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Congressional Investigation

8/31/2015

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We at OB/GYN Reform are demanding a Congressional investigation into the decades-long practice of removing healthy ovaries in women without proven increased risk of breast or ovarian cancer. We believe the government's failure to regulate a multi-billion dollar industry has left room for that industry's judgment to spiral out of control, resulting in serious health crises in women of an age, where health issues are not considered or addressed, who have become a profit center for this specialty. The 740,000 annual elective hysterectomies 242-244 in this country (those not to treat diagnosed cancer, source: AHRQ & CDC) cost an average of $33,130 per surgery according to the AHRQ. That's $24,516,200,000 a year.

Can 40% of a 160 million person population (source: HHS) truly require an elective major surgery? Why is no one asking this question?

Why does removal of healthy ovaries matter? Because, despite the fact that only 2% of all women are able to be diagnosed with a genetic predisposition to breast or ovarian cancer and might benefit from this surgery, the OB/GYN medical specialty removes the ovaries at time of hysterectomy for benign conditions like fibroids or endometriosis a staggering 55% of the time. (This percentage may be higher, but the CDC stopped publishing this data in 2000. We know it is very unlikely to be lower because it has risen from 25% in 1965 to 40% in 1984 to 55% in 1999.)  It is also done in an additional 300,000 women who have benign ovarian cysts, which brings the number to at least 700,000 women a year.

In fact, this year, scientists finally began to ask how helpful this surgery has been in the reduction of BRCA 1/2 breast cancer. The answer? It has not been. (Read more here.)

The ovaries are not, as commonly believed outside of medicine, part of a hysterectomy. Hysterectomy only includes the uterus, and possibly, cervix. The ovaries are part of both the exocrine (ducted, in this case, egg-producing) and the endocrine systems. It's proven that their endocrine function does not stop working at menopause, and many studies published in the American Congress of Obstetricians & Gynecologists' own medical journal detail the fact that this surgery leads to significantly increased risk of significantly premature mortality resulting from diseases including up to 7x risk of heart disease, 2x lung cancer, fracture due to severe osteoporosis, Alzheimer's and other forms of dementia, Parkinson's, and many more. Removing the ovaries does not result in "early menopause"; it results in sick women who die prematurely. The practice makes no sense and must stop immediately.

Under Section 1557 of the Affordable Care Act, women should be protected from disparate treatment in hospitals, the majority of which receive federal funding. Ovaries and testes are both gonads. They have homologous functions in the body's HPG axis. 1,000 healthy sets of ovaries are removed each day "to prevent cancer." Removing testes is the "gold standard" in preventing prostate cancer, which kills twice as many men each year as ovarian cancer kills women. How many preventative testis removals take place each day? Each year? It's never done. Though the mortality rate is double, the surgery is never performed in men without diagnosed cancer who've tried hormone suppressant treatment first.

We must thank Senator Mark Warner, who wrote on Aug. 6 to say, "Thank you for contacting me regarding issues with the professional judgment of OB/GYN doctors. I've taken the liberty of contacting the Food and Drug Administration on your behalf asking that they review your concerns and get back to me with a detailed and appropriate response. As soon as I receive a reply, I will again be in touch with you. To sign up for my newsletter please visit www.warner.senate.gov. Sincerely, MARK R. WARNER United States Senator"

However, we wrote to the FDA also, and they don't think they're the right agency since the issue is unrelated to pharmaceuticals and devices.

We must also thank Virginia Governor Terry McAuliffe for sending the issue to the Virginia health department for a response on August 28, and Congressman Gerry Connolly for writing to Dr. Nancy Lee, head of Women's Health within the Department of Health & Human Services on September 1, 2015.

These are important steps, but the most important is a Congressional hearing. Why? Because there is no possibility that any health advisory group can come back with the opinion that disassembling healthy endocrine systems is ever ok. Because there is no question that the removal of healthy ovaries, which is done a staggering 1,900 times a day, is harmful. The OBGYN specialty has things to answer for. We need access to a forum to share the harm these surgeries have done to millions of women, and to put an end to these types of surgery once and for all.

www.gynreform.com
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Uterine fibroid morcellation: confusing "choice" with bad medicine. ("I don't care if 1 in 10 has sarcoma...")

