When surgery is the next step in treating endometriosis—know your patient’s priorities and how to optimize long-term pain relief

Cara R. King, DO, MS, is a member of the Cleveland Clinic Section of Minimally Invasive Gynecologic Surgery (MIGS). She is the Director of Benign Gynecologic Surgery,  and Associate Program Director of the MIGS Fellowship, and Director of Innovation for the Women’s Health Institute. She is a member of the American Association of Gynecologic Laparoscopists (AAGL), the Society of Gynecologic Surgeons (SGS), American College of Surgeons (ACS), and the American Congress of Obstetricians and Gynecologists (ACOG).

Q: How much of your surgical practice is dedicated to patients with endometriosis?

Dr. King: The majority of my practice is dedicated to treating women with endometriosis. I practice at the Cleveland Clinic in Cleveland, Ohio, which is a high-volume referral center, so many of my patients are coming to me for endometriosis or pelvic pain-type symptoms. For most of my patients, I serve as a consultant, which means it's not their initial visit for this issue. I'm often seeing patients who have not found relief through alternate medical or surgical treatments and typically, have more deeply infiltrating or complex endometriosis disease.

Q: How do you make the treatment decision with patients that surgery is the next or proper needed step?

Dr. King: This decision depends on the goals and priorities of each of my patients. I don't have a one-size-fits-all type approach as every patient's journey and unique experiences vary. Ultimately, deciding on the available options and order of treatment depends on the patient's symptoms and priorities. I always start with a thorough history, including a detailed physical exam. The pelvic exam includes evaluation of the bladder, bowel, pelvic floor muscles, nerves, as well as the gynecologic organs including vagina, uterus, cervix and adnexa. If I palpate a nodule on the uterosacral ligaments or behind the cervix, I will sometimes perform a rectovaginal exam to assess for deeply infiltrating bowel disease. Various imaging modalities, including a transvaginal ultrasound or an MRI, can be helpful to further characterize the disease. This allows us to create a treatment plan that best aligns with the patients’ priorities and goals. As a general rule, surgery is usually indicated if empiric options have failed or if they desire definitive diagnosis; meaning the patient is still having pain symptoms despite conservative options or if they have failed or are intolerant to medical options. Some patients are not candidates for medical therapy, such as those who desire pregnancy or who are trying to conceive, so medical options wouldn't be an option for these patients. For patients who prefer an immediate diagnosis, surgical intervention may also be the best option. When I see initial consults for patients who haven't previously seen an endometriosis specialist, if they're not trying to conceive and if they are candidates for medical therapy, I think that's a reasonable first step. We must understand that medications are not curative, they are merely suppressive for endometriosis, so when patients come to me that have been on medical therapy for more than 3 months without pain improvement, and they haven't been offered a surgical approach, diagnostic laparoscopy is often the next best step.

Q: Please detail the presurgical discussion, or the consent process, that would allow you to go beyond the agreed-to procedure, if necessary?

Dr. King: Endometriosis is extremely unique in that you sometimes cannot tell how deeply infiltrative the disease is until you start excising it. So, my consent process and discussions are substantial parts of all patient presurgical conversations. This is crucial for understanding how comfortable the patient is with more aggressive surgery and to fully understand each individual’s symptoms and priorities. I spend a significant amount of time talking to patients about their exact goals for surgery and I conduct a thorough workup before we get into the operating room so that when coupled with a proper physical exam and detailed imaging, the element for surprise, such as finding disease that is much more advanced than you had thought, is decreased. Understanding your patient's symptoms as well as how aggressive they want you to be with regards to surgery is of utmost importance. The more accurate the description that I have of the type of disease that we're working with allows me to talk about all possibilities that could occur before the patients get into the operating room so that we can ensure expectations are met, for the patient and for the surgeon.

Q: Do you have any protocols to share with the audience that relate to limiting reoperation for residual disease?

Dr. King: Conducting a thorough history and physical exam in addition to having detailed imaging is crucial to optimize success. That said, there are times when imaging may appear “normal” when endometriosis is actually present, which is why it is of utmost importance to listen to your patient’s history. With deeply infiltrating endometriosis, superficially, if you look at the peritoneum, it can sometimes appear as if the disease is not that invasive. Again, endometriosis is unique in that until you start excising it, sometimes you don’t know the extent of the infiltration. So, having detailed imaging is going to allow for better mapping of the endometriosis beforehand which will allow you to properly focus in on those areas and enhance preoperative counseling.

