National Uterine Fibroids Foundation

Stanley West , MD
April 5 , 2003

Carla Dionne ..	Welcome everyone. The information provided during this chat is to be used for informational purposes only. In no event shall the host moderator or chat guests or the National Uterine Fibroids Foundation be liable to you or anyone else for any decision made or action taken by you because of this information nor does your use of this information constitute the offering of medical advice by the chat guests. Please seek the advice and supervision of a health care provider when considering the medical information provided here today. That said, let's get started. First of all, welcome Dr. West and thank you for agreeing to participate in this live chat. I'd like to throw out the first question and after Dr. West answers, we'll take questions from other chat participants. Dr. West, how long have you been performing myomectomies AND how many myomectomies do you guesstimate you have performed to date?

Dr. West ..	I began doing myomectomies in 1970. To date I’ve done several thousand, more than anyone in the world. I also do the cases that no one else will handle.

Carla Dionne	I’m still trying to help members get into the chat room….anyone else have a question they’d like to ask right now? Everyone should feel free to type in their questions of Dr. West.
Dr. West	I’m prepared to discuss any questions that come to mind. Don’t hesitate.
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Gerocar	Dr. West, are there any cases of women with uterine fibroids which you would not accept right off the bat? I’m referring to women too old, or too many fibroids, or too large of fibroids?
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Dr. West	If it is the woman’s wish, and she requires surgery, it would be my privilege to do the surgery regardless of the size, number or location of fibroids.
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Gerocar .	Dr. West, you wrote for women "requiring surgery" – isn’t this the sticking point in your case – debating who "requires" myomectomy?

Chiweeluther .	Sounds like you are saying that there are no contraindications for myomectomy.

Dr. West	There are four symptoms of fibroids that require surgery. Heavy bleeding, severe pain, inability to get pregnant, or the fibroids have become so large that they are pressing on other organs. I do not operate if one or more of these symptoms are not present. There are no absolute contraindications. However, prior to surgery certain medical problems, etc., may preclude surgery. For those unaware of my problems, the NY health department has been trying for years to get me to stop acceding to women’s wishes, and only do hysterectomies, which I refuse to do.

Chiweeluther	I'm not aware of the controversy surrounding Dr. West. Can you give a brief synopsis? I'm sorry, I don't want to waste other's time if everyone already knows about this, but what are they alleging?
Dr. West	They recently suspended my license for three months. They have posted their findings on the NYDOH website, and I have posted my response on the NUFF site. Basically, their charges are bogus, such as failure to document a pap smear on a patient chart.

Eaaaw	Hello Dr. West, this is your patient Effie from Holland.

Dr. West	Good to hear from you Effie.

Chiweeluther	Do you know what percent of your patients have returned for a repeat myomectomy?

Dr. West	The percentage of repeat myomectomies depends upon the age of the first surgery. The older the patient, the less likely the need for repeat surgery. Taking both groups, approximately twenty five percent have a repeat myomectomy.

Gerocar	Traditionally, many gynos have discouraged patients with fibroids from pursuing myomectomy because it is considered to be "too bloody" or that it would leave the uterus looking like "swiss cheese." How would you respond to your colleagues making these comments?

Dr. West	These are common comments from patients. Studies done by EXPERIENCED gynos show that there is less blood loss and fewer complications doing a myomectomy than a hysterectomy. Any doc talking about "Swiss Cheese" simply does not know how to do a myomectomy.

Chiweeluther	Would you please discuss adhesions and how you prevent them?

Dr. West	The cause of adhesions is blood left in the operating field, therefore, attributable to sloppy surgery.

Heatherlbeckman	Hi Dr. West. I hope you are well - I am recovering from my myomectomy (et al) procedure that you performed on February 5. I read your response at NUFF, are you saying that insurance companies have lobbied the NY Department of Health to interfere with your performing myomectomies (presumably because they are more costly than hysterectomies)? Has this been a problem for any of your colleagues who regularly perform myomectomies.

Dr. West	While I cannot say that the insurance company is behind the health department pursuit of me, the fact that they offered to drop all charges if I agreed to stop operating certainly sounds like it.

Eaaaw	Yes, that sounds suspicious.

Discover20012003	What have you done to address the issue of the suspension with your patients who are awaiting surgery with you?

Dr. West	Here is a large part of why I am involved in this chat session. I have also spoken on the phone with a number of patients, both old and new.

Eaaaw	You know that you are under scrutiny….and in the position of a dissident you are at risk of being jumped upon for the slightest error….it seems to me that this is reason enough to be extra careful.

Dr. West	Believe me, I am constantly looking over my shoulder! I have had a number of "shills" call to make appointments during my suspension.