8/27/2015

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Hysterectomy has been done vaginally since 120 A.D., and through a laparotomy, as with a c-section, since the mid 1800s, centuries before the advent of the morcellator. 92% of hysterectomies are elective surgeries for benign conditions: fibroids, heavy bleeding, endometriosis. Though these conditions are painful without question, none represent conditions we'd risk upstaging cancer to an incurable level for - agreed?

As far as the way the surgery is performed goes, there are no circumstances under which a morcellator, a stick blender-like device used to chop up the uterus so it fits out the holes of a laparoscopic surgery, is required. More women agree to surgery when it is referred to as "minimally-invasive," sure, but the question is whether they would agree to this if they knew it increased their risk of death.

An even better question is why doctors would propose it, given how obvious it is that grinding up potential cancer inside the body can never be preferable to removing it intact. Yet, that's what's been done for a couple of decades now, and that's what continues, even after the well-covered case of Dr. Amy Reed, brought to light through her tireless advocacy and that of her husband, Dr. Hooman Noorchashm, as she fights her upstaged cancer and they continue to work and to raise their 6 children.

Because they pressed the issue, the FDA reworked the ACOG's math. The ACOG had been saying that the risk of a fibroid turning out to be cancer was 1 in 10,000. In fact, the FDA concluded, the risk is 1 in 352. The ACOG hadn't been using the right denominator to arrive at the risk. They'd been using "all women in the U.S." versus "all women who presented for surgery with fibroids."

Even according to the ACOG's own guidelines for when to perform a hysterectomy, this surgery is performed far too often. Other types of surgeons, those who are trained in general surgery (OBGYNs are not), remove illness, not entire organs. In the cases where women's fibroids turned out instead to have been sarcoma (cancer), had the cancer been removed in place ("in situ"), it certainly would not have been upstaged in the manner in which it is when a morcellator is used.

As you're reading these notes, which are directly quoted from the ACOG's May 2015 Annual Meeting, it's helpful to be aware that Dr. Keith Isaacson was a member of the panel that heard women's testimony to the FDA in 2014 about the fact that the women's cancer had been rendered incurable through the use of morcellation. Dr. Isaacson was allowed to remain on the panel despite the fact that he had a known financial conflict, having received money from robotic surgery device makers. You can read about that here.

The original ACOG meeting notes can be found here.

Directly quoted from the ACOG's May 2015 Annual meeting:

"Mathers Lecture to Focus on Power Morcellation Concerns Posted By: ACOG on: May 03, 2015 This year’s John and Marney Mathers Lecture will consider the risks and rewards of power morcellation.

“Morcellation Debate,” coming on the heels of last year’s FDA safety communication about the procedure, takes place at 3:15 pm today in Hall D and features Keith B. Isaacson, director of minimally invasive gynecologic surgery and infertility and Newton-Wellesley Hospital in Boston, and Javier F. Magrina, MD, professor of obstetrics-gynecology at the Mayo Clinic in Arizona. They will debate power morcellation’s benefits, concerns, sequelae, prevention of complications and the use of alternate techniques.

The communication, first released in April 2014 and updated in November, warned against using laparoscopic power morcellators in most patients undergoing hysterectomy or myomectomy for uterine fibroids because of a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, outside the uterus. Contraindications include suspicion of cancer, menopause and small uterus.

The risk of sarcoma in a fibroid exists, and morcellation of that fibroid may spread and upstage the disease, Dr. Isaacson said, but the treatment decision should rest with the patient and her health-care provider.

“We just don’t have enough additional information to say that this is considered bad medicine because there are many advantages to a smaller incision, depending upon the patient’s preferences and her lifestyle and priorities, she may elect to do that,” said Dr. Isaacson, who was on the FDA panel that looked into power morcellation but didn’t work on the final document.

The FDA document lists several contraindications. But for many younger or perimenopausal women, the procedure has great benefits that must be considered.

The FDA and physician statements from ACOG, the AAGL and other organizations that have examined existing data still provide an opportunity for the informed patient to make the final call.

