Getting an IUD Doesn’t Have to Hurt Like Hell

My quest for a painless insertion

by Jamie Peck

I contemplated getting an intrauterine device (IUD) for over seven years. Every time I asked a friend who had one about her experience, she would say the same two things: It hurts like hell to get one inserted, and I should definitely do it.

Once an IUD is placed properly in the uterus, the tiny, T-shaped device is over 99% effective at preventing pregnancy for anywhere from three to 10 years, depending on the type. The Paragard brand is totally hormone free, but even hormonal IUDs, like the Mirena, keep the hormones localized in the uterus so they cause fewer side effects. Since 2012, the American College of Obstetrics and Gynecologists (ACOG) has recommended long-acting reversible contraception, or LARCs, as “first-line recommendations for all women and adolescents.” OB-GYNs even choose this form of birth control for themselves at rates much higher than the general population…

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Why it Makes Sense to Have Your Office GYN Procedure Done Here

The Center provides a nationally and internationally standard of excellence in the care of menstrual disorders. Dr. Wortman has been an important innovator in gynecology for decades. He has invented procedures such as hysteroscopic endomyometrial resection and reoperative hysteroscopic surgery for endometrial ablation failures. Dr. Wortman serves on the Editorial Board of the Journal of Minimally Invasive Gynecology and is the Medical Director of the Center for Menstrual Disorders.

At the Center’s offices we also offer the option of virtually any office-based gynecologic procedure to be performed with Intravenous Sedation or with Monitored Anesthesia Care.

Why is this important?

Many so-called “office procedures” –simply put—are painful. You may have heard of some of these procedures but here’s a sampling.

• Insertion of an Intrauterine Device (IUD)
• LEEP (loop electrosurgical excision procedure)
• Diagnostic hysteroscopy
• Cervical biopsy
• Endometrial biopsy
• D and C
• Removal an endometrial polyp (polypectomy)
• Endometrial ablation
• Hysteroscopic myomectomy
• Vaginoplasty

Although many women do fine with having these procedures performed with the use of “local anesthesia” or oral medications, the truth is that most women find these procedures uncomfortable and even painful.

Why doesn’t my own doctor use anesthesia or intravenous sedation in an office-setting?

The simple fact is that gynecology offices in New York State can offer these services only if they are accredited for office-based surgery. Our office has been accredited since 2008 by the Accreditation Association for Ambulatory Health Care (AAAHC). Accreditations are performed every 3 years and provides the public with the reassurance that an important standard of care has been achieved and maintained.

If you would like to learn more about having your office-based procedure performed at the Center, please contact our office.

First, a disclaimer. I don’t perform endometrial ablation (EA) anymore. But, I was the first physician in Western New York to perform it 30 years ago in 1988. In 1991 our team invented a procedure called Endomyometrial Resection or “EMR”. Since then we, at the Center for Menstrual Disorders, have performed some 3500 operative procedures for managing abnormal menstrual bleeding.

To my knowledge we are the only facility in the United States that manages the common complications of endometrial ablation known as LOEAF or late-onset endometrial ablation failure. LOEAFs often present months or years after an ablation with women complaining of pain, irregular or heavy periods, or both.

As you might imagine we get many calls and take care of many out-of-town “guests”. Many of the cases are heartbreaking as women often report severe pain, very inconvenient and untimely emergency room visits, inconclusive testing, unnecessary operative procedures and more. Especially vulnerable are women with pain who often feel worse off than prior to their procedure.

In 99% of cases the treatments fall into 3 categories which include (i) “live with it”, (ii) oral contraceptives, or (iii) hysterectomy. At our office we are able to treat many, but not all, of these failures and, in well-selected patients, we have been quite successful in averting a hysterectomy.

But that is NOT why I’m writing this article.

I realize that most women are not going to travel to Rochester for their care. But I implore you that before you undergo an endometrial ablation, of any type, please ask your doctor the following questions?

