Dr. Jay M. Berman is Assistant Professor of Gynecology at Wayne State University School of Medicine. He is in private practice in general and clinical gynecology. Actively involved in research, Dr. Berman is principal or co-investigator for several ongoing trials. His main area of interest is in operative laparoscopy, operative hysteroscopy including endometrial ablation and hysteroscopic sterilization, colposcopy, lower genital tract disease and laser surgery. He is also the principal investigator for an ongoing animal laboratory for training residents in laparoscopic surgery.
Uterus1: With dozens of medical specialties available, what made you choose obstetrics and gynecology?
Dr. Berman: I think it was something that happened in my junior year rotation on OB/GYN. Until that time, I was thinking about going into surgery; however, I found a specialty and a rotation where the physicians really seemed to be engaged in what was going on in their patients’ lives, on a much more personal level. I think that’s why I changed my mind and opted for a different path. There were many mentors that I identified with on that rotation – one of whom was Dr. Milton Goldwrath, the inventor of the hydrothermablator. The rotation really changed my thinking and set me on the career path that I eventually followed.
Uterus1: How do you feel the field has changed since you began practicing medicine?
Dr. Berman: I think there have been tremendous advances in terms of what we can offer patients in gynecology, as well as in obstetrics. Technology has allowed us to make great strides both in the types of surgeries that we can offer and how we teach those surgeries to our residents. At the same time, we’ve taken a more patient-oriented approach, encouraging them to participate in the decision-making process. We’ve really individualized the patient therapies and made the patient a participant in selecting those therapies. This was not common when I started out. Plus, we have way more to offer, both surgically and in terms of medical therapy. We have a ways to go in making sure that it spreads to medical practices throughout the country. That’s part of what we try to do from an education perspective in training our residents to think that way.
Uterus1: What is endometrial ablation and how many techniques are there?
Dr. Berman: Endometrial ablation is a group of techniques to remove the lining of the uterus to reduce a patient’s bleeding to more normal levels or even to eliminate bleeding completely. The first successful method was published in 1981 by Dr. Goldwrath who was my mentor when I was a resident. There had been many methods tried in the preceding 75 to 100 years, none of which had been successful. But technology made this a practical method that could be applied with a hysteroscope without a major incision. Around 10 years after that, an electrical method called rollerball was approved for use. Rollerball allowed a lot more physicians to offer endometrial ablation to their patients.
I think part of it was the patients’ participation in the decision-making and the patients’ desires to reduce the invasiveness of the surgical procedures that drove these new techniques forward. Patients were getting very good results from essentially an out-patient procedure where they could resume their normal lives much faster than if they had a traditional vaginal hysterectomy, an abdominal hysterectomy, or even an laparoscopic hysterectomy. In the late 90s, several other methods were approved including the hydrothermablator, the balloon, the cryoblation method, and the microablation method. They really provided a third wave of interest in endometrial ablation because they required much less technology equipment and were available to more and more gynecologists who could provide these services at the same time patients were asking for them.
Uterus1: What is the hydrothermablator technique and for how long has it been around.
Dr. Berman: The hydrothermablator procedure (HTA) was approved in April of 2001, but it had been under investigation for about seven or eight years. Dr. Goldwrath got me involved in the research in the very early stages. It is a method to bring endometrial ablation to more gynecologists who were not doing operative hysteroscopic surgical procedures but were doing basic diagnostic hysteroscopy. It involves placing a hysteroscope inside the cervix, viewing the endometrial cavity, and then gradually heating up saline solution until four or five millimeters of the endometrial lining are destroyed to reduce the patient’s bleeding. There have been many studies over the last 20 years that show that 4 or 5mm is the depth that you need to be.
The unique feature of this device is that you can see what you’re doing the entire time and, because the fluid isn’t contained in any type of shaped device, it will flow into any size or shape uterine cavity and apply the heat evenly to all those areas – something that can be really difficult to do with traditional rollerball methods or any of the devices that have a shape built into them like the balloon or the bi-polar electrical devices. So it really affords the opportunity to treat any size or shape uterine cavity. It can also be used to treat mild abnormalities of the uterus which are difficult to do with the shaped devices or the traditional methods. HTA is also something that is applicable to being used in the office or on an outpatient surgery basis. The success rate is very good and the complication rate is extremely low.
Uterus1: How and why was this new technique developed?
Dr. Berman: HTA was developed because Dr. Goldwrath, who is a great innovator in gynecologic technique, was looking for a method that could be easily taught and was extremely safe to produce endometrial ablation without the equipment-intensive problems of laser surgery or traditional rollerball surgery. I think there’s been a very slow rise in these endometrial ablation techniques, primarily because they were a little bit difficult. Both the laser and the rollerball have a very steep learning curve so you have to be very experienced to be good at it. The hydrothermablator is much easier to teach. Other than the instrument itself, it doesn’t require much else in regard to technology in the operating room. It’s a very simple procedure that requires the ability to place the hysteroscope in one position in the uterine cavity and not have to move it around. Really, the control panel and the machine do the rest of the work.
Uterus1: How does the saline solution at 90 degrees Celsius not burn the uterus?
Dr. Berman: The ingenious feature of the hydrothermablator machine is that the inflow pressure is kept at about 50 to 55 millimeters of mercury. The pressure required to force fluid out the tubes is at least 70 millimeters of mercury.
So if you keep the pressure low – and the machine won’t let you go above that pressure – the fluid does not come out the tubes. We demonstrated this in the first two phases of the clinical trial where we actually looked at the tubes during the procedure through a laparoscope.
The hydrothermablator device is held in place in the cervix to prevent the solution from leaking out through the cervical end. Even in the event that some of the fluid does come out the tubes, by the time it reaches the end of the tube, it’s down to 42 degrees Celsius which is really not harmful because you don’t notice any increase in the patient’s body temperature. We are quite confident that if done properly, and if doctors follow the recommendations for the height of the fluid about the uterine cavity, fluid won’t come out the tubes. There are no controls that would allow you to increase the pressure … and no doctor override … It’s a doctor-proof control panel.
Uterus1: What are the expected outcomes for the hydrothermablator technique?
Dr. Berman: The clinical trial has, at three years, about 60 percent of patients with no periods, about 20 percent with light periods, and 20 percent with normal periods. The procedure takes about a half hour in experienced hands and has excellent results. The recovery time is somewhere between one and five days. I would say the majority of patients are back to normal in 48 hours after the procedure with some minor discharge that last up to three or four weeks, but doesn’t interfere with their day-to-day activities. This is a dramatic improvement for the vast majority of these patients that are coming in for this procedure.
Uterus1: Who is the ideal candidate for HTA?
Dr. Berman: The perfect candidate for HDA is a woman in her 30s or 40s who has finished childbearing and who has no further plans to have children under any circumstances. She tends to have heavy menstrual periods for three, four or five days out of the month that interfere with her work or exercise activities. Although she can be very anemic, the perfect candidate generally has no other significant gynecologic problems.
We do have some patients that have bleeding disorders – inherited bleeding disorders or medication-induced bleeding problems. We can also use HTA to treat them without subjecting them to major surgery.