Cynthia K (not her real name) of
Toronto has suffered from heavy menstrual bleeding for
years. A hysterectomy's the surest way to solve the
problem, but even though Cynthia doesn't want more kids,
other health problems make the surgery too risky. Ditto
for hormones, so OCs and the new hormone-releasing IUDs
are out too. Her ob/gyn said he had nothing left to
offer her.
Cynthia's sister, a nurse, has
the same problem and underwent a relatively new procedure
called endometrial ablation, which has an 85% success
rate and can be done under local anesthetic. She was
happy with the results and advised Cynthia to try it
too. Cynthia's ob/gyn didn't know about it, but did
a little digging and called her back with some shocking
news: even if he knew how, he (or indeed a qualified
colleague) wouldn't be able to do the ablation because
his hospital had reached its yearly quota for that procedure.
As many as 30% of women suffer
from abnormal bleeding, according to the Society of
Obstetrics and Gynecology of Canada (SOGC). The organization
recognized endometrial ablation — a procedure where
the lining of the uterus is destroyed — as a safe
and effective treatment in 2001. But according to Dr
Nicholas Leyland, chief of ob/gyn services at St Joseph's
Health Centre in Toronto, it's nearly impossible to
find someone to do it. The crux of the problem, he says,
is not so much a lack of trained physicians — though
that certainly doesn't help — but access.
Under the current healthcare system
in Ontario, an endometrial ablation has to be performed
in a hospital setting or the province won't cover the
cost of the equipment needed for the procedure. "And
the operating room in Canada is certainly not something
I would call 'easily accessible'," notes Dr Leyland,
who does ablations in his office. "I believe in the
public system, but it's just not equipped to respond
to new technologies like this."
ABLATION
101
Endometrial ablation's hardly 'new' — it's been
used for twenty years as an alternative to hysterectomy
to treat pure menorrhagia, or excessive bleeding. Traditionally,
the procedure is done with a hysteroscope — an
endoscope used to visualize the inside of the uterus
— while the endometrium is destroyed by one of
several surgical techniques. In the late 90s, 'global'
ablation was introduced as a simpler alternative. Disposable,
single-use devices were developed that rely on either
heat or cold to destroy the uterine lining and require
only local anesthetic. A number of different systems
have been developed since — using lasers, microwave
therapy, electrocoagulation or extremely hot water.
They sell for between $600 and $1,000.
"These single-use devices are relatively
expensive, but the advantage is that they can be used
in an office or outpatient setting, so it's really far
less expensive than in a hospital environment, where
you have all the additional costs associated with the
OR, in-hospital recovery, etc." explains Dr Leyland.
ROCK,
MEET HARD PLACE
Unfortunately, it's an advantage that's not exploited
under the current system. It's a catch 22: if you don't
do the procedure in the hospital, there's no way to
cover the cost of the equipment. But since hospitals
operate under limited global budgets, there are only
so many they can pay for.
Most Ontario hospitals have capped
the number of ablations they do, as Cynthia found out
the hard way. When she finally found a physician who
would do it, he told her "I can't do any more this year.
I've already reached my quota."
Dr Leyland says it's not uncommon
for patients to hear that sort of thing. "I understand
our hospital budget so I can understand why it happens,
but that doesn't make it OK. The fact that these [ablation]
systems are being used in the OR is just ludicrous to
me. It's a complete waste of money."
"It's the cost that's a barrier,"
agrees Dr Guylaine Lefebvre, president-elect of the
SOGC. "If you do it in the office, patients would have
to buy the device. If you do it in hospital, you have
to convince the system to inject new money," she says.
IN
THE KNOW
There's a handful of physicians who, like Dr Leyland,
offer the procedure in their offices or clinics. But
they're few and far between. "The only reason I can
do it is because I get investigational devices from
the manufacturer," says Dr Leyland. That deal will run
out in a couple of months though, and then he'll have
no choice but to turn his patients away too. At least
he's got the experience to know where to send them.
Not all his colleagues do. "Part of the problem is that
most women will talk to their FP first, and many aren't
even aware that this is available." As a result, he
says, unnecessary hysterectomies are still common.
Dr Lefebvre doesn't buy that. "We
don't jump right in with hysterectomy anymore. It's
standard practice across the board for physicians to
inform women of all their options." Whether or not an
ob/gyn will actually do the procedure, she says, is
"an individual thing. You can't generalize."
STAND
ALONE
Dr Leyland thinks the solution is to establish free-standing
clinics, known as Independent Health Facilities (IHF).
"When you do a procedure like this, the cost goes down
if you do a lot and the quality improves," he says.
Under provincial law, you need
a licence to open an IHF. But those seem pretty hard
to come by. Dr Leyland's been trying for a couple of
years now, and he hasn't gotten anywhere. "The government
is reluctant to issue this type of licence because they
want to control cost. Clearly, we have to have good
clinical guidelines to determine who it's appropriate
for, but it's not a valid reason to basically withhold
the option."
According to John Letherby, a spokesperson
for the Ontario Ministry of Health, there are 930 licensed
diagnostic IHFs in the province, but only 25 treatment
facilities. None offer endometrial ablation.
To Dr Lefebvre, the most important
thing is for patients to have the choice. "Ablation
is not an alternative to hysterectomy, but an alternative
to managing abnormal bleeding. What no one is talking
about here is what women really want," she says. In
her experience, women choose to have a hysterectomy
because it's a permanent solution, and most are overwhelmingly
satisfied with the result.
As for Cynthia, she was eventually
referred to a doctor in another hospital that hadn't
yet met its ablation quota for the year. The results,
she says, are "fabulous."
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