Gynecologist Jeannette Lager, MD, MPH, associate director of the UCSF Endometriosis Center, offers a thorough update on this painful condition impacting around 10% of U.S. women. She notes essential elements of the history and physical exam, including tips on assessing pelvic pain, then discusses treatments, ranging from NSAIDs and hormones to surgical options. Learn to align therapeutic choices with patient goals and better appreciate all the factors influencing pain perception – and relief.
Great. Thank you so much for that introduction and um I'm glad that all of you are here to hear about endometriosis and chronic pelvic pain. It's one of my passions. um and so um I'm excited to share that with you. I have no disclosures, um, and I do appreciate you taking your time out of your busy days, um, to listen. We're gonna go over um a few things. We're gonna talk about endometriosis, dysmenorrhea, and chronic pelvic pain, discuss the initial management for treatment, um, rationale for imaging, and then when to refer patients. Um, is, um, as she mentioned, we, we do have a comprehensive endometriosis center, um, and so, um, I'll go over a little bit of that evaluation, the treatment modalities, and then answer any questions that you put in the Q&A chat at the end. So, dysmenorrhea in general is painful menses. Primary is when it is in the absence of pathology, whereas secondary, of course, is when there is a reason for the dysmenorrhea. It's very common in young women from the time, in young patients when, from the time when they start their period, um, as high as 50 to 90%. Um, can lead to students that end up missing school. Um, they administer pain medications, um, even before seeing a physician for evaluation and can be associated with nausea, vomiting, difficulty sleeping, um, among other symptoms. The secondary dysmenorrhea, as I mentioned, is related to um some etiology. One of the most common is endometriosis and that's what we're um focused on. But because dysmenorrhea is so common um among patients, even from the time of their first menses, um, the time to diagnosis can be quite long. So on average, it's 7 years, um, ranging from 3.5 to 12.1. Endometriosis, um, as you likely know, is when the ectopic endometrial glands are noted in other areas outside of the endometrial cavity. So most often that's in the pelvic area, near the ovaries, behind the uterus, by the bladder, um, sometimes near the bowels. Um, occasionally we can see it near the diaphragm and, um, rarely, patients can even have pleural endometriosis. It's estrogen-dependent, um, and, um, it's an inflammatory condition that can affect women in all stages of life. The prevalence is very difficult to estimate, um, because of delay in diagnosis. Um, some patients Don't necessarily present. Um, so it's about 10% as we, is what we estimate in the US and it has an incredible economic impact, um, where patients will have enough pain that either they're missing school or work and can cause a decrease in, um, employment productivity of 16.9% and up to $87 billion. Um, so, this is just a laparoscopic image of the uterus. You can see the bilateral fallopian tubes, the white off down at the bottom is um the ovary and the bowels are at the bottom. Um, and what happens with endometriosis is that as, um, these inflammatory, um, signals occur with each menstrual cycle, the Endometrial glands that are outside of the uterus cause chronic hemorrhage, inflammation, and this can lead to areas of fibrosis and ultimately distortion of pelvic architecture. So in the image to the right, you can see that there's some areas where you can see the dark patch. of endometriosis. Um, it can sometimes be, um, what they would describe like is powder burn lesions. It can look like clear vesicles, and later I'll show you pictures, um, comparing to adolescents who can, who can have very subtle, um, images, but, um, you can see the different types of endometriosis here. What can also happen is, um, Where distortion of pelvic architecture where the ovaries can be in a kissing appearance, so they're actually stuck together, um, there can be obliteration of the posterior cul-de-sac because all of that area of endometriosis and fibrosis, um, it can often meet there and, and can distort the pelvic architecture. The most common theory as to why endometriosis occurs is Samson's theory, which is, um, a theory of retrograde menstruation, so that when a patient starts their period, that the endometrial cells travel through the tubes, um, Into the pelvis, that we do know that people do have retrograde menstruation that's, that's been noted prior to this, even prior to that kind of a diagnosis of endometriosis. Um, but that's the most common theory. However, some challenge this theory because there are patients who present even premenstrual with endometriosis, um, and so it's thought that it may be also related to a mallerian embryonic breast or some sort of, um, Preceding, um, Occurrence that happens prior to menstruation, so even um related to endogenous estrogen from um the parent, from the mother, that they can have an increase of um endometrial cells for that reason as