Re: GYN: recurrent abnormal paps

From: ainsron@msn.com
Wed Apr 25 11:30:23 2001

I grew up in the days of TVH for sterilization, on request, as long as there was some other reason to tack on to justify it, which was good for residency training. What woman hasn't had enough dysmenorrhea, or heavy enough periods to document a "problem"? I think you have a reasonable enough indication, especially with patient and family concerns that as long as they are counselled appropriately about the usual "risks, benefits, alternatives, etc" and make that choice, so be it. The troublesome ones are the ones you wish you had done differently - and it can go either way. For example, the patient who has a "simple" hysterectomy for a problem that might have been treated more conservatively with an ablation or LEEP - who develops a major complication. The other side is the patient for whom you "deny" or don't offer a hysterectomy, who later develops a problem that could have been "prevented" by the procedure. I had one like that last week. I did an ablation on her six years ago for PMB with submucous fibroids that I resected. Didn't see her for a couple of years until she was referred back by her GP, who noted an enlarging fibroid. TAH/BSO last week showed an endometrial stromal sarcoma! Now I wish I would have done a "simple" hysterectomy six years ago.

>44 YO postmenopausal woman underwent a LEEP for CIS around 5 years ago,
>with a positive endocervical margin. Her paps have been normal since,
>and her followup has been regular as requested.
>
>Since the LEEP, she now has rheumatoid arthritis, and intermittently has
>been on steroids and other immunosupressives.
>
>Also, FWIW, her health insurance will expire in August 2001, and she
>thinks that she'll be a nightmare getting new coverage (her husband is
>self-employed and her job is being downsized or something like that in
>August, or her COBRA is over then).
>
>Her recent pap came back as squamous atypia, and she couldn't just wait
>to repeat it in 3 months, as I suggested, due to the health insurance
>issue and general nervousness. So, she had a colpo, and the exam was
>adequate, with two small areas of white epithelium that were
>histologially "squamous atypia c/w HPV", and her ECC showed
>endocervitis.
>
>The woman and her husband are pretty much jumping up my case to treat
>this surgically, as opposed to observation. I believe that this is due
>to their insurance situation. I've told them that I think another LEEP
>is overkill at this point, but that I could live with doing it. They
>actually are pushing for a hysterectomy, which I could again live with,
>but frankly think that it is overkill for sure. However, their feelings
>are motivated by the real issue of pre-existing illness.
>
>Any thoughts?
>
>Garry
>
>--
>Garry E. Siegel, M.D., F.A.C.O.G.
>Roswell, GA
>Private Practice
>

--
Ronald E. Ainsworth, MD



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