endometriosis, hysterectomy, OB GYN, Uncategorized

Not Everyone with Endometriosis Should Get a Hysterectomy Like Lena Dunham

The internet is aflame with people suffering from endometriosis wondering if they should be getting a hysterectomy after Lena Dunham revealed she had one at the age of 31.

Best wishes to Lena Dunham in her future health, it sounds like she has been through so much the past few years. I would not presume to know all the details behind her medical condition. She is quoted regarding her recent health battles here , and she has an article coming out in Vogue in March detailing her personal experience.

However, it is important for people to understand that not everyone with endometriosis or chronic pelvic pain should get a hysterectomy- in fact, the overwhelming majority should not. The truth of the matter is that it’s the ovaries that cause the problem with endometriosis and therefore you cannot be cured from endometriosis if the ovaries remain. A hysterectomy means simply taking out the uterus (typically with cervix too) but leaving the ovaries behind.

The simple fact is that endometriosis pain is tied to the estrogen provided by the ovaries. Therefore, even if the uterus is removed, the pain may continue if even just one ovary remains.

So, why don’t we just take out the ovaries too?

It’s complicated. You need the ovaries for more than just the obvious ability to produce an egg to allow for the ability to get pregnant and conceive a child. While the sole purpose of the uterus is for childbearing, the ovaries involve much, much more.

The estrogen produced by ovaries is protective to our bones and cardiovascular health as well, amongst many other things. Taking out the ovaries prematurely would cause an instant menopause in a woman in her 20’s or 30’s which has serious ramifications on long term health.

This is the reason why many physicians are reluctant to do such a major surgery as hysterectomy and/or removing of the ovaries in a woman in her 30’s. Your reproductive choices are absolutely your right. However, it is important to understand that simply removing a uterus will not cure a patient of endometriosis. Knowing this fact, it makes little sense to go through a major surgery to remove an organ which is not directly causing endometriosis.

Endometriosis implants can be found throughout the abdominal cavity. During surgical procedures, I’ve personally seen implants on bowel (intestines), pelvic sidewall, bladder, and even in the skin of the abdominal wall. Therefore, you can see how taking out the uterus may relive some pain, but it is not a cure.

Is there ever a time for removing both the uterus and ovaries in someone at a young age with debilitating pain from endometriosis? The answer is yes, rarely.

This is only after a multitude of other less risky and effective measures have been attempted and failed. It is exceedingly rare that a patient would not benefit from other methods of suppressing estrogen for short periods of time. Therefore, the case where a hysterectomy is needed for endometriosis alone is very rare and should never be a first treatment for endometriosis.

A hysterectomy alone may be considered for other reasons such as excessive bleeding not responding to less invasive treatments, large fibroids, uterine abnormalities, and even cancer. We may never know all the reasons behind Lena Dunham’s decision to have her uterus removed- that is between her and her doctor. However, given the fact the ovaries remain tells me it’s about more than endometriosis.

So, to any patients suffering with endometriosis, please know there is always more to t story and discuss all options with your doctor.

This article should not be taken as medical advice, but each patient should explore options with their own physician regarding treatment options for this painful and sometimes debilitating condition called endometriosis (there are many!).

 

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OB GYN, Parenting

8 Things Your Doctor Wants You to Know About Your Miscarriage

Miscarriage is one of the hardest (and most common) challenges women face. If you have not had a miscarriage yourself, you most certainly have a best friend, sister, or daughter who has. There are many myths floating around the internet, however there are a few important truths everyone should know about miscarriage.

1. You aren’t alone. Miscarriage is common and occurs more frequently than you might think. Often, a miscarriage occurs before a woman even knows she is pregnant. If you include these cases in statistics, up to 50% all pregnancies end in miscarriage. However, the number is closer to 15-20% for recognized pregnancies.

2.  Most miscarriages occur in the first trimester, but they can also happen later too. Luckily this is rare after 13 weeks. It is often more traumatic emotionally and physically in later trimesters. Women who experience late second trimester or 3rd trimester fetal losses (the term used when occurs later in pregnancy) will have physiologic responses from their bodies that think they just had a child. Their breasts may engorge with milk, a painful reminder of what was lost.

3.  It’s not your fault.

4.  It’s not your fault. Bears repeating. Also, its okay to grieve an early pregnancy loss. You likely had hopes, expectations, and dreams already wrapped up around this pregnancy. It may take a while to recover.

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5. Up to 80% of pregnancy tissue from first trimester miscarriage is chromosomally abnormal- meaning that there was a genetic problem with the developing baby.

