The Prerogative of Women
Innovative approaches to conditions from infertility to menopause to pelvic floor reconstruction are the hallmark of the USC physicians who are pioneers in the field of gynecology.
Protecting the gynecologic health of women is not just about controlling hot flashes and premenstrual pangs. It is more than birth control and birth plans. It is about issues and conditions that many women feel uncomfortable talking about: painful fibroids, devastating and malignant tumors, stress incontinence. The discomforts, the embarrassments, are not only real; they can have far-reaching consequences.
That is why it is important for women to be able to turn to doctors who are comfortable and adept at addressing even the most complex gynecologic conditions—from infertility to menopause to pelvic floor reconstruction. Daniel R. Mishell, Jr., M.D., and his colleagues at the Keck School of Medicine of USC have cared for thousands of women coping with often disabling and distressing conditions. At USC University Hospital, Mishell, the Lyle G. McNeile Professor of Obstetrics, and chair of the Department of Obstetrics and Gynecology, has led an effort to develop and fine-tune surgical procedures to alleviate or eliminate as much of that distress as possible. And in collaboration with oncologists at the USC/Norris Comprehensive Cancer Center, he and his colleagues have worked to attack gynecologic cancers from every angle possible.
Eliminating Incontinence
Wendy Reese began leaking urine when she was 40 years old. “I couldn’t do jumping jacks, I couldn’t run,” she says. “Just sneezing caused me to leak.” But the final insult came during a day at the shopping mall, when she had a sudden coughing fit. Once she had caught her breath, she realized she was standing in a puddle of urine. “I knew then that I had to do something about this.”
Reese—who asked not to have her real name used— is just one of 11 million women in the United States who suffer with the limitations imposed upon them by urine leakage. But while this condition is treatable some 80 percent of the time, fewer than half its sufferers find the courage to talk to their physicians about their condition.
Now, however, USC’s commitment to developing innovative procedures to treat urinary incontinence is helping to turn this closely guarded secret into a thing of the past for women like Reese.
Once the embarrassment of leaking began to outweigh the embarrassment of speaking up, Reese talked to her family physician. She was told that her problem was caused by her uterus pushing on her bladder. After a partial hysterectomy to relieve the pressure, she had about five years of relief. But then the leaking began again. “I had to wear a thick pad during my regular 3-mile walk,” she recalls. “After a while, even the pad could not keep me from wetting all over myself before the walk was halfway done. I tried to cope with this, but the situation continued to get worse.”
It was then that Reese was referred to USC University Hospital, and from William H. Kobak, M.D., assistant professor of obstetrics and gynecology, she learned about a minimally invasive surgical technique that might just be able to give her back her quality of life, and her well-deserved dignity.
When Reese met with Kobak, she was impressed with the number of choices available to her. “The one thing we stress to our patients,” says Kobak, “is that with fairly complex problems like this, one size doesn’t fit all. It is imperative to match the technique to the patient and make sure that the woman receives the treatment that works best for her.”
In fact, says Kobak, surgery is only necessary to treat urinary incontinence about 50 percent of the time. For the other half of patients, medication or physical therapy can do the trick. “Here at USC, we’re actively involved in some of the newer drug studies, offering the latest generation of medications that patients otherwise would not have access to,” he says. “This is the true beauty of our practice—we offer the full range of options.”
For Reese, however, surgery was deemed the best option. She and Kobak agreed to try a procedure to suspend the urethra using a new product called tension-free vaginal tape, or TVT, made by Ethicon, Inc. TVT and the minimally invasive operation needed to install it were approved three years ago by the Food and Drug Administration for use in the United States.
“The data has been limited, but so far it has proven to be effective and can be performed with minimal side effects,” Kobak says. “One of the best things about this approach is that it’s appropriate for many women, including those who have previously undergone other operations for incontinence.”
The operation creates a supportive sling out of polypropylene mesh tape, which is woven through the pelvic tissues and positioned beneath the urethra (the tube through which urine passes from the bladder to the outside of the body). When a patient coughs, runs or lifts something heavy, the TVT sling provides just enough support to allow the urethra to stay sealed, while still allowing the patient to empty her bladder when necessary.
The operation, which can be done on an outpatient basis under local anesthesia, generally takes under half an hour to complete. And most patients can return home the same day.
Reese was back at work within a week, and could walk around without a pad. “I still do some physical therapy exercises to maintain my continence, but it has improved my condition enormously,” she says. She gives much of the credit to USC University Hospital and Kobak, whom she calls “concerned, caring, respectful and gentle.”
She also has some words of advice for other women with urinary incontinence: “Don’t wait until you are embarrassed in public to take care of the problem. With the high quality of care available and all the new procedures, there is no reason not to obtain help.”
Removing Fibroids
Gynecologic surgery today bears little resemblance to the operations of old when complete hysterectomies were often the knee-jerk solution to many gynecologic problems. Today’s surgical mindset is one of minimalism. The most exciting areas of research in gynecologic surgery are those that seek to reduce invasiveness, or even eliminate the need for cutting altogether.