well, or that it may be vascular lymphatic spread. And as we mentioned, um, that this can cause the alterations which can cause disease. Risk factors for endometriosis include obstruction of the menstrual outflow, similarian anomalies, um, prolonged endogenous estrogen exposure, so, um, if a patient has never been pregnant before, um, If they have early menarche, um, late menopause, DES exposure in utero, um, a history of childhood trauma, lower BMI, and shorter menstrual cycles. Protective factors include multiple births, kind of the opposite, multiple births, extended intervals of lactation, where they're amenorrheic, and late menarchy. The most common symptoms that patients present with are dysmenorrhea, pelvic pain, dyspareunia. Sometimes they'll present initially with a nexal mass, especially if they don't have many other symptoms. It may be a finding it when they have an ultrasound for a different reason. Um, same thing with infertility, they may come in for an infertility evaluation, not have any symptoms related to their period, but then are noted to have, um, an endometrioma. And then less commonly um related to endometriotic lesions that are in the bowels or near the bladder, they may have dyskesia, dysuria, hematuria, rectal bleeding, um, or shoulder blade related to, um, referral pain, um, of the endometriotic lesions of the diaphragm. There are no clinically useful biomarkers to diagnose endometriosis. Um, we know CA 125 is often elevated but can be elevated in many, many other inflammatory conditions. Um, the ultrasound and MRI can sometimes identify cysts that are endometriomas. Um, however, those are limited to the size of endometriosis lesions. MRI usually doesn't pick up lesions that are, um, smaller than 5 millimeters, and, um, it can also be tricky because a cyst that appears to be an endometrioma could also be a hemorrhagic cyst, um, but if it is persistent, because those both can be very similar, if it's persistent and often is an endometrioma, so it's, um, Close to diagnostic, but the definitive diagnosis is laparoscopy and biopsy of the surgical specimen. Um, first-line treatments include hormonal agents. Usually, what, um, most patients will have, have already tried NSAIDs or other forms of, um, analgesia. And then, um, Really the whole gamut of hormonal, um, medications are options. So that could be the M Mirena IUD, combined oral contraceptives, progesterone-only pills, Nexplanon, Depo-Provera, um, NuvaRing or the vaginal ring, um, and all of those will help improve the, um, symptoms of endometriosis. Um, and the decision of which to start with and which one, to do a trial of is directly related to kind of the patient's medical conditions and history and then, um, what, what they prefer to use as well. So as we talk about the first-line treatments, um, you know, I think it's very, even though the gold standard is laparoscopy, we can also manage and treat patients for endometriosis without a surgical diagnosis. And when patients have, um, the majority of the Symptoms, they have a negative ultrasound to rule out other um anatomic pathology. Um, I think that it's very reasonable to give them a presumptive diagnosis of endometriosis and move forward with um treatment options. So, um, NSAIDs, hormonal management, and then I'll go into further detail about, um, some of the other treatments. So the question of when to refer patients to the endometriosis center, um, that can be really anytime when it feels like, um, You would prefer to have um an opportunity to have the patient talk to us as well. Most of the time, when we see patients, um, they have already had a trial of NSAIDs, hormonal management. They may have tried 5 different birth control pills, an IUD, um, they may, may have tried only, you know, a couple of different hormonal, um, regimens, um, before they're referred. If If a provider is comfortable doing a trial of one of the GRNH agonists or antagonists, I think that that's very reasonable too. Um, the issue with the GRNH agonist and antagonist is sometimes they can be a little bit difficult to get approved or they need pre-authorization, um, so that can sometimes take a little bit of, um, time to, to take care of that. Um, but I think that Any form of management that a provider feels comfortable with, um, makes perfect sense and then referring when it's out of the, the provider's comfort level or, um, scope. Um. Typically, we'll see patients who usually have ultrasounds prior to coming to see us as well, um, but Um, but that's, that's generally where, when we usually will see the referrals. The other time that we'll see referrals is sometimes if the patient has, um, Really negative experiences with birth control pills or hormonal medications and they strongly desire surgical diagnosis, um, prior to starting hormones just because of their negative experiences, then, um, sometimes they'll be referred to us as well. Um, and I think that's, that's very reasonable as well. We can always discuss risks and benefits of surgery with the patient. Um, other considerations for management, um, is just because pelvic pain, um, the etiology of pelvic pain is so broad and the