Women Learn Your Choices, Use Your Voices

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1 Special Edition Featuring GYN Surgical Options $3.00 Value Women Learn Your Choices, Use Your Voices New Tools, Faster Relief All Roads Lead to Freedom from Pain

2 Paul P. Hinchey Live Life Smart Pelvic Floor Disorders 1 Women - Learn Your Choices, Use Your Voices 2 The Anatomy of Mesh What is urinary incontinence? Women can experience a small leakage of urine every once in a while, but when leaks become frequent or severe, that s urinary incontinence or loss of bladder control. The two most common types are urge incontinence and stress incontinence. A Word from the President and CEO When new and different treatments develop in healthcare, it usually generates some excited discussion. But there are some conditions that people don t want to talk about, even with their trusted doctor. In fact, research has shown that millions of women suffer from a variety of gynecological issues, and do so in silence. The anxiety caused by sensitive or potentially embarrassing problems with their bodies can lead some women to endure a lesser quality of life. But there s simply no reason to suffer anymore. We are issuing this special edition of Smart Living to shed light on these conditions and the various ways that they can be effectively treated. In this issue, eight physicians give us the basics of some of the most common gynecological disorders. We learn that even the most serious types of these disorders can be treated with great success. We hope this edition of Smart Living will help women to communicate with their doctors with a new confidence, knowing that their condition is probably more common than they once thought and that their specific needs will be considered. Please feel free to share any suggestions or comments you have with us. 2 St. Joseph s Candler (Issue Name) Advancing the Standard 3 New Tools, Faster Relief 4 The Freedom of Stability 5 3 Pelvic Pain and Discomfort 5 All Roads Lead to Freedom from Pain 6 Seeing is Believing... and Treating 6 A Growing Concern 7 Shrinking the Problem 8 Too Much, Too Long 9 Quiz- Just the Facts, Ma am Savannah s Hospital for Women Several procedures detailed in this edition are completed in the exclusive integrated surgical suites of Mary Telfair Women s Hospital, where the physical and emotional needs of women and their families come first. Find out more at Women Learn Your Choices, Use Your Voices Laughter has often been called the best medicine. But for some women, the idea of laughing in public strikes fear in their hearts. These women suffer from urinary incontinence. They believe they are suffering alone, but according to recent research, almost 25 percent of American women have a pelvic floor disorder such as urinary incontinence or pelvic organ prolapse. Because of embarrassment, or the belief that these conditions are a natural part of aging, women don t tell their doctors about the problem. But physicians not only know how to treat incontinence and prolapse, they also have several different ways to do it. Treatments today are minimally invasive and each one can be matched to every woman to ensure the best chances for a successful outcome. With guidance from your physician, the choice is yours. Pelvic floor disorders can be treated effectively in different ways What is pelvic organ prolapse? To prolapse means to fall out of place, and that s what a woman feels is happening when pelvic organs, such as the bladder, have dropped out of their normal position. The organ has created a herniation because a tissue called the endopelvic fascia, which forms the connective structures of the pelvic floor, has weakened and given away. How does it feel? Depending on the degree of the problem, women may feel discomfort or even pain, and may experience abnormal bladder function, such as difficulty urinating or urinary incontinence. How is it treated? Kegel exercises, the contracting and relaxing of pelvic floor muscles, may help those who are only experiencing mild symptoms. But when a woman s quality of life is affected, she should discuss surgical options with her gynecologist (see pages 2-3). How does it feel? Urge incontinence feels like just that an overwhelming urge to empty the bladder that often causes leaks before a woman can get to the bathroom. Stress incontinence occurs when the tissues that support the bladder or the muscles of the urethra are weakened. A woman may feel leakage when she laughs, coughs, sneezes, or engages in strenuous activity. How is it treated? Kegel exercises and medications are used to treat urge incontinence. Kegels can also help with mild stress incontinence. But severe stress incontinence is treated surgically (see page 4). Do not hesitate to tell your doctor if you have symptoms of pelvic floor disorder. You don t have to suffer, you re not alone. 1

