PAUL MONIZ: I'm Paul Moniz. Thank you for being with us today. We are discussing how hysteroscopy has become an alternative to hysterectomy in treating abnormal uterine bleeding. Here to walk us through this procedure and its effectiveness is a gynecologist and one of his patients. We appreciate you being here.
Dr. Martin Goldstein is Associate Clinical Professor of Obstetrics and Gynecology at Mt. Sinai Hospital. Next to him is Valerie. She is a 50-year-old mother of two who has agreed to share her story, though because of its sensitive nature, she does not want her face shown. Thank you both for being here.
Dr. Goldstein, let's talk again about hysteroscopy. What exactly is it?
MARTIN GOLDSTEIN, MD: Hysteroscopy is a technique that can be either diagnostic or therapeutic. Hysteroscopy began in the United States in the 1970s, initially as a diagnostic procedure. In the mid-1980s, we linked hysteroscopy to resectoscopy, which is a way of using a surgical instrument to be able to cut fibroids out of the uterus or remove polyps from the uterus. By removing fibroids from within the central cavity of the uterus without making an abdominal incision, we have the option to do conservative, minimally invasive surgery, and allow a patient to get back to her normal function, usually within one or two days.
PAUL MONIZ: We're talking about a submucosal fibroid. Is that right?
MARTIN GOLDSTEIN, MD: Yes.
PAUL MONIZ: What percentage of women have this type?
MARTIN GOLDSTEIN, MD: Somewhere between 30 percent and 50 percent of the female population in the United States has fibroids. Most of these fibroids do not create any problem. When people have heavy bleeding, usually it is due to a submucosal fibroid. The actual number of submucous fibroids in the United States is much fewer than the 40 percent of people who have overall fibroids. Probably 2-5 percent of people with fibroids might have a submucous fibroid.
PAUL MONIZ: Valerie, when you went to see Dr. Goldstein, what symptoms were you experiencing at the time?
VALERIE: I had been weak and tired, and I had anemia. I was not aware how heavy my periods were over the last months.
PAUL MONIZ: Is that common doctor that a woman would not be aware that she is actually bleeding more heavily than either she's used to, or she should?
MARTIN GOLDSTEIN, MD: Most of us are creatures of habit. If we are accustomed to a usual circumstance, we may not think that's abnormal, unless you would compare your story. If a woman would compare how many pads she went through during her period with a neighbor, then she might say, "Gee, I'm bleeding twice as much as my neighbor."
PAUL MONIZ: Valerie, if you're comfortable with this, can you give us a sense of how much you were bleeding? Obviously, this may help some of the women out there. Subsequent to having a discussion with him, you realize, "Well, maybe I'm bleeding more than I should."
VALERIE: My periods were always like clockwork every 28 days. I had no change in that. Nor was there a change in the length of my period. It was the intensity of the flow. It was a freqency of changing, but once Martin started asking me questions. I guess every two hours. Then, when I looked back on it, it must have been even an hour-and-a-half for a 24-hour period.
PAUL MONIZ: She comes to see you. You do a long workup of tests. You come to the conclusion that she had a submucosal fibroid. Then what?
MARTIN GOLDSTEIN, MD: Then we presented the options of treatment to Valerie. We found what was ideal for her. Valerie wanted to maintain her uterus, which most women will want to do. By hysterogram, we found that the fibroid was in a location that was amenable to hysteroscopic resection. We used a medicine called Lupron to stop Valerie from bleeding, to decrease the blood supply to the uterus and decrease the amount of bleeding during the procedure. Then we scheduled the procedure.
PAUL MONIZ: Let's talk about the procedure. We have some video of it. This is actually Valerie's case. We should tell our audience that Valerie had a tennis ball-sized submucosal fibroid.
MARTIN GOLDSTEIN, MD: This is one of the larger ones that we can do.
PAUL MONIZ: What are we seeing now? There is a scope that you go in with?
MARTIN GOLDSTEIN, MD: We're now looking through a hysteroscope, which is attached to a television camera. The wire loop that you're seeing is an instrument called the resectoscope, which goes through the hysteroscope. You see two structures here. Directly in front of us being touched by the resectoscope is a small polyp. The structure that we're now touching is the large submucous fibroid. You can see the large blood vessels on the surface of the fibroid. You also see blood vessels on the surface of the polyp.
