Telemedicine: An Opportunity to Lower Hysterectomy Rates in Rural Georgia

1
Telemedicine An Opportunity to Lower
Hysterectomy Rates in Rural Georgia

• John C. Lipman, MD, FSIR

2
Possibilities of Telemedicine

• Popular science magazine from the 20s
• Imagines potential impact of advances in
  telecommunication technology (radio, telegraph,
  telephone, and television) on the practice of
  Medicine.

3
Telemedicine

• Use of multimedia (ex. videoconferencing) to
  improve access to care and improve quality of
  care at affordable cost.
• CME through a distance is also an example of
  telemedicine.
• Telemedicine is also an opportunity to educate
  our community to improve health (ex. prevention,
  improve compliance, awareness of treatment
  options).

4
Consultation
5
Fibroid facts

• Fibroids, while benign tumors, can cause
  significant suffering (affect health, work,
  relations with spouse/sig. other, etc.).
• By age 60, 1 in 3 women in US will have had
  hysterectomy (fibroids most common reason). 3,000
  women/day.
• Hysterectomy is 2nd most common surgical
  procedure, and SE has highest hysterectomy rate
  for any region in US (twice that of NE).
• Fibroids disproportionately affect Afr-Am women
  (1 in 3 women, up to 75 of Afr-Am women.
• Hysterectomy along racial lines Caucasian women
  for cancer, Afr-Am for fibroids.
• Hysterectomy rates highest in Afr-Am
  (gtLatinogtCaucgtAsian), rural (vs. urban), age of
  1st child lt20 yrs., poorer physical mental
  health (SF-36 QoL), and inversely associated with
  years of education.
• While genetic predisposition in Afr-Am out of our
  hands, the factors above suggest opportunities
  (particularly with telemedicine) for education to
  change outcome and behavior.

6
Why not hysterectomy?

• 1. Hysterectomy carries a great cost in terms of
  risk of complications, time needed for recovery,
  and health care costs to the individual and the
  community, but theres even more costs to the
  women that are often not discussed.
• Many women who undergo hysterectomy suffer after
  effects
• -Psychological (castration)
• -Sexual (loss of libido, loss of orgasm)
• -Urinary (leakage/incontinence)
• The fact is 90 of all hysterectomies are
  unnecessary. Worse, the surgery can have
  long-lasting physical, emotional, and sexual
  consequences that can undermine your health
  well-being. Considering the importance of the
  uterus, a disorder should have to be very serious
  to justify removing it. Unfortunately, that is
  not the case. Most of the female problems that
  lead to hysterectomy are medically trivial. They
  can be uncomfortable. Untreated, some can make
  your life miserable, but they will not kill you.
• -Dr. King, gynecologist,
  Manhattan Fibroid Associates
• 2. We have a much better proven safe effective
  (over 15 years),non-surgical, outpatient
  procedure, that relatively no one knows about
  Uterine Fibroid Embolization

7
Uterine Fibroids African-American Women Why?

• Genetic Cytogenic aberrations have been
  identified involving Chr 6,7,12, 14. Existence
  of heretability component has been implicated.
  Gene studies underway (identify fibroid genes,
  estrogen receptor).
• Fibroids grow with estrogen stimulation (grow
  during pregnancy cease with menopause).
• Estrogen stored in fat
• 3rd Natl Health Nutrition Examination Survey
  50 Afr-American women obese (gt20 ideal weight).
• Racial incidence of fibroids Afr-AmgtLatinogt
  CaucasiangtAsian
• Opportunity to educate/improve health (i.e. good
  for heart health, TypeII DM, stroke, and now
  fibroid health).

8
Uterine Fibroid Embolization (UFE) vs.
Hysterectomy

• Hysterectomy
• -3 days in the hospital
• -General anesthesia
• -Major abdominal surgical procedure
• -6-8 wk recovery
• -(Psych (castration), sexual dysfxn, urine
  leakage)
• UFE
• -Outpatient procedure
• -No general anesthesia (local and iv sedation)
• -Bandaid
• -4-5 day recovery

9
Fibroid Symptoms Bleeding Bulk Symptoms

• Most frequent cause of abnormal uterine bleeding.
  
