Hysterectomy: improving the patient's decision-making process

A Study of Patients Undergoing Abdominal Hysterectomy in Tertiary Care Institute

Background Hysterectomy is one of the most common surgical procedures performed.Patient education, compliance, and socioeconomic status are important determinants in choosing the mode of treatment; however, medical treatment is usually inadequate.Thus, in the present study, we tried to study the various profiles of patients undergoing abdominal hysterectomies reported in tertiary care centers. Materials and Methods  Brief clinical data were noted from the case records, which include age, parity, presenting symptoms, past surgical and medical history, hemoglobin status, preoperative dilatation and curettage, and indications of hysterectomy. Results Most hysterectomies were performed on women between the ages of 41 and 45, with the average parity being 3.2 and the majority of cases having three children. Abnormal vaginal bleeding associated with various forms of menstrual irregularities was the most common complaint for which patients sought advice, and the incidence of patients undergoing tubal ligation was the most common previous surgery procedure, with anemia being the most common preoperative-associated condition. The fibroid was the most common demonstration in the current study, which brought forth abdominal hysterectomy for the chosen participants. Conclusion Findings from the current study suggest abdominal hysterectomy to be the most preferred route of surgery commonly in the women of age group 40 to 45 years or higher, precisely due to the occurrence of a higher parity rate in this age category. Fibroid uterus, dysfunctional uterine bleeding, and the presence of other menstrual complaints were the most probable indications for abdominal hysterectomy demonstrated by the individuals in the present study. Moreover, anemia was the most predominant complication associated pre-operatively, followed by other clinical manifestations such as hypertension, diabetes mellitus, and urinary tract infection.

Discussing sarcoma risks during informed consent for nonhysterectomy management of fibroids: an unmet need

There is no reliable way to distinguish symptomatic uterine fibroids from sarcoma without a surgical specimen. Many women with a uterine sarcoma are initially managed without hysterectomy under a presumed fibroid diagnosis, without understanding sarcoma risks. Currently many alternatives to hysterectomy, including medical and procedural interventions, for treatment of fibroids are promoted. The sarcoma incidence among women with presumed fibroids is 0.29% (1/340) to 0.05% (1/2000). Nonmetastatic leiomyosarcoma has a 63% 5-year survival rate whereas metastatic leiomyosarcoma has a 14% 5-year survival rate. In uterine sarcoma, we often cannot identify who has sarcoma before making a potentially cure-denying decision by delaying surgery. Therefore, women electing an alternative to hysterectomy for fibroids should undergo an informed consent process that specifically includes discussion of uterine sarcoma incidence and mortality. Alternatives to hysterectomy for presumed fibroids remain preferable treatment options for many women with symptomatic fibroids, so long as underlying sarcoma risks are adequately discussed. The challenge for obstetrician- gynecologists then is how to provide better informed consent and maintain the primacy of patient autonomy over our concern to "First, do no harm." Major threats to patient's autonomy are faced in the sarcoma risk discussion. How we should present sarcoma risk information to avoid being dismissive of sarcoma or frightening women toward hysterectomy is unstudied. Research is needed to determine how to provide sarcoma risk information with less bias during informed consent.

Association of the CYP17 gene polymorphism with risk for uterine leiomyoma in Brazilian women

BACKGROUND

Uterine leiomyoma is the most common pelvic tumor in women of reproductive age. It is well established that endogenous sex hormones are involved in disease pathogenesis, and polymorphisms in genes encoding enzymes which act in the metabolism of steroid hormones, such as that for cytochrome P450c17alpha enzyme (CYP17), may therefore play a role in fibroid genesis. Variations in this gene have been thought to influence the susceptibility to hormone-related diseases. A single nucleotide polymorphism (T-->C) [rs1042386] in promoter region of CYP17 may alter its transcription. The present study was conducted to investigate the association between this polymorphism and the presence of uterine leiomyoma in Brazilian women.

METHODS

Genotyping of CYP17 was performed in 121 uterine fibroid patients and 120 unaffected women, using polymerase chain reaction and restriction fragment-length polymorphism analysis.

RESULTS

No significant difference in the CYP17 genotype distribution was noted between cases and controls (p = 0.165).

CONCLUSION

These findings suggest that the CYP17 gene polymorphism studied is unlikely to be associated with risk for uterine leiomyoma in Brazilian women.