1. What are my options besides an endometrial ablation?
2. Do I have any evidence of a uterine fibroid within the uterine cavity (submucous myoma)? And if I do, will you remove it before performing the endometrial ablation.
3. What is the likelihood that someone MY AGE I will make it to menopause without a hysterectomy?
4. If my endometrial ablation fails how will I know it? Will it be obvious or will it mask as something else?
5. If my endometrial ablation fails how might you treat me?

This is by no means a complete list of questions you’ll need to ask your doctor. But keep in mind that 25% of women who undergo endometrial ablation in the United States will ask to have a hysterectomy within a period of 5 years. The SINGLE MOST IMPORTANT RISK FACTOR FOR FAILURE IS AGE! Women under the age of 35 are the most likely to experience an endometrial ablation failure, while women over the age of 45 are least likely.

If you are inclined, please visit our website and the following links to learn more about the prevention and management of endometrial ablation failure.

https://www.cmdrc.com/treatment-of-endometrial-ablation-failure/

https://www.cmdrc.com/wp-content/uploads/2017/08/Late-onset-endometrial-ablation-failures-COLOR.pdf

https://www.cmdrc.com/wp-content/uploads/2016/02/LATE-ONSET-ENDOMETRIAL-ABLATION-FAILURE-JMIG-MARCH-2015.pdf

https://www.cmdrc.com/wp-content/uploads/2017/01/Diagnosis-and-treatment-of-global-endometrial-ablation-failure-Ob.Gyn_.-News.pdf

https://www.cmdrc.com/wp-content/uploads/2016/02/MIGS-APPROACH-TO-EA-FAILURE-CONTEMPORARY-OB-GYN-2014.pdf

If you would like to learn more about why we invented endomyometrial resection (EMR) click below:

https://www.cmdrc.com/menstrual-disorders-fibroids/treatment-options/endomyometrial-resection-emr/

Been Told That You Need An Endometrial Biopsy?

Here are some things to consider

An endometrial biopsy (EB) is often done on women who are undergoing evaluation of abnormal periods or for an infertility issue.

An EB involves the passage of a small instrument into the cervix at which point the lining is randomly scraped and the specimen which is obtained is submitted to lab for analysis. The endometrial biopsy is a screening test for abnormalities such as endometrial hyperplasia (a pre-cancerous condition of the uterus) and endometrial cancer.

While endometrial biopsy provides valuable information there are several things worth noting if you are considering this procedure in a physician’s office.

1. Endometrial biopsy is a blind Even though EB produces a tissue specimen it is a random specimen and may not be adequate in assuring you and your physician that you don’t have a pre-cancerous lesion of the uterus.
2. Endometrial biopsy is often painful. Most physicians do not offer analgesics or sedation for endometrial biopsy. While many women tolerate it quite well, others find it painful or intolerable. Postmenopausal women or those that have never had a vaginal delivery are at high risk of significant pain with endometrial biopsy.
3. Endometrial biopsy, itself, provides little information regarding the existence of uterine fibroids or endometrial polyps.
4. Endometrial biopsy does not offer treatment. In other words if a physician sees a polyp, endometrial biopsy will not effectively remove it.

With the invention of small diameter hysteroscopes—no larger than a biopsy instrument—a diagnostic hysteroscopy can be performed with intravenous sedation right in our accredited office-based surgical center. The information you and your physician are provided with is far superior to blind endometrial biopsy and very often treatment is possible at the very same time.

Dementia – My Personal Journey by Amy Daggett

The Alzheimer’s Association reports that 5.5 million Americans suffer from Alzheimer type dementia in
the United States. This makes up approximately 70% of all dementias. It also reported that 15.9 million
Americans provided 18.2 billion hours of unpaid assistance to family and friends with Alzheimer’s and
other dementias in 2016. It comes as no surprise that almost daily I encounter a patient who shares
their story about caring for a loved one with dementia. This is my story.

In 2006, the very weekend that I graduated with my masters in nursing, my dad was diagnosed with
dementia. My mom was his primary caregiver until he passed in 2012. Losing a parent is never easy.
The person charged with your care and protection is no longer there. As I grieved the loss of my dad, it
became apparent that I was losing my mom to dementia as well. After my dad’s passing, we started to
notice a cognitive decline in my mom. Those of you that have family or friend with dementia are
familiar with this subtle progression, that at first you try to deny, but then have to admit that someone
you love is gradually being stolen away from you.

