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Endometriosis Treatment: Surgical Decisions, Adjunctive Therapies & Social Determinants
Taylor Spurgeon-Hess • Aug 31, 2023 • 37 hits
Endometriosis treatment, fraught with challenges, requires a multifaceted approach that extends beyond surgical decisions. Patients, often grappling with multi-site pain and overlapping conditions, underline the necessity for individualized care. The potential of adjunctive therapies in managing pain, despite limited empirical support, brings another dimension to treatment strategies. Moreover, the role of social determinants, particularly in the context of long-term health stresses, cannot be understated. As the landscape of endometriosis care evolves, the demand for comprehensive, tailored solutions becomes increasingly urgent.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• Delays in diagnosis and varying levels of surgical quality are significant challenges in treating endometriosis.
• Multi-site pain and overlapping conditions like interstitial cystitis (IC), inflammatory bowel syndrome (IBS), and chronic migraine are common among patients with endometriosis.
• The evolving debates around hormonal therapies, postmenopausal endo, and oophorectomy add complexity to the treatment landscape.
• Central sensitization of pain in endometriosis brings challenges to treatment, leading to the exploration of therapies like gabapentin or amitriptyline. These therapies have shown effectiveness in other disorders but lack supporting evidence for use in chronic pelvic pain and endometriosis.
• Variability in endometriosis presentation and inconsistent study designs make the evaluation of adjunctive treatments difficult.
• The lack of clear categorization of patient groups within endometriosis hampers the precise identification of those who would benefit from adjunctive therapies, underscoring the need for tailored research and clinical approaches.
• The connection between social stresses and the progression of endometriosis indicates a need for a broader perspective in treatment and diagnosis.
• "Weathering" describes how chronic exposure to stressors can worsen health outcomes over time, a concept that is applicable to understanding endometriosis.
Table of Contents
(1) Navigating Complexities in Endometriosis Treatment
(2) Adjunctive Therapies for Endometriosis
(3) The Role of Social Determinants of Health (SDOH) in Endometriosis Treatment
Navigating Complexities in Endometriosis Treatment
Treating endometriosis presents myriad challenges, starting with delays in diagnosis and extending to the different levels and quality of surgeries performed. The types of surgery, whether excision or ablation, play a vital role in treatment outcomes. A significant concern arises from the fact that patients with endometriosis often experience multi-site pain, putting them at a higher risk of developing overlapping pain conditions like IC, IBS, chronic migraine, and myofascial pain. Historically, the focus on medications and surgery has led to frustrations, with calls for better understanding and personalization of treatment, rather than borrowing from other disease processes. The intersection of pain and hormonal components in endometriosis makes the treatment even more complex. The push for more personalized therapy and a lack of funding for basic science and pathophysiologic studies highlight the urgent need for a more nuanced approach to this multifaceted disease.
[Dr. Isabel Green]
Yes, I think there's a bunch of challenges for treating endo. One is delay in diagnosis. Two is the different levels and quality of surgery in the sense of quality being degree of excision, ablation. That's an entire conversation to be had in terms of the types of surgery. Then there's, I think, that other huge piece of the fact that patients with endometriosis can have multi-site pain, they can have those overlapping pain conditions, so they're at much higher risk of developing other pain conditions like IC, IBS, chronic migraine, and they also can have myofascial pain as a secondary or a coexisting condition.
We, I think, have been frustrated with the history of treatment of endometriosis, which has been based in medications and surgery and it's been somewhat historical, so I think Frank trying to say, "I don't know that we have the data to support that," is also a way of saying we need to be able to better answer that and understand this as a disease and not just borrow from other disease processes. There are a lot of patients with endo that probably, if you look at them, they are also meeting criteria for those other overlapping pain conditions and fibromyalgia and chronic pain, where there is a role for those medications, those alternative to opiates, those chronic pain medications to help with that sensitization and that process of dysregulation.
[Dr. Amy Park]
Yes, because there's the pain component but there's also the hormonal component. I think there's like really good evidence about the adjunct hormonal therapies like OCPs or what have you, but it is interesting postmenopausal endo or the whole role of oophorectomy. These were all debates that have evolved over the course of my career and I've seen it swing one way and the other. We don't have good subtyping and urogyn either. There's lots of pathways to overactive bladder, lots of paths to prolapse, but we end up all treating it the same.
