 had a device removed for infection; 2 were lost to follow-up). The women were aged 27 to 52 years (median, 40.5 years), and their BMI ranged from 30 to 68 kg/m2 (median, 40.6 kg/m2). At recruitment, 6 months, and 12 months, participants completed the Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart--2 validated tools.

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Compared with baseline Pictorial Bleeding Assessment scores, the authors found the LNG-IUD to be effective in 73.2% (95% CI, 55.3%-83.9%) of women at 6 months and in 92.8% (95% CI, 80.0%-97.4%) of women at 12 months. Taking into consideration device failures, including removed and expelled LNG-IUDs (which occurred in 4 women, or 20%, in the intent-to-treat analysis), the actual efficacy rate was 67%. Similarly, there was significant improvement at 6 and 12 months in Menstrual Impact Questionnaire scores for social activities, work performance, tiredness, productivity, hygiene,  and depression.

Read about doing more diagnostic hysteroscopy in the office

Is it time to abandon diagnostic hysteroscopy in the OR?

Leung S, Leyland N, Murji A. Decreasing diagnostic hysteroscopy performed in the operating room: a quality improvement initiative. J Obstet Gynaecol Can. 2016;38(4):351-356.

Diagnostic hysteroscopy: Are we stuck in the 1990s? Why are we still performing so many diagnostic hysteroscopies in the OR, thus subjecting our patients to general anesthesia and using our precious OR time? That is the question asked by a group of researchers in Canada. 

According to data from the Ontario Ministry of Health and Long Term Care, diagnostic hysteroscopy was performed 10,027 times in the 2013-2014 fiscal year. Ontario researchers designed and implemented a quality improvement initiative at their institution and successfully decreased the number of diagnostic hysteroscopies performed in their hospital by 70% from their baseline 12-month period. The improvements resulted in a savings of 78 hours of case costing, or $126,984. When these data are extrapolated to the Ontario population (in which more than  10,000 diagnostic hysteroscopies were performed), potentially 7,000 women could avoid the risk of general anesthesia and the health care system could save $11 million. 

Re-education protocol was key to reducing OR procedures

How did the researchers accomplish their results? The multifaceted intervention had  3 key components:

Staff education and review. Many surgeons were performing diagnostic hysteroscopy in the OR because that is how they were trained, and they were unaware of less invasive options. An awareness campaign was conducted by e-mail, during staff meetings, and at rounds. 

Accessible sonohysterography. This diagnostic modality was made more accessible to referring physicians in a timely manner.

Initiation of an operative hysteroscopy education program. To allow more surgeons greater comfort with office hysteroscopy, the authors instituted didactic sessions, dry and wet lab simulations, and mentorship.  

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