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From: sbharris@ix.netcom.com (Steven B. Harris )
Subject: Re: Chi or Qi (was Re: ho
Date: 28 Sep 1995
Newsgroups: misc.health.alternative
In <44e79o$lhm@ixnews2.ix.netcom.com> netstuff@ix.netcom.com (Jim )
writes:
>In <44cf4j$mo4@ixnews4.ix.netcom.com> sbharris@ix.netcom.com (Steven B.
>Harris ) writes:
>
>> Well, whenever I hear a statistic like that, I always wonder who
>>decided "need." Quite a lot of surgery is done to make people's lives
>>better. Do they really "need" it? That sort of depends on who you
>>ask. Does a 55 year old woman with vaginal bleeding every day from
>>fibroids "need" a hysterectomy? No doubt a fitting question for the 12
>>men on the board of the XYZ insurance company 2,000 miles away. Yes?
>>Let's not ask the woman-- after all, what does she know about medicine?
>>
>>
>> Steve Harris, M.D.
>
>Don't get met started on the sexist medical view of women by male
>doctors. Here's another dumb statistic for you. 70% of surgical patients
>are women. It's easier to make a case for castration of men over 50 for
>medical reasons than the typical hysterectomy for a woman.
Not really. I just gave you the reason for the typical hyterectomy
undertaken by the typical woman. Men don't have anything remotely like
it.
> When and
>ever IF did you recommend that procedure for a man?
I used to in the days before Lupron for prostate cancer. But it's a
completely different thing. At 45-55 years of age, for instance, a
woman's ovaries simply quit working anyway. This doesn't happen to
most men. There again is a big intrinsic difference. I'm not
responsible for it-- go out and shake you fist at the sky if you don't
like it.
> The fox
>(insurance) and wolf (doctor) have got the chicken (patient) cornered
>in the chicken pen (medicine). BTW bad example. Hysterectomy for
>bleeding fibroids is a thing of the past even in modern conventional
>medicine.
You're quite wrong. Lasers and so on have reduced the need, but
not to zero. And we haven't had lasers that long.
> Any OB/GYN who recommends that procedure should be taken out
>>and castrated.
In your informed opinion? What the hell do you know about it?
Please post your credentials, and the training which is behind this
obnoxious opinion.
> The good doctor still has his balls but some his patients are missing
their wombs.<<
Ovaries are a bit more like balls (with the exception of the fact
that beyond 55 the average woman's ovaries do nothing but sit there
threatening to kill her). If you want a better analogy to hysterectomy
or uterine surgery, it would be TURP for prostatic problems. And yes,
I know many an older male physician who's had a TURP.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Steven Harris MD
Date: Sat, 02 Aug 1997
Newsgroups: misc.health.alternative
In <5rt770$3ta$1@news.enterprise.net> John Scudamore
<whale@mail.enterprise.net> writes:
>And around 500,000 hysterctomies are performed every year, of which
98% are unnecessary.<
Hystectomies aren't generally done because of medical necessity.
They are done because women get tired of bleeding all the time. For a
long time when all gynecologic surgeons were male, hysterectomies were
medical rape. Now that a lot of these surgeons are women,
hysterectomies have become feminist sacrements. It's a lot like
hormone replacement, actually.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: My story
Date: Wed, 17 Sep 1997
Newsgroups: alt.support.menopause
In <5vnhfc$n48@winter.news.erols.com> "Cheryl A. Snider"
<RCSnider@Erols.com> writes:
>I really feel jerked around by all of this. Before I did not realize
the seriousness of my dependence on these hormones and how profoundly
they affect all of me - body-mind-emotions-soul. I have to love the
fact that these little white pills can take all of the nasties away.
At the same time I hate the thought that I am dependent on them now-
forever unless I am willing to face (for me) unendurable consequences.
I have to learn to deal with the anger inside me that this is my fate.
This is what it is like to be a castrated/hysterectomized women.<
It's also what it's like being a post-menopausal woman, for many
women (excepting your nerve damage, of course). You'll get a lot of
stuff from folks saying that hormone-side effect wise a surgical
menopause is much worse than the regular kind, but there's not much
evidence for that. Except, of course, that the surgical one is
sometimes made more endurable by the presence of someone to blame for
the side effects!
Alas, the effect of hystectomy per se on sexual function is wildly
variable. For most women the effect is nil, but averages are not the
whole story in medicine or biology, of course. For a minorty the
effect is appreciable or even devastating, depending (I hypothesize) on
whether or not cervical motion and deep organ sensations contribute
more or less to sensation and orgasm for that woman. I well remember a
patient who spent half an hour telling me that a hysterectomy long ago
had totally ruined her sex life, and why. The doctors had ruined her
before I was born, but she didn't want me to forget it, and I never did
<g>. Probably there should be some kind of self-evaluation and
questionaire to try to tease out such women before they have their
hysterectomies, and I wonder if the world is quite ready for such a
thing? Sounds like a project for Masters and Johnson who whoever has
taken up their mantle.
Discussion groups such as this one may help in the problem that
people without a lot of experience tend to think that the entire world
should be like they are. Women who don't have many problems with
menopause or with hysterectomy figure the others are hysterics, and
those who do, figure that the others are suffering in silence what must
be a plague on all women (yes, I know-- not likely...grin, duck,
run...). Regarding the sexual problems above, there was for quite a
few years a long running debate about "vaginal" vs "clitoral" orgasm,
and which was real and which wasn't, and which was mature and which
wasn't. Psychiatists even chose up sides and wrote learned papers.
All it was all nonsense! Different women are just wired differently,
is all. That being the case, I think it might help to think about how
they are wired in each patient's case, before they contemplate a
surgery which may change the circuits.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Tamoxifen - Italian study
Date: 20 Nov 1998 04:21:54 GMT
In <731jpn$kou$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>A disgusting practice IMO. For one thing, estrogen has been found to be
>important for the proper functioning of memory.
Yeah, it's important for memory until you're 50, after which it
isn't. And doctors are doing something horrible when they cut out an
ovary making estrogen at (say) 45, but not when they replace the
estrogen a ovary quits making at (say) 50. Why don't you and Terri
argue about this for awhile?
In truth ovarectomy is up to the woman, and women who chose to have
ovaries removed with a hysterectomy are not being dumb. There is no
good test for ovarian cancer, which is generally silent until too late.
It's a lot easier to replace ovarian hormones than it is to treat
ovarian cancer when it finally shows up on its own.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Tamoxifen - Italian study
Date: 21 Nov 1998 02:19:59 GMT
In <3655C823.287D0390@erols.com> Terri <vl-hb001@erols.com> writes:
>No, it isn't. Ovarian cancer *is* very difficult to diagnose in its early
>stages while it is still treatable. Ultrasound and CA125 levels are
>notoriously inaccurate and pelvic exam will find it only after is very
>advanced. That does not, however, excuse removing healthy ovaries in
>order to prevent malignancy. First, it won't necessarily prevent it
>anyway - ovarian tissue exists outside the ovaries and may become the
>locus for ovarian malignancy even if the ovaries are removed just as
>prophylactic mastectomy won't guarantee that one won't develop breast
>cancer. Second the disease is relatively rare - the article cited by
>tishy claims 99.7% are done for nothing. I would wager that there is no
>other human organ which would be routinely removed if leaving it in place
>caused serious difficulty in only 3 out of a thousand cases.
>
>Terri
You'd lose that bet. The appendix is often removed in the course
of other abdominal surgery (and it always is, if the surgery is being
done for possible appendicitis, even if on entering, the appendix is
found to be normal). But your chance of dying down the road from a
burst appendix which you didn't have removed when you had the chance,
is far less than your chance of dying of ovarian cancer.
So please explain this bigotted behavior. Is it a result of
mis-appendicy--- the irrational hatred of the appendix by people who
don't have one, and suffer from secret appendix envy, only treatable by
prophylactic removal or the offending organ from those who still have
one? Surely this is a civil-rights violation of a unprecidentedly
sneaky kind. A whole group of abused people here, who don't even have
enough group consciousness to know what is being perpetrated upon them,
in the name of medical care. Cecally intact people of the world,
unite! You have nothing to lose but the end of your colon, and who
wants that? Eh?
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 08:54:59 GMT
In <36E7DF2D.F7ECB516@erols.com> Terri <vl-hb001@erols.com> writes:
>Steven B. Harris wrote:
>
>> Hysterectomies get done on 40 year-old anemic
>> women.
>
>Hysterectomies are done on perfectly healthy very young women far too
>frequently. Up to 50% are deemed unnecessary. And anemia is very much a
>relative term.
>
>Terri
Unnecessary is very much a relative term. Hysterectomies are a lot
like knee replacements. Most people who have them don't absolutely
have to have them or die. But we don't just do operations on people
who'd die without them. The purpose of medical treatment is to help
people feel better. I've talked to perhaps a thousand women who've had
hysterectomies, and in all that time only a handful of them told me
they were sorry they'd had one, and would make the decision differently
if they had it to do over. And if you ask any group of unselected
women who've had this operation the same question, you too will get the
same answer.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 09:16:31 GMT
In <clw-1103990833560001@i48-15-29.pdx.du.teleport.com>
clw@teleport.com writes:
>
>In article <36E7DF2D.F7ECB516@erols.com>, Terri <vl-hb001@erols.com> wrote:
>
>> Steven B. Harris wrote:
>>
>> > Hysterectomies get done on 40 year-old anemic
>> > women.
>>
>> Hysterectomies are done on perfectly healthy very young women far too
>> frequently. Up to 50% are deemed unnecessary. And anemia is very much a
>> relative term.
>
>The only regret I ever heard from a woman who had a hysterectomy was that
>she had not had it done earlier. No more bleeding, no more discharge, no
>more pelvic discomfort, no more anemia, chance of cancer reduced 50% etc.
>Don't knock it until you try it!
>
>----------------------------------
>Fas Est Et Ab Hoste Doceri
>----------------------------------
I believe that Terri posts from an alternate universe where 70% of
women who have hysterectomies become sexually dysfunctional. I haven't
yet determined where the timelines of that universe and mine diverge.
I think somewhere about 200 million years ago, when mammals were
evolving. Some dinosaur stepped where it shouldn't have THERE, but not
HERE.
Terri, would you happen to have a fur coat and whiskers? A
bicornucate uterus? Have they developed the placenta where you are, or
do you folks get born as a wormy sort of thing which crawls up into a
pouch?
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 22:34:51 GMT
In <36E91737.12D5B3F0@erols.com> Terri <vl-hb001@erols.com> writes:
>Steven B. Harris wrote:
>
>> I believe that Terri posts from an alternate universe where 70% of
>> women who have hysterectomies become sexually dysfunctional. I haven't
>> yet determined where the timelines of that universe and mine diverge. I
>> think somewhere about 200 million years ago, when mammals were
>> evolving. Some dinosaur stepped where it shouldn't have THERE, but not
>> HERE.
>>
>> Terri, would you happen to have a fur coat and whiskers? A bicornucate
>> uterus? Have they developed the placenta where you are, or do you folks
>> get born as a wormy sort of thing which crawls up into a pouch?
>>
>
>I suspect that a gerontologist doesn't have too much occasion to discuss
>sexual finctioning in the middle-aged woman with his patients.
>
>Terri
You'd be surprised: I'm allowed to have up to 10% of non-geriatric
patients in the practice under Medicare specialist guidelines, and I
actually see a fair number of other family members, who come to bring
their parents and stay on as patients themselves. And, things being
the way they are with caregiver gender, most of these are middle-aged
daughters of daughters-in-law.
However, it's true that I mostly have occasion to discuss sexual
function with *elderly* men and women. Did you have the impression that
women give it up when they get past middle age? If so I have shocking
news for you: some do, but some don't. The population of women of
geriatric age in 1999 has had a fair fraction of hysterectomies. So
far as I can tell, it makes no difference in sexual function (if you
like, I'm sure there are stats to back this up). Best predictor of
sexual satisfaction and function in elderly women is marriage and good
sexual relations in the history of that marriage (again, not in my
experience related to incidence of hysterectomy). Use it or lose it,
is the rule in geriatrics. But past childbearing age there's not a lot
of use for a uterus (at least, not which outweighs liability in many
cases).
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 22:47:43 GMT
In <36E91B11.859D97AE@erols.com> Terri <vl-hb001@erols.com> writes:
>clw@teleport.com wrote:
>> And isn't it the women who must finally decide if the operation was of
>> benefit to her? My experience (and I live with one happy
>> hysterectomized woman) is that essentially every woman, except the
>> neruotics who are looking for reasons for their inadequacies, are happy
>> with the operation.
>>
>
>Since you discount the ones who aren't happy as "neurotics" of course you
>know only happy ones. When you remove those who are unhappy from the set
>of women who have had hysterectomies you're left with ones who are happy.
>Any venn diagram will show you the logic.
Yep, but that may not be what he's doing. The way you suspect
"neurotics" (and old word for somatizers and dysthymics and anxiety
disorder and personality disorder people and their Venn diagram
intersection <g>) is that they're not happy about anything. They don't
come to you with one problem, but 15. And (most importantly) not 15
problems they are willing to tackle one by one and cope with, but
rather with all 15 presented in ways which it is impossible for you or
even God to do anything about.
>> And, if you consider the ultimate costs of cancers of the cervix,
>> endometrium and ovaries, "prophyllactic" hysterectomies just might be
>> cheaper than carfe of the cancer patients.
>
>
>Removal of testicles and penises at birth would prevent all cancer of
>those organs. It would also serve to prevent most STD's and all
>pregnancies both of which are costly problems. As for the neurotic men
>who think they are sexually handicapped by the loss of their organs -
>send them to a psychiatrist - they must have had an unnatural attachment
>to those ridiculous appendages that serve no purpose. I hope some HMO
>looks at the cost effectiveness of such procedures.
>
>Terri
If you think that the uterus is analogous to the penis in sexual
function (you DO use the analogy above) that certainly explains your
point of view. However, for most women, there's not much comparison.
I think feminists made that point some time ago, and laughed a lot at
the stupid men who thought otherwise. I suppose they should have had a
conversation with you first.
Which is not to say that I think the uterus contributes nothing for
anyone. I'm simply saying that on average, the contribution is small.
For a very few, it's important. It's up to every woman (and her
gynecologist-surgeon) to do some historical questioning to try to
figure out which women are which, before deciding on risks-vs-benefits
as regards an elective hysterectomy (ie, one not done because the woman
is bleeding to death then and there). That's just common sense.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 23:09:35 GMT
In <36E92BFD.78D48218@erols.com> Terri <vl-hb001@erols.com> writes:
>Perhaps you might explain sexual functioning in women as
>*you* see it. Presumably it is not hormonal and is totally divorced
>from their reproductive organs. A rather strange notion in my book,
>but I guess you read a different one.
What hormones does the uterus make which are important for sexual
function? Indeed, what hormones do the ovaries make which can't be
easily replaced by a pill, if necessary?
And no, I'm not under the impression that good sexual function in
women necessarily has a lot to do with the presence of "reproductive
organs." Are you?
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
talk.politics.medicine,sci.med,alt.support.menopause
Subject: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 14 Mar 1999 16:32:48 GMT
For those who are tried of anecdotes and want some hard inforamtion:
As promised, here is some recent research on hysterectomy
outcomes. The question, as with any surgery, is not whether the
outcome is sometimes bad, but whether or not the outcome overall
for patients is better than the situation before. That is the
situation with all surgeries and medical treatments.
Such questions can be looked at epidemiologically, but there is
always a selection factor. There is evidence that women
having a hysterectomy have more sexual dysfunction to begin with
than women who do not. Sexual dysfunction before the procedure
is (as may not be surprising) correlated with that after. Thus,
the group of women who finally have the operation are enriched in
women with poorer sexual function, but only because they started
out that way. The operation itself, which looked at
prospectively, has a positive effect, or at least no negative
one.
Epidemiologic retrospective studies of women in which there is a
typically a low return rate of questionnaires are also suspect,
and it is those which find the most sexual dysfunction associated
with hysterectomy. However, there is also good reason to believe
that women with problems will be more likely to return a
questionnaire than women who feel perfectly well. In general,
these are the poorest studies, design-wise.
The best data are from the best-designed trials: these include
prospective trials which control for initial pre-op extent of
dysfunction (one below is even randomized); and also
epidemiologic trials in which ALL, or nearly all, of women who
had the operation were interviewed, thus eliminating response
bias. These studies, which are also the latest and largest,
generally find that the impact of hysterectomy per se (not
including ovaries) as practiced for non-malignant indications in
a number of countries is, overall, positive on the average
patient's well-being and sexual function over the long term 1-3
years of followup). The aforementioned randomized study of total
vs. subtotal hysterectomy, in addition, failed to find much
difference between subtotal and total hysterectomies in sexual
function, although un-selected epidemiologic evidence had
strongly suggested this. This is a telling example of the
careful prospective randomized study contradicting the mass of
uncontrolled retrospective epidemiologic data, and the lesson
should be taken to heart. (To be fair, we should add the caveat
that this particular controlled study has yet to be confirmed.
It is the only one like it I can find. Still, it's not the first
time that a good prospective randomized study has contradicted a
mass of complex retrospective selection-biased datat).
All of this should be born in mind as regards the question of
oophorectomy post menopause. There do not yet exist controlled
studies of this which I would find. However, there is
epidemiologic evidence of reasonable quality that removal of
ovaries does influence sexual function in a fraction of women
(especially in the period AFTER 3 months after operation), and
that this deficit is only partly corrected with estrogen. The
role of androgen needs to be more closely examined, and until it
is, the routine prophylactic removal of ovaries in women with
good sexual function, even postmenopausaly, should be discouraged
without some careful discussion of the risk in this area a woman
faces (women who don't care much about sex anyway will obviously
find this little deterence to drastically cutting future risk of
ovarian cancer). Too little is known at present about whether or
not androgen replacement fully corrects these problems in
ooporectomized women.
Steve Harris, M.D.
---------------------------------------------------------------
Abstracts:
Clin Obstet Gynecol 1997 Dec;40(4):939-46
Outcomes of hysterectomy.
Carlson KJ
Harvard Medical School, Massachusetts General Hospital, Boston
02114, USA.
