2020 Symposia Series 1 Reducing the Burden of Endometriosis: The - - PowerPoint PPT Presentation

2020 Symposia Series 1

Reducing the Burden of Endometriosis: The Role of Primary Care

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• Use a thorough clinical assessment to evaluate patients for endometriosis
• Integrate appropriate first-line therapies for pain management and other

aspects of endometriosis based on patient factors and preferences

• Implement strategies to improve the long-term care of patients with

endometriosis, including multidisciplinary coordination

Learning Objectives

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• Prevalence in general population difficult to

assess; many women have limited or no symptoms

• Highest incidence in women aged 25 to 29 years
• Prevalence among women:

̶ Of reproductive age: 6% to 10% ̶ With infertility: 20% to 50% ̶ With chronic pelvic pain: 71% to 87% ̶ Adolescents with pelvic pain: 57%

• No clear racial predisposition

Epidemiology of Endometriosis

American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Janssen EB, et al. Hum Reprod Update. 2013;19:570-582; National Institutes of Health. www.nichd.nih.gov/health/topics/endometri/conditioninfo/at-risk. Accessed April 22, 2020; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

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Patient Burden

• Associated cognitive, behavioral,

sexual, and emotional consequences

• May cause infertility
• Potential precursor to clear-cell and

endometrioid ovarian carcinomas

Burden of Endometriosis

*For chronic pelvic pain, including endometriosis. Brawn J, et al. Hum Reprod Update. 2014;20:737-747; Burney RO, Giudice LC. Fertil Steril. 2012;98:511-519; Nezhat F. www.mdedge.com/obgyn/article/107567/gynecologic-cancer/managing-endometriosis-prevent-ovarian-cancer. Accessed April 22, 2020; Schrager S, et al. Am Fam Physician. 2013;87:107-113; Soliman AM, et al. J Manag Care Spec Pharm. 2019;25:566-572.

Healthcare Burden

• 3rd leading cause of gynecologic

hospitalizations

• 2nd leading cause of benign

hysterectomy*

• Increased healthcare costs:

‒ Estimated $11,686 annual cost in the year after diagnosis vs $5216 in women without endometriosis

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Pelvic Pain Definitions

Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Brawn J, et al. Hum Reprod Update. 2014;20:737-747; Practice Committee

• f the American Society for Reproductive Medicine. Fertil Steril. 2014;101:927-935.

Dysmenorrhea

• Painful menstrual cramps
• f uterine origin
• Pain is limited to time of

menstrual bleeding Chronic pelvic pain

• Noncyclic pain
• ≥6 months’ duration
• Localizes to anatomic pelvis,

anterior abdominal wall at or below umbilicus, lumbosacral back, or buttocks

• Of sufficient severity to cause

functional disability or lead to medical care

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Possible Causes of Chronic Pelvic Pain

• Functional bowel disorders

⎻ Chronic constipation ⎻ IBS

• Inflammatory bowel disorders

⎻ Crohn’s disease ⎻ Ulcerative colitis

• Chronic appendicitis
• Hernias
• Diverticular disease
• Intermittent bowel obstruction

Gynecologic Urologic Gastrointestinal Musculoskeletal

• Endometriosis
• Adenomyosis
• Adhesions
• Chronic PID
• Leiomyoma/fibroids
• Pelvic congestion
• Ovarian remnant
• Interstitial

cystitis/painful bladder syndrome

• Urethral syndrome
• Chronic UTI
• Kidney stones
• Pelvic floor myalgia
• Trigger points
• Low back pain
• Lumbosacral disc

disease

• SI joint disease
• Coccydynia

PNS & CNS

• Peripheral nerve

injury

• Central pain

disorder

IBS = irritable bowel syndrome; PID = pelvic inflammatory disease; PNS = peripheral nervous system; SI = sacroiliac; UTI = urinary tract infection. As-Sanie S, et al. Am J Obstet Gynecol. 2019;221:86-94; As-Sanie S, et al. Pelvic pain. In: Managing Pain: Essentials of Diagnosis and Treatment. 2013:408-429; Biggs WS, et al. J Fam Pract. 2018;67:E1-E9; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116.

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• An inflammatory, estrogen-dependent disease defined by the presence of

endometrial stroma and glands outside the uterus

Endometriosis Definition

Endoscopic images courtesy of Kristin E. Patzkowsky, MD.