The transition for a parent to go from caretaker to being the one requiring care is often a difficult one
for both the parent and the child. For me, this adjustment coincided with my daughter’s departure out
of the house for college. It was overwhelming trying to balance the emotions of encouraging one
generation to gain independence while slowly reducing the independence of another. It was a struggle
to gain the courage to confront my mom with her disease. Then even after difficult discussions were
had, they soon evaporated as the result of the disease and had to be repeated. The weight of having a
loved one with dementia was almost unbearable.

I have sat with many patients in my office, following their annual exams, sharing our struggle with how
to best manage our loved ones’ care. Some moved loved ones into their home to care for them, others,
like me, hired home health aides in an attempt to keep them out of facilities. My experience was that
this worked for a while but as the disease progressed, my mom’s social isolation grew. Boredom is an
environment in which cognitive decline thrives. This past summer my sister and I had to face the reality
that Mom’s condition was quickly deteriorating and a change needed to be made.

The decision to move my mom out of the only home we have ever known was the most agonizing
decision that my sister and I have ever had to make. In August, we starting looking for assisted living
care facilities with memory care units. I am happy to say that our tale comes with a happy ending. On
September 23 rd we moved my mom into a facility which allowed her to bring not only own furniture but
her beloved cat, Lucy, as well. Initially she was homesick and spoke only of going home. As time has
passed, she has become content and happy in her new home. With better nutrition and socialization
she is thriving. I look forward to visits and always take fresh flowers which she loves.

All of our stories are different. Each of us will navigate through these decisions differently but we all
have love in our hearts. I still mourn for the loss of the mom that I once knew but now I am joyful as I
get acquainted with the person she is now. During my last trip to visit we took her to a restaurant/bar
near her facility. When our meal was delayed we were delighted when she joined us in a game of pool!

Why Bother Getting a Second Opinion?

Never in the history of women’s health care have there been as many alternatives to hysterectomies.

Obviously we are not talking about life-saving hysterectomies that are performed for cancers or acute hemorrhage following the birth of a child. But many—and possibly most–hysterectomies can now be replaced with other modalities that include:

1. Careful observation and non-surgical monitoring of the condition.
2. Hormonal medication and Intrauterine Devices (IUDs) to control heavy vaginal bleeding
3. Non-hormonal medication to control heavy vaginal bleeding
4. Endometrial ablation and Endomyometrial Resection
5. Myomectomy (removing fibroids that reside inside or outside of the uterine cavity)
6. Uterine artery embolization or uterine fibroid embolization

In addition, if you and your physician decide that hysterectomy is an appropriate choice for you there are still many choices that include the following:

1. Does the hysterectomy involve the removal of the entire uterus or can the cervix remain?
2. Does the hysterectomy also include removal of the ovaries?
3. Will the hysterectomy be done laparoscopically?
4. Will the hysterectomy be done robotically?
5. Will the hysterectomy be done vaginally (with no abdominal incisions)
6. Will the hysterectomy be done with a large abdominal incision (laparotomy)
7. If I keep my ovaries should the fallopian tubes be removed?

WHO IS BEST SUITED TO PROVIDE A SECOND OPINION?

Years ago a colleague of mine entertained the idea that he would open a “second opinion” practice in Rochester. He envisioned a practice in which he was paid for his opinion only—in other words he would not use his position of knowledge or authority to siphon patients from other physicians only to enrich himself.

This would be the “ideal second opinion.” Under the best of circumstances you can visit a physician with your medical records in hand, allow for an examination (if necessary) and a thorough history so that the physician can get to know your particular needs and expectations and together reach a decision about hysterectomy—whether it is necessary. Perhaps you might decide that no therapy is required or that a less invasive method is appropriate. If a hysterectomy should prove appropriate for your condition you would be referred to a physician (who had no financial relationship with your “second opinion doctor”) with an excellent reputation and superior skills.

