My Visiting Professorship in Cape Town and helping to finance the NHS
During Blair’s premiership, the Government was very keen on the concept of PFI (that is the private financing initiative). We now know that this was pretty disastrous and meant that private firms would give the Government money up front taking debt off their books but then they would have to pay punitive interest down the line. In the early part of the Blair years, I gave an interview to a Civil Service magazine read by the Chief Executive of my NHS Hospital in which I said two things: 1) that I did not think that the private finance initiative was a good thing and expressed the view that private hospitals should be integrated into NHS hospitals so that the doctors working in the hospital could move from one sector to the other easily and that 2) the money and profit from the private hospital should be pumped into the integrated NHS hospital. Unfortunately this interview did not go down well with the ‘powers that be’ and in particular the Chief Executive of my hospital was very angry about the interview. I also criticised the concept that the NHS was the envy of the world when every external assessment of NHS waiting times, in hospital infection rates, cancer survival rates, emergency treatment and care of the elderly, showed the NHS to be one of the worst health service providers compared to most western European countries, USA, Canada and Australia. Only last month the OECD produced damning figures on the comparison of the NHS to other first world services. I say this because it is the true situation. Personally, I have always supported the NHS working on a maximum part-time contract from 1981-2005 and for the last 8 years have worked four sessions a week for the NHS voluntarily for no remuneration.
At around the time of the PPI controversy, I proposed a way for my NHS hospital to increase its revenue. There was a privately owned MRI scanner on the land owned by my NHS hospital. I knew that the American company that owned it wanted to pull out of the UK and I put forward a proposal (which would have been agreed by the US company who I had already talked to) for the NHS hospital to take over the MRI scanner at very low cost and to pay for the leasing of a new MRI scanner which would only have taken two private patients a week. Once again, this option was rejected by the same Chief Executive and also unfortunately by my radiological consultant colleagues. It then transpired that MRI scanning boomed massively and had the NHS hospital carried out the proposal it would have made millions of pounds in profit which could have been used to treat more NHS patients.
You might wonder who opposed the integration of private hospitals into the NHS sector and the answer is surprising. Firstly, and obviously, it is the private insurance companies who of course would lose money as such integration would reduce their client base. Secondly, the consultants themselves and thirdly the politics of the NHS which is of course essentially philosophically anti the private sector.
How does this connect with my Visiting Professorship to Cape Town University? Well, last year I was invited as a Visiting Professor to Groote Schurr Hospital in Cape Town where I spent two weeks teaching fibroid embolisation. Although qualifying as a doctor in the UK and the Middlesex Hospital in Soho (which is now a block of flats) I trained in radiology at Groote Schurr which is part of the University of Cape Town. That particular hospital has recently built a new private hospital which is attached to Groote Schurr Hospital, which is a huge teaching hospital. The profits from that private hospital are injected into the state hospital. Doctors can move freely from place to place making it much easier to look after patients in both sectors and profits and payment to the doctors is pooled. So far, the concept seems to be working despite problems which relate to the political situation in South Africa.
Fibroid embolisation has a huge potential in South Africa as African women have such a high incidence of fibroids and it is a more aggressive disease. However, it has been very slow to gain acceptance. I will be lecturing in Johannesburg in January next year so perhaps I can help to encourage the service provision there.
Hormone Replacement Therapy and Fibroid Embolisation
Many patients who have problems with fibroids in their 40s are only advised a hysterectomy and sadly all too often fibroid embolisation is not discussed with them by the gynaecologists. Because of this, many patients delay treatment hoping that post-menopausally the fibroids will shrink. This is a myth and post-menopausally most fibroid masses remain the same; some do shrink if the blood supply to the fibroids is tenuous but that situation is unusual. For this reason, we not infrequently perform fibroid embolisations on women in their sixties who have persisting fibroid masses in their abdomen.
Another disadvantage, of course, of not having your fibroids treated pre-menopausally is that after the menopause you may have persisting fibroid problems if you choose to go on hormone replacement therapy, as this can feed the fibroids. A great advantage of fibroid embolisation is that it kills all the fibroid mass at one hit in the overwhelming majority of cases. This is also an advantage over something called MRI guided ablation of fibroids which is very limited in the fibroids it can treat and appears in many cases to cause only a partial improvement leaving viable fibroid tissue behind.
Women who have fibroid embolisation pre-menopausally can be satisfied that after the menopause they can go onto hormone replacement therapy with impunity. Hormone replacement therapy is continually being improved and indeed there is a new product coming out on the market which may actually help protect against breast cancer currently being approved, I gather, by the FDA.
The myth of fibroid shrinkage after the menopause
Unfortunately I am seeing too many women who leave their fibroids and do not get them treated when they are relatively easy to treat allowing their fibroid masses to grow and hoping that after the menopause (because their GP, and in some cases gynaecologist, tell them) that the fibroid mass will shrink. This is a myth. Doctors who perform ultrasounds on patients, as I do, follow up these fibroids post menopausally and in the majority of cases they stay the same. They cannot grow, assuming the patient is not on hormone replacement therapy, but they often remain the same and so the patient may have a persisting unsightly lump. Also if they are then put on HRT, patients may suffer side effects and further growth of the fibroids.