• Ineffectual uterine contraction to stop menstrual
  flow.
• Typically starts as a prolonged menses, which can
  lead to anemia (can be severe).
• Anemia lt11.7g/dL,lt35. Sxs lethargy,
  lightheaded, palpitations, chew/crave ice and/or
  pica.
• Gushing, flooding, and soiling clothes/linens
  in blood.
• Period usually regular but heavy i.e. usually
  dont bleed between periods.
• Whats heavy? nl6-12 tsp/menses, 3-6pads/menses.
• gt8pads/day, changing lt2hrs

10
Menorrhagia

• I have to wear a dn diaper (Depends), a flat
  maxi pad heaviest flow, plus a thick pad, plus a
  super deluxe tampon. When I have a gush, it only
  stops the clots, not the gush. Im in trouble no
  matter how padded up I am. If Im not near a
  bathroom, I m a sunken ship. Today, I definitely
  was sunk because I was out without my Depends on
  ! I have to work. I just cant keep getting up
  and leaving whenever this happens. I bet Ive
  raised eyebrows and I cant afford to lose my
  job.
• Ive been there too. I was shaking my head
  reading your message. I shop at Costco and buy
  the hugest box of the biggest, heavy duty pads,
  along with the super tampons, and Depends.
  Sometimes, I will have all this gear on just to
  go to the grocery store or a quick errand. It is
  a pain. I can handle it in the winter, but its
  horrible in the summer. I was at my sons
  baseball game one night when a gusher hit.
  Lets just say it wasnt pretty. Hope the
  bleeding stops soon for you.

11
Bulk Symptoms

• Bulk symptoms are the other major symptoms from
  fibroids.
• -Pelvic pain/pressure.
• -Urinary pressure/frequency
• 1. Often wake up in the middle of the
  night.
• 2. While bladder feels full and patient
  expects to urinate a lot, she is often surprised
  by the low volume.
• -If large can block kidneys, bowel
  (constipation).
• -Painful intercourse (low-lying or cervical
  fibroids).

12
Pelvic MRI
13
Fibroid Treatments

• 1. Nothing Most asymptomatic
• 2. Dietary/Herbal
• 3. Medical can provide relief for some often
  temporary.
• (4. MRgFUS Local, no insurance approval)
• 5. UFE
• 6. Surgical Hysterectomy or Myomectomy (removing
  the fibroid without trying to remove the uterus).

14
Uterine fibroid embolization UFE

• Discovered serendipitously.
• No surgery or anesthesia.
• Procedure performed like a heart catheterization.
• Catheter directed into the blood supply of the
  fibroids. Particles are injected from the
  catheter that plug the branches to the fibroids.
  Without a blood supply, the fibroids die off.
• (Avg. reduction 40 _at_ 3m, 60-70 _at_ 6m)

15
Approach
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
Uterine artery embolization

• Most patients stay 6 hours and then go home the
  rest leave by the following morning.
• Recovery is 4-5 days versus 6-8 weeks for
  surgery.
• A bandaid covers where the doctor entered the
  skin (NO incision, stitches,etc.)
• (Insurance routinely covers UFE)

20
UAE Results

• gt90 women experience significant or complete
  resolution of symptoms (heavy bleeding, pain,
  urinary frequency, etc.)
• Procedure has no limit for size of fibroids and
  treat all fibroids at once (unlike local
  therapies).
• Typically a one-time procedure with a rare need
  to repeat embolization.

21
UFE Advantages

• -Treats all fibroids simultaneously (Global
  therapy).
• -Very effective in treating menorrhagia and bulk
  symptoms.
• -Minimally invasive (lt1hr procedure time,
  conscious sedation).
• Dont burn any bridges.

22
UFE Disadvantages

• -Not 100 effective (Collateral supply,
  adenomyosis)
• -Post-procedure pain Usu. well tolerated.
• -Radiation Dose very small.
• -Amenorrhea 2 overall, 10-15 gt45yrs.
• -6 out of 3,000 needed an elective DC.