A QUESTION YOU SHOULD ALWAYS ASK YOUR DOCTOR—WHETHER IT’S YOUR “FIRST OPINION” OR YOUR “SECOND OPINION”

A question you should always ask your physician who is proposing an invasive treatment is simply this—“if I was your family member, daughter, wife, sister or other loved one would you recommend this surgery?” This is a legitimate question. Most physicians are honest, well-meaning and want the best for you. But this question may have them think a little harder. It’s a worthwhile question and you should strongly consider asking it no matter who is proposing surgery.

WHY DON’T WOMEN GET A SECOND OPINION?

There are many reasons women choose to not get a second option. Here are a few to consider. There are others as well.

1. I don’t want to offend my doctor
2. I trust my doctor and another doctor is just going to tell me the same thing anyway.
3. It may cost some extra money to get a second opinion.
4. A second opinion may mean that I have to delay my surgery and I can’t live with the problem any longer
5. My friend had the same problem and she had a hysterectomy and she’s happy.
6. My mother had a hysterectomy and so I knew I would eventually have one anyway.
7. “I just want it out!”
8. I did my on-line research and a hysterectomy seems the best way to go!

This will begin a multi-part series in which we begin to explain what might be gained by a second opinion. This article may not answer all of your questions but you will likely learn that there are a vast array of options available today that were not available only 10 years ago. You may learn that some of the “latest technologies” such as “robotic hysterectomy” do not offer results that are superior to other forms of hysterectomy—and they are not “less invasive” that other treatment options.

REASONS HYSTERECTOMIES ARE PERFORMED

Hysterectomies are the second most commonly performed surgical procedure performed on women today—over 600,000 annually in the United States. In general, the reasons for which hysterectomy is recommended fall into one of 3 categories:

1. To save lives. This is not why the vast majority of hysterectomies are performed. This group includes women with various cancers and women who have rare life-threatening hemorrhage that may follow the birth of a child.
2. To correct serious problems that interfere with normal function. This group includes women with very large pelvic masses (including some uterine fibroids), serious and incapacitating endometriosis as well as some other uncommon issues related to urinary and bowel function.
3. To improve the quality of life. This is the largest group of women who eventually undergo hysterectomy and includes women with heavy, irregular or painful periods. Many of these women have fibroids (though not as large as in the previous group). Other women in this group may have uterine or pelvic organ prolapse while some have moderate amounts of endometriosis or adenomyosis.

With the exception of group 1 – there is generally both time and reason for a second opinion.

PERSONAL DISCLAIMER

I have been a practicing gynecologist in Rochester since 1980. Like most gynecologists I trained to perform hysterectomies and was among the first to perform laparoscopic hysterectomies as far back as 1989. Frankly, our practice took off in a different direction and approximately 10 years ago I stopped performing them. They are still necessary and I still refer patients for hysterectomy. However, after years of looking for alternatives to hysterectomy I no longer performed enough of them to feel that I was the best person to offer them. I feel that women who should undergo hysterectomies should be referred to the best physicians I know.

Under no circumstances, should you require a hysterectomy, will I personally perform one—but I will refer to the very best talented surgeons available.

Endomyometrial Resection (EMR) vs. Endometrial Ablation (EA)

If you are considering any type of endometrial ablation (EA) you should strongly consider endomyometrial resection (EMR) and why I believe it has many advantages over any of the ablation techniques that are available today. Here’s a bit of background on each. Keep in mind that in 1988 I became the first physician in Western NY to successfully perform endometrial ablation and had extensive experience with it before I set out to on a different direction and invented the technique of EMR.

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FIRST OF ALL—WHAT IS ENDOMETRIAL ABLATION?

Endometrial ablation is the systematic burning of the uterine lining. The goal of endometrial ablation is to destroy –through burning—the uterine lining and replace it with scar tissue so that it no longer grows and sheds each month. If endometrial ablation is 100% successful the woman no longer experiences a monthly period. This does not cause menopause—which occurs when the ovaries stop producing eggs along with several classes of hormones. Because the uterine lining is important for pregnancy, endometrial ablation is only offered to women who have completed their families.

