BackTable Women's Health

This week on BackTable OBGYN, Drs. Mark Hoffman and Amy Park are joined by Dr. Barbara Levy to discuss the latest advancements in endometrial ablation using cryotherapy. Dr. Levy, a professor at George Washington University and a volunteer at the University of California San Diego OBGYN and reproductive sciences department, has dedicated her career to gynecological advancements.

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Cerene Cryotherapy

https://cerene.com/healthcare-professionals/

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SHOW NOTES

Initially, the physicians delve into the history of endometrial ablation, originally conceived as an alternative to hysterectomy for severe menstrual bleeding. The early method involved using a fiber to ablate the entire cavity, followed by electrosurgery using a roller ball, which has various control-related challenges. This approach necessitates operating room time, anesthesia, and prolonged recovery with significant pain. As techniques advanced, complications, including burns and bowel injuries, emerged. The introduction of cryotherapy marked a significant breakthrough in ablation. However, it initially had a steep learning curve.

Barbara then details the new Cerene handheld cryoablation device, highlighting its advantages over traditional rollerball electrocautery. The primary benefit of cryotherapy is the improved healing pattern of the uterus compared to electrocautery. Electrocautery often results in Asherman's syndrome, leading to scarring and adhesions, making visualizing the uterine cavity for concern of future pathologies very difficult. Cryotherapy offers over 90% visibility into the cavity, making assessment for uterine or endometrial cancer much easier.

Barbara emphasizes that cryotherapy minimizes or avoids complications such as abnormal vaginal discharge, prolapsed fibroids, dyspareunia, persistent bleeding, and post-ablation pain syndrome when compared to heat-based methods.She outlines various patient-centric advantages, notably in pain management. Cryotherapy numbs nerves before ablation, allowing in-office procedures without sedation or anesthesia. Patients can tolerate the procedure well, typically requiring only NSAIDs for comfort during device insertion through the cervix. The accessibility of this procedure through telehealth and brief in-office appointments reduces the impact on patients' daily lives and costs, eliminating the need for operating room time and anesthesia. Instead, patients only pay a copay in the office.

Barbara highlights specific patient populations that can benefit from this therapy, including those with heavy menorrhea leading to iron deficiency anemia. It is also suitable for women unable to use additional hormones due to breast cancer concerns or those who prefer not have an IUD but suffer from heavy menorrhea. Patients facing barriers to healthcare, such as those in rural areas, those with time constraints due to work, or financial constraints, may significantly improve their quality of life. Additionally, women in their forties, no longer in their childbearing years, with heavy periods and an alternate form of long-term contraception, can particularly benefit from this therapy.

In this episode, host Dr. Amy Park interviews co-host Dr. Mark Hoffman about laparoscopic hysterectomies.

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SHOW NOTES

The episode begins with Mark describing his journey to becoming a minimally invasive gynecologic surgeon, with more exposure to traditional laparoscopic surgery (“straight stick”) throughout his career, but with a recent revival of robotic surgery as well. Overall, Mark still prefers traditional laparoscopy. However, there are certain instances where robotics is especially helpful – namely in patients with a high BMI and in myomectomies where robots make the extensive suturing more manageable. Additionally, robotic surgery is easier to do in a situation where students and residents are not available to assist. Most importantly, he likes to get an MRI, look at the anatomy, and decide what the best approach is for each individual patient. And of course, the doctors emphasize the importance of having a strong team to operate with.

Next, Mark discusses his tips and tricks to a successful laparoscopic hysterectomy. He likes to be in the operating room before the patient is there to ensure it is set up correctly. Once the patient arrives, he stresses the importance of proper patient positioning on the bed, with the arms always tucked at the patient’s side, and then inserting the Foley catheter after draping. The doctors then discuss incision locations and sizes, with Mark preferring all 5 cm incisions. Mark continues with the steps of the procedure – he starts with the fallopian tubes, then gets the utero-ovarians and carries around the round ligament to move the ovaries laterally. He then emphasizes skeletonizing the uterines/posterior peritoneum. He saves the anterior incisions for last as they can get complicated with adhesions from prior C-sections, for example. Mark highlights the “critical view,” which is the anterior cup, posterior cup, ring, and vessels on the other side. The doctors go on to discuss colpotomy, barbed sutures, visualization, antibiotics, and more.

The physicians end by expressing the importance of asking for help, knowing your limits as a surgeon, and ensuring patient safety.