“I don’t care what number you pick. Let’s say the risk of cancer is 1 in 10 instead of 1 in 8,000,” he said. “I still think the patient should be involved in the decision-making process after a discussion of the benefits vs. the risks.”


Dr. Magrina opposes any morcellation that takes place outside an endobag. He will argue that morcellation safety will improve with use of endobags to contain the morcellated material.

“Stopping only power morcellation doesn’t stop the problems that happen with morcellation by other means, such as using a regular cold knife if what you’re morcellating is exposed to the intraperitoneal cavity,” he said.

Dr. Magrina said that the FDA missed an opportunity in its safety communication by not addressing the use of endobags. More companies are working with contained morcellation concepts that will improve patient safety.

“I’m actually con and pro depending on how you do it — contained or uncontained,” he said. “The point that I’m making has never been discussed at the FDA level.”

While concerns about spreading and upstaging cancer have grabbed most of the attention, Dr. Magrina said that more people develop benign conditions such as endometriosis and peritoneal leiomyomatosis that spread into the peritoneal cavity during morcellation done without an endobag.

“The problem is not only with cancer,” he said. “And it makes no difference whether the morcellation is by knife or power morcellator.”


In this 2014 video, you can hear the doctors explain that they would all perform morcellation.  "The current situation with morcellation has not changed my practice in any way."

So, what are these OBGYNs saying about endobags to contain the pieces and what are they saying about screening beforehand?

Dr. Reed was carefully screened before her surgery.

Any use of an endobag is an experiment at the patient's own risk, designed only to allow OBGYNs to keep using unsafe devices.

According to the ACOG's own May 2014 Morcellation special report, endobags can tear or block the surgeons view: "Use of a Bag During Morcellation in Gynecologic SurgerySome investigators have suggested that the use of an intra-peritoneal bag during manual or power morcellation may be helpful in reducing intraperitoneal tissue dissemination (8, 30). However, power morcellation performed within a bag is not well studied and has several limitations that potentially increase the risk of the procedure. For example, currently available bags were not designed specifically for use in conjunction with power morcellation. The bags often have size limitations and have not been adequately constructed to prevent tearing by the morcellator. Further, the use of bags limits simultaneous visualization of the tissue being morcellated and the surrounding tissue that must be protected from the sharp morcellator blade."

The third doctor in the video says that if a patient is at "low risk" of cancer, he would "absolutely" use a morcellator. Is that good enough for you? In Boston, hospitals disagree as to policy.

Now imagine if, instead of figuring out better ways of dealing with uterine sarcoma, surgeons were sitting around constructing studies about how much it would cost not in lives, but in money, not to keep doing it? At Northwestern, that's exactly what they did. Is that how you imagine residents and surgeons spending their time?

"Conclusions:
Eliminating morcellation hysterectomy as a treatment for myomas is not cost-effective under a wide variety of probability and cost assumptions. Performing laparotomy for all patients who might otherwise be candidates for morcellation hysterectomy is a costly policy from a societal perspective."

This isn't the first study of its kind, either. The device manufacturer, Ethicon, sponsored this one in 2011 before the doctors broke their story.

Some OBGYN device advocates think it's ok to argue that we can't let go of technology. Though hospitals have invested heavily in these robots, that's not an excuse to keep using them if they're unsafe.

In terms of policy, who makes policy if not the FDA? Their conclusion was to put a warning on the device, but they chose not to ban it.

What about the ACOG? The ACOG's advice to its 58,000 OBGYN members was to continue to use the device, but, as usual, to put the onus back on patients. Their Committee Opinion in May 2014 was to inform patients of risk and to create a national registry of women made ill by the device. Does that make sense to you, as a patient?

Once a physician suggests performing a surgery a certain way, doesn't that bias a patient even if only by making the patient consider that option? Would a patient imagine that something being offered could take something bad and make it worse?

So, again, Dr. Keith Isaacson from Newton-Wellesley Hospital, who "doesn't care if 1 in 10 fibroids is sarcoma," is in favor of morcellation.

As with study results, it's important to follow the money:
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Dr. Javier Magrina of the Mayo Clinic was less enthusiastic. He'll do the surgery, but only using an endobag. He was also paid less by morcellation manufacturers.

