#436 Endometriosis for the Internist with Dr. Cope & Dr. Green

April 22, 2024 | By Carolyn Chan

Audio

Video

Transcript available via YouTube

Energize your education on endometriosis! Learn common clinical presentations, optimal diagnostic imaging tests, and how to counsel patient on treatment options. We are joined by Dr. Adela Cope (Mayo Clinic) and Dr. Isabel Green @isabelgreenMD (Mayo Clinic).Claim CME for this episode at curbsiders.vcuhealth.org or here!

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Show Segments

• 00:00 Intro 
• 03:00 Guest Introduction
• 06:45 Topic
• 07:30 Endo Definition & Symptoms
• 14:40 Endo phenotypes
• 21:30 Differential Diagnoses to Consider
• 25:47 Making a Diagnosis 
• 31:00 Imaging to consider
• 37:40 Endo Hormonal Treatment Optiosn
• 48:30 Monitoring Treatment
• 52:20 When to Refer
• 57:30 Surgical Treatment
• 1:09:20 Pain Management
• 1:13:30 Take Homes
• 1:19:00 Outro

Endometriosis for the Internist Pearls

1. Endometriosis (endo)  is a common condition that affects one in ten reproductive-aged individuals born with a uterus or ovaries.
2. The symptoms of endometriosis can vary and may include dysmenorrhea, pain with intercourse, pelvic pain, and other symptoms that span across organ systems.
3. Pelvic or transvaginal ultrasound can be utilized as an initial screening test for an individual you suspect may have endometriosis. However, normal imaging does not rule out the diagnosis of endo. 
4. Laparoscopy with a tissue diagnosis is the gold standard for making a diagnosis of endometriosis. However, if clinical suspicion is high, one can still offer treatment with hormonal therapy even without a surgical diagnosis.   
5. First-line treatment is often hormonal therapy such as a combined estrogen-progestin OCP pill or progesterone pill for individuals who do not desire pregnancy.
6. If a patient does not respond to hormonal treatment, this does NOT rule out the diagnosis of endo. 
7. For patients on a combined estrogen-progestin OCP for endo, if individuals are not meeting their treatment goals, consider switching from taking the pill in a cyclical manner to a continuous manner to fully suppress their menstrual cycle (e.g. don’t take the placebo week).
8. If abnormal imaging is present, a patient is not meeting treatment goals, a definitive diagnosis is needed or sought, or fertility is desired, refer to a specialist, ideally a multidisciplinary center for endometriosis care. 
9. Be sure to validate the patient’s pain and take a multidisciplinary approach to managing endometriosis.

Endometriosis for the Internist – Notes

What is Endometriosis 

Endometriosis (endo) is the presence of endometrium, or endometrium-like tissue, outside of the uterus (Zondervan, 2020). Endo lesions can vary, they can be superficial, nodular, or associated with fibrosis and scarring. It affects approximately 1 in 10 reproductive-aged women or people born with a uterus or ovaries (As-Sanie, 2019).  It takes the average person 7-10 years to be diagnosed with endo from the onset of symptoms (As-Sanie, 2019). Endo is not always progressive, but it can be in some individuals (Zondervan, 2020). At this time, we do not fully understand the pathogenesis of endometriosis, and ongoing basic science research will explain the disease process better. 

Overview of  Endometriosis Phenotypes

• Superficial 
• Invasive – Associated with fibrosis & scarring. 

Common Endometriosis Symptoms

Endo symptoms can vary greatly between individuals (Zondervan, 2020). Consider the 3D’s: dysmenorrhea, dyspareunia, and dyschezia as symptoms that should make you consider endo on your differential diagnosis. 

Some presenting symptoms of endo can span organ systems. For example, some individuals may present with more bowel-related symptoms such as bloating, painful bowel movements, and dysuria. Notably, pain can occur during and outside of menses. Certain individuals experience generalized fatigue. Individuals can even be asymptomatic from endometriosis lesions. More research is needed to better understand the etiologies, mechanisms of disease, and responsiveness to therapy for endometriosis. 

Differential Diagnosis Considerations

“Sometimes, always think endo and sometimes think of other things besides endo.” – Dr. Green 

Endo patients are at higher risk of developing other pain disorders, such as irritable bowel syndrome (Chiaffarino, 2020). They are also at increased risk for central sensitization and chronic overlapping pain conditions (Green, 2022).  Furthermore these patients may also experience myofascial pain. When developing your differential for a patient, be sure to consider endometriosis as well as any co-occurring conditions, as they can impact management. 

Making a Diagnosis

It can be challenging to make a diagnosis of endo.  Clinical history, physical exams, imaging, and labs can be helpful to make sure you are not missing something else, but have their limitations.  Most of the time, endo will be a suspected diagnosis based on a patient’s symptoms. 