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RESOURCES

ACOG: Choosing the Route of Hysterectomy for Benign Disease

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease

In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park have an in-depth discussion on the topic of vaginal hysterectomy. Amy, who handles a substantial caseload of vaginal hysterectomies, takes the lead in this conversation as she walks through the procedure and its intricacies. In Mark's practice as a Minimally Invasive Gynecologic Surgery (MIGS) surgeon, he typically deals with cases involving candidates for laparoscopic hysterectomies, while many vaginal hysterectomy cases are referred to urogynecologists.

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SHOW NOTES

Both Amy and Mark stress the critical importance of selecting a surgical approach that aligns with a patient's medical history and anatomical considerations. Amy asserts that a patient is a suitable candidate for a vaginal hysterectomy when they possess a tall and mobile uterus, with ample vaginal space, and a pelvic outlet of sufficient width. Furthermore, she highlights that patients with a cervix located within 6 cm from the hymenal remnant are good candidates for vaginal hysterectomies.

The physicians delve into the topics of competency and confidence within the operating room. They agree that the volume of surgeries, repeated practice, pattern recognition, and experience in managing complications are pivotal factors contributing to a surgeon's growing competence with each case. Both doctors concur that it typically takes approximately three to five years to achieve confidence and a reduction in anxiety levels regarding surgical cases.

Amy proceeds to describe each step of a vaginal hysterectomy and shares her preferred practices in the operating room. To ensure patient comfort and safety, she positions her patients in the dorsal lithotomy position, taking special care to avoid exerting pressure on the peroneal and femoral nerves. While providing sacral support, she positions the remainder of the perineum as close to the edge of the table as possible to maximize vaginal access. Amy initiates the procedure with a posterior colpotomy using a 10-blade after administering lidocaine. Gradually, she progresses anteriorly, retracting the vaginal epithelium until the peritoneal folds become visible. She tags the uterosacral ligaments and proceeds to access the pelvis anteriorly, paying careful attention to avoid injuring the ureters. She systematically advances to the utero-ovarian ligament and artery, concluding by addressing the fallopian tube and ovary. Amy emphasizes her preference for two-handed knotting in all vaginal cases to achieve optimal tension and mentions her infrequent use of energy devices.

Finally, Mark and Amy discuss the evolution of training within the operating room over the years, acknowledging the changing landscape due to advancements in technology and varying case volumes. They underscore the significance of mastering technical skills outside of the operating room, which enables trainees to dedicate the necessary time to enhancing their operative abilities.

In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park invite Dr. Linda Bradley to discuss advanced hysteroscopy. Linda is a professor of OB/GYN and Reproductive Biology at Cleveland Clinic as well as the Director of Center for Menstrual Disorders, Fibroids, and Hysteroscopic Services.

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SHOW NOTES

The episode begins with Linda describing the utility of hysteroscopy: it is a great option to visualize the endocervix, endometrium, uterine healing after complicated surgeries, foreign bodies, broken IUDs, and hyperplasia. It should be used for uterine bleeding, retained products of conception, evaluating women for Asherman’s, and evaluating why the endometrium is thick on ultrasound. Hysteroscopy has two main roles: diagnosis and therapeutics. Hysteroscopic surgery allows for the uninterrupted visualization and removal of pathology, as opposed to other measures like D&C where the uterus is scraped blindly. It is also great for visually-directed, targeted biopsies and treating pathologies like fibroids and polyps. Linda emphasizes that it is a disservice to women to go in blind because fibroids or cancer can be missed with blind biopsies--in fact, pipelle biopsies picked up zero polyps in their study. Hysteroscopy surgery has a faster recovery, is less invasive, has less risks of bleeding or damaging other structures, and has low risk of infection.

The physicians then discuss techniques involving hysteroscopy. Linda prefers using a flexible hysteroscope that is 3.2 mm wide because dilation isn’t needed. She also explains that there isn’t a need for a paracervical block (just oral ibuprofen) as the patients have minimal pain when the walls of the uterus are appropriately avoided.

Linda focuses on the need to believe women when they are bleeding. It takes 3-5 doctors and 3-5 years for many women to get their bleeding appropriately treated instead of trying the same medicines without success. We have the technology to do something different, and hysteroscopy is the best option to look into the uterus and understand what is going on. Mark asks about the training of physicians in hysteroscopy, and Linda responds that simulators are key in addition to having courses and mentors to teach the technique properly. Finally, the doctors finish by talking about future applications of hysteroscopy.

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RESOURCES

Orlando, Megan S. MD; Bradley, Linda D. MD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstetrics & Gynecology 140(3):p 499-513, September 2022. | DOI: 10.1097/AOG.0000000000004898

This week on BackTable OBGYN, Dr. Suzette Sutherland and Dr. Rachel Rubin discuss the diagnosis and treatment of genitourinary syndrome of menopause (GSM) with vaginal estrogen.