23
Pre-UFE 6 mo Post-UFE
24
Pre-UFE 6-mo Post-UFE
25
Pre UFE 6 month f/u
26
Why arent women hearing about UFE? Communication

• Studies have shown that the vast majority of
  patients are not hearing about UFE from their
  gynecologist.
• While the internet is a great tool, patients need
  to hear their treatment options from physicians.
• Gynecologists need to discuss with patients all
  of the available treatment options not just the
  ones they can provide.

27
Communication What patients are saying

• I was appalled that my well respected, young and
  bright, female, African-American Ob/Gyn offered
  me no alternatives to total hysterectomy.
• Without hearing about UFE from a friend, I would
  not have had this great procedure. I am so
  grateful. I would have either suffered for a lot
  longer or gotten the hysterectomy my Gyn
  recommended.
• When I approached my Gyn about UFE, she couldnt
  understand my reluctance and was determined that
  I needed hysterectomy. Here I am two years after
  UFE, 66 smaller uterus, light periods, and my
  bodily organs back where they started out.
• I originally accepted hysterectomy. After all my
  gynecologist said Ill be much relieved. I
  cancelled at the last minute due to a due to a
  professional conflict. I decided to do some
  research and found UFE. When I asked my
  gynecologist for a referral to an IR, she said
  Oh, so you want to try UFE? She told me 2
  months ago that my only option was hysterectomy.
  Needless to say, Im going to find a new
  gynecologist.

28
E-mail from 2/11/09 _at_ 130am

• Dr. Lipman,
•  
• I could not think of anyone else to email at this
  late hour...after starting my menstrual cycle
  today.  It is still amazing how my mind and body
  is on auto-pilot to wake up at this hour to
  change the towel on my mattress as well as my
  diaper because of the heavy blood flow I would
  normally receive.  I just returned from the
  bathroom and the minipad that I'm wearing has
  only a few drops in it.  I ABSOLUTELY CANNOT
  BELEIVE THIS!!!  
•  
• Not sure you remember me, but you performed the
  UFE procedure on me on 4 Nov 09. Before I heard
  about the UFE procedure, I was close to deciding
  on a historectomy.  My health and my life was a
  mess.  I was severely anemic...hemoglobin down
  to 8.1 and dropping, thyroid level all over the
  place, suffering from urine incontenence because
  fibroids were resting on my bladder and strapped
  up like a gangster with pads and tampons! I had
  pads everywhere, in the car, in my office, in my
  bible, in every purse, in my children's luggage,
  in my boots...etc.  At times, I thought I would
  literally bleed to death with periods lasting 3
  weeks every single month.  My blood clots were
  painful and scary!  The clots would drop into the
  toilet like little Angry Airborne Aliens! 
  Sometimes I would stand up and blood would
  explode into my panties and run down my leg into
  my shoes.  I cried many nights because I felt
  helpless and embarrassed.  I couldn't enjoy many
  of the activities I enjoyed because my periods
  kept me prisoner. 
•  
• Not anymore!  I have my life back and my family
  has me back. My hemoglobin level is already up to
  10.3, my thyroid (TSH) is normal and I no longer
  suffer from  urine incontenence. I just started
  training for a marathon.  I plan to spend lots of
  time at the beach this summer...in a swimsuit! 
  This summer I can wear the cute, short sun
  dresses and can fall asleep on my girlfriends
  couch if I need to.  Thanks so much for
  performing this amazing procedure.  I cannot
  express how grateful I am to you and your staff. 
  
•  
• ...I just checked again.  Still only a few
  drops.  God is good!  Going to bed, not planning
  to get up until it's time for work.
•  
• Thank you Dr. Lipman!!!!!
•  
• Goodnight!
•  
• Nicole

29
UFE Conclusions

• Telemedicine offers a tremendous opportunity to
  improve the health of our community and bring
  specialized skills/information to rural areas.
• Hysterectomy rates for fibroids way too high.
• Empower physicians/patients with information on
  UFE
• Embolization of uterine arteries for symptoms due
  to fibroids should replace hysterectomy as
  1st-line option for treating fibroids.
• Can expect excellent results for both menorrhagia
  and bulk symptoms with reductions in uterine
  size.
• Patients tolerate procedure well with high
  satisfaction rate.