MARY WAGNER: Welcome to our webcast. I'm Mary Wagner. Today we have four of the leading gynecologists and experts on hysteroscopy and abnormal uterine bleeding.
Dr. Linda Bradley, Director of Hysteroscopic Services at the Cleveland Clinic; Dr. Steven Cohen, Director of the Center for Women's Minimal Access Surgery at Columbia University; Dr. Keith Isaacson, Director of Reproductive Endocrinology and Infertility at Massachusetts General Hospital and Harvard Medical School, and Dr. Grace Janik, Associate Clinical Professor at the Medical College of Wisconsin and Director of Reproductive Endocrinology at St. Mary's Hospital in Milwaukee.
So what are some of the questions that patients need to ask about hysteroscopy?
KEITH ISAACSON, MD: Well, first of all, patients need to again be aware that hysteroscopy is a valuable tool for making the diagnosis of the cause of their abnormal uterine bleeding. And then patients should understand the procedure itself. When they come into the examination room, the more information they have ahead of time, the less anxiety that will be produced. So they should understand the procedure. They're going to get on a routine exam table. They're going to have a speculum exam. There will be a rigid or semi-rigid scope placed through the cervix, but this should cause minimal cramping. The uterine cavity needs to be distended with some fluid, usually just some saline or salt water. Very little has to be used to visualize the cavity and the whole procedure will take somewhere between two and five minutes and they can go about their daily activities after that.
I think once they understand the whole procedure is fairly benign. It's not too uncomfortable, then they're going to be more anxious to ask for it when they approach their health care provider.
STEVEN COHEN, MD: We're in a state of transition now. There are some gynecologists who are doing hysteroscopy in the office. There are some doing it in the operating room and then there are some not doing it at all. So the patient may or may not even get offered hysteroscopy. And somewhere along the line and I think the purpose of these types of webcasts are to tell patients that this is available. So they may say to the doctor, even if the doctor doesn't bring it up, what about a hysteroscopy? What about helping me -- would that help me in the diagnosis of what my problem is? Especially, if they've had a D & C or other procedures done. So they may bring it up and that might open up a conversation with their physician and the physician may either bring it up or say, "Well, I don't do hysteroscopy, but I'll refer you to somebody who is expert in that." So I think it's nice to educate the patients out there so that they know that these procedures are now available in this modern era.
LINDA BRADLEY, MD: I had a patient just last week who thought for many, many years it was normal to use 50 pads a day for a menstrual cycle. She actually went so far as to make plastic covers for her chairs at home. She had a seat that she sat in when she was on her menstrual cycles. Her whole life revolved around knowing when her period occurred. She wouldn't make a vacation or travel plans or be able to attend her kid's soccer game because she was always incessantly changing her pads.
So I think knowing what's normal, what's abnormal and getting an evaluation when a problem persists and knowing that there is absolutely something else that can be done to help in the evaluation for your problem.
KEITH ISAACSON, MD: Some patients were worried that if they get a second opinion and their physician doesn't offer hysteroscopy that they're going to have to pay for this out-of-pocket and be a very expensive procedure. That's not the case. This is a routine standard procedure that's accepted by all insurance companies, covered by all insurance companies as well as Medicare, Medicaid. So it's not an out-of-pocket expense for the patient.
GRACE JANIK, MD: I think it's important for the patient's to see getting a diagnosis for their abnormal uterine bleeding before they initiate treatment, rather than start the treatment process. This is where the second opinion fits in. So commonly you see people going on treatments that are not focused to their problem.
STEVE COHEN, MD: And you know, not only do they pay for the hysteroscopy but the insurance companies pay for second opinions. In fact, they encourage second opinions to make sure that the treatment, the diagnostic procedure and the treatment are the most effective and efficient for that patient. So we've changed over the last decade to becoming a very modern specialty that wants to do what's right for the patient. That's the main purpose. Do what's right for the patient. Do what's efficient and effective and cost effective for the therapy.
GRACE JANIK, MD: I think there is great benefits to the physician to learn this in addition to being able to service her patients well. It's much more efficient from a physician perspective to be in the office setting -- to not have to go to the hospital and have that extra expense incurred by the insurance companies, too. So there is benefit definitely to the patient, but to health care in general by having hysteroscopy done in an office setting. It's a huge waste of money to take someone to the OR, put them asleep to just quickly look.
STEVEN COHEN, MD: It also limits -- in this day and age we always see shows and programs on medical errors. When you expand it out to the hospital, there is more chance of error. When you're in your office, the team knows everybody. Everything is constrained. There is much less chance of a medical error occurring. Everybody knows the patient. They know them by name. As opposed to trying to move it into the hospital setting which is not -- like you said, not cost effective, but reduces the chance of everybody knows what's happening here. It's just a more convenient place to do it.