Eaaaw	However, I thought the allegations were serious. I expected some trumped up charge, but the story of Patient A was worrying.

Dr. West	Patient A was, and is, a very lovely lady. As I said in my posted reply on this website, she was not the best historian, making it difficult for me to address her problems sooner than I did.

Eaaaw	That side of the story didn't get into the documents….they were pretty damning.

Dr. West	If you are able to read the original findings of the hearing board, you will find a different finding.

Eaaaw	Yes, there was a marked difference. I also liked that during the original hearing, the point was made that there is a need for good myomectomy skills and you provide a valuable service. The AMB said no such thing.

Dr. West	Understand that the AMB consisted of a board convened by the health department from members of the health department to hear the appeal. I had no opportunity to appear or appeal.

Gerocar	Shifting gears for just a sec - Can you explain why so many gynos appear not to be interested in becoming experienced in doing myomectomy - is it simply lack of a financial incentive?

Dr. West	It is more difficult to do a myomectomy, longer and in inexperienced hands, more complications.

Eaaaw	What do your colleagues at St. Vincent's think of this?

Dr. West	My colleagues at St. Vincent's are appalled.


Carla Dionne	Dr. West, with Patient A, there seems to be discrepancies in the record over whether or not she was able to urinate appropriately prior to discharge. There were no nursing notes from the floor or physician notes indicating a problem and yet the patient testified there was. Can you explain what happened here?

Dr. West	At the time patient A was in the hospital, there were no notes indicating a problem because there was never a complaint.

Eaaaw	How is it that these voices are not heard, and that nobody substantiates that you did what was appropriate for Patient A?
Dr. West	They are not heard because no one wants to listen.

Eaaaw	How does the hospital feel about your pro-uterus bias? Are they indifferent to it, or do they support your effort to change the pro-hyst bias that is currently the norm?

Chiweeluther	In spite of the fact that your suspension seems trumped-up to you, as you look at your practice, is there anything that you would do differently?

Dr. West	The one thing that I would do differently, is to keep more detailed records.

Chiweeluther	To cover your ass or to help you diagnose/prepare for surgery?

Dr. West	Both.
Heatherlbeckman	So a doctor in your position has no recourse with the DOH?

Dr. West	Sorry, I do have a recourse. I can appeal to the health department. Obviously you know what would happen.

Eaaaw	Does it solely depend on the patient then whether a doctor does any follow-up?

Dr. West	No, there are routine follow-up procedures, but a good surgeon would also be prepared for occurrences out of the ordinary.

Carla Dionne	When patient A was finally readmitted and a bladder perforation discovered on CT scan, who did the reparative surgery? You or someone else at the hospital?

