Avoiding Hysterectomy

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Barbara Nesbitt: Good morning. I’m at AAGL with Dr. Herbert Goldfarb who is on several of our editorial advisory boards and we are here this morning to talk about hysterectomy and what is new. Why don’t you tell us a little bit about yourself?

Herbert Goldfarb, MD: Good morning. I’m the Director of Endoscopic Surgery at NYU Downtown Hospital in New York City and an Assistant Professor of Clinical Obstetrics for Gynecology at New York University. My specialty is helping women avoid hysterectomy. We could talk about hysterectomy, I can do hysterectomies, I can do them with one hand tied behind my back, I can do them vaginally, abdominally, laparoscopically, but the women who seek me out are women who have been threatened with hysterectomy, and I use that word very judicially because that is the truth, and they’ve been threatened with hysterectomy because they happen to have abnormal bleeding, they may have fibroids, they may be young and my definition of young is anywhere.…

Barbara Nesbitt: Under 100.

Herbert Goldfarb, MD: . . . any person who is younger than I am is young. Many of these women are in their early 40s and they have fibroids and bleeding and their physician tells them there are no other alternatives but to do a hysterectomy. That myomectomies are very dangerous and extremely bloody and they could hemorrhage and they could need blood transfusions. Well, I am here to tell you that that is not true. The procedures that we do, and there is a myriad of procedures that we do to treat fibroids and help women who have significant bleeding with fibroids.

First of all, I would like to tell you that every woman over 40 years of age will have episodes of abnormal bleeding. That is called dysfunctional bleeding, abnormal function to their bleeding, and when that is so, when they have this abnormal bleeding and they happen to have fibroids, immediately the physician will blame the fibroids for their bleeding and seek to treat them and usually the treatment of choice is hysterectomy.

What we like to do is first to make a diagnosis. We have to look at the pelvis; we usually get an MRI, a magnetic resonance test, which really outlines exactly where the fibroids are. We do an ultrasound, sometimes you look inside the uterus. We do a hysteroscopy, which means looking inside the hyster or the uterus in order to identify what the real problem is. If the woman wishes to maintain fertility, she wishes to have children; our mandate is to remove the offending problem which is the fibroid. We can do that laparoscopically or we do it through a minimally invasive incision, usually no more than a two to three inch incision above the pubic synthesis. Patients are usually out of the hospital the morning of the second day and they are back to work in a few weeks with such a small incision. If the woman has had her family and does not wish to have any more children, then we have a much wider latitude of treatment options. We can treat the inside of the uterus with a number of different techniques. One of them is a technique where we instill hot water through a hydrothermal ablation system and we can destroy the lining of the uterus or we can do an old-fashioned transcervical resection where we actually excise the lining of the uterus and this stops their bleeding. Oftentimes, women have no more bleeding at all, about 50%, and the ones who do, have essentially normal menstrual periods. Then we also perform a procedure that I developed almost thirteen years ago called myolysis. We use electric needles to undermine the fibroids and utilizing this technique, the fibroid shrinks, the lining of the uterus becomes atrophic and the woman does not know she has fibroids anymore. So these alternative treatments are such to help us help women avoid hysterectomy.

Barbara Nesbitt: Do you do the myolysis procedure laparoscopically?

Herbert Goldfarb, MD: Yes. This is a laparoscopic procedure, the myolysis.

Barbara Nesbitt: Okay, and it then contracts the fibroids.

Herbert Goldfarb, MD: Well, the fibroid cells will die. The fibroid will shrink down to half of its size. Interestingly enough, what we do is we use a special medication called GnRH analogue pre-operatively for a month or two and usually with this medication, the fibroid shrinks, it blocks the hormone production, the fibroid shrinks and with the shrinkage of the fibroid, the symptoms disappear. When the symptoms disappear, then we know that our procedure will be successful. We do not have to say to patients, well, we are going to do this procedure - hopefully it will work. Interestingly enough, I am going to present this in a few minutes myself to the physicians here, but we have been able to reduce the hysterectomy rate of patients who have undertaken this procedure down to 5.5%.

Barbara Nesbitt: So with the way the world is now and all the women, if they worked or for whatever reason, wanted to delay having children to their late 30s and 40s, this is a wonderful option for them because they can still remain fertile.

Herbert Goldfarb, MD: Well, we do not do the myolysis and the ablation procedure in women who want to have children. But what we do is perform these minimally invasive myomectomies, we hardly ever need blood. We get the patient to donate her own blood, but very rarely do we have to use it. We can remove very large fibroids that way and restore this woman to fertility.

Barbara Nesbitt: Wonderful. Thank you. Good to see you again.

Herbert Goldfarb, MD: Thank you very much.

Hear Dr. Goldfarb describe his new Endoscopic Center for Advanced Gynecological Surgery.