diagnosis can be multifactorial, that, um, if it seems like it's more likely painful bladder syndrome, um, which often overlaps with endometriosis, then, um, it would make sense to do a referral to urology, um, prior. To referral here and then um GI if it's related to IBS. Sometimes patients will have back pain or they'll have other musculoskeletal issues or um PT can be helpful. Um, there are pelvic floor physical therapists too that kind of focus on the pelvic floor and so that can be very helpful for patients. And then if they have other overlapping chronic pain, um, Conditions, then pain management or pain anesthesia can be helpful. When um they get referred to us, and I'm sure that this is the same thing that you're doing when um you're evaluating patients is that we, we always take a history of their pain. Um, with pelvic pain, it's particularly important to hear A detailed story of when, um, when they first started having the pain. Was it from the time that they first started having menses? Um, what have they, um, taken so far? What makes it worse and better? Um, the quality of the pain and the location. So if it's more vulva pain, I think that's very Helpful information when we're thinking about a focused exam. If it's dyspreunia with deep penetration, um, if the pain is only during their cycles, if, um, oftentimes patients who have pain for a long time, they'll start by having pain during their cycles and then it'll become outside of, um, the time that they have their period. Um, if there's any temporal association with other events, and I think the other thing that can be helpful is just to, they can keep a pain diary or a calendar to know when they're having the pain. Um, taking this history, I think can be helpful too because it helps us think about um, what their goals are, um, of care. So for example, if they have very severe pain that they rate as a 9 out of 10, and it's causing them to miss work or school in a way that they weren't able to before, that may be one of their important goals of care is to get back to doing their normal job. Um, When taking a medical history, it's important to cover any other pain syndromes. So sometimes patients will have fibromyalgia and to try to differentiate some of their symptoms of fibromyalgia with their um endometriosis symptoms. Psychiatric, Pediatric history can really increase their um pain sensitivity and so, um, if they have high anxiety that's untreated or depression, that can make their pelvic pain much worse. Um, and then a sleep history because it may be that they have a pre-existing sleep condition, um, that is separate from the pelvic pain and endometriosis pain, so just making sure that that's treated as well. And then it's helpful to know what treatments they've done so far, what the outcomes were of each of the treatments, whether it helped, um, if it made the pain worse, um, side effects to the medications, and I think that can be really helpful as, um, we think about what we recommend for each patient. Um, if they have significant side effects, try 10 different birth control pills, then, you know, it would, I would likely not recommend birth control as one of the first recommendations for that patient. But then, you know, they, it might be that they only took each birth control pill for 1 week or 2 weeks, um, and I think that that is hard to really get a good trial of that specific birth control pill. So that would be another aspect of, of taking an opportunity to kind of talk them through all of that. If they've had previous surgery, it's very helpful to have the details of the surgery. Um, patients will sometimes have just a diagnostic laparoscopy, so, um, a surgeon will look in, see if there's endometriosis or not, and, um, then take out the camera and that's the end of the procedure. So sometimes it can be a really quick surgery, um, And so it's helpful to see the op report. Um, surgeons will often give their patients pictures from the surgery, um, so the, that, that's really helpful to see and to see the extent of endometriosis. Um, with a, a patient who's had a conversion to an exploratory laparotomy from a laparoscopy, that tells me that there was probably significant adhesions or maybe related. To previous surgeries like a C-section or tubal or, or other surgeries or they might have a history, say, of tubal ovarian abscesses and because of that, they have significant adhesions. So, um, usually the operative report and the details of that can be very helpful. Um, and they might have something like if they, for example, had a history of heavy menstrual bleeding. We're done with childbearing and had an endometrial ablation, which is um a procedure that treats the middle part of the uterus and heats it up to decrease bleeding. They may still have pain that they had thought was related to the bleeding but the pain is persistent because an ablation doesn't always help with the pain aspect, um, and so that can be helpful to, to understand and think about their history. Abuse, the history of abuse is very common in patients with chronic pelvic pain. Up to 47% of patients will have um a history of abuse. It can be helpful to