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 (>Latino>Cauc>Asian), rural (vs. urban), age of 1st child <20 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 there’s 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 Nat’l Health & Nutrition Examination Survey: 50% Afr-American women obese (>20% ideal weight). • Racial incidence of fibroids: Afr-Am>Latino> Caucasian>Asian • 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: <11.7g/dL,<35%. 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 don’t bleed between periods. • What’s heavy? nl:6-12 tsp/menses, 3-6pads/menses. • >8pads/day, changing <2hrs

10. Menorrhagia • “I have to wear a d**n 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. I’m in trouble no matter how padded up I am. If I’m 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 can’t keep getting up and leaving whenever this happens. I bet I’ve raised eyebrows and I can’t afford to lose my job.” • “I’ve 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 it’s horrible in the summer. I was at my son’s baseball game one night when a “gusher” hit. Let’s just say it wasn’t 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% @ 3m, 60-70% @ 6m)

15. Approach

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 • >90% 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 (<1hr procedure time, conscious sedation). • “Don’t 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% >45yrs. • -6 out of 3,000 needed an elective D&C.

23. Pre-UFE & 6 mo Post-UFE

24. Pre-UFE & 6-mo Post-UFE

25. Pre UFE & 6 month f/u

26. Why aren’t 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 couldn’t 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 I’ll 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, I’m going to find a new gynecologist.”

28. E-mail from 2/11/09 @ 1:30am • 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.