Dr. West	I along with a urologist.
Carla Dionne	So, Patient A consented to you as her surgeon, along with a urologist - regardless of the complications she was experiencing?
Dr. West	Patient A indeed consented to me repairing her bladder injury, because she retained full confidence in my surgical skills.
Chiweeluther	Is it possible that you were doing too many myomectomies? Too pressured?
Dr. West	I am very comfortable at the rate I do surgery.
Heatherlbeckman	Did the health department have an obligation to inform you that you were officially "under investigation" at some point in the last 3-4 years (after they contacted you to discuss these cases)?
Dr. West	The health department certainly had an obligation to inform me that I was officially under investigation.
Heatherlbeckman	So it looks like the health department could improve on their record keeping as well!!!
Discover20012003	In reading your book would you speak about the issue of estrogen and heavy women, fibroidians, who are on a weight loss program?
Dr. West	Development, growth and recurrence of fibroids is related to estrogen which is made from fat.
Gerocar	What is the minimum acceptable type of post-op care that a myo patient should expect? After my myo, I had only the PGY-3 resident to see me in the hospital. And one cursory visit at the gyno's office a week after surgery to remove steri-strips. As the patient, I felt this was inadequate. Your comments?
Dr. West	I see the patient immediately after surgery and every day in the hospital. I then see them several times in the office.
Eaaaw	What if you don't hear anything from a patient after she is discharged? Do you follow up? Does the hospital? Does the GP? Can a doctor rely on a layperson's ability to articulate her problems? Post-op care certainly is an issue.
Dr. West	When I discharge a patient, I instruct her on what to do and not do. I then have her schedule an appointment for one week after the surgery. She is to call me for any question or problem that might occur before I see her.
Eaaaw	Are any tests done as part of post-op care, or is it an interview?
Dr. West	Post operative testing is done as necessary.
Chiweeluther	Would you please discuss the most common post-op complications and/or problems, and how you deal with those? What is post-operative testing?
Dr. West	The most common post-op complications are bleeding, infection, injury to the bowl or bladder and ureteral damage. Post-op tests include a CBC (blood count) which will pick up post-op bleeding and/or infection. X- ray or cat scan will show bowel or bladder injury. IVP will show any problem with the ureter. Once the diagnoses is made, prompt correction is required.
Carla Dionne	Dr. West, I wanted to summarize for the group the final findings of the NYDOH regarding the 6 patients originally brought forth in your proceedings. At any rate, the final report indicated a complete dismissal of charges in regard to Patients B & E. Patient A charges were held up on post-operative issues regarding follow-up care. However, patients C, D, & F - charges were upheld on PRE-operative negligence of not performing an endometrial biopsy or pap smear. A lot of gyns "out there" are not performing endometrial biopsies…and I don't see their hands getting slapped over this. Even so, is there any information you can provide about this pre-operative situation with these specific patients?
Dr. West	During the hearing, I testified that preoperatively a number of the tests (pap smear, etc.) had been done by previous doctors. I did not feel it necessary to repeat these tests as a patient is certainly competent to report a negative pap smear. EMB testing is for cancer, and at age forty five or under this is too rare to do.
Eaaaw	My Dutch gyno didn't want to bother with endometrial biopsies. They wanted to take my uterus out straight away. One of them refused to map my fibroids because they were too big and too many and I was getting a hysterectomy anyway.
Bdrcollie1	I did have an endometrial biopsy prior to my ablation.
Carla Dionne	I had abnormal bleeding for nearly a decade…and never had an endometrial biopsy until prepping for fibroid embolization….some gyns said it wasn't necessary…others said it couldn't be done due to presence of fibroids. So, my question is "What gives?" Why no consistent practice among docs and why did these charges stand in your case?
Dr. West	EMB is done to rule out cancer and for no other reason. It is a wasted procedure on women under age forty-five. If you have bleeding and fibroids, the odds are it is not cancer, but the fibroids. Even from the age forty-five to menopause, uterine cancer is RARE.
Eaaaw	What if there is a history of cancer in the family? Both my parents died of cancer, there are breast cancers in the family, not uterine or cervical, though.
Dr. West	You are not at risk for uterine cancer any more than anyone else, regardless of your family history.
Bdrcollie1	If endometrial biopsies had been done preoperatively by other physicians within a reasonable amount of time, then why were charges upheld on patients C, D, and F?
Dr. West	Unfortunately, I did not document as well as I should have.
Discover20012003	If a woman is on a weight loss program and the fibroid symptoms change for the better, is a MYO advisable?
Dr. West	Since fibroids are never cancer, there is no reason to do surgery unless the patient is experiencing some of the above symptoms.
Gerocar	You see the patient at your office several time post op? With or without a pelvic exam? Even if the patient appears to be problem-free at the 1-week point?
Dr. West	I see patients post operatively even though my patients RARELY have problems.
Eaaaw	Dr. West, since it is undisputed that myomectomies require good skills, what are you doing to pass your skills to others? Do you teach?
Dr. West	Yes, I teach medical students and residents as well as visiting doctors.
Eaaaw	It's good to hear that you teach. Those skills are so needed, as are more doctors who believe in saving the uterus.
Libarias	May I have your view on pre-operative treatments as it relates to Lupron.
Dr. West	I never use GnRH agonists. They're terrible drugs.
Libarias	The use of GnRH - other doctors insist they are necessary to reduce blood loss. What other medication can be used for this end result to make surgery safer?