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SHOW NOTES

GSM is not only a condition of "vaginal dryness", but rather a multi-faceted symptom set including pain with sitting, urinary frequency and urgency, bladder pain, opioid use, and recurrent UTIs. First, the doctors discuss the myths and misconceptions about the use of estrogen creams, suppositories, and rings to treat GSM . However, Suzette and Rachel also discuss the importance of advocating against the misrepresentation of vaginal estrogen in box labeling. They conclude that the benefits of using a low-dose vaginal estrogen far outweigh the risks, and doctors should advocate for better labeling and understanding of this treatment.

Suzette and Rachel also discuss the American Urologic Association (AUA) guidelines for GSM and its importance. Systemic hormone therapy is rarely enough to address GSM symptoms, so screening for GSM symptoms is essential. They also talk about estrogen therapy for special patients, such as those on hormone replacement therapy (HRT) and cancer survivors. Suzette and Rachel emphasize the importance of understanding the general hormone fluctuations of patients particularly oral contraceptives, those with disordered eating, those who are breastfeeding, and those who are transgender. They end the episode by encouraging the production of more research and data to back up treatment options for GSM in premenopausal women.

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RESOURCES

WellPrept

https://wellprept.com/

Femring

https://www.femring.com/

This week on BackTable Urology, Dr. Suzette Sutherland (University of Washington) and Dr. Olivia Chang (UC Irvine) discuss reasons for uterine preservation and hysteropexy techniques for prolapse repair.

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SHOW NOTES

First, Suzette and Olivia discuss the value of keeping the uterus in place for women undergoing prolapse repairs, as well as the indications for apical suspension surgery. They also note the historical context of hysterectomy and why it has been the go-to treatment for so long. Next, the doctors discuss the advantages of hysteropexy over hysterectomy for prolapse repair, such as a shorter operative time, less bleeding, and a quicker recovery. The doctors then go into more detail about the best approaches for prolapse repair, like weighing the options of permanent sutures versus delayed absorbable sutures. They also analyze recurrence rates after prolapse surgery, specifically in the anterior compartment.

Then, they explore the data on how the choice to keep the uterus in place can stem from a woman's personal and cultural views. Olivia shares about the Value of Uterus questionnaire, a six-question survey instrument that can quantify how a woman values her uterus. It can streamline clinic visits and help to predict whether a woman would choose a uterine-preserving procedure. The doctors note that there is research demonstrating a correlation between valuing the uterus and sexual activity.

Finally, Suzette and Olivia contraindications for leaving the uterus in place. They emphasize the importance of assessing for abnormal uterine bleeding and cervical pathology before recommending uterine preservation. They suggest that listeners review the current guidelines around preoperative workup and consider transvaginal ultrasound or endometrial biopsy first. Lastly, they emphasize the importance of symptom and risk stratification and shared decision making when it comes to uterine preservation.

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RESOURCES

Chang OH, Walters MD, Yao M, Lapin B. Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus. Am J Obstet Gynecol. 2022 Jun 25:S0002-9378(22)00483-5. doi: 10.1016/j.ajog.2022.06.029. Epub ahead of print. PMID: 35764134.

https://pubmed.ncbi.nlm.nih.gov/35764134/

In this episode, Dr. Mark Hoffman hosts Dr. Jan Baekelandt, a gynecologic surgeon from Mechelen, Belgium, to discuss a novel gynecologic surgery approach known as vaginal natural orifice transluminal endoscopic surgery (vNOTES).

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SHOW NOTES

This technique involves entering the pelvic cavity through the vaginal lumen, eliminating the need for abdominal incisions and promoting a less invasive procedure. Dr. Jan Baekelandt explains that during his career this approach originated from the single-side surgery technique, gradually evolving into a fully transvaginal procedure. He highlights that the advanced tools required for vaginal surgeries now offer equivalent visualization and hemostatic control as laparoscopic techniques, while providing the added benefit of reduced invasiveness.

The benefits of vNOTES for patients are discussed, including findings from two randomized control trials comparing vNOTES hysterectomy and adnexectomy to laparoscopic approaches. The results indicate non-inferiority, reduced postoperative pain, decreased analgesic use, and shorter hospital stays for vNOTES. Complications were also lower in the hysterectomy trial. Notably, the vNOTES technique especially benefited patients who were obese, had undergone prior abdominal surgeries, or had large uteruses. Jan underscores the significance of technique standardization to facilitate teaching and complication avoidance. He acknowledges vNOTES-specific complications, such as a higher cystotomy rate, but notes a lower ureter damage rate. However, he cautions that vNOTES might not be suitable for certain patients, like those with endometriosis, prior pelvic inflammatory disease or pelvic abscesses.