My second level of advice is to know your limits with regards to surgical complexity and your laparoscopic skills. For instance, if an endometrioma is present on imaging, you will most likely encounter peritoneal disease and fibrosis below that ovary on the pelvic side wall adjacent to the ureter. If you are not comfortable excising this disease, you should consider referring the patient to an advanced pelvic surgeon. When you see certain characteristics on imaging, understanding what the disease process will look like when you get in there and understanding your own skill level at which you can safely and efficiently perform that dissection is very important. And if you do not have that skill level or if you are still working on detailed knowledge of retroperitoneal anatomy, then the opportunity exists to build up your team; consider including another subspecialist within GYN or urology, colorectal surgery, or cardiothoracic surgery, if you are working with diaphragmatic endometriosis. Loading your boat will allow you to safely and efficiently remove as much of the disease as you can and decrease the risk of leaving any behind. You could also consider video based surgical coaching to further enhance your own laparoscopic skills and surgical performance when treating this complex disease.

Q: How do you approach postsurgical management to maximize the pain-free period for patients?

Dr. King: We know that the best intervention for pain relief is complete excision of endometriosis. By performing a complete excision, we know that this procedure will prolong the length of time for pain-free interval. So, getting as close as possible to a complete excision is going to be the first step. It is also important to treat alternate sources of pain that can be impacted by endometriosis such as spasm of the pelvic floor muscles or central sensitization. While it is difficult to say whether recurrent endometriosis pain is secondary to reactivation of residual disease as opposed to new disease, we do know that complete excision provides longer relief. Assuming surgery has relieved a majority of or, all of the endometriosis associated pain, then the main strategy that we can use to postoperatively maximize that pain-free period is to minimize ovulation. This is typically accomplished with hormonal suppression. It is worth nothing that this isn't indicated for all patients and it is not mandatory as we, again, must be mindful of the patient's goals and priorities. But a recent systematic review did find that when we start hormonal suppression within 6 weeks of our endometriosis surgery, there is a significant reduction in recurrent endometriosis pain scores for up to one year postoperative. Currently, there are no non-hormonal medications that we can offer, nor do we have any interventions to alter genetics or immune aspects of the disease, though it is hoped such could possibly become available in the near future. At the current point in time, hormonal suppressive options are typically the best route but again, I want to reiterate that medications are suppressive and are not curative. And with regards to details of medical options, pulling in patient preference, financial aspects, underlying comorbidities, and long-term reproductive plans, are factors that are important to consider when making weighing decision.

Cara R. King, DO, MS, is a member of the Cleveland Clinic Section of Minimally Invasive Gynecologic Surgery (MIGS). She is the Director of Benign Gynecologic Surgery,  and Associate Program Director of the MIGS Fellowship, and Director of Innovation for the Women’s Health Institute. She is a member of the American Association of Gynecologic Laparoscopists (AAGL), the Society of Gynecologic Surgeons (SGS), American College of Surgeons (ACS), and the American Congress of Obstetricians and Gynecologists (ACOG).

Q: How much of your surgical practice is dedicated to patients with endometriosis?

Dr. King: The majority of my practice is dedicated to treating women with endometriosis. I practice at the Cleveland Clinic in Cleveland, Ohio, which is a high-volume referral center, so many of my patients are coming to me for endometriosis or pelvic pain-type symptoms. For most of my patients, I serve as a consultant, which means it's not their initial visit for this issue. I'm often seeing patients who have not found relief through alternate medical or surgical treatments and typically, have more deeply infiltrating or complex endometriosis disease.

Q: How do you make the treatment decision with patients that surgery is the next or proper needed step?

