Randy Dotinga

LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.

“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.

The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”

Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”

Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.

Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).

Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.

What about other situations? She offered these pearls in the presentation:

• Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
• Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
• Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
• Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.

“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that instead of removing ovaries in most women undergoing hysterectomy, it’s quite important to consider removing just the fallopian tubes to best optimize cancer risk reduction and general health outcomes.”

Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.

LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.

“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.

The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”

Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”

Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.

Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).

Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.

What about other situations? She offered these pearls in the presentation:

• Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
• Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
• Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
• Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.

“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that instead of removing ovaries in most women undergoing hysterectomy, it’s quite important to consider removing just the fallopian tubes to best optimize cancer risk reduction and general health outcomes.”

Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.

LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.

“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.

The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”

Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”

Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.

Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).

Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.

What about other situations? She offered these pearls in the presentation:

• Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
• Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
• Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
• Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.

“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that instead of removing ovaries in most women undergoing hysterectomy, it’s quite important to consider removing just the fallopian tubes to best optimize cancer risk reduction and general health outcomes.”

Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.

LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.

There are many reasons to spare the uterus, from ensuring natural menopause timing to providing a quicker operation associated with a faster recovery, said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”

According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.

But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.

She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:

• It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
• Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
• Hysterectomies hasten menopause.

There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”

U.S. Air Force photo by Staff Sgt. Ciara Gosier

As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).

There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.

The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).

As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.

She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).

Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.

There are many reasons to spare the uterus, from ensuring natural menopause timing to providing a quicker operation associated with a faster recovery, said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”

According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.

But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.

She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:

• It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
• Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
• Hysterectomies hasten menopause.

There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”

U.S. Air Force photo by Staff Sgt. Ciara Gosier

As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).

There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.

The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).

As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.

She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).

Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.

There are many reasons to spare the uterus, from ensuring natural menopause timing to providing a quicker operation associated with a faster recovery, said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”

According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.

But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.

She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:

• It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
• Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
• Hysterectomies hasten menopause.

There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”

U.S. Air Force photo by Staff Sgt. Ciara Gosier

As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).

There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.

The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).

As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.

She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).

Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Inappropriate patient positioning can cause nerve injuries in gynecologic laparoscopic surgery, and it’s not just nerves below the waist that are vulnerable.

But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Falcone offered tips about avoiding injuries to these nerves:

Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.

How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.

Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.

Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.

Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.

Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)

Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.

Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).

Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).

Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Inappropriate patient positioning can cause nerve injuries in gynecologic laparoscopic surgery, and it’s not just nerves below the waist that are vulnerable.

But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Falcone offered tips about avoiding injuries to these nerves:

Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.

How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.

Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.

Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.

Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.

Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)

Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.

Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).

Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).

Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Inappropriate patient positioning can cause nerve injuries in gynecologic laparoscopic surgery, and it’s not just nerves below the waist that are vulnerable.

But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Falcone offered tips about avoiding injuries to these nerves:

Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.

How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.

Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.

Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.

Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.

Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)

Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.

Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).

Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).

Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

 

 

Worldwide differences in surgical technique choice

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

 

 

Worldwide differences in surgical technique choice

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

 

 

Worldwide differences in surgical technique choice

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.