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In order to destroy the uterine lining—and keep it from growing back–it is important to destroy the very base of the lining tissue called the endometrial basalis. A good analogy would be if you were trying to destroy a patch of grass in your front lawn using a blow torch. The only way it will work is if you apply enough heat to destroy the deep grass roots. If you simply apply heat to the blades of grass above the ground the grass regenerates and grows back. The challenge with endometrial ablation is to deliver enough heat to the lining so that the basal layer–the equivalent of roots—is destroyed without causing injury to other pelvic organs. If the basal layer isn’t destroyed the endometrium easily regenerates and grows back.

EARLY DAYS OF ENDOMETRIAL ABLATION (1988-1991)

When I first began performing endometrial ablation (EA) at Highland Hospital in 1988 we used a $110 thousand laser (neodymnium: YAG). The laser represented a major breakthrough in gynecology and allowed us to treat women with abnormal uterine bleeding in a simple outpatient procedure that often avoided hysterectomy. The laser was introduced through a hysteroscope so that we could actually look and work inside the uterine cavity. In the picture just below the laser fiber is introduced through a special telescope—called a hysteroscope—which then heats up or “cooks” the uterine lining.

Within a year (1989) the FDA had approved an electrified hysteroscope known as a “rollerball”resectoscope. The resectoscope was both less costly and more efficient—an example of sometimes “cheaper is better.” Although we were able to treat dozens of women with the laser it was soon replaced by “rollerball” resectoscope which was more effective in destroying the tissue inside the uterus (endometrium).

Within 2-3 years however it became apparent that even the “rollerball” resectoscope did not produce entirely predictable and acceptable results. At least 40% of women continued to have vaginal bleeding after endometrial ablation—which meant there was plenty of room for improvement.

One of the reasons, I felt, for the lack of predictability with endometrial ablation is that “burning” or “cooking” the uterine lining is not a very reliable way of destroying it!

It was the unpredictability of endometrial ablation that led us to invent endomyometrial resection (see below) in 1991.

IN THE MEANTIME….

Even though endometrial ablation was performed in different parts of the world it never really caught on in the United States. But this changed in 1995 when a series of devices began making their appearance on the American and European markets. These devices were designed to improve the safety of endometrial ablation and encouraged many physicians—for the first time—to strongly consider their use.

Thanks to these devices, endometrial ablation became an important tool for gynecologists in this country and in Europe. However, while these devices improved the safety of endometrial ablation they did not improve their results! These systems—which include the ThermaChoice Balloon, Hydrothermal Ablation and NovaSure devices—account for nearly 400,000 ablation procedures performed in the U.S. each year.

THE PROBLEM WITH ENDOMETRIAL ABLATION

It is now recognized that 25% of women undergoing endometrial ablation with these devices will subsequently undergo a hysterectomy within 3-4 years. The number of women who are dissatisfied with the results is likely to be higher but many of them simply elect to accept their results and not undergo further surgery.

ENDOMYOMETRIAL RESECTION (EMR): DEFINITION AND GOALS

Endomyometrial Resection (EMR) grew out of the need to improve the results of endometrial ablation while not compromising on safety.

Definition: Endomyometrial resection is the systematic removal of the entire uterine lining (including the basal endometrium) together with the underlying muscle in order to insure that a known depth of lining tissue and muscle is removed—not burned. This is done to insure that the very base of the endometrium (lining tissue) has been removed and does not survive.

Goals: There are 3 goals of endomyometrial resection:

1. To achieve a highly reliable outcome of diminished or absent menstrual bleeding compared to endometrial ablation techniques.
2. To have a specimen that can be sent to a lab for analysis and determine whether or not there is a precancerous or cancer lesion of the uterus as well as other conditions that increase the risk for abnormal uterine bleeding.
3. To minimize the risk for endometrial ablation failure which frequently requires some form of  subsequent surgery—especially hysterectomy.

HOW DOES ENDOMYOMETRIAL RESECTION PROVIDE MORE RELIABLE OUTCOMES THAN ENDOMETRIAL ABLATION? WHAT ARE THE SPECIFICS?

There are several ways of comparing endomyometrial resection and endometrial ablation. The first is determine how many women stop having periods altogether (amenorrhea) following both procedures. The second—and more important—is to determine what percentage of women will require a second procedure. The “second” procedure may be either a repeat procedure or a hysterectomy.

