Uterus1: Why did you choose obstetrics and gynecology, and how long have you been in this current practice named Devoted to Women?
Dr. DeFreese: I guess even in high school, and this sounds funny, I was fascinated by the dynamism and the ever-changing physiology of the female reproductive system. I mean it’s not the same everyday, it’s always different, and I always liked that.
Uterus1: Particularly in your field, there have been a lot of changes through the years. In your 19 years, what are some of the changes you’ve seen in terms of healthcare for women?
Dr. DeFreese: I think technology has really made a difference. We’ve seen ultrasound technology advance dramatically, and we’ve seen laparoscopy on the GYN part of things advance to where you can do almost everything that way. There’s been much more introduction of science and technology into our field.
Uterus1: Some physicians in certain states claim that rising malpractice costs are forcing them out of your profession. Have you felt similar pressure, and how does the malpractice situation impact your practice and your commitment to staying in this field?
Dr. DeFreese: Well, mainly here it’s been an increase in cost. In other words, what you see are costs going up every year as far as malpractice insurance even if you don’t have any claims. As far as what happens in Florida, we just have people leaving. It seems like every few months, there’s an OB/GYN that leaves here or quits practicing OB and you just don’t see new people coming in. That’s what I see, and of course what that does is puts more of a burden on the people who are doing OB to do more. It’s also made a difference—like around here, you don’t see physicians hiring new physicians or bringing new physicians in. Of course nobody in the rest of the country wants to come to Florida because of all of this dreadful stuff. So you see more midwives. That’s a real shift that’s taken place here, because when I first started here in Altemonte 16 years ago, there were no midwives delivering babies in the hospital. They were all in freestanding birthing centers, and now one works with me, the other groups have them, some groups have several, and patient actually prefer them—a very significant number of patients actually request and prefer [midwives].
Uterus1: Tell me more about your practice.
Dr. DeFreese: I would say our practice is pretty much evenly divided between OB and GYN. The nurse/midwife does the majority of the OB and I do all the GYN surgery. Most of my surgery is laparoscopy and hysteroscopy, and I am mostly treating patients with endometriosis, fibroids, adhesions, and heavy periods. Most of our surgery now is outpatient, so people really don’t stay in the hospital very long.
Uterus1: There were fewer options for treating these conditions in the past, with one of the only options being hysterectomy, but today there are less-invasive treatments that you are performing. Please explain.
Dr. DeFreese: Most surgeries used to be either a hysterectomy, or what we call laparotomy—where you make an incision and you go in and cut out whatever’s there and then close the incision back up. But of course that meant two or three days in the hospital, a longer recovery and more long-term complications. Whereas today, you can do sometimes even a two or three hour laparoscopy, and even though it’s a three hour procedure, patients still go home the same day. They recover more quickly; have fewer adhesions, less bleeding and such.
Uterus1: One procedure you perform often is endometrial ablation. Is this in the category of minimally-invasive surgery?
Dr. DeFreese: What I see are two areas. On the one hand, when somebody comes in with bleeding problems, you go through all the medical things. What I have to offer them now, as far as the endometrial ablation, is more palatable to people than, “Oh you have to have a hysterectomy.” On the other hand, there are a number of people who come in, who have heavy bleeding, who have researched [ablation] and said, “That’s the operation I want, I don’t want to have a hysterectomy if I don’t have to, I’ve read about it and I’ve researched it.” It’s nice to have a broader spectrum of things and less disruptive procedures to offer people. Plus, it’s nice to see people coming in who know what they want too.
Uterus1: When a patient comes into your office complaining of heavy bleeding or excessive menstrual pain, how do you do a diagnosis?
Dr. DeFreese: We do a blood count, check the thyroid, administer blood tests, and check the proactin level. And then we would also do a pelvic sonogram. That would tell us whether there were any fibroids or polyps, the size of her uterus, and the status of her ovaries.
Uterus1: How do you decide which procedure is best for a patient?
