Hysterectomy and a tummy-tuck

Who would not want to get that extra belly fat removed while you are getting a hysterectomy?  Many of my patients ask me if I could just remove their belly fat while I am removing their uterus.   If I just need to revise their previous old surgical scar and some fat, I usually don't mind.  However, to remove large amount of fat, skin and tighten the abdominal muscle (Tummy tuck or abdominoplasty), it would take considerable amount of time and effort.   The hospital and your surgeon would probably charge you extra $4000 to $6000 since insurance company does not cover the cost.

But again, if you have less than appealing old surgical scar and you are about to go to another abdominal surgery, do ask you surgeon if he/she could revise it for free.  Does not hurt to ask...

Vaginal spotting after my hysterectomy

It is common to have vaginal spotting a few days after hysterectomy.  This is usually due to the healing of vaginal cuff.  During surgery, the end part of the vagina was cut then sutured.   In contrast to your outside skin that was cut then dried up and forming scab, the vaginal areas are usually moist and take longer time to heal.  Thus, vaginal spotting is OK for a few days after hysterectomy.   But if you have heavier bleeding than just dark spot, or if you have bright red bleeding or you are concerned, please call your surgeon.

Occasionally, you have a few blobs of dark blood coming off from your vagina in the first day of being home.  This could come from blood that clotted after surgery but left over in the vagina.  if this is all you have, you usually will be OK.  But if you have persistent vaginal clot, please call your surgeon.

When you come, we usually examine your vaginal cuff and stop the bleeding using a chemical cautery (Monsel solution or silver nitrate).  The cauterization usually has minimal or no pain but the exam is somewhat uncomfortable since you are still sore from the surgery. 

Shingle (herpes zoster) and chemotherapy

Varicella-zoster virus (VZV) can cause two types of diseases.  First, primary infection with VZV results in varicella (chickenpox), characterized by skin blister.   After this infection, the virus could live dormant in your nerves.   The 2nd type of disease is what we called Herpes zoster or shingles.  Herpes zoster is due to reactivation of VZ virus that live dormant earlier in your nerves - not the same as sexually transmitted herpes. Herpes zoster/ shingle usually causes painful, one sided painful blisters on your skin.  Before the rashes or blisters show, you may have nerve symptoms of pain, itching, burning, or tingling. The rash has blisters that scab over in about a week. Although shingles isn’t contagious, the virus can spread to others and can cause chickenpox.

We don't know what exactly causing the reactivation of the VS virus in shingle but it occurs more often in immunosuppressed persons such as with HIV or in chemotherapy.  Thus, if you have any painful skin rash or blisters during chemotherapy, do come see your oncologists or PCP.  Your doctor may give you antiviral therapy to help healing of the rash and decrease the painful inflamed nerves.  Antiviral medications are Famciclovir or Acyclovir or Valacyclovir pills.  Pain medication such as tylenol or stronger narcotic prescription may be needed depending the degree of your pain.

Can I just take aspirin for my blood clot, instead of coumadin/warfarin ?

Patients are usually asked to take coumadin/ warfarin (blood thinner pills) for about 6 months after diagnosis of blood clot.  Coumadin or warfarin are vitamin K antagonists.  Thus, it is inconvenient since patients need to avoid certain green leafy vegetables, which contain vitamin K, in their diet.  In addition, they have to get their blood tested frequently to make sure that their blood is not too thin or too thick (INR test).

Some of my patients have asked if they could be switched to aspirin alone.  It would be a lot easier than taking warfarin.   In this month New England Journal, a study randomly assigned 822 patients who had completed initial anticoagulant therapy after a first episode of unprovoked venous thromboembolism (blood clot) to receive aspirin, at a dose of 100 mg daily, or placebo for up to 4 years.  The results showed aspirin, as compared with placebo, did not significantly reduce the rate of recurrence of venous thromboembolism but resulted in a significant reduction in the rate of major vascular events, with improved net clinical benefit.

Sorry, you still have to take the warfarin if you have blood clot but discuss this question with your physician.  Furthermore, there are newer pills that may be easier to take than warfarin.  FDA just approved Xarelto for blood clot but I expect this drug would cost a lot more than warfarin.

Reference:
Brighton TA, et al. Low dose aspirin fo recurrent thromboembolism.  NEJM. Nov 2012.

Should I take vitamin supplements?

