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Alternatives to Hysterectomy Duncan Turner MD, MBBS, FACOG,  October 28th 1998  Santa Barbara,California
HYSTERECTOMY <ul><li>600,000 per year in USA </li></ul><ul><li>35% chance by 60 </li></ul><ul><li>Traditional Surgery </li...
TOPICS <ul><li>Alternatives to Hysterectomy </li></ul><ul><li>Alternatives to Traditional Hysterectomy </li></ul><ul><li>W...
Definitions <ul><li>Hysterectomy </li></ul><ul><ul><li>Removal of Uterus, With/Without Ovaries </li></ul></ul><ul><li>Subt...
The Uterus
Definitions <ul><li>Endoscopy: Looking through a narrow tube </li></ul><ul><li>Types of Endoscopy </li></ul><ul><ul><li>Hy...
Cost of laparotomy <ul><li>$5,000 - $15,000 </li></ul><ul><li>3 Days in Hospital </li></ul><ul><li>Significant Pain </li><...
Cost of laparoscopy <ul><li>$4,000 - $15,000 </li></ul><ul><li>Outpatient or Inpatient </li></ul><ul><li>3 Hours to 2 Days...
Cost of hysteroscopy <ul><li>$2000 </li></ul><ul><li>Outpatient </li></ul><ul><li><3 Hours in Surgery Center </li></ul><ul...
The Conditions <ul><li>Abnormal Uterine bleeding </li></ul><ul><li>Fibroids </li></ul><ul><li>Endometriosis </li></ul><ul>...
ABNORMAL UTERINE BLEEDING <ul><li>Prolonged, Irregular or Heavy Bleeding </li></ul><ul><li>30% of Hysterectomies </li></ul...
Causes of A.U.B. <ul><li>Hormonal Irregularity </li></ul><ul><li>Growths in Uterus </li></ul><ul><li>Cancer and Precancero...
Investigation and Treatment <ul><li>Nothing </li></ul><ul><li>Ultrasound and Biopsy to Rule Out Cancer or Precancerous Con...
Hormonal Therapy for A.U.B. <ul><li>Birth Control Pill </li></ul><ul><li>Adjustment of Current Therapy </li></ul><ul><li>O...
D and C for A.U.B. <ul><li>Traditional Treatment </li></ul><ul><li>Blind Procedure </li></ul><ul><li>Good for Biopsy </li>...
Hysteroscopic Treatment of A.U.B. <ul><li>Visual Procedure </li></ul><ul><li>Removal of Growth </li></ul><ul><ul><li>Good ...
Thermachoice
Thermachoice VS Electrocautery <ul><li>Improvement at 12 months </li></ul><ul><ul><li>85% vs 89% </li></ul></ul><ul><li>Hy...
Benefits of Thermachoice <ul><li>Effective </li></ul><ul><li>Simple </li></ul><ul><li>Safe </li></ul><ul><li>Short Procedu...
Hysterectomy for A.U.B. <ul><li>Traditional </li></ul><ul><li>Laparoscopic </li></ul><ul><li>With or Without Ovaries or Ce...
Fibroids <ul><li>Non-cancerous Growths of Uterine Muscle </li></ul><ul><li>35% of Women </li></ul><ul><li>30% of Hysterect...
Treatment of Fibroids <ul><li>Nothing </li></ul><ul><li>Hormonal Therapy </li></ul><ul><li>Destruction </li></ul><ul><li>R...
Hormonal Therapy for Fibroids <ul><li>Side Effects </li></ul><ul><li>Temporary </li></ul><ul><li>Expense </li></ul><ul><li...
Destruction of Fibroids <ul><li>Blocking Blood Supply </li></ul><ul><ul><li>(EMBOLIZATION) </li></ul></ul><ul><li>SURGERY ...
Removal of Fibroids <ul><li>Individual - </li></ul><ul><ul><li>Traditional or Endoscopic </li></ul></ul><ul><ul><li>Hyster...
Endometriosis <ul><li>Endometrial Tissue in Abnormal Places: </li></ul><ul><li>On Ovaries, Uterus, Bowel </li></ul><ul><li...
Treatment of Endometriosis <ul><li>Nothing </li></ul><ul><li>Hormonal </li></ul><ul><li>Excision </li></ul><ul><li>Cutting...
Hormonal Therapy for Endometriosis <ul><li>Birth Control Pills </li></ul><ul><li>Progesterone </li></ul><ul><li>Danazol </...
Excision of Endometriosis <ul><li>Traditional Surgery </li></ul><ul><li>Laparoscopic Surgery </li></ul><ul><li>Better Visu...