Stage 4 Endometriosis Normal Pelvis Histologic Diagnosis Made by Surgical Biopsy Uterus Endometriosis Bowel

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Pelvic pain + dysmenorrhea + dyspareunia, 34.4% Pelvic pain + dysmenorrhea, 25.2% Dysmenorrhea

• nly, 12.7%

Pelvic pain

• nly, 6.5%

Dysmenorrhea and dyspareunia, 6.5% Dyspareunia

• nly, 0.7%

Pelvic pain and dyspareunia, 3.3%

• Variable symptoms, including

variable degrees of: ‒ Dysmenorrhea ‒ Dyspareunia ‒ Dyschezia ‒ Chronic pelvic pain ‒ Infertility

• Or may be asymptomatic

Endometriosis Symptoms and Diagnosis

Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Bruse C. endometriosforeningen.com/wp- content/uploads/2018/08/uppdated_150401_english-endometriosis-pink-pamphlet.pdf. Accessed April 22, 2020; Kuznetsov L, et al. BMJ. 2017;358:j3935; Sinaii N, et al. Fertil Steril. 2008;89:538-545.

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• Current theories of how endometrial tissue reaches locations
• utside of the uterus

‒ Retrograde menstrual flow ‒ Coelomic metaplasia ‒ Lymphatic spread

• Other likely contributing factors

‒ Immunologic defects, alterations in cell adhesion and inflammatory milieu ‒ Neovascularization needed for implant to establish and grow ‒ Process driven by systemic and local production of estradiol ‒ Modulated by genetic and environmental factors

Endometriosis Pathogenesis and Growth

Giudice LC, Kao LC. Lancet. 2004;364:1789-1799; Kasinecz A. u.osu.edu/endometriosis/2014/10/20/endometriosis-case-study/. Accessed April 22, 2020; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116; Practice Committee of the American Society for Reproductive

• Medicine. Fertil Steril. 2014;101:927-935; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

Endometrial tissue Retrograde menstrual flow

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• Pain symptoms do not correlate with extent/location of endometriosis implants,

inflammatory markers, or nerve fiber density surrounding lesions

• Pain may recur after medical and surgical therapy
• Pain perception may result from inflammatory environment within the pelvis
• Untreated, persistent pelvic pain likely contributes to development of central

sensitization ‒ Excessive sensory awareness can develop across a number of body systems unconnected to any overt tissue damage ‒ Can explain common comorbid syndromes characterized by pain

Endometriosis and Pain Symptoms: An Uncertain Relationship

Agarwal SK, et al. Am J Obstet Gynecol. 2019;220:354.e1-354.e12; Brawn J, et al. Hum Reprod Update. 2014;20:737-747; Bullones Rodriguez MA, et al. J Urol. 2013;189:S66-S74; Burney RO, Giudice LC. Fertil Steril. 2012;98:511-519; Chapron C, et al. Nat Rev

• Endocrinol. 2019;15:666-682; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

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Importance of Early Diagnosis of Endometriosis

• Average 7 to 12 years and 5+ clinicians before diagnosis—why?

⎻ Early onset of symptoms ⎻ Normalization of menstrual and abdominal pain by patients and clinicians ⎻ Intermittent use of contraceptives causing suppression of some symptoms ⎻ Variable presentation; may have nongynecologic symptoms

• Delays in diagnosis may:

⎻ Result in transition of pain from cyclic to daily, chronic pain and centralized

pain state

⎻ Lead to reduced fertility ⎻ Increase patient frustration and feelings of demoralization

Agarwal SK, et al. J Obstet Gynecol. 2019;220:354.e1-354.12; Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Chapron C, et al. Nat Rev Endocrinol. 2019;15:666-682; Hudelist G, et al. Hum Reprod. 2012;27:3412-3416; Kuznetsov L, et al. BMJ. 2017;358:j3935; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

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Case Study: Rachel

• 30-year-old legal secretary; married with a 5-year-old daughter
• Typical menstrual cycle starting at age 12 with only mild pain on the first day
• Progressively increasing pelvic and lower back pain (described as “killer cramps”)

that last between 1 and 3 days of each cycle

• NSAIDs of minimal help
• Unable to work for several days a month
• Would like to have more children

NSAID = nonsteroidal anti-inflammatory drug.

