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Treatment of myoma by Gruppo Italo Belga

Treatment of myoma We suspend (temporarily) the use of ESMYA Treatment of Myoma by GIB : suspension of ESMYA treatment Symptomatic  uterine myoma’s need  treatment.  Symptoms can be discomfort and/or pain especially when larger.  Submucous myoma’s can contribute to infertility. The etiology of most –if not all- myoma’s are genetic or epigenetic incidents to the myometrial cells, similar to the etiology of endometriosis. This explains  racial and hereditary differences in prevalence. It also suggest that similar to endometriosis myoma’s can be heterogeneous and that all myoma’s do not react in a similar manner to estrogens and progestogens.  Surgical treatment Being a benign tumour the primary treatment is surgery which can be Hysteroscopic myomectomy for intracavitary or submucous myoma’s.  We explain the possibilities and relative benefits of a 2 step surgery  when these myoma’s are bigger than 4-5 cm or intramural. This will permit a personal choice by the individual woman. Laparoscopic myomectomy . The relative benefits and possibilities of a laparoscopic myomectomy,  of eventually multiple myomectomies  and of a subtotal hysterectomy will be explained. This will permit women to take personal decisions after taking into account age, and fertility. Also for very large myoma’s  it will be discussed beforehand when we consider that a mini-laparotomy is preferable  to extensive laparoscopic suturing Also the risk and benefits of morcellation  and the risk of sarcoma spreading  are discussed  in order to permit individual choices. Medical treatment Until the recent introduction of ESMYA there was no effective medical treatment of myoma’s. Results have been promising especially for bleeding. ESMYA an antiprogestin.  Recently serious liver injury, including liver failure leading to transplantation was...

Variable Quality of surgery

Quality of surgery   Quality of surgery is variable In Belgium we are having a discussion on quality of surgery and cost for the patient. At the University hospital gasthuisberg, patients were informed that for private patiens the Professor would do the intervention himself; otherwise it would be done by a registrar in training. This has been widely considered unethical and socially unacceptable since equal quality for everybody is a dogma of Belgian medicine.  In a press release, the conclusion was that quality was the same for everybody since the registrars in training  were well supervised and since all gynecologist or surgeon are considered equal because of their diploma. Unfortunateoly this is  not true and the quality of diagnosis and of treatment can be very variable.  This is easy to illustrate for surgery and the examples given are restricted to comments made before during presentations or in publications. Quality is variable “We only recognize what we know ”. This is well known for the diagnosis of endometriosis. Even large and vaginally visible nodules are often missed during clinical exam. Even during surgery many severe deep endometriosis nodules of the sigmoid will be missed. ‘The best technique is the one the surgeon is familiar with  ”, is often heard at meetings . This is unacceptable.  If the superiority of a technique has been demonstrated, the surgeon should be obliged to use it.  The advantages of a laparoscopic treatment of an extra-uterine pregnancy in comparison with a laparotomy are well demonstrated. Yet so many women are still treated by laparotomy because the gynecologist on duty does not have the skills. “Do...

Pandora’s box of endometriosis therapy

Pandora's box of endometriosis therapy   Pandora’s box of endometriosis therapy Evidence based medicine Therapy in medicine should be based on evidence.  This is important to ascertain that a therapy is useful without side effects.  It protects the patient from practices without a proven benefit and reduces the cost of medicine. Evidence based medicine has developed a ranking of evidence known as the pyramid of evidence. This ranking is mathematically correct with the Randomised Controlled Trial on top. Randomisation avoid an allocation bias and ascertains that the 2 groups are identical. The limitations of a RCT A non blinded trial of pain therapy is not useful. The effect of a treatment should be evaluated without bias. This is obvious If the effect can be objectively measured as height or weight. For endpoints as pain or well being, there is the well know placebo effect and observer bias. RCT on pain and well being thus have to be double blinded to be valid. A RCT trial is not useful for complex multimorbidities. The results of a RCT are rue only for the group of women investigated and cannot be extrapolated. What can be a valid conclusion for 20 year old is not necessarily valid for a 60 year old. For this reason RCT are not suited for multi-morbidities. only Clinical observation can detect rare events. A RCT evaluates a group as a whole and cannot detect or exclude a (hidden) small subgroup with an opposite effect. Only after detection by clinical observation this can be evaluated by another RCT. The player Bias Treatment varies with the specialist in infertility medical...

Premenstrual syndrome

Premenstrual syndrome PMS - endometriosis   PMS or premenstrual syndrome and endometriosis A recent question by a patient prompted us to review premenstrual syndrome(1-4). The traditional view Premenstrual syndrome is a frequent, well known (4500 hits on pubmed) but poorly understood syndrome, occurring to some extend in most if not all women in the premenstrual period . The symptoms of PMS are variable. Some women have mainly brain symptoms or premenstrual dysphoric disorder with feelings as irritability, depression, mood swings, nervousness, irritation, sleep disturbances, character changes and more severe psychiatric syndromes. Other women mainly complain  of  ‘progesterone’ effects  as abdominal bloating, water retention and breast tenderness. Traditional gynecology and endocrinology consider progesterone concentrations or hormone changes  as the driving motor of PMS. It seems logical since PMS occurs in the luteal phase of an ovulatory menstrual cycle. The ‘classic’ but empirical treatment with progesterone orally or intra-vaginally,  unfortunately is not very effective. Even the suppression of ovulation is not that effective according to a recent Cochrane review (5). What is missing in the literature ? Traditional gynecology and endocrinology do not consider clinical observation as valuable information. When Evidence Based Medicine becomes a religion what is not proven -preferentially in a RCT-  does not exist.  We recently discussed this in detail for surgery(6). After 30 and 40 years of gynecologic endocrinology and endometriosis we consider important for PMS The effect of age : in young women severe PMS is rare; it increases with age and decreases after 45 years The importance of an uterus : severe PMS is extremely rare in the absence of a uterus even in women...

Shiny Trinket

Shiny trinkets are shiny.