Recent randomized trials and prospective cohort studies have
provided new information on the health outcomes of hysterectomy
for nonmalignant conditions. These studies consistently have
demonstrated a marked improvement in symptoms and quality of life
during the early years after surgery. The long-term effects of
premenopausal hysterectomy on ovarian function have not been
established, but existing evidence suggests there is no adverse
effect on risk for cardiovascular disease from hysterectomy
alone. Epidemiologic studies have indicated that premenopausal
hysterectomy with ovarian preservation is associated with a
modest decrease in future risk for ovarian cancer and possibly
breast cancer. There is no consistent evidence for adverse
effects on bowel or bladder function. Hysterectomy does not cause
long-term psychiatric morbidity, and psychological status
generally improves. Studies of sexual function have shown varying
results, with most suggesting improvement or no change in sexual
function for the majority of women.
Publication Types:
Review
Review, tutorial
PMID: 9429807, UI: 98091642
----------
Clin Obstet Gynecol 1997 Dec;40(4):928-38
Complications of hysterectomy.
Harris WJ
East Tennessee State University, Quillen College of Medicine,
Johnson City, USA.
Hysterectomy is a popular operation that has a number of
complications associated with it. The most common are hemorrhage,
infection, and injuries to adjacent organs. Unintended major
surgical procedures and second operations occur in approximately
4% of patients undergoing hysterectomy. Laparoscopic hysterectomy
is a controversial new procedure that has both advocates and
detractors. In skilled hands, the complication rate of laparosco-
pic hysterectomy does not exceed that of traditional hysterectomy
methods. At the present time, there is a growing consensus that
removal of the uterus only does not lead to an increase in
psychosexual morbidity. It also appears that hysterectomy
procedures have little, if any, effect on lower urinary tract
function.
Publication Types:
Review, tutorial
PMID: 9429806, UI: 98091641
----------
The following is the largest series reported to date, to my
knowledge:
Obstet Gynecol 1994 Apr;83(4):556-65
The Maine Women's Health Study: I. Outcomes of hysterectomy.
Carlson KJ, Miller BA, Fowler FJ Jr
Massachusetts General Hospital, Boston.
OBJECTIVE: To assess the effect of hysterectomy for nonmalignant
conditions on symptoms and quality of life and to identify
adverse effects 1 year after surgery. METHODS: The Maine Women's
Health Study was a prospective cohort study of 418 women ages
25-50 years undergoing hysterectomy for any nonmalignant
condition. Patients recruited from the practices of 63 physicians
performing hysterectomy throughout Maine were interviewed at the
time of surgery and 3, 6, and 12 months later. Clinical and
hospitalization data were obtained from physician reports and
from a statewide hospital discharge data base. The primary
outcomes of interest were symptom relief, changes in quality of
life, and the development of new symptoms or problems during the
year following surgery. RESULTS: The most frequent indications
for hysterectomy were leiomyomas (35%), abnormal bleeding (22%),
and chronic pelvic pain (18%). For these indications, hysterecto-
my resulted in marked improvements in a range of symptoms,
including pelvic pain, urinary symptoms, fatigue, psychological
symptoms, and sexual dysfunction. Significant improvements in
scores for indices of mental health, general health, and activity
were evident at 6 months and sustained at 1 year. New problems
after hysterectomy (measured in those free of the symptom
preoperatively) included hot flashes (13%), weight gain
(12%), depression (8%), and lack of interest in sex (7%).
CONCLUSIONS: Hysterectomy is highly effective for relief of
symptoms associated with common nonmalignant gynecologic
conditions. Symptom relief following hysterectomy is associated
with a marked improvement in quality of life. New problems are
reported after hysterectomy by a limited number of women.
PMID: 8134066, UI: 94181209
----------
This next paper emphasizes again that earlier studies have not
carefully controlled for psychosexual disorders BEFORE
hysterectomy, and thus non-prospective studies (retrospective
studies) which find large amounts of sexual dysfunction, are all
suspect for this bias. When women are assessed both before and
after surgery, it is found that the CHANGE is insignificant,
although incidence of sexual dysfunction is higher both before
and after surgery than in the general female adult population.
Baillieres Clin Obstet Gynaecol 1997 Mar;11(1):23-36
Hysterectomy: social and psychosexual aspects.
Ryan MM
Royal Australian College of Obstetricians and Gynaecologists,
East Melbourne, Victoria, Australia.
Studies of the psychological and sexual outcome of hysterectomy
have often arrived at conflicting conclusions and this has
resulted in some confusion among health professionals as well as
among women themselves. This situation should cause concern,
since the incidence of this surgery is high in most countries of
the western world. The confusion about outcome arises out of the
methodological problems that plagued earlier research. Some of
the more recent studies using prospective design, standardized
measures and appropriate statistical analysis have not implicated
hysterectomy with increased psychological or sexual disorders.
However, both before and after hysterectomy in samples studied,
the rate of psychological disorder was higher than would
have been expected in a normal population, although a clearer
picture has emerged from the most recent study. In this paper,
risk factors are identified, and the need to include women's own
evaluation of the procedure is emphasized.
Publication Types: Review, academic
PMID: 9155934, UI: 97300914
----------
Here is a review of total vs. subtotal hysterectomy concluding
the cervix should be left in when possible. Note that many of
papers reviewed, however, suffer from the defects discussed
above.
J Reprod Med 1993 Oct;38(10):781-90
Cervical removal at hysterectomy for benign disease. Risks and
benefits.
Hasson HM
Department of Obstetrics and Gynecology, Grant Hospital of
Chicago, Chicago, Illinois.
An assessment of the risks and benefits of total and subtotal
hysterectomy for benign disease was performed using the published
literature, including a MEDLINE search, on all studies dealing
with hysterectomy and related topics from 1946 to 1992. The shift
from subtotal to total hysterectomy occurred before cytologic
screening was accepted. Currently, SIL is diagnosed by cytology,
evaluated by colposcopy and treated preferentially with cone
biopsy. Prophylactic removal of the cervix does not eliminate the
risk of cancer: it may shift the risk to the vaginal epithelium.
The cervix has a role in sexual arousal and orgasm, probably due
to stimulation of the Frankenhauser uterovaginal plexus. Bladder
and bowel dysfunction following total hysterectomy may be related
to loss of nerve ganglia closely associated with the cervix.
Increased operative and postoperative morbidity, vaginal shorten-
ing, vault prolapse, abnormal cuff granulations and oviductal
prolapse are other disadvantages of total hysterectomy. The
cervix is not a useless organ and should not be removed during
hysterectomy without a proper indication.
Publication Types: Review literature
PMID: 8263867, UI: 94087670
--------
Here is one such study for illustration (I am not only including
studies which support my previously stated point of view). Note
however, that this study is (as is typical) not randomized, and
not even prospective, so the high incidence of sexual dysfunction
might well have preceded the operation, and the difference
between the two groups may be due to a selection factor (for
example, the women getting the abdominal procedure may have been
less obese).
Acta Obstet Gynecol Scand 1983;62(2):147-52
Supravaginal uterine amputation vs. hysterectomy. Effects on
libido and orgasm.
Kilkku P, Gronroos M, Hirvonen T, Rauramo L
Postoperative symptoms of hysterectomy have received relatively
little attention. In the present study, the first author has
personally interviewed and examined 105 abdominal hysterectomy
patients and 107 patients with supravaginal uterine amputation
preoperatively and 6 weeks, 6 months and 12 months postoperative-
ly. Participation in the follow-up study was 99.5% (211/212) at
one year. This paper deals with the effects of the two operations
on libido and the frequency of orgasms. In the statistical
analysis, McNemar's test of symmetry and the Fisher exact test
were used. Weak or absent libido was reported preoperatively by
28.0% of hysterectomy patients and by 26.4% of amputation patien-
ts. One year postoperatively the corresponding figures were
35.4% and 31.4%. No statistical changes were observed between the
two groups or within either group. In the frequency of orgasms a
highly significant (p less than 0.001) reduction from the situat-
ion before operation to one year postoperatively was detected
after hysterectomy. In the supravaginal amputation group no
statistically significant decrease was detected. Preoperatively
the two groups were alike; one year postoperatively the
difference was almost significant (p less than 0.05). The
reductions in orgasms after hysterectomy as compared with
supravaginal amputation appears to result from the greater
radicality of the former; at hysterectomy, the autonomous
innervation of the proximal vagina and cervix is damaged more
than in supravaginal amputation, the anatomy of the vagina is
altered and scar tissue forms in the vagina. It is
probable that these changes and subconscious psychological
reactions due to total removal of the uterus explain why
supravaginal uterine amputation gives better results than
hysterectomy.
PMID: 6868963, UI: 83252149
----------
And to suggest that a selection bias is indeed operative, here in
a prospective randomized study, the best yet done on the subject,
which finds that cervical removal makes no difference. Yep, done
in Utah, where I practice. Coincidence, so far as I can tell, as
I know nothing about Utah women which would keep them from
benefiting from their cervixes (no smart remarks, please).
Am J Obstet Gynecol 1997 Jun;176(6):1186-91; discussion 1191-2
Subtotal hysterectomy in modern gynecology: a decision analysis.
Scott JR, Sharp HT, Dodson MK, Norton PA, Warner HR
Department of Obstetrics and Gynecology, University of Utah
Medical Center, Salt Lake City 84132, USA.
OBJECTIVE: Our purpose was to compare the risks and benefits of
subtotal (supracervical) hysterectomy with those of total
hysterectomy in women at low risk for cervical cancer. STUDY
DESIGN: A decision analysis was performed. Baseline probabilities
for operative and postoperative morbidity, mortality, and
long-term quality of life were established for subtotal and total
hysterectomy. RESULTS: Operative complication rates and ranges
for total abdominal hysterectomy were infection 3.0% (3.0% to
20.0%), hemorrhage 2.0% (2.0% to 15.4%), and adjacent organ
injury 1.0% (0.7% to 2.0%). Those for subtotal hysterectomy were
infection 1.4% (1.0% to 5.0%), hemorrhage 2.0% (0.7% to 4.0%),
and adjacent organ injury 0.7% (0.6% to 1.0%). Operative mortali-
ty, the risk for development of cervicovaginal cancer, and
long-term adverse effects on sexual or vesicourethral function
were low in both groups. CONCLUSIONS: Recently proposed benefits
from subtotal hysterectomy are not well proven. Total
hysterectomy remains the procedure of choice for most women.
PMID: 9215172, UI: 97358029
----------
Follow-up in the study below was short (3 mo) but no significant
morbidity was seen from hysterectomy in the U.K.
Br J Obstet Gynaecol 1995 Aug;102(8):611-20
Indications for and outcome of total abdominal hysterectomy for
benign disease: a prospective cohort study.
Clarke A, Black N, Rowe P, Mott S, Howle K
Department of Public Health and Policy, London School of Hygiene
and Tropical Medicine, UK.
OBJECTIVE: To describe the indications for total abdominal
hysterectomy for women with nonmalignant disease and to determine
the immediate (initial ten days) and medium term outcome. DESIGN:
A prospective cohort study. SETTING: Three district general
hospitals in shire counties, two in outer London and one
London teaching hospital. SUBJECTS: Three hundred and sixty-six
women undergoing total abdominal hysterectomy (with or without
other procedures) for nonmalignant disease. INTERVENTIONS:
Self-completed patient questionnaires before and ten days, six
weeks and three months after surgery. Data extracted from patien-
ts' hospital case notes. MAIN OUTCOME MEASURES: Complications
plus change in symptoms, urinary and bowel function, general
health status, sexual function, activities of daily living and
quality of life. RESULTS: The principal indications were
bleeding, pain or both. Symptoms were severe enough to be
socially debilitating and have a major impact on lifestyle.
Otherwise, the women were in good health. During the first ten
post-operative days the women suffered more pain, urinary
discomfort, constipation and a reduction in their ability to
perform activities of daily living. Urinary (25%) and wound
(25%) infections were the commonest complications. At the same
time, significant improvements in psychological health occurred.
By six weeks, the principal symptoms had resolved for 95% of the
women and early adverse effects on urinary and bowel function had
settled. This was reflected in improvements in health status and
quality of life including sexual activity. Despite this,
these changes did not meet the pre-operative expectations of some
women. CONCLUSIONS: Most women reported substantial benefits from
hysterectomy. However, women should be warned about early,
transient adverse effects. These findings can serve as a
benchmark for nonexperimental evaluations of the effectiveness of
new treatment modalities.
Publication Types: Multicenter study
PMID: 7654638, UI: 95383245
----------
This next paper suggests that short term follow-up does not catch
long term problems with hysterectomy-- however the overall effect
here is still viewed as "less positive" at 3 years, not negative.
Health Care Women Int 1992 Jul-Sep;13(3):281-91
Consequences of hysterectomy in the lives of women.
Bernhard LA
A longitudinal study of 63 adult, premenopausal women of low
socioeconomic status who underwent hysterectomies is reported.
Face-to-face in-depth interviews with the women were conducted on
the day before hysterectomy and 4 weeks and 3 months after
hysterectomy. After the interview, each woman completed the
Derogatis Sexual Functioning Inventory (Derogatis & Melisaratos,
1979). The Responses to Hysterectomy tool was mailed to the women
about 2 years after hysterectomy. Before their hysterectomies,
most of the women had both positive and negative feelings about
the hysterectomy. By 3 months posthysterectomy, most women had
fairly positive general and sexual outcomes. However, by 2 years
posthysterectomy, there were less positive outcomes. Most
women reported at least sometimes having negative symptoms that
they associated with their hysterectomy. More research must be
conducted to fully understand the experience of hysterectomy in
women's lives.
PMID: 1399868, UI: 93015294
----------
In the next paper also, short term consequences are positive,
while longer ones (11 months) are apparently less so, but again
not negative. There is simply no evidence there that
hysterectomy is the plague which it has been represented on some
of these newsgroups to be.
J Obstet Gynecol Neonatal Nurs 1997 Sep-Oct;26(5):540-8
Women's sense of well-being before and after hysterectomy.
Lambden MP, Bellamy G, Ogburn-Russell L, Preece CK, Moore S,
Pepin T, Croop J, Culbert G
Children's Health Center, Scott and White Clinic, Temple, TX
76508, USA.
OBJECTIVE: To describe women's perceived sense of well-being
before and after hysterectomy by examining a broad array of
outcomes experienced by women undergoing hysterectomies for
benign conditions. DESIGN: Prospective, descriptive. SETTING: A
regional tertiary care facility in central Texas. PARTICIPANTS:
One hundred seventy-eight women presenting for hysterectomies for
nononcologic reasons who completed all three periods of data
collection. MAIN OUTCOME MEASURES: Subjects completed a questi-
onnaire assessing information pertinent to their current gynec-
ologic health and the SF-36 Health Survey before surgery and of 4
and 11 months after surgery. The women also completed the Zung
Self-Rating Depression Scale preoperatively and at 4 months
postoperatively. Additional demographic and medical information
was extracted from the medical record. RESULTS: In the initial
period after surgery, the patients experienced an improved health
status. In addition, the women reported on improvement in their
psychologic well-being, including less depression and improved
sexual functioning. Relationships with others also improved after
the surgery. CONCLUSIONS: Outcomes for these women undergoing
hysterectomy for nononcologic reasons were generally positive.
This information is vital for preoperative counseling by nurses
of women contemplating or about to undergo this surgery.
PMID: 9313184, UI: 97458364
----------
This study finds that women's sex lives were improved on average
by hysterectomy (half improved, 21% deteriorated). Not surprisi-
ngly, deep dyspareunia (pain on intercourse with deep penetrati-
on) was most influenced, and another analysis of this same data
set by the same group (Acta Obstet Gynecol Scand 1994 Aug;73(7):-
575-80) emphasizes this point.
Obstet Gynecol 1993 Mar;81(3):357-62
Sexuality after hysterectomy: a factor analysis of women's sexual
lives before and after subtotal hysterectomy.
Helstrom L, Lundberg PO, Sorbom D, Backstrom T
Department of Obstetrics and Gynecology, University Hospital,
Uppsala, Sweden.
OBJECTIVE: To study the effect of subtotal hysterectomy on a
woman's sexuality. METHODS: One hundred four women were intervie-
wed 1 month before and 1 year after surgery. Data concerning
their sexuality before and after the operation were evaluated
using a multivariate method. RESULTS: Half of the women reported
improvement in their sexuality after surgery and 21% reported
deterioration. There were only small changes in sexual variables:
Frequency of cyclicity of sexual desire was reduced, coital
frequency increased, and frequency of desire, frequency of
orgasm, and multiplicity of orgasm were unchanged for the entire
series. The best predictive factors for sexuality after surgery
were presurgical coital frequency, cyclicity of arousability,
frequency of desire, and frequency of orgasm. Multiplicity of
orgasm, cyclicity of desire, and attitude to the sexual partner
also correlated with postoperative sexuality. Preoperative deep
dyspareunia had a small influence, although 83% (48 of 58)
with deep dyspareunia experienced relief after the operation.
Preoperative deterioration of desire and coital activity had no
correlation to sexuality after surgery. CONCLUSION: Preoperative
sexual activity is more important in predicting postoperative
sexuality than is the occurrence of dyspareunia or deterioration
of sexual activity because of uterine disease.
PMID: 8437786, UI: 93173424
----------
This next study is typical of those which find large sexual
consequences of hysterectomy. There is no pre-evaluation, so
change is impossible to measure. Return rate on questionnaires
is small, so that there is a huge opportunity toward negative
bias.
Aust N Z J Obstet Gynaecol 1994 Aug;34(4):471-4
Sexual function after pelvic surgery in women.
Poad D, Arnold EP
Department of Obstetrics and Gynaecology, Christchurch Women's
Hospital, New Zealand.
To assess the prevalence of sexual dysfunction after pelvic floor
surgery for nonmalignant conditions, a retrospective survey was
performed. Replies from a postal survey were received from 66 of
the 200 women canvassed. Dyspareunia developed in 10 patients who
had never had it before the operation, however of those who had
it preoperatively the pain stopped completely in 12 of 23.
Reduced libido was noted in 16 of 54 (29%), reduced lubrication
in 21 (38%), and reduced genital sensation in 10 (18%). Lack of
information about the potential effects of surgery on sexual
function was identified as a major deficit and of considerable
concern to 35 of the 66 women. Sexual function after surgery
should be evaluated more intensively, and the subject discussed
openly before any contemplated operation.
PMID: 7848244, UI: 95150977
----------
The next also appears to be a retrospective study only, and is
epidemiologic. It suggests, but does not by any means prove, that
oophorectomy contributes to post-hysterectomy sexual dysfunction.
J Psychosom Obstet Gynaecol 1993 Dec;14(4):283-93
Elective ovarian removal and estrogen replacement
therapy--effects on sexual life, psychological well-being and
androgen status.
