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When is a surgery not like a surgery?

8/7/2015

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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When is a surgery not like a surgery?

Informed Consent - Hysterectomy & Ovary Removal (Oophorectomy)

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