6. There has been debate over the amount of time you should wait after a miscarriage before trying again, but newer research shows that in most cases you can start trying again with the next cycle. Although, 3 months is a commonly quoted and may give you more time to heal physically and emotionally.

7. The fact that you got pregnant is a good sign that you will be able to get pregnant again.

8. You have 3 options when a miscarriage occurs- make sure you discuss all 3 with your doctor to determine the best course of option for you.

Expectant: this means waiting for your body to complete the miscarriage on its own. It may include moments of severe cramping and bleeding. The timing can be unpredictable, but you may be able to avoid a procedure if this is important to you. However, if the bleeding is severe you may still need medical intervention.

Medication: If you haven’t started bleeding yet, a pill can help your body to start the process once miscarriage is confirmed. This gives you a measure of control over when the process will start. It is successful in most cases, but sometimes you may still ultimately need a procedure if everything does not pass on its own.

Surgical: The procedure is called Dilation and Curettage “D & C”. This is a minor procedure to remove the contents of the uterus (failed pregnancy). Some women prefer this option as bleeding and cramping time is limited after the procedure. The process is over sooner and may cause less interruption for women who may need to be back at work, or have other children at home dependent on their care. There are risks with any surgical procedure, and although minor, must also be considered.

Since many people wait to tell family and friends about a new pregnancy until safely out of the first trimester, it can be a lonely experience if you go through a miscarriage without the support of your loved ones. In recent years, women have become more vocal about miscarriage and this has helped women feel less alone when it occurs. Don’t be afraid to reach out to others during this time. Be sure to discuss any concerns with your doctor and don’t lose hope about what the future may bring.

 

 

OB GYN, physician, Physician Training, work hours

The Wrist Band Challenge: A Safe “Strike” Against Unsafe Working Conditions That Can Harm Patients (and Physicians)

My shift had finally ended. As a second- year resident, I was driving home after 30 hours awake straight. During this time, I delivered several babies, performed a cesarean section or two, a couple of circumcisions, rounded on many patients the following morning, triaged new patients, and taught medical students. Never during that 30 hours was a 5- minute nap possible; clinical load would not permit this.

I couldn’t wait to get home at the end of the shift as I was completely exhausted. So, I buckled up and prepared to drive the 20 minutes home on interstate 95 so that I could finally get some rest before my next shift started less than 24 hours later.

I could feel my eyes starting to droop as I was driving. I turned the radio up loud, drank a big gulp of my hot coffee, and rolled down the window. I had done this many times previously after these long shifts and had figured out all the tricks to make it home safely, or so I thought.

I must have not been able to fight off my increasingly heavy eyelids, because I woke up suddenly to the jarring bumps on the side of the road- intelligently placed to wake up drivers such as myself who may be drifting out of the lane. This startled me, and I turned the wheel hard to get back on the road. However, I overcompensated, confused, and dazed from no sleep, and spun around 180 degrees so that I was facing the opposite direction of traffic on the interstate. I slammed into the wall of an overpass and my car came to a sudden and jolting stand still.

 

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My heart was racing, my hands were shaking, and I tried to get my bearings to understand if I hit someone, or if I was still in danger and needed to get out of my car. I quickly got out, unbelievably unharmed (and miraculously no one else either) and called my husband with trembling hands. I was only 5 minutes from home.

A man with his wife and children in the car quickly pulled over to see if I was ok. He could see how shaken I was an offered to sit with me until the police and my husband could make it.

My car was totaled. I walked away fine, without a scratch, but with a new understanding of the inhumane conditions expected of physicians.

Ultimately, I believe patients have the right to know if they are receiving care in optimal situations that promote safety and decrease preventable medical errors. Physicians have an incredibly strong, important and powerful ally in our quest for humane working conditions- our patients.

We’ll call it the wristband challenge. It works like this:
Physicians take call for any varying amounts of time. I propose physicians start wearing rubber wristbands (like those commonly seen promoting the “LIVE STRONG” campaign) signifying to their patients how many hours straight they have been responsible for patient care without a break

 

Green: 0-24 hours
Yellow: 24-30 hours 
Red: 30+ hours

                                                                                                                      
Think this could never work, or that nobody would do this? Guess what, its already been done. Please see how the South African Medical Association came to bring this project to fruition in their country. https://www.samedical.org/campaign “The SAMA campaign makes it easier to identify doctors who have worked longer hours. It is also a visible reminder that South Africa should employ more doctors to manage their workload”.