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Diagnosis of Endometriosis: History

• Pain history: location, quality, duration, frequency, impact on sleep, mood, activities of daily living,

what worsens and/or relieves pain

• Menstrual and reproductive history

⎻ Age at menarche; cycle length and flow characteristics ⎻ History of contraceptive use and any sexually transmitted infections ⎻ Pregnancies, miscarriages, abortions, attempts to conceive, lactation

• Family history: endometriosis and/or pain symptoms (“difficult periods”)
• Previous pelvic surgery
• History of benign ovarian cysts and/or ovarian pain
• History of other pelvic pain or irritative symptoms

Agarwal SK, et al. J Obstet Gynecol. 2019;220:354.e1-354.e12; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

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• Low BMI
• First-degree relative with endometriosis (up to 6-fold increased risk)
• Early menarche (<11 yrs)
• Late menopause
• Short intermenstrual interval (<27 days)
• Heavy or prolonged menstrual cycles (>5 days)
• Nulliparity
• Shorter lactation duration

Endometriosis Risk Factors

Agarwal SK, et al. J Obstet Gynecol. 2019;220:354.e1-354.e12; American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Ballard KD, et al. BJOG. 2008;115:1382-1391; Bloski T, et al. Nurs Womens Health. 2008;12:382-395; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116; Schrager S, et al. Am Fam Physician. 2013;87:107-113.

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Recommend a Pain and Symptom Diary for Patients Who Have Trouble Qualifying Their Pain

*Rate your pain on a scale of 1 to 10, where 1 = tolerable and 10 = worst imaginable; **Indicate whether symptoms affected your work, education, relationships, sleep, exercise, eating, sex life, stress level, or quality of life. Endometriosis UK. www.endometriosis-uk.org/sites/default/files/files/Information/pain-symptoms-diary.pdf. Accessed April 22, 2020; National Institute for Health and Care Excellence. www.nice.org.uk/guidance/NG73. Accessed April 22, 2020.

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Date During your period? Describe pain* and location How does it feel? How long does it last? Other symptoms (eg, bloating, bleeding, bowel, urinary problems)? Take or do anything to help? Did it work? What effect did it have

• n you?**

Mon Tues Wed Thurs Fri Sat Sun

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Diagnosis of Endometriosis: Physical Exam

• Findings may be unremarkable in early-stage

endometriosis

• Findings that suggest advanced endometriosis include:

⎻ Tenderness and nodularity of posterior cul-de-sac or uterosacral ligaments ⎻ Adnexal adhesions or masses, decreased uterine mobility, enlarged ovaries

Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Kuznetsov L, et al. BMJ. 2017;358:j3935; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116.

Does palpation cause pain?

• Similar to chronic or cyclic pain?
• Diffuse or focal?
• Correspond to anatomic

pathology?

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Case Study (cont’d): Making a Presumptive Diagnosis

• Rachel’s mother had endometriosis when she was young
• Physical exam findings:

‒ Abdominal: tenderness upon palpation of right and left lower quadrants ‒ Pelvic: pink, rugated vaginal mucosa; no cervical abnormalities or tenderness; 7-week size anteverted uterus, mildly tender with palpation, moderately mobile, no adnexal masses appreciated, mild tenderness with palpation of left adnexa ‒ Rectovaginal: smooth rectovaginal septum, without nodularity of the uterosacral ligaments

• Normal pelvic ultrasound results
• History, reported symptoms, and exam are consistent with possible endometriosis

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• Currently, no imaging or laboratory study that can

routinely diagnose endometriosis ‒ Imaging (ie, ultrasound, MRI) can be useful in diagnosing

• Large implants, including ovarian

endometriomas or DIE

• Adenomyosis

‒ Serum markers (CA-125, cytokines, MCP1, adhesion molecules) are nonspecific

• Consider CBC if concomitant anemia; urinalysis,

pregnancy, and STI testing if indicated

Diagnosis of Endometriosis: Imaging and Laboratory Studies

CBC = complete blood count; MCP1 = monocyte chemoattractant protein-1; STI, sexually transmitted infection. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Hsu AL, et al. Clin Obstet Gynecol. 2010;53:413-419; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116.

Ovarian Endometrioma on Ultrasound Ovarian endometrioma

Image courtesy of Kristin E. Patzkowsky, MD

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• Empiric hormone suppression is an appropriate first step before laparoscopy for

endometriosis in patients with normal imaging and without: ‒ Evidence of large ovarian mass or bowel/urinary tract obstruction due to deeply infiltrative endometriosis ‒ A current desire for pregnancy ‒ Red flags that might indicate a need for additional evaluation

• No evidence that medical treatments improve fertility

‒ Fertility eliminated during hormone-suppressive treatment

Medical Treatment Considerations

Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Bruse C. endometriosforeningen.com/wp- content/uploads/2018/08/uppdated_150401_english-endometriosis-pink-pamphlet.pdf. Accessed April 22, 2020.

