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 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

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Vaginismus: Managing a Misunderstood and Underdiagnosed Condition

Why vNOTES Make Sense for My Patients

click             here for RealAudio/Video version

 "Good       afternoon, we are at ACOG, and I have the pleasure of interviewing Dr.       Trevor Watson, from Columbia, Missouri. He's just done his presentation on       the vaginal cuff closure with abdominal hysterectomy. I spoke with him       yesterday, it's a new approach, sutures instead of clamps, and it sounds       really, really good to me. Good afternoon, doctor."
       
       

       "Thank you. I've been asked to come back yearly for presenting this       at a round table at lunch, and I enjoy this. I usually make a bet with the       first one that shows up to the table as to a mix of men and women, and I'm       always right because there's always more women than men. And the reason -       who has dyspareunia?"
       
       

       "Women - that's right - and why do women have dyspareunia - for       various reasons, they have pain with sexual activity, and very often that       pain emanates after a hysterectomy. What we have tried to do here is to       eliminate that problem. We are trying to accomplish other things, one of       those things is give the woman more support, we're trying to reduce the       blood loss with our procedure, we're trying to show a method by which we       can take out that uterus, close that cuff in a side to side manner so that       this woman does not have any shortening whatsoever of the vaginal       vault."
       
       

       that I showed you yesterday that's directed towards the women patients,       and we have a great forum on there. Over the last two years, I have to       tell you - I was ignorant of that fact. I had a hysterectomy, and I never       had that problem. When women would write in, I have to tell you, I didn't       understand what they were talking about. But after talking with you       yesterday and you drawing pictures and showing me things, I now can       understand. Tell them what happens to women."
       
       

"Starting       in 1926, there was a description in the literature about closure of the       vaginal cuff from the abdominal approach, which essentially is a       front-to-back closure. The front-to-back closure leaves a scar in a       transverse manner at the end of the vaginal vault, and that scar very       frequently is very tender. Now for other reasons some surgeons do not       close the vaginal cuff but let it granulate an end. Granulation tissue       leaves a tender scar, when this is at the end of the vaginal vault -       you've left a woman with dyspareunia too."
       
       

 "Now       can you get adhesions from that scar?"
       
       

       "Not so much, but you have a tender area there, and you know that old       saying that the vaginal vault will accommodate sexual activity after       hysterectomy even if you do shorten it - is not right. But this problem       happens because doctors put a clamp around the end of the vagina, and then       cut off the vagina. Measuring specimens that have been taken this way,       you'll find a 2-4 centimeter rim of vagina around the cervix, then you       further close it from front-to-back - you have further shortened it, and       left the scar right there where deep penetration is…"
       
       

       "If it doesn't hit the scar, it's pulling against the scar. So what I       wanted to describe to you is how to avoid that and how to close that in a       sagittal or side-to-side manner."
       
       

 "You       showed me yesterday - it is so wonderfully simple."
       
       

       "Yes, I would like to be able to send a monograph to anybody that is       interested in this, and I would be happy to do so at no cost. Now, the       method involves - when you get down to taking down the cardinal ligaments       and you've divided them from the cervix, before you take off your clamps,       you want to take a suture through your cardinal - but don't tie it. You       hold it, and put a clamp on it on both sides. Then take a another suture,       and an #O Vicryl -MO4 needle is usually what I use, and go in that angle.       Try to go underneath the vaginal mucosa and bring it back through the       center of your clamp, underneath the center part of your clamp, and then       hold that. It doesn't matter if you miss and go all the way into the       vaginal vault - it's not important. But at any rate, tie down your       cardinal, and then tie this suture which is controlling your lateral       vaginal plexus of vessels. Or do that on both sides, and then enter your       vagina at the reflection from the cervix. Cut it off with your Jorgenson       scissors all away around, and you've left as much room on that vagina as       you can. Now the matter is just taking those sutures you've left from the       lateral vaginal plexus, going through the endopelvic fascia and the mucosa,       out the mucosa on the other side, and use the other one coming on this       side and pull on them. It pulls your vagina together from a side-to-side       manner."
       
       

       "Rather from front-to-back and then use one suture to close the       anterior parts. When you come back, bring the endopelvic fascia back over       your cuff, and tie those sutures in the middle. Let your bladder come       back, and you will find that it tents your bladder because you've given       support under your bladder. If you have sutured that bloody angle and not       put a clamp on it and then tried to get it, you'd be surprised your blood       loss will be much less. Now there are sometimes varices in this area, you       can clamp or you can suture, use a figure of eight suture on this cuff       with impunity. Your ureters are way out of the way. They have been       reflected when you take your bladder away. They're off to the sides, you       have no worry about those ureters."
       
