BackTable / OBGYN / Podcast / Episode #26
Persistent Pain in Endometriosis Patients
with Dr. Isabel Green
In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Isabel Green, fellowship director of MIGS at Mayo Clinic, to speak about persistent pain in endometriosis patients.
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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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.
Dr. Green begins by defining endometriosis as endometrium-like tissue that grows outside the uterus, but emphasizes the complexity of the disorder with its varying phenotypes and inadequate knowledge about the disease process. Patients with superficial endometriosis can have terrible pain while others with deep disease may have little pain. It’s also common for people to have comorbid conditions, like IBS, fibromyalgia, migraine, myofascial pain, and central sensitization disorders. This makes it a difficult disease to diagnose and treat, and highlights the need to tailor therapy for individual patients. The doctors discuss the lack of data to support pain medications like gabapentin or amitriptyline, and even the typical treatments of birth control pills or excision surgery can fail to help patients.
The doctors then go on to discuss the pathophysiology of endometriosis. Dr. Green believes it may be different for different people as retrograde menstruation fails to explain all cases of endometriosis. There is research on immune dysregulation and inflammatory cytokines that could show the disease is systemic and not just contained in the pelvis. Additionally, some believe it could be cells transforming similar to a malignancy or even a nervous system issue, but more research is needed on the topic. There is a lot we still don’t know about endometriosis.
Next, Dr. Green explains the challenges in diagnosing endometriosis. Patients have variable symptoms, people may dismiss pelvic pain and normalize the symptoms, and ultrasound/MRI is only good at visualizing deep lesions. It is often years by the time patients go to surgery and endometriosis is visualized.
The episode ends with the doctors discussing how to manage patients long-term, especially if the typical treatment of hormonal and pain medications and excision surgery fail. Listening to the patient’s history, knowing exactly what the patient’s lesions looked like during surgery, repeat imaging, and learning the degree of neural involvement can help tailor the next steps. It’s important to remember that the treatment of endometriosis is a marathon, and it’s necessary to acknowledge the patient’s pain.
[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.
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