Nathorst-Boos J, von Schoultz B, Carlstrom K
Department of Obstetrics and Gynecology, Karolinska Institutet,
Stockholm, Sweden.
Conflicting data have been reported on the psychosexual impact of
hysterectomy combined with bilateral oophorectomy. Three age-m-
atched, hysterectomized groups of women were investigated: Group
A (n = 33): oophorectomized, not receiving estrogen replacement
therapy (ERT); Group B (n = 33): oophorectomized, receiving ERT;
and Group C (n = 35): ovaries preserved and not receiving ERT.
The McCoy Sexual Rating Scale and the Psychological General
Well-Being Index as well as a semi-structured interview were used
to assess postoperative experience with respect to libido,
vaginal lubrication, ability of getting pleasure from intercours-
e, and ability to achieve orgasm. Serum concentrations of total
and free testosterone, insulin-like growth factor I (IGF-I), sex
hormone binding globulin, dehydroepiandrosterone sulfate and
4-androstene-3,17-dione were determined. In oophorectomized women
sexual life was impaired as compared to those with intact ovaries
and these women complained about less pleasure from coitus,
impaired libido and lubrication. Regardless of whether estrogens
were administered or not a similar pattern was found, indicating
that estrogens are of little value in treating these specific
sexual dysfunctions. Oophorectomized women receiving ERT reported
less anxiety and depression and more well-being similar to women
whose ovaries had been preserved. No correlation was found
between psychosexual variables and biochemical androgen markers.
However, the IGF-I levels were strongly correlated to sexual
activity and responsiveness.
PMID: 8142982, UI: 94191755
----------
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: talk.politics.medicine,sci.med,alt.support.menopause
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 15 Mar 1999 04:42:14 GMT
In <Pine.SUN.4.05.9903141110450.17247-100000@coyote.rain.org> jinelle
<jinelle@rain.org> writes:
>
>>
>> I'm not going to repeat myself completely. Read what I said again.
>> I don't know what the overlap is, but in a sense it's not important.
>> The average physical and mental health for the group improved,
>> according to the evaluations used. Period.
>>
>> When you can post a study showing an analogous amount of physical
>> and mental health improvment of a group of 400 women using these
>> techniques you speak of, published in the literature, get back to us.
>> Otherwise you're comparing a real and available medical proceed which
>> has been proven to help over all, to snakeoil and hearsay.
>>
>> Steve Harris, M.D.
>
> Attention women: Do you want this man and his one study helping
>you decide if you want/need a hysterectomy. Is this what passes for
>adequate "informed consent?" The answer is clearly no.
The answer is that clearly you don't have even ONE study to back of
the point of your you've been pushing, which is that most of the time
hysterectomies are bad. I asked out above, and now I'll ask you again.
Produce your evidence. That's not an unreasonable request.
>> Please read well beyond this man's reported study.
It's not my study. It's one of a dozen studies I posted from any
countries, all pointing more or less to the same conclusions.
> Life is an art,
>as well as a science. Keep reading, follow your intuition as well as
>your intellect. It is your body, not his study that will count in the
>end.
Certainly. But "intuition" is what you rely on after you're
informed as well as you can be, in the time you have to spend. It's
not a sustitute for a library, or consultation with an expert.
>But be aware when in the sacred chamber of the medical office, men
>like this, armed with a single study like this, do exist.
The medical office is not a sacred chamber. This is not a
religion. This is a difficult decision, like many others in life,
from whether or not to marry or have a child to buy a house to put
money in your 401k. Some people do everything by intuition. Others
but Housebuying for Dummies and read some, first. Then they get a good
real-estate agent. Then they solicity advice from various experts like
appraisers and engineers and so on and so on. A medical decision is
absolutely no different, save that the time pressure are sometimes
worse (as if you had to buy a house TODAY.)
> Do not assume their medical degree confers unapproachable authority
>or inherent expertise.
No, and don't assume it means nothing, either. It goes into the
pot, along with the data from studies, as with any other decision.
> Read, read, read, question, question, question. Ask for a
>congruence of studies, over and over that reach the same conclusion if
>a single "study" is offered for justification for your surgical
>decision.
Sure. In this case a single study was not offered. We merely
discussed the study somebody wanted to. A list of other studies has
been posted. Feel free to look them all up. Anybody can sit on the
sidelines and kibitz.
>A man like this thinks he is doing you a favor relieving you of body
>parts. How neutral in the setting in his office?
Who in the world are you talking about? I'm not a surgeon. The
only body parts I remove are the occasional skin tag or keratosis.
> When it comes to intimate decisions only a woman can make, listen
>to your doctor, but also talk to other women. Lots of other women.
But beware the bias, because the women with the bad experiences
will be talking more. If you want a better picture you have to bring
the subject up also with women who are thinking about, and thinking
about, something else. Or a group of women selected for some other
purpose, like your bridge club. If you solicit for bad opinions,
you're going to get what you ask for. That's part of the reason we do
statistical studies. I'm a general internist who happens to work
mainly with the elderly. I see them for all kinds of problems, but
since I'm in primary care, I ask about previous surgeries and things
like incontinence and sexual function. I have no vested interest in
hysterectomies any more than I do in total hip replacements. My
opinion of them as effective therapies is based on reading studies, and
on talking with lots of people who have had them, but don't come to ME
for that reason. By knowledge base is bigger than yours, in either
case. I don't care if you don't believe that. You may in fact be one
of those people who thinks they know everything, or (much the same) who
thinks their own personal intuition is the ultimate path of truth in
every sphere of human knowledge. That's too bad, if so.
>In time there will be a more significant number of women physicians
>who have also gone through menopause, and their counsel will be based
>upon experience as well as medical "facts", badly footnoted in their
>medical textbooks.
How do you know they're badly footnoted? You don't know a damn
thing about it.
> Presently, women physicians are reading the same poor quality
>medical textbooks as the men have long read. Check one out at your
>local hospital library and track the footnotes yourself.
Good advice. Post your efforts right here and feel free to
critique them, in your best scientific and logical style.
> There is little in them on the topic of menopause that rise above
>pure shamanism.
How do you know? That's the essential question in all debates:
what makes you think so? What is your evidence?
> Except a shaman
> at least did not have poisonous drugs and lethal surgeries in his kit
> bag.
Doing nothing may be poisous or lethal also. Eventually, it's sure
to be, since everybody dies, and everybody does of something. That's
the problem. The world is full of people who think that their lives
are going to be as long and healthy (if they just live "right") as the
lives of the longest-lived and healthiest person they know of in their
family (or somebody else's, if theirs didn't do well). We doctors know
that most will be wrong. But we can only say that most will be wrong,
we can't tell exactly who. We admit it. The difference seems to be
that you don't.
> The modern MD today will do just as well rattling chicken bones
>when it comes to any "science" backing up "his" treatment decisions
>regarding the menopausal woman.
Since I've posted about 10 times more science in this thread than
anybody else, that's a curious statement for you to be making. Did I
miss your post with the science in it? Please re-send.
> And by all means, if your doctor relies on a study. Read the
>-entire- study yourself before ever making a decision based upon it.
I've got no problem with that. And the same goes if you want to do
that with your lawyer. Get out those law books and study. Go to his
or her office and discuss them. Do it an hour a day. Eventually
you'll be fully informed, or at least as well as your lawyer is. If
you've got the time and money, the teacher appears when the student is
ready to learn. That's true in every field, not just medicine. Of
course, there's a slight difference between what you're learning here
on the net and what you learn from a lawyer or doctor in the office.
WHat you learn here you don't appreciate because it's free.
> Never feel rushed into an irrevocable, and often voluntary, surgical
>decision. Never. Your doctor owes you no less than competent
>deliberation on these types of decisions.
Yes, but your doctor does not owe you a full explanation, based on
your personal 2-person review of the entire literature, paper by paper.
Unless you're Bill Gates and have blocked out a couple of weeks of
office time, like renting the top floor of some hotel. That's the
problem with information. People feel it ought to be free, or next to
free. It isn't. It costs just as much to make some good decisions as
it does to buy a car, and for the same reason. People understand this
in law, but have missed out on it in medicine. I don't know why.
>You alone are the guide to knowing when that decision
>is right for you.
No. You alone have the right to make the final decision. But if
you think you alone are the best guide you have pretty bad ego
problems. When I go to my attorney with a problem that can mean years
of life in jail if I decide wrongly, or to my auto mechanic with a
problem that can mean a painful death on the road if I don't do the
right thing, do you think I do armed with the latest literature form
the library and make them sit with me all day and regurgitate what they
learned in law school or auto mechanic's school, or whatever? I might
if it was important to me, but I'd be prepared to pay and pay well,
because I know the real cost of information. I understand it better
than many, because it's most of what I sell (also true for most
professional people-- the problem being that they don't realize it)
> If you feel badgered, belittled or uneasy about any surgical
>decision, walk out of that office immediately. No, run out of that
>office.
Yep. But meanwhile remember to treat your doctor like the $300 an
hour IBM network or architectural consultant. Or attorney. Show a
little respect, and you'll get what you want.
>Your intuition is sending you powerful messages that co-opt a man's
>view of "science."
If I read the above aright, it's feminist garbage. Science is
neuter. It's not coopted by anything.
> This man has done you a favor by so clearly exposing his
>prejudices.
Prejudice: that which someone else believes which we don't agree
with.
> This man's filter of scientific evidence needs to be
>recognized for what it is worth. He could be the darker soul of your
>physician as well.
Yep, that's me. The darker soul of your physician. Out here on
the internet, sowing abstracts just to confuse your feminine intuition.
Recognize real evil when you see it, madames.
Brouhahahahah,
Dr. Jekyl
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.menopause,sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 15 Mar 1999 08:16:35 GMT
In <36ef93b7.141403849@news.erols.com> vl-hb001@erols.com (Terri)
writes:
>I produced evidence showing that women with dysfunctional uterine
>bleeding can be treated equally well with more conservative measures.
>You've chosen to ignore the whole list of cites..
Not yet, I just haven't gotten to them. Interesting stuff.
However, while I'm going though it, do address my point that endoscopic
ablation or removal of uterine myomas was not available until rather
recently, and is available now only in some quite specialized centers.
And it's usable only in selected cases where a woman may have one
relatively small tumor causing a problem, not a woman whose uterous is
5 times it's normal volume due to these benign tumors. You're guilty
of showing me highly selected series, and arguing that this is the
answer for the average women. I cry "foul." Show me the series in
which ALL women who presented for hysterectomy are instead fixed with
other techniques. Or even a good fraction thereof.
High tech fixes are not germane to the idea that doctors have been
doing this horrible thing to women for half a century when they could
have been doing something else. At best, it serves only as an
arguement that it's time NOW to change style of practice, for a few
highly selected women who could benefit from it. An argument I'm
always open to, if there's evidence behind it. If you think I have
some pathological desire to send women to have as much cut out as
possible, think again.
>Dr. Pinhiero has twice posted that he sees the results of hysterectomy
>especially with oopherectomy in his office quite frequently - he's a
>psychiatrist.
Yeah, he's a psychiatrist. As I said, beware of selecting your
group beforehand, if you want to know the odds of getting a certain
problem. Life is a game of odds. You don't talk to groups of losers
to find out if you should play the game. You talk to everyone who's
played, losers and winners alike.
>.
>>madames
>
>Tsk tsk, the plural is mesdames.
>
>Terri
Actually, in English, madams is a perfectly good plural, and may be
used without *necessarily* carrying impolite connotations. But clearly
I should have added an s or left out an e.
Steve
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: talk.politics.medicine,sci.med,alt.support.menopause
Subject: Re: Post-hysterectomy Sex Abstracts
Date: 16 Mar 1999 04:20:39 GMT
In <Pine.SUN.4.05.9903150644130.16775-100000@coyote.rain.org> jinelle
<jinelle@rain.org> writes:
>
>On Mon, 15 Mar 1999, Robert Ames wrote:
>
>> In <Pine.SUN.4.05.9903141110450.17247-100000@coyote.rain.org> jinelle
>> <jinelle@rain.org> writes:
>>
>> > Life is an art,
>> >as well as a science. Keep reading, follow your intuition as well as
>> >your intellect. It is your body, not his study that will count in the
>> >end.
>>
>> WTF? You asked for studies you could read. Seems to me you got
>> what you asked for. You have a talented physician with many years
>> of clinical and research experience spending quality time to not
>> only find the studies for you, but even to annotate them, and you
>> have the incredible bad grace to complain. What a malcontent.
>
>
> It is called "wholism," Robert.
It is the wholism of asses. Whenever you hear anyone say they
know they're right, no matter what, because of their "intuition," you
can guess that's what you're dealing with. Ass wholism.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.menopause,sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 16 Mar 1999 04:42:34 GMT
In <Pine.SUN.4.05.9903150653030.16775-100000@coyote.rain.org> jinelle
<jinelle@rain.org> writes:
> The far more important issue is why, in the US, did women and the
>medical profession agree that female body parts were so expendable?
They had the money to do it. You can look at the artifical hip
replacement rate in other countries (also a proceedure done more often
in women) and find the same thing. The US does it more. In Canada you
can wait years for it (in a wheelchair). In Africa, forget it.
>And why have not other countries where women's health markers are
>higher than the US, why did they not go down this same path? (WHO
>statistics).
Some of it is genetics and some of it is money. In Scandinavia
they told Milton Friedman: "You know, we hardly have any poor
Scandinavians." To which Friedman replied: "That's interesting! In
America we hardly have any poor Scandinavians, either."
Women in Japan are healthier than US women. But the difference is
less that for Japanese-American women. And Japanese American women in
Hawaii are closer in health to Japanese women than Japanese American
women on the mainland. The difference is not American medicine.
Evidently the main influences are diet and genetics. And, as I said,
money. African American women are less healthy than other US women.
But not less healthy than women in Africa. WHO statistics don't
separate confounding variables well.
> What made the treatment of the female body so different in the US?
As I said: money. They don't do that many bypasses on male bodies in
Africa, either. And genetics. And culture. Circumcision is more
common in America because there are fewer Jews, and Jewish doctors, in
Africa.
> In Africa, of course we hear about genital mutitlation surgeries.
>In India stories of female immolation exist. Chinese footbinding
>existed for hundreds of years. And in the US, ritual excision of
>reproductive organs. How do these customs evolve?
Who knows? In Africa there are places where the men slit their
penises open, and undergo tests of manhood like trying to kill a lion
with an asagai spear (talk about the possibility of mutilation....).
In all cultures there seems to be the idea that sacrifice and pain are
ways to control the natural world. I suspect it all comes down to our
memories of trying to control our parents, as children, by crying or
hurting ourselves deliberately. But of course I don't really know.
It's buried in human psychology everywhere, though.
>
> A good "research" exercise is to reveiw all the stories from
>women who have come to this newsgroup with post-surgical complications
>they did not expect. While not scientific by your calculations, it is
>an exercise in compassionate listening. The stories are moving.
>
>j
Undoubtedly. But they don't help one make correct decisions. If
you spent your formative years looking at autoaccident victims in
morgues, and never doing anything else, you'd never learn to drive.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.support.menopause,sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 16 Mar 1999 05:31:15 GMT
In <Pine.SUN.4.05.9903150705340.16775-100000@coyote.rain.org> jinelle
<jinelle@rain.org> writes:
>
>On 15 Mar 1999, Steven B. Harris wrote:
>> answer for the average women. I cry "foul." Show me the series in
>> which ALL women who presented for hysterectomy are instead fixed with
>> other techniques. Or even a good fraction thereof.
>
> You are right, Steve, this is the study that needs to be done
>before you rely on any "science" to support your "scientifically
>established preference for hysterectomy. You claim to be a man of
>"science" yet you rely for this irrevocable decision, that you do not
>have to make for yourself ever, on a study that was not done in
>randomized, placebo controlled form. I agree, where is that definitive
>study?
I did post a randomized study. It's rather difficult to have
double blinded surgical studies of such things, of course, as a woman
can obviously discover if she still has a cervix in 10 seconds,
whenever the doctor isn't looking. Science does what it can: all I ask
for is studies where what can be done, has been approached. You cannot
compare 30 year old women trying to get pregant who need uterine myomas
removed, with 50 year old women and their uteri. They aren't the same.
Success in one group does not even suggest success in the other.
It might be possible to do a randomized blinded study of partial
hystectomy vs myomectomy. But with multiple myomas to resect, the
difference between the two surgeries starts to get rather academic.
Why the passion in debating one vs the other? It's not uncommon to see
uteri which are MOSTLY myomas. If you manage to somehow disect them
all out (in a much longer and more dangerous procedure) and leave what
is left of the uterine fundus exterior (sort of) intact--- so what? Is
it worth it? Only a study will tell for sure, but I'm awfully dubius.
It should also be possible to do a randomized blinded study of
hysterectomy plus oophorectomy (TAH/BSO) vs hysterectomy only, in poar
menopausal women. Shame on the NIH for not having done it already. If
you want to knock the establishment here, I have no defense at all.
> The Mayo Clinic study did find that a "wait and see" approach was
>valid when dealing with ovarian cysts in the pre-menopausal woman. The
>vast majority of them were taken care of only with time. Yet, we
>continue to hear stories from women to this newsgroup who become
>burdened with fear planted by their doctors in this situation that may
>have cancer and the woman herself now becomes a co-conspirator in her
>own surgery willingness.
Well, that's what second opinions are for. Did this Mayo study
randomize women two approaches and then follow outcomes and total
mortality and morbidity? No? Then what are you doing here using
standards which you start this message by accusing me of employing?
There are various grades of evidence in medicine. I've done my
best to discuss them, but it's not working too well. One of the
problems is that I've lately realized that this series is being cross
posted to alt.support.menopause, a group of black-and-white thinkers
and silent lurkers who've been cowed by them (no pun intended), which I
swore I'd never post to, again. Thus, interested people from ASM can
continue to follow in sci.med, if they like. Further messages in this
thread from me will be trimmed of the ASM header.
> Would it not have been better to reassure her with this study, if
>one is to rely on a single study, than to scare her with the word
>cancer.
If you're talking of the Mayo study, that depends. Were women
randomized? Were long term outcomes followed? If so, it would indeed
be a reassuring study, and worth using to avoid surgery and allow women
who want to wait, to rationally do so without fear. Why would you
imagine I would not welcome such a thing? I spend half my time as an
internist and geriatrician treating anxiety. Whenever I find a study
that will help me do this, I'm happy. So far half the people in this
debate have acted as though I make a kickback when I refer somebody to
a surgeon. On the contrary. Not only do I make nothing, it's just
more work for me in information transfer and coordination that I often
don't get paid for. It's negative income. I'd have to be not only a
sadist, but a masochist as well, to want my patients to have surgeries
that did them no good.