Dr. King: This decision depends on the goals and priorities of each of my patients. I don't have a one-size-fits-all type approach as every patient's journey and unique experiences vary. Ultimately, deciding on the available options and order of treatment depends on the patient's symptoms and priorities. I always start with a thorough history, including a detailed physical exam. The pelvic exam includes evaluation of the bladder, bowel, pelvic floor muscles, nerves, as well as the gynecologic organs including vagina, uterus, cervix and adnexa. If I palpate a nodule on the uterosacral ligaments or behind the cervix, I will sometimes perform a rectovaginal exam to assess for deeply infiltrating bowel disease. Various imaging modalities, including a transvaginal ultrasound or an MRI, can be helpful to further characterize the disease. This allows us to create a treatment plan that best aligns with the patients’ priorities and goals. As a general rule, surgery is usually indicated if empiric options have failed or if they desire definitive diagnosis; meaning the patient is still having pain symptoms despite conservative options or if they have failed or are intolerant to medical options. Some patients are not candidates for medical therapy, such as those who desire pregnancy or who are trying to conceive, so medical options wouldn't be an option for these patients. For patients who prefer an immediate diagnosis, surgical intervention may also be the best option. When I see initial consults for patients who haven't previously seen an endometriosis specialist, if they're not trying to conceive and if they are candidates for medical therapy, I think that's a reasonable first step. We must understand that medications are not curative, they are merely suppressive for endometriosis, so when patients come to me that have been on medical therapy for more than 3 months without pain improvement, and they haven't been offered a surgical approach, diagnostic laparoscopy is often the next best step.

Q: Please detail the presurgical discussion, or the consent process, that would allow you to go beyond the agreed-to procedure, if necessary?

Dr. King: Endometriosis is extremely unique in that you sometimes cannot tell how deeply infiltrative the disease is until you start excising it. So, my consent process and discussions are substantial parts of all patient presurgical conversations. This is crucial for understanding how comfortable the patient is with more aggressive surgery and to fully understand each individual’s symptoms and priorities. I spend a significant amount of time talking to patients about their exact goals for surgery and I conduct a thorough workup before we get into the operating room so that when coupled with a proper physical exam and detailed imaging, the element for surprise, such as finding disease that is much more advanced than you had thought, is decreased. Understanding your patient's symptoms as well as how aggressive they want you to be with regards to surgery is of utmost importance. The more accurate the description that I have of the type of disease that we're working with allows me to talk about all possibilities that could occur before the patients get into the operating room so that we can ensure expectations are met, for the patient and for the surgeon.

Q: Do you have any protocols to share with the audience that relate to limiting reoperation for residual disease?

Dr. King: Conducting a thorough history and physical exam in addition to having detailed imaging is crucial to optimize success. That said, there are times when imaging may appear “normal” when endometriosis is actually present, which is why it is of utmost importance to listen to your patient’s history. With deeply infiltrating endometriosis, superficially, if you look at the peritoneum, it can sometimes appear as if the disease is not that invasive. Again, endometriosis is unique in that until you start excising it, sometimes you don’t know the extent of the infiltration. So, having detailed imaging is going to allow for better mapping of the endometriosis beforehand which will allow you to properly focus in on those areas and enhance preoperative counseling.

My second level of advice is to know your limits with regards to surgical complexity and your laparoscopic skills. For instance, if an endometrioma is present on imaging, you will most likely encounter peritoneal disease and fibrosis below that ovary on the pelvic side wall adjacent to the ureter. If you are not comfortable excising this disease, you should consider referring the patient to an advanced pelvic surgeon. When you see certain characteristics on imaging, understanding what the disease process will look like when you get in there and understanding your own skill level at which you can safely and efficiently perform that dissection is very important. And if you do not have that skill level or if you are still working on detailed knowledge of retroperitoneal anatomy, then the opportunity exists to build up your team; consider including another subspecialist within GYN or urology, colorectal surgery, or cardiothoracic surgery, if you are working with diaphragmatic endometriosis. Loading your boat will allow you to safely and efficiently remove as much of the disease as you can and decrease the risk of leaving any behind. You could also consider video based surgical coaching to further enhance your own laparoscopic skills and surgical performance when treating this complex disease.

Q: How do you approach postsurgical management to maximize the pain-free period for patients?