Informed consent issues in the conduct of bariatric surgery

BACKGROUND

The goals of this article are to set forth the principles involved in obtaining informed consent in the context of bariatric surgery and to change the widely held perception that proper informed consent is an empty paper exercise. The ever-expanding use of bariatric procedures is associated with a profusion of data regarding the risks, benefits, and expected outcomes. It is now possible for physicians who perform bariatric surgery to know the reported data on the morbidity, mortality, and rehospitalization rates. Communicating this information to prospective patients is necessary for the process of informed consent.

METHODS

A literature review of the work done in the areas of informed consent as it relates to bariatric procedures was performed to provide state-of-the-art information of this important topic.

RESULTS

Ethically, the concept of informed consent arises from the deep-rooted American respect for the independence of one's right to decide what is or is not done to one's body. Legally, the physician has two duties: to obtain consent and to provide information to allow the consent to be informed. The elements required for proper disclosure and consent have been codified by a variety of professional organizations.

CONCLUSION

Done properly, informed consent allows patients to have a more realistic expectation of the outcome and could also allow more effective participation in their own care. We conclude with possible directions for additional research, improvement of the consent process, and the inclusion of new technologies as they arise.

The second National Institutes of Health International Congress on advances in uterine leiomyoma research: conference summary and future recommendations

OBJECTIVE

To summarize the proceedings of the Advances in Uterine Leiomyoma Research: 2nd NIH International Congress, which was convened on February 24-25, 2005 by the Department of Health and Human Services (DHHS), National Institutes of Health (NIH) in Bethesda, Maryland.

DESIGN

Scientific information was presented at a 2-day conference, which was a collaborative effort of agencies across the DHHS and members of the academic, clinical, and medical communities involved in uterine leiomyoma research.

CONCLUSION(S)

The conference brought together scientists in biomedicine, epidemiology, basic research, therapeutics, and translational medicine and fostered an exchange of scientific information among members of the uterine leiomyoma research and health care communities. This document summarizes this exchange and outlines research needs and recommendations for future research directions.

The integration of a woman's perspective in hysterectomy decisions

It has been argued, based on a limited amount of research data, that patient participation in decision-making regarding surgery, results not only in more patient satisfaction, but also in better surgery outcomes. Especially in a procedure such as hysterectomy, with far-reaching consequences and many potential side effects, it may therefore be relevant to promote an active role of the patient in the decision-making process. The article identifies contextual elements that might promote this active role. Subsequently a model of participative, informed decision-making is outlined. The model entails that clinical guidelines should be adjusted to the particular situation at hand and that patients should be fully informed about hysterectomy-involved risks. An overview of the various guidelines and risks is provided. Proper counseling in the decision-making phase as well as in the post-hysterectomy period is advocated. Throughout the article attention is paid to documented and undocumented ethnic differences regarding various aspects of hysterectomy, particularly differences in patient participation around the world.

Offering patients the opportunity to choose their hospital for total knee replacement: Impact on satisfaction with the surgery

OBJECTIVE

To describe the extent to which patients were offered a choice between 2 or more hospitals for total knee replacement (TKR); to examine the association between having a choice of hospital for TKR and satisfaction with the surgery; and to identify population groups less likely to be offered a choice.

METHODS

We studied a population-based sample of 932 Medicare beneficiaries who underwent elective TKR in 2000. We surveyed patients about their participation in choosing a hospital and their satisfaction with surgery. We examined whether lack of hospital choice influenced satisfaction with surgery after adjusting for age, sex, preoperative function, and socioeconomic status.

RESULTS

Among 932 TKR recipients (mean age 74 years, 67% women), more than half (53%) reported having a lack of hospital choice. After adjusting for socioeconomic status, patients reporting lack of choice were approximately twice as likely to be dissatisfied with the results of surgery as patients who reported choosing among 2 or more hospitals for TKR (odds ratio [OR] 2.09, 95% confidence interval [95% CI] 1.13-3.87). Results of logistic regression revealed that patients reporting lack of choice were more likely to be women (OR 1.52, 95% CI 1.14-2.04), >80 years of age (as compared with 65-70 years; OR 1.63, 95% CI 1.03-2.57), living in suburban areas (OR 1.68, 95% CI 1.23-2.30), nonwhite (OR 1.57, 95% CI 0.86-2.87), and were less likely to have TKR performed by a high-volume surgeon (OR 0.71, 95% CI 0.53-0.96).

CONCLUSION

More than half of the patients did not have a choice in selecting the hospital where they had TKR. Patients reporting lack of choice were more likely to be dissatisfied with surgery. Interventions to address preferences for hospital may improve satisfaction with care for patients with advanced knee arthritis.