>The word itself is malignant when it gets thrown around so easily by
>the medical industry. How many women in the hysterectomy study were
>also scared into their decision with the threat of cancer? This too
>needs to be investigated.
It would be interesting. At the same time, we need to acknowledge
that cancer is a scary disease. What are the odds? How scared should
a person be? Always a difficult question. The NCI gets more money
than any other NIH institute, but more people actually die of heart
disease and stroke. And ultimately most of these are caused by the
aging process, reserach into which is hardly funded at all (the NIA
gets one of the least slices of the pie). Is any of this rational?
That depends a lot on your values.
> By way of single situation example, when I was 51 going in for
>an annual OBGYN exam, I mentioned in my health history that I was
>having hot flashes. The PA immediately asked if I wanted to be tested
>for menopause. I laughed and said why on earth would I want a test, as
>I was of the right age with all the classic signs.
>
> Her immediate response was that "might have cancer." And this is
>one example of how some women come to fear their bodies. Luckily, the
>only affect on me was to fear that particular medical office and I
>said good-by.
Well, good for you. Glad it wasn't the doctor. Ugly story.
> The point I am making in this ramble away from your topic of
>"science" is that seeds of well-being and fear are planted in a
>patients mind that are not based in "science" and that too needs to be
>brought into the diagnostic decision making process. And that is just
>one way I see the art and science of healing.
The main problem here is the one Harry Rubin keeps bringing up. In
the first place, we lack the studies to know the true odds. In the
second place, people are bad judges of what they should do, even if
they know the true odds (see Las Vegas-- most people feel lucky).
Lastly, values differ greatly from person to person. One perhaps will
be mad as hell at the doctor who points out that a given state means a
0.1% chance of cancer. Another will be mad as hell that the doctor
knew it and didn't disclose it. For every person who feels violated by
being informed of a small risk of a very bad thing, there's another who
feels violated by being kept in the dark. How to tell who is who
before you do it? And that's when you're pretty sure of exactly what
the risk is, which isn't often. Due to lack of information (which
simply does not exist), the doctor often knows the risk is there, but
can bound it only approximately. Now what?
Again, followup headers trimmed.
Steve Harris, M.D.
>
>j (32 years in dentistry - also a healing art)
>
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 17 Mar 1999 07:54:34 GMT
>On Tue, 16 Mar 1999 06:29:06 GMT, drozdik@home.com (Kathryn) wrote:
>
>>On 16 Mar 1999 04:42:34 GMT, sbharris@ix.netcom.com(Steven B. Harris)
>>wrote:
>>
>>> They had the money to do it. You can look at the artifical hip
>>>replacement rate in other countries (also a proceedure done more often
>>>in women) and find the same thing. The US does it more. In Canada you
>>>can wait years for it (in a wheelchair).
>>
>>You can wait years if you don't really need a hip replacement but that
>>is different. <smile>
>>
>>The wait for hip replacement is not all that long Steve, [ I can't
>>produce any figures right now ] at least not in my province. Several
>>of my Meals on wheels clients have had a hip replacements and they
>>weren't in wheelchairs when they headed for the hospital either.
>>
>>Kathryn
>>drozdik@home.com
Oh, golly-- some were still able to use walkers? Be still, my
heart! Oh, Canada, Oh Canada!...
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts
Date: 17 Mar 1999 07:58:14 GMT
In <TCp72YDFGONH092yn@istar.ca> gnome@istar.ca (Robert Ames) writes:
>In article <36edf8a1.3361592@news>, drozdik@home.com (Kathryn) wrote:
>>On 16 Mar 1999 04:42:34 GMT, sbharris@ix.netcom.com(Steven B. Harris)
>>wrote:
>
>>>The US does it more. In Canada you can wait years for it (in a wheelchair).
>
>>The wait for hip replacement is not all that long Steve....
>
>Moreover, the government (at least here in Ontario) pays 75% of the
>cost of medical equipment for patients, so when the weather permits
>we see large numbers of people zipping around on those electric golf
>cart type conveyances.
>
>Apparently the radiation exposure during hip replacement is a real
>problem, as the gonads and prostate are not shielded. Anecdotally
>I've heard of several cases of men having hip replacements and then
>prostate cancer a few years later. This needs to be studied more.
Anecdotally I've heard of several men zipping around on these
electric golf carts and then having prostate cancer a few years later.
It's probably the radiation pattern from the plaid cloth overhead
sunshield. Drives the immune cells mad.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 17 Mar 1999 08:37:47 GMT
In <36f27a78.266042500@news.erols.com> vl-hb001@erols.com (Terri)
writes:
>> Science does what it can: all I ask
>>for is studies where what can be done, has been approached. You cannot
>>compare 30 year old women trying to get pregant who need uterine myomas
>>removed, with 50 year old women and their uteri. They aren't the same.
>
>Why not? Why is it not equally important to conserve organs whenever
>possible regardless of age or childbearing status.
I mean they aren't the same physiologically. A thirty year old
women is far more likely to have one two two small tumors, while a
significant fraction of 50 year old women will have almost nothing BUT
tumors. One group is presenting because a delicate function won't
work, the other because they're in pain. Or bleeding uncontrollably.
It's just not the same.
> But here's a study
>which directly answers your concerns. Ablation for DUB instead of
>hysterectomy.
>
>The abstract follows the url and the entire study is available on line
>Please note the researchers' inherent bias-one of the reasons why it
>is essential to read critically and make sure the conclusion actually
>follows logically from the study. Because 25% of women (and this
>number may be high because of incomplete follow-up) required further
>surgery, this is not necessarily a good procedure for DUB.
>Interesting. The 75% of women who were spared unnecessary removal of
>their reproductive organs are discounted. Wonder why that is?
>
>http://www.medscape.com/Medscape/WomensHealth/journal/1998/v03.n03/wh376.webe/wh3276.webe.01.html
>
>
>
>
>Dysfunctional uterine bleeding (DUB) is a common clinical condition that
>frequently leads to hysterectomy. Endometrial ablation -- a "minimally
>invasive" surgical technique that removes or destroys the endometrial
>lining of the uterus -- is a conservative alternative to hysterectomy for
>DUB. While endometrial ablation has lower immediate costs and shorter
>recovery than hysterectomy, symptoms are not always resolved. Available
>data from studies with admittedly incomplete follow-up suggest that up to
>one quarter of patients treated with endometrial ablation require repeat
>ablation or subsequent hysterectomy to stop DUB. This suggests that the
>short-term advantages of endometrial ablation may be offset by possible
>longer-term disadvantages. The Surgical Treatments Outcomes Project for
>Dysfunctional Uterine Bleeding (STOP-DUB) is a randomized trial designed
>to compare endometrial ablation against hysterectomy. The primary
>outcomes address issues of importance to women, such as quality of life
>and resolution of symptoms that led to surgery. Other outcomes include
>subsequent surgery and cost-effectiveness of the procedures. The study's
>target enrollment is 800 women -- 400 in each treatment group -- from 20
>clinical centers throughout the US. The women will be followed for 2
>years after surgery. Part of the STOP-DUB is a parallel observational
>study that involves women who do not choose surgery or who are not
>eligible for the randomized trial but could become eligible with time. It
>is anticipated that the result of this research will provide important
>information to women and their health care professionals as they consider
>the relative merits of surgical treatments for DUB. [Medscape Women's
>Health 3(3), 1998. © 1998 Medscape, Inc.]
Yes, this looks like a good study. Alas, it hasn't been done
yet. When it has been done, and if the intent-to-treat followup
results favor ablation, I will begin to recommend ablation.
Now, if the results favor hysterectomy, will you recommend that?
>>Success in one group does not even suggest success in the other.
>
>Again, why not? Do we not use surgical techniques discovered in other
>organ sparing sugeries whenever possible in other cases?
No. Nobody worries about draining an infected appendix so that it
can be left in place. I'm sure it could sometimes be done, but the
risks would outweigh the dubious benefits. Perhaps the appendix does
something or other. But the chance that it does is outweighed by the
extra danger of trying to "save" the thing.
Is it always better to try to do endodontics on a broken tooth, and
"save" it? No. Even the people who do it for a living will tell you
that sometimes the attempted cure is worse than the disease. Some
fraction of cataractous lenses might be partly fixable is very delicate
surgery or lasering was done to get just the right spot. But the
results would not be as good as just yanking the thing out. Same for
joints, in some cases. I've given you many examples.
>Why are
>women's reproductive organs excluded from this general rule? That's
>the question you refuse to engage.
>
>Sci. med added to header.
>
>Terri
The general rule?? What general rule? The general rule in surgery
is cut it out if trying to save it is dangerous and you can live a
quality life without it. Organ salvage doesn't come free-- it costs
in risk and money. Most people don't want to pay the price. For those
who do-- hey, I'm a libertarian. It's their party.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,talk.politics.medicine
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 18 Mar 1999 07:08:54 GMT
In <Pine.SUN.4.05.9903170638320.7413-100000@coyote.rain.org> jinelle
<jinelle@rain.org> writes:
> My concern with US medical care is often the rush to treatment,
>skipping adequate differential diagnosism or even a good health
>history.
This is also the concern of a many a doctor. Alas, there are
powerful forces which push less talk and less thinking in medicine, and
more expensive diagnostics and treatments. The basic reasons are
three:
1) It's hard to charge for thinking, especially to third party payers.
Laywers simply charge by the hour, but they get away with different
hourly rates for different quality of thinking, because they work in a
market system. If you want to see what a government pay system looks
like, consider the pay for public defenders. And the quality thereof.
2) It's hard to charge for talking, because who knows what you're
talking about? Without the patient conscious that it's a taxi with the
meter running and he or she is footing the bill, it's not very
efficient.
3) Finally, last but not least, there is very little respect for
information in our society. We have not yet reached the advanced stage
of civilization where we recognize that information is one of the few
things of basic value. Perhaps information and human life (hours
spent) are the only true commodities. And one often equates to the
other, in some manner. Especially in medicine.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Post-hysterectomy Sex Abstracts (Re: Doctor-bashing)
Date: 18 Mar 1999 12:49:16 GMT
In <37012839.376081027@news.erols.com> vl-hb001@erols.com (Terri)
writes:
>This simply isn't true. First fibroids are seldom painful, just as
>pregnancy isn't painful. They may be uncomfortable if they're pressing
>on other organs, but they are not often the source of pelvic pain.
Agreed, but it happens. And pregancy is often painful. If the
women didn't know it would soon be over, and if the expected outcome
wasn't anticipated so much, it wouldn't be tolerated for long.
>Second, the 50 year old woman is about to undergo a change which is
>virtually guaranteed to shrink her fibroids. So long as no one
>pushes estrogen at her and tells her it is the elixer of life and the
>fountain of youth without which she will surely die of all manner of
>dread diseases. How many doctors tell women that time will solve the
>problem?
Most of them. But a 40 year old woman may have 10 years to go, or
a 45 year old women 5 or even 7. Some don't want it.
The epidemiology suggests that estrogen replacement lengthens life,
for the average woman. The double blind randomized study to find out
once and for all has been going only 5 years, and the answers are not
in.
>How many women are doing well with elixer of time until their doctors
>push a prescription on them which since it's a "one size fits all"
>often causes more problems than it solves?
Not many. Most hysterectomies are NOT done for problems that
started only after hormone replacement. Indeed, such problems would
certainly cause almost all doctors to suggest hormone withdrawal first.
>> Now, if the results favor hysterectomy, will you recommend that?
>>
>Since it seems that a 75% success rate with ablation will still be
>reported negatively, I'd have to see the numbers and the percentages
>before I could answer that. My feeling would be that hysterectomy can
>always be done as a last resort so if it can be avoided why not give
>the other treatment a try first.
Because some women who end up having the hysterectomy will feel
they could and should have saved themselves the time, money, and pain
of the first procedure.
> And if hysterectomy is required
>ovaries should be left inplace abd probably the cervix too if that is
>feasible (ie there is no malignancy)
Regarding the cervix, the best study has failed to confirm that.
However, if the woman is middle aged with never any suggestion of
malignancy, it's probably not worth the whatever risk there is of
causing sexual problems (a risk we still cannot quantititate, but know
is small). As for the ovaries, it all depends on tradeoffs. How much
does cancer scare you? What's your family history? How good is your
sex-life already and how important is it to you? What is the
likelihood that androgens will not be able to replace those produced by
the ovaries after menopause?
>>
>>>>Success in one group does not even suggest success in the other.
>>>>
>>>Again, why not? Do we not use surgical techniques discovered in other
>>>organ sparing sugeries whenever possible in other cases?
>>
>> No. Nobody worries about draining an infected appendix so that it
>>can be left in place. I'm sure it could sometimes be done, but the
>>risks would outweigh the dubious benefits. Perhaps the appendix does
>>something or other. But the chance that it does is outweighed by the
>>extra danger of trying to "save" the thing.
>
>Your comparison here is so faulty that I'm not even going to address
>it. Your underlying belief that the uterus (and ovaries?) is/are
>nothing more than the appendix and equally disposible is reprehensible
>to my way of thinking.
I'm sure it is. But you brought up the general rule. I'm simply
refuting it. You don't address the tooth example, and for a good
reason. You don't have an answer.
>> Is it always better to try to do endodontics on a broken tooth, and
>>"save" it? No. Even the people who do it for a living will tell you
>>that sometimes the attempted cure is worse than the disease. Some
>>fraction of cataractous lenses might be partly fixable is very delicate
>>surgery or lasering was done to get just the right spot. But the
>>results would not be as good as just yanking the thing out. Same for
>>joints, in some cases. I've given you many examples.
>>
>Another piece of medical wisdom is that their is no ovary good enough
>to leave in and no testicle bad enough to take out. Do you subscribe
>to that too?
Nope.
>>
>>>Why are
>>>women's reproductive organs excluded from this general rule? That's
>>>the question you refuse to engage.
>>>
>>>Sci. med added to header.
>>>
>>>Terri
>>
>>
>> The general rule?? What general rule? The general rule in surgery
>>is cut it out if trying to save it is dangerous and you can live a
>>quality life without it.
>
>And who defines dangerous? or quality life?
The answer is below. Did you miss it?
>
>Terri
>> Organ salvage doesn't come free-- it costs
>>in risk and money. Most people don't want to pay the price. For those
>>who do-- hey, I'm a libertarian. It's their party.
>>
>> Steve Harris, M.D.
>
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Hyterectomy and urinary incontinence in women
Date: 3 Jul 2005 19:35:02 -0500
Message-ID: <42c883e1$0$16182$bb4e3ad8@newscene.com>
> Another cause of urinary incontinence and prolapse as a result of
> medical intervention - hysterectomy, especially vaginal hysterectomy.
>
>
> Want me to post a few references?
>
Urinary incontinence and prolapse are indeed recognized potential risks of
hysterectomy, vaginal or abdominal. Although, it is worth pointing out that
abdominal hysterectomy has only limited application these days. Likewise,
vaginal hysterectomy is a procedure that is too often done badly. GYN
surgeons COMMONLY omit the basic step of securing the vaginal cuff to the
uterosacral ligaments. State-of-the-art is laparoscopic assisted vaginal
hysterectomy (LAVH). In cases of non-malignant disease and no cervical
dysplasia, a supracervical hysterectomy would be preferred, in which case
prolapse is not an issue, nor would be urinary incontinence. For cases of
dysfunctional uterine bleeding, endometrial ablation would be the procedure
of choice.
One of the problems with the complications of GYN surgery is that that
surgery tends to be done by gynecologic surgeons. Of a 4 year residency, a
typical OB-GYN doctor will have a total of ONE year of surgery training. The
typical GYN surgeon is NOT a good surgeon, and those procedures should be
left to surgeons with specific training. Colporrhaphy, LAVH, virtually ALL
vaginal surgery and certainly all urogynecologic surgery is very difficult
and is simply too far beyond the training and resultant skill set of the
typical OB-GYN.
If I were going to have one of these procedures (I'm not)...the first
question I would ask my GYN surgeon is if he/she delivers babies. If he/she
says "yes", then I would immediately find another surgeon. Surgery should be
done by surgeons, not someone who only does it part time, spending the rest
of their time doing obstetrics and primary care.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Hyterectomy and urinary incontinence in women
Date: 3 Jul 2005 17:43:54 -0700
Message-ID: <1120437834.198499.116650@g43g2000cwa.googlegroups.com>
>>If I were going to have one of these procedures (I'm not)...the first
question I would ask my GYN surgeon is if he/she delivers babies. If
he/she says "yes", then I would immediately find another surgeon. Surgery
should be done by surgeons, not someone who only does it part time,
spending the rest of their time doing obstetrics and primary care. <<
COMMENT:
Amen. **Number one rule of surgery** is: get it done by somebody (and
some PLACE) that does that surgery every day, day in and day out, and
nothing but. These guys are boring, but you're not hiring them for
their sparkle.
The GYN surgeons who specialize in GYN cancer tend to have a lot more
surgical training, and of course a lot more experience. They're who to
go to if you have a funny ovarian nodule. Of course, they all do open
surgeries, and are not the laparoscopic folks, so you don't want to go
to them if you DON'T have a nodule.
If you simply need a repair and need the minimally invasive procedure,
than see somebody who does it laparoscopically. And yes, who does
nothing but that kind of repair.
SBH
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Hyterectomy and urinary incontinence in women
Date: 4 Jul 2005 09:38:01 -0500
Message-ID: <42c94972$0$50273$bb4e3ad8@newscene.com>
"Terri" <terrisk@vverizon.com> wrote in message
news:C81ye.19554$Fn4.11499@trnddc06...
> I agree. Would you also recommend uterine artery embolization for fibroids
> or myomectomy if UAE isn't feasible for some reasaon?
I think that embolization has it's place, but I'm of the opinion that it's
used more often than it should be. Submucous fibroids can often be addressed
via hysteroscopy, and subserosal or intramuscular fibroids can (and should)
be addressed laparoscopically (myomectomy). The discomfort from UAE can be
prolonged, and it's been my observation that recovery is generally quicker,
with less discomfort, from a minimally invasive approach
(laparoscopy/hysteroscopy) to myomectomy. You may attribute that opinion to
parochial thinking on my part as a surgeon, and I would grant you that there
may be some truth in that. In cases where the fibroid is not amenable to
these minimally invasive techniques, a supracervical hysterectomy with
morcellation of the uterus and fibroid(s) would be the method of choice
(again, assuming the cervix shows no tendency toward cervical cancer).
