Endometriosis experts describe the role of surgery for the treatment of endometriosis.
Hugh Taylor, MD: When somebody fails medical therapy, I’m thinking that they might have adhesive disease, fibrosis—things that aren’t amenable to medical treatment. Is that what you see when you do those surgeries? What’s your most common reason why patients fail medical therapy?
Sawsan As-Sanie, MD: That’s a great question. That’s what we see sometimes, but we see a range of patients, and that’s 1 of the many reasons that we’ll proceed to surgeries in patients who have medical therapy and whose symptoms don’t improve within a minimum of 3 to 4 months of treatment. But even among those patients, we definitely see a wide range of pathology, from superficial disease to deep disease. Most of the deep disease we’ve diagnosed prior to surgery because we routinely get ultrasound or pelvic MRI before surgery, so we’re aware of it.
The question is incredibly important and not well understood: in patients with deep disease, what is the role of fibrosis and adhesions? How much of it needs to be excised? How much of it is explaining their pain symptoms? There are pain symptoms that are refractory to treatment, but we see patients with less severe disease who still have persistent pain. For patients with ovarian endometriomas that are enlarging or are not getting smaller, we’re going to have a lower threshold to take to surgery sooner. Patients who have obstructive symptoms are going to go straight to surgery rather than medical therapy. For example, bowel-type obstruction symptoms and urinary tract obstructive symptoms are going to go to surgery immediately without a trial of medical therapy. Those tend to be a pretty small minority of patients.
Hugh Taylor, MD: You mentioned without the endometrioma getting smaller, and how you expect it not to grow. But that blood and debris in there doesn’t necessarily go away even with effective medical therapy. What difference do you expect it to see? If something is enlarging on that therapy, I’m concerned. If it’s not shrinking, how much time should we give them before we worry about that? I tend not to worry about much even if they don’t shrink.
Sawsan As-Sanie, MD: As long as they stay stable in size and the patient isn’t interested in having surgery, I’m fine with surveillance. There was an interesting study published not long ago from Dr [Tommaso] Falcone’s group at the Cleveland Clinic that looked at the cost-effectiveness of surveillance in patients with endometriomas. If you continue to monitor the ones who stay stable vs opt for surgery, there are some interesting results. Ultimately, it’s up to the patient. As long as it’s not getting bigger and the patient’s symptoms are well controlled and there aren’t any imaging findings that appear atypical or concerning for underlying malignancy, then it’s fine to monitor them if that’s what the patient prefers. I don’t necessarily expect them to get smaller, but as long as they’re not getting bigger, surveillance remains an option in those patients.
Hugh Taylor, MD: We all agree that a trial of medical therapy is appropriate, and surgery is most appropriate for those who failed medical therapy. The other thing I do is put them back on medical therapy postoperatively to make sure they don’t get a recurrence. We have to remember this is a chronic disease. The same criteria that caused it to start will be there after you do your surgery, so it’s important to think about the same type of medical therapies we discussed postoperatively as well to prevent recurrence.
Linda Giudice, MD, PhD: Hugh, may I ask you and Susie 1 question?For those who have stage IV disease, extensive disease, and postoperatively, do you suppress with elagolix at the high dose, or do you do the low dose? Do you use the relugolix combination therapy, or do you use a GNRH agonist?
Hugh Taylor, MD: I’m sorry. At what time, postoperatively?
Linda Giudice, MD, PhD: Yes.
Hugh Taylor, MD:I wouldn’t put them on something they failed before and brought to the surgery. I’m using surgery in patients who failed medical therapy. If they had adhesive disease, and their disease was fully suppressed on whatever they were on, I might put them back on what they were on. But if I find active disease at the time of surgery, I usually opt for a more aggressive therapy. Susie, what do you do?
Sawsan As-Sanie, MD: It goes without saying that our goal is a safe surgery where we maximally excise the endometriosis that’s presented at the time of the procedure. There are some patients who have bowel endometriosis, for example, who don’t wish to have a bowel resection as part of their procedure. Things might be slightly more tailored there. The vast majority of time, I’m going to put patients back on medication that worked well, in terms of minimal adverse effects. For a high proportion of patients, I’ll put them back on an oral contraceptive pill or a progestin-only method. If the endometriosis is maximally excised, I might not go straight to a GNRH antagonist or agonist. But it’s going to depend on that individual patient, and hopefully, the endometriosis was debulked as best as possible in most cases.
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