by Margaret Aranda, MD, Ph.D.
1. INFORMED CONSENT AND ETHICS: There are two main components of Informed Consent:
(A) The patient is informed of the risks and benefits of the procedure in the general population, as well as the risks and benefits in the individual patient; the patient is also told what the alternatives are to NOT having the procedure done;
(B) The Consent is given without harassment, undue admonishment, coersion, ridicule, nor when a patient is deemed incompetent, has a Conservator for Health Care, or is under the influence of drugs including but not limited to: Valuim, Xanax, Benadryl, compazine, demerol, morphine, fentanyl, alfentanyl, heroin, cocaine, marijuana, hash, alcohol, or other drug rendering the patient unable to give Consent. Exceptions to this include when the benefits outweigh the risks: delivering a baby; repairing a head injury after a motorcycle accident; and ICU patient needs a chest tube for a pneumothorax, or perforated lung, AND every effort has been logically made to inform the next of kin and/or the family.
2. EFFICACY: A BTL is 99% effective after the first year. Over time, the tubes can reconnect, with 15 - 20% leading to a tubal pregnancy. A TUBAL PREGNANCY IS A LIFE-THREATENING CONDITION, and YOU SHOULD BE TAKEN TO THE OPERATING ROOM WITH "A LARGE-BORE IV", YOUR BLOOD "TYPED & CROSSED," AND AS A STAT. No matter what, the baby will die; our focus is to not let YOU DIE. Take heart, as you are NOT killing your baby, who can not survive. I have had many religious discussions with women very concerned about this issue, and I assure them that I have never given anesthesia for an elective abortion because I think it goes against the Hippocratic Oath. I have only given anesthesia to SAVE THE LIFE of a mother with a tubal pregnancy.
3. SIDE EFFECTS and CONTRAINDICATIONS: The existence of Post-Tubal Ligation Syndrome (i.e., increased menstrual bleeding, decreased libido, fluctuating mental health, and more pronounced PMS, abdominal pain, some leading to hysterectomy.) has been a scientific debate for decades. In 2005, Shobeiri et al (2) showed in 112 post-Pomeroy BTL patients vs. 'normal' patients, that menstrual abnormalities did not differ. However, women in two age categories experienced statistically more uterine bleeding: ages 30 - 39; and ages 40 - 45. In 2011, Moradan et al studied 160 women, finding no changes due to BTL.(3)
Although there may be an increased rate of hysterectomy due to increased mentrual bleeding after a BTL, no where in the medical literature can a biologic correlation be found as the culprit except the decrease in hormones after a hysterectomy. But talk to individual women, glance through FaceBook and other social media sites, and these women are gaining momentum and a Voice.
Perhaps what we need now is a study that includes an n > 10,000, for the rate of hysterectomies is so high in the United States. CONTRAINDICATIONS: bladder cancer.
4. BILATERAL TUBAL LIGATION (BTL)* The most common method of family planning, with vasectomy, a BTL is best performed after a couple days of childbirth, when the uterus is still swollen, and the Fallopian tubes are just under the skin. There are many different types, all requiring spinal anesthesia for optimal pain control:
A. Bipolar Coagulation: cauterizes portions of the Fallopian tubes;
B. Monopolar Coagulation: same as (A) + radiating current for more damage + cutting the tubes at the end;
C. Fimbriectomy: takes a part of the Fallopian tube that is closest to the ovaries, preventing the tube from accepting an egg, and therefore from fertilization;
D. Irving Procedure: two ties are placed at a length on one Fallopian tube: then the tube is cut and sewn to the back of the uterus;
E. Tubal Clip: metal devices such as the tubal clip made by Fishie(R), or Hulka (R): smashes the Fallopian tube shut, so the egg does not pass from the ovary to the uterus;
E. Tubal Ring: with a silastic Band or Tubal Ring, the Fallopian tube is doubled up and then surgically placed to clamp it shut;
F. Pomeroy Tubal Ligation: often referred to as having the Fallopian tube "cut, tied, and burned."
G. ESSURE(R) Tubal Ligation*: Bilateral (both sides) have Nickel-plated and fiber coils that are screwed into each Fallopian tube under spinal anesthesia or pelvic block. An immune response is desired, causing inflammation and scar tissue, blocking the tube from receiving sperm.
