Management of Chronic Gynecologic Conditions During Covid and Beyond - Episode 7
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.
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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: We’ll move on to the surgical treatment option. I’ll go to you, Eric. Using the same approach, what are the risk benefits on normal surgery and management of endometriosis associated pain?
Eric Surrey, MD: You know I think in terms of the surgical approaches, there’s certainly a vast controversy in terms of the role of surgery as there is a role of medicine. There are folks that feel very strongly about 1 versus the other. I look at it a little more like being a gardener where you have to be able to use all the tools that you own, not just use a shovel.
It depends on the goals of the surgery Surgery for helping infertility. The data is relatively weak, particularly when it comes to the Endocan study. The surgery improves pregnancy rates, but to a very small extent. We weigh risk and benefit; I’m not sure if this really outweighs the risks or outweigh the benefits.
With regard to exclusion versus ablation, this also is a major controversy, particularly as we get into some of our national meetings that are coming up. There have been very few, if any, well designed trials that have compared excision of endometriotic lesions to ablation of endometriotic lesion. There are definitely folks who feel very strongly about 1 approach to the other, but there is a lack of data to support this.
Part of the reason is there’s different skill sets and different techniques. What you might consider an excision is not what I consider. What someone may consider is ablation, which is thoroughly destroying tissue, someone else may touch with a cautery and think they’ve done a good job.
I really think it’s what the person does best in their own hands. Because our training really has changed so much, so many of our residents are not quite as comfortable with surgeries, and I think just to look and treat the little bit that you feel comfortable treating isn’t really an operation at all, in my view.
The last bit on hysterectomy, you know we often feel that this is the ultimate surgery for endometriosis. We must remember, recurrence rates have been well described with hysterectomy, particularly when the ovaries are left in place. I think if you do a hysterectomy and ignore additional endometriosis in the pelvis, it is maybe not the best operation. Just taking out the uterus and ignoring the rest of the disease, particularly if the ovaries are left in situ maybe not ideal.
Whether ovaries are removed or not does depend on the age of the woman of course. If she’s perimenopausal, again, the ovaries play major roles and you have to really think of, again, risk and benefit. Recurrence rates are higher when the ovaries are left in place, the health risks may be higher by removing the ovaries.
Ayman Al-Hendy, MD, PhD: Excellent. I’m going to stay with you Eric, and we kind of touched a little bit on that earlier when we talked about individualized treatment plans for each patient, but do you want to comment on the rate of recurrent pain with the various medical and treatment options we talked about, and again, the importance of defining a long-term frequent plan for each particular patient?
Eric Surrey, MD: Sure. I’ll start by saying, again, we need to define what we mean by recurrence, because the pain cannot be completely resolved but significantly improved. I have to ask, is that truly a failure? I think just maybe it’s not only important just for data collection, it’s important for patient comfort. You may not get to 100%, but is 80% good enough? I think that’s something that gets into patient counseling as well. I think the other important piece, particular of medical, and, frankly, multiple surgeries. If something’s not working, continuing to do it is probably not the wise choice. You should move on to a different approach.
We know that there are recurrence rates of every form of therapy for endometriosis, and no matter what you’re deep-held beliefs are, there are recurrence rates. There are virtually no studies looking at recurrence rates for surgical versus medical therapy and even less looking at various medical therapeutic approaches. We really don’t have good data to share with the patient. What I tell them is, “There’s a good chance you’re just discomfortable. Come back at some point, and what we’re going to hope is you get a long time, a long benefit, and that whatever comes back will be relatively low in its intensity.”
I think we have to look at recurrence as failure versus the treatment, but it’s now 3 years later, and symptoms have returned. I’m not sure we look at that as a failure of the initial treatment. I might look at that more as a reason there to reinstitute that therapy that worked so well before.
One other piece we often talk about surgical versus medical therapy that a key point is that virtually every trial that’s looked at this has showed that the appropriate medical therapy which, typically, in my hands I would use a GnRH antagonist or perhaps an agonist with add back. After surgery, it’s consistently been shown to decrease recurrence rates. I don’t look at this as an A versus B, but maybe an A plus B.
Ayman Al-Hendy, MD, PhD: A very good point.