       

 "You       know, Dr. Watson, we're going to put your monograph up along with this       video on the website. We're going to have the diagrams so the physicians       will be able to see how the placement of the sutures are. From a woman's       standpoint, how does she find a physician that will do this? Can she read       it and know about it, and go and talk to a physician? How does a woman - I       had a hysterectomy, I didn't know, I'm fine so maybe they did use it…"
       
       

       "I think it's very hard for a patient to tell a doctor how to do       something."
       
       

 "Can       she ask him if he does it?"
       
       

 "Can       she ask him if he's familiar with it?"
       
       

 "You       know, we're educating women, and in the process we're educating physicians       as you're trying to do."
       
       

       "We trying to educate physicians, and we're trying to get them to       understand. Now I won a nickel at the table today because I bet the first       lady that was there, there'd be more women than men in the mix. The mix       was three men and seven women."
       
       

       "They're potentially hysterectomy candidates themselves."
       
       

       "Women understand dyspareunia."
       
       

       "And most men don't because most men don't ask. They don't ask if       they're depressed, and they don't ask if they have dyspareunia."
       
       

 "No       they don't. I want to tell you one thing, I think one of the better things       about having done this post-surgery is the fact that you're going to make       a lot of couples very happy. I mean, there's married couples that have       been married thirty or forty years, and all of a sudden the woman doesn't       want to have sex with the man she loves and has lived with, and he can't       understand it."
       
       

 "So       this is a wonderful procedure."
       
       

       "I could make some other comments. Occasionally while a patient is       still in the hospital there may be a question whether or not she's       developing a hematoma beneath this area. I'll tell you that you can put       your hand in the vagina vault, and put it back as far as you will without       hurting the patient. Now if you have bleeding or you have inflammation at       the time you do the hysterectomy, it's easy to put a Jackson-Pratt drain       in the center of that cuff. It's very simple to do that, and that will       keep you out of trouble."
       
       

 "This       is done with an abdominal hysterectomy. Just in case anybody missed this,       everything is going down through the opening in the abdomen - so that's       why the vagina is not then ended or like in a vaginal hysterectomy."
       
       

 "So       you can do that examination and know that everything is all right there.       Thank you, Dr. Watson."
       
       

 "It's       been a pleasure."
       
       

       "Thank you very much. I hope this helps women, and I hope this helps       doctors help women."
       
       

 "I'm       just a bit of a devil, and I think that women should ask around, and see       if their doctor does it. They can even tell their doctor to check it out       on 

ACOG

From ACOG - Philadelphia, Pennsylvania - May, 1999

Vaginal Cuff Closure with Abdominal Hysterectomy

 "I'm       Jeff Levy, and I'm the Director of Medical Education for IMET which is       Innovations in Medical Education and Training. We run several conferences       and educational programs. Tim McKinny, who is sitting on my right, has       been involved in many of those programs and is at the University of       Medicine and Dentistry in New Jersey, and he has an expertise in       urogynecology. He's had tremendous experience with multiple types of       procedures in one of the world's largest experiences in laparoscopic Burch       procedures - and especially using mesh, but is now started working with a       new procedure called the "TVT." I'd like Tim to talk about that       procedure a little bit, and tell us why he uses it."
       
       

"Thanks       a lot, Jeff. It's kind of an exciting, innovative procedure that has not       been new to the world but it's new to this country. It's been used since       about 1984 in Europe, and particularly over the last three to four years       heavily. There's been over 14,000 of these procedures done over in Europe,       which has been followed very carefully and studied very carefully by Dr.       Ulmstun. The results is three-year data which has been very scrutinized as       86% total cure, with another 11% tremendously improved - for about a 97%       success rate which rivals most procedures. The beauty of this is that it       is a procedure that can be done under a local anesthesia in a rather rapid       sequence with these kind of results. It is done so that the patients       themselves can participate in the surgery and actually give us the input       for when we have completed the procedure and gotten them dry. So during       the procedure, once we get the tape in the right position, we're able to       have the patient cough, sneeze, and do their normal provocative maneuvers.       When they end up losing the urine, we tighten up the tape until we stop       seeing them leak from the urine - at that point, we end the procedure. In       that way we can actually customize the procedure to the patient, not       customize the patient to what we're doing, which is a tremendous       improvement. The other design difference is most of the procedures for       incontinence have all been designed around supportive measures with the       urethra-vesico junction. This is a supportive procedure for the       mid-urethra, which physiologically is where most of the urethral closure       pressure occurs in a normal patient. In fact, post-operatively, if we look       at this, we're not changing the physiology at all of the urethra at rest,       we actually augment the urethra and the maximal urethral closure pressure       during stress situations, so pressure transmission tests will show a       tremendous uplifting of the pressure, and therefore, causes us to have the       incontinence procedure done."
       
