Management of Chronic Gynecologic Conditions During Covid and Beyond - Episode 6

Risks/Benefits of Medical Treatment for EM-Associated Pain - Podcasts

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’re going to talk about the risk benefits of the various medical treatment options for endometriosis associated pain. As we heard earlier from Linda, of course, there are alternative medical approach and complementary medicines. As far as, let’s say, traditional medical treatment options, I think of NSAIDs, combination of contraceptive pills, progestin, different forms of progestin, and then GnRH agonists, and then the new kind of family of compounds, the GnRH antagonists.

I’m going to comment about this, but please, I’m going to go back to you Linda in a second to get your experience with that.

So NSAIDs, Of course are very simple approach, and they actually help in some patients as pain medicine but also in a mechanistic way. Because of this information we know it is a major player on the basic science side and endometriosis and a very good anti-inflammatory agent. Usually I start with this, and if the patient has used this, then ask about their response and maybe adjust the dose and so on.

Birth control pills, combination oral contraceptives, traditionally have been advocated as a first line of therapy both in a cyclic fashion or there’s some literature support with that to use it continuously. Also, it works in some patients, at least on the short-term; of course you have to select the patient for that, the patient needs to be motivated, and of course you need to counsel them about the traditional potential side effects, especially early on in the therapy such as breast tenderness, a change in appetite, maybe some nausea in some patients, and, of course, some patients worry or complain about weight gain and so on. You need to counsel them about this to keep them motivated so that hopefully if it’s going to work for them, at least they stay on it long enough to reach that benefit.

Progestin, of course, different forms, oral, injection, implants, etc, we know from the basic science that endometriosis is a progesterone resistant disease. It would make sense to, let’s say, oversaturate the system with progestin. Again, literature supports some utility and shows some benefit, at least on the short-term. I actually use progestin quite a bit in my endometriosis patients with pain. Of course, we need to select the patient and we need to counsel them. Traditional side effects for progestin that has been reported, including GI upset, nausea, and mood changes. You actually have to be particularly careful with high-dose progestin, some kind of cognitive function, and, probably, some psychological issues. I typically screen my patient carefully before I use progestin, especially if I’m going to use the high dose.

For GnRH agonists, of course the mechanism of action is well known, and it would make sense to deprive endometriosis from estrogen and progestin, especially the estrogen component, but, of course, as well all know, we cannot use them on the long-term because of the severe side effects such as bone mineral density loss and all the typical hypo-estrogenic side effects. Like painful intercourse on top of what the patient already has is because of the vaginal dryness, the hot flashes, night sweats, all the hypo-estrogenic side effects. Usually, therapy is limited to 3 to 6 months.

The new family of compounds in this area is the oral GnRH antagonist, and it is exciting because it works right away; there’s no flaring effect. It goes and binds the receptor and starts inhibiting follicular genesis, ovarian estrogen, and progesterone production right away. You have to adjust the dose. They are available in different dose regimens, and at the high dose, you also get some of the same side effects I mentioned a second ago, the hypo-estrogenic side effects.

At the lower dose you can actually use it a bit longer, but some of my patients on that also complain of some menopausal-like symptoms such as hot flashes and night sweats. You have to, again, counsel them and be ready to assist that, and maybe switch to something else. This is kind of my experience with the risk benefit balance for the various medical treatment options for endometriosis associated pain.

Linda, what’s your experience with these different options?

Linda Bradley, MD: Well I think we have, as you mentioned, newer options. I tend to be conservative. I certainly agree with all of our speakers this evening in terms of, especially your erudite description just now. Sometimes I would say starting with NSAIDs; I also do the multimodal. I do believe that acetaminophen with an NSAID. A lot of patients think that they’re going to “overdose” on something. I just let them know, depending on when they’re having their symptoms, if it’s dysmenorrhea, alternate between an NSAID of choice to acetaminophen. I think that would be 1 thing that I would add.

Also, you mentioned all of the parameter, all the different drugs that we have to look at any risk factors. We mentioned ,just to add, if you have a 38-year-old who’s a smoker, who has had a DVT, then the traditional contraception estrogen-progestin contraception may be contraindicated. The progestins I also love, but you know, maybe it’s anecdotal, I don’t know if there’s an article, but I think the older I’ve gotten, the more I ask patients if they’ve been pregnant or if they have mood changes, if they have depression that had significant postpartum depression, again, it’s very anecdotal, I just tend to be leery about high-dose progestin. That’s a little part of my history that I try to note somewhere or if they have been on an antidepressant.

I don’t know if that’s something we could talk about, but I’ve been a little leery for patients who become really suicidal with high doses of progestin. I’ve moved away from that.

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