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OB/GYN Editorial NOVEMBER 2005
Lessons Learned From the Hammer
and the Nail
Arnold P. Advincula, MD
Renowned psychologist Abraham Maslow once said,“If the only tool you
have is a hammer, you will see every problemas a nail.” This oft-quoted
phrase certainly applies to a variety of situations. In
medicine, the hammer can refer to medications, technologic
advancements,or procedures. Recently,
this phrase came to mind as I evaluated a patient who was
referred to me for consultation.
The patient was a 52-year-old nulligravida with chronic pelvicpain
(CPP). She had undergone uterine artery embolization(UAE)
6 months earlier for abnormal uterine bleeding (AUB) attributed
to fibroids. As I reviewed
her medical records, I found one disturbing piece of information:
Although pelvic ultrasonography obtained just prior to
UAE confirmed the presence of three fibroids, the largest
was only 1.2 cm in diameter,
and all were
subserosal. In fact, her uterus preprocedure measured just
10 x 4 x 4 cm. Pelvic pain developed almost immediately
postoperatively. Since then, the pain
had persisted and intensified.
Further questioning revealed that although the UAE seemed to have resolved the
patientÍs AUB,this more than likely occurred due to iatrogenic menopause; evidently,
she had not been aware that 15% to 20% of perimenopausal women over age 45
years undergoing UAE experience ovarian failure.1-4 The
procedure had left both physical and psychological scars, because the patient
had
undergone UAE in the hope of avoiding hysterectomy and making a natural, gradual
transition into menopause. Now she was not only menopausal, but had CPPas well.
As I suspected, physicalexamination disclosed a normal-sized but tender uterus
and adnexa. I recommended hormone therapy and analgesics, and noted that the
patient
may need hysterectomy in the future.
My initial reaction to what hadhappened to this patient was one of anger and
disgust. I recalled an article in TheWall Street Journal suggesting that gynecologists
failed to offer UAE becausethey wanted the higher hysterectomy fees.5 The
American College of Obstetricians and Gynecologists replied with a letter
to the editor that vigorously defended the integrity of womenÍs health professionals.6
However, as I considered the case at length, I realized that it illustrated two
very important lessons that could be applied to daily practice. First, despite
the amazing technical advancements in medicine, it is easy to be overzealous
in the use of therapy. Although UAE has demonstrated clinical success rates
as high
as 90% for the treatment of AUB secondary to fibroids, in this case, a lack
of understanding of the proper context in which to implement a therapy resulted
in an undesirable outcome.1-4 The fact that this patient had fibroids did not
automatically mean that UAE was the appropriate solution to her problem. In
otherwords, a sledgehammer was usedon a finishing nail.
The second lesson to be learned from this case is the importance of listening
to the patient and carefully reviewing available information. As my mentor
taught me, a thorough history and physical examination can reveal the nature
of the
problem 90% of the time. This simple, fundamental interaction can make all
the difference in choosing the right therapy.
In gynecology, the hammer can be anything from the latest slingprocedure for
urinary incontinence to the newest electrosurgical instrument for ovariectomy.
As we learn from the mistakes of others, we should always remember that when
we
drive those nails, the hammer can sometimes miss—and in the end, it will
be more than our thumb that aches. Ultimately, it is the patient who pays the
price.
ARNOLDP. ADVINCULA, MD
Editorial Advisory Board Member
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References
- Walker WJ, Pelage JP. Uterine artery embolization
for symptomatic fibroids: clinical results in 400 women with
imaging follow up. Br J Obstet Gynaecol. 2002;109(11):1262-1272.
- Pron G, Bennett J, Common A, etal. The Ontario
Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction
and symptom relief after uterine artery embolization for fibroids.
FertilSteril. 2003;79(1):120-127.
- Spies JB, Ascher SA, Roth AR, Kim J, Levy EB,
Gomez-Jorge J. Uterine artery embolization for leiomyomata. Obstet
Gynecol. 2001;98(1):29-34.
- Spies JB, Spector A, Roth AR, Baker CM, Mauro
L, Murphy-Skrynarz K. Complications after uterine artery embolization
for leiomyomas. Obstet Gynecol. 2002;100(5 pt 1):873-880.
- Helliker K, Etter L. Silent Treatment: Hysterectomy
alternative goes unmentioned to many women; Gynecologists OftenDonÍt
Cite Less-Invasive Proce-dure To Treat Fibroid Tumors; Bailiwick
of Other Specialists. The Wall Street Journal. August 24, 2004:A1.
- Hecht BR. ACOG strongly disputes UAE story
[press release]. Washington, DC: American College of Obstetricians
and Gynecologists; September 3, 2004.
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