       

       "Tim, you have the device here. Can you explain to us what it is and       how you use it?"
       
       

"The       device involves a disposable portion which involves two trocars that are       connected by way of the actual tension free tape, which consists of       Prolene mesh, as well as a covering over it of a plastic sheathing that is       perforated or separated in the middle, and it kind of overlies itself. The       reason why you need to have this plastic sheathing is so that it can slide       through the tissue easily. Once you've exposed the mesh, it's almost like       Velcro, it sticks to everything. That's why when you end up finishing the       procedure - after you get the sling in the right place and the right       tension - you release the cellophane off the outside of it. Now you've got       the sling underneath it, and you don't have to sew it in place because it       sticks that well. The other device to introduce it - attaches onto the       tail end and gives you a handle to be able to give you some fulcrum and       elevation ability, and allows you some distance away from your trocars to       slide it right underneath the pubic bone and out."
       
       

 "The       sling procedures are generally done by urogynecologists, do you feel that       general gynecologists can do this procedure?"
       
       

"I       think that people with proper training and proper abilities to understand       the complexities of incontinence, and who have an interest in incontinent       patients and not just trying to do the procedure, can absolutely do this.       It doesn't take a tremendous training aspect to be able to do this. You       need to be able to assure that you don't do any harm to the patient so you       have to have cystoscopy privileges to be able to make sure that this has       not done any harm. You also need to do appropriate work-ups for the       patient so you don't miss any underlying disease states because       incontinence is a symptom for underlying reasons that include things such       as cancer, neurological reasons - multiple sclerosis, so we don't want to       miss those little early key off to other diseases. As long as we don't       miss those, I think anybody can take care of this."
       
       

 "Now       do you have any pearls or suggestions of how you would select patients for       this procedure?"
       
       

"Originally,       I started off with utilizing this procedure on the worst of my worst       population, by that I mean the worst candidates for surgery. I had a       350-pound lady with a two pack per day smoke history, couldn't even lay       flat, that I ended up doing a procedure on times eight, eight other       surgical procedures ! She had been wet since 1985, and I performed this       procedure on her. My selection process at first was intrinsic sphincter       deficiency, the classic sling usage. Over in Europe, they use this as a       primary procedure for incontinence. Indeed, it's probably because of the       low mobility to it; it is probably a good choice for a primary procedure       especially with the data that's coming in. Although not long, long term       data, it's getting to be rather compulsive as far as the actual findings       and with the minimum invasion to it, with the shortness of time involved       in the O.R. which everybody is concerned over - cost containment and O.R.       time equals money. The average time for our study in the United States,       which is a virgin study over the last six months, we looked into the first       ninety-five patients, and we found that even our time in the initial       findings were less than thirty minutes - anything from sixteen to about       forty some odd minutes for the procedure. So it's very exciting, and I       wish I'd have come up with the design."
       
       

       "We're going to have several courses at IMET that are going to be       featuring some of the issues around TVT. Tim will be involved in those       courses so we look forward to some of the developments, and we look       forward to some of the long term data in the United States."
       
       

TVT Procedure for Stress Incontinence

       "Hello, my name is Chip Butrick, and we're here speaking with Dr.       Insu Kong. Today we're going to talk about a new technique that Insu has       been using for problems that are retroverted uterus and uterine prolapse.       Can you tell us a little bit about the symptoms that patients would have,       Insu, if they have problems with that kind of concern?"
       
       

 "Yes, the       people with the retroverted uterus usually complain of dysmenorrhea - a       painful period and dyspareunia - which is painful sexual       intercourse."
       
       

       "Now what can be done for those kind of problems?"
       
       

 "In the       past, many gynecologists have used open surgery to lift the uterus. Now       there's a new procedure called the 'uplift.' We can do this with a       laparoscope, which is very small, normally in a two-millimeter incision on       the skin, and we can do this procedure very quickly without having to open       the abdominal wall."
       
       

       "How is this procedure done - is this all, again, through the       laparoscope as an outpatient?"
       
