Spring 2006 - Women's Health Experience

Practical strategies inVolume 1 Number 2 Spring 2006A quarterly newsletter for clinicianswww.womenshealthexperience.comIN THIS ISSUEWomen’s Health TodayA magazine connectingwomen to nationalhealthcare experts in adialogue about today'shealth concerns.1 | CHRONIC PELVIC PAIN:It isn't all in her headBy Steven D. McCarus, MD2 | LET'S TALKA message from the founderBy Mickey Karram, MD3 | IN SKILLED HANDS:An overview of minimallyinvasive proceduresInterviews with Andrew Brill, MDand Susan Cera, MDBy Lynn Waltz8 | EASING THE WAY TOMENOPAUSEBy Kristen GeorgiChronic pelvic painIt isn’t all in her headBY STEVEN D. McCARUS, MDChronic pelvic pain poses a significantproblem in women’shealth care in the United Statesfor patients and clinicians, and in overallcosts to the health care system. Anestimated 9 million American women,or nearly 15% of women in theirreproductive years, have chronic pelvicpain (CPP), defined as pelvic pain thatlasts longer than 6 months. 1Three of 4 women who experienceCPP do not recognize the serious implicationsand do not seek consistent medicalmanagement. More than half neverreceive any diagnosis. 1 Instead, they relyon over-the-counter pain medications,jumping from physician to physician orvisiting urgent care centers wheneversymptoms worsen. Only about 10% ofwomen with CPP are under the care ofa physician for this condition.A diagnostic challengeAccurately diagnosing CPP can be apainstaking process of eliminationrequiring patience, diligence, and compassion.There can be numerous explanationsfor pelvic pain. Once anatomic,GI, and genitourinary causes areruled out, there is an 80% chance thatthe patient has pelvic endometriosis. 2Approximately 5.5 million womenin North America have endometriosis,one of the top 3 causes of infertility,which affects 30% to 40% of womenwith endometriosis. 3 The resultant paincan destroy sexual relations in a marriageand lead to depression as womenlose hope for finding a solution. It isalso the leading reason for hysterectomyand the third most likely reason forhospitalization of women during theirchildbearing years. 4continues on page 6Talking to your patients about painPatients who experience chronic pain can assist in arriving at a diagnosis bykeeping careful records and being specific about what they are feeling.Here are some suggestions to help your patients act as partners in health care:❚ Ask patients to bring a written pattern ofsymptoms instead of relying on their ability torecall and talk about them. This is especiallyhelpful for patients who are feeling emotionaland frustrated by the lack of a diagnosis.❚ Have patients prepare monthly symptom calendars,illness progression timelines, andtemperature charts like those used to trackovulation and bring them to your office whenthey come for checkups.❚ Encourage patients to be honest about theirsymptoms and to not feel shy about mentioningpainful intercourse or problems withbowel movements or urination.❚ Establish trust. It may be necessary to ask difficultquestions about domestic violence,physical or sexual abuse, or psychologicalconditions that can be fueled by chronic pain.This newsletter is brought to you through grants from American Medical Systems; Ethicon Endo-Surgery, Inc.;Ethicon Women's Health and Urology; Synova Healthcare; and TAP Pharmaceutical Products, Inc.

