Blind D&Cs Are Not the Answer for Dysfunctional Bleeding

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Dr. Roy Jackson:  “Good afternoon, ladies and gentlemen.  I’m here today in Florida and we’re at the American Association of Gynecological Laparoscopists annual meeting.  It’s my pleasure to have with me Dr. Paul Indman who is from California and is an extremely well known gynecologist in the endoscopy area.  Today we’re going to be talking about women who present to the gynecologists with abnormal bleeding or persistent bleeding in the area of menorrhagia.  Dr. Indman, how long have you been working now in the area of endoscopy?”

Dr. Paul Indman:  “I’ve been working in endoscopy even as a resident and doing hysteroscopy for over fifteen years.”

Dr. Roy Jackson:  “What percentage of your practice would you say is orientated towards women who have dysfunctional uterine bleeding or should we say abnormal bleeding as a problem?”

Dr. Paul Indman:  “A large percentage of my practice is comprised of women who bleed, they may be referred by friends.  We’ve done a number of studies in which we’re treating bleeding by various methods.  It often amazes me that women who are bleeding have been to three, four, or six doctors, had procedures, had D&C’s, they’re still bleeding, and nobody knows why they’re bleeding.  They’re putting up with it, maybe even going to the emergency room, and their bleeding isn’t diagnosed so I see a lot of that.”

Dr. Roy Jackson:  “In terms of diagnosis of the bleeding, what’s some of the key factors in your approach to how you diagnose the bleeding?”

Dr. Paul Indman:  “Diagnosing abnormal bleeding is not difficult, there’s some basic questions.  First of all, could someone be pregnant because if someone’s pregnant and you don’t know it, that’s a problem, so we’ll almost always do a pregnancy test.  Are they ovulating - many women have a history – I haven’t had a period for three months and then I have a heavy period.  Typically, they’ve not ovulated, that’s fairly simple so we need to evaluate the hormone status.  If it’s not clear from the history, often, I’ll have a woman take a temperature chart just like for fertility, we look at that several months later, and we can easily see without any blood test whether someone’s ovulating.  Also, most importantly, we assess the uterus.  The uterus is bleeding, how do we do that – as a basic first visit test we’ll always look with the vaginal probe ultrasound.  It’s amazing, I’ll see women who’ve been to a number of doctors over a period of years and now it’s a game to see how many seconds it will take to diagnose why they’re bleeding.  Often it’s less than ten seconds with a vaginal probe ultrasound, we take a look and find a fibroid right in the middle of the uterus, this is why they’re bleeding, and it’s been overlooked for years.  They may have been in the operating room twice for D&C’s but nobody’s evaluated what’s going on inside the uterus.”

Dr. Roy Jackson:  “What do you think about those patients that are receiving a D&C or dilatation and curettage as their investigative procedure for the bleeding?”

Dr. Paul Indman:  “The old fashioned - let’s go in the hospital or just do a scrapping has been obsolete for twenty years.  If someone is hemorrhaging, we can often stop the bleeding by vacuuming out the uterus, which takes a few seconds.  We can look and it will help us be sure there’s not cancer in the uterus but a D&C will not see fibroids.  A D&C will not necessarily get out polyps and it’s totally blind so to me the D&C is something long, long overdue to be buried other than an office suction D&C to treat heavy bleeding.”

Dr. Roy Jackson:  “In your experience, what percentage of the uterine cavity is missed when you do a D&C?”

Dr. Paul Indman:  “We have to look at studies because it’s been shown that the D&C and the most complete D&C’s at best will assess 50% of the endometrial cavity but you miss 20%-30% of polyps, submucous myomas, and often you just don’t have an answer.  So I think it’s helpful to use a combination of procedures, one is an ultrasound, which is very helpful, and the vaginal probe can easily be done by the gynecologist in the first visit.  Very honestly, with all due respect to my radiology colleagues, some are good at reading them and some are not.  They can come in with an ultrasound in their hand and we’ll still look because holding this and looking at it in real-time in motion gives me information that I can’t otherwise get.  Looking at a static ultrasound is like looking at a few frames or a movie review and trying to assess the movie.  You need to see this in real-time.  If the endometrial cavity is totally normal on ultrasound and it’s a young woman, I found that the chances of finding anything in the endometrial cavity are very, very low.  We may not do anything else but as we get older, and I’ve looked at this data in over 250 patients and this has been published, as we get into the 30-40 and especially the 50-60 age group, the vast majority of patients have disease within the endometrial cavity.  Often we can get an idea of what it is with the ultrasound and then we can look at it with a hysteroscope, not necessarily in the first visit.”

Dr. Roy Jackson:  “What concerns me most is the fact that a large number of gynecologists are still relying on a D&C as the primary procedure to diagnose abnormal bleeding.  They’re not turning to more innovative techniques such as a vaginal probe, saline infusion sonography, or diagnostic hysteroscopy for that matter.  How do we as opinion leaders or how do you as an opinion leader in the area of endoscopy in women’s healthcare, how are we going to change that to the providers of healthcare around the world and in the United States to make them realize the importance of a better assessment of the uterine cavity in women that are bleeding?”

Dr. Paul Indman:  “That’s an excellent question that I’ve been asking myself for the last 15-20 years.  I think what motivates physicians is patient demand, and I think as long as women lie down and have a blind D&C, they’re going to keep getting blind D&C’s.  Just as if they lie down to have an ovarian cyst removed through a laparotomy, they’ll keep getting that instead of having it removed through the laparoscope.  Now there’s some that do require laparotomy but most can be managed with telescopes so I think women need to be educated.  We’ve tried to work with physicians.  The data is there, it’s clear, there’s not a single article in the literature that supports the use of the blind D&C, not a single one.”

Dr. Roy Jackson:  “So if the data is there and, therefore, the data has been there for several years, we can assume indirectly that we as a group of physicians may have been somewhat ineffectual in delivering the results of that data to the public and to women in general.  Therefore, maybe sources such as the Internet are going to change this as women turn to the Internet for their source of healthcare information.  Do you agree with some of those comments?”

Dr. Paul Indman:  “Absolutely, I think the Internet will help women become informed.  Let me give you an idea, when we were treating cervical disease, precancerous disease of the cervix, I saw a woman who had a baby a few months ago and she had a little baby at home.  Her physician told her that she needed a hysterectomy and I said - yes, a hysterectomy will work but we can take five minutes with my laser and we’ll treat that and the results are just about as good.  So we did that and her physician took my next course in laser surgery.  Until women say - okay, if you can’t look in my uterus in the office and that’s as basic as looking in my ear if I have an earache, I mean nobody would think of scrapping an ear if it hurts, you look in it. So doctor, if you’re a specialist in gynecology and you can’t look in my uterus, I’ll go to a doctor who can.  And there are a lot of us around who can.  Until women do that, they’re going to keep getting what they’ve been getting.”

Dr. Roy Jackson:  “Where are women going to get that information, and how are we going to disseminate that information?”

Dr. Paul Indman:  “I think women are going to have to ask around.  Right now there’s the Internet, and they’re going to have to ask physicians in the community if they do this procedure and if they don’t, could they refer them to someone who will.  Often it takes a lot of research to find someone and find someone who’s skilled in it.”

Dr. Roy Jackson:  “Dr. Indman, I think that draws to a close our interview, and it’s been an absolute pleasure hearing from you on an approach to abnormal bleeding.  Hopefully, we will be able to share this information that you’ve given us today with women who will be able to be more discerning in their choice of healthcare.”

Dr. Paul Indman:  “Thank you so much.”

Dr. Roy Jackson:  “Thank you very much.”