Again, I would add the caveat that these minimally invasive techniques are
great procedures in the hands of someone who knows how to do them. The
problem with minimally invasive surgery is that it's hard to do (ever try to
play Nintendo against your kids?). Consequently many surgeons convince
themselves, and subsequently their patients, that an open procedure is
better. If a surgeon were to tell a women that an open total hysterectomy
was a better treatment for fibroids than a minimally invasive approach, I
think it would be very reasonable to suspect that what he/she was REALLY
saying is that they are not skilled at minimally invasive surgery. My point
above about UAE is illustrative of this opinion - it's easier to just send
the patient to the invasive radiologist than it is to struggle with a
minimally invasive myomectomy that the GYN surgeon really doesn't know how
to do very well.
So, yes...there is no question (in MY mind) that, assuming UAE *truly* isn't
adviseable, a myomectomy (laparoscopic for subserosal/intramuscular -
hysteroscopic for submucous) is the procedure of choice. If MIS myomectomy
*truly* isn't feasible, then a laparoscopic supracervical hysterectomy is
the option of choice, with it's resultant quick recovery, minimal
discomfort, and lack of problems with pelvic floor issues.
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 18 Aug 2005 19:02:02 -0500
Message-ID: <43052132$0$16187$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
news:1124405822.052846.302460@g44g2000cwa.googlegroups.com...
> Today I received a pathology report which both concerns and confuses
> me. I have come to respect each of you, and sincerely wish to know your
> most candid comments.
>
> When *you* see this, what are you seeing? When *you* see this, what do
> you advise? How is this treated where you practise? What are my
> options, as you see them?
>
> The gynecologist who did my diagnostic surgery is now on vacation. Her
> stand-in was very kind, and gave me some idea of my options. I want to
> hear from you. Also, I kind of blanked out here and there, and he is
> run off his feet. Yesterday he was a resident. Today he's flying on his
> own. ; )
>
> I have been told I have a pre-cancerous condition. Here is my
> pathology.
>
> "...three polyp like structures. The first measures 2.5 x 1 cm... The
> other two polyp like structures measure 1.0 x 1.9 and 1.2 x 1.2 cm
> (Zee: and some remarks which I assume mean location 2E and 2F)
>
> "sections show endocervix and endometrium with evidence of simple and
> complex hyperplasia with focal atypia. Most of the hyperplasia is seen
> within the polyps. Some appear to involve the underlying endometrium.
> ..."
Zee:
I agree that this is at least a pre-cancerous condition. The areas of focal
atypia in particular would make me nervous because of the possibility that
it might actually signify adjacent areas of adenocarcinoma. Assuming that
adenocarcinoma is not currently present, it's generally considered that
about 40-50% of patients with atypia in complex hyperplasia will progress to
adenocarcinoma.
The report states that most of the hyperplasia is contained within the
polyps, but some is in the surrounding endometrium. I can't tell if there
was any atypia in that adjacent endometrium. That would make a difference as
to whether or not this might be treated with local resection rather than
hysterectomy. However, having said that, this is a case where a hysterectomy
would generally be recommended based on what little I know from your above
post.. Given the complex hyperplasia in the the endocervical samples, a
total hysterectomy is indicated (as opposed to a supracervical). My approach
would be to recommend an LAVH/BSO (total laparoscopic hysterectomy and
remove both ovaries) assuming that you are at least in your late 30's. In
some cases, a frozen section might be done at the time of that operation to
try to assure that there is not invasive cancer present. If there is, and it
is greater than 50% of the uterine wall thickness, then a more extensive
open operation would be indicated, including iliac and periaortic node
sampling..
This is distressing news, Zee. While I am sorry that you are now faced with
this difficult situation, I do applaud what has every possibility of an
early diagnosis with a resultant good outcome. Good luck.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 18 Aug 2005 17:00:04 -0700
Message-ID: <1124409604.551862.264400@g47g2000cwa.googlegroups.com>
David Rind wrote:
> fresh~horses@despammed.com wrote:
> > Today I received a pathology report which both concerns and confuses
> > me. I have come to respect each of you, and sincerely wish to know your
> > most candid comments.
> >
> > When *you* see this, what are you seeing? When *you* see this, what do
> > you advise? How is this treated where you practise? What are my
> > options, as you see them?
> >
> > The gynecologist who did my diagnostic surgery is now on vacation. Her
> > stand-in was very kind, and gave me some idea of my options. I want to
> > hear from you. Also, I kind of blanked out here and there, and he is
> > run off his feet. Yesterday he was a resident. Today he's flying on his
> > own. ; )
> >
> > I have been told I have a pre-cancerous condition. Here is my
> > pathology.
> >
> > "...three polyp like structures. The first measures 2.5 x 1 cm... The
> > other two polyp like structures measure 1.0 x 1.9 and 1.2 x 1.2 cm
> > (Zee: and some remarks which I assume mean location 2E and 2F)
> >
> > "sections show endocervix and endometrium with evidence of simple and
> > complex hyperplasia with focal atypia. Most of the hyperplasia is seen
> > within the polyps. Some appear to involve the underlying endometrium.
> > ..."
> >
> >
> > With thanks.
> >
> >
> > Zee
>
> Unfortunately, I don't have much experience with pathology reports for
> endometrial polyps. Without your comments/concerns, I would have thought
> this was a pretty benign sounding report. With those comments, I'm
> guessing that one option recommended was to perform a hysterectomy to
> prevent the future development of endometrial cancer. I have no idea,
> though, what the risk of progression is.
>
> --
> David Rind
> drind@caregroup.harvard.edu
COMMENT:
And since most of my patients are frozen and also I'm not a
gynecologist, there's little I can add to that. Uterine cancer can be
anywhere, and you don't always biopsy through it. So the biopsy is
sepecific but not sensitive. If it's not in the area where you
biopsied, it might not show.
There's argument about whether or not endometrial polyps _per se_ even
predispose to cancer-- they aren't like colon polyps. Hyperplasia is a
risk factor for cancer, but far more important is age and endometrial
thickness-- if it's less than 5 or 6 mm, usually you can avoid the
reflex hysterectomy. Age (>70), diabetes and no childbearing history
are also important risk factors for uterine cancer in post menopausal
bleeding.
Complex hyperplasia in women of childbearing years who want to preserve
the uterus is sometimes treated with high dose progestins. This is
often successful but not always. If it was, everybody could avoid
hysterectomy. Since most women with complex hyperplasia and bleeding
who are > 10 years from menopause just get the hysterectomy, there's
not a lot of experience treating this any other way.
I recommend take it out. You can't get cancer in an organ that has been
removed. Progestins like Provera aren't completely benign, and do bad
things to blood lipids. I would encourage natural progesterone if a
women insisted on going that route.
SBH
1: Acta Obstet Gynecol Scand. 1985;64(8):653-9.
Endometrial polyps and hyperplasia as risk factors for endometrial
carcinoma. A case-control study of curettage specimens.
Pettersson B, Adami HO, Lindgren A, Hesselius I.
As part of a comprehensive case-control study, the impact of previous
endometrial pathology on the risk of developing endometrial carcinoma was
investigated. The study comprised 254 consecutive women with
histopathologically confirmed cancer of the uterine body in a
well-defined population, and their age-matched controls. Ninety-eight
(39%) of the patients and 81 (32%) of the controls had previously
undergone endometrial curettage. More than one previous curettage was
positively associated with endometrial carcinoma (odds ratio = 2.5; 95%
CL = 1.4-4.5). Endometrial abnormalities in previous curettage specimens
occurred significantly more often among carcinoma patients (57%) than
among controls (25%) (odds ratio = 4.0; 95% CL = 2.0-8.0). Twelve
patients, but no controls, had adenomatous hyperplasia and this
hyperplasia antedated the cancer diagnosis by a mean of 4.6 years.
Endometrial polyps were present significantly more often in patients
(20%) than in controls (10%) (odds ratio = 3.4; 95% CL = 1.3-9.3). The
present results suggest that both of these conditions are risk factors
for endometrial carcinoma. Among women who had undergone endometrial
curettage more than 4 years after the menopause, 19 out of 30 patients,
but none out of 7 controls, showed abnormality in the curettage
specimens. Postmenopausal women with endometrial abnormality should thus
be regarded as being at risk of developing endometrial carcinoma.
PMID: 3832756 [PubMed - indexed for MEDLINE]
2: J Clin Ultrasound. 2004 Jun;32(5):219-24.
Combination of endometrial thickness and time since menopause in
predicting endometrial cancer in women with postmenopausal bleeding.
Bruchim I, Biron-Shental T, Altaras MM, Fishman A, Beyth Y, Tepper R,
Aviram R.
Department of Obstetrics and Gynecology, Sapir Medical Center, 59
Tchernichovsky Street, Kfar Saba, 44281, Israel.
PURPOSE: This study was conducted to assess the combination of
endometrial thickness, as measured by transvaginal sonography, and time
since menopause, in predicting the presence of endometrial cancer in
women with postmenopausal bleeding. METHODS: The study group consisted of
95 women with postmenopausal bleeding who underwent sonographic
measurement of endometrial thickness followed by endometrial biopsy. No
patient had ever received hormone replacement therapy. RESULTS: The mean
endometrial thickness was significantly lower in the absence of
endometrial carcinoma (6.9 +/- 4.3 mm) than in its presence (13.5 +/- 7.7
mm) (p < 0.005). The incidence of endometrial carcinoma increased with
increases in endometrial thickness and the number of years since
menopause. No patient had carcinoma when the endometrium was less than 5
mm thick, but 18.5% did when the thickness exceeded 9 mm. The incidence
of cancer was 2.6% in women who had undergone menopause less than 5 years
earlier but was 21.4% in women who had undergone menopause more than 15
years prior. Multiple logistic regression analysis showed that time since
menopause and endometrial thickness were statistically significant
predictors of endometrial carcinoma. CONCLUSIONS: Time since menopause
and endometrial thickness together define cutoff points for the
diagnostic biopsy of tissue samples for endometrial carcinoma; that is,
within a particular time interval, sampling should not be performed if
the thickness is below a given value. When using cutoff points of 6 mm of
endometrial thickness for women experiencing menopause 5-15 years prior
and 5 mm in those going through menopause 15 or more years prior,
approximately 60% of invasive procedures may be avoided. In addition,
models derived by multiple logistic regression can be used to calculate a
patient's risk of cancer based on her age and endometrial thickness.
Copyright 2004 Wiley Periodicals, Inc.
Publication Types:
Clinical Trial
Controlled Clinical Trial
PMID: 15124187 [PubMed - indexed for MEDLINE]
3: Ann Chir Gynaecol. 1983;72(5):274-7.
Endometrial findings following curettage in 2018 women according to age
and indications.
Holst J, Koskela O, von Schoultz B.
A retrospective study on 2018 Scandinavian women undergoing conventional
and aspiration curettage was performed. The outcome in terms of
endometrial pathology was analyzed against age and indications. A large
number of operations (38.2%) were performed on young women before the age
of 45 years. 98% of endometrial samples were normal from 430 younger than
40 years. Better selection of cases might help to reduce the number of
operations. In women of reproductive age the relation between normal and
pathological findings was the same for both methods with the exception
that conventional curettage seemed to detect more polyps. The frequency
of insufficient samples after aspiration curettage increased markedly
with age. Postmenopausal bleeding remains a strong indication for
conventional curettage.
PMID: 6660829 [PubMed - indexed for MEDLINE]
4: Am J Obstet Gynecol. 2003 Feb;188(2):401-8.
Comment in:
Am J Obstet Gynecol. 2004 Aug;191(2):677; author reply 678.
Can ultrasound replace dilation and curettage? A longitudinal evaluation
of postmenopausal bleeding and transvaginal sonographic measurement of
the endometrium as predictors of endometrial cancer.
Gull B, Karlsson B, Milsom I, Granberg S.
Department of Obstetrics and Gynecology, University of Goteborg,
Sahlgrenska University Hospital, Sweden. berit.gull@obgyn.gu.se
OBJECTIVE: The purpose of this study was to evaluate postmenopausal
bleeding and transvaginal sonographic measurement of endometrial
thickness as predictors of endometrial cancer and atypical hyperplasia in
women whose cases were followed for > or =10 years after referral for
postmenopausal bleeding. STUDY DESIGN: Women (n = 394) who had
postmenopausal bleeding from November 1987 to October 1990 underwent
transvaginal sonographic measurement of endometrial thickness and
curettage. It was possible to assess the medical records (regarding
recurrence of a postmenopausal bleeding, development of endometrial
cancer, and death) in 339 of the 394 women (86%) > or =10 years after
referral for postmenopausal bleeding. RESULTS: Thirty-nine of the 339
women (11.5%) had endometrial cancer, and 5 women (1.5%) had atypical
hyperplasia. The relative risk of endometrial cancer in women who were
referred for postmenopausal bleeding was 63.9 (95% CI, 46.0-88.8); the
corresponding relative risk for endometrial cancer and atypical
hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women of
the same age from the general population of the same region of Sweden. No
woman with an endometrial thickness of < or =4 mm was diagnosed as having
endometrial cancer. The relative risk of the development of endometrial
cancer in women with an endometrial thickness of >4 mm was 44.5 (95% CI,
6.5-320.1) compared with women with an endometrial thickness of < or =4
mm. The reliability of endometrial thickness (cutoff value, < or =4 mm)
as a diagnostic test for endometrial cancer was assessed: Sensitivity,
100%; specificity, 60%; positive predictive value, 25%; and negative
predictive value, 100%. The incidence of endometrial cancer or atypical
hyperplasia in women with an intact uterus whose cases had been followed
for > or =10 years was 5.8% (15/257 women) compared with 22.7% (15/66
women) in women who had < or =1 episode of recurrent bleeding. No
endometrial cancer was diagnosed in women with a recurrent postmenopausal
bleeding who had an endometrial thickness of < or =4 mm at the initial
scan. CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk
for endometrial cancer. There was no increased risk of endometrial cancer
or atypia in women who did not have recurrent bleeding, whereas women
with recurrent bleeding were a high-risk group. No endometrial cancer was
missed when endometrial thickness measurement (cutoff value, < or =4 mm)
was used, even if the women were followed up for < or =10 years. We
conclude that transvaginal sonographic scanning is an excellent tool for
the determination of whether further investigation with curettage or some
form of endometrial biopsy is necessary
PMID: 12592247 [PubMed - indexed for MEDLINE]
5: Gynecol Oncol. 1995 Mar;56(3):376-81.
Predicting endometrial cancer among older women who present with abnormal
vaginal bleeding.
Feldman S, Cook EF, Harlow BL, Berkowitz RS.
Department of Obstetrics, Gynecology, Brigham and Women's Hospital,
Boston, Massachusetts, USA.
We studied 203 women ages 49 or over who presented with abnormal vaginal
bleeding and who underwent either endometrial biopsy or dilation and
curettage at the Brigham and Women's Hospital. Using information from the
clinical history, we predicted their risk for endometrial cancer (36
patients) or complex endometrial hyperplasia (16 patients). Factors
independently associated with endometrial cancer/complex hyperplasia
included age 70 or older (OR = 9.1, P = 0.0001), diabetes (OR = 3.7, P =
0.02), and nulliparity (OR = 2.7, P = 0.02). After adjusting for age,
menopause was borderline significant (OR = 2.6, P = 0.07). Our data
estimated a risk of endometrial cancer/complex hyperplasia of 87% for a
woman possessing all of these factors, and a risk of less than 3% if she
had none of them. Our model provides an inexpensive, simple means for
assessing the risk of endometrial cancer and complex hyperplasia in the
post- or perimenopausal woman with abnormal bleeding.
PMID: 7705671 [PubMed - indexed for MEDLINE]
6: Acta Obstet Gynecol Scand. 2000 Apr;79(4):317-20.
The risk of premalignant and malignant pathology in endometrial polyps.
Bakour SH, Khan KS, Gupta JK.
Birmingham Minimal Access Surgical Training Centre, Academic Department
of Obstetrics and Gynaecology, University of Birmingham, UK.
OBJECTIVE: To evaluate the risk of premalignant and malignant pathology
among endometrial polyps. DESIGN: Prospective cohort study. SETTING:
Minimal Access Surgical Training (MAST) center in a large teaching
hospital. METHODS: Among 248 patients seen in outpatient hysteroscopy
clinic (1996-97), 62 had endometrial polyps. All patients had endometrial
sampling for histological assessment. To determine the magnitude of
malignant potential among polyps, we compared the pathological findings
in polyps (cases) with non-polypoidal specimens (controls). RESULTS: Out
of 62 polyps, histologically 53 (85.5%) were benign, seven (11.3%) had
hyperplasia, and two (3.2%) were associated with malignancy. Hyperplasia
was more frequent in endometrial specimens with polyps than in those
without (11.3% vs 4.3%, p=0.04), but the incidence of carcinoma in the
two groups was the same (3.2% vs 3.2%, p= 1.0). CONCLUSION: In abnormal
uterine bleeding, hyperplasia was, but cancer was not, more common in
women with endometrial polyps compared to those without polyps.
PMID: 10746849 [PubMed - indexed for MEDLINE]
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 08:03:08 -0500
Message-ID: <4305d812$0$426$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
news:1124416410.986069.240910@g43g2000cwa.googlegroups.com...
>
> He also
> said if I refused what he recommends, they would ask me to sign that he
> (they) had told me what my risk is, and that I declined to have what
> they recommended
Seems a little...uh...over the top, and an unnecessary application of
pressure. If I were a patient, that kind of request would kind of piss me
off.
>I didn't ask if it would be laparoscopic. I will, if I
> make the decision for this surgery, which I view as castration.
>
If you decide on the hysterectomy, it should be all means be laparoscopic
unless the surgeon can provide you with a good reason why, in your
particular case, it would not be appropriate (other than his/her lack of
ability with that operation).
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 10:12:08 -0500
Message-ID: <4305f637$0$419$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
>
> Can you tell me why laparoscopic is preferable and what might be
> reasons for not doing it that way?
Laparscopic assisted vaginal hysterectomy (LAVH) results in less pain, fewer
complications, quicker recovery. Generally, gynecologists are not very
well-trained surgeons and LAVH, which is difficult, is beyond many of them.
GYN-oncologists are generally competent surgeons, but generally don't have
much training or skill with laparoscopy.
>
> Howard I really don't want to lose my ovaries.
>
> I am angry that when men have "pre-cancerous" conditions, no one is
> recommending immediately that they be castrated. Why is this so for
> women? Why?
