22 Jul Fibroid Awareness Month: Choosing Wisely Part 2
In the previous article, we talked about how our Fibroid Clinic addressing and utilizing Choosing Wisely® recommendations from The American College of Obstetricians and Gynecologists (ACOG). In this article, we will address the recommendations of The American Association of Gynecologic Laparoscopists (AAGL).
At Froedtert & The Medical College of Wisconsin since April 2018, the departments of Obstetrics & Gynecology and Radiology have collaborated to offer women affected by uterine fibroids a joint consultation with a fellowship-trained Minimally-Invasive Gynecologic Surgeon (Dr. Benjamin Beran) and an Interventional Radiologist (Dr. Alexandra Fairchild). The focus of this visit has always been treatment options that are alternatives to hysterectomy, but discussions of hysterectomy also occur.
Since 2012, the Choosing Wisely® campaign’s mission has been to promote conversations between clinicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
The Choosing Wisely® campaign asked leading medical organizations to come up with lists of tests or procedures commonly used in their field whose necessity should be questioned and discussed. A complete list of recommendations can be found at their website www.choosingwisely.org.
The American Association of Gynecologic Laparoscopists (AAGL) is the largest international, professional society in minimally invasive gynecology with over 7,000 members. AAGL works with some of the world’s finest gynecologic surgeons to promote quality health care for women by advancing minimally invasive gynecologic practices through clinical practice, research, innovation, and dialogue.
Recommendation #1 – Do not perform a laparotomy for the management of non-malignant disease when surgical management is indicated and a vaginal, laparoscopic, or robotic-assisted approach is feasible and appropriate.
Laparotomy is the term for surgeries of the abdomen and pelvis that require large skin incisions (similar to those used for cesarean deliveries). Laparoscopy involves the use of multiple small, 1-2cm, incisions through which cameras and instruments are used to perform surgery. Performing surgery through small incisions reduces the risk of infection, blood clots, and adhesions, and allows patients to have quicker recovery times. Most patients having minimally-invasive surgery, including myomectomy or hysterectomy, are able to go home the same day of surgery. Dr. Beran’s fellowship training helped him gain surgical skills to perform laparoscopy for fibroids, including very large fibroids, in most cases so that our patients are exposed to the least risk, and the shortest recovery times possible. Dr. Fairchild’s treatment options including uterine artery embolization and MR-guided focused ultrasound therapy do not require incisions at all!
Recommendation #2 – Do not perform routine oophorectomy in premenopausal women undergoing hysterectomy for non-malignant indications who are at low risk for ovarian cancer.
A hysterectomy, by definition, does not involve the removal of ovaries. If indicated, ovaries can be removed during a hysterectomy, but is typically not necessary in non-cancer cases. Ovaries make estrogen, a hormone beneficial for women’s heart, brain, and bone health. While production is at its highest prior to menopause, there is benefit to not removing ovaries after menopause until at least age 65. As fibroids are much less likely to cause symptoms after menopause, it is rare that ovaries would need to be removed during surgery for uterine fibroids.
Recommendation #3 – Do not routinely administer prophylactic antibiotics in low-risk laparoscopic procedures.
In many surgeries, intravenous antibiotics are given near the time of incision to reduce the risk of surgical infections. This has been demonstrated to be extremely helpful in reducing infections after hysterectomy, and recent data suggests that patients undergoing myomectomy have lower risk of infection when receiving antibiotics at the time of surgery. Given this data, patients undergoing hysterectomy or myomectomy with Dr. Beran receive antibiotics before all cases, unless it is a myomectomy performed through hysteroscopy alone (sliding a camera through the cervix without making any incisions).
Recommendation #5 – Avoid opioid misuse in the chronic pelvic pain patient without compromising care through education, responsible opioid prescribing, and advocacy.
The opioid epidemic has had a negative effect on many Americans with numerous lives affected through addictions and overdoses. As physicians, Dr. Beran and Dr. Fairchild, take their roles seriously in reducing the use and prescribing of opioid medications. By performing minimally or non-invasive procedures, the need for pain medications is less. Additionally, it is rare that uterine fibroids cause chronic pain issues, and the team works to identify what other conditions may exist to lead to these chronic conditions. Some fibroids may grow so large that patients are uncomfortable with pressure due to the size, and this is best addressed through surgery or procedures, not opioid prescribing. Opioid medications are used responsibly during the post-operative period to ensure adequate pain control.
Learn more about our Fibroid Clinic: Alternatives to Hysterectomy.