Current treatment of dysfunctional uterine bleeding

OBJECTIVES

We performed a review of the treatment modalities for dysfunctional uterine bleeding.

METHODS

Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies.

RESULTS

Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores.

CONCLUSION

Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

Danish gynecologists' opinion about hysterectomy on benign indication: results of a survey

AIMS

To survey Danish gynecologists' recommendations concerning hysterectomy and its method for benign diseases.

METHODS

A questionnaire of seven clinical cases was sent to all gynecologists in Denmark (n = 450). The gynecologists were asked to recommend one of 14 possible treatments as the most appropriate for each case. In cases of hysterectomy the gynecologists were asked to rate the appropriateness of oophorectomy. Questions about age, employment, geographic area, sex of the gynecologist and preference of the hysterectomy method for themselves/their wives were included. RESULTS. THE RESPONSE RATE WAS: 73%. For women aged > or = 50 years meno-metrorrhagia and symptomatic fibroids seemed to be important for hysterectomy recommendations, and for those aged < 50 years asymptomatic fibroids and unexplained pelvic pain seemed important for recommendation of other treatments. Employment, gender and geographic area influenced the recommendation of hysterectomy, and employment and geographic area only for the recommended method. Most of the gynecologists recommended the abdominal route and preferred the subtotal method. The gynecologists agreed on the recommendation concerning oophorectomy in cases of women aged under 46 years and over 55 years. Disagreement was found in cases of perimenopausal women. The gynecologists' preferences for hysterectomy methods did not differ from their recommendations for the cases.

CONCLUSIONS

Agreement regarding the recommendation of hysterectomy was found in cases of postmenopausal metrorrhagia, while disagreement was found in cases of asymptomatic leiomyomas and unexplained pelvic pain. The gynecologists preferred the abdominal route and the subtotal hysterectomy method. Certain attributes of the gynecologists were found to be important to the recommendation of hysterectomy and its method.

Reduced expression of early growth response-1 gene in leiomyoma as identified by mRNA differential display

OBJECTIVES

Despite being the most common pelvic tumor in women, little is known about the molecular basis of uterine leiomyoma growth. The purpose of this study was to (1) identify genes important for leiomyogenesis by comparing gene expression in leiomyoma and normal myometrium and (2) examine the expression level of selected genes on a larger panel of leiomyomas.

METHODS

The technique of mRNA differential display (DD) was used to perform a larger survey of gene expression in leiomyoma by comparing it to matched normal myometrium. Transcripts differentially expressed in leiomyoma were sequenced and further analyzed. Selected differentially expressed transcripts were used as probes on RNA blots of 20 pairs of leiomyomas and their matched myometria to evaluate their expression. The level of expression was analyzed by densitometry.

RESULTS

From 80 differentially expressed transcripts picked by DD, 30 were sequenced and compared to GenBank data. Selected transcripts were analyzed for mRNA levels on a panel of 20 pairs of leiomyomas and matched normal myometria. One transcript that matches the early response gene EGR1 was found to be dramatically reduced (9.2 times on average) in leiomyomas. The reduction was present in 100% of the tumors.

CONCLUSIONS

mRNA differential display is a valid method for finding differences in gene expression between leiomyoma and normal myometrium. The consistency and level of EGR1 mRNA reduction in leiomyoma is an indication that this gene may play a role in the origin or growth of leiomyoma.

When withdrawal of life-sustaining care does more than allow death to take its course: the dilemma of left ventricular assist devices

BACKGROUND

Left ventricular assist devices (LVADs) are a relatively new technology that is increasingly used to preserve cardiac function. These devices work by a mechanism that may complicate ethical decision-making for patients who subsequently lose decision-making capacity and are no longer considered transplant candidates.

METHODS

Using a clinical case from our medical center, we explored the complex ethical issues associated with the discontinuation of LVAD therapy by discussing how this device is distinct from the withdrawal of other treatments.

RESULTS

While halting an implanted LVAD may permit a patient to die, the deactivated device itself may contribute to patient death due to the potential for blood backflow and pooling, as well as the disruption of heart contractility. Inadequate informed consent and failure to appoint a surrogate decision-maker in advance of the implant procedure resulted in a complex ethical dilemma for the patient's family and the medical team.

CONCLUSIONS

Clinicians and families must consider the benefits and burdens of LVAD therapy as they do when considering removal of other life-sustaining treatment. The informed consent process associated with LVADs as bridging technology should include extensive consideration of the purpose of the device, future circumstances in which it may be halted, and how such situations would be recognized and handled. Appointment of a surrogate decision-maker before the surgical procedure is essential.