>
I'm not 100% sure that you have to lose your ovaries. The problem is a)
whether or not there is already adenocarcinoma in the uterus and b) if there
is, has it spread beyond 50% of the thickness of the uterine wall.
It would be a mistake to try to apply some sort of misogynistic motive to
what is actually a vagary of human anatomy relative to his particular
pre-cancerous condition. IF there is cancer present in your uterus, and IF
it has spread deeply into the uterine wall, it then has the potential to
also have lodged itself in the lymphatics that it shares with the ovaries
and fallopian tubes. In that case, to remove the cancer (uterus) and not
remove the tissue where it tends to spread (ovaries) is a bad thing. The
basis for your gyn recommending TH/BSO is that it is *conceivable* that
there is already adenocarcinoma in the uterine wall. The fact that there is
focal atypia may mean that cancer could develop someday, OR it might mean
that cancer has already developed.
The treatment of cancer is a study in playing the odds. Treatment tends to
be aggressive, in many cases overly aggressive I'm sure, because the
consequences of being *under* aggressive are death, perhaps unnecessary
death, by cancer.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 16:45:32 -0700
Message-ID: <1124495132.696779.151220@o13g2000cwo.googlegroups.com>
Terri wrote:
> I think you haven't talked to very many women if you haven't run across
> some who found that oopherectomy had a negative effect on their sex lives.
COMMENT:
A postmenopausal oopherectomy, where fertility is not at issue? Hardly
to be compared with the effects of an orchiectomy in a man, where
fertility is always lost (hormones in both cases can be replaced). Nor
is a hysterectomy, after which sexual function is almost always
preserved in a women, to be compared with the old radical
prostatectomy, in which it was almost always lost in a man (along with
fertility also). The cancer research money has followed the odds of
major damage from cancer surgery, not the gender.
Please don't tell me tales of women whose sex lives were destroyed or
badly disrupted by a TAH/BSO. I've even heard a few myself, asking many
women about this as a geriatrician. However, it's comparitively rare.
(And I suspect can be predicted by the woman herself before-hand from
certain clues in her own sexual response, though no surgical Kinsey has
yet done that study). A woman with uterine cancer who strongly suspects
she needs her uterus to have satisfactory sex, would indeed be in the
same position as a man facing a radical prostatectomy to save his life.
But medicine in its present state has no good solution for *either* of
them.
That's what gives cancer a bad name, don't you know. If afflicts things
you need, and you must sometimes choose to lose these things, and their
function, or else die. Hello? As I've said many times, there is no
person to blame for this, the human condition. If you don't like it, go
out and shake your fist at the sky!
Certainly don't blame medicine. At least medicine gives the *option* of
life in some cases. And if you don't like it, you can always say "no."
Put your tongue up behind your front teeth and try it. NNNnnnnn--oohh.
What part of the word don't you understand?
Alas, you are an adult and will be responsible for what happens to you
if you should use the N word. Perhaps that's what you don't like?
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 19:14:33 -0700
Message-ID: <1124504073.414787.93790@g47g2000cwa.googlegroups.com>
Terri wrote:
> I'm not quite sure what your point is. I was merely objecting to what
> struck me as a blanket claim that oopherectomy has no effect on female
> sexual functioning. I don't think that's true and many women that I've
> talked to have told me that it isn't true. Others say it didn't affect
> them sexually. I don't think this is a one size fits all issue.
Obviously not, but we need statistics at this point. Do 1% of women
miss their ovaries? 10%? 50%
> Again, what's your point? I'd agree that if your choice is your sex life
> or your life itself, the choice is pretty clear. I think in this case
> though we're talking about a far less clear cut matter, where sparing
> the ovaries might well be a legitimate choice.
It's always a choice. Whether or not it's a wise one depends on the
individual. And of course will be heavily informed by statistics. If
only 1 women in a 100 has sexual problems related to a postmenopausal
oophorectomy, it's a different kind of thing than if it's 50%. And
whether or not the problem can be corrected by drugs. All this against
some small but real chance that (say) a uterine cancer may spread to a
retained ovary. Or that an ovarian cancer may occur, or recur.
> I have this annoying belief that people should hang on to their normal
> healthy organs if they can do so without doing themselves any harm.
But nobody would suggest cutting out an organ unless there was some
chance that retaining it would cause you harm! An oophorectomy is not
done like a circumcision, as a religious ritual. There's always a
medical reason, and it's usually one directly related to risk of loss
of life. Sometimes small, sometimes large, but always there.
>I think anyone who's going to have surgery should make sure that nothing
> more will be removed than is necessary. I don't think humans come with
> truly disposable parts. Do you?
Like the baby teeth? Sure. More often, humans come with organs that
cease to function and die, or mostly die, in the course of normal
aging. Like some of the follicles on my head! And actually, a lot of
your second set of teeth if there was no dentistry, even if you ate
perfectly. Things just wear out. Oravies run out of ova and turn into
fiberous tissue with little function (perhaps not none, but very
little). The uterus quits doing the primary job it is obviously there
to do. You eye lenses quit being flexable and you can no longer focus
closely. The disks between your vertebrae lose water and all but
disasppear. Your lungs and joints and arteries lose elasticity, etc,
etc.
> I understand the word "no" quite well. I've had a lot of practice in
> saying it. I'm a mother of two (now grown) kids. I've also had to say it
> to members of your profession on occasion when they were urging a course
> of action *I* deemed unwise.
Good for you. And the second part of that (ignoring expert advice) is
that you're forbidden to whine if you find out that you erred in doing
so. You gotta take it like a man. So to speak.
Your choices are up to you. Sometimes you'll win, and sometimes you'll
lose. So long as you remember that your personal experience may not fit
all, I've got no problem with choice. The closest you or anyone can get
to truth about what is most likely to happen in the future as a result
of choice, is honest statistics. What percentage of women have problem
x as a result of choice y? The rest is just storytelling, and sometimes
stories are very poor guides indeed. We should use them only where we
have nothing better.
SBH
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 21:58:12 -0500
Message-ID: <43069bf4$0$91641$bb4e3ad8@newscene.com>
"Terri" <terrisk@vverizon.com> wrote in message
news:mJwNe.384$g47.9@trnddc07...
> Actually when the topic is ovaries that's often not true. Oh there are
> arguments that removing them is always a good idea "while we're in there"
> to prevent ovarian cancer but I think most good gyns and surgeons don't
> follow this practice anymore. The recent study reported in the past week
> or two showing serious deleterious long term effects as a result of
> oophorectomy will give more good doctors pause now before recommending
> this, I think. And then there are the incidental appendectomies that I
> think are no longer quite so frequently done either. Dr McCollister???
Oophorectomy is generally recommended as part of a hysterectomy operation in
patients who are within about 10 years of menopause. Incidental
appendectomies are still done in some circumstances, but not nearly so
frequently as in years past
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 19 Aug 2005 08:13:15 -0500
Message-ID: <4305da8d$0$480$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message >
>
> Howard is an endometrial ablation an option here?
>
That is debateable. Generally, it might be considered appropriate for
hyperplasia - especially for simple hyperplasia, less so for complex, and
even more less so when there is atypia present. As I mentioned, your case is
a little outside the box because the complex hyperplasia (and presumably the
atypia) was present primarily in rather large endometrial polyps. The
problem with endometrial ablation is that it obviously changes the lining
enough that if there are ongoing changes, they might be picked up late, and
if there is already adenocarcinoma, well, that would end up being a big
problem. One thing that I would consider is whether or not a repeat
hysteroscopy AND thorough fractional D&C might not help answer the
endometrial ablation question.
It's a good question for a GYN-Oncologist, and that's where I 'd go for a
second opinion if I were you.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 13:40:05 -0700
Message-ID: <1124570404.981771.45750@g43g2000cwa.googlegroups.com>
fresh~horses@despammed.com wrote:
> HERS Foundation
> http://www.hersfoundation.com/articles.htm
> http://www.hersfoundation.com/facts.html
>
> FACT: Women experience a loss of physical sexual sensation as a result
> of hysterectomy.
> FACT: A woman's vagina is shortened, scarred and dislocated by
> hysterectomy.
COMMENT:
These are somewhat relative facts. The surgery, and the effects of the
surgery, differ from woman to woman. And are affected by hormone
replacement afterwards (including andogen replacement). And sometimes
must be weighed against the "loss of physical sexual sensation" a women
experiences when she dies of cancer. :( After which the vagina is
shortened and dislocated also, during the process of decay. ("The
grave's a fine and private place/ but none I think do there
embrace...")
> FACT: Hysterectomy's damage is life-long. Among its most common
> consequences, in addition to operative injuries are:
>
> * heart disease
> * osteoporosis
> * bone, joint and muscle pain and immobility
> * loss of sexual desire, arousal, sensation
> * painful intercourse, vaginal damage
> * displacement of bladder, bowel, and other pelvic organs
> * urinary tract infections, frequency, incontinence
> * chronic constipation and digestive disorders
> * profound fatigue
> * chronic exhaustion
> * altered body odor
> * loss of short-term memory
> * blunting of emotions, personality changes, despondency,
> irritability, anger, reclusiveness and suicidal thinking
>
> FACT: No drugs or other treatments can replace ovarian or uterine
> hormones or functions. The loss is permanent.
COMMENT:
These are NOT "facts." These are premature conclusions based on the
*very* same kind of lousy post-hoc epidemology which got doctors into
trouble with estrogenic HRT replacement, before the HRT randomized
trials came out. And which poor-quality data now are being used by the
VERY same people who are still beating doctors over the head for their
old HRT prescribing actions based on "mere epidemiology"! (Actually, it
was far better epidemiology than used by HERS-- it just happened to be
wrong). Hypocrites! In some cases the bad things that are supposed to
be "caused" by oophorectomy (heart disease, digestive disorder), may
well have been *caused* by estrogenic/progestinic HRT, but the people
who bring you these factoids would find that very inconvenient to
mention, because it doesn't fit their agenda. But they'll be glad to
point to the problems caused by estrogenic HRT, in other contexts.
As for lack of sexual desire and mental changes after BSO, there is
just as good epidemiologic evidence associating them with the loss of
androgens that acompanies oophorectomy. In addition, there is now
direct placebo-controlled experimental evidence that andogenic hormone
replacement is helpful to many women in this regard.
http://www.biomedcentral.com/1534-5874/1/202
So let us not hear about the mental and physical problems associated
with oophorectomy surgery until it's been evaluated in a double blind
fashion, with androgen replacement. Until then, we're in the same boat
as with HRT in 1995.
> FACT: The medical term for the removal of the ovaries is castration.
> Most women are castrated at hysterectomy.
True enough, technically. Although we note that in the case of the word
"castration", the term is loaded by association with what it does to
men, tomcats, horses, and cattle, which is very much more than what it
does to postmenopausal women (take a look at the magnitude of the
testosterone change). "Castration" as a term used inflammatorially for
oophorectomy reminds me of saying "weapons of mass destruction" (with
connotations of nuclear war) when we'd really have been better off
saying "nerve gas."
<snip irrelevent, uncheckable, and inflammatory stuff>
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 12:48:28 -0700
Message-ID: <1124567308.013577.52350@g49g2000cwa.googlegroups.com>
Terri wrote:
> > You might want to actually look on pub med.
> >
> > Health Expect. 2005 Sep;8(3):234-43. Related Articles, Links
> >
> > Psychosexual health 5 years after hysterectomy: population-based
> > comparison with endometrial ablation for dysfunctional uterine bleeding.
> >
> > McPherson K, Herbert A, Judge A, Clarke A, Bridgman S, Maresh M,
> > Overton C.
> >
> > Visiting Professor of Public Health Epidemiology, Nuffield
> > Department of Obstetrics and Gynaecology, Oxford, UK.
> >
> > Abstract Background We report a population-based comparison of
> > psychosexual health 5 years after contrasting amounts of surgical
> > treatments for heavy periods [dysfunctional uterine bleeding (DUB)].
> > Women's fears about sexual function after hysterectomy might not be
> > unfounded. The psychosexual problems may return and/or develop with
> > time. The removal of ovaries at the time of hysterectomy is associated
> > with greater deterioration of self-reported sexual function. Surgical
> > menopause significantly impairs sexual wellbeing. We failed to observe
> > uniform beneficial effects of hormone replacement therapy (HRT) on
> > reported psychosexual health. Objective To compare self-reported
> > bothersome sexual function; loss of interest in sex, difficulty in
> > becoming sexually excited and vaginal dryness 5 years after surgical
> > management of DUB [transcervical endometrial resection/ablation (TCRE)
> > or subtotal and total hysterectomy, with and without prophylactic
> > bilateral oophorectomy (BO)]. Design Prospective cohort study up to 5
> > years post-surgery for DUB, TCRE or hysterectomy, with or without BO.
> > Setting Over 400 NHS and private hospitals in England, Northern Ireland
> > and Wales. Cohort Of 11 325 women who responded to the 5-year
> > questionnaire, over 9500 (84%) were valid cases, and over 8900 (94%) did
> > complete the questions relating to psychosexual function. Most were
> > between the ages of 39 and 45 years, married or cohabiting. Main
> > outcomes Self-reported experience of bother, recorded as 'some',
> > 'severe' and 'extreme', to questions on (1) libido loss, (2) difficulty
> > with sexual arousal, and (3) vaginal dryness during the past 4 weeks, 5
> > years after surgery. Results Five years after surgery for DUB, the crude
> > and adjusted prevalence of psychosexual problems was higher after
> > hysterectomy than after TCRE. Amongst the women with concurrent BO, the
> > age- and HRT-adjusted odds ratios for extreme psychosexual problems were
> > increased by 80% (libido loss), 82% (difficult sex arousal) and 69%
> > (vaginal dryness) compared with TCRE. Conclusions Five years after
> > hysterectomy more women reported having bothersome psychosexual function
> > than did the women who had a less invasive operation. Hormone therapy,
> > although related to surgical method, did not reduce this long-term
> > detrimental effect. The odds were particularly high amongst women with
> > concurrent BO. Women should be advised that they might be at higher risk
> > of psychosexual problems following hysterectomy, compared with a less
> > invasive procedure.
COMMENT:
They might be if treated in the way the women in this study were. But
how WERE they treated? The abstract does not say whether or not the
"HRT" included androgens and bloodwork to ensure proper androgen
levels, and this being the UK and it's public health system, I can bet
you money they didn't. If not, this paper is merely reporting a failure
to do *proper* hormone replacement. For instance, have a look at:
J Clin Endocrinol Metab. 2005 Jul;90(7):3847-53. Epub 2005 Apr 12.
Androgen levels in adult females: changes with age, menopause, and
oophorectomy.
Davison SL, Bell R, Donath S, Montalto JG, Davis SR.
The Jean Hailes Foundation, Clayton, Victoria, Australia.
Womens.Health@med.monash.edu.au
CONTEXT: Changes in androgen levels across the adult female life span and
the effects of natural menopause and oophorectomy have not been clearly
established. OBJECTIVE: The objective of this study was to document the
effects of age on androgen levels in healthy women and to explore the
effects of natural and surgical menopause. DESIGN, SETTING, AND
PARTICIPANTS: A cross-sectional study was conducted of 1423
non-healthcare-seeking women, aged 18-75 yr, randomly recruited from the
community over 15 months. MAIN OUTCOME MEASURES: Serum levels by age of
total testosterone (T), calculated free T, dehydroepiandrosterone
sulfate, and androstenedione in a reference group of women free of
confounding factors. Women in the reference group had no usage of
exogenous steroid therapy; no history of tubal ligation, hysterectomy, or
bilateral oophorectomy; and no hyperprolactinemia or polycystic ovarian
syndrome. The effects of natural and surgical menopause on sex steroid
levels were also examined. RESULTS: In the reference population (n =
595), total T, calculated free T, dehydroepiandrosterone sulfate, and
androstenedione declined steeply with age (P < 0.001), with the decline
of each being greater in the earlier than the later decades. Examination
of serum androgen levels by year in women aged 45-54 yr showed no
independent effect of menopausal status on androgen levels. In women aged
55 yr or older, those who reported bilateral oophorectomy and were not on
exogenous steroids had significantly lower total T and free T levels than
women 55 yr or older in the reference group. CONCLUSIONS: We report that
serum androgen levels decline steeply in the early reproductive years and
do not vary because a consequence of natural menopause and that the
postmenopausal ovary appears to be an ongoing site of testosterone
production. These significant variations in androgens with age must be
taken into account when normal ranges are reported and in studies of the
role of androgens in women.
PMID: 15827095 [PubMed - indexed for MEDLINE]
> And after you've explained the above you can have a go at this one:
>
> Obstet Gynecol. 2005 Aug;106(2):219-226. Related Articles, Links
> Click here to read
> Ovarian Conservation at the Time of Hysterectomy for Benign Disease.
>
> Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS.
>
> The David Geffen School of Medicine, University of California, Los
> Angeles, California; Cerner Health Insights, Beverly Hills, California;
> School of Medicine, University of Southern California, Los Angeles,
> California; and School of Medicine, University of Auckland, Auckland,
> New Zealand.
>
> Objective: Prophylactic oophorectomy is often recommended
> concurrent with hysterectomy for benign disease. The optimal age for
> this recommendation in women at average risk for ovarian cancer has not
> been determined. Methods: Using published age-specific data for absolute
> and relative risk, both with and without oophorectomy, for ovarian
> cancer, coronary heart disease, hip fracture, breast cancer, and stroke,
> a Markov decision analysis model was used to estimate the optimal
> strategy for maximizing survival for women at average risk of ovarian
> cancer. For each 5-year age group from 40 to 80 years, 4 strategies were
> compared: ovarian conservation or oophorectomy, and use of estrogen
> therapy or nonuse. Outcomes, as proportion of women alive at age 80
> years, were measured. Sensitivity analyses were performed, varying both
> relative and absolute risk estimates across the range of reported
> values. Results: Ovarian conservation until age 65 benefits long-term
> survival for women undergoing hysterectomy for benign disease. Women
> with oophorectomy before age 55 have 8.58% excess mortality by age 80,
> and those with oophorectomy before age 59 have 3.92% excess mortality.
> There is sustained, but decreasing, benefit until the age of 75, when
> excess mortality for oophorectomy is less than 1%. These results were
> unchanged following multiple sensitivity analyses and were most
> sensitive to the risk of coronary heart disease. Conclusion: Ovarian
> conservation until at least age 65 benefits long-term survival for women
> at average risk of ovarian cancer when undergoing hysterectomy for
> benign disease.