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Read more at Drs. Reed and Noorchashm's page, here.
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SSRIs During Pregnancy

8/17/2015

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It appears that the trending press release, er, news story this week concerns the use of SSRI anti-depressants in pregnant women. The article, barely rewritten by health journalists at all the leading papers, says some risks are increased, others decreased.
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First question, always, when reading about a "new study" is, who paid for this? This one is based on an NIH and a Finnish grant, so the question of big pharma influence is a bit opaque, but because this one has been released in all the major publications at the same time, see picture at left, that's a good tip-off that pharma has a hand in there somewhere. Normally-financed studies that aren't reporting a major breakthrough don't get this kind of wide release.
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The headline in the ACOG's Facebook post says, "ACOG recommends women and their health care providers work together..." This is something I have only seen the ACOG do. They suggest something to patients that may, in fact, not be beneficial at all, but if their suggestion of it to patients increases patients' likelihood to bring it up with their OBGYNs, well, that's just their choice. It's not readily obvious, but the ACOG is actually using the language they learned when talking about pro-choice issues.

How many of us will read past that headline? According to a 2014 survey by the American Press Institute, only 4 in 10 of us will click through and read the article. http://www.americanpressinstitute.org/publications/reports/survey-research/rational-attentive-news-consumer/
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So, what would the ACOG's readership miss if they're among the 59% who don't click on this article? Let's join the 41% and find out.

The article, itself, is hard to get to. It's not the link within the copy above the picture. You have to click on the copy under the photo to get to it. Here's the study.

“Our findings provide evidence that taking these antidepressants is associated with a lower risk of preterm birth and Caesarean section and further confirm the results from previous research of a higher risk for several neonatal problems,” noted Brown. “Given these divergent findings, the decision whether to prescribe these medications during pregnancy should be individualized to the mother’s medical and psychiatric history.”

Well, no. This is only true if this study were all the data available to us, but that's far from the case.
Instead, it looks like the vast majority of data about women who take SSRIs indicates that they are increasing the risk of their babies being born with birth defects. I don't know too many pregnant women who would be comfortable with that risk.

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In fact, babies are born addicted to SSRIs, and with a host of birth defects. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/content/tags/breastfeeding/use-selective-serotonin-reuptake-inhibitors-during-pre?page=full

The study results are really very negative. "...women who took an SSRI during the second or third month of pregnancy had nearly twice the risk of having children with congenital malformations as women who took no SSRI during pregnancy" http://www.bmj.com/content/333/7573/824.5

In Finland, the study indicates that the percentage of pregnant women taking an SSRI is 4%. In the US? 10%.

Are alternatives are tried first? Hormonal fluctuations can lead to depression, but is there a better, safer answer than SSRIs? Yes, of course. Even altering diet can have a beneficial effect. Wouldn't that be a better place to start? These are, after all, steroid hormones made by the ovaries that we're talking about, and the ovaries do link to the brain (the hypothalamus and pituitary) via the HPG axis. Can those steroid hormone levels be influenced by diet? Yes.
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So, what about the information the ACOG links to on its own site through that little link in the copy above the picture?
At the ACOG's own site, linked to from the article, we learn:

1) The tiny print along the top indicates that the content on the page is not about the study, but an advertisement. See the tiny print at the top, there? That's pretty important.

2) There's no indication of who paid for the ad.

That doesn't stop people from taking it all at face value.
But, wait, why is the ACOG advertising on its site at all? Isn't this a professional organization's site with unbiased information for patients and medical professionals? Nope. Far from it. Though I can't find any other physician organizations selling themselves in this way on their site, the ACOG has all kinds of ways you can pay to play.

If I click on that little word "Advertisement" at the top of the Depression ad page, I'm brought here: http://www.acog.org/About_ACOG/Advertising.aspx
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And if I click on the first link, Annual Meeting, and then Rate Card.pdf, I'm brought here. http://www.acog.org/-/media/Departments/Annual-Clinical-Meeting/acog2015ratecard.pdf?la=en
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Holy crap. Even I am shocked.
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That's all I have for today because I am speechless.
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Menopause: 8 Things You Didn't Know - and one is: It's Wonderful

8/16/2015

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Would you be surprised if you found out that you had no idea what menopause is? It sounds like a boring topic, and you suspect you already know, but what if you don't?

