Management of Chronic Gynecologic Conditions During Covid and Beyond - Episode 2
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: When discussing a specific gyno condition, let’s say endometriosis-associated pain, what can we do? What can be done to enhance communication during this telemedicine visit? Let’s start; for example, let’s kind of divide it up, and let’s start in the 3-visit prep. Do you use any screening tools such as the EndoWheel, some kind of screening tool like the Painful Period Screening Tool, PPST, or some other things that you might use in your practice along those lines?
Eric Surrey, MD: I think that’s a great point. I agree with Linda completely. One of the problems that does come though, with a lot of physicians who have limited time, is to somehow try to be prepared. Regardless of the condition, particularly the pelvic pain, it’s so open-ended. I think it’s helpful for the patient to create a document of some sort so that you know what their concerns are. They’ve almost started to answer that open-ended question when they come in the office, and certainly the EndoWheel is incredibly helpful. I agree that PPST gives you a sense of what are their concerns, and you can focus your questions.
These are absolutely critical and of major help. Oftentimes when the patient is being scheduled, instead of just saying I’m coming in for pelvic pain, they actually maybe ask a little more specifics; give them just something to fill out before they come in to see you so you’re prepared.
Ayman Al-Hendy, MD, PhD: Absolutely. We have done the prescreened visit now. The patient is in the office, so then of course what we do? We need to establish the diagnosis, so I’m going to talk a little bit about that. Obviously, there are various guidelines out there from different society: ACOG, ASRM, AAGL. Also there was some excellent review articles recently addressing diagnosis of endometriosis. In my practice right now we use, of course, the good old history and exam, and then we go to other additional tools, such as imaging for example. Then lab work, although I’ll mention in a second that there is no good reliable biomarker for endometriosis.
On the history side, of course the typical symptoms that the patients usually complain with endometriosis are pain, pelvic pain, and infertility. Those are the classic typical symptoms, but then you go a little further in the history, and classically we think with the endometriosis that everything is cyclic. Cyclic pelvic pain usually kind of make us think about endometriosis: cyclic acute or chronic pelvic pain, dysmenorrhea, cyclic dychezia, painful bowel movement, cyclic dysuria, painful voiding, etcetera. Once we hear the patient talking about pain-related symptoms in the pelvic region that’s really associated with her menses, of course we think of endometriosis.
Other general symptoms also associated with menses, mood changes, digestive symptoms, and nausea and vomiting. General symptoms that mainly associate with the menses also usually point towards endometriosis, although most of the symptoms usually center in the pelvic region. Then on the exam, classically we think about feeling nodules in the cul-de-sac and the vaginal rectal region. Usually it suggests or points towards endometriosis, although the post predictive value of these are very limited.
Also, classically we think of fixed uterus, fixed retro, and retroverted uterus also might suggest endometriosis. However, in real clinical practice these things are, have very poor specificity and sensitivity. Then we of course go to additional tools such as imaging, typically in the form of transvaginal ultrasound, although I use also MRI in many cases. This is particularly helpful typically in the cases of endometriosis, ovarian endometriosis.
For the more generalized type of endometriosis, unfortunately these imaging tools are of limited utility. Of course, the gold standard classically has been laparoscopic diagnosis, so visualizing and then biopsy conformation of endometriosis lesion has been considered the gold standard.
Of course we go to the lab, and I said in a second earlier, there’s no good reliable biomarkers for endometriosis. That’s really one of the main challenges in this field, and then it’s a huge unmet need, and a huge, I would say, research goal to address.
Because of that and because of the kind of ambiguity about most of what I mentioned as far as symptoms and so on, there’s usually a huge delay in diagnosis of endometriosis and also additional factors such as normalization of symptoms and so on, which Stacey will talk about at the end of this session. The average duration of delay from patients from the onset of symptoms to the diagnosis has been anything between 4 years to up to 11 years. Clearly, a huge delay until diagnosis is confirmed.