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• Blood in stool
• New bowel symptoms after age 50
• Irregular vaginal bleeding after age 40
• Postcoital bleeding
• New pain after menopause
• Excessive weight loss
• Pelvic mass
• Suicidal ideation
• Change in character or severity of pain in a patient with a history of chronic pain

Red Flags

Speer LM, et al. Am Fam Physician. 2016;93:380-387.

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• Reduce pain
• Induce atrophy of eutopic and ectopic endometrial tissue
• Decrease prostaglandin production
• Reduce inflammatory status
• No overwhelming evidence for one treatment over others for pain relief; choose

treatment based on patient preference, cost, and side effects

• On average, 66% to 75% of patients report improvement in symptoms

Goals of Medical Treatment

Becker CM, et al. Fertil Steril. 2017;108:125-136; Bloski T, Pierson R. Nurs Womens Health. 2008;12:382-395; Ferrero S, et al. Drugs. 2018;78:995-1012; Ferrero S, et al. Expert Opin Pharmacother. 2018;19:1109-1125.

BUT medications are not cytoreductive; thus, recurrent symptoms are common after discontinuation and long-term therapy should be considered the norm

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Class of Agent Comments NSAIDs May help manage dysmenorrhea but not effective in treating endometriosis; epigastric side effects COCs Generally best tolerated treatment and highly effective; use monophasic formulation continuously to induce amenorrhea; contraindicated in: smokers aged >35 years; history of thrombosis; cardiac, liver, kidney disease Progestogens Well tolerated with few contraindications; multiple forms (eg, oral, subcutaneous, IUD); norethindrone is FDA-approved for endometriosis and can be used as monotherapy

First-line Options for Empiric Treatment of Endometriosis

FDA = US Food and Drug Administration; IUD = intrauterine device. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Dunselman GA, et al. Hum Reprod. 2014;29:400-412; Kavoussi SK, et al. Curr Opin Obstet Gynecol. 2016;28:267-276; Practice Committee of the American Society for Reproductive Medicine. Fertil

• Steril. 2014;101:927-935; Tafi E, et al. Exp Opin Pharmacother. 2015;16:2465-2483.

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• Pelvic floor, abdominal wall, and back myofascial pain highly prevalent in

women with endometriosis and pelvic pain ‒ Negatively affect urinary, genital, colorectal, and neuromuscular function ‒ Pelvic floor physical therapy can help treat such symptoms

• Acupuncture, exercise, electrotherapy, and yoga have demonstrated a

positive trend in relieving symptoms ‒ Only acupuncture has demonstrated significant improvement in dysmenorrhea

Nonpharmacologic Therapies

Foundational Concepts. www.foundationalconcepts.com/the-pelvic-chronicles-blog/treating-the-pain-of-endometriosis-with-pelvic-physical-therapy/. Accessed April 22, 2020; Mira TAA, et al. Int J Gynaecol Obstet. 2018;143:2-9.

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Case Study (cont’d): Next Steps

• Six months of COCs have provided some relief from

dysmenorrhea, but Rachel still has significant nonmenstrual pelvic pain

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• Reconsider the diagnosis and evaluate for other chronic overlapping pain conditions

‒ Chronic fatigue syndrome ‒ Chronic low back pain ‒ Fibromyalgia ‒ Interstitial cystitis ‒ IBS

• Increased risk of developing a new chronic overlapping pain condition as the number of

pain conditions increases

• Re-evaluate comorbid psychosocial variables

Considerations After Initial Treatment Failure

Chronic Pain Research Alliance. www.chronicpainresearch.org/public/CPRA_WhitePaper_2015-FINAL-Digital.pdf. Accessed April 22, 2020.

‒ Migraine ‒ Tension-type headache ‒ Temporomandibular disorders ‒ Vulvodynia

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Laparoscopy: Key Role in Endometriosis

• “Gold standard” for diagnosis of endometriosis and/or pelvic

adhesions and evaluation of adnexal masses

• Definitive diagnosis of endometriosis made by surgical biopsy

⎻ Histologic appearance: endometrial glands and stroma with varying amounts of inflammation and fibrosis ⎻ 54% to 67% of suspected endometriotic lesions confirmed histologically

• Goal of laparoscopy is to diagnose and treat identified

endometriosis

• 30% to 50% of diagnostic laparoscopies for pelvic pain are

negative

American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Hsu AL, et al. Clin Obstet Gynecol. 2010;53:413-419.