And as we've all agreed, there is very rarely a reason to do a diagnostic procedure outside the office. It just doesn't need a hospital setting.
KEITH ISAACSON, MD: When we get into the cost efficiency, diagnostic and operative hysteroscopy, again of going back when patients don't have the proper diagnosis. When the patient has to leave work time and time again to go to the office for the D & Cs, the birth control pills, for the progesterone treatments that are ineffective. That is an overall cost to the entire health care system and society. We can reduce that.
LINDA BRADLEY, MD: I think so many women have been told, just live with the problem. I think the message is diagnosis, diagnosis, diagnosis. So if you have a problem where medical therapy has failed, and you have not had an invasive procedure where someone has looked inside the uterus or done an ultrasound, or done a procedure really limiting, targeting the target organ that's offending agent, then I think you do need to get a second opinion. Because this is not a problem that women need to live with. There has to be a reason. And even if there is nothing that's found, there are times that some women just bleed heavily. There are treatments. And what we're looking at is minimally invasive treatments that also work for these patients.
So once the diagnosis is made, there may be a very brief outpatient procedure where a polyp is removed or a fibroid is removed or where the tissue that grows every month -- if that can be destroyed or burned, the person's bleeding may get a lot better. So I think we want to make a diagnosis and then offer the simplest, most effective procedure that will treat that problem. And if those options are made available to patients, then our rates of major surgery like hysterectomy will go down. Our rates of complications from surgical procedures will go down. The ability for women to get back in the swing of things will escalate. There is very, very little downtime for our operations.
STEVEN COHEN, MD: That's why I think in the old days, it was "live with it" because you come in complaining of heavy bleeding, heavy bleeding. You'd see it in the chart for two or three years and then finally the doctor would push his chair back and say, "You know, we just need to do a hysterectomy." And we'll schedule in a patient, saying "Whoa, hysterectomy. I mean that's a big thing. Maybe I'll just will live with it." Or they go in for hysterectomy. And now we have, as you mentioned, all these minimally invasive procedures that take 15, 20 minutes -- painless to do and we can cure your problem for the rest of your life. But somehow we're still looking at the extremes -- do nothing or do everything, the big shot gun. But we can fine-tune the treatment nowadays and that's what patients need to know.
LINDA BRADLEY, MD: One thing I don't think we've mentioned today is just that women are waiting longer to have their children and so certainly for that woman who may be late 20s, early 30s -- even late 30s, early 40s who wants to have a child and has been told that her only treatment is hysterectomy, that's a definite group that needs to get a second opinion also.
STEVEN COHEN, MD: Absolutely.
MARY WAGNER: So where do you think the future of hysteroscopy is?
KEITH ISAACSON, MD: The future of hysteroscopy is that it will be in every gynecologists office and it will be offered to every appropriate patient. And I say that because when things make sense, they happen to get done. This is better medicine, better care for the patient. This is better medicine and it's financially reasonable for the physician. It's more efficient for the whole insurance industry and the health care system. So there is really no impediment -- no reason that it shouldn't be implemented worldwide.
LINDA BRADLEY, MD: This, in my mind, hysteroscopy's future will be the extension of the gynecologist's examining hands. That it will be another tool. It's an eyeball into the uterine cavity and that I agree, I think in the next three to five years because consumers will demand it and request it, physicians will have to come up to bat and provide these services.
STEVEN COHEN, MD: We will also develop -- in light of that we'll develop better endometrial oblation techniques, techniques that stop your periods entirely. We're still -- we do have a fine job, but our rates are not a hundred percent successful. It takes a little bit of time to do it. The treatments are actually a little bit sort of -- I don't want to say crude. That's probably not the right word. But not as perfect as they could be. It would be wonderful to put through the hysteroscope a little plastic catheter with a laser light, step on the pedal for five minutes and your periods are done with -- no pain.
So we're developing new techniques to use through the hysteroscope as well as the hysteroscope itself. We're going to see some of that. That's already in research right now. We'll see some of that being brought out very shortly.
LINDA BRADLEY, MD: Tubal sterilization is likely to be done through the hysteroscope.
STEVEN COHEN, MD: Absolutely.
GRACE JANIK, MD: I think the future is an expansion of what operative procedures can be done in the office. Once we get the wave of really what's happening of diagnostics in the office, expansion of procedural items including tubal ligation, maybe expansion of treating oblations and myomas in a more controlled setting in the office.
MARY WAGNER: Thank you again for this informative discussion on hysteroscopy and abnormal uterine bleeding. And thank you for watching our webcast.
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