Letters

OB/GYN News, Oct 1, 2001

Endometrial Ablation

I was glad to see the report on newer technology that has long been needed in our field ("Two New Endometrial Ablation Devices Approved," June 1, 2001, p. 4).

We still perform too many hysterectomies, and we should look for alternatives for our patients. I am disappointed, however, that you did not report accurately on the Her Option procedure. As the lead physician in the country with this procedure, I am confused about some of the comments made by those quoted in the article.

I've performed 150 of these procedures and am able to see the "CryoZone" at all times. This is the only procedure that allows you to see the inside of the uterus, the myometrium, and the serosal surface all at one time. As the CryoZone grows, you can see it advance through all of the layers.

I am unable to comment on the visualization of the Hydro ThermAblator procedure as I have not performed it to date. As an experienced hysteroscopist, I can tell you that I have only been able to see just the inside of the uterus.

I totally disagree with the person you quoted who said you need to be an expert in ultrasound to see what you are doing during the Her Option procedure. The pictures are so basic that even the nurses can see the CryoZones as the procedure is performed. I have never had any problem positioning the probe, and have never thought that I had poor probe placement.

Having performed many endometrial ablation-type procedures over the past 15 years, I have not found any better technology than Her Option. This procedure gets the deepest penetration of all. This new operative tool is adaptable and will offer gynecologists a new way to take care of many problems that we are faced with daily.

Seth Jordan Herbst, M.D. paid consultant to CryoGen Inc. West Palm Beach, Fla.

Pelvic Floor and C-Section

As I read Dr. Linda Brubaker's guest editorial "Don't Forget the Pelvic Floor" (July 15, 2001, p. 4), I kept nodding my head in agreement as she articulated thoughts I have held for some time now.

Obstetricians have done women a disservice by not helping them make a clear choice in the method of delivery. In a survey some time ago, senior medical students were asked how they would prefer to be delivered of their first baby. The majority said elective cesarean, which stunned me.

Dr. Brubaker's appointments place her in the arena of late obstetrical trauma, when youthful exuberance and muscle tone can no longer compensate for the overstressed pelvic structures of 20-30 years back. The preening obstetrician who manages a tough delivery and avoids a cesarean may sow a harvest of gynecologic problems years down the road. That is not exactly something to be proud of.

P. Declan Burke, M.D.

Fredericksburg, Va.

VBAC Safe in Practice

In a recent guest editorial, Dr. Linda Brubaker cast aspersions on vaginal birth after cesarean and postdate induction without presenting evidence to substantiate this perspective ("Don't Forget the Pelvic Floor").

Dr. Brubaker implied that VBACs have an inherent increased risk of pelvic floor damage; however, over 20 years of clinical experience at our practice does not support this concept. I am also unaware of any data that support this opinion.

Many VBACs are performed in patients with non-reoccurring risk factors. Many deliveries are difficult because of presentation rather than pelvic size. A woman who has a cesarean section for a posterior presentation may easily deliver a larger baby vaginally the next time.

Dr. Brubaker also suggested not performing an induction at 42 weeks' gestation if the cervix was unfavorable. I am not aware of any studies that equate postdates with pelvic floor dysfunction. Until randomized controlled trials prove that pelvic floor dysfunction clearly occurs in certain at-risk patients, we are left with an all-or-none choice: Perform cesareans on all patients to prevent pelvic floor dysfunction or perform them on none.

Perhaps the perspective of urogynecologists is flawed because they only see the worst circumstances of pelvic floor destruction. We must remember that cesarean sections are major abdominal surgery with potentially severe complications. In our practice VBACs have been safer than routine repeat cesarean sections.

Richard Waldman, M.D.

Syracuse, N.Y.

Dr. Brubaker replies:

Over the past decade the pendulum of obstetric practice has swung widely. Thoughts on episiotomy forceps, and now mode of delivery have varied greatly.

Dr. Waldman is correct that there are no data demonstrating that a VBAC has an increased risk of pelvic floor damage compared with a vaginal delivery without prior cesarean section. The compelling difference is the VBAC informed consent process, during which obstetricians must compare and contrast the risks and benefits of cesarean section and VBAC in a balanced manner.

Although there is ample science to support a deleterious effect of vaginal delivery for a significant minority of women, each woman should be given the available information and allowed to choose her route of delivery.