Donna Shoupe, M.D., professor of obstetrics and gynecology, takes USC’s desire for medicine high in innovation and low in invasiveness and applies it to the treatment of problems that can arise at menopause—or during the years that precede it, called perimenopause, when hormone levels start to fall. One such problem is the appearance of fibroids. Fibroids are non-malignant tumors arising from muscle cells in the uterus. While fibroids are not life-threatening, they can be extremely troublesome, causing a variety of problems depending on their size and location in the uterus. Excessive and frequent menstrual periods, pelvic pain, frequent urination, constipation and pain during sexual intercourse are all commonly associated with fibroids.
While some fibroids can be treated medically, surgery is sometimes necessary. Until recently, such surgery—called a laparotomy—invariably involved a large abdominal incision, the removal of the uterus and a three-to-five-day hospital stay, not to mention a six-to-eight-week recovery period. But now, Shoupe says, by employing a minimally invasive technique called laparoscopic myomectomy, the fibroids are removed and the uterine wall is repaired through several small incisions in the abdomen. “The advantage of this, in addition to a shorter hospital stay and quicker recovery time, is that some younger women can keep their uterus intact so that they can have children,” says Shoupe.
By offering this surgery, says Richard Paulson, M.D., professor of obstetrics and gynecology and an infertility specialist, USC and University Hospital are offering women a second chance that they might not get elsewhere. “Most women are still advised to have a hysterectomy when their uterus is distended with fibroids,” he says. “But that’s a big decision, especially for women of childbearing age. Even some women who are menopausal or postmenopausal want to keep their uterus. And that’s their right.”
Restoring Fertility
For many women, the decision to be voluntarily sterilized as a method of birth control can suddenly seem like it is no longer the right decision. “In 1995 alone, nearly 28 percent of reproductive-age women in the U.S.—10 million women—used sterilization as their method of birth control,” notes Paulson. “Later, many of these women found themselves remarried, or for some other reason decided to start a family or a second family. Whereas in vitro fertilization is very effective for these women, the most cost-effective method to achieve pregnancy is to undergo what is called microsurgical sterilization reversal or reanastomosis.”
What this entails, says Paulson, is a minimally invasive procedure to reconnect the two ends of the cut fallopian tubes through a tiny incision in the abdomen. “This is no small feat,” says Paulson, “since the channel inside the fallopian tubes is about as thick as a single hair on your head.”
Sterilization and sterilization reversals are not the only minimally invasive reproductive surgeries done at USC, notes Paulson. For instance, Charles March, M.D., professor of obstetrics and gynecology, treats women with recurrent miscarriage problems due to a uterine cavity defect (like fibroids or a partial wall of tissue called a septum) by excising the anomaly through a minimally invasive surgical procedure performed through the cervical opening.
Treating Cancer, Preserving Fertility
Even when the issue at hand is cancer, USC surgeons and physicians like to keep open as many reproductive options as possible. At the USC/Norris Comprehensive Cancer Center and Hospital, cervical cancer patients, for instance, are offered a new surgical procedure that may preserve fertility. Called radical trachelectomy, it involves the removal of the cervix while preserving the uterus, and it offers younger women with cervical cancer the chance to both retain reproductive capabilities and still effectively treat their disease.
“The traditional approach to invasive cervical cancer is to do a radical hysterectomy: the cervix and uterus are removed, and fertility is gone,” says Lynda Roman, M.D., associate professor of obstetrics and gynecology at the Keck School and head of gynecologic oncology at USC/Norris. That is not the case, however, for radical trachelectomy.
In fact, it gave Roman’s patient Raquel Rivas—just 25 years old when diagnosed with cervical cancer—the chance to conceive and give birth to twin girls only three years after her surgery.
The gynecologic oncologists at USC/Norris have popularized the procedure, which was developed in France. They are one of the few U.S. centers with substantial experience in the technique and have performed the majority of radical trachelectomies done in the United States. The USC/Norris group hosted a post-graduate course on this technique in 2000. Still, Roman is careful to control her enthusiasm. “For a select group of women with very early cancers, this appears to be a reasonable option that may allow them to maintain their fertility,” she says. “But until we have larger numbers with larger follow-up, we can’t say much more than that.”
Of course, being on the cutting edge of the treatment of women’s cancers is nothing new for the USC/Norris division of gynecologic oncology—thanks to gynecologic oncologist C. Paul Morrow, M.D., the Charles F. and Helen Ann Langmade Professor in Obstetrics and Gynecology. “The fact that we have physicians such as Morrow, who is a pioneer in the field with 30 years of experience treating women with cancers of the female reproductive tract, vividly illustrates the depth of expertise we have at USC,” says Mishell.
Morrow has led the division to international regard for its so-called multimodality approach to treating cancer. “We are effective because we attack the problem from all sides,” says Morrow, “determining the best combination of therapies for each individual patient.”
Morrow, Roman and their colleagues offer radical surgery procedures, pelvic reconstruction techniques and laparoscopic surgeries. And, always, they are searching out the latest and best techniques to treat cancers—and getting them to their patients as quickly as possible.
In the Department of Obstetrics and Gynecology — and at USC University Hospital and at USC/Norris — there is a shared goal. Throughout, all seek to help women cope with some very intimate problems, and help stop their often-silent suffering by providing visionary therapies.
“The innovations of the past 30 years continue to benefit women today,” notes Mishell. “The range of conditions we treat here at USC—and the complexity of these conditions—gives us a unique strength and allows us to offer women newer and more advanced alternatives.” ?
Lori Baker Schena contributed to this article.
For more information about gynecological research and treatment, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).
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