PROLAPSE <ul><li>Loss of Support of: </li></ul><ul><li>Uterus </li></ul><ul><li>Bladder </li></ul><ul><li>Vagina </li></ul...
PROLAPSE <ul><li>Resulting in: </li></ul><ul><li>Protrusion of Structures </li></ul><ul><li>Pain and Pressure </li></ul><u...
Non-Surgical Treatment of Prolapse <ul><li>Pessary </li></ul><ul><li>Kegel Exercises </li></ul><ul><li>Weights </li></ul><...
Surgical Treatment of Prolapse <ul><li>Vaginal </li></ul><ul><li>Abdominal </li></ul><ul><li>Laparoscopic </li></ul><ul><l...
CHRONIC PELVIC PAIN <ul><li>Debilitating Pain - Chronic </li></ul><ul><li>No Obvious Cause </li></ul><ul><li>Pain With Int...
Treatment of Chronic Pain <ul><li>Hormones </li></ul><ul><li>Pain Killers </li></ul><ul><li>Diagnostic/Therapeutic Surgery...
PRECANCEROUS CONDITIONS of UTERUS <ul><li>Hormonal Therapy </li></ul><ul><li>Observation </li></ul><ul><li>Hysterectomy </...
PRECANCEROUS CONDITIONS of the CERVIX <ul><li>Freezing </li></ul><ul><li>Conization </li></ul><ul><ul><li>Office of Out Pa...
CONCERNS REGARDING MANAGED CARE <ul><li>Underutilization vs Overutilization </li></ul><ul><li>Diminished Freedom to Choose...
SUMMARY <ul><li>Alternatives Exist </li></ul><ul><li>Treatment Should be Suited to the Individual </li></ul><ul><li>A Mini...
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Transcript of "alternatives to hysterectomy"

  1. 1. Alternatives to Hysterectomy Duncan Turner MD, MBBS, FACOG, October 28th 1998 Santa Barbara,California
  2. 2. HYSTERECTOMY <ul><li>600,000 per year in USA </li></ul><ul><li>35% chance by 60 </li></ul><ul><li>Traditional Surgery </li></ul><ul><ul><li>3 days in hospital </li></ul></ul><ul><ul><li>6 weeks of recovery </li></ul></ul><ul><li>Total Cost: $15,000 + loss of productivity </li></ul>
  3. 3. TOPICS <ul><li>Alternatives to Hysterectomy </li></ul><ul><li>Alternatives to Traditional Hysterectomy </li></ul><ul><li>Why? </li></ul><ul><ul><li>New Treatments </li></ul></ul><ul><ul><li>New Surgeries </li></ul></ul><ul><ul><li>You Have A Choice </li></ul></ul>
  4. 4. Definitions <ul><li>Hysterectomy </li></ul><ul><ul><li>Removal of Uterus, With/Without Ovaries </li></ul></ul><ul><li>Subtotal Hysterectomy </li></ul><ul><ul><li>Removal of Uterus Without Cervix, With/Without Ovaries </li></ul></ul><ul><li>Approaches </li></ul><ul><ul><li>Abdominal (Laparotomy) </li></ul></ul><ul><ul><li>Vaginal </li></ul></ul><ul><ul><li>Endoscopic (Laparoscopic) </li></ul></ul>
  5. 5. The Uterus
  6. 6. Definitions <ul><li>Endoscopy: Looking through a narrow tube </li></ul><ul><li>Types of Endoscopy </li></ul><ul><ul><li>Hysteroscopy - into uterus via vagina </li></ul></ul><ul><ul><li>Laparoscopy - into the abdomen </li></ul></ul><ul><ul><li>Cystoscopy - into bladder </li></ul></ul><ul><ul><li>Others </li></ul></ul>
  7. 7. Cost of laparotomy <ul><li>$5,000 - $15,000 </li></ul><ul><li>3 Days in Hospital </li></ul><ul><li>Significant Pain </li></ul><ul><li>6 Weeks of Recovery </li></ul>
  8. 8. Cost of laparoscopy <ul><li>$4,000 - $15,000 </li></ul><ul><li>Outpatient or Inpatient </li></ul><ul><li>3 Hours to 2 Days in Hospital </li></ul><ul><li>3 Days to 3 Weeks Recovery </li></ul>
  9. 9. Cost of hysteroscopy <ul><li>$2000 </li></ul><ul><li>Outpatient </li></ul><ul><li><3 Hours in Surgery Center </li></ul><ul><li>1-2 Days of Recovery </li></ul>