COMMENT:
Okay, I'll have a "go."
First of all, obviously in this paper, dispite the fact that it says
"outcomes were measured," what they *mean* is they were measured in a
*computer simulation.* IOW, the authors are running is a mathematical
model based on clinical outcomes measured in a whole lot of *other*
disparate papers, all using post hoc uncontrolled epidemiology. Their
conclusions are just as good as their computer model, which may not be
all that good. In computer studies we call this phenomenon "GIGO" which
stands for = Garbage In, Garbage Out. The studies this one is based
on, is epidemiology which are NOT corrected for things like HRT use,
and which cannot (not being randomized) be corrected for all the kinds
of population-based differences which made HRT itself look so (falsely)
good in the *epidemiology* for all those years. GIGO. Again, Terri, it
never fails to amaze me how the general lessons of HRT epidemiology,
followed by the devastating WHI and HERS trials are TOTALLY lost on
you, when you want to argue in favor of something (ie, some crappy
piece of epidemiology) you WANT to believe in.
Even if you believe the heavily reworked and poorly controlled
epidemiologic conclusions here (and I'm heavily skeptical) what do you
propose as the mechanism? IOW, what is it you think postmenopausal
ovaries make, which keeps up to 9% of women from dying from stroke or
heart attack or hip fracture, from 40 to 75 or so? The ovarian
androgens are really all that are known. And they are a possibility
(there is modest, but not overwhelming epidemiology in favor of the
idea). I wouldn't dismiss the hypothsesis, if the mortality data behind
it was a little better quality. However, if you believe it (on the
basis of the same kind of epidemiology that gave us estrogen/progestin
HRT mind you!), you have to accept the consequences and start
suggesting that women who've had an ovarectomy from 40 to 75 get at
least *androgen* HRT, so that they don't suffer the excess mortality
associated with loss of THIS set of ovarian hormones.
No fair claiming that doctors who give ovarectomized women androgen
replacement are trying to kill them at the behest of the drug
companies, the way they did with estrogenic/progestinic HRT. You can't
have it both ways.
If you want to argue that postmenopausal ovaries make some essense, or
elixer, which hasn't yet been discovered, I think you're not justified
in inferring that as a needed hypopathis, unless you're forced to to
explain really GOOD data. Such as excess mortality and functional
problems in a PROSECTIVE RANDOMIZED study of women who had elective
ovarectomy, in spite of full hormonal replacement with all hormones
that are presently known from postmenopausal ovaries. I know of no
study that even comes *close* to this. And in the absense of evidence
to the contrary, I prefer to keep my hypotheses as few as possible. We
all know that crappy HRT, bad post-hoc epidemiology, and lousy computer
models based on poor data, are very common in medicine. Whereas the
discovery of a new life-extending gonadal hormone that nobody even
suspected, doesn't happen too often these days. New planets are
discovered more commonly than that.
SBH
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 09:18:02 -0500
Message-ID: <43073b22$0$256$bb4e3ad8@newscene.com>
"Terri" <terrisk@vverizon.com> wrote in message
news:NfENe.1456$0U6.467@trnddc09...
> Thank you. Why are incidental appendectomies done much less frequently
> now?
Removing an appendix while one is already there is a trivial exercise that
takes perhaps 30 seconds. Futher, the appendix is one of those organs that
provides absolutely NO value to the human body, yet whose presence poses a
serious (though rarely life threatening) potential infection. Having said
that, it is understood more clearly now that the incidence of acute
appendicitis is relatively low, and even lower in adults beyond the age of
about 30 (and those people are more likely to have abdominal operations than
younger people). The main reason why incidental appendectomy is currently
out of favor is that removing it is cutting across contaminated bowel,
changing the operation from a class I (clean) operation to a class II
(clean-contaminated) which in turn results in a higher rate of infectious
complications. So, not so much benefit to that 'en passant' operation, and
potential complications (though slight) associated with it. That's the
general rationalization, and it's supported by studies. The overall reality,
however, is that surgeons are susceptible to "fads" too, and sometimes
shaking those fads is a slow process. Surgeons, especially surgeons of the
past, have a tendency to change concepts slowly, with a tendency to rely on
what they were taught by their professors, and often what THEY were taught
came out of an era where evidence-based medicine was not nearly so prominent
as it is today. I've seen this first hand, as have most surgeons of my
generation. A very substantial portion of what I was taught as a resident
was based on dogma rather than science, and has turned out to be just wrong.
More relevant is the issue of removing one or both ovaries as part of a
hysterectomy for benign disease in menopausal or peri-menopausal women. This
approach could also, technically, be labeled "incidental oophorectomy". The
rationale for recommending that (rightly or wrongly) has been that they
provide no benefit that can't be replaced with a daily pill, and ovarian
cancer, should it develop, is a deadly, deadly cancer that is difficult to
detect early enough to be cureable. My own approach is to inform the patient
of the risks, benefits, alternatives, and let them decide. This is less of
an issue in benign uterine conditions, but gets a little trickier in cases
of malignancy or potential malignancy. In Zee's case, assuming she is
perimenopausal, I would recommend LAVH/BSO based on my bias and
understanding of the risks/benefits/consequences of her condition. If HER
bias and understanding of the risks/benefits/consequences was different, I
would agree to leave the ovaries after making sure she clearly understood my
point. Certainly, I'd document the discussion and her decision, but I
wouldn't make her sign some kind of dramatic statement, and I certainly
wouldn't refuse to do her operation. It is not infrequent that I will
present alternatives to a patient, and they will choose one that I think is
less-than-optimal. That's OK - it's their body, I'm working for them, and
they get to choose. I have little doubt that surgeons of the past tended to
trivialize the uterus and did more hysterectomies than would be considered
necessary today, based on dogma, bias and rather shakey science. I also have
little doubt that organizations like HERS have gone way over the top in the
other direction.
As I said before, I think Zee does need a hysterectomy, but I'm not sure she
needs an oophorectomy. Yes, there is a potential that her dysplasia
represents an already-present uterine cancer, which in turn may represent
involvement of ovarian tissue or lymphatics. But a good idea of that
possibility can be obtained at hysterectomy with frozen section, and an even
better idea can be had on final path review. I think a reasonable approach
would be LAVH and explain that permanent path sections may indicate invasive
cancer that might necessitate a second operation for staging. OTOH, if there
IS no cancer, oophorectomy wouldn't be necessary (assuming we can trust the
path report to be completely accurate - we can't, not completely). In Zee's
case, the path report makes me think that that might be a reasonable gamble.
The point is, it's HER gamble, not mine.
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 09:52:03 -0500
Message-ID: <43074322$0$254$bb4e3ad8@newscene.com>
"Kurt Ullman" <kurtullman@yahoo.com> wrote in message
news:ImHNe.8900$WD.7891@newsread1.news.pas.earthlink.net...
> In article <43073b22$0$256$bb4e3ad8@newscene.com>, "Howard
> McCollister" <nospam@nospam.net> wrote:
>
>>Removing an appendix while one is already there is a trivial exercise
>>that
>>takes perhaps 30 seconds. Futher, the appendix is one of those organs that
>>provides absolutely NO value to the human body, yet whose presence poses a
>>serious (though rarely life threatening) potential infection.
>
> I have always thought that God made the appendix solely to give
> general surgeon's a floor to their income (g).
>
Incidental appendectomy is a freebie. Surgeons can't charge for incidental
concomitant operations.
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 10:44:08 -0500
Message-ID: <43074f79$0$257$bb4e3ad8@newscene.com>
"Terri" <terrisk@vverizon.com> wrote in message
news:3xHNe.1774$0U6.1516@trnddc09...
> Howard McCollister wrote:
The overall reality,
>> however, is that surgeons are susceptible to "fads" too, and sometimes
>> shaking those fads is a slow process. Surgeons, especially surgeons of
>> the past, have a tendency to change concepts slowly, with a tendency to
>> rely on what they were taught by their professors, and often what THEY
>> were taught came out of an era where evidence-based medicine was not
>> nearly so prominent as it is today. I've seen this first hand, as have
>> most surgeons of my generation. A very substantial portion of what I was
>> taught as a resident was based on dogma rather than science, and has
>> turned out to be just wrong.
>
> But it is a rare doctor who will admit this.
>
That's harder to judge than most people realize. I acknowledge that ancient,
anachronistic, paternalistic doctor-patient relationships are not uncommon
across the country, but I wouldn't call patient-centered care (patient as a
member of the decision-making process) exactly rare any more. Granted, there
can be substantial regional variation in these attitudes. Some patients
embrace that approach with more interest than others. I see more and more
patients that come to their appointment with a folder of printouts of their
research. I think that's great, except there is frequently a lot of
erroneous information from the internet. OTOH, on a daily basis I also
encounter patients who, after a lengthy explanation of the
options/risks/benefits, will say "do whatever you think is best, Doc...".
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 11:49:04 -0500
Message-ID: <43075ea1$0$232$bb4e3ad8@newscene.com>
"Terri" <terrisk@vverizon.com> wrote in message
news:YOINe.4771$M3.2917@trnddc05...
> I think many doctors honestly believe that they are practicing what
> you're calling "patient-centered care." However if you examine their
> language they are slanting their discussion in the direction of the course
> of action they (the doctor) deems advisable by using loaded words.
Very likely true. It's rendered all the more problematic when one takes into
account the egos that most physicians need to practice medicine effectively.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 16:41:09 -0700
Message-ID: <1124581269.520932.53500@g14g2000cwa.googlegroups.com>
Howard McCollister wrote:
> OTOH, on a daily basis I also
> encounter patients who, after a lengthy explanation of the
> options/risks/benefits, will say "do whatever you think is best, Doc...".
>
> HMc
COMMENT:
Or, "what would you recommend to a member of your own family." As if
I'd recommend anything to a patient I wouldn't consider for a loved
one. It's sort of insulting, but I deal with it.
On the other hand, I occasionally get a patient who says, "What would
you do if this was YOU?" That's a harder one, because I take lots of
risks I'd never take with a patient, including sometimes taking a drug
for the hell of it, just to see what it "feels" like. And I certainly
work harder at my biggest risk factors (like staying alive on
California's freeway system) than I know many of my patients are
willing to.
Risk is the hardest thing to talk about, because acceptance of it so
personal. I drive a Volvo or a Suburban or an old diesel Mercedes
vintage 1981, because California freeways look very risky to me, and
I've nearly died more than once on them. But I've been scuba diving in
the water-filled cenote caves of the Yucatan. Some risks are worth
taking. I don't enjoy sports cars enough to risk dying in one; I don't
care what people think of my lunker cars. On the other hand, some
people love their cars. The statistics are impersonal, but what you do
with them is very personal.
If there was one thing I could recommend to the layman, it is to try to
see that every medical question (or indeed question of risk) splits
itself into two very different parts. The first one is scientific and
statistical and impersonal and more or less a-political. Even though it
may still require some judgment, that judgment needs to be tempered and
kept as far as possible from what you'd LIKE to be true. You ask: "What
happens (on average) to people as much as possible like me, if they do
(say) X vs. Y?" That gives you some idea of a risk number. It will
never be perfect, but at least it's an answer. You need to follow this
process out as well as you can, without letting your emotions rule you.
THEN comes the (perfectly permissible) decision of what to do with the
scientific data. There you can be as emotional and political and
choosy as you like. The question of whether or not the globe is warming
up should not depend on whether or not you're a Republican or a
Democrat. Only the ANSWER as to what do DO about it THEN (what to give
up to fix it, if there's a problem), is political. You might decide it
is warming up, BUT you don't give a damn because you love your big car,
and think you're more likely to die on the freeway, and let coming
generations take care of their own survival problems. But try not to
decide what you believe about reality based on the way you wish reality
was.
Fortunately, unlike pollution or global warming, most medical decisions
are not inherently democratic (unless you live in some doofus country
that makes them unnecessarily so). So you can decide in medicine what
risks you personally are comfortable with, ala carte. And in that case,
it's perfectly fine to decide to do "A" even if it gives you twice the
chance of dying in way "X," if you happen to particularly loathe or
fear safer option "B" for purely personal or aesthetic reasons. All I
ask is that you realize WHY you're taking the risk.
If you want to smoke, and it's important to you to smoke and it gives
you great pleasure to smoke, then have at it (out on the patio,
please). But don't tell yourself, or me, that the dangers of smoking
are overrated and/due to pesticides and pushed by a giant conspiracy
that wants to sell nicotene gum. That's childish thinking. That's
paranoid witchhunter's thinking.
Take your risks honestly. The web and the world is so full of people
bullshitting themselves about the goodness of things they want to do
for other reasons, and the badness of things they fear irrationally, or
can't have anyway, sour-grapes. All of that hurts people at the very
statistical beginning of decision-making processes, who haven't even
*gotten* to the ethical or aesthetic or political part, yet.
If I drown on some coral reef, it won't be while telling myself that
the dangers of scuba are overrated and you're perfectly safe if you
just do A, B and C. It's not true. If I drown it was because I took a
risky bet for the curiosity-satisfaction and pleasure of doing it, and
lost. If I get fat, I don't join some club that holds that obesity is
good for you. The facts say otherwise. If I grill my steak, I'm not
going to pretend it's soybean tofu, or just as good as. It's not.
Find out the facts first, THEN follow your heart with your eyes open.
Do not trust conclusions from people with a witchhunter agenda.
And finally--- no whining!
SBH
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 19:24:03 -0500
Message-ID: <4307c936$0$199$bb4e3ad8@newscene.com>
Steve Harris <sbharris@ix.netcom.com> wrote in message
news:1124581269.520932.53500@g14g2000cwa.googlegroups.com...
> Do not trust conclusions from people with a witchhunter agenda.
>
> And finally--- no whining!
>
Great post, great perspective. As an inveterate risk-taker myself, I can
relate completely, having had to come to grips long ago with balancing that
compulsion against my ability to calculate the odds. Airplanes, skydiving,
hang gliding, motorcycles, and yes, I've dived the Yucatan cenotes too and
recall being intrigued by the fresh-water/saline interface (although the
name of it escapes me - some kind of "-cline" ) That was worth the trip. As
my body ages, I have to keep re-evaluating those risk calculations, but last
week I landed my first dismount gainer on a towed hydrofoil (Air Chair)...so
I've got that going for me, which is nice...(left knee is about gone...can't
wakeboard anymore, but I have a T-shirt that says "No Whining", and I
believe it).
So, I completely share your views on giving advice to patients. I treat ALL
of them as I would a member of my own family, but their question "what would
you do if it were you?" is a more difficult one for me to answer.
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 20:12:03 -0500
Message-ID: <4307d472$0$230$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
news:1124585739.365001.136810@g14g2000cwa.googlegroups.com...
>
> Oh pshaw!
>
> Risk is being nine months pregnant with your water breaking, in a
> Noordyn Norseman on floats cresting up behind a Russian icebreaker
> making a runway in the ice for so the plane can take off...in the
> Northwest Passage.
>
> He was born in the plane. With his father the only other occupant.
>
> That's risk.
>
>
Wow! You're such an adrenaline junky that you chose that particular time to
go into labor? Hat's off...
Personally, I'd have waited until we were on the ground. I think vaginal
childbirth is scary enough in a hospital.
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 23:42:03 -0500
Message-ID: <430805c3$0$213$bb4e3ad8@newscene.com>
"fresh~horses" <fresh~horses@despammed.com> wrote in message
news:1124595169.331515.68350@g49g2000cwa.googlegroups.com...
> We got caught. The same day I went into labour, the bay froze over.
> With the plane still on floats. We had to get the plane out; we had to
> get me out.
>
> Life's a rush....
>
> Want more? Or do you have to have a nap now?
>
> ; )
Nah, I'm good.
To be honest, it actually sounds a little more like poor planning than
intentional risk-adventure. But, whatever gets your heart pumping...:)
HMc
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 21 Aug 2005 00:37:02 -0500
Message-ID: <4308129d$0$195$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
news:1124600767.671836.215960@g14g2000cwa.googlegroups.com...
>
> Howard McCollister wrote:
>> "fresh~horses" <fresh~horses@despammed.com> wrote in message
>> news:1124595169.331515.68350@g49g2000cwa.googlegroups.com...
>> > We got caught. The same day I went into labour, the bay froze over.
>> > With the plane still on floats. We had to get the plane out; we had to
>> > get me out.
>> >
>> > Life's a rush....
>> >
>> > Want more? Or do you have to have a nap now?
>> >
>> > ; )
>>
>>
>> Nah, I'm good.
>>
>> To be honest, it actually sounds a little more like poor planning than
>> intentional risk-adventure. But, whatever gets your heart pumping...:)
>>
>> HMc
>
>
> Poor planning?
>
> This is often the way children come into the world Howard. You and your
> colleagues try to pin it down (nine months 40 weeks whatever) but it
> doesn't often happen that way.
>
> In your world risk adventure is planned, comes with toys, cute clothes,
> logistics?
>
> Real risk adventure is here. Now. Deal with it.
>
> Like uterine cancer.
>
Cripes Zee. We humans all face the same risks. Today you may have uterine
cancer, tomorrow I may have prostate cancer. Sorry to say, it doesn't make
you special. It just makes you human. The conversation that you butted into
was about self-challenge and you're just talking about the plain old
day-to-day risks that every single person on the planet faces from getting
up in the morning. Go jump out of an airplane next time you're 40 weeks
pregnant. Then I'll be impressed. Having a baby in the back of an airplane
just because your husband can't read a weather briefing...yeah...I was
talking about something else.
HMc
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 22:41:21 -0700
Message-ID: <1124602881.119287.84390@g14g2000cwa.googlegroups.com>
Howard McCollister wrote:
> Great post, great perspective. As an inveterate risk-taker myself, I can
> relate completely, having had to come to grips long ago with balancing that
> compulsion against my ability to calculate the odds. Airplanes, skydiving,
> hang gliding, motorcycles, and yes, I've dived the Yucatan cenotes too and
> recall being intrigued by the fresh-water/saline interface (although the
> name of it escapes me - some kind of "-cline" ) That was worth the trip.
COMMENT:
The boundary where things go wavery from light refracting from the
interface of two liquids with different indicies of refraction is
called a halocline. Weird effect indeed. And also good is the snowglobe
effect as your bubbles hit the cave roof and knock off tiny calcium
flakes....
