The Management of Chronic Gynecologic Conditions During COVID and Beyond - Episode 11

Treatment Algorithm for Fertility vs Uterine Preservation

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Supported by: AbbVie

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Stacey Missmer, ScD, provides an overview of the treatment algorithm based on patient choices and discusses gaps in care for specific medical management.

Ayman Al-Hendy, MD, PhD: I’m going to charge you, Stacey, with a big task, to frame for us the treatment algorithm based on the various patient choices for fertility versus uterine preservation, and maybe identify the gaps in the current guidance regarding these issues.

Stacey Missmer, ScD: Absolutely. I think this really stems from what already has been so clearly stated repeatedly: the critical branching point is the patient’s intentions around childbearing and continued fertility. That is a definitive demarcation that sends clinicians on 1 path or another that has been so nicely described already. I think the critical thing around uterine preservation is that we still have emerging data in terms of short- and long-term consequences of hysterectomy and also of bilateral salpingo-oophorectomy. For example, we’ll probably 15 to 20 years on with the evidence that BSO has some association with cardiovascular disease, certainly an association with surgical menopause and bone loss and other outcomes in those areas.

We now have some emerging data particularly from Ebbie Stewart and some of the Rochester, Minnesota data that’s suggesting that even with hysterectomy with preservation of 1 or both ovaries, there is suggestion of increased risk of cardiovascular disease. I think it’s Dr Bradley who referred to that there are associations emerging with mental health, depression, and anxiety. We, in studying, have seen increased risks among women with fibroids of hypertension, for endometriosis, we’ve certainly seen increased risks of hypertension and early onset cardiovascular disease. One thing that some of the more recent studies have suggested is that some of that relationship particularly between endometriosis and cardiovascular disease risk is in part about 50% of that relationship is driven by surgical menopause; hysterectomy with bilateral oophorectomy.

There are long-term implications that can’t be ignored, but again this falls into that realm of understanding risks. For example, it had been increasingly discussed and perhaps becoming more normalized for ovary removal for women who had completed their desired childbearing when they had an endometrioma to remove the ovaries to prevent ovarian cancer. Really when you look at those data, while women with endometriosis do have an increased risk of ovarian cancer and possibly driven primary by endometriomas, we don’t know that definitively yet. We know that even with that increased risk, the lifetime risk of ovarian cancer is extremely small, but the lifetime risk of cardiovascular disease is large, and, frankly, most women are going to be taken out by cardiovascular disease.

Now to go back to Dr Bradley’s comment at the very top of our discussion that these gynecologic conditions aren’t life threatening, but we do need to consider these long-term outcomes and how interventions can be influencing things like cardiovascular disease. There are gaps in the data, we have not enough adequate long-term follow-up. There are also gaps in the data in terms of if we think about pain remediation. There are patients for whom a hysterectomy improves pain for endometriosis specifically, and then there are patients who still have a return of pain. Dr Susie As-Sanie is currently doing studies around what are risks for triggering de novo pain, new pain post-hysterectomy. That’s certainly a phenomenon that in our field we’ve not talked about a lot. I think a really important synergy between clinicians and scientists is continuing to push and identify the important clinically translatable gaps in care, and then again also thinking about what these algorithms mean for short-term goals and long-term health.

Ayman Al-Hendy, MD, PhD: Absolutely. This is a fascinating discussion, [and] we can really go on and on.

Transcript edited for clarity.

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