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This is a way to promote transparency with patients. They should have a right to know if their obstetrician is on their 30th hour awake and about to deliver their first born child. Or if their physician is admitting their father with congestive heart failure and writing detailed medication orders without sleep for over 24 hours.

Physicians want to have humane working conditions that promote patient safety, but it is complicated for a profession such as ours. We have been told it is illegal to form a union. We are threatened that going on strike puts patients at risk. We can’t just all walk out of an ER at the same time, and therefore we don’t, out of respect for our patients and concern for their well-being. However, this puts us in a trap of beneficence where “do no harm” compels us to continue working in unsafe conditions not only for our patients but for ourselves.

A physician can wear their wristband and not have to fear speaking out or arguing with an employer or worry about being labeled a “trouble maker”. If the bands become standard, hospitals who are employing safe practices can use this as a bragging tool that their physicians are well rested and rightfully claim to be advocates for their patients. It is a silent tool of protest for physicians who will continue working without going on physical strike and allow our patients to do the fighting. In the end, it is the collective voices of our patients that matters most and will get the most promise for change to a dysfunctional system.

As a patient you may ask, “well, why don’t you just not schedule yourself for more than 24 hours on call”? If you are a physician in private practice you can. However, the trajectory of medicine now has more physicians employed through a hospital or HMO. The loss of autonomy in these positions does not allow a practicing physician to dictate the amount of time on call thought to be “reasonable” or “safe”. This is especially true for resident physicians and medical students who are bound by their teaching programs rules. Importantly, the number of residency spots has not sufficiently increased each year to allow for enough doctors to fill in the patient needs that continue to increase in number.

Up until now, no hospital or CEO of an organization wants their patients to know how long their doctors have been working straight. It isn’t posted on websites like C-section rates, repeat hospitalization rates, or complication rates. The government isn’t mandating reporting this statistic that directly impacts the safety of patients AND physicians. Perhaps if the public knew and could see first-hand, in real time, the types of hours the doctors caring for their family members were working, they would demand change.

It would no longer be an abstract concept. I don’t blame current residency programs- they are simply trying to meet patient needs with the limited number of physicians employed to fulfill this demand. This would mean increasing the number of residency positions so that we have enough doctors to provide required care. This in turns means there needs to be increased funding for residency positions from the government.

we can seek meaningful change in our profession without going on “strike”. Patients will see wristbands turn from green to orange, and ultimately red. Patients will begin to speak up. Not only out of concern for themselves, but out of care for their physicians.

We remain a team, with health and healing at the core of our mission. With enough help from our patients I do believe we can see a change in the culture of medicine. I believe this should start with our teaching institutions and residency programs that are treating our most vulnerable of patients.

hospital, OB GYN, physician

Working the Holidays: The Invisible Heroes of Healthcare

No one wants to be sick around the holidays, or go into labor during Christmas Eve Service.  We are constantly reminded that we have no control over these things as emergencies arise 365 days a year and thankfully, there is always a place to seek help and someone who is ready to be of assistance.

The holidays are what remind us of what is important in life.  They are a time for gathering with family and friends when the otherwise hurried pace of life doesn’t usually leave time for a home cooked meal with Mom, chatting with cousins, or playing in the snow with kids.

Unfortunately, some people have to miss these precious moments- their jobs require it.

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If you walk through a hospital during Christmas, you will notice it to be eerily quiet.  Only patients with true emergencies will be there, and health care workers will be ready.

You will see a phlebotomist with a Santa hat on striking up a conversation with a patient while skillfully drawing their blood.  You will see a nurse comforting a woman in labor and a surgeon closing the incision from an appendectomy.  You will see a cafeteria worker flipping burgers and humming a song while he works, providing the sustenance to keep the rest of the team going through their 12-24 hour holiday shifts.

They are all happy to have their jobs, but they are missing their families immensely during this time.  Few professions require the dedication to work during a time when everyone else is tending to the people that make their lives meaningful.

Alternatively, some health care workers may have volunteered to work.  Perhaps the holidays are a particularly difficult time as they are acutely reminded of the loss of a loved one and the memories forged on these holidays in the past.  Working may provide a necessary and welcome distraction.

Regardless of the reason these people are working over the holiday, they are providing a desperately needed service- a service to others at the expense of their own families.  These actions are what remind us all of the need to take care of each other.

Thank you to all of the janitorial staff, medical assistants, nurses, phlebotomists, ultrasound techs, and doctors (to name just a few) who keep America’s hospitals running and care for our patients over the holidays.

Merry Christmas and Happy Holidays!

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