I'll survey you at the end to see if this came as news to you.

Meno: Bleeding
Pause: End

That's all that word means. Let's be very, very clear about this, because it leads to some uninformed and crucially poor choices on our part as women. It does NOT mean that your ovaries shrivel up and die.

Not an illness

The idea that menopause is an illness started in the 1940s when Wyeth Pharma, now part of Pfizer, started selling pills made from pregnant horse pee (yes, Premarin/PremPro really is derived from horse pee from horses kept in HORRIBLE conditions) to women for menopausal symptoms.

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1950s Premarin ads
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Nice, huh?

Menopause can suck, so if you want to use drugs, go for it. Just not Premarin or PremPro, please. Besides the inhumane conditions the horses are kept in, the drugs are also bad for your liver because you take them orally. PremPro is linked to breast cancer, and both are linked to stroke. Doctors who say they're not risky, or that the risks have been misconstrued because the WHI study was flawed, either do not understand it or are paid to prescribe them. It's another story, and I'll cover that another day. There are so many other, less risky choices. Whatever you might choose to take - know the risks. They all carry risks.

But, bottom line: menopause is not an illness. It's just the natural course of things for every woman. By definition, that means it's the norm, not something that requires medication.

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Changing of the guard
Some women have shared with me that their OBGYNs told them that their ovaries shrivel up to useless raisins that they may as well just remove. I won't use the harsh words I want to about that because this is about facts, not editorializing, so here are facts:

1. Menopause usually takes about 4-5 years and ends around age 51 for most women.

2. The hormones produced by the ovaries (no, not just estrogen, but estrogen, progesterone, testosterone, androstenedione, DHEA, and the proteins activin and inhibin) fluctuate. In some cases they fluctuate wildly, so some of us have more severe symptoms, like hot flashes and mood changes, than others.

3. When our endocrine system's chemistry is out of whack, it naturally affects the whole system. That system includes chemistry that is linked to depression, insomnia, anxiety, and ability to deal with stress - these chemicals are norepinephrine, dopamine, serotonin, and oxytocin. Unless you have things going on in your life - divorce, loss of a loved one, unemployment - that can explain your depression as psychological, understanding the effect of changing hormones on your body is essential to ensuring that you don't think it's "you" when it's not.


These are BIOCHEMICAL reactions to the fact that your ovarian hormone levels are in flux as the ovaries are changing their function. It's a SYSTEM that works together, and big changes lead to big ripples.

4. Understanding your endocrine system at even the most basic level will help you to think about your body differently. It's not new age or 'one theory about the body' - it's hard science that makes the interconnectedness of things much clearer.

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5. Testes and ovaries are both called gonads in medicine, and serve the two functions, shown above on the right. Women: ovulating, men: making sperm, and both: creating steroid hormones.

6. As with post-partum depression, rather than checking hormone levels and balancing them, many doctors instead put women on SSRI anti-depressants.

(If you look at my link, above, imagine risking cardiac birth defects before trying to balance ovarian hormone levels?? See the tiny print at the top of the ACOG's page on that link that says that's an ad? What business do they have serving up ads for things linked to birth defects on that site?)

7. Women are already taking just a buttload of anti-depressants: According to the Centers for Disease Control & Prevention, U.S. women between the ages of 45 and 64 are on anti-depressants at a rate twice the national average.
SSRI anti-depressants (SSRI = selective serotonin reuptake inhibitors, changing the way your brain handles one of those chemicals), like Prozac, may have their place when people are severely depressed, but it's my opinion that they're a life raft, not a boat. (So much for not editorializing.)

These drugs can mask the problem by flattening or numbing us out, and in many cases make women feel like everything has been done that could be, so if they're not feeling better, it's up to them to work it out.