just get the details of um physical, sexual, or emotional abuse, whether it's current or it's happened in the past, and that information can be very important to inform tra Our trauma-informed care. So, um, to know what might be traumatic or trigger triggering with the procedure, to use the appropriate language with each patient, have a chaperone in the room, talk about where the chaperone would be in the room, um, for the exam, discuss the exam in advance, what components of the exam, um, we'd be doing, and Um, also, for example, if we're doing a transvaginal exam or ultrasound, um, to kind of talk them through any imaging that we did so they know what that we would do so that they know what to expect. Um, some patients who can't tolerate exams at all, um, we can always plan to, um, either do an exam under anesthesia or with premedications. Um, it's helpful to talk about their current treatment regimen, so not only the treatments that they've done in the past, but what they're doing currently, um, including any medications, narcotics, hormones, any topicals. Um, a lot of patients who see, um, a naturopath or have, um, another Integrative medicine provider may offer, you know, they may be taking supplements for that reason. They may use illicit substances, they may be getting their prescriptions from, um, a family member or friend, so it's helpful to just know what medications they're on, how, um, they obtain the medications, and then any other treatments, osteopathic treatments, acupuncture, um, and how much their activity is limited and how those medications kind of manage that. And I think that when we talk about um the current treatment regimen and what the outcome of what they're doing currently, it can be very helpful to talk about expectations moving forward. So, if a patient has had pain, for example, for 20 years, um, it's rare to be able to treat that pain and have it go away in a month. It, it, it often has overlapping um Reasons for the pelvic pain and just takes time to kind of work towards a place of less pain and maybe not no pain at all, but at least to decrease their pain. Um, for the exam, um, we'll do a, a detailed exam and we don't always do the exam on the, um, first visit, especially because a lot of patients come from so far away. We utilize a lot more, um, telemedicine to be able to do consultations with the patients. So, um, and I think that that's great, especially for the patients so that they don't have to drive 4 or 5 hours to get to, um, Mission Bay. Um, and so, um, we, this may be either the first visit or this could be a separate visit. And, um, to do a general exam, um, at the time of the abdominal exam to just look really carefully to see if there's any scars, masses, um, palpate the back and the flank for any tenderness. Um, if there's areas that are perhaps trigger points for the patient that can be really helpful and it's helpful when we think about treating trigger points, um, during the exam. The scars can be really helpful because sometimes um they um they're very good descriptors of surgical history. Um, so if a patient may have had an appendectomy but it was 18 years ago, um, We'll see that, that it's an open incision and, and that's helpful when we're kind of thinking about surgical planning. Um, Then, after the abdominal and back exam would be a visual inspection of external genitalia and particularly with someone who has vulvodynia, um, to look carefully for other diagnoses such as lichen sclerosis, um, or other, other reasons that that they could have the pain, they could have, um, fissures or some sort of vaginal trauma and that can be helpful from that initial inspection. And then a neurologic exam, often what I'll do is I'll take a cotton swab and break it in half so that there's one side that's a little bit sharper and then the cotton swab side and to do a careful exam on the external genitalia, um, to see if sensation is equal, um, can check reflexes, and then, um, also to identify any areas of, of pain. For the speculum exam, um, looking for any discharge, um, any signs of atrophy, trauma, infection, do a wet mount if appropriate, and then also to look at the location where the cervix is. If the cervix is, um, asymmetric or, um, You know, very, very anterior. Those are all signs that they could have, um, significant uterosacral endometriosis, um, so that can be helpful information as well. Then, um, after I do the speculum exam, I'll do a single, single finger digital exam. So usually just one finger and I try to let the patient know that it's just gonna be one finger, um, And um start with the perineal muscles. So kind of going from um most distal to deep, so perineal muscles, and then I'll have the patient contract and relax because, um, we, that can give us an opportunity to check also for pelvic floor dysynergia, um, which pelvic floor physical therapy can be, be very helpful for. And then I go to, um, basically 3 o'clock and 9 o'clock to check operator muscles. Um, 5 to 7 o'clock for the piriformis muscles, which is the whole, um, kind of basket weave of the large, um, pelvic floor muscles, and then behind that, um, piriformis. And