It would be nice if we could tailor the therapy with a little bit more precision, and I guess we're not there yet. I was hoping that there was more because I'm not, like I said, in tune and going to IPPs like you guys are, but it seems like there's more scholarship in this arena. That's actually good and interesting, but I think that it just points to the underfunding of these basic science and pathophysiologic questions.
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Adjunctive Therapies for Endometriosis
Endometriosis treatment presents unique challenges related to the central sensitization of pain and the potential application of adjunctive therapies such as gabapentin, nortriptyline, or amitriptyline. Although these therapies have proven useful in disorders like fibromyalgia, supportive data for their effectiveness in chronic pelvic pain and endometriosis is limited. The variable presentation of endometriosis and inconsistent design of studies adds complexity, as it's recognized that treatment effects may vary among patients. While some might benefit from neuromodulator treatment, reflecting underlying pathophysiologic mechanisms involving peripheral and central sensitization, the precise identification of those who would benefit is not clear. This highlights the urgent need for a better understanding and categorization of the multiple presentations under the endometriosis umbrella to enhance personalized care.
[Dr. Amy Park]
Isabel, I wanted to circle back to one of the things that you had alluded to before and we're just talking about patient response to surgeries and we had Frank too come and do a pelvic pain talk for us at one point in DC and just this whole idea about the central sensitization of pain. Then I asked him at that point, it was many years ago, probably like 2012 or something, about the role of using things like amitriptyline or gabapentin and he was like, "Well, there's not really a lot of evidence or data that has supported their use," but it does seem like there is some lots of pathways that activate that central sensitization pathway if it's the reflex of [unintelligible 00:18:11] dystrophies and the limbs and a lot of these syndromes go together, IC, vulvodynia, pelvic pain, et cetera. What are your thoughts on the adjunctive therapies, et cetera?
[Dr. Isabel Green]
That's a great question. It's going to be the same story as we talk about the variable presentation of endos like that heterogeneity in the studies. When we look at the data, there is not great data to support the use of gabapentin or nortriptyline or amitriptyline or those medications in the treatment of chronic pelvic pain and endometriosis. There's very good data for its use in disorders like fibromyalgia and other sensitization disorders.
The question then is, are we leaning into a similar pathophysiology in a process and depending too much on that, or is the literature just not very helpful because of how heterogeneous the patients are? The studies are not well designed to answer those questions. There's probably, in some individuals, I would say that in any given day we might lean too far in one or the other of those directions where we're under treating central sensitization or overtreating the possibility of a central component with a neuromodulator. It's so hard to answer these questions because of the heterogeneity in the populations that are treated for these studies and the kind of design of the studies.
That's an area I think that a lot of people are interested in as we've learned more about the inner play of not only just the chronic pain that comes from endometriosis, but potentially some pathophysiologic mechanisms where endometriosis can actually lead to not only that local neurogenesis and nociceptive response, but actually peripheral sensitization, central sensitization, crosstalk through the spinal cord and the sacral nerves. There's probably a group of patients where that works very well for them and that's a very helpful adjunct. We just don't have a great way of exactly saying that each patient fits into each separate category of endo, but there probably is a population where that would be helpful.
[Dr. Mark Hoffman]
We're looking at four or eight or some number of different presentations, but they all are just under the endometriosis umbrella and we're studying them all together when they may have very different presentations or they may be impacting patients very differently, each one, and so we're all grouping them together. Is that the challenge that you're saying?
The Role of Social Determinants of Health (SDOH) in Endometriosis Treatment
The social determinants of health, including factors like socioeconomic status, education, and neighborhood environment, can significantly impact the diagnosis, progression, and treatment of endometriosis. These factors may also contribute to the concept of "weathering," where the prolonged impact of social stresses can exacerbate health conditions over time. In the context of endometriosis, weathering can be a significant concern, as the chronic nature of the disease often intersects with long-term social stressors. Addressing these elements requires a multifaceted and individualized approach to care that recognizes the complex interplay between physical health and social dynamics. The future of endometriosis care must move beyond mere symptom management, focusing on a comprehensive understanding of each patient's unique circumstances and the integration of various therapies tailored to their needs.
[Dr. Amy Park]
The thing that I think about is this whole concept of the delay of diagnosis. You have a nerve injury and then back in the days of transvaginal mesh kits or whatever [unintelligible 00:44:44] entrapment, you get it right away, you take out the stitch, it's fine but if it's greater than-- we don't even know how long a period of time it takes then it becomes a chronic problem. I see this manifest in different arenas. I don't know if you guys read a couple of weeks ago in the New York Times, there's that concept of weathering.