3 Advancing the Standard Pelvic organ prolapse can occur in different ways. Fortunately, physicians can treat it in different ways. Barry Schlafstein, MD Gynecology/Urogynecology The Anatomy of Mesh Even if you haven t heard of pelvic organ prolapse, odds are good that someone you know has it. Your friend, aunt or grandmother could have this, but she may be uncomfortable telling anyone, says Barry Schlafstein, MD. In fact, approximately half of all women over the age of 50 complain of symptoms associated with prolapse. They feel a heaviness or have a feeling that things are falling out, Schlafstein says. His preferred method of treating this disorder is linked to the connective tissue that is unique to the female s pelvic floor. All pelvic defects involve a weakening of the endopelvic fascia, Schlafstein says. This fascia contains wavy, smooth muscle fibers that are not found anywhere else in the female body and nowhere at all in the male body. The question was how to duplicate this tissue in a way that mimics its natural properties. The tongue-twisting answer is monofilament polypropylene material, which is knitted into a soft, flexible weave simply called mesh. This strong, permanent mesh basically becomes the fascia, Schlafstein says. The physician lays the mesh flat, repairing the prolapse and making sure the loads of stress are evenly distributed. The mesh has arm straps that function as ligaments and allow the physician to deliver the mesh into the proper position. The success rate for this procedure is high, and Schlafstein has received plenty of positive feedback from his patients. But he notes that it takes four to six weeks of topical hormone therapy to increase the supporting tissue strength needed for surgery. As always, women should discuss any possible side effects with their doctor. Schlafstein believes that mesh is an exceptional tool for restoring normal anatomy and function to the pelvic floor, and will continue to be for years to come. This concept is here to stay, he says. The use of mesh has revolutionized the repair of pelvic organ prolapse. When I choose a procedure, it s individualized for the patient s particular problem, says E. Daniel Biggerstaff, III, MD. For certain conditions, Biggerstaff s preferred procedure is what s known as a sacrocolpopexy. If the major problem is an enterocele with vaginal prolapse, the sacrocolpopexy is the gold standard, Dr. Biggerstaff says. An enterocele is the type of prolapse that occurs when the small intestine drops into the lower pelvic cavity, creating a bulge. For this condition, the defective tissue is reinforced with a synthetic mesh. The mesh is attached to an area at the lower end of the spine called the sacral promontory. This works as an anchor, reconstructing the defect to its normal anatomic position and holding it strongly. E. Daniel Biggerstaff, III, MD Gynecology Though the outcome of this procedure has provided relief to women for years, the surgery itself was another story. Traditionally, this required a large abdominal incision, Biggerstaff says. But if you can do it laparoscopically, it hastens the patient s recovery significantly. A laparoscopic procedure is a minimally invasive surgery in which a camera and surgical instruments are inserted through a small incision in the bellybutton. Being able to suture laparoscopically opens up a number of things that I can do for the patient s benefit, Biggerstaff says, noting the faster recovery time. Most patients who I treat with this procedure are able to go home that same day, and the return to normal activities is a lot quicker. Joseph T. Stubbs III, MD Fellowship - Trained Urogynecologist New Tools, Faster Relief Another reason that some women are reluctant to have surgery for pelvic organ prolapse... is that they ve already had prolapse surgery that has failed or know friends and family members who had prolapse surgery in the past with less than satisfactory results. Unfortunately many of the older procedures didn t work very well, says Joseph T. Stubbs III, MD. In the past, surgery for pelvic organ prolapse simply corrected the bulge; very little attention was paid to restoring normal anatomy and function. Women were dissatisfied with this. Today, new procedures meet the goals of pelvic reconstructive surgery: restore normal anatomy, restore normal form, and restore normal function. Abdominal sacrocolpopexy is one of the most successful operations used to correct vaginal vault prolapse, and is considered by many to be the goldstandard. However, over the decades, the tools and the approach have changed. Traditionally, abdominal sacrocolpopexy was performed through a single large abdominal incision after which patients had to remain in the hospital for several days. Additionally, patients were at risk for postoperative complications like infection, wound breakdown, and bowel obstruction. Today, by using the da Vinci robotic surgery system, Dr. Stubbs is able perform the surgery through a few small Band-Aid incisions, which is a much better option for prolapse patients. With the da Vinci surgical system, I am able to perform very complex surgeries through small incisions with a greater degree of accuracy than that afforded by open or other methods, says Dr. Stubbs. And for most patients this translates into a more meticulous dissection, less pain, less blood loss, and a shorter hospitalization. In fact, most women go home the morning after their surgery, and a great majority of these women report that they had little if any pain or discomfort after their surgery. All of which allows women suffering from pelvic organ prolapse to get back to their normal routines much faster and enjoy a better quality of life. 2 St. Joseph s/candler Special Edition