then, um, bladder tenderness, um, which can be either related to endometriosis or it can be painful bladder syndrome. Um, to move the cervix to check for, um, cervical motion tenderness which may not be related to PID but can be related to the endometriotic lesions on the, um, uterus sacral ligaments, um, rectal and rectal tenderness. Then, um, after the single, um, finger digital exam, we'll do a bimanual exam to evaluate the uterus, and NEA, and then, um, sometimes a rectal vaginal exam which can be very helpful if the uterus is, um, retracted back, um, and very retro. Reflex, which we often can see with stage 4 endometriosis is where the ovaries are in a kissing appearance behind um the uterus. The uterus is tilted back, um, and so, um, to examine for an obliterated cul-de-sac or uterusacbral nodularity. As I mentioned that most patients will have had um an ultrasound performed before I see them, um, often normal. Sometimes they'll be, um, ovarian cysts, and if there is an endometrioma that increases the likelihood that they'll have an obliterated cul-de-sac by 5, and it also allows for a diagnosis of maerian anomalies. We often consider doing a dedicated MRI and we've worked closely with the radiologists here and have a multidisciplinary team and we meet, um, regularly twice a month to review, um, images together. Um, and so they have a special protocol to evaluate for areas of deep infiltrative endometriosis and, um, depending on what the findings are and what the patient's symptoms are, we can also do, um, rectal and vaginal Contrast. If a patient has, um, either, let's say a lesion that was noted on colonoscopy, it can be helpful to do rectal contrast. Um, if they have rectal bleeding, that can be helpful. Um, and, um, sometimes we'll see lesions that are posterior to the cervix or lateral to the cervix and the thoices that, um, are endometriosis and so the vaginal, um, contrast can also help to kind of delineate those, those borders. So when we think about treatment options, um, the goals are symptom relief, suppressing, um, disease progression, or future fertility. And I think that this is when it's important to kind of talk to the patients about what their main goals are, because some, for some patients, for example, fertility may be their number one, goal, and so they might have minimal pain or even if they have pain, they really wanna focus on, um, fertility. Um, so, Any sort of hormonal contraception or hormonal management that gets in the way of fertility would be, um, we wouldn't use as a, as one of the treatment options. Um, some patients desire future fertility but have so much pain that they would rather address the pain first and then, um, follow with their desires for pregnancy. Um, and then there's, then we always think about the conversation of, um, especially for example, after surgery or how to suppress disease progression. It is often multifactorial, so it depends on what we see on the physical exam from their history and what treatments, um, discussed with the patients if further imaging is appropriate as we're making those decisions that you're gonna, um, Proceed with any referrals, um, we also go through the same. We have a great team of urologists, um, colorectal surgeons, um, pain anesthesia, pain psychology, integrative medicine on our teams, and so, um, we'll sometimes refer, um, to different, different folks in the, in the integrative center, and then, um, also consideration of pelvic floor PT. And so we have a pelvic floor physical therapy. The group that sees patients in our office, um, but we also will refer out, um, ideally, it's great for patients, especially if they don't live close to UCSF to, um, be able to see somebody that is, um, closer to them and we'll give them resources of, um, outside pelvic floor physical therapists, um, or they can see our pelvic floor physical therapist and our pelvic floor physical therapists also do, do telemed if there isn't anybody that is near them or is not covered by their insurance. And before I discuss um treatment options in further detail, I just want to review a few theories of pain because I think it can be helpful to direct treatment options. In the early 1960s, a new theory of pain was developed by um Ronald Melzack and Patrick Wall to account for um the importance of the mind, brain, um, relationship and pain perception, and it's called the Git Control theory of pain. This theory accounts for the physiologic basis for the complex phenomenon of pain, and it does this by looking at the two major divisions. So there's the peripheral nervous system, all the nerves that are outside of the brain and spinal cord, including branching nerves in the torso and extremities, and then the central nervous system, which includes the spinal cord and the brain. So if you look at this image, you know, let's say somebody gets hit in the hand, the painful stimulus will um send A response to um via the A, delta, and C fibers to the dorsal horn, and then it then travels to the secondary neuron and up to the brain, and then the brain detects pain. Conversely, if there is um deep touch or pressure, um, this can travel through the pin and