Dr. DeFreese: Well, it’s usually something you do in concert with a patient. There are some circumstances where there’s really only one choice if you want a cure. Where somebody has huge fibroids, you can only go in and remove those. You can’t go in and just ablate the endometrium and make things better. But most of the time what I do is sit down with them and explain this is what you have, these are the choices for your treatment—including both medical and surgical therapy—and with each one of them, talk about the good things and the bad things, the pros and the cons, so to speak, about it. And it depends on where somebody is. You’re gonna treat somebody who is 22, who hasn’t had kids, differently than you are somebody who is 40 years old and has already had their kids. And it also depends on patient preference. There are some people, who the hysterectomy is the last thing they’ll do, and they’ll do three surgical procedures before they do that; and there are other people who say, if I’m going to do something I’m going to do one operation one time and that’s it. It’s not like there’s one right thing for everybody—there are different things that are right for different people, depending upon their condition and their outlook.
Uterus1: What are the advantages and disadvantages of hysterectomy versus the ablation procedure?
Dr. DeFreese: The ablation procedure is an outpatient procedure, minimal pain, minimal recovery time and it’s highly effective in over 90% of people. The downside to it is that it’s not effective in 10% of people. That’s really about the only downside, especially with the technique we use. You can treat pretty much anybody, whether they have small fibroids in their uterus, whether they have polyps, or a large uterus, or a uterus that kind of has a funny shape—I mean you can treat anybody with that, so that’s the nice thing about the procedure. The downside is that it’s not effective in 10%, so in those people you have to go in and do something else. You have to do a hysterectomy. With the hysterectomy itself, the advantage of that is that it’s a cure—it’s 100% effective. The disadvantage is that it’s major surgery; it has more potential complications than the endometrial ablation, although it depends on the situation—where the person is in life and everything.
Uterus1: Please explain exactly how the endometrial ablation procedure is performed. What can patients expect the moment they walk through the door?
Dr. DeFreese: I usually tell people that they come to the hospital approximately two hours before the procedure and a nurse checks them in. The preparation is very simple. All they do is give them a gown, do paperwork with them, take their blood pressure, and go over or address any concerns that the patient has about surgery. They have one needle for blood work and one for an IV and that’s it. Then the anesthesiologist talks with them and reviews their medical history and any fears they have. I usually come along and talk to them to see how they feel and to answer any questions, and then we go into the operating room and that’s when they’ll get their general anesthetic.
Once they’re asleep we do an exam, we look at the cervix, sometime we have to dilate the cervix manually with little dilators to insert the hysteroscope—a scope used to look inside the uterus. Everything is done through the cervix, so the person does not get any incisions or cuts at all. What we do is insert this. It’s connected to a camera so we watch the whole thing on a monitor, and we can visualize the inside of the uterine cavity and look for polyps or fibroids or anything that distorts the area, and pay special attention to that. We take pictures so we can show what it looked like before we do the procedure and after we do the procedure.
What we do then is, according to the manufacturer’s protocol, we circulate a hot saline solution—it’s virtually 190 to 195 degrees Fahrenheit—inside the uterine cavity for about ten minutes. And what that does is essentially cooks and destroys the lining of the uterus. Many times, what we do is pre-treat the patient with a medication called lupron for about a month, that thins out the lining, and what that does is makes the procedure more effective. This is so that you’re more likely to have absolutely no periods afterwards or very minimal bleeding. What we do then is say, “complete the cycle, ” and the nice thing about this technique is that you can see all of this as you’re doing it. You know you’re visualizing it, you’re not just inserting an instrument in there blindly and either cauterizing the inside with electricity or using microwave or anything like that, so I feel safer doing that. The other nice thing is that you can treat the patient more thoroughly, since what you’re circulating in there is saline, which is essentially made up of water and salt. Water is obviously a very small molecule and it can get in every little crack and crevice that it has to. This is opposed to putting a balloon in, which of course is not going to have contact with every single part of the uterine cavity—because you can’t make a balloon that fits everybody.
There’s another technique that’s called the NovaSure® where they put this netting in the uterine cavity. They expand it, and you kind of have to work it around one way or the other. Again, it doesn’t have contact with every single part of the uterine lining. Then what we do is cool the fluid off, because this is very hot and we wouldn’t want that to burn the patient coming out, so we wait until the machine cools it off and then we take our final pictures. We then remove the scope. The patient wakes up, goes to the recovery room for about an hour and then goes to the extended recovery area for about two hours, and then she goes home. Most people afterwards have minimal pain. Once in a while someone will need a narcotic, but most people do just great with either Tylenol or ibuprofen. Most people have just a little bit of a watery-bloody discharge for just a week or two, but it is rare to have somebody call us up and say this stuff is really heavy, when is this gonna be over with—I mean it just doesn’t happen. With some of the older techniques that we used to do years ago—it was called roller ball ablation, some of the older techniques—you had more complications and you had more bleeding afterwards. It was just more problematic for people.