4 Stress Urinary Incontinence (SUI) affects more than 13 million women in the United States, all of whom may experience a leakage of urine when they laugh, sneeze, or exercise. But the public perception of what kind of women suffers from SUI has deterred women from seeking treatment. I think most women imagine an elderly woman wearing a diaper in a nursing home, says Carmela A. Pettigrew, MD. That s not representative of the majority of women who are suffering from it. In fact, women in their thirties and sometimes younger have dealt with SUI. Pelvic muscle strengthening and behavioral therapy can help alleviate symptoms for mild sufferers. But when you get to the point that you re wearing a pad every day, those won t work, Pettigrew says. Depending on the individual circumstances of the patient and the preference of the physician, the solution could be a Burch or sling procedure. A Burch procedure involves re-supporting the bladder neck, Pettigrew explains. We re-suspend the neck behind the back side of the pubic bone. There s a ligament there called Cooper s ligament, and we re-suspend it using permanent sutures to that area. The Burch procedure creates a stable environment that prevents any leakage when women are engaged in normal or even strenuous activities. It has been used for decades, but today physicians are able to do the surgery laparoscopically. This minimally invasive method allows physicians to create the same environment without making a large abdominal incision, resulting in minimal blood loss, shorter hospitalization, and a faster recovery for the patient. A tension-free transvaginal bladder sling is another minimally invasive option. Because the pelvic floor tissue can no longer support the urethra in its normal position, physicians use a strip of polypropylene mesh to take its place. The mesh prevents involuntary urine loss by allowing the urethra to remain closed when necessary, just as a women s natural tissue did before it was weakened. The Freedom of Stability Even women with severe incontinence will find strength in minimally invasive procedures. No matter which treatment option is chosen, the results can be dramatic. Opening up to your doctor about your symptoms is the first step in finding the best solution for you. Carmela A. Pettigrew, MD Obstetrics/Gynecology This changes a woman s life, Pettigrew says. Patients have an increase in self-image, and they can exercise without worry. Opening up to your doctor about your symptoms is the first step in finding the best solution for you. Soon after, you may rediscover the freedom in having a good laugh. All Roads Lead to Freedom from Pain Women may feel overwhelmed by the number of gynecological issues that they could possibly face. But for every condition, physicians have discovered more than one method of treatment. Discuss options with your doctor for every challenge that arises, including: Uterine Fibroids Uterine fibroids are non-cancerous tumors that develop within or attach to the wall of the uterus. They usually affect women over age 30. Fibroids don t always cause symptoms. When they do occur, the symptoms may include prolonged bleeding with periods, increase in urinary frequency, pelvic cramping or a feeling of pressure in lower abdomen. Some women may just need pelvic exams or ultrasounds every once in a while to monitor a fibroid s growth. Two very different procedures for more serious cases of fibroids are the myomectomy (see pages 6-7) and the uterine artery embolization (see page 7.) Endometriosis Endometriosis is a condition in which the tissue that normally lines the uterus grows in other areas of the body. This can cause painful periods, pain in the lower abdomen or pelvic cramps and pain during sexual intercourse. It can also result in irregular bleeding and possible infertility. Treatment depends on factors such as age and the severity of symptoms. Some women with mild endometriosis may just be monitored, having regular exams every six to twelve months so the doctor can make sure the disease isn t getting worse. Surgery is usually only done if a woman has a severe case (see page 6.) Different treatments exist for pelvic discomfort and heavy bleeding. Heavy Menstrual Bleeding One in five women experiences heavy bleeding during their menstrual cycle within their childbearing years. It is most common in women approaching menopause. Besides the risk of socially embarrassing menstrual accidents, heavy bleeding can also lead to anemia, or a lack of iron in the blood. If the condition can t be controlled with medication, a physician may use ablation, a procedure that can be done in different ways (see page 8.) These three conditions can sometimes be intimidating, but a thorough discussion with your physician can help you choose the best path to relief. You can walk away from pelvic pain and heavy bleeding confidently with your physician by your side. 4 St. Joseph s/candler Special Edition