corpuscle, and then, um, travel to the dorsal horn as well, and that can have a negative or an inhibitory effect on the, um, interpretation of pain. Um, so this is why sometimes when someone gets hit on the hand and you kind of rub the hand or, or Put pressure on it. It's using a different um sensor, and it actually can inhibit the um message to the brain. So, this can be helpful because activation of touch sensors can then modulate the sensation of pain. Additionally, um, the neurotransmitters from a painful stimulus can, um, release neurotransmitters to make it easier to feel the sensation of pain, which then leads to pain sensitization. Pain sensitization is acute pain. When, when a patient has acute pain that's not managed over time, this long-term pain can continue to be amplified. Now, this is different from um the sensation of touch. So, for example, when you first put your socks on in the morning, you can feel a sensation of the socks, but as you go through your day, that, that sensation is diminished and you forget that you even have socks on. Um, but pain is actually the opposite where if a patient experiences pain, the gate there is important because it can The continued pain can amplify the pain, and so they may have pain that continues that's either leads to hyperalgesia, um, or it can also lead to central sensitization, where that stimulation continues, releases more of those neurotransmitters which, um, then travel up to the secondary neuron to the brain and then have increased hyperalgesia related to that. So if we look back at um the image for the gate theory, um, the yellow is the peripheral sensitization and where it can occur, where people will be hypersensitive and have a hypeathesia, and central um sensitization is where the red arrow is. So anywhere above, including the spinal cord, can be, um, Hyper-responsive and patients can experience more pain. This theory is important as we kind of think about the different treatment medications. So, um, we've talked about hormonal management, um, and I just wanted to review the other, um, areas where we think about treatment. So, um, First-line hormonal agents, birth control pills, vaginal ring, all of those. Second-line hormonal agents are um GNRH hormone agonists, and antagonists. Both of them down regulate the hypothalamic pituitary ovarian axis and can cause hypoestrogenism. So along with that, patients will often have hypoestrogenic side effects like hot flashes, sometimes mood changes, um, and that can range from 25 to 45% um that patients will have things like vasomotor symptoms. Um, we don't usually recommend it in, um, patients that we suspect primary dysmenorrhea just because those are often, um, adolescents and, um, it can affect their bone density, um, but we do consider it as a second line if, um, the other medications are not effective. Um, this can work really well for patients, but all of them have, um, most, most patients don't stay on this long term and are on it for, um, a period of time for management. Other, um, second line medications include danazol, which is an androgenic medication that will inhibit LH surgeon steroidogenesis, um, but some patients do not tolerate the androgenic side effects of it, which include acne, muscle cramps, weight gain, spotting, hirsutism, and voice deepening. And then aromatase inhibitors such as letrozole can be used for severe and refractory pain. Complementary therapies have been promising, but there's limited data on them. Um, exercise, heat, and if you think back to the, um, gait control theory, you know, heat, pressure, all of those things can help to decrease, um, the pain response. Dietary supplements have limited evidence, but, um, may be beneficial. There's some evidence that anti-inflammatory diets can be helpful, so I often recommend that to patients when looking at kind of the multiple treatment options for each patient. And then things like a TENS unit, acupuncture, herbal preparations, all of those have demonstrated some improvement in dysmenorrhea, uh, in some studies, but we, you know, like many herbal treatments, there's not a lot of data. It's a little bit less regulated, so, um, the safety and efficacy, uh, efficacy datas are unclear. Um Physical, um, exercise, activity, um, there's very little data, but there's also very little harm for those. Um, physical therapy and occupational therapy can be helpful, um, especially pelvic floor physical therapy can be super helpful. Osteopathy. Um, trigger point injections, sometimes, um, based on the physical exam, if the patient has specific trigger points that can make, um, a big difference. Um, for example, there can be patients that'll have just a trigger trigger point on their abdomen, um, near their C-section incision. It's, it's often on one lateral side or the other, and a trigger point injection with, um, uh, And analgesia like lidocaine, with or without steroids can make a huge difference, and I've had patients that have had a couple of trigger points and a pain that they've had for years will improve and go away. Um, so, there are, um, some studies that show that that can be beneficial. Studies that have looked