2020 Symposia Series 1
Reducing the Burden of Endometriosis: The Role of Primary Care
Learning Objectives • 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 3
̶ ̶ ̶ ̶ Epidemiology of Endometriosis • 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 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. 4
Burden of Endometriosis Patient Burden Healthcare Burden • • Associated cognitive, behavioral, 3rd leading cause of gynecologic sexual, and emotional consequences hospitalizations • • May cause infertility 2nd leading cause of benign hysterectomy* • Potential precursor to clear-cell and • endometrioid ovarian carcinomas Increased healthcare costs: ‒ Estimated $11,686 annual cost in the year after diagnosis vs $5216 in women without 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; 5 Schrager S, et al. Am Fam Physician . 2013;87:107-113; Soliman AM, et al. J Manag Care Spec Pharm . 2019;25:566-572.
Pelvic Pain Definitions Dysmenorrhea Chronic pelvic pain • • Painful menstrual cramps Noncyclic pain of uterine origin • ≥6 months’ duration • Pain is limited to time of • Localizes to anatomic pelvis, menstrual bleeding anterior abdominal wall at or below umbilicus, lumbosacral back, or buttocks • Of sufficient severity to cause functional disability or lead to medical care Bloski T, Pierson R. Nurs Womens Health . 2008;12:382-395; Brawn J, et al. Hum Reprod Update . 2014;20:737-747; Practice Committee of the American Society for Reproductive Medicine. Fertil Steril . 2014;101:927-935. 6
Possible Causes of Chronic Pelvic Pain Gynecologic Urologic Gastrointestinal Musculoskeletal PNS & CNS • Pelvic floor myalgia • Functional bowel disorders • • Peripheral nerve Endometriosis • Interstitial • Trigger points ⎻ injury • Chronic constipation Adenomyosis cystitis/painful bladder • Central pain • Low back pain syndrome ⎻ • IBS Adhesions disorder • Urethral syndrome • Lumbosacral disc • Inflammatory bowel disorders • Chronic PID disease • Chronic UTI ⎻ Crohn’s disease • Leiomyoma/fibroids • SI joint disease • Kidney stones ⎻ • Ulcerative colitis Pelvic congestion • Coccydynia • Chronic appendicitis • Ovarian remnant • Hernias • Diverticular disease • Intermittent bowel obstruction 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 . 7 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.
Endometriosis Definition • An inflammatory, estrogen-dependent disease defined by the presence of endometrial stroma and glands outside the uterus Uterus Endometriosis Bowel Histologic Diagnosis Made by Surgical Biopsy Normal Pelvis Stage 4 Endometriosis Endoscopic images courtesy of Kristin E. Patzkowsky, MD. 8
Endometriosis Symptoms and Diagnosis • Variable symptoms, including Pelvic pain + Dysmenorrhea Pelvic pain variable degrees of: dysmenorrhea, only, 12.7% only, 6.5% 25.2% ‒ Dysmenorrhea ‒ Dyspareunia Pelvic pain + ‒ Dyschezia dysmenorrhea + ‒ Chronic pelvic pain dyspareunia, ‒ Infertility 34.4% • Or may be asymptomatic Dysmenorrhea Pelvic pain and and dyspareunia, dyspareunia, Dyspareunia 6.5% 3.3% only, 0.7% 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 . 9 2017;358:j3935; Sinaii N, et al. Fertil Steril . 2008;89:538-545.
Endometriosis Pathogenesis and Growth • Current theories of how endometrial tissue reaches locations outside of the uterus ‒ Retrograde menstrual flow ‒ Coelomic metaplasia ‒ Lymphatic spread Endometrial • tissue Other likely contributing factors ‒ Immunologic defects, alterations in cell adhesion and Retrograde inflammatory milieu menstrual flow ‒ Neovascularization needed for implant to establish and grow ‒ Process driven by systemic and local production of estradiol ‒ Modulated by genetic and environmental factors 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. 10
Endometriosis and Pain Symptoms: An Uncertain Relationship • 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 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. 11
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. 12
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. 13
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. 14
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