ESHRE Guidelines (Becker, 2022)

“It’s important to be aware too that even if all of your workup comes back negative, all of the imaging is negative. That does not tell you for sure that you do not have endometriosis… It can be difficult even to diagnose at the time of a laparoscopy depending on the eyes that are doing the procedure and looking for lesions.” – Dr. Cope

Society Guidelines for Endometriosis: (Kalaitzopoulos, 2021) 

• ACOG, 2010 
• ESHRE Guidelines (Becker, 2022)

Imaging

Many different factors can influence the sensitivity and specificity of identifying the disease on imaging. For an internist, imaging is a way to rule out diseases that may require an earlier surgical consult. Dr. Green suggests thinking that an absence of positive findings on imaging can help keep patients in your clinic, and if there are findings (e.g., endometrioma), consider an early referral for a surgical consult. She reminds us that the lack of any findings on imaging does NOT rule out endo.

Either a pelvic, abdominal, or transvaginal ultrasound can be used as an initial screening test for a patient you suspect may have endometriosis  (Zondervan, 2020). A pelvic MRI can be considered in certain patients but should not be used as an initial screening test. CT scans have many limitations in assessing for endometriosis and the pelvic organs in general. From a GYN lens, CT scans are less helpful to look at the uterus, ovaries, and surrounding structures. 

Treatment

History can be sufficient enough to start treatment without a laparoscopy or formal referral to OB/GYN.  Be sure to consider other possible pain generators if individuals are not experiencing any improvement from treatment. 

Hormonal Therapy

First-line treatments are geared toward hormonal suppression, which are typically estrogen and progestin-containing contraceptives that can be pills, patches, or vaginal rings, depending on the patient’s preference  (Zondervan, 2020). Alternatively, if a patient is not a candidate for an estrogen-containing method of hormonal suppression, consider a progestin-only option. In addition, conservative treatments can be considered, such as NSAIDS, and acetaminophen. 

Use patient-centered, functional goals to determine and monitor treatment effectiveness. For example, some individuals may require complete suppression of menses to improve function, and others may not. It is important to note that pain from endo can still occur even if an individual has their menses fully suppressed. 

Surgical Treatment

The goal of surgical treatment is to obtain a diagnosis and improve the symptoms. Specialists will often offer a diagnostic laparoscopy with the possible excision of endometriosis lesions. Recovery is often 2 weeks, with lifting restrictions, pelvic rest, and 2 weeks off from school or work. Depending on the phenotype of endometriosis, having surgery could potentially impact the patient’s fertility, so it is important to discuss this with the patient. If there is deep endometriosis involving multiple organs, sometimes collaboration with other surgical specialties may occur depending on the extent of the disease. Recovery can be longer for more complex surgeries.

Hormonal suppression after surgery can reduce the risk of recurrence of endometrioma, lengthen the improvement of symptom benefits after surgery, and reduce the risk of recurrence of symptoms. If patients can tolerate it, they should resume hormonal suppression after surgery.

When to consider referring to OB/GYN

• Abnormal imaging 
• After attempting 1-2 hormonal treatment strategies and treatment goals are not achieved
• Fertility goals
• Assess for other pain generators on a pelvic exam
• When considering a laparoscopy for a definitive diagnosis

Ideally, a patient should be referred to a specialized endometriosis center, which may include OB/GYNs who have completed a fellowship in minimally invasive surgery.  If there is a lack of access to these specialists in your area, find practices in your community that can add meaningful treatment, imagining, or surgical excision to your patient’s care. 

Endo related pain

If you are seeing pain outside of menses related to endo, and physical findings of central sensitization, in Dr. Green’s opinion, consider starting a neuromodulator like amitriptyline or gabapentin.  Consider working with pain psychologists. More research is needed in this area. Chronic opioid therapy is not recommended for chronic pelvic pain, though in Dr. Green’s expert opinion, there is possibly a role for judicious use of opioids in some patients, for the management of flares if first, second, and third-line treatments are ineffective. 

Links

1. Missmer article: Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020 Mar 26;382(13):1244-1256. doi: 10.1056/NEJMra1810764. PMID: 32212520.
2. Green article: Green IC, Burnett T, Famuyide A. Persistent Pelvic Pain in Patients With Endometriosis. Clin Obstet Gynecol. 2022 Dec 1;65(4):775-785. doi: 10.1097/GRF.0000000000000712. Epub 2022 Apr 15. PMID: 35467583.
3. International Pelvic Pain Society
4. Beyond the Belt

Goal

Listeners will describe clinical symptoms, work-up, and treatment of endometriosis.

Learning objectives

After listening to this episode, listeners will…  

1. Identify common clinical presentations of endometriosis
2. Develop an approach to diagnose endometriosis
3. Describe medical treatment options for endometriosis
4. Describe surgical treatment options for endometriosis.

Disclosures

Dr.  Adela Cope and Dr. Isabel Green report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Chan CA, Cope A, Green I, Williams PN, Watto MF. “436 Endometriosis for the Internist”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast April 22, 2024.