Listen to an interview with Fred M. Howard, MD, MS
My name is Fred Howard. I’m a professor of obstetrics and gynecology at the University of Rochester School of Medicine and Dentistry, associate chair of the department, and the director of gynecologic specialities.
My clinical and research activities are mostly in the area of chronic pelvic pain with special interest in endometriosis and interstitial cystitis.
I recently had the pleasure of helping in the development of a supplement to OBG Management on the evaluation and diagnosis of endometriosis.
This is of particular interest to me because endometriosis is one of the major pain-generating disorders that gynecologists deal with. Certainly, it’s helpful for us to always stay as up-to-date as we possibly can.
When we do evaluations of patients who have pelvic pain, particularly those of chronic duration, it’s always a challenging evaluation. But very frequently—particularly for gynecologists—more than a third of patients we see are likely to have endometriosis as at least as one of the major generators of pain. So it’s always important to keep that in our differential diagnosis and try to seek the diagnosis pretty carefully.
Some patients have classic history. In that classic history, they start initially with dysmenorrhea. In fact, most of the published series suggest that in patients who have endometriosis associated with pelvic pain, more than 90% of them will have dysmenorrhea. The other two major pain symptoms are dyspareunia, or pain with intercourse, and of course, chronic or noncyclic pelvic pain. Those numbers vary--anywhere from 40% to 70% of patients will have one or both of these other pain symptoms as well.
Certainly the only definitive way to make the diagnosis is with histologic confirmation of the ectopic endometrium. But very often in clinical practice, for patients who have a very classic history, it is not unusual to start with empiric therapy. And again, there is pretty good evidence for this.
For patients who have a classic history and where we’ve done a thorough history and physical examination—and really think the patients is likely to have endometriosis—gynecologists turn out to be correct 75% to 85% of the time when, in fact, laparoscopy is done to confirm the diagnosis.
Our clinical diagnosis is fairly accurate. So, for that reason, it not at all unreasonable to think about empiric treatment.
Some major points I would stress, though—when one decides to do empiric treatment—is to recognize that if the patient does not respond, it does not mean she does not have endometriosis. And to the contrary, if she does respond, it doesn’t mean that she has endometriosis—because we know that other diagnoses, such as irritable bowel syndrome and interstitial cystitis, also frequently improve when we use medications such as GNRH agonists.
Certainly, if one chooses or the patient chooses not to do empiric treatment and you want to go ahead with definitive diagnosis, the ideal way to do that—in current modern methodology—is to proceed with laparoscopic evaluation. One of the major benefits of that is that it is certainly possible to go ahead with surgical treatment laparoscopically at the same time. We have good evidence based studies, well-done studies, showing that surgical treatment is very effective in terms of relief of pelvic pain and certainly that is always an option.
When, for whatever reason, surgical treatment is not deemed to be appropriate or when surgical treatment is going to be combined with medical treatment, probably the most commonly used class of medication for endometriosis—at least in the US currently—are the GNRH agonists. And again, we have really strong good data from randomized placebo controlled trials showing the efficacy of GNRH agonists for relief of pain.
Again, one of the major points that I think is important in modern treatment of endometriosis is that when GNRH agonists are going to used for medical treatment, with rare exceptions, add-back treatment with a progestin or estrogen progestin combination is almost always indicted.
There are a number of benefits to doing that: one of the true major ones overall is the recognition that you are able to really avoid a loss of bone mineral density that occurs with a GNRH agonist. Again, as most of us know who use GNRH agonists, one of the major things we worry about is the loss of bone mineral density.
Although certainly we think that is reversible—particularly for patients where response is good and we would like to continue long-term therapy for greater than 6 months—it really is important to add add-back treatment.
The other major benefit is that the side effects, particularly hot flushes, headaches, sometimes even atrophic changes that can occur during long-term treatment with GNRH agonists can also be avoided with add-back therapy.
With current modern practices, it is advisable in almost all cases start add-back treatment pretty much immediately when one is going to use GNRH agonist treatment.
Overall it is important to remember that conservative treatments—whether they are surgical or whether they are medical—are for all intents and purposes not curative for endometriosis. But they certainly have a role because, at least by our current standards, the only definitive treatment seems to be hysterectomy and possibly salpingo-oophorectomy. And certainly in the younger woman, that is certainly not the appropriate approach. And we can greatly ameliorate symptoms and improve quality of life with conservative treatment. And so it is important that we remember in young women to be aggressive with our treatment even though we are using conservative treatment—surgical or medical—and in fact not to allow our patients to endure pain for long periods without appropriate treatment.