You know, the cenote cave-spring complexes are in a nice string of
pearls semicircle, exactly along the shockline of the Chicxulub
asteroid impact crater. It screwed up the groundwater in the whole
area, and the cenotes are the only thing left. So the end of dinosaurs
not only allowed the mammals to take over and some of them eventually
evolve into us, but it's also the scuba-diver's gain, too. Just goes to
show every cloud has a silver lining. :)
Nevertheless, I'm sure I'd tire of the cenotes after a while. They are
a lovely Lovecraftian cyclopean stone block maze, but there's little
life in them. The coral reef and the kelp forest is where the
interesting live stuff is. By day or night.
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 20 Aug 2005 15:41:59 -0700
Message-ID: <1124577719.045682.134270@g47g2000cwa.googlegroups.com>
fresh~horses@despammed.com wrote:
> The whole thing angers me Howard.
>
> Not the least of which is; no one has mentioned STATINS: The drugs I
> took for years with horrible, and still lingering side effects; kept
> taking myself off but was urged to go back on because I would die if I
> didn't; the drugs which were tested on rats and men not women, but
> prescribed for me, a woman, with no evidence for me, and especially no
> evidence for me in primary prevention. I know that now.
COMMENT:
You don't know as much as you think you do. Nobody has done a primary
prevention trial of statins in women with cholesterols of 500, or
anything in that range, so there really are no studies of statins that
apply to your particular risk group. When they do such a study, we'll
have some answers. Until they do, we don't *know* the answers. We can
extrapolate from studies in men combined with the natural history of
what happens to women with cholesterols in that range, which is bad
(despite what you think you're read, cholesterols that high are a huge
risk factor IN WOMEN). But it remains possible there's some especially
bad effect of statins in women which makes up for the 30% lowering of
cardiovascular events in women who already have heart disease.
> Rats in statin trials developed cancer.
As they have in cyclamate and aspartame trials. Rats are cancer-prone
beasts, and poor models to use for carcinogenicity in humans. Rats in
black pepper trials develop cancer--- I hope you didn't use any of that
horrible stuff? By the way, rodents in statin toxicity trials developed
gut and hepatic cancers, not uterine cancers.
> And some research says there is
> a higher incidence of cancer in older people taking STATINS.
COMMENT:
But again, no uterine cancer. That "some research" consists of ONE
study, in people over 70 (the only study of many statin studies which
was done in people that old). Which you now want to EXTAPOLATE to
yourself, even though you're younger. Yet there is no increase in
cancer in half a dozen other large statin trials in younger people,
including several much larger and lasting longer than PROSPER. And even
though the PROSPER cohort was MORE than half female, there was no
excess of gynocological cancers in PROSPER. In fact, no particular
excess cancer site stood out, according to the study authors. But you
want to ignore that, too. Do you know of any carcinogens that increase
the incidence of cancer everywhere? I do not.
And while we're at it, do you know of any carcinogens that act sooner
rather than later? A third of PROSPER's cancers occured in the first
year, with a slightly decreasing risk during the 3.2 year study. This
is highly suggestive of a rare randomization statistical effect, and
occult disease in people entering the study. Cancers take time to
develop. This sort of distribution is not in the least what one would
expect if the excess cancer was a *drug* effect, where you'd expect the
excess cancers to show up nearer the end of the study.
I know of not a single carcinogen which doesn't cause a bigger cancer
risk, the longer it is given. Do you? Nor do statins behave other than
that way, even in rodents. So if statins did that in PROSPER, it would
be maybe most remarkable carcinogen-action finding ever reported: a
general cancer promotion effect which is site-independent and not
time-intensive, and which acts this way in elderly humans only, and not
younger people or rodents. Remarkable.
> I am angry that when men have "pre-cancerous" conditions, no one is
> recommending immediately that they be castrated. Why is this so for
> women? Why?
>
> Zee
COMMENT:
Because there aren't any sites to routinely *see* "precancerous"
reproductive cancers in men. Certainly not on screening. If such
changes are seen in something like a prostatic biopsy, that's a long
way from the gonads in men, with no good physical routes for cancer to
spread from prostate to testicles. Check anatomy books, if needed.
Finally, men do not normally undergo complete loss of gonadal
reproductive function around age 50, followed by nearly complete
gonadal involution. If they did, they'd be much more ready to part with
the things, if they somehow had some reason for a surgeon to be messing
about in the area anyway (which seems unlikely--- again check you
anatomy books--- but you DID ask). That's why. It's because men are
built differently from women. But I suspect you could have figured it
out for yourself, if you weren't in witch-hunting mode.
SBH
From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: 21 Aug 2005 01:56:04 -0500
Message-ID: <430824f1$0$233$bb4e3ad8@newscene.com>
<fresh~horses@despammed.com> wrote in message
news:1124603807.414743.101080@g49g2000cwa.googlegroups.com...
> It was everything extreme adventurists crave: something impossible to
> plan for, drama, the unknown, skill, luck...and success.
>
> Yeah. I was talking about somethingn else. Too.
>
> So what have you flown Howard?
>
Yes...daily living is a risk for all of us. Some people choose to live a
little closer to the edge, for whatever little quirk in their personality
drives that. It's all a big adventure, but my point was that there's a
difference between intentional risk-taking and being a victim of
circumstances.The challenge of choosing to jump out of an airplane is
different than the challenge of dealing with prostate cancer.
I got my PP license when I was 17 and in that subsequent 30-some years,
I've flown most of the general run of general aviation plane types. I'm also
glider-rated and seaplane rated. I have a fair number of multi-engine hours,
but never took the check ride. I haven't filed an instrument flight plan in
many years. I was a Mission Pilot for the Civil Air Patrol for years (Major
McCollister), but they overregulated that organization to the point where it
was just too painful. Lots of free flying at government expense while it
lasted, though. We took turns in the northern state squadrons flying
surveillance along the Canadian border for marijuana grow operations, flying
DEA agents around, but that ended when one of the CAP planes landed with a
surprise bullet hole in one of the wings. Currently, my flying is limited to
occasional local puddle-jumping in my neighbor's 182 on floats. He's a
CFI-I. I pay him for instruction and I rent it from him every so often for
gas and free medical advice.
HMc
From: David Rind <drind@caregroup.harvard.edu>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: Harris, McCollister, Rind
Date: Sun, 21 Aug 2005 08:28:07 -0400
Message-ID: <de9s12$qme$1@reader2.panix.com>
Steve Harris wrote:
> That "some research" consists of ONE
> study, in people over 70 (the only study of many statin studies which
> was done in people that old).
Although I agree with the sentiment and the conclusion, PROSPER was not
the only statin trial in people that old. It was, however, the only
statin trial exclusively in people that old.
The enormous HPS had lots of people over age 70 and showed no hint of
increased noncardiac mortality or cancer in people this age who received
statins.
--
David Rind
drind@caregroup.harvard.edu
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Oscillations: Re: Harris, McCollister, Rind
Date: 21 Aug 2005 14:09:12 -0700
Message-ID: <1124658552.250516.237890@z14g2000cwz.googlegroups.com>
fresh~horses wrote:
> We chose to do those things. They are what make life worth living.
>
> There is no correlation with your chosen extreme sport risk and
> grappling with the possibility of uterine cancer. It's normal for
> someone who's been handed such a possiblity to say "why?". To become
> angry, at the world, and self.
>
> It's a healthy response.
>
> And then we move on.
COMMENT:
You see, I'd dispute that. It may well be "normal" and human, but it
can be unhealthy when it leads to irrational thinking and decisions
that are later regretted, and seen as unwise.
In medicine, the sort of ideas you hold have become fashionable mainly
due to Kubler-Ross, who helpfully pointed out many of the emotions that
people deal with when faced with impending death or risk, but whose
slavish followers then decided that these "stages" HAD to be gotten
through for mental health, UNT ALL of zem haff to be gotten thrrough,
UNT you vill skip none of zem, UNT you vill do zem in der prroper
order---- UNT you VILL like IT! I think of all this as the
Nazification of grief. Or excuse me, the Natzificaton of the "grieving
process." The idea that the things you are talking about are "healthy"
leads too easily to the wholly objectional idea that somehow NOT doing
them is "unhealthy." But that's unproven and I think wrong. There are
no requirements that people engage in denial. None that anybody become
angry or search for scapegoats or self-guilt. There are no
requirements for irrational bargaining. There are no requirements even
for acceptance of death, and in fact it's just as natural for people to
fight death to the last agonal breath, the way the average animal does,
and the way our ancestors no doubt did. I've seen many a person die
without doing any given thing that Kubler-Ross describes, and even a
few people who did NONE of them, though they had plenty of time and
energy to.
I'm not about to follow some average mental-state-change process that
some shrink "prescribes" for me, because it's "normal." Screw
"normal." What I'm after is better than normal. What I'm after is
"true" and "good." And "normally" truth and goodness are tracked very
perfectly. We can do better.
I was talking of anger and witchhuntery and how it leads to bad
judgments. I'm reading Late 20th century at the moment. Scapegoating
Kimmel for Pearl Harbor led to the loss of Wake Island. In the early
1950's, scapegoating Oppenheimer for the US failure to have an answer
to the Soviet atom bomb led to his loss in the late 1950's at the very
time we needed somebody other than Dr. Strangelove in charge of the US
nuclear program. That nearly gave us global nuclear war in 1962. But
JFK's refusal to find scapegoats for the Bay of Pigs (even though he
had plenty of good choices, insofar as the expert advice he was given),
I think led to directly to his ability to take direct responsibility
for Cuba later, when it was really important in the Cuban missile
crisis (that was almost providential, because JFK wasn't all that big
on personal responsibility overall--- yet he was capable of learning in
very specific instances). And so on. If you want 21st century
instance, consider the fact that when the US couldn't find bin Laden
after 9/11, we (as a country) settled on scapegoat Saddam Hussein as
somebody to punch around. Which led directly to the soup we're in.
Sometimes there is a badguy. But having to *have* a badguy in all cases
where something bad happens, is never a good way to think.
Howard has talked about fads and fashions in medicine, and of course
he's right. They exist in all fields of human endeavor, in absence of
information. And in some cases even in the presence of information,
because they are outgrowths of our ethical and esthetic senses, which
we certainly wouldn't want to give up. I'm NOT saying that they're
always bad things, though sometimes they can be.
Remember, please that the present fad of treating women as though they
were just small men with breasts when it comes to heart disease, wasn't
always the case. I'm old enough to remember when women, especially if
middle-aged or younger, were often given antacids for their vague chest
pains if nothing showed on EKG, and sometimes sent home if the pains
stopped. Whether they been going all night or not. And often nobody
tread-milled women a routine screen (there was a good reason for that)
and often nobody aggressively worried about their cholesterol or
heart-attack preventative medicine for middle-aged women, if they'd
never HAD a heart attack. All this was NOT changed by Pfeizer, but
rather people like Dr. Marianne Legato (immortalized as The Leggo in
_The House of God_), who campaigned long and hard to get the medical
system to pay attention to heart disease in women, and got handsomely
rewarded academically for doing so. How politically correct it all
seemed. And yet here we are, with everybody having learned that lesson
maybe too well. Wups. So we'll now do some MORE correction, and start
treating women like they were a little more immune to heart disease
again (sigh). That's how it goes. Politics drives screw-up fads in
medicine in both directions, and the "villains" if you want to call
them that, are not always the usual suspects. So do be careful.
I wouldn't want to pillory Dr. Legato for all her part in this. Don't
write her a nasty letter, please. But then I wouldn't want to pillory
Pfizer, either. Remember that in all fields of endeavor, reality is
approached, as a free point, in an oscillating fashion, where the
pendulum of opinion swings back and forth to one side of the truth or
the other, but usually with a shorter swing on each pass, as we learn.
That shorter swing is called "ring-down" and the phenomenon is called
"overdamped oscillation." You'll see it in medicine with the
introduction of every new drug, which goes from "panacea" to "pandora
plague" to "perfectly pedestrian pharmaceutical" and sometimes this
process is even repeated over again, with smaller deflections (think
Thalidomide and Prozac and AZT). You'll see it in the introduction of
every new consumer piece of technology. You can see it happen in the
approval ratings of every president, and in the evaluation of
presidents later, by history. You will see it in the clumsy grasping
motions of infants as they learn to judge distance, and in robots, too
(the over-reach, then under reach, etc). In fact it remains in all
motion (though you must speed of time very fast to see it in the very
fine normal human arm-- but watch the end of a really good snappy
salute). You'll see it in the rapid aiming of a pistol or a bow. It's a
general property of any system in which there is proportional negative
feedback. A great deal has been written about it in cybernetics.
But are we to *blame* people as individuals for their parts in these
oscillations which take place in the absence of perfect information---
for the oscillations of stock prices and the oscillations of political
opinions and theories in science? No. It's just the way things work.
It's much like the wind and tides-- a natural phenomenon. And there's
even some deliberately induced "noise" in it, as with hemline length,
because we primates need novelty and entertainment. Try to see it for
what it really is. It's not really aimed at you, though as the center
of your universe, it must seem so. And it's not really driven by
criminal minds. In many cases it's driven by people of good will, like
Dr. Legato. Try not to take all of it quite so personally.
SBH*
*(This small essay brought to you courtesy of _Pfizer_. Visit
PrizerForLiving. Because learning how to live healthier can help you
get more out of life. TM)
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: The boundary where things go wavery: was Harris, McCollister, Rind
Date: 21 Aug 2005 16:53:58 -0700
Message-ID: <1124668438.653490.216850@o13g2000cwo.googlegroups.com>
David Rind wrote:
> David Wright wrote:
> > Agreed. Though it must be said that much of the risk in piloting (or
> > riding a motorcycle) is under the control of the pilot. So many
> > accidents are caused by stupid actions like buzzing houses, running
> > out of gas, or flying into thunderstorms.
>
> While this is true, nearly all pilots you talk to believe that they fly
> much more safely than the average pilot, either because they are
> technically competent, or because they have lots of experience, or
> because they are very careful.
>
> Since half of pilots are likely less safe than the average pilot, it
> seems like it might be smarter for an individual to believe that his or
> her chances of an accident are probably not that different from the average.
COMMENT:
But that's the fun point. Every pilot thinks they're a
better-than-average pilot (like Lake Wobeggone, where all students are
above average), and the reasons they give you for this, have to do with
special things they do, like being very, very careful not to buzz
houses, run out of gas, or fly into thunderstorms. :)
"If the sun don't shine, I don't fly" is something I've heard many,
many, many times, even from IFR qualified people. It's their St.
Christopher medal. And of course, I agree with their thinking :).
I read a study once where they looked at the psychology of people in a
ICU who'd just had the guy next to them die. They wondered if these
people would be undergoing a lot of stress. Turns out no. They all had
many reasons why the guy next to them was a lot sicker, and a lot
different, from themselves. Hard to say if they were always right about
that, but we know, at least, what they *thought* about it. This is very
human. I don't know how well we would survive without some of this
special kind of irrationality. The only people you find without it are
chronically depressed. Hmmm.
So, who ARE these guys out there getting killed in light planes? Some
of them really do buzz houses and fly into storms. What DO those young
guys weaving in and out of traffic on the freeway in order to go 5 mph
faster than the average traffic flow, think about their own driving? I
hypothesize that such people don't think they're safer than the average
driver, but instead think they're more SKILLFUL than the average
driver. The guy who flies a light plane into a storm or into a dark
nightime field or ocean must be thinking SOMETHING.
This seems to happen more often with men carrying passengers. Less
often do they do it alone. I have a theory it has something to do with
male unwillingness to show fear or anything but total mastery and
competence in front of an audience. Sort of the JFK, Jr. syndrome. But
something like it got Holly and Valens and the Bopper, too. And Patsy
Cline and many others.
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: The boundary where things go wavery: was Harris, McCollister, Rind
Date: 21 Aug 2005 14:30:10 -0700
Message-ID: <1124659810.701036.193300@g43g2000cwa.googlegroups.com>
fresh~horses@despammed.com wrote:
> Steve Harris wrote:
> > Do not trust conclusions from people with a witchhunter agenda.
> >
> > And finally--- no whining!
> >
> > SBH
>
>
>
> I get lost in this post (and many others of yours) because it looks
> like you are talking about one thing, but really, there's such a heavy
> sub-text in all your posts which follow something I've posted.
>
> I'm not making myself too clear, easily, because I don't have it
> anymore; but I won't piss you off with my idea of why. Again.
>
> Don't blow me off. I find understanding your posts, and your point,
> difficult, but I keep trying because I want to know, and to learn
> (which you haven't figured out yet but could if you'd quit going
> lalalalala).
>
> Whenever I (and likely others haven't checked) tick you off you go off
> on a rant, posting to someone else, but talking *at* me, and talking
> *at* the issue. There's this pony you ride and it really doesn't have
> anything to do with what I have said, but what you think I said, coming
> from something or somewhere else in your experience. I'm tired of
> taking the rap for whatever some lefty feminist journalist Canuck did
> to you.
>
> You completely misrepresent my posts as anti-doctor and whining. I
> don't think they are that at all, and was stunned the first time you
> accused me of that. I think physicians are hurt as much by this stupid
> system as any, and we are all responsible for making it better; leaving
> aside what my idea of solution is and how that might differ from yours,
> as you do. I'm on your side.
>
> Please stop talking *at* me.
COMMENT:
Why should I? You've put a thousand posts up here over the last couple
of years, which is twice as many as one-topic-Sharon, and the content
of your non-statin half is even more inflamatory than the statin half.
I am complelled to set the record straight whenever I see medicine and
doctors unfairly abused. If you post some leftist nonsense about how
people in Africa aren't being given full and proper control of medical
research somebody *else* is completely paying for, what do you expect
me to do? What do you *expect* to happen? It's so completely outrageous
that all I can really say is: expect flames. We already had one Joan of
Arc, Zee. And you know what happened to HER. If you don't like the
heat, climb down from your stake.
SBH
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology
Subject: Re: The boundary where things go wavery: was Harris, McCollister, Rind
Date: 22 Aug 2005 12:27:58 -0700
Message-ID: <1124738878.627227.75230@g14g2000cwa.googlegroups.com>
Howard McCollister wrote:
> Nah. Speaking for myself, this ain't my first day at the Usenet rodeo.
>
> Anyway, Zee's questions and concerns in her original posts were cogent,
> valid, and to the point. The thread wandered subsequent to that, as Usenet
> discussions are wont to do, but I suspect that none of those originally
> involved would let that detract from trying to help someone who was
> concerned about a potentially serious medical condition.
>
> HMc
CORRECT. There's politics, social nastiness, and then there's
MEDICINE, where a real person's in trouble. May Hippocrates send me all
that bad juju he mentions, should I ever mix them up.
SBH
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