Alternatives to Hysterectomy

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Paul Indman, MD: "Hi, I'm Dr. Paul Indman, and I'm at the 30th Annual AAGL meeting in San Francisco. I'm fortunate to have with me Dr. Herb Goldfarb. Herb, you're involved quite a bit in taking care of women with abnormal bleeding. I want to talk to you for a minute about the approach to someone who comes in and says my periods are heavy and I'm bleeding all the time. Let's say she's forty-two years old, she's been to three doctors, nobody's found anything, and she's been on three different doses of birth control pills, perhaps Provera, for about three days. How do you approach such a woman?"

Herbert Goldfarb, MD: "It's very interesting that you asked this particular question, I just saw a young woman who is a little younger than that, she's thirty-five years old. She came in just about crying to me that she had had a D&C six months ago and she has extremely heavy bleeding. She bled so heavily that she required a blood transfusion, and they've given her all kinds of medications - hormones just as you mentioned, and it hasn't solved her problem. Now I would like to tell our audience first that almost every single woman over the age of thirty-five will end up with abnormal bleeding at some time in her life. Most of the time this abnormal bleeding is related to what we called dysfunction, which means the hormones are out of cycle. She'll have some abnormal bleeding, especially as she gets into her forties, mostly because of what we call anovulatory bleeding. But in any case, this particular woman who wants to conceive was so appalled that she continued to bleed, she said - can you save my uterus? That was her main approach so I'd like to tell you that I think the first intervention should be an endovaginal ultrasound."

Paul Indman, MD: "You do that on the first exam?" 

Herbert Goldfarb, MD: "Yes, and not only that but the fact is I like to follow women regularly with endovaginal ultrasounds to rule out ovarian tumors and to protect them against abnormal situations in the lining of the uterus. In any case, I took one look inside at the endovaginal ultrasound and I could see that she had a mass inside the uterus, so at the same visit we performed a procedure called a fluid sonography. That's very interesting, you can put a little bit of fluid inside the uterus as an optical backdrop against what's inside the cavity, and we use a very small little cannula with a small little balloon that goes inside the cervix. When someone is bleeding the cervix is very well dilated already because they bled a lot. It's essentially a painless procedure, and we could see that she had a lump inside the uterine cavity. This woman had a previous D&C by a board certified physician, so the point I want to make is that the place for the curettage (D&C) is in history. The curettage is not directed by observation, and no urologist who is actively practicing would treat the bladder without looking inside the bladder so why should a gynecologist treat the uterus without looking inside the uterus to try to solve the problem."

Paul Indman, MD: "Here you diagnose it just on the first visit using an ultrasound and doing a hysterosonogram and she is bleeding or did the bleeding stop?"

Herbert Goldfarb, MD: "No, she's bleeding."

Paul Indman, MD: "Okay, so she's bleeding acutely and she needed a blood transfusion. She was in the hospital to get a blood transfusion, and they still didn't figure out what was going on. It's an exciting feeling I must say; now it's a game to see if we can diagnose the bleeding in ten seconds or whether it takes thirty seconds. I've literally had someone that had been sent home from the hospital, with four units of blood from another hospital down the street - go see Dr. Indman. Monday morning they come in with a bucket under them. The bloods running out and there's their submucous myoma."

Herbert Goldfarb, MD: "Now you're located in California and I'm in Montclair, New Jersey and New York City and Manhattan so we've got both coasts covered now in terms of physicians who are interested in making the diagnosis before they say to the woman - you need a hysterectomy." 

Paul Indman, MD: "Or you need to get a blood transfusion. So how did you stop the bleeding because she is bleeding heavily?"

Herbert Goldfarb, MD: "There's a drug called Aygestin which is norethindrone acetate, and you can stop almost any bleeding temporarily with Aygestin. I put her on a dose of Aygestin until we could get a date for her and put her in the hospital. We did a hysteroscopy examination, looked inside, and saw the large mass that she had. I used an instrument that is commonly sold, the myoma forceps, and once we scheduled her in the hospital I took it out. I used a suction curettage, which is a very common instrument to clean out the remainder of the cavity, and she's been fine. She's been totally asymptomatic and she can go on and have as many babies as she wants. I think the point to be made here is that physicians are obligated to make a diagnosis and the diagnosis can be made either with ultrasound or if the ultrasound appears normal then a hysteroscopic examination should be done. It can be done in the office or it can be done in a hospital, then tissue is obtained, an adequate diagnosis is made, and then a plan of treatment can be made to try to care for this woman."