Vitamins have done wonder in our medical history.  Vitamin D supplement has made Rickets a rare disease.  Folic acid intake by pregnant women have reduced the incidence of spina bifida in newborns.   These public health achievements led many of us thinking that if a little is good, then more is better.   Some have speculated that antioxidants such as beta-carotene, vitamins A, C and E, may protect human cells from premature degradation.  Thus, they may prevent or even cure cancers.  Not surprisingly, many of us jump into conclusion of taking multivitamins is good for our health.

However, the science of vitamins is not very clear.   The Women's health initiative study which followed 160,000 women for about 8 years showed that 42% of study subjects who took multivitamins suffered the same rates of cancers, heart attacks, and strokes as the study participants who did not take the multivitamins.  A trial showed concerning increased rate of lung cancer in patients who took beta-carotene and other supplements.  A randomized trial of 30,000 men was halted in 2008 when preliminary analysis of the study showed that selenium and Vit E supplements were increasing number of cancers.

From Uptodate, I found this statement: The US Preventive Services Task Force (USPSTF) clinical practice guideline provides several recommendations for vitamin supplementation and can be accessed through the website for the Agency for Healthcare Research and Quality at www.ahrq.gov/clinic/uspstfix.htm. The USPSTF recommends 400 to 800 micrograms/day Folic acid for all women planning of pregnancy. The USPSTF found insufficient evidence to recommend for or against the use of supplements of vitamins A, C, E, multivitamins with folate, or antioxidant combinations for the prevention of cancer or cardiovascular disease. The USPSTF also recommend against the use of beta carotene for the prevention of cancer or cardiovascular disease.

What shall we do?  My suggestion is we should follow the USDA's dietary guidelines: for most of us, our vitamins should come from our foods rather than vitamin supplements.  Our meals should consists of wide variety of fruits, vegetables and even some proteins (lean meat).  I usually tell my patients that their meals should have variety of colors and variation.  Foods are very complex with many undiscovered biologically active ingredients and we have evolved for many millions years adapting to them.  A few single vitamins, recently discovered, are too simple solution to meet our dietary needs. 

Reference:

- U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(9):626

-Routine vitamin supplementation to prevent cancer and cardiovascular disease: recommendations and rationale.Ann Intern Med. 2003;139(1):51

- Uptodate. Vitamin supplementation.  November 2012

Genetic testing for ovarian cancer

About 10-15% of epithelial ovarian cancer are due to BRCA genes mutations.   Some of my patients with ovarian cancer are concerned that their daughters and sisters may also have an increased risks to develop ovarian cancer.   They are correct that first degree relatives (mother, sister, child) of an ovarian cancer patient would increase their baseline life time risk from 1.4% to around 2%.  If they have BRCA genes mutations, their life time risk jumps to about 50-85% for breast cancers and15 to 40 percent chance of developing ovarian cancer.

BRCA genes mutations are found more commonly in patients with a personal history of breast cancer and/or a family history of breast and ovarian cancer, especially if associated with young age of onset, multiple tumors, and involvement of male family members affected with breast cancer.  Ashkenazi Jews ethnicity is also a known risk factor.  Thus, if you have these histories, do talk to your physician about getting genetic counseling.  The genetic counselor will obtain more detail history and use a program to estimate your risk for BRCA genes mutations.  Genetic testing is usually recommended if your risk is estimated to be around 10% or higher.

Patients may have concerns of being discriminated after a genetic testing.  Fortunately, the Federal Genetic Information Nondiscrimination Act (GINA) of 2008 prohibits health insurers and employers from asking or using genetic test information in decisions about employment or insurance eligibility/coverage.
 
References:
- Pharoah PD, et al. Int J Cancer 1997; 71:800

- Hudson KL, et al. Keeping pace with the times--the Genetic Information Nondiscrimination Act of 2008.N Engl J Med. 2008;358(25):2661.

-Colditz G, et al. JAMA 1993; 270:338.

Does air cause my cancer to spread during surgery?

A few patients have concerns that when I operate to open their abdomen that air would make the cancer to spread.  Usually the story goes as "my grandmother went to surgery for cancer.  The surgeon opened her abdomen and closed.  Then she died a few days later because the cancer spread faster".  

I searched the literature and could not find the scientific basis for this.   However, the story may have a merit.  I could only speculate that the grandmother's cancer was too extensive that the surgeon decided to open, (may be biopsy), then closed the abdomen again.  She probably died from the extensive cancer or cancer complications (such as blood clot), but not from the air that entered her abdomen.