In skilledhandsAn overview ofminimally invasiveproceduresINTERVIEWS WITH ANDREW BRILL, MD, ANDSUSAN CERA, MD, CONDUCTED BY LYNN WALTZWith the rapid increase and expansion ofminimally invasive procedures (MIPs) insurgery over the past 2 decades, primarycare clinicians are increasingly called upon to offeradvice and make suitable referrals. Growing consumerawareness and demand for these procedures requirephysicians to guide patients who are in need of surgeryto decide whether an MIP is an appropriate choice,and to make a surgical referral with confidence.In the hands of a skilled surgeon, the benefits ofMIPs have been established in multiple studies andanalyses. 1-3 While outcomes that are equivalent to thoseof open surgical procedures have been shown with MIPs,patients who underwent these procedures were found toexperience reduced pain, better cosmesis, and acceleratedrecovery. Faster recovery time translates into shorterhospital stays, less dependence on narcotic painkillers,and a quicker resumption of normal activities.“The quality of life differences are enormous forthe patients,” says Andrew Brill, MD, Professor andMinimally invasive surgeryWhen performed by experienced surgeons,MIPs are increasingly found to be safe andeffective for many types of intra-abdominal disease,including relatively complex colorectalprocedures.Director of Gynecologic Endoscopy in theDepartment of Obstetrics and Gynecology, Universityof Illinois at Chicago College of Medicine. “Perhapsthe greatest triumph of MIP is accelerating recoveryback to ‘normal humanhood.’ However, the reducedhard costs incurred by shorter hospital stays is somewhatoffset by the longer operating times and use ofdisposable instrumentation during MIPs.”History and applicationThe use of laparoscopy as an alternative to open surgerytook root in gynecology, first as a diagnostic6 Questions your patients might ask1 What will the procedure involve?2 Will you be using minimally invasive techniquesto perform the procedure?3 Are there any potential risks of surgery thatI should be aware of?4 How long will I have to stay in the hospital?5 What can I expect during my recovery?6 How soon after surgery can I return to my joband/or everyday activities?www.womenshealthexperience.comSpring 2006 ❚ Practical Strategies in Women’s Health 3

Advantages of MIPs fordiseases of the colonAs of 2005, numerous case series and severalrandomized, controlled, clinical trialshave compared laparoscopy with open colonresection in patients with a variety of colonconditions, such as Crohn’s disease, diverticulitis,rectal prolapse, ulcerative colitis, andcancer of the colon. (TABLE, PAGE 5)In 2 meta-analyses, outcomes have beencompared in these trials with varyingresults. 1,2 Laparoscopic procedures appear tooffer several short-term advantages includingdecreased blood loss, less pain, shorterduration of postoperative ileus, reducedstress response, less scarring, shorter recoveryas measured by length of hospital stayand return to normal activity, and improvedpulmonary function.Operating time is always shorter for opensurgical procedures. However, operative timefor laparoscopic procedures appears todecrease with increased surgeon experience,and operative time for laparoscopic right colectomyis now approaching that of open rightcolectomy.Long-term results of MIPs versus opencolectomy were studied in the ClinicalOutcomes of Surgical Therapy trial. 3 Additionalrisk for cancer recurrence was evaluated at 48North American institutions in 428 patientswith cancers of the right or left colon. At 3-yearfollow-up, cancer recurrence (combined distant,distant/local, and local) was similar in bothgroups. Patients randomized to laparoscopyhad a recurrence rate of 16%; those randomizedto open surgery had a recurrence rate of 18%.At 3 years, 86% of those in the laparoscopygroup and 85% in the open-surgery group werestill living.REFERENCES1. Schwenk W, Haase O, Neudecker J, et al. Short-term benefits for laparoscopiccolorectal resection. Cochrane Database Syst Rev. 2005; Issue 2.2. Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomesafter laparoscopic resection for colorectal cancer. Br J Surg.2004;91:1111-1124.3. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopicallyassisted and open colectomy for colon cancer. N Engl J Med.2004;350:2050-2059.tool and then for tubal sterilization. Despite its widespread acceptanceby American gynecologists, it remained undifferentiated for anumber of years. During the 1970s and 1980s, pioneering work byEuropean surgeons invigorated interest in the United States, leadingto laparoscopic treatment for virtually all benign gynecologic conditions.Innovative work by French surgeons led to the rapidembrace of laparoscopy by general surgeons for the removal of thegallbladder. On the heels of these developments, the medical instrumentindustry responded with a plethora of innovative devices thatserved to vitally fuel the revolution of laparoscopy across all surgicaldisciplines.Despite early studies showing that the laparoscopic approach togallbladder removal was more dangerous than the laparotomic alternative,through training and education general surgeons were able toerase this difference, and laparoscopic cholecystectomy is now regardedas the standard of practice. The same transformation is expected inother surgical arenas.