The FDA states that "permanent," specifically with Essure(R), is "one year or more." Controversy surrounds this metal device implant, which has been known to lead to side effects in individual patients (including but not limited to): breakage of coils into pieces; tubal pregnancies; perforation (i.e., poking a hole through) of the coils through the Fallopian tubes; perforation of the uterus; perforation of the colon; infants born with the coil going through the upper ear; colonic-vaginal fissure (a space or track leading from the colon to the uterus, whereby E.Coli stool can be passed through the vagina; hives; abdominal pain; back pain; and more.
H. Adiana Tubal Ligation: No longer used due to a 2012 lawsuit and judgement announced by Conceptus(R) (the developer of Essure(R) procedure), against Hologic, Inc. (http://globenewswire.com/news-release/2012/04/30/474765/253823/en/Conceptus-R-Announces-Settlement-of-Patent-Infringement-Lawsuit-With-Hologic.html)
5. REVERSAL OF BTL: requires microsurgery, and a fertility specialist may be consulted. Remember to get 2 Opinions on any surgery, and take someone with you. It makes the most sense to go to a surgeon who does this frequently, rather than go to a surgeon who does this infrequently.
6. HYSTERECTOMY (LAP-HYS): In the USA, women over age 45 have a 40% chance of having a hysterectomy. At 70 years of age, 70% have had a hysterectomy. Usually, the procedure is done as a laparoscopic procedure, where little slits in the abdomen are used to push in CO2 gas, blow up the belly, and insert instruments to cut and chop the uterus out. The risks of anesthesia include vomiting under anesthesia, aspiration pneumonia, death, tooth chips or tooth breaks, heart attacks, and a multitude of other general complications. Your specific risk factors should also be explained to you in language that you understand. Plan to have "referred" shoulder pain to your scapula; and plan to wear jogging pants for a few weeks before your belly shrinks back down to size.
7. HYSTERECTOMY WITH MORCELLATION: All the above is included with LAP-HYS by morcellation, with additional risks. The morcellator is almost like a vacuum machine that follows the 'carpet' of the uterus in a line, while water is slurped over it. It essentially turns the uterus into one long piece. It is impossible to know if your "fibroids" are truly cancerous or not prior to surgery, so off go some slides to the Pathologist. After a few days, you get the news, either good or bad: it is benign fibroid, or it is cancerous sarcoma or leiomyosarcoma. Only 15% of women are sill alive 5 years after this diagnosis, which the morcellator/surgeon caused by whizzing that morcellator all over your abdominal cavity. What once was Stage I (baby) Cancer, is now Stage IV (monster) Cancer. Because anesthesiologist Amy Reed, MD, PhD and her husband who is a REAL MAN have fought the FDA, the medical boards, and the government medical device department (501(k)), Johnson & Johnson pulled the morcellator worldwide. Its use has been banned by hospitals, insurance companies, and manufacturers due to the increased risk of "upstaging" a uterine cancer. Yay! We have more work to do, ladies, as the 501(k) needs to be rigorously disbanded as a thing of the 80's, and we have found Panel members who had to resign their positions because they took money from the manufacturers! Wow. They thought we would never find out. And now? "We will not be STOPPED!"
8. "OVARIAN CONSERVATION": Refers to the view that the ovaries belong in the pelvis, and are not to be taken out during a hysterectomy, if possible. There are risk factors for ovarian cancer that you can put yourself on, assessing your own risk, and remember that this is an individual decision for each woman. Some ovaries can secrete hormones like estrogen, progesterone, and testosterone for up to 15 years after a hysterectomy, so ladies, they are NOT just decorations. They are an endocrine system on their own right. They protect against bone injury, fractured hips, memory loss, heart disease (America's #1 killer), and when they "lose" communication with the uterus as it is surgically removed, the biofeedback communication between the "talking" of the uterus and the ovaries is lost. Ladies, we are living shorter lifespans for the first time in history. Men, on the other hand, are gaining lifespans. So put down that fried chicken and eat a salad.
9. HYSTERECTOMY WITH BILATERAL OOPHORECTOMY (LAP-HYS--BSO): OK, so your surgeon says you have to have "it all" taken out: uterus, both Fallopian Tubes, and both ovaries. It is done laparoscopically, and you make sure there is no morcellator used. Why do you need your ovaries out? Because of the risk of ovarian cancer (0.05%)? The risk of heart attack from NOT having your ovaries is higher, and you are going to be in overnight, full-on, surgical menopause.
