Alternatives to Hysterectomy Duncan Turner MD, MBBS, FACOG, October 28th 1998 Santa Barbara,California

HYSTERECTOMY 600,000 per year in USA 35% chance by 60 Traditional Surgery 3 days in hospital 6 weeks of recovery Total Cost: $15,000 + loss of productivity

TOPICS Alternatives to Hysterectomy Alternatives to Traditional Hysterectomy Why? New Treatments New Surgeries You Have A Choice

Definitions Hysterectomy Subtotal Hysterectomy Approaches Removal of Uterus, With/Without Ovaries Subtotal Hysterectomy Removal of Uterus Without Cervix, With/Without Ovaries Approaches Abdominal (Laparotomy) Vaginal Endoscopic (Laparoscopic)

The Uterus

Definitions Endoscopy: Looking through a narrow tube Types of Endoscopy Hysteroscopy - into uterus via vagina Laparoscopy - into the abdomen Cystoscopy - into bladder Others

Cost of laparotomy $5,000 - $15,000 3 Days in Hospital Significant Pain 6 Weeks of Recovery

Cost of laparoscopy $4,000 - $15,000 Outpatient or Inpatient 3 Hours to 2 Days in Hospital 3 Days to 3 Weeks Recovery

Cost of hysteroscopy $2000 Outpatient <3 Hours in Surgery Center 1-2 Days of Recovery

The Conditions Abnormal Uterine bleeding Fibroids Endometriosis Prolapse Chronic Pelvic Pain Cancer and Precancerous Conditions

ABNORMAL UTERINE BLEEDING Prolonged, Irregular or Heavy Bleeding 30% of Hysterectomies 200,000 a Year

Causes of A.U.B. Hormonal Irregularity Growths in Uterus Cancer and Precancerous Conditions Bleeding Disorders

Investigation and Treatment Nothing Ultrasound and Biopsy to Rule Out Cancer or Precancerous Conditions Hormonal Therapy D and C Hysteroscopic Therapy Hysterectomy

Hormonal Therapy for A.U.B. Birth Control Pill Adjustment of Current Therapy Other Hormones

D and C for A.U.B. Traditional Treatment Blind Procedure Good for Biopsy No Evidence of Therapeutic Benefit

Hysteroscopic Treatment of A.U.B. Visual Procedure Removal of Growth Good for Biopsy Very Accurate Endometrial Ablation Destruction of Lining Tissue by Laser Electricity Hot Water Balloon

Thermachoice

Thermachoice VS Electrocautery Improvement at 12 months 85% vs 89% Hysterectomies by 12 months 2% = Repeat Ablations by 12 months <1% = Complications 4% vs 6%

Benefits of Thermachoice Effective Simple Safe Short Procedure Local or General Anesthetic 85% Successful

Hysterectomy for A.U.B. Traditional Laparoscopic With or Without Ovaries or Cervix 100% Successful

Fibroids Non-cancerous Growths of Uterine Muscle 35% of Women 30% of Hysterectomies Can Cause: Bleeding Pain Pressure or Nothing

Treatment of Fibroids Nothing Hormonal Therapy Destruction Removal Hysterectomy

Hormonal Therapy for Fibroids Side Effects Temporary Expense Can be Utilized Before Surgery

Destruction of Fibroids Blocking Blood Supply (EMBOLIZATION) SURGERY Laser Electricity Freezing

Removal of Fibroids Individual - Total - Traditional or Endoscopic Hysteroscopic or Laparoscopic Total - Hysterectomy Subtotal Hysterectomy Traditional or Laparoscopic

Endometriosis Endometrial Tissue in Abnormal Places: On Ovaries, Uterus, Bowel Can Cause: Pain Infertility Growths

Treatment of Endometriosis Nothing Hormonal Excision Cutting of Nerve Supply Hysterectomy

Hormonal Therapy for Endometriosis Birth Control Pills Progesterone Danazol Lupron Side Effects Expensive

Excision of Endometriosis Traditional Surgery Laparoscopic Surgery Better Visualization More Precise Surgery Nerve Supply May Be Cut Hysterectomy May Not Be Necessary

PROLAPSE Loss of Support of: Uterus Bladder Vagina Rectum Because of: Childbirth Genetics Chronic Increase in Pressure

PROLAPSE Resulting in: Protrusion of Structures Pain and Pressure Urinary Incontinence Urinary Retention

Non-Surgical Treatment of Prolapse Pessary Kegel Exercises Weights Electrical Stimulation Biofeedback Therapy

Surgical Treatment of Prolapse Vaginal Abdominal Laparoscopic Does not Have To Include HYSTERECTOMY

CHRONIC PELVIC PAIN Debilitating Pain - Chronic No Obvious Cause Pain With Intercourse Pain With Periods

Treatment of Chronic Pain Hormones Pain Killers Diagnostic/Therapeutic Surgery Microlaparoscopy Smaller Instruments Quicker Recovery Traditional Surgery

PRECANCEROUS CONDITIONS of UTERUS Hormonal Therapy Observation Hysterectomy

PRECANCEROUS CONDITIONS of the CERVIX Freezing Conization Office of Out Patient Surgery Center Hysterectomy - Traditional or Laparoscopic

CONCERNS REGARDING MANAGED CARE Underutilization vs Overutilization Diminished Freedom to Choose

SUMMARY Alternatives Exist Treatment Should be Suited to the Individual A Minimally Invasive Approach is Almost Always Available Be Part of the Decision Making Process