“Surgical treatment of nearly every disease process has beentried with laparoscopy,” says Susan M. Cera, MD, of theDepartment of Colorectal Surgery at the Cleveland Clinic in Naples,Florida. Dr Cera operates almost exclusively laparoscopically.“Some conditions are more suitable for a minimally invasiveapproach, such as gallbladder removal, gastroesophageal reflux,appendicitis, and benign or noninflammatory colon disorders. Someare more difficult or challenging and must be completed by moreexperienced surgeons.”Risks generally include complications at the trocar sites (accessports) and unintentional vascular and visceral injuries. Drawbacksinclude being restricted to a 2-dimensional view, with its inherentlack of depth perception, and loss of direct tactile feedback for thesurgeon. In some instances, this has led to a hybrid used in a range ofdigestive-tract-related surgical procedures called hand-assistedlaparoscopic surgery (HALS), in which the surgeon’s hand is insertedinto the field. 4 In some cases, this approach may help to prevent theconversion of a modified laparoscopic procedure to an open procedure.Other potential challenges of MIPs include difficulties withlarge specimen removal and the risk of access port site metastasis inthe face of spilled malignancy.The benefits of experienceThe learning curve for MIPs is steep, and outcomes can be linkedto the innate visual-motor skills and operative experience of a particularsurgeon. This significantly contrasts with open surgery,where the learning experience is comparatively accelerated andunencumbered by the intrinsic limitations created by the laparoscopicalternatives.“The absolute two-dimensionality of the video view, coupledwith fixed operative ports, necessitates an entirely new visual-motorprocessing at which some individuals excel and some do poorly,”says Dr Brill. “This is a specific skill set that varies from human tohuman and is very different from open surgery, where there is a normalthree-dimensional reality in which the surgeon can palpate andfeel tissue and the sensory feedback is unaltered.”4 Practical Strategies in Women’s Health ❚ Spring 2006

Meta-analyses and select randomized, controlled trials comparinglaparoscopy with open laparotomy for colorectal diseaseN Operating time (min) Hospital stayStudy Disease state L O L O L OMeta-analysesSchwenk, 2005 1 Colorectal disease 2992/2554 * 8-275 60-188 3.9-10.4 6-12.7Abraham, 2004 2 Colon cancer 1055/1237 † L>O by 32.9% LO by -60 L

Chronic pelvic paincontinued from page 1Historically, the disease has been dubbed “husbanditis”because the complaint of pelvic pain during intercoursewas deemed an excuse to avoid sexual encounters.This bias may still linger today. Because of the difficultyof diagnosing the disorder, in some cases it may be temptingto consider that the pain is “all in the patient’s head.”However, current research shows that with rare exceptions,such as in cases of sexual abuse, trauma, or mentalillness, endometriosis is a real disorder in need of medicalintervention.It is challenging for busy primary care clinicians tocommit the time to properly take a thorough patient historyin order to rule out the many disorders that can presentin the same way as endometriosis. On average, ittakes a woman 9 years to receive a diagnosis ofendometriosis.While symptoms of endometriosis are varied, manypatients complain of dysmenorrhea, dyspareunia, heavy orirregular bleeding, and infertility. A questionnaire distributedby the Endometriosis Association revealed that 100%of respondents experienced pain 1 to 2 days prior to menstruation,and 71% reported pain midcycle.Less common are reports of bowel or bladder symptoms,including painful defecation or urination, lowerback pain, or pain that radiates down one or both legs,particularly during menstrual periods. Endometrioticpain can be either cyclic or noncyclic. It is essential tonote that some women with even advanced endometriosishave no symptoms, and that the size or number ofgrowths is not directly correlated to pain.Although some primary care clinicians may chooseto refer these patients directly to a gynecologist, manydiagnostic eliminations can be completed by the generalpractitioner. First, the clinician should complete a thoroughreview to rule out conditions such as ruptured ovariancyst, ectopic pregnancy, appendicitis, GI disorders,urologic or neurologic conditions, musculoskeletal disorders,psychological issues, and domestic violence.Knowing when to referIf the patient has suffered CPP of at least 3 to 6 months’duration, and has been unresponsive to a trial of nonsteroidalanti-inflammatory drugs (NSAIDs) and/or oralcontraceptives, a diagnosis of endometriosis should besuspected and referral to a gynecologist would beappropriate.Thorough rectal examination and pelvic examinationof the uterus, ovaries, fallopian tubes, and cervix are essential.If possible, the examination should be performed duringearly menses when endometrial lesions are likely to beEndometriosisThe most common locations for endometriotic lesions are theoutside and anterior of the uterus, the roof of the bladder, theperitoneal folds, the cul-de-sac, and the anterior rectum.at their largest and most tender (FIGURE). An axis deviationof the uterus is an anatomic sign that endometriosismay be retracting a ligament, causing the uterus to tilt.During the rectal examination, the physician will testfor focal tenderness at the uterosacral ligaments, cardinalligaments, and rectovaginal septum. Focal tenderness isassociated with a 97% chance that a lesion exists in thearea that will be visible during laparoscopy and a 66%chance that the lesion is related to endometriosis. 