Paul Indman, MD: "Why do you think there are so many women going around bleeding without a diagnosis? What's wrong with this picture because they're seeing specialists in gynecology?"

Herbert Goldfarb, MD: "Here's the problem, I've been on the staff of one of the hospitals in New York City that shall remain nameless, and I went to the operating room to do a hysteroscopy and they handed me a single tube instrument and a vial of Hyskon. They said this is what we use at this hospital."

Paul Indman, MD: "What year was this - eighteen...?"

Herbert Goldfarb, MD: "This was 1998, just two and a half years ago. I said to them that's not what I do. They don't have a continuous flow diagnostic hysteroscope, and no one has ever used it. I am giving grand rounds there next week and I will try to educate them. I don't know about you but I've been doing it now since the seventies and I hate to date myself."

Paul Indman, MD: "I wasn't even born then."

Herbert Goldfarb, MD: "You've got some grey hair, I think you were born then. In any case, hysteroscopy has evolved to the point where in the 1970's when I was doing it, I would use the Hyskon, which is a molasses type liquid that's placed inside the uterus to extend the uterus and give an optical medium. It's very difficult to use, you can't see very much, and certainly diagnosis is anything but adequate. Then we evolved; we started to use carbon dioxide and even with carbon dioxide, which so many people use, if there's any pathology in the uterus you get bubbles and you don't get adequate distension lots of times. A number of years ago I presented at the AAGL film festival a comparison of using carbon dioxide versus fluid for hysteroscopy, and the visual effects are most dramatic - how much you can see. So now when we do hysteroscopy in the office we use fluid, and we give the patient one tablet of Percocet, which is a narcotic. They walk into the office, I use a little novocaine, and they hardly feel anything. I can look inside the uterus, I can diagnose, and I can eliminate any unknowing and unsure nature of problems."

Paul Indman, MD: "What do you think we can do to further hysteroscopy among our colleagues?"

Herbert Goldfarb, MD: "We're busy in this area where all these surgical companies are selling their products of doing things and selling things because they feel that doctors don't have the ability to do adequate diagnostic procedures. You can use a balloon to destroy the lining of the uterus, you can put hot fluid in to destroy the lining of the uterus - you can do everything but look inside and use a classical loop electrode or a roller device to destroy the lining of the uterus. They say that the reason they're doing this is because it's too hard for doctors to do the standard procedures. I think we need these companies to concentrate more on training and to get doctors to know how easy it is to do these procedures in the hospital with proper equipment. If you don't have proper, what we call, continuous flow of the instrument then you're not going to see easily - you're going to have difficulty seeing."

Paul Indman, MD: "I think the message is out that as physicians we ought to share our knowledge with our colleagues, and I think it's really going to come down to women demanding that this be done because as long as women go on without requesting a diagnosis then they're not going to get it."

Herbert Goldfarb, MD: "It's amazing, even at my hospital and I have an office in New Jersey and one in Manhattan, I know physicians who will not bother to do a hysteroscopy. I can't see, it's not good, or the instruments may not be good, and the hospitals are not being pressured. Just because you go to a university hospital it doesn't mean that everything is up-to-date. It's not necessarily Kansas City where everything is up-to-date; you know that song in 'Oklahoma.' In any case, I think it's important and our best patient is a wise consumer. I wrote a book called, 'The No Hysterectomy Option' published by John Wiley ten years ago. It was revised three years ago and in it we stressed the importance of diagnosis and that women should be knowledgeable and not succumb to hysterectomies when alternative methods of treatment are available."

Paul Indman, MD: "Thank you very much. That's Dr. Herb Goldfarb and I'm Paul Indman at the AAGL meeting in San Francisco, thank you."

See also: OBGYN.net Editorial Advisors, James E. Carter, MD and Herbert Goldfarb, MD discuss Dr. Goldfarb's book "No Hysterectomy Option", a comprehensive, authoritative and timely book which will cover the information you'll need when you have to make a choice. Audio/Video Link ordering information