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• Laparoscopy with excision of endometriosis should be considered for

patients who: ‒ Wish to become pregnant ‒ Have pain that does not respond to medical treatment ‒ Have large endometriomas or palpable disease

Conservative Surgery for Endometriosis

American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Bruse C. endometriosforeningen.com/wp- content/uploads/2018/08/uppdated_150401_english-endometriosis-pink-pamphlet.pdf. Accessed April 22, 2020; Kavoussi SK, et al. Curr Opin Obstet Gynecol. 2016;28:267-276; Kuznetsov L, et al. BMJ. 2017;358:j3935; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116; Practice Committee of the American Society for Reproductive Medicine. Fertil Steril. 2014;101:927-935.

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Case Study (cont’d): Laparoscopic Findings

• Laparoscopic findings included scattered

powder-burn lesions of bilateral uterosacral ligaments

• Surgeon excised bilateral uterosacral lesions
• Pathology of both lesions was consistent with

endometriosis

• Diagnosis of stage 1 endometriosis confirmed

Image courtesy of Kristin E. Patzkowsky, MD

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Other Possible Laparoscopic Findings Associated With Endometriosis

Images courtesy of Kristin E. Patzkowsky, MD

Left uterosacral nodule Powder burn lesion near left round ligament/inguinal canal Erythematous patches of right

• varian fossa

Left ovarian endometrioma Stage 4 endometriosis Scarred right uterosacral ligament with deep endometriosis

Uterus Hematosalpinx & ovary Uterosacral ligaments Bowel Uterus Endometriosis

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ASRM Stages of Endometriosis

ASRM = American Society for Reproductive Medicine. Endometriosis Foundation of America. www.endofound.org/endometriosis-stages. Accessed April 22, 2020.

Minimal disease—few superficial implants Mild disease—more and deeper implants Moderate disease—many deep implants, small cysts on

• ne or both ovaries, presence of filmy adhesions

Severe disease—many deep implants, large cysts on one

• r both ovaries, many dense adhesions

Stage 1 (1-5 points) Stage 2 (6-15 points) Stage 3 (16-40 points) Stage 4 (>40 points)

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GnRH Agonists GnRH Antagonist

• Bind to GnRH receptors in pituitary gland →interrupt pulsatile

stimulation → desensitize GnRH receptors

• Suppress LH and FSH → decreased estrogen/progesterone
• Blocks GnRH receptors in pituitary gland
• Suppresses LH and FSH → decreased estrogen/progesterone
• Injection
• Oral
• Anti-estrogenic AEs are common
• May increase serum lipids and cause bone loss
• Add-back hormonal therapy decreases bone-loss risk
• Anti-estrogenic AEs are dose dependent
• Dose-dependent increase in serum lipids and bone loss
• Add-back hormonal therapy recommended for higher doses;

decreases bone loss risk

• Duration typically limited to 6 to 12 months
• Duration typically limited to 6 to 24 months
• Not a form of contraception (need barrier or hormonal therapy)

Second-line Agents to be Prescribed at the Gynecologist’s Discretion

AE = adverse event; FSH = follicle-stimulating hormone; LH = luteinizing hormone. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Dunselman GA, et al. Hum Reprod. 2014;29:400-412; Kavoussi SK, et al. Curr Opin Obstet Gynecol. 2016;28:267-276; Orilissa [prescribing information]. AbbVie Inc; 2019; Practice Committee of the American Society for Reproductive

• Medicine. Fertil Steril. 2014;101:927-935; Tafi E, et al. Exp Opin Pharmacother. 2015;16:2465-2483; Taylor HS, et al. N Engl J Med. 2017;377:28-40.

Both classes of agents cause sustained reductions in dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia

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• Elagolix, a GnRH antagonist, approved in 2018 for management of moderate to

severe pain associated with endometriosis

• Most common AEs:

‒ Hot flashes or night sweats, headache, and nausea

• Both 150-mg once-daily and 200-mg twice-daily dosages are effective
• Due to the dose-dependent increase in serum lipids and decrease in BMD:

‒ 150-mg dosage should be prescribed only for up to 24 months ‒ 200-mg dosage should be prescribed only for up to 6 months

Elagolix—A Recently Approved Option

BMD = bone mineral density. Orilissa [prescribing information]. AbbVie Inc; 2019; Taylor HS, et al. N Engl J Med. 2017;377:28-40.