10. SURGICAL, MENOPAUSAL "SHOCK": With surgical "shock", you don't get 10 - 15 years to have your ovaries gradually lose their ability to secrete hormones. Nope. Just jump in a cold pool. "Surgical shock" involves hot flashes, pain during intercourse, memory loss, depression and guilt, irritability, inability to sleep with sometimes severe insomnia, lashing out at your loved ones, and generally turning into that old crone of a witch that you never wanted to be. So check out the situation yourself; this is a monumental decision, not a small one. Find your Risk Factors in my book, and check off where you are. There. NOW get 2 surgical opinions. One study showed 50% of hysterectomies were unnecessary upon 2nd Opinion; the other found that 90% were unnecessary.
It's not a status symbol any more, ladies. It's a chance at an early death, WITH the rest of your days being miserable. And is the surgeon going to put you on hormone replacement therapy (HRT)? Ha! Watch his face! Could it be that he just wants to 'cut' you, get paid, and then GO? You make sure you have a good gynecologist, endocrinologist, or Age Management Medicine specialist to follow-up on your hormone levels and HRT.
11. BIOIDENTICAL HORMONE REPLACEMENT THERAPY (HRT): BHRT is also known as Bioidentical Replacement Therapy (HRT), or natural hormone therapy. This is a huge topic that can hardly be covered in one paragraph, but suffiice to say that I studied this subject, as I am menopausal, and I like the reproducibility of compounded hormones from the pharmacy that Cenegenics uses. If it were not for my knowledge there, I would not know who to recommend. So if you are pre-menopausal, post-menopausal, or have surgical menopause, I suggest you read my book and obtain a 2nd Opinion (from an Endocrinologist or Ob/Gyn) on your hormone levels. If you would like a separate discussion solely on this topic, just let us know and we would be happy to oblige. In my opinion, this is a really, really, REALLY individualized, custom-made recipe of hormone replacement needed for each women.
12. LONG-TERM CARE: I've seen plenty of CEOs, CFOs, Presidents, and Owners of companies that fly jets to their destinations on demand. I want people to know that you are not going to be 25 or 30 forever. A car accident, where the lady pressed the gas instead of the brakes, changed my entire life in the blink of an eye. I didn't even know how much it would be changed. Especially now, looking 9 years later, I have a full-time 24/7 Caregiver. She shops, takes me to my multitude of appointments and studies, and literally picks me up when I fall down. Or when my face turns green, she finds a bag for me to throw up into. I bought my policy 12 years ago, when my father had Alzheimer's disease, thinking that one day perhaps I would have it too. At that time, there were certain riders you could add: cost of living increase, no maximum benefit, etc. Now, as the Baby-Boomers age, one can not buy the same policy that was available to me then. So get on your horse, don your cowgirl hat, and spend the money now to buy Long-Term Care Insurance. Whatever it costs now per year, that it what it will cost per month years from now. Take it from me. Never planned to use it at 45 years old. But I planned to use it sometime before I died, so I 'got in' early. Please check your budget and do what you can to make it fit in.
Believe me when I tell you that when you are sick or disabled, all your friends and family disappear over the years. It's been 9 years for me now, and I have only a few real friends. I have only one house full of family. That's why I took up writing. I didn't want the time to pass, without having something to show for it, without the "MD" in me wanting to help others; without the "Ph.D." in me to think ahead and come up with solutions before the problems occurred.
13. QUALITY OF LIFE: Oh, but stay with me. Quality of Life is our God-given right, and we shall work to do the best we can to make sure that no one is left behind. It's not enough to lay in bed staring at the ceiling for 9 years. I wrote 5 books; I got my Ph.D. I listened to people tell me crap after crap, and instead of wallowing in my own pity, I chose to rise above the occasion and make myself a better person that still knew how to smile.
NO ONE IS TAKING AWAY MY SMILE.
*** DON'T LET THEM TAKE YOUR SMILE AWAY, EITHER ***
ARCHIVES OF THE VAGINA: A JOURNEY THROUGH TIME
* ALL SUBJECTS BUT BTL (# 3) ARE COVERED IN MY NEW BOOK, #13.
I FIXED THAT HERE.
1. Wikipedia: Tubal Ligation, http://en.wikipedia.org/wiki/Tubal_ligation.
2. BMC Womens Health. 2005 May 2;5(1):5.
The risk of menstrual abnormalities after tubal sterilization: a case control study.
Oman Med J. 2012 Jul;27(4):326-8. doi: 10.5001/omj.2012.81.