Management of Chronic Gynecologic Conditions During Covid and Beyond - Episode 4
In this podcast series, experts discuss management of women’s health including chronic pelvic pain resulting from endometriosis and heavy menstrual bleeding from uterine fibroids. They also discuss ways to help improve patient-provider communications and overcome the normalization associated with non-malignant gynecological conditions.
Supported by AbbVie Inc.
To read an article summarizing key points from this podcast series, click here.
This program is also available as a video series. Click here to watch.
Discussion moderated by:
Ayman Al-Hendy, MD, PhD
Professor and Director of Translational Research
Department of Obstetrics and Gynecology
University of Chicago in Illinois
Ayman Al-Hendy, MD, PhD: Now we have intervened, whatever the intervention was, but let’s say there are unresolved symptoms. When doing a follow up assessment for this for that kind of patient, let’s call it the “problem visit”; the patient still had unresolved symptoms. How do you approach that? How do you enhance the communications to appropriately managing their symptoms, especially in the virtual setting?
Stacey Missmer, ScD: I thought that Dr Bradley’s description of the short-and-long-term goals was such a lovely lead-in for now conceptualizing the problem visit that I’m seeking from the scientist and the patient’s point of view. Thinking through what that communication was at the previous visit that set up the expectations, that set up the timeline, that helped the patient to understand clearly what her experiences could be that would warrant an urgent callback. What are our concerns in terms of say is the problem a side effect? That is something that was already discussed when choosing the trial of her treatment.
Is the problem because there hasn’t been any remediation or there hasn’t been adequate remediation of the prioritized symptom that was the target of the change? Does the patient understand, and was there sufficient dialogue around the amount of time it would take? For example, Dr Bradley nicely used the example of acupuncture. You would not encourage a patient to contact you within a week after the treatment to say that this either did work or it didn’t work. Some treatments take a longer amount of time to assess if they are beneficial. Some take a shorter amount of time. Then I think the last really important thing around this problem, [and] this concept is so important as Dr Bradley so nicely summarized. Dr Surrey mentioned the EndoWheel, for example, and kind of what that dialogue is about the spectrum of symptoms that some patients are experiencing.
Some are experiencing very few or are experiencing a lot, and there has to be a discussion of prioritization. Or they’re experiencing some that add visits or deems to be what was important to them and what we’re tackling with this treatment. It may be that the problem is now because that primary symptom or set of symptoms that this treatment was designed to tackle has now actually been beneficial but now, they’re experiencing a sense of fatigue, weight gain, weight loss, or other symptoms that weren’t necessarily part of that previous discussion but hasn’t been a shift in importance for the patient in her quality of life.
Again, it comes back to this global issue of communication and finding a way to dialogue in those interactions to help set priorities and expectations. With the scientist lens on, this becomes really important as we’re doing studies of patient outcome. Patients who we can get [in] these studies of only including the patients who come back to the same clinician or more visits from the patients who are interacting more, perhaps because they are struggling more.
Perhaps because they have a very good communication dialogue with this physician and they’re tackling different issues. Considering what that means in terms of patient visits and what happens at those, and really thinking thoughtfully about what that means in terms of trajectories of improvement, becomes really important, and it’s something that often is kind of glossed over in the research as we think about what are successful treatments.
Ayman Al-Hendy, MD, PhD: Thanks Stacey and well said. Eric, do you have any pearls of wisdom, words of wisdom, about this dreaded “problem visit”?
Eric Surrey, MD: No. I mean Stacey said it very nicely, but I may be going in a little different way. One is I do tend to be a little more directed with patients. Whatever the first plan is, I think it’s important to set realistic expectations. At the first visit that involves treatment planning that you should expect improvement if you don’t have improvement in ‘X’ period of time and understand that not everyone is the same. You may not get maximum improvement within months; you might see some. You should get your maximum improvement if this therapy is going to work by 3 months.
If the person has in their mind, whatever the treatment is, this is what should be expected. Am I an outlier so to speak? The second piece that I think Stacey very nicely addressed is, in that what is it that’s not working? Because the patient will often say, “Nothing’s working.” You know, there’s disaster, whatever you suggested to me is a total failure. When you dig a little deeper it may be, for example, dysmenorrhea has improved, but I still have dyspareunia.
I mean we’ve published several papers looking at the comorbidities associated with endometriosis, and you would think that this patient would: “I’m exhausted all the time, I didn’t pay attention to this before because I have severe pain.” I think you have to drill down on, “Tell us exactly what it is what your concern is. What is it that’s not working for you?” Then instead of just knocking down the building, you can just correct the problem that may be easily fixable, but the actual treatment is indeed correct.
I mean that would really be my view, and I think that the other last piece is the problem the therapy or the side effect from the therapy. In other words, the drug is working just fine, but now I’m having these other issues. Certainly that can help you channel the next step.
Ayman Al-Hendy, MD, PhD: Fantastic. Excellent discussion guys.
Linda Bradley, MD: Could I add 1 thing because I think that we didn’t mention; maybe it would go with your first question. I think the emotional health is important. I don’t think any of us intentionally didn’t put this in there, but an important part of that history taking is looking at issues of violence, domestic, incest, other kinds of relationship issues, psycho-social issues as it relates to depression. Again, we’re talking in the era of COVID, which is its own separate stressor; we try to figure out a little bit about her background and potentially whether any of this was related to an incident or an issue of the relationship.
I was just thinking about how that is important. It’s not to say that violence against women is a cause of pain. I do think that we cannot put women in silos, and treating multiple things may help her and how she also frames improvement and overlapping issues with depression and also pelvic floor disorders that also can mimic endometriosis. I was just thinking and put a note to myself of something I didn’t say and wanted to add that.
Ayman Al-Hendy, MD, PhD: Excellent, and thank you, and definitely a very important topic.