The Management of Chronic Gynecologic Conditions During COVID and Beyond - Episode 3

Individualized Treatment Goals for EM-Associated Pain

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Supported by: AbbVie

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Linda Bradley, MD, provides her perspective on individualized treatment goals to help develop short- and long-term plans to manage endometriosis (EM)-associated pain.

Ayman Al-Hendy, MD, PhD: We have confirmed the diagnosis, and we go to the treatment goals. I’m going to go you, Linda, so how do you sit a specific goal? How do you do kind of individualize treatment goal for a patient? Of course, you have heard many different terminologies along those lines: patient-centered, precision medicine, and so on. How do you set goals between you and your patients on the short-term and the long-term in management of this disease?

Linda Bradley, MD: I think it’s important to try to divide patient’s desire. Is she interested in pregnancy now? Is she 38? Today I’m thinking of just other patients, and I say, “If you have the magic wand or if you could tell me, would you want to be a mom?” So if I have a 38-year-old sitting in front of me, her time is running out and she wants to be pregnant like a woman that’s 20, 21, I say, “What month, if you could choose it?” My treatment for someone that says, “I want to start to be pregnant in February or March,” is 1 pathway.

If I have a 21-year-old who’s trying to avoid pregnancy, I think the treatment will be different. You eloquently discuss the importance of a physical exam in imaging, whether it’s ultrasound and/or at the Cleveland Clinic we have really a wonderfulMRI protocol to look at endometriosis involving every place, from cul-de-sacs, to bladder, to endometriomas, to diaphragm; it depends. We actually have something like a tumor conference, so to speak, where our radiologist will go over very discrete images.

If I can just briefly sort of summarize, it depends, at least for me (and I may be just very unit dimensional on my thinking) but the issue of pregnancy and age. I would just right now let the other speakers have an opportunity. I use that as sort of a dividing mark; what we’re going to do here versus there. Base it on pregnancy.

Ayman Al-Hendy, MD, PhD: Actually, this is very intriguing. Please go ahead. Elaborate more on that please.

Linda Bradley, MD: Okay. I think we have many new options for therapy. I’m sure we’re going to get into those things now, and it depends on the degree of what symptoms bother her most. We talked about the importance of listening, and we can have patients to give us. I always say, “Okay, tell me your story,” and then, “What are the top 3 or 4 or 5 things that you want fixed?” I always say, “We’re going to try to fix everything, but tell me what you want fixed the most.”

Because my listening, I may think that dyspareunia is the bigger problem, but she may think cyclical pain is the problem. I really want the patient for me to identify what she wants corrected the most. Then it depends on symptoms. Is it bad cramps? Then we can go through the litany of what are some easy things to use such as multimodal nonsteroidal anti-inflammatory drugs and Tylenol. Maybe that’s all she needs with the normal exam.

You know many different things that it could be from birth control pills or ways that we treat what with hormonal therapy, which could include that to extirpative surgery. If she’s got stage IV endometrial disease on an exam that’s coming through, the rectal vaginal space and big masses, that’s going to be more surgical for most of us at our institution to, you know, different kinds of symptoms. Just in general without specifying the medications right now, it would be listening and treating those symptoms and finding what drug or drugs work.

There are some patients also who were adverse as a first response from a physician to recommend hormonal medical or surgical therapy.

We’re here to improve your quality of life.” I have to go with what the patient wants. I have patients that want to use acupuncture. If you want to try it for 3 months and then come back to me, we can do the next step. I have to ask her, what is she interested in? Maybe it’s taking off of work and using a heating pad. Maybe it is deep breathing or yoga.

Again, knowing that it is rare that your patient is going to be life-threatening because of this problem. I always say there is another appointment and let’s try. It’s like patients with hypertension who don’t want medicine. Unless they’re coming in with a blood pressure of 220/140, we’ve got to do something else, but if it’s moderate, “Oh Doctor, I’m going to lose weight. I’m going to exercise and stop eating fast foods.” Okay, let’s try it, but when you come back if you’re not better, let’s move to phase 2.

I really try to get an edge. “What do you want? What pleases you? What would you like to try? What have you read about?” I think you get a buy-in, and if that patient comes back, “Okay Mrs. Jones, Miss Jones, we can try this acupuncture or herbal medicine.” We have a big Asian population who do a place in Cleveland that does all these teas and herbs. I must say I don’t know much about it, but I don’t think it’s going to hurt. Let’s try that.” And when they leave, I say, “Well how much time do you want to give trying something alternative?” Then, “Three months.” I said, “Okay why don’t we, when you leave today, make an appointment in the next 3 months.” Then they come back. I do ask them to journal, to let me on a daily basis, what’s your pain, how much, the duration? Is it cyclical like you mentioned earlier?

I’m very liberal when it comes to any of these things because I think you get the best buy-in when they’re ready for treatment instead of us pushing treatment unless there’s something. Both ureters, they’ve got hydronephrosis. They’re not urinating. They got poor kidney function. Not all of us in this room have seen patients with that, but in our lifetime cumulatively, it’s a handful of patients.

Transcript edited for clarity.


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