  10. 10. The Conditions <ul><li>Abnormal Uterine bleeding </li></ul><ul><li>Fibroids </li></ul><ul><li>Endometriosis </li></ul><ul><li>Prolapse </li></ul><ul><li>Chronic Pelvic Pain </li></ul><ul><li>Cancer and Precancerous Conditions </li></ul>
  11. 11. ABNORMAL UTERINE BLEEDING <ul><li>Prolonged, Irregular or Heavy Bleeding </li></ul><ul><li>30% of Hysterectomies </li></ul><ul><li>200,000 a Year </li></ul>
  12. 12. Causes of A.U.B. <ul><li>Hormonal Irregularity </li></ul><ul><li>Growths in Uterus </li></ul><ul><li>Cancer and Precancerous Conditions </li></ul><ul><li>Bleeding Disorders </li></ul>
  13. 13. Investigation and Treatment <ul><li>Nothing </li></ul><ul><li>Ultrasound and Biopsy to Rule Out Cancer or Precancerous Conditions </li></ul><ul><li>Hormonal Therapy </li></ul><ul><li>D and C </li></ul><ul><li>Hysteroscopic Therapy </li></ul><ul><li>Hysterectomy </li></ul>
  14. 14. Hormonal Therapy for A.U.B. <ul><li>Birth Control Pill </li></ul><ul><li>Adjustment of Current Therapy </li></ul><ul><li>Other Hormones </li></ul>
  15. 15. D and C for A.U.B. <ul><li>Traditional Treatment </li></ul><ul><li>Blind Procedure </li></ul><ul><li>Good for Biopsy </li></ul><ul><li>No Evidence of Therapeutic Benefit </li></ul>
  16. 16. Hysteroscopic Treatment of A.U.B. <ul><li>Visual Procedure </li></ul><ul><li>Removal of Growth </li></ul><ul><ul><li>Good for Biopsy </li></ul></ul><ul><ul><li>Very Accurate </li></ul></ul><ul><li>Endometrial Ablation </li></ul><ul><ul><li>Destruction of Lining Tissue by </li></ul></ul><ul><ul><ul><li>Laser </li></ul></ul></ul><ul><ul><ul><li>Electricity </li></ul></ul></ul><ul><ul><ul><li>Hot Water Balloon </li></ul></ul></ul>
  17. 17. Thermachoice
  18. 18. Thermachoice VS Electrocautery <ul><li>Improvement at 12 months </li></ul><ul><ul><li>85% vs 89% </li></ul></ul><ul><li>Hysterectomies by 12 months </li></ul><ul><ul><li>2% = </li></ul></ul><ul><li>Repeat Ablations by 12 months </li></ul><ul><ul><li><1% = </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>4% vs 6% </li></ul></ul>
  19. 19. Benefits of Thermachoice <ul><li>Effective </li></ul><ul><li>Simple </li></ul><ul><li>Safe </li></ul><ul><li>Short Procedure </li></ul><ul><li>Local or General Anesthetic </li></ul><ul><li>85% Successful </li></ul>
  20. 20. Hysterectomy for A.U.B. <ul><li>Traditional </li></ul><ul><li>Laparoscopic </li></ul><ul><li>With or Without Ovaries or Cervix </li></ul><ul><li>100% Successful </li></ul>
  21. 21. Fibroids <ul><li>Non-cancerous Growths of Uterine Muscle </li></ul><ul><li>35% of Women </li></ul><ul><li>30% of Hysterectomies </li></ul><ul><li>Can Cause: </li></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Pressure </li></ul></ul><ul><ul><li>or Nothing </li></ul></ul>
  22. 22. Treatment of Fibroids <ul><li>Nothing </li></ul><ul><li>Hormonal Therapy </li></ul><ul><li>Destruction </li></ul><ul><li>Removal </li></ul><ul><li>Hysterectomy </li></ul>
  23. 23. Hormonal Therapy for Fibroids <ul><li>Side Effects </li></ul><ul><li>Temporary </li></ul><ul><li>Expense </li></ul><ul><li>Can be Utilized Before Surgery </li></ul>
  24. 24. Destruction of Fibroids <ul><li>Blocking Blood Supply </li></ul><ul><ul><li>(EMBOLIZATION) </li></ul></ul><ul><li>SURGERY </li></ul><ul><ul><li>Laser </li></ul></ul><ul><ul><li>Electricity </li></ul></ul><ul><ul><li>Freezing </li></ul></ul>