5The physician should test for adnexal and uterinetenderness, looking for retroflection of the uterus, limiteduterine mobility, pelvic masses, and uterosacral ligamentsthat may be indurated or nodular. The rectovaginalexamination should focus on uterosacral, cul-de-sac,and septal nodules.Imaging studies can be extremely helpful during theworkup for CPP. Pelvic ultrasound can detect ovarianendometriomas with a high level of sensitivity and specificityand, when performed transrectally, has been usedwith some success to diagnose rectovaginal endometriosis.6,7 Magnetic resonance imaging (MRI) also shows ahigh level of sensitivity. However, neither MRI nor ultrasonographycan detect peritoneal endometrial implants. 8If the ultrasound shows any abnormality, a laparoscopyshould be recommended.6 Practical Strategies in Women’s Health ❚ Spring 2006

Easing the way to menopauseKRISTEN GEORGIThe presentation of a patient for an assessment ofmenopause provides a unique opportunity forpatient education, whether the reasons for the visitarise from the desire to alleviate vasomotor symptoms ora concern about risk factors accompanying themenopause transition.“Early confirmation of menopause is important as itprovides women with a sense of control and allows them tobe proactive about countering the effects of menopause,”says Laura Corio, MD, an obstetrician/ gynecologist at Mt.Sinai Medical Center and author of The Change Before TheChange. “By diagnosing the onset of menopause early, treatmentcan be sought for the relief of stressful symptoms. Anearly and accurate diagnosis can improve long-term healthand offer peace of mind that symptoms, such as moodchanges and feelings of anxiety, are associated withmenopause and not a potential illness.”Regardless of the issues that prompt the visit, assessmentfollows a standard course. 1 A detailed history andphysical examination are conducted, along with laboratorystudies that include baseline serum chemistry and hormonalevaluation. Levels of follicle stimulating hormone (FSH)are the key indicator in determining where the patient liesalong the continuum of declining ovarian function.During a woman’s late 30s, FSH begins to elevate asthe level of inhibin declines. Several studies have demonstratedthat inhibins decrease in reproductive aging andthat the ovaries are the source of inhibin production. 2-4 Onestudy documented the changes in inhibins and theincreased release of FSH following surgical menopause. 5Measuring serum FSH levels is the traditional way todetermine ovarian function. Blood is drawn during the follicularphase of the cycle at 2 or 3 days after the onset ofbleeding in women who are experiencing cyclical or erraticmenstrual bleeding. The FSH levels are considered to beincreased when they exceed 10 to 12 mIU/mL. Thisincrease can be intermittent in perimenopausal women.Menopause is described as FSH levels that are greater than40mIU/mL. 1 Because results of FSH testing are usuallyavailable within 24 hours, a second visit is necessary toimplement a treatment plan.Measurements of urine FSH are closely correlatedwith serum FSH. 6 Testing is now available for office usethat provides results of urine FSH levels within 3 minutes.This rapid response enables a clinician to open a discussionwith a patient about the source of her symptoms and institutean appropriate course of therapy while she is still inthe office. ■R E F E R E NCES1. Cobin RH, Bledsoe MA, Futterweit W, et al. AACE Medical Guidelines for Clinical Practicefor Management of Menopause. Endocr Pract. 1999;354-366.2. Burger HG, Cahir N, Robertson DM, et al. Serum inhibin A and B fall differentially as FSHrises in perimenopausal women. Clin Endocrinol. 1998;48:808-813.3. Danforth DR, Arbogast LK, Mroueh J, et al. Dimeric inhibin: a direct marker of ovarian aging.Fertil Steril.1998;70:119-123.4. Klein NA, Illingworth PJ, Groome NP, et al. Decreased inhibin B secretion is associated withthe monotropic FSH rise in older, ovulatory women: a study of serum and follicular fluid levelsof dimeric inhibin A and B in spontaneous menstrual cycles. J Clin Endocrinol Metab.1996;81:2742-2745.5. Muttukrishna S, Sharma S, Barlow DH, et al. Serum inhibins, estradiol, progesterone andFSH in surgical menopause: a demonstration of ovarian pituitary feedback loop in women.Hum Reprod. 2002;17:2535-2539.6. Marcus M, Grunfeld L, Berkowitz G, et al. Urinary follicle stimulating hormone as a biologicalmarker of ovarian toxicity. Fertil Steril. 1993;59:931-933.8 Practical Strategies in Women’s Health ❚ Spring 2006110 Summit AvenueMontvale, NJ 07645