at physical therapy and trigger point injection, they, they seem to be pretty similar, um, but can be used together, um. And along with that, sometimes the pelvic floor physical therapist, if they have a lot of um muscle spasm, we can also do um Botox of the pelvic floor, and that can help in conjunction with physical therapy to improve pelvic pain. Behavioral treatments include things like CBT, which, you know, is, can be a focused cognitive behavioral therapy where they can focus on pain management, um, psychotherapy, just depending on what other factors are contributing to their pain, and if their pain is related to dyspareunia and pelvic pain, sometimes there can be, um, other issues and communication and relationships, um, that can contribute and sex therapy can be very helpful as well. Pain sensitization as we think about um the different interventions for um pain, to think about it if it's more of a peripheral sensitization, if it's more central, um, and then using the medications accordingly. Um, as far as pain management, medications, um, and pharmacologic management, um, the World Health Organization had originally created an analgesic ladder that was, um, created in 1986, talking about kind of a three-step. Increase for um pain, severe pain being opioids, um, you know, starting with NSAIDs and other uh medications. And in 2020, it was revised to make it more of um Uh, bidirectional, um, ladder because patients may kind of move up and down along the ladder. It may be due to different, um, different diagnoses, and that if patients don't have pain relief, that it may be that there's a minimally invasive treatment, um, or invasive treatment that may be helpful to address their pain, and then it may be a step up when they're in their period. Pre-operative period of recovery and then I'll go back down as their pain improves. So, um, so, you know, this is not a perfect paradigm, um, but I think that it's helpful as we think about, um, treatment and medications and, and as we all are aware, um, opioids are a significant problem in our country and so, um, Avoiding opioids for mild pain. is, is obviously important. Um, other medications that um have shown a benefit are um anticonvulsants like gabapentin or pregabalin, and, um, antidepressant medications like tricyclics can be very helpful for neuropathic pain, um, SSRIs, and there's great good evidence for SNRIs as well. Some adjuvant medications can be things like um topical medicine, like caspasin cream, if if someone has um hypoestrogenic um symptoms that are related to the pain, using a topical estrogen or using antispasmodics? Surgical approaches, I think, um, whenever I talk to patients about surgical approaches, approaches, it's it's important to talk about um what their expectations are, what their priorities are, um, for the surgery, and, um, That's, that's exemplified and, you know, sometimes we'll talk about conservative surgery versus someone who's had pelvic pain for a long time and really wants definitive management. Um, and there's one retrospective study of 240 women, um, that either had just a laparoscopy with excision versus hysterectomy versus hysterectomy with oophorectomy, and the rate of reoperation changes significantly with each group, so 58% with laparoscopy alone. Um, 19% um risk for re-operation for hysterectomy, and then it goes down significantly for hysterectomy with oophorectomy. But, um, when we think about that, we also take into consideration, um, the effects of having surgical menopause and oophorectomy and And um, I'll always discuss with patients that when ovaries are removed for, um, benign disease, that the overall, all-cause mortality increases with the oophorectomy. Um, so we'll usually discuss the risks and benefits of each of those if we're talking about definitive management. Some patients have significant deep infiltrative endometriosis, where um, The lesions are invading into the bowel or the bladder, and so I think that it's really important to talk to patients about the risks associated with the procedure. If they have had multiple procedures, each procedure, um, the risk of, um, resolution of pain. The likelihood of complete resolution of pain or need for re-operation increases, so the shorter amount of time with each surgery, um, there's the risk of increased adhesions associated with repeat surgery. Um, so I think that it's important to kind of talk through all of that with patients and then, um, If they do have a lesion, for example, in the rectum or in the bladder, we also talk about um a multidisciplinary approach and working with our urology, our colorectal colleagues, and having them see those providers as well, pre-surgical to kind of discuss um what the patient's desires are and risk for, you know, bowel resection, risk of colostomy, even if it's temporary, um, so that they can decide what is the best approach for that particular patient. Um, the, so as far as surgical management, that can be diagnostic laparoscopy alone. Generally, we don't do, um, a diagnostic laparoscopy alone. We'll, we'll treat if we see areas of endometriosis, so that can be excision or ablation of