  25. 25. Removal of Fibroids <ul><li>Individual - </li></ul><ul><ul><li>Traditional or Endoscopic </li></ul></ul><ul><ul><li>Hysteroscopic or Laparoscopic </li></ul></ul><ul><li>Total - </li></ul><ul><ul><li>Hysterectomy </li></ul></ul><ul><ul><li>Subtotal Hysterectomy </li></ul></ul><ul><ul><li>Traditional or Laparoscopic </li></ul></ul>
  26. 26. Endometriosis <ul><li>Endometrial Tissue in Abnormal Places: </li></ul><ul><li>On Ovaries, Uterus, Bowel </li></ul><ul><li>Can Cause: </li></ul><ul><li>Pain </li></ul><ul><li>Infertility </li></ul><ul><li>Growths </li></ul>
  27. 27. Treatment of Endometriosis <ul><li>Nothing </li></ul><ul><li>Hormonal </li></ul><ul><li>Excision </li></ul><ul><li>Cutting of Nerve Supply </li></ul><ul><li>Hysterectomy </li></ul>
  28. 28. Hormonal Therapy for Endometriosis <ul><li>Birth Control Pills </li></ul><ul><li>Progesterone </li></ul><ul><li>Danazol </li></ul><ul><li>Lupron </li></ul><ul><li>Side Effects </li></ul><ul><li>Expensive </li></ul>
  29. 29. Excision of Endometriosis <ul><li>Traditional Surgery </li></ul><ul><li>Laparoscopic Surgery </li></ul><ul><li>Better Visualization </li></ul><ul><li>More Precise Surgery </li></ul><ul><li>Nerve Supply May Be Cut </li></ul><ul><li>Hysterectomy May Not Be Necessary </li></ul>
  30. 30. PROLAPSE <ul><li>Loss of Support of: </li></ul><ul><li>Uterus </li></ul><ul><li>Bladder </li></ul><ul><li>Vagina </li></ul><ul><li>Rectum </li></ul><ul><li>Because of: </li></ul><ul><li>Childbirth </li></ul><ul><li>Genetics </li></ul><ul><li>Chronic Increase in Pressure </li></ul>
  31. 31. PROLAPSE <ul><li>Resulting in: </li></ul><ul><li>Protrusion of Structures </li></ul><ul><li>Pain and Pressure </li></ul><ul><li>Urinary Incontinence </li></ul><ul><li>Urinary Retention </li></ul>
  32. 32. Non-Surgical Treatment of Prolapse <ul><li>Pessary </li></ul><ul><li>Kegel Exercises </li></ul><ul><li>Weights </li></ul><ul><li>Electrical Stimulation </li></ul><ul><li>Biofeedback Therapy </li></ul>
  33. 33. Surgical Treatment of Prolapse <ul><li>Vaginal </li></ul><ul><li>Abdominal </li></ul><ul><li>Laparoscopic </li></ul><ul><li>Does not Have To Include </li></ul><ul><li>HYSTERECTOMY </li></ul>
  34. 34. CHRONIC PELVIC PAIN <ul><li>Debilitating Pain - Chronic </li></ul><ul><li>No Obvious Cause </li></ul><ul><li>Pain With Intercourse </li></ul><ul><li>Pain With Periods </li></ul>
  35. 35. Treatment of Chronic Pain <ul><li>Hormones </li></ul><ul><li>Pain Killers </li></ul><ul><li>Diagnostic/Therapeutic Surgery </li></ul><ul><ul><li>Microlaparoscopy </li></ul></ul><ul><ul><li>Smaller Instruments </li></ul></ul><ul><ul><li>Quicker Recovery </li></ul></ul><ul><li>Traditional Surgery </li></ul>
  36. 36. PRECANCEROUS CONDITIONS of UTERUS <ul><li>Hormonal Therapy </li></ul><ul><li>Observation </li></ul><ul><li>Hysterectomy </li></ul>
  37. 37. PRECANCEROUS CONDITIONS of the CERVIX <ul><li>Freezing </li></ul><ul><li>Conization </li></ul><ul><ul><li>Office of Out Patient Surgery Center </li></ul></ul><ul><li>Hysterectomy - Traditional or Laparoscopic </li></ul>
  38. 38. CONCERNS REGARDING MANAGED CARE <ul><li>Underutilization vs Overutilization </li></ul><ul><li>Diminished Freedom to Choose </li></ul>
  39. 39. SUMMARY <ul><li>Alternatives Exist </li></ul><ul><li>Treatment Should be Suited to the Individual </li></ul><ul><li>A Minimally Invasive Approach is Almost Always Available </li></ul><ul><li>Be Part of the Decision Making Process </li></ul>
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