The resectoscope is attached to a television screen, so the image that I see when I'm doing surgery is the same as you see on the monitor now. To the left of the polyp that we're removing is the opening of the left fallopian tube. Using the resectoscope with a cutting current, we are cutting the polyp out and removing it. That is now accomplished.
We're now looking at the submucosal fibroid, which occupies about half of the volume of the uterus.
PAUL MONIZ: Is this the largest that you've seen?
MARTIN GOLDSTEIN, MD: No. I've had some other fibroids that were similar in size to this. But, this is a fairly large submucous fibroid.
PAUL MONIZ: What is Valerie feeling at this point?
MARTIN GOLDSTEIN, MD: Valerie is anesthetized at this point, so Valerie is not feeling anything.
The resectoscope is now pressing on the submucous fibroid. Using current, we are shaving the fibroid away. It is almost like cutting a wire knife through cheese. The electric current going through the wire loop allows us to cut. It also coagulates vessels as we're cutting.
PAUL MONIZ: We're seeing a lot of vessels on the surface here. The question that most people would have looking at this is, "Is the patient in danger of bleeding to death with all of these vessels being cut into?"
MARTIN GOLDSTEIN, MD: During the procedure this is done under control. As we're cutting the vessels, the current coagulates the vessels. As we remove the segment of the fibroid that has the vessels on it, we do not see any bleeding. When we get to the base of the fibroid, the part of the fibroid that comes from the muscle wall of the uterus, we get into the blood supply of the fibroid, which you are seeing now. The fibroid is a muscle tumor. It's very similar to the muscle of the uterus. We're now using coagulating current of a different frequency to coagulate the blood vessels that are feeing the fibroid. This is going to stop bleeding.
PAUL MONIZ: Tell us about the fluid that's used here. We want to get in some of that.
MARTIN GOLDSTEIN, MD: The liquid that we use is a substance called glycine, which distends or stretches the muscle of the uterus. The uterus itself is a potential cavity, rather than a true cavity. Unless we do something to stretch the cavity of the uterus, we won't be able to see.
PAUL MONIZ: You're taking something out here. Is this the actual mucosal area that's coming out?
MARTIN GOLDSTEIN, MD: We're removing segments of the submucosal fibroid. As we remove the segments of the submucosal fibroid, any parts of the fibroid that are within the muscle wall, the intramural component, is going to be further pushed into the cavity of the uterus. By doing this in a continuous fashion, we can remove a fibroid that may only be 50 percent submucous and 50 percent intramural. You can't take the instrument and push it into the muscle of the uterus because you run the risk that you may go through the outer wall. But, if you allow the muscle of the uterus time to contract, as the muscle contracts it pushes the fibroid into the cavity, so we can safely shave away more parts of the fibroid. By taking time and doing this carefully, we can remove almost the entire fibroid, and in most cases, the entire fibroid.
PAUL MONIZ: You have the instrument in your hand, the scope you use. Tell us about it? It looks almost like a staple gun of sorts with no staples.
MARTIN GOLDSTEIN, MD: The instrument that I have is a hysteroscope. This is the introducer of the hysteroscope. It is an obturator, or solid center. The patient has the cervix pre-dilated by use of a laminaria. When we get to the operating room, the cervix is open. I'm able to gently place this instrument through the cervix and into the uterus above. If my fingers were the cervix, I'm placing the instrument through the cervix and into the uterine cavity. Once the instrument is through the cervix, then I would remove the obturator and replace the obturator with the resectoscope.
The resectoscope is an instrument which has a viewing port, which will have a television camera attached to it, a light source, which provides light through a fiber optic source through the instrument into the uterus itself so we can see. Then there is a wire loop resectoscope that permits me to move the instrument back and forth and shave the fibroid.
PAUL MONIZ: This is what's key. At the end of this is the wire loop that has an electrical charge. That's what’s cutting, right?
MARTIN GOLDSTEIN, MD: The wire loop is the operative part of the instrument.
PAUL MONIZ: Very good information. Valerie, thanks for joining us. Again, we are obliterating your face because of the sensitive nature of this, but we do appreciate you turning up on our program today. Dr. Martin Goldstein, who is the Associate Clinical Professor of Obstetrics and Gynecology at Mt. Sinai. Thanks for you time as well.
I'm Paul Moniz. Thanks for joining us. Remember that 20-50 percent of all women have fibroids. If you believe you have one, and even if you think it's not causing any problem, you may want to talk it over with your doctor. As Valerie suggested, if there are problems, get a second or third opinion.