Risks of Heart Disease, Perspective on Research

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Risks of Heart Disease, Perspective on Research

Guest Editorial exclusively for Nancy’s Nook:
James Dana Kondrup, M.D., FACOG, ACGE
Minimally Invasive Surgeon
Assistant Clinical Professor at Upstate Medical Center
Syracuse NY – Binghamton Campus
Binghamton N.Y.

April 3, 2016

Recently a scientific article appeared in The American Heart Association Journal, “Circulation” from researchers at The Brigham and Women’s Hospital in Boston Mass. The study followed 120,000 women over 5 years and 12,000 women had laparoscopically confirmed endometriosis. The results of the study were shocking and concluded huge increases in heart disease risks, angina (chest pain) and the need for open heart surgery for women with confirmed endometriosis. Even more concerning was the fact that the higher relative risk was in those women under the age of 40.

In addition the study concluded that by performing ovary removal at an earlier age (a common treatment for endometriosis) increased the risk even higher.

So it wasn’t bad enough that women have to suffer from the pain of endometriosis but now they have to deal with the “fear” of endometriosis! 

So what does this mean to you and your loved ones? Perhaps I can share some insight with you based on my 28 years of treating endometriosis and after performing thousands of endometriosis surgeries. 

So what do we do now? Or more importantly what can you or should “you” do now faced with this knowledge? 

Some of the things I have to say may not make you happy and some things may confirm what you already know. Your opinions and comments are welcome.

First of all we have known for many years that Endometriosis (Endo) is an inflammatory state. However, what we didn’t know for sure was that it had systemic effects. Any surgeon or patient looking at their surgical pictures of the endometriosis could see the redness, the vascularity, the adhesions and damage to the tissue. In other words we could see the inflammation. Furthermore, many surgeons realize that Endometriosis can be an aggressive and infiltrating or invasive disease. We see this when endometriosis invades the bowel and other structures. Often my patients with Deep Infiltrating Endometriosis (DIE – the medical symbol) ask the question, “Well how the heck did it get in there?” And this is why “excision” of the Endo is so important as opposed to “ablation.”

What still remains a mystery is why some women develop endometriosis in the first place while others don’t and why some women with minimal disease have severe pain and while others with severe disease have very little pain. Perhaps it’s the inflammatory response? Ah hah! So perhaps inflammation plays a bigger role than we originally thought.

So what follows are some of my observations, opinions and suggestions:

The Study:First of all let’s look at the article. It is a newly published article and it will soon undergo close scrutiny like all articles, however, this one will be looked at extremely closely since the percentages of risk are so high. This means that we must be patient and wait for the dissection of the article before we panic and worry (both of which can increase your heart attack risk).

So often I see young women aged 15-16 come to see me saying they have endometriosis without ever having a laparoscopy. Well the truth is they have “presumed” Endo, not confirmed. This is why the study only included “laparoscopically” proven cases. So it is important to get a definitive diagnosis early on so you can be treated in the early stages. I have done many laparoscopic surgeries on women aged 15-18 to “see and treat” the Endo early on. Our non-robotic techniques use 2.3mm – 5mm incisions and almost 100% of the time the umbilicus incision is never seen.

Surgery and Surgeons:Well truth be told not all surgeons have the same experience or training when it comes to excising Endo. The old technique of diagnostic laparoscopy is fading away. Patients want to be treated at the time of diagnosis. This is not always possible depending on the disease severity, the hospitalfacility and surgeon experience. In severe cases it is best that the surgeon doesn’t “muck around” and partially treat the Endo. It makes it harder when they come in for the excision surgery. I often review the operative reports and pictures that my patients bring in with them and show them lines in the report that may read, “The endometriosis near the ureter could not be removed” or “As much Endometriosis as possible was removed and…” These statements all say the same thing: It’s still there.

So what you have to do is get the best surgery you can. Does it mean you need the “best” surgeon? No, but you need an experienced surgeon if it’s bad. I myself will sometimes refer patients to other experts around the country if I cannot do what needs to be done. (Dr. Jon Einarsson at Brigham and Women’s deals with some of the worst cases of Endo).

Does the hospital make a difference? You bet it does! Some hospital facilities are better than others. I have been to some places where you couldn’t even see small areas of endometriosis because the video and surgical equipment was never updated or repaired. With economic stress and cutbacks the hospitals sometimes sacrifice quality to try to stay economically viable. I have always been of the opinion that when it comes to surgery I want the best not just the “adequate.”

Your Health:Well this opinion/fact may upset you but you need to know the truth. Poor health makes the surgery harder for you and your surgeon. Obesity, smoking, etc. can make a really difficult surgery even harder. Endo is often an invasive and “sticky” disease. Meaning that often times the organs are stuck together and the surgeon needs to separate the tissue to protect the vital organs such as the bladder, bowel, ureters and blood vessels. When all of these organs are surrounded by an immense amount of fat the surgeon can have difficulty locating these organs. In some cases the surgeon will delay surgery until the patients loses weight or undergoes bariatric surgery to make the surgery easier. 

The other aspect that patients usually do not appreciate is that the surgeon needs to place the patient in a very steep “head down” position during the surgery to move the bowels out of the way to see the pelvis and endometriosis. If the patient is obese or a heavy smoker this can sometimes be impossible for the anesthesiologist to accomplish. Luckily I am blessed with a great team that can work under difficult circumstances but there are limits.

So the point is: be in the best shape you can not only for your surgeon but if the findings of the study are true then you need to be in the best of health from the get go any way to even the odds on the playing field of heart disease. Eat right, exercise and do things that decrease you risks such as meditation, Yoga etc.

Take my ovaries?So many surgeons are quick to take your ovaries. “Don’t worry honey, we should take those ovaries out and your endometriosis will go away?” Have you heard that? Even the American College of OB/GYN (ACOG) has changed their recommendations concerning ovary removal because they realized the multiple adverse effects of early ovarian removal. We can always go back and remove the ovaries if we have too but we can’t put them back. Often times the woman makes an “emotional” decision to remove them when they are in severe pain so I encourage my patients to wait until the flare up is over before making a radical decision. This study shows that early ovary removal may not be the wisest decision. If we do have to go back in to get the ovary(s) the procedure is often a single belly button incision.

Pain meds:So I live in N.Y. and the new law just went into effect that all prescriptions must be electronically sent and all narcotic prescriptions have to be checked on the state database to insure that patients aren’t receiving narcotics from multiple doctors. This is good and bad. It makes it difficult to abuse the meds but also difficult to prescribe them too. If you want to addict a woman to narcotics then treating their endometriosis with increasing doses of narcotics is the way to do this. This is why pain management centers are so important as well as proper diagnosis and treatment.

Insurance:Try your best to carry some insurance. The reality is that very few surgeons/ hospitals will see you if you have no coverage at all and some surgeons limit the amount of Medicaid they accept. This is economic reality and we could spend hours alone debating this issue.

Summary:OK so the basic points include:

-Find an excellent surgeon. Do your homework. If you are on this site you have already taken the first steps.

-Be your own advocate. Ask questions. Get a second opinion.

-Be in the best health you can be in since if the study proves true you are taking a positive approach to decrease your risk of heart disease and making it easier for your surgeon too.

-Wait until all of the evidence is in on this study. Stay educated from the professionals as they review the data.

Stay with Nancy’s Nook so you never feel alone in your battle and for God’s sake don’t have blind faith, check everything out in an intelligent way.

James Dana Kondrup, M.D.Dr. Kondrup is an international trainer and speaker who travels the world teaching minimally invasive surgical techniques. He has published many educational videos for surgeons and patients.