5 A Growing Concern The surgical procedure known as myomectomy is an effective way to remove uterine fibroids, Melanie Helmken, MD Obstetrics/Gynecology Seeing is Believing and Treating Women who suffer from endometriosis might think that the more it hurts, the worse it is. But this condition is unique when it comes to pain. The pain is not in direct relationship to the amount of endometriosis you see, says Melanie Helmken, MD. Women can have incapacitating pain with just a few spots. Likewise, women who feel little to no pain may have severe endometriosis. Physicians can diagnose and treat based on symptoms, patient history and a clinical check-up, but they also have the option of using a laparoscope. With the laparoscope, you can not only confirm the diagnosis, but treat as well by using the laser to basically debulk, or remove, the majority or all of the endometriosis that s visible, Helmken says. Medication can also be used in conjunction with laparoscopy or on its own if a woman wants to avoid or cannot undergo surgery. Of the four different stages of endometriosis, most women have stage 1 or 2, with just a few spots that occur in different places in the pelvis. Stage 4 can include cysts full of clotted blood, extensive scarring and infertility. but patients and doctors must first decide what kind of myomectomy is ideal for each situation. The size and location of the fibroids determines whether to use open surgery or to do it laparoscopically, says A. Joseph Edwards III, MD. Laparoscopic surgeries result in less blood loss, less pain, and shorter recovery time. But it also takes longer than open surgery. Ultimately, it s between the patient and the physician to decide what s best for her. Fibroids can be microscopic or grow very large. They may fill the entire uterus, and could weigh several pounds. Although it is possible for just one fibroid to A. Joseph Edwards III, MD Obstetrics/Gynecology develop, usually there is more than one. Though the exact cause of fibroids is unknown, their growth seems to depend on a woman s estrogen. As long as a woman is menstruating, a fibroid will probably continue to grow, usually slowly. Fibroids are more common in African-Americans than Caucasians, but are rare in women under 20 or in those who have gone through menopause. Fibroids don t necessarily have to be removed, Edwards III says. It depends on the symptoms. I will hear the patient s history, and give them a physical exam and pelvic ultrasound. A patient s symptoms often speak for themselves. Robert Myers, MD Radiology Shrinking the Problem Uterine fibroids are benign, but they are also unpredictable. Women may have just one or a few large fibroids that, depending on their location, can be removed surgically. On the other hand, women can have several small fibroids that are located in areas where the surgeon has difficulty reaching them. One method of treating all the small fibroids at once is called uterine artery embolization. Embolization is the injecting of particles to stop the blood flow to a particular part of the body, says Robert Myers, MD, a radiologist who is specially trained in this procedure. The idea is that fibroids are very vascular structures, so they require a lot of blood flow to grow and live. If you can cut off their blood flow, they can no longer cause the symptoms. With embolization, a small catheter is placed into an artery in the groin through which microscopic beads are injected. The beads selectively occlude the blood flow to the fibroids, essentially killing them and causing them to shrink. Though they remain in the uterus, these shrunken fibroids no longer cause pain or excessive bleeding during periods because they no longer have the blood supply. Removing those cysts can be one of the most difficult surgeries there is, Helmken says. Severe menstrual cramps may be a symptom of endometriosis. Suspecting and controlling this common condition early can prevent more severe problems later in life. It often has a familial component, Helmken says. If you have endometriosis, your mother, sister, or aunt may have already gone through it. Luckily, in most cases, endometriosis can be controlled with oral medications, allowing women to avoid surgery and still find relief from the pain. The unique thing about it is that they don t stop the blood supply to the uterus, just to the fibroids, Myers says, noting that women will have a normally functioning uterus and can have successful pregnancies after the procedure. Not all women who suffer from fibroids are candidates for this procedure. The size, number, and location of the growths are all variables that a woman and her doctor must consider. It is important for women to see their gynecologist and discuss their treatment options before choosing one, because different procedures will be right for different women, Myers says. The most important thing is to have an informed decision process. 6 St. Joseph s/candler Special Edition