Dr. West	GnRH agonists make you instantly menopausal. It makes surgery much more difficult with increased bleeding and the fibroids turn to mush.
Eaaaw	GnRH?
Libarias	GnRH is drugs like Lupron.
Carla Dionne	GnRH refers to the broader class of these drugs…there are more drugs than simply Lupron that do the same thing as Lupron. It would be my assumption that if Dr. West doesn't like/use GnRH agonists pre-operatively, then that perspective probably applies to the entire class of these drugs, including Lupron.
Libarias	So are you advising to avoid all GnRH as pretreatment?
Dr. West	Any GnRH agonists functions the same.
Libarias	I would like to avoid the artificially induced menopause.
Dr. West	Then avoid GnRH at all costs. We use vasopressin injected into the fibroid and a cell saver to recover any blood lost.
Discover20012003	Thank you Dr. West for taking the time to answer all our questions so candidly.
Gerocar	Dr. West, how is your health these days? Any injuries from your car accident?
Dr. West	I am less hurt from my car accident than from the health department ruling. Thank you for asking.
Discover20012003	Will you continue to be the Chief surgeon at your current hospital?
Dr. West	I will remain with the same status at my hospital.
Carla Dionne	Dr. West, can we talk about patient F in the DOH findings? I'm very disturbed by some of the comments/conclusions drawn by the panel on this patient's case.
Dr. West	Carla, remind me, who is patient F?
Carla Dionne	48 yo w/ovarian cysts and fibroids…you performed a myomectomy and right oophorectomy. Comment/conclusion by panel read as follows, "…the performance of a myomectomy and uterine reconstruction in such a patient is not generally accepted as a procedure of choice. Most gynecologists given this situation would perform a total abdominal hysterectomy." My concern, of course, is that this panel was attempting to force the performance of hysterectomy on patients who do not desire that procedure. Could you share your impressions?
Dr. West	If I am not mistaken, the original hearing panel only criticized me for not documenting and for doing a myomectomy. Certainly if you are operating for, in this case an ovarian cyst, and you see a condition easily fixed, I believe it is incumbent upon the surgeon to fix it. Certainly the patient should be the final choice as to what is done to her body.
Eaaaw	…but they recognized patient preference as a factor, too. The "higher incidence of myomectomy indications" is not surprising. Can you tell us anything about the percentage of patients who with myomectomy surgeries who expressly have stated this preference?
Carla Dionne	The original hearing panel, under "General Discussion" stated, "…his selection of patients for myomectomy was sometimes questionable."
Eaaaw	Yes, but in the light of what? Compared to the national average? Or, given contraindications?
Dr. West	All my patients express a preference for myomectomy. Since I am known for being able to perform myomectomies, my patient population is slanted. Over all, however, most patients decide on whatever their gyn says. Also many gyns feel that a woman not preserving her uterus for child bearing should only have a hysterectomy in the face of fibroids. In patient F the surgery was done soley for a large ovarian cyst of questionable malignancy. The myomectomy was an incidental procedure done only because I was in the neighborhood. The panel questioned doing a myomectomy only because they felt that at age 48 hysterectomy was the preferred surgery.
Carla Dionne	I guess, in regard to patient F, my concern was that on one hand the panel said major gyn surgery was not indicated as no symptomatic complaints were noted in the medical charts…while at the same time suggesting that a total abdominal hysterectomy should have been performed. Seemed a bit duplicitous to me….
Discover20012003	What are the symptoms of calcified fibroids?
Dr. West	Calcified fibroids can produce a number of symptoms, but the most common is pain.
Discover20012003	How do calcified fibroids affect bleeding? I mean bleeding over a long period after the calcification process during monthly periods?
Dr. West	Calcified fibroids cause bleeding in the same way as noncalcified fibroids.
Libarias	Do calcified fibroids pose more problems during surgery? Are there an abdominal myomectomy and a vaginal?
Dr. West	Calcified fibroids pose no more problems than any other. There are three ways to do a myomectomy: abdominally, vaginally, or laparoscopically.
Discover20012003	Sorry…so what creates changes in monthly bleeding for fibroidians…that is bleeding for a much shorter period of time (when in the past excessive bleeding lasting much longer)?
Dr. West	Changes in bleeding can be from different causes. You need to be seen to correctly evaluate your situation.
Chiweeluther	I was informed by a doc that my 8cm fibroid at the fundus could not be removed hysteroscopically. Would you agree?
Dr. West	Yes, if the instrument cannot be passed behind the tumor.
Chiweeluther	Have you removed large fibroids at the fundus hysteroscopically? How large?
Dr. West	A large fibroid cannot be removed hysteroscopically, because even in stages it usualy cannot be reached.
Folkwarepottery	Why can't a large (9cm) submucosal fibroid be removed hysteroscopically, if even in stages. Or, can it?
Dr. West	Hysteroscopic myomectomy requires that the surgeon can get behind the attachment of the fibroids.
Kerie0408	I am interested in finding out whether I am a candidate for laparoscopic myomectomy. I do not know where to turn for this info other than to talk to a lot of doctors. If it turns out that I need open myomectomy, I am more likely to just opt for UAE.
Libarias	What determines if laparoscopic myomectomy is indicated?
Dr. West	Laparoscopic myomectomy is indicated depending upon several factors, and mostly the experience of the surgeon.
Carla Dionne	Dr. West, this 90 minute chat has quickly turned into a two hour chat and I wish to thank you for your time and energy in joining us here today. I think we'll cut off questions for now and, perhaps, discuss the possibility of hosting another chat in the near future. If, that is, you have the time and would be gracious enough to spend it with us another day.
Dr. West	Thank you all for joining me in this most interesting chat. I look forward to perhaps a repeat.