Uterus1: How long is the recovery period?
Dr. DeFreese: When people go home, it’s very common to see somebody go back to their normal activities within two or three days easily. I tell people you can do whatever you want to as long as it doesn’t hurt. I tell people I have never seen a serious complication from people going home and doing too much. I do tell them that sometimes if you’re really active, maybe you’ll get a little more bleeding, and it’s not a sign that you’re hurting anything, you’re just kind of making that tissue rub a little bit more. But it’s probably your body telling you to kind of back off and slow down a little bit here, but otherwise people can swim, take a bath, shower, they can run, they can drive whenever they feel comfortable driving.
Uterus1: How long has the HTA (hydro-thermal ablation) procedure been practiced?
Dr. DeFreese: I don’t know precisely when it was approved by the FDA, but I would say right around five years or so. It’s a relatively new procedure, but you know you always have to put things in perspective too, because things come to Europe a lot earlier than they come here.
Uterus1: What is the recurrence rate of fibroids after endometrial ablation?
Dr. DeFreese: When we do endometrial ablation, we can treat someone who has fibroids that kind of distort the uterine cavity up to about 3 or 4 cm in size, and it treats that very effectively. I don’t think we have a good study that has followed people like that for five years to say what’s the recurrence of bleeding and such in people like that, but it’s still considered to be a reasonable treatment.
Uterus1: Just for clarification, is the uterus preserved, and does the menstrual cycle permanently terminate following the procedure?
Dr. DeFreese: In over 90% of people, you either have complete lack of a period afterwards or you have minimal bleeding. It is possible to become pregnant, but it is not advised because you’ve destroyed most, if not all the lining of the uterus, and the egg is going to grow in a place that’s not going to be good. It’s going to grow up in the top of the uterus close to the fallopian tube where it can rupture, or the lining itself is just not going to be healthy and it’s not going to sustain a pregnancy. So we also tell people to not count on this to be a method of birth control.
Uterus1: What advice do you have for patients considering this procedure or any procedure involving the reproductive organs?
Dr. DeFreese: Well, I guess the thing that I tell people, whenever I’m uncertain about what to do I figure I need more information, so the best thing people can do is research it on the Internet. I really think that’s about the best way these days, because a lot of times when you talk to friends you get the anecdotal information. And even on the Internet, you have to look at what the source is—is it just a bulletin board where people are posting their opinions, or is it a presentation of scientific facts? Because there’s a big difference between an anecdotal account and a randomized controlled trial. That’s what I tell people, is just really to get more information. They can talk with their doctor, go in for consultation and ask, what are my choices. If somebody doesn’t give you choices, then talk to somebody else, because there are always choices.
Uterus1: Looking ahead, are there any experimental procedures or research being conducted that you see as being very promising for the treatment of fibroids or any other gynecological condition?
Dr. DeFreese: You know, you see a lot of things—there’s microwave, there’s cryotherapy, and you know there are a lot of different techniques out there. But sometimes you just have to wait and see, give it time and see how things pan out. Even when they introduced uterine artery embolization a few years ago, everybody thought it would just entirely replace surgery, and it really hasn’t. It has its problems too. Of course people are doing research in the medical therapy of fibroids, trying to shrink them. I’ve seen people over the years put these little needles down into the fibroids and try to zap them and make them go away, but these things just don’t seem to pan out, so I think we’ll just have to wait and see which technology ends up being the best. Sometimes you have not just one technology being the best, but you have one is better for this type of condition, and another one is better for that type.
Uterus1: In talking to your staff, they have nothing but praise for you, and one of them mentioned that you recently won the Care Award for the Florida Hospital Systems. Tell me more about the award.
Dr. DeFreese: Every year, Florida Hospital solicits nominations from their doctors, nurses, and employees for physicians in different categories. One of them is integrity, one of them is care, one is stewardship, things like that, and they give out these awards based upon who they think is best in that category, and I guess that’s what I got it for—I got it for caring.