6 Too Much, Too Long Women can find relief from heavy bleeding without fear of incision. The menstrual cycle is not the same for every woman. On average, menstrual flow occurs every 28 days and lasts about 4 days. But there is wide variation in timing and duration that is still considered normal. Women who think their bleeding is too much or too long should talk with her doctor about possible causes and treatment options. For those whose Quiz Just the Facts, Ma am Myths and half-truths can make women fearful of learning the truth about what s bothering them. Take this quiz and when you talk with your doctor, you ll be surprised to find how much you already know. Alan Smith, MD Obstetrics/Gynecology symptoms are severe and resistant to medical therapy, the physician may suggest endometrial ablation. The endometrial glands are where the bleeding comes from in a period, says Alan Smith, MD. This area changes during a woman s normal cycle. It builds up, getting thicker and thicker, then sheds off with a period. An endometrial ablation destroys much of this layer, which is rich with blood vessels. The physician destroys most of the layer down to the muscle, so that when it s time to bleed, there s essentially nothing there, Smith explains. There are different types of ablations, but all methods are quick. Luckily, there are no incisions involved. Several physicians will use an electrosurgical tool or laser to remove the lining. Other physicians prefer a method known as hydro-thermal ablation. The physician fills the uterine cavity with fluid, which is then heated almost to the boiling point. Through a tiny camera that is inserted into the uterus, the physician can see the dark red or pink lining turn to a grayish-white. This indicates that the glands have been effectively destroyed. This kind of ablation is also effective for women who have an irregularly shaped uterus or a large fibroid. A third method utilizes a handheld wand that expands within the uterus according to the physician s measurement. The instrument then delivers electromagnetic energy to remove the lining. No matter which procedure is chosen, women can expect a fairly short recovery time. It s pretty straightforward and simple, Smith says, noting his high success rate with the hydro-thermal method. Between 80 to 90 percent of patients have either a reduced period or no period at all after the procedure. Approximately 50 percent of patients simply have no period. Women who want to become pregnant should not have endometrial ablation. However, a woman who does have the procedure will still have her reproductive organs and should continue to visit her doctor for pelvic exams. No matter which procedure is chosen, women can expect a fairly short recovery time. Within a day or two, women are able to return to work and enjoy the simple pleasure of being themselves again. One of the most important issues women should discuss when weighing treatment options for pelvic floor disorders or pelvic pain is: A. Which procedures Angelina Jolie and Jennifer Aniston have had. B. Whether or not you want children. C. Which procedure uses the newest technology. D. Options for what? I don t have those old lady problems and never will. B. Whether or not you want children. Women of child-bearing age who plan to have kids are not candidates for certain procedures. Source: The Health Encyclopedia at Pelvic prolapse can occur in women who have: A. Had one or more vaginal births. B. A lack of estrogen after menopause. C. A chronic cough. D. Problems with obesity. E. All of the above. E. All of the above. Prolapse can also be caused by a pelvic tumor, although this is rare. Chronic constipation and the pushing associated with it can worsen prolapse. Pedunculated fibroids are different from other uterine fibroids because they: A. Don t occur in child-bearing years. B. Are cancerous. C. Hang from a long stalk that is attached to the outside of the uterus. D. Always grow in an L or foot shape. C. Hang from a long stalk that is attached outside of the uterus. Pedunculated fibroids may cause sudden and severe pain. Only older women should worry about suffering from urinary incontinence. A. True B. False B. False. While incontinence is most common among the elderly, it does not exclude younger women. If a woman suspects she has urinary incontinence, she should not hesitate to mention it to her doctor, no matter what her age. Menstrual cycles vary among women, but bleeding may be something to worry about if it occurs between periods or after intercourse. A. True B. False A. True. Prolonged bleeding for women over the age of 50 or who have already gone through menopause could also indicate a serious problem. 8 St. Joseph s/candler Special Edition

7 TO LEARN MORE The medical staffs of St. Joseph s/candler and the Mary Telfair Women s Hospital have some of the most highly skilled physicians in the region. The contributors to this edition are examples of some of these outstanding physicians on staff at St. Joseph s/candler. For more information, call CareCall at (912) or (800) or visit our website at Edward D. Biggerstaff, III, MD A. Joseph Edwards, III, MD Melanie B. Helmken, MD Robert K. Myers, MD (Radiology) Carmela A. Pettigrew, MD Barry Schlafstein, MD Alan E. Smith, MD Joseph T. Stubbs, III, MD Mary Telfair Women s Hospital, the regional leader in the delivery of women s healthcare services, provides a full array of obstetrical, gynecological, surgical, and educational health services, and includes the Telfair Pavilion, The Telfair BirthPlace and The Children s Place as well as dedicated, integrated operating rooms for the special needs of gynecological surgery. Find out more at St. Joseph s/candler is the recipient of the national Magnet Award for Nursing Excellence St. Joseph s/candler. All Rights Reserved Reynolds Street Savannah, GA CHANGE SERVICE REQUESTED Nonprofit Organization U.S. Postage PAID Savannah, GA Permit # 254