COMPARISON OF MEDICAL VERSUS SURGICAL ABORTION

	Endomyometrial Resection	Endometrial Ablation
Amenorrhea (no further periods)	85.5% (10)	40-50%
Pathology specimen	yes	no
Requiring second procedure	5% (8, 10)	25% (1 – 3, 8)

IF ENDOMYOMETRIAL RESECTION (EMR) IS SO SUCCESSFUL WHY AREN’T MORE PHYSICIANS PERFORMING IT?

To successfully perform EMR requires 3 separate skills:

First. The physician must develop expertise in operative hysteroscopy. EMR requires the skill to operative inside the uterine cavity. Most expert hysteroscopists around the world are self-taught as these skills are generally not learned during a typical residency or fellowship program. Most “minimally invasive” gynecologic surgeons are laparoscopists who are trained to operative inside the abdominal or pelvic cavity.   They utilize small, narrow instruments passed through small skin incisions. Operative hysteroscopy, however, is an entirely different skill that requires the ability to perform surgery inside the uterine cavity and without skin incisions. Most major communities have barely a handful of skilled hysteroscopists.

Second. The physician needs to be skilled in dynamic ultrasound or “ultrasound guidance”. In addition to a surgical skill the physician needs to be perform and direct imaging during surgery and learn to rely on ultrasound images to guide their surgery.

Third. The physician must be able to assemble and maintain a “team” devoted to hysteroscopic surgery. Our “team” consists of a surgeon, 2 nurse practitioners and 2 medical technicians –with over 80 years of combined experience in operative hysteroscopy.

Simply stated, this is not the kind of expertise that is easily acquired!

SUMMARY

If you are seriously considering an endometrial ablation you should take the time to learn about endomyometrial resection. EMR is an office-based procedure (11) that is extremely safe in our hands and produces results that we believe are superior to any of the endometrial ablation techniques. EMR has been well studied – in many cases we have over 20 year follow-up. In addition to these advantages EMR also provides an abundant amount of tissue for laboratory analysis. In a significant number of patients EMR has been able to diagnose both cancerous and pre-cancerous lesions that were missed on endometrial biopsy as well as D and C.

But the bottom line for most women is simply this— the results of EMR are better. You are more likely to achieve your desired outcome with EMR compared to any ablation procedure. To learn more about endomyometrial resection contact our office and schedule an appointment for a consultation.

REFERENCES

1. Munro MG. ACOG Practice Bulletin: endometrial ablation. Obstet Gynecol 2007; 109:1233-47.
2. Longinotti MK, Jacobson G, Hung Y, et al. Probability of hysterectomy after endometrial ablation. Obstet Gynecol 2008; 112:1214-20.
3. McCausland AM, McCausland VM. Long-term complications of minimally invasive endometrial ablation devices. J Gynecol Surg. 2010; 26:133-49.
4. Gimpelson RH, Kaigh J. Endometrial ablation repeat procedures case study. J Repro Med. 1992;37:629-34.
5. Wortman M. Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J Am Assoc Gynecol Laparosc. 2001; 8:272-7.
6. Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2013. IN PRINT.
7. Wortman M, Daggett A. Hysteroscopic endomyometrial resection: a new technique for the treatment of menorrhagia. Obstet Gynecol. 1994; 83:295-8.
8. Wortman M. Minimally Invasive Surgery for Menorrhagia and Intractable Uterine Bleeding: Time to Set Standards. Journal of the AAGL. 1999; 6: 369-373.
9. Wortman M. Sonographically Guided Hysteroscopic Endomyometrial Resection. Surg Technol Int. 2001. Dec 1; XXI:      163-169.
10. Wortman M, Daggett A. Hysteroscopic Endomyometrial Resection. JSLS 2000; 4(3): 197-207.
11. Wortman M, Daggett A, Ball C. Operative hysteroscopy in an office-based surgical setting: review of patient safety and      satisfaction in 414 cases. J Minim Invasive Gynecol. 2013: 10;26-6

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