These black teenagers, if they entered motherhood when they were teenagers, they were fine, but as they got older the outcomes got worse. It's like your body undergoes this stress associated with all these social determinants of health and whatever. Endometriosis is a true physical issue and the more you've traveled down that path, the harder it is to reverse or what have you. It's a big problem. I was talking about this with my resident in clinic many years ago. I came out and I was like, "Gosh, this patient is so negative, and the doctors." A lot of doctors can't-- residents and a lot of doctors do treat their patients with pain really poorly. [chuckles] There's a lot of heterogeneity in the way the patients get diagnosed and treated and validated like you alluded to earlier, Isabel.
All of that is part of the art of medicine and doctoring and it's tough. I see all these gaps in our knowledge and our patient care getting filled by the internet. They're going to Facebook [chuckles] groups to get advice. It is very sobering but also fascinating what's been bubbling up. Actually, then you see academic literature analysis of the social media I'm using [chuckles] which I also love, but it does inform us of what's going on. There's stuff like, I didn't even think about this and boo on me.
I don't put in a lot of IUDs, but the pain with IUD insertion that became a thing on TikTok and Green Journal article and all these other things and endometriosis the same way. It's like the patients are bringing up all this patient experience stuff. Now the celebrities are coming forward and saying, "Give raising awareness", which I also find super fascinating. The lists of the vetted surgeons that you guys I'm sure part of and acknowledged it's part of the vernacular. I find it all really fascinating. I'm in parallel to it. I am on some lists. Like on Facebook, some patient told me, "It's not like for you guys totally different."
[Dr. Mark Hoffman]
I'm not on Facebook. I want to hear Isabel's feeling about all these things. Some of these groups are very strong in their feelings about one approach to management or another. Some are excision is it. If you don't do these massive excision surgeries, you're not managing endometriosis and others-- everyone has their feelings about it. This is coming from a place of pain and frustration and failure from the medical system on these folks. I can see where this is coming from, but as a surgeon with what we're talking about how complex it is, it's hard for me to believe that there's a simple approach to managing this incredibly complex disease process.
[Dr. Isabel Green]
Of all the data on surgery that exists, the best data is on excision of deep endo, nodules of endo, uterosacral fibrosis. If you can imagine going through an experience of being delayed in a diagnosis or seeing multiple providers and there is this treatment that has some good inner research to support outcomes, I think I understand that mission to educate and to promote that option for these patients. If you follow social media, it's interesting in that I do think that there's this greater sense now though of the complexity. I think that wave is coming and I think people are appreciating that even excision of deep endo and fibrosis and scarring is helpful, but there are extra abdominal manifestations of disease.
There's other things happening that I think there's a greater understanding and sharing that it's a heterogeneous disorder and not just solely explained or treated with the surgery. I get though that if you've had a lot of poor outcomes and poor treatments and there is something that has evidence behind it. I think what's hard is that there's not great evidence in the world of superficial disease. Those are probably the patients that we understand the least because they have the smallest disease and significant pain and persistent pain a lot of times after excision.
From a patient's perspective, I understand it. I think what helps is to talk to patients about what we do know. We do know that if you have another overlapping pain condition. We know that the outcome of your excision surgery is less robust if we don't address those other sources. Not that excision surgery isn't needed for your pain, but that we really do need to cover all our bases to get the best outcome we can for our patients, and so trying to put excision surgery, I think, in the context of a multimodal therapy, I think is the individualized way to treat patients, and I think that resonates. It's this or that, I think. It's excision surgery or chronic pain meds. It's excision surgery or psych. There's a role for all those components depending on that exact patient. Each patient's going to be different.
Dr. Isabel Green
Dr. Isabel Green is a gynecologist, clinical researcher, and assistant professor with Mayo Clinic in Rochester, Minnesota.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Dr. Mark Hoffman
Dr. Mark Hoffman is an OBGYN and minimally invasive gynecologic surgeon with University of Kentucky Healthcare.
Cite This Podcast
BackTable, LLC (Producer). (2023, June 29). Ep. 26 – Persistent Pain in Endometriosis Patients [Audio podcast]. Retrieved from https://www.backtable.com
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