Some of the women who do not have their fibroids treated are simply afraid of surgery, others have had previous surgery, such as myomectomies, and are very frightened of undergoing further major surgery. In my opinion, the sooner symptomatic fibroids are treated the better. The earlier they are treated, the easier they are to treat and the quicker the quality of life for the patient will be improved as a result of therapy.
Submucous fibroids and heavy bleeding
Fibroids cause different symptoms, sometimes they simply cause an enlarging lump in the pelvis, extending into the abdomen giving rise to what we call compression syndrome which is frequency of urination, bloating of the abdomen, distension of the stomach (with a cosmetically unsightly protuberance), sciatica, constipation and other symptoms. In other cases, fibroids cause very heavy bleeding leading to anaemia and debilitation. Sometimes both symptom patterns are present.
In this post we are going to talk specifically about submucous fibroids. These are fibroids which although developing in the wall, are very close to the endometrium and bulge into the cavity of the uterus to a variable degree. The problem with this type of fibroid is that they invariably cause very heavy periods: they grow under the influence of oestrogen and the periods get worse and worse, the anaemia becomes more and more problematical and the quality of life for the patient is progressively impaired. Gynaecologists may try treatments such as the Mirena coil or endometrial ablation where the lining of the womb is burned off, but these rarely or never work in the case of submucous fibroids. The best treatment for these fibroids, if they are not small and cannot be resected hysteroscopically, is fibroid embolisation. This procedure is very rapidly effective, the fibroid is killed and shrinks and patients normally feel completely cured within three months of the procedure.
Sometimes, these submucous fibroid detach from the wall of the uterus and the uterus starts to contract to pass them out. Because these fibroids are dead, they can be easily removed hysteroscopically leaving the patient, if that is the only problem, with a normal uterus. In the main though these fibroids will simply die and shrink. The success rate of fibroid embolisation in these patients (plus or minus hysteroscopic resection) is well over 95%. Very often I see patients who have staggered on with these symptoms, in some cases having multiple blood transfusions, because they have only been offered hysterectomy by the gynaecologist. These patients are rapidly cured by embolisation and are always very pleased with the procedure and wonder why they did not have it before.
The moral of the story is: If you have this type of fibroid, which can be easily classified on ultrasound or MRI study, don’t delay treatment and, unless that fibroid is very small and can be resected easily hysteroscopically, fibroid embolisation is rapidly curative and life transforming.
Adenomyosis and Fibroids
Not infrequently, I am referred patients with a diagnosis of fibroids, particularly in ultrasound diagnosis, and when I scan the patient I find that the main problem is a condition called adenomyosis. Obviously, this condition is much less common than fibroids but invariably causes quite severe symptoms which gradually get worse. It is a condition in which the cells from the lining of the womb migrate into the muscle of the womb leading to pockets of endometrium, i.e. the womb lining in the muscle of the womb. Increasingly, we are using fibroid embolisation to treat this condition and details can be found on my website. The efficacy of fibroid embolisation for adenomyosis, for which the usual treatment is hysterectomy, is not a high as it is for fibroids. The literature, including our own paper, shows that you can cure around 50% of patients with one embolisation. In the case of the other 50%, although they may have an initial improvement, the heavy periods gradually return and they require a second embolisation which will usually cure a further percentage. Although often you can diagnose most adenomyosis on ultrasound, the best method of diagnosing it is with MRI.
Before contemplating hysterectomy, I would certainly advise patients with adenomyosis to try a fibroid embolisation first as this may well solve the problem.
The Mirena Coil and Submucous Fibroids
The Mirena coil has been a great invention that in most instances effectively stops women having significant periods. The majority of patients with dysfunctional uterine bleeding i.e. bleeding for which there is no specifically definable cause, get enormous benefit from this device. Some women however do not do so well on it and may be sensitive to the progesterone etc. which it excretes.
This can also apply to patients who have submucous fibroids (that is fibroids which protrude into the cavity of the uterus and affect the lining of the womb) that cause heavy bleeding. Unfortunately, experience shows that the Mirena coil is ineffective in the majority of patients with submucous fibroids causing menorrhagia and also with significantly sized intramural (in the wall) fibroids which are causing heavy bleeding by increasing the size of the endometrial cavity. Again, these patients are best treated with fibroid embolisation after which a Mirena coil can be successfully employed to remove their periods. After fibroid embolisation, the Mirena coil should not be inserted for at least 6 months as otherwise there may be a danger of infection at the time of insertion of the device.
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Dr Walker to lecture in Johannesburg, South Africa in January 2016 following his previous Visiting Professorship in Cape Town. Fibroid embolisation is still not achieving its potential in South Africa yet.
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