I compare this to putting so many boys on ADD medication - flattening out the spikes in mood in both genders at either end of the age spectrum. Those moods may lead to problems in social settings or in terms of how we feel about ourselves, but is one blanket medication the right answer? Not if it doesn't get at the underlying cause. Not if it's just a pat on the head or done to make you easier for others to be around. That's not your job. When you're crashing, you put the oxygen mask on yourself before you try to help others. Your job is to get yourself well, not to hide your discomfort.

Bottom line? In many cases, especially at times when hormones are in flux, it's not you, it's chemistry.

8. Whether the World Health Organization chooses to recognize it or not, men absolutely do experience an equivalent, andropause, as they age. Their hormone levels, including testosterone, do decline, but that change doesn't result in the same side effects, so it doesn't receive the same attention.

If the same chemical changes were taking place in men, they'd be feeling and acting the same way we women do, so do NOT beat yourself up. DO advocate for yourself. We've tolerated cycling monthly hormones in order to produce ALL the world's people - we deserve better than the use of the pejorative "hormonal." And we do not deserve to be treated as though everything we experience is psychological or psychosomatic when it's quite clear that it's very often biochemistry.

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8. But I promised you that something about this was wonderful. I'm going to deliver on that promise now. When menopause is done, something has happened that is pretty damned magical. It's one of life's absolutely beautiful and miraculous changes - no exaggeration.


The ovaries do shrink down when women get to about age 50, but not to turn into useless raisins. That's NOT who we are once we're done being able to reproduce. Turns out that there's more to us than just making babies. We are meant to live long, full lives.
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The ovaries' stroma begins to emit a different mix of hormones. We had always made androgens - testosterone, androstenedione, and their precursor, DHEA. Now, we make more than we did before, and in an amount that increases throughout our 60s and levels off in our 70s.

Yes, this brings many of us those awesome chin hairs. It's true. That is NOT damned magical, but along with this, this change in what our ovaries produce makes muscle mass, balanced brain chemistry, our bones stronger, and our hearts stronger - all kinds of things...and that is why I think of this as the changing of the guard. We don't need the outside for all the egg producing tasks, but we do need the inside for the hormones it makes, so that becomes the focus.

Our bodies are so smart! Our ovaries are just adapting to our changing needs. Isn't that kind of amazing? Why isn't it taught? I don't know... Instead, we're taught they're part of the "reproductive system," and while that's true, it's misleading. So, yes, menopause symptoms can suck, but it's the price we pay to allow our ovaries to turn into machines that protect our health, mood, and strength as we age.

    So...

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When is a surgery not like a surgery?

8/7/2015

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A: When it is inherently un-medical.

When is that?

When the approach to surgery is destructive, not conservative, meaning more is taken away from the body than necessary. During typical surgery, only the amount necessary to provide a good outcome is removed from a person's body. When I had a tumor on my kidney, they didn't just yank it out. They took 5% of my right kidney. That's surgery for you.

The current problem with hysterectomy is that it is often done in lieu of more appropriate procedures. Even when women are canny enough to ask for a myomectomy to remove only their fibroids, surgeons often convince them that they are a "special case," and that it's just too hard to take only the fibroids.

Same thing with endometriosis. Of course, this is ridiculous. Endometriosis (where the lining of the uterus grows outside instead of inside, which is quite painful) grows on the lining of the abdomen, the bladder....those organs are not removed when surgery is done. Why would the uterus be removed? Or the ovaries, if it's grown on them?

Because of a really weird, destructive attitude toward OB/GYN patients and surgical training accreditation hours that train surgeons to remove the uterus. 70 hysterectomies are required to be certified. 0 myomectomies. That sends gynecological surgeons a BAD message.

It's this kind of thinking that's led to 365,000 healthy pairs of ovaries being removed a year, too. If OB/GYN surgeons looked at patients differently, this tragedy would never have taken place.

#1000womenaday overy.org



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Informed Consent - Hysterectomy & Ovary Removal (Oophorectomy)

8/4/2015

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When the issue I advocate for - a ban on preventative ovary removal in women who aren't at diagnosed or demonstrated high risk of breast or ovarian cancer - or hysterectomy come up, doctors and others who haven't had the surgeries invariably say,

"So, the issue is fully-informed consent."