       

 "Yes,       through the laparoscope and as an outpatient, and it could be done in       conjunction with other procedures because the procedure only takes about       ten minutes to complete."
       
       

       "And yet after this brief procedure, the success rate for pain with       intercourse and menstrual cramps would be…?"
       
       

       "Significantly reduced. I have seen many patients who had pain with       intercourse completely gone with this simple procedure."
       
       

       "Have you seen any complications? Is this a risky procedure to       undergo?"
       
       

 "No, it's       very non-risky because the needle size is only about one or two       millimeters - so there is no injury that could occur."
       
       

       "Fantastic - so then for patients with problems of pain with       intercourse or dysmenorrhea and where the doctor feels that the uterus is       tilted backwards, this is a new technique that sounds very       successful."
       
       

 "Yes,       very much so."
       
       

       "Fantastic. I wish you luck, Dr. Kong."
       
       

From American College of Obstetricians and GynecologistsPhiladelphia, Pennsylvania - May, 1999

The Uplift Procedure for Treatment of Retroverted Uterus and Uterine Prolapse

 "I'm       Robert Rivard, Professor and Chair of the Department of Obstetrics and       Gynecology at the University of Cincinnati College of Medicine. I'm here       today with Dr. Bruce Ettinger, who is principle investigator - a senior       investigator - at Kaiser Permanante in Oakland, California. We're here to       talk about hormone replacement therapy and customizing therapy. Dr.       Ettinger, you've had an interest in low dose estrogen therapy for many       years."
       
       

       "Absolutely, that's one of my favorite topics. We started in this       field about fifteen years ago with some bone studies, and it's interesting       to see how many others have come along in the last several years showing       that low dose estrogen is adequate to prevent bone loss at the time of       menopause and does a pretty good job of relieving menopausal       symptoms."
       
       

 "Now       you're also a proponent of, if you will, cyclic therapy - but you have       taken a look in the past and are giving a progesterone at less frequent       intervals than once each month."
       
       

 "Yes,       but I like to call this long cycle therapy. We did a study and published       that a few years ago in Obstetrics       and Gynecology, looking       at every three-month cycling using standard hormone replacement therapy       and showed that that was safe - about a 1% hyperplasia rate at the end of       one year and another 1% at the end of a second year. We're now about       halfway through a very interesting study using both a low dose and a       longer cycle that, I think, will be really revolutionary. What we've done       is switched women from standard dose monthly cyclic HRT .625 with       conjugated estrogens and cyclic monthly MPA to a low dose, half strength       every six-month progesterone cycle. We're using an esterified estrogen       Estratab .3 and we've actually gotten all the women into the study, 138       women, to switch from the standard dose monthly to the half strength every       six-month - and you have some very interesting preliminary data. We really       were interested in two aspects, one - would this be acceptable to women?       Would there be a problem with symptoms when they made the switch, and       would the bleeding pattern be acceptable? And we're very pleased to see       that in both regards we're doing quite well. These 138 women had been on       HRT for an average of nine years so they were pretty satisfied with their       standard monthly HRT. Yet they were able to make the switch, and only 10%       of them had any increase in vasomotor symptoms - so 90% of women had       adequate control of hot flashes and night sweats, etc. and were happy to       be on this. In fact, in addition to the good control of vasomotor       symptoms, overall there was a reduction in both psychological and somatic       symptom scores so women had less breast tenderness, less headache, less       irritability, and less mood disturbance when they switched from standard       dose to the low dose. From the point of view of bleeding, we looked at two       things - one was the breakthrough bleeding that would occur during the six       months of unopposed low dose estrogen, and we found just 9% of the women       had any breakthrough bleeding. In fact, it was very close to the 6%       breakthrough bleeding rate that these women had had previously on their       monthly regiment. So breakthrough bleeding didn't appear to be a problem.       What was a big surprise for us was that 60% of these women did not have       significant withdrawal bleeding when they took their Medroxyprogesterone       after six months. We gave them MPA 10 mg a day, for fourteen days - we       wanted to be very conservative and give a very adequate amount of       progesterone. Even after that much progesterone the bleeding, if there was       any, was quite light so only 4% of the cohort had heavy periods compared       to 28% that had reported heavy periods on their monthly standard dose of       HRT. So 60% - no bleeding, very low incidence of heavy bleeding,       relatively shorter cycles, and shorter duration of bleeding. So all of       that, I think, says that this regiment is going to be very acceptable for       women who want safety with this approach.
       
       

 " What       about the long term data for women who want safety with this       approach?"
       