endometriosis, adhesiolysis, so taking down any adhesions, performing ovarian cystectomy, and then if the patient strongly desires fertility, um, a chromoperturbation, which is where we insert dye into the, um, Cervix into the uterus and then look to see if um the dye passes through the tube, so evaluating for tubal patency and um the, these images you can, you can see um Compared to the previous image, laparoscopic images, this shows, really shows that distortion of the architecture where um the two ovaries are almost a kissing appearance, this I wouldn't call exactly kissing, they're not quite touching, but what's right in between them is the bowel adhesion and the bowel that's pulled up to the back of the uterus. So, um, often with patients who have stage 4 endometriosis, we'll see this. Um, then next picture shows just the adhesions of the uterus to the bowel. And then, um, the third picture shows all of the paraovarian adhesions and then, um, the bowel fat that's connected to the, um, posterior aspect of the uterus. Um, Diagnostic laparoscopy and excision of endometriosis is considered conservative surgery, so leaving all of the organs in place for as much as we can, uh, you know, rarely with an ovarian cystectomy, depending on the location and the size, we'll need to do an oophorectomy. Um, Otherwise, um, more definitive surgery is hysterectomy or plus or minus oophorectomy. And one of the goals of surgery is really just to kind of return normal anatomy back to its, it's normal location, um. Rather than being kind of tacked up like you see in and see. Really awesome. An additional note about adolescence, um, I had mentioned that I was gonna show a few images. With adolescents, the lesions can be really subtle, so sometimes they can just look like clear vesicular lesions. Sometimes they can be tiny, um, brown powder burn lesions, and so, um, they can be a little bit more difficult to identify. Um, often we'll do, um, peritoneal stripping or excision. and send them off to pathology, even if it's a subtle appearance of endometriosis and um in adolescence, sometimes, um, a diagnostic laparoscopy can be performed just to identify and diagnose that it is indeed um Endometriosis in someone who say has um Secondary dysmenorrhea but it's not clear on what the diagnosis is, um, to proceed with things like HGNH antagonist or agonist. Um, after laparoscopy, we often, um, consider continued hormone treatment. Um, so this is usually a discussion that I'll have with patients is, um, what to do after surgery, you know, does that mean that I can get off all of my hormones? You know, not, not necessarily. Sometimes, um, they may decide that the risk and benefits of it. It makes more sense to stay. of hormonal management, um, but ASRM, the, um, reproductive medicine, recommends long-term medication suppression for 6 to 24 months, um, especially if somebody, for example, is, um, planning to get pregnant in a year, then I recommend that they go on hormonal suppression until they decide to get pregnant. Um, and then we'll also consider and discuss putting in a lenogesterol IUD at the time of the surgery so that, um, to help manage it and, and, you know, we, we can put IUDs in the office, of course, but, um, if they have significant pelvic pain, that can make it much worse. So we're already, um, in the operating room, it's easier to place it then. And um if they do want to resume sexual activity, usually they can resume their sexual activity at 2 weeks after surgery or whenever they feel comfortable. Um, patients that have had chronic pelvic pain and endometriosis, um, benefit from ongoing education and support, um, integration and multidisciplinary services, and so here's a couple of resources online for patients that can be helpful. Um, and, um, It's not, we don't always have groups, but we do. Our Doctor Cunea is the integrative medicine gynecologist, and she does do some um chronic pain and endometriosis groups, so that's something else that the patients can participate in. And then this is just a list, it's not exhaustive of our endometriosis team. We have um an amazing group of providers that all work together to take care of our patients and um that includes the GYN, minimally invasive brain surgeons. And nurse practitioners, um, the physical therapists, and we have several physical therapists that are focused on pelvic floor physical therapy. Um, I mentioned Doctor Cuneo. She, um, is an integrative medicine gynecologist, um, and she has a team of acupuncturists as well. Um, GI colorectal surgeons like Doctor Cerin, um, the urogynecologist that we work closely with, um, the reproductive endocrinologists and infertility doctors who we often will share patients that desire future fertility and they are, um, great resources, um, pain medicine and pain anesthesia, who, um, have pain psychologists in their department as well, and then our, um, incredible radiology team that, um, reviews all of the images and, um, Can kind of are super helpful as we're thinking about surgical planning, um, and our pathologist. So, um, we're fortunate to have such a great team of providers that work together um to focus on patient care.