It's not. Because people trust their doctors, the moment a surgeon suggests hysterectomy, or adding ovary removal to hysterectomy, the patients they're talking to are no longer able to make an informed decision. Why? The very act of suggesting the surgery biases the patient. If a surgery is harmful, and not at all beneficial, a surgeon would not suggest it, right? Well, that's not the case with the majority of ovary removals. So, when an OBGYN surgeon tries to put the responsibility back on the patient for agreeing to something the surgeon suggested, the nature of their relationship renders that disingenuous. Just as a surgeon would never offer to remove a patient's healthy thyroid gland during rotator cuff surgery in order to avoid thyroid cancer later, the ovaries shouldn't be removed just because surgeons are nearby operating on the uterus.

STILL. If you want to know what fully-informed consent would have to look like to be meaningful, here it is:

In the case of hysterectomy, here you go:

You can have this surgery three ways:
1) vaginally
2) abdominally - large incision in the abdomen
3) robotically - using a morcellator to remove the cut up parts through small holes in the abdomen

In all three cases, we surgeons will often try to talk you into unrelated surgeries: removing your cervix and ovaries.

We will talk to you about avoiding cancer later in life, but not provide actual statistics (ovarian cancer, for example: 1.3% of all women are at risk in the U.S.) or genetic testing to determine your personal risk.

The surgery? We will need to cut your uterus away from your bladder and bowel. They are connected. We will need to cut the uterus down from the ligaments that suspend it.

What takes its place in the hole left there? Your bowel. We can't determine what shape that will take, but it falls in there when the uterus is gone and we just hope for the best.

You will develop a crease in your sides and lose a bit of height, sometimes an inch or so. It sounds odd, but it's true. The uterus provides part of the structure in there. If we decide to suspend what remains, your vaginal vault, hopefully you will not have prolapse, but you might. If so, that will require another surgery.

A lot of people can no longer have a normal bowel movement because their pelvic floor or bowel is damaged, but we count on them not to talk about that in polite company. Some women also become incontinent because of the effect on their bladders and pelvic floor.

At least 15% of the time, your ovaries will fail. No, having no ovaries is NOT the same as menopause. More about that in a minute.

If we do this surgery robotically, with a morcellator, your risk of us upstaging cancer that we thought was just a fibroid is 1 in 352. (We used to say it was 1 in 10,000 - which we thought was acceptable - until the FDA corrected our math.) We did hysterectomies that way about 60,000 - 100,000 a year until they made us slow down.

We do about 715,000 hysterectomies in the U.S. a year.


Or:

We can just scrape off the endometriosis, or remove the fibroids through a process called myomectomy
and leave your healthy body parts like all other surgeons do during a surgery. Myomectomy? We only do about 40,000 of those a year.

Your ovaries? Sure. We will remove them, too. No problem. Here's your informed consent:

When they're gone, your overall mortality over the next 35 years will be 67% greater than if you didn't do it. No sex drive will be the first thing you notice. Then the depression. Then the insomnia. Then the weight gain. Throw in some anxiety.

You'll need to be on expensive medicine (estrogen) for the next 5 years. Really, since you'll now make 45% less testosterone than a normally-menopausal woman makes, you still need hormone medication, it's just not considered safe after that long. Your choice will be to accept that risk to feel closer to healthy or to feel poorly.

Also, the medication only replaces one of at least seven chemicals (hormones and cytokine proteins) your ovaries made, but they're gone now, so we're just doing our best here...

After the ovaries are gone, you will be certain to be at increased risk of  - Alzheimer's, Parkinson's, dementia, memory, cognition problems, glaucoma, heart disease, depression from the biochemical changes in your endocrine system, so you are more likely to suffer from a terrible disease before you die prematurely.

But sure, many of us will encourage you to take them out. We remove healthy ovaries 365,000 times a year at the time of hysterectomy, and possibly up to another 300,000 times a year when women have operable ovarian cysts.

Or:

We can just remove the cyst itself, like other surgeons do, or in the case of hysterectomy, not remove your ovaries just because we are nearby, and you can have the hormones they produce for the rest of your life, well past menopause, and not compromise your health. Your call.


THAT is informed consent. Some questions should simply not be asked.

www.gynreform.com/citations.html 


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