       

 "Now       that's a very important question. Our study is designed for one year, and       we have done endometrial biopsies in all of these 138 women at baseline so       we know that they do not have any endometrial hyperplasia to begin with.       We will be repeating their biopsies as they close out their second cycle.       Those first biopsies are going to be done in the next few weeks, and over       the next six months we'll complete the study, so by early 2000 we should       have all of the endometrial safety data. We're hoping that we can come up       with the same low incidence of endometrial hyperplasia that we found in       our previous study with every three-month cycling. We have good reason to       believe that that will be the case. You know the esterified estrogen study       that was published in the Archives       of Internal Medicine -       two year, unopposed, .3 mg had less than 2% hyperplasia rate, a rate that       was actually similar to the placebo in that study. Of course .625 mg and       higher doses have had higher rates but this was a remarkably low incidence       of endometrial hyperplasia with .3 mg unopposed, and here we're giving       very good opposition every six months. So we hope to get in that same       range of about 1% or less hyperplasia."
       
       

 "How       about protection of bone and cardiovascular effects?"
       
       

 "I       think, of the best bone data that's out, in terms of the quality of the       studies on esterified estrogens is the study that was published in the       archives - Genant, was the first author in December 1997, had about       one-hundred women in each arm of the study - one-hundred on placebo,       one-hundred on .3 mg, one-hundred on .625 mg, and one-hundred on 1.25 mg.       It was very convincing that the .3 mg was adequate to protect against bone       loss over this two-year period. All of the women received calcium in that       study, and I think that's an important element that total calcium intake       of 1200 mg a day helps the estrogen to work better. I understand now that       esterified estrogen testing approved the .3 mg dose by the FDA for       prevention of osteoporosis. Of course, there are several other estrogens       in the low dose category that are also being approved or considered for       osteoporosis prevention. So I think it's just a matter of time until we       are using half strength estrogens for prevention of osteoporosis in a much       more wide spread fashion. Currently only 13% of women in northern       California Kaiser are using half strength estrogen, it goes up to about       18-19% for women over age 65 but it's still a minority of women that are       taking advantage of the benefits of low dose estrogen. I really think the       benefits are the convenience, the lack of side effects, and probably in       the long run - a safer regiment for women to be on. Now you did ask about       cardiovascular disease, and that's a tough one because there aren't that       many women who have been on .3 mg for a very long period of time. We don't       have rock solid data on this, and we know that the half strength estrogen       has a smaller effect on HDL than LDL cholesterol but the nurse's health       study produced some very interesting data a few years ago in the New       England Journal of Medicine.       They showed that compared to women who weren't using hormone therapy at       all, that those on .3 mg or the equivalent of a half strength estrogen,       had about the same degree of cardio protection - around 45-46% reduction       in MI rates as those on .625 mg and that women who use higher doses have       less cardio protection. That's really interesting, and I think it makes us       rethink about the mechanism - the way that estrogen is working to reduce       heart disease may not be all that HDL-LDL dependant. There are a lot of       other factors - the beta receptors that were now discovered in the       endothelium that are very sensitive to small amounts of estrogen and other       mechanisms whereby, a small amount of estrogen could protect against heart       disease without having a big effect on HDL and LDL."
       
       

 "So who       is the ideal candidate for this kind of therapy to your way of       thinking?"
       
       

 "In       my practice, I typically give standard dose estrogen to women who are very       symptomatic at menopause, and who are having a lot of hot flashes and       sweats. I will typically use a monthly cyclic regiment for them because       the continuous combined is terrible for breakthrough bleeding and       irregular bleeding at that time - right at the menopause transition. But       if a woman is on HRT and she likes the way she feels, and she wants to       continue it for the long term benefits, then I typically transition after       a couple of years to a half strength estrogen. I think the choice right       now is half strength estrogen with long cycle either the three-month cycle       or if our six-month cycle works out or a low dose half strength with       continuous combined. I know there are some studies ongoing looking at       continuous combined half strength estrogen and the hope there is that we       can get by with half as much progesterone. I think in a year or so we'll       see those studies. So there are a lot of new options, and physicians are       going to have to learn the new ways of using low dose estrogen."
       
       

 "Bruce,       I want to thank you for sharing your data with us. I'm sure we're all       going to be looking forward to the completion of the study and the final       presentation and publication of these results. Thank you again, Dr. Bruce       Ettinger, from the Kaiser Clinic."
       
       

"Long-Cycle,       Low-Dosage HRT Using Esterified Estrogens, (Estratab)"

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