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Danazol Aromatase Inhibitors

• Antiestrogenic
• Oral administration
• Androgenic side effects: oily skin, acne,

weight gain, deepening of voice (irreversible)

• Inhibit estrogen production
• Oral administration
• Must be given with COC or progestin to

prevent bone loss

• Only used for refractory pain
• Used off-label in endometriosis

Other Second-line Agents to be Prescribed at the Gynecologist’s Discretion

American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:223-236; Dunselman GA, et al. Hum Reprod. 2014;29:400-412; Kavoussi SK, et al. Curr Opin Obstet Gynecol. 2016;28:267-276; Practice Committee of the American Society for Reproductive Medicine. Fertil Steril. 2014;101:927-935; Tafi E, et al. Exp Opin Pharmacother. 2015;16:2465-2483.

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• Ethinyl estradiol/drospirenone flexible extended regimen

‒ In phase 3 for endometriosis-associated pelvic pain ‒ Similar to other COCs

• Relugolix

‒ GnRH antagonist ‒ In phase 3 for endometriosis-associated pain ‒ Similar to elagolix

Medical Therapies in Development

Harada T. Fertil Steril. 2017;108:798-805; ClinicalTrials.gov. clinicaltrials.gov/ct2/show/NCT03204331?cond=Relugolix&rank=4. Accessed April 22, 2020.

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• Consider for patients with persistent symptoms that do not respond to medical and

conservative surgical therapy, who do not desire future fertility, and who have attempted treatment for all sources of pain

• Should be combined with excision of all visible endometriotic lesions
• Bilateral oophorectomy not routinely indicated; decision should be made by surgeon and

patient with careful consideration of risks and benefits

• Hysterectomy not a guaranteed cure for endometriosis or pelvic pain

− 5% to 32% of women have persistent post-op pain − 1% to 15% have new or increased post-op pain

Hysterectomy: Key Points

Brandsborg B. Dan Med J. 2012;59:B4374; Bruse C. endometriosforeningen.com/wp-content/uploads/2018/08/uppdated_150401_english- endometriosis-pink-pamphlet.pdf. Accessed April 22, 2020; Kavoussi SK, et al. Curr Opin Obstet Gynecol. 2016;28:267-276; Kuznetsov L, et al.

• BMJ. 2017;358:j3935.

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• Women with painful endometriosis also

have issues with self-esteem, body image, and intimate relationships ‒ Impact their mental health and QoL ‒ Necessitate effective clinician-patient communication ‒ Require use of a multidisciplinary approach for long-term pain management

Collaborative Management in Patient Care

CAM = complementary and alternative medicine; QoL = quality of life. Facchin F, et al. Hum Reprod. 2017;32:1855-1861; Mao AJ, Anastasi JK. J Am Acad Nurse Pract. 2010;22:109-116. Exercise and diet Pharmaco- therapy Hormonal modulation Nerve blocks and modulation Surgery Physical therapy Treatment

• f mood

disorders CAM therapies Cognitive behavioral therapy

Education

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Overall Approach to Management of Endometriosis

• A chronic condition requiring long-term therapy

⎻ Mainstay of therapy: hormone suppression to induce hypoestrogenic environment; appropriate before and after surgical intervention ⎻ Approximately 10% to 20% of women with endometriosis will have disease recurrence with conservative treatment

• Evaluate all sources of pain; co-occurring pain conditions are highly prevalent
• Provide appropriate referral and collaborative management with a gynecologist
• Offer treatment according to patient’s symptoms, preferences, and priorities
• Ensure patient makes informed choices based on treatment benefits/risks,

tolerability, costs, provider experience, and expected adherence

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Case Conclusion

• After surgery, Rachel’s gynecologist prescribed a GnRH antagonist for 6

months with add-back hormonal therapy and barrier contraception

• She and her husband decided to try for a second child, so her gynecologist

discontinued hormonal therapy

• She gave birth to a son 16 months later
• Gynecologist recommended that she restart hormone suppression therapy

after she finished breastfeeding to mitigate a recurrence of symptoms

• Primary care clinician continues to follow Rachel in collaboration with her

gynecologist

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PCE Action Plan

✓ Establish diagnosis early to improve likelihood of treatment success ✓ Elicit an accurate, thorough history in patients with possible endometriosis, because symptoms are variable ✓ Conduct thorough physical exam that includes pelvic, abdominal, and rectovaginal palpation ✓ Refer to gynecologist for laparoscopy to confirm presence of endometriosis and excise lesions, if identified ✓ Offer individualized, patient-centered care using a multimodal approach and collaboration with a gynecologist

PCE Promotes Practice Change

2020 Symposia Series 1