The potential impact of vNOTES on non-hysterectomy surgeries, future deliveries, and sexual function is briefly discussed, though data in these areas remain limited. Dr. Jan Baekelandt is hopeful that more evidence will emerge to guide physicians. He shares that, based on available data and his own experience, vaginal deliveries following vNOTES have generally proceeded without complications, without a notable increase in cesarean sections or vaginal tears. He notes that to protect sexual function, surgeons should take care to make incisions away from the posterior cervical fornix to avoid subsequent dyspareunia for their patients. The episode concludes with Jan emphasizing the importance of formal training and starting with simpler cases to build proficiency and confidence. He asserts that the best technique for a surgeon is the one that instills confidence in keeping patients safe.

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RESOURCES

Baekelandt J, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BW, Bosteels JJ. HALON-hysterectomy by transabdominal laparoscopy or natural orifice transluminal endoscopic surgery: a randomised controlled trial (study protocol). BMJ Open. 2016 Aug 12;6(8):e011546. doi: 10.1136/bmjopen-2016-011546. PMID: 27519922; PMCID: PMC4985989.

Baekelandt JF, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BWJ, Bosteels JJA. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial. BMJ Open. 2018 Jan 10;8(1):e018059. doi: 10.1136/bmjopen-2017-018059. PMID: 29326183; PMCID: PMC5780723.

In this episode, Dr. Mark Hoffman invites Dr. Ted Lee, an OBGYN specializing in MIGS and professor of OBGYN at University of Pittsburgh Medical Center, about the ambulatory workup of endometriosis patients.

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The episode begins with the physicians discussing the difficulties of diagnosing endometriosis, including: the stigma of pelvic pain/not believing women’s pain, recognition that pelvic pain is not normal, the discomfort of physicians asking the appropriate questions for pelvic pain, and the hesitancy towards surgery by physicians and patients all play a role. Many patients have been having pain for years that may have been covered up by OCP use or misdiagnosed as IBS or interstitial cystitis.

Ted emphasizes the importance of a thorough history in diagnosing endometriosis. Essential information includes age of onset of symptoms, gravidity and parity, prior C-section (abdominal wall endometriosis) and the “3 D’s” of dyspareunia, dyschezia, and most importantly dysmenorrhea. A quality physical exam can also elucidate endometriosis. Ted starts by palpating the anterior vaginal wall, then the levator ani muscles and cervix, and finally the rectovaginal exam. Palpation of the uterosacral ligament and posterior cul-de-sac in endometriosis patients causes a visceral reaction, and advanced disease may also have nodules felt. The majority of patients don’t require additional imaging since ultrasound is insensitive for stage 1 and 2 endometriosis. Indications for MRI include endometrioma, nodularities felt on exam, and abdominal wall endometriosis. When it comes to surgery, both doctors emphasize the importance of having other surgeons on your team, including colorectal surgery, general surgery, and urology. Ted dives into some surgical tips and techniques from his years of experience.

Finally, the physicians end by discussing the future of endometriosis diagnosis. A Japanese study has recently found fusobacterium in the uterine microbiome in endometriosis patients more often than those without. Also, a French study has taken saliva samples and found signature microRNAs for endometriosis. It will be interesting to see how studies like these change the future of endometriosis diagnosis and if it will bring new challenges, such as overtreatment and overdiagnosis.

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RESOURCES

Muraoka, A., Suzuki, M., Hamaguchi, T., Watanabe, S., Iijima, K., Murofushi, Y., Shinjo, K., Osuka, S., Hariyama, Y., Ito, M., Ohno, K., Kiyono, T., Kyo, S., Iwase, A., Kikkawa, F., Kajiyama, H., & Kondo, Y. (2023). Fusobacterium infection facilitates the development of endometriosis through the phenotypic transition of endometrial fibroblasts. Science translational medicine, 15(700), eadd1531. https://doi.org/10.1126/scitranslmed.add1531

Bendifallah, S., Suisse, S., Puchar, A., Delbos, L., Poilblanc, M., Descamps, P., Golfier, F., Jornea, L., Bouteiller, D., Touboul, C., Dabi, Y., & Daraï, E. (2022). Salivary MicroRNA Signature for Diagnosis of Endometriosis. Journal of clinical medicine, 11(3), 612. https://doi.org/10.3390/jcm11030612

In this week’s episode, host Dr. Mark Hoffman discusses quality and safety in OBGYN and medicine as a whole with Dr. Komal Bajaj, a professor of OBGYN at Albert Einstein College of Medicine, reproductive geneticist and Chief Quality Officer at NYC Health and Hospitals/Jacobi in North Central Bronx. In addition, Dr. Bajaj is the clinical director of the NYC Health Simulation Center.

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SHOW NOTES

The episode begins by discussing the core principles of a Chief Quality Officer and how a typical week demonstrates those values. Dr. Bajaj emphasizes the importance of measurement as a key tool for quality and safety assessment. Information is helpful, however data literacy and transparency is also important to help the healthcare community to better understand a set of data. A significant challenge in ensuring quality and safety is identifying a precise dataset and developing an effective measurement methodology, which may be costly and labor intensive.

Dr. Bajaj discusses how a culture of safety adopted by the entire healthcare team protects the patient and adds to the quality of care. An additional key principle is learning from events through risk management; each event should be thoroughly discussed as an opportunity for future changes.

According to Dr. Bajaj, a crucial aspect of her role as the quality and safety officer is to take into account regulatory and accreditation standards. These guidelines aid healthcare systems in identifying areas of care that require improvement. Dr. Bajaj often looks at her hospital as a functioning ecosystem, with multiple interplaying parts, each which interact with one another to help make patient care of the best quality. She stresses the importance of physicians as leaders understanding the interlinking between the different parts of the system to improve patient safety and outcomes.

Dr. Hoffman and Dr. Bajaj engage in a discussion about the prevalent issue of resistance when it comes to finding solutions for enhancing quality and safety. They strongly advocate for empowering providers to take initiative in identifying problems within their institutions and seeking necessary changes. The two doctors believe that unanimity is not always essential to make a positive impact on quality and safety. Rather, they acknowledge that some providers may require more time to embrace change in their routines.

Dr. Hoffman and Dr. Bajaj then delve into the relationship between quality, safety, and the financial aspects of healthcare. They reach a conclusion that emphasizes how quality and safety initiatives in a healthcare system provide financial incentives for all stakeholders, including staff, patients, and the entire ecosystem. The level of care patients receive directly influences crucial factors such as hospital funding, ratings, and assessments by national organizations.

The future of quality and safety in OBGYN is explored last. Dr. Bajaj introduced the idea of a person-centeredness approach to quality and safety that incorporates staff and patients' voices into initiatives. Then she shared how an emphasis on the basics, safety, an empowering culture, and strong leadership are being re-examined as key goals for the future. Lastly, she touched on sustainability as an emerging area for improvement in healthcare delivery.

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RESOURCES

Accreditation Standards:

https://www.accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ce

In this episode, Dr. Amy Park invites Ingrid Harm-Ernandes, a pelvic floor physical therapist and co-director and mentor for Duke University's Women's Health Physical Therapy residency program, to shed light on the advantages of pelvic floor physical therapy for various types of conditions and patients.

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SHOW NOTES

Dr. Park and Harm-Ernandes dive deep into the definition of pelvic floor therapy. They emphasize the significance of a comprehensive initial exam to determine the specific assessments that a patient may require. For instance, internal assessments may include evaluating muscle strength, endurance, trigger points, and fascial restrictions. Another key component to pelvic floor therapy is the importance of behavioral therapy integration with physical therapy. For example, it is important to provide patient education over bladder relaxation to reduce urinary urgency and pelvic floor relaxation to prevent constipation. Assessing all body systems, particularly other areas of musculature, can help providers understand how the pelvic floor interacts with other symptoms. Overall, the key feature of pelvic floor therapy is individualized treatment. Pelvic floor physical therapists form the treatment plan around each patient’s goals.

During the discussion, Harm-Ernandes places a significant emphasis on the numerous indications for pelvic floor therapy, as well as common misconceptions surrounding it. For instance, she highlights that many women are often taught to believe that occasional urinary incontinence, particularly with age or after childbirth, is entirely normal. However, she stresses the importance of dispelling these myths and encourages women to seek professional help rather than accepting incontinence, pain during sexual intercourse, or chronic constipation as inevitable experiences. By dispelling these misconceptions and seeking appropriate treatment, individuals can significantly improve their quality of life and overall well-being.

Collaboration among health professionals is pivotal in treating patients holistically and addressing the complexities of pelvic floor disorders. Harm-Ernandes’ extensive knowledge and commitment to educating both patients and providers has been instrumental in highlighting the essential role of pelvic floor therapists.

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RESOURCES

Book: “The Musculoskeletal Mystery: How to Solve Your Pelvic Floor Symptoms”