Dr. King: We know that the best intervention for pain relief is complete excision of endometriosis. By performing a complete excision, we know that this procedure will prolong the length of time for pain-free interval. So, getting as close as possible to a complete excision is going to be the first step. It is also important to treat alternate sources of pain that can be impacted by endometriosis such as spasm of the pelvic floor muscles or central sensitization. While it is difficult to say whether recurrent endometriosis pain is secondary to reactivation of residual disease as opposed to new disease, we do know that complete excision provides longer relief. Assuming surgery has relieved a majority of or, all of the endometriosis associated pain, then the main strategy that we can use to postoperatively maximize that pain-free period is to minimize ovulation. This is typically accomplished with hormonal suppression. It is worth nothing that this isn't indicated for all patients and it is not mandatory as we, again, must be mindful of the patient's goals and priorities. But a recent systematic review did find that when we start hormonal suppression within 6 weeks of our endometriosis surgery, there is a significant reduction in recurrent endometriosis pain scores for up to one year postoperative. Currently, there are no non-hormonal medications that we can offer, nor do we have any interventions to alter genetics or immune aspects of the disease, though it is hoped such could possibly become available in the near future. At the current point in time, hormonal suppressive options are typically the best route but again, I want to reiterate that medications are suppressive and are not curative. And with regards to details of medical options, pulling in patient preference, financial aspects, underlying comorbidities, and long-term reproductive plans, are factors that are important to consider when making weighing decision.

Cara R. King, DO, MS, is a member of the Cleveland Clinic Section of Minimally Invasive Gynecologic Surgery (MIGS). She is the Director of Benign Gynecologic Surgery,  and Associate Program Director of the MIGS Fellowship, and Director of Innovation for the Women’s Health Institute. She is a member of the American Association of Gynecologic Laparoscopists (AAGL), the Society of Gynecologic Surgeons (SGS), American College of Surgeons (ACS), and the American Congress of Obstetricians and Gynecologists (ACOG).

Q: How much of your surgical practice is dedicated to patients with endometriosis?

Dr. King: The majority of my practice is dedicated to treating women with endometriosis. I practice at the Cleveland Clinic in Cleveland, Ohio, which is a high-volume referral center, so many of my patients are coming to me for endometriosis or pelvic pain-type symptoms. For most of my patients, I serve as a consultant, which means it's not their initial visit for this issue. I'm often seeing patients who have not found relief through alternate medical or surgical treatments and typically, have more deeply infiltrating or complex endometriosis disease.

Q: How do you make the treatment decision with patients that surgery is the next or proper needed step?

Dr. King: This decision depends on the goals and priorities of each of my patients. I don't have a one-size-fits-all type approach as every patient's journey and unique experiences vary. Ultimately, deciding on the available options and order of treatment depends on the patient's symptoms and priorities. I always start with a thorough history, including a detailed physical exam. The pelvic exam includes evaluation of the bladder, bowel, pelvic floor muscles, nerves, as well as the gynecologic organs including vagina, uterus, cervix and adnexa. If I palpate a nodule on the uterosacral ligaments or behind the cervix, I will sometimes perform a rectovaginal exam to assess for deeply infiltrating bowel disease. Various imaging modalities, including a transvaginal ultrasound or an MRI, can be helpful to further characterize the disease. This allows us to create a treatment plan that best aligns with the patients’ priorities and goals. As a general rule, surgery is usually indicated if empiric options have failed or if they desire definitive diagnosis; meaning the patient is still having pain symptoms despite conservative options or if they have failed or are intolerant to medical options. Some patients are not candidates for medical therapy, such as those who desire pregnancy or who are trying to conceive, so medical options wouldn't be an option for these patients. For patients who prefer an immediate diagnosis, surgical intervention may also be the best option. When I see initial consults for patients who haven't previously seen an endometriosis specialist, if they're not trying to conceive and if they are candidates for medical therapy, I think that's a reasonable first step. We must understand that medications are not curative, they are merely suppressive for endometriosis, so when patients come to me that have been on medical therapy for more than 3 months without pain improvement, and they haven't been offered a surgical approach, diagnostic laparoscopy is often the next best step.

Q: Please detail the presurgical discussion, or the consent process, that would allow you to go beyond the agreed-to procedure, if necessary?

Dr. King: Endometriosis is extremely unique in that you sometimes cannot tell how deeply infiltrative the disease is until you start excising it. So, my consent process and discussions are substantial parts of all patient presurgical conversations. This is crucial for understanding how comfortable the patient is with more aggressive surgery and to fully understand each individual’s symptoms and priorities. I spend a significant amount of time talking to patients about their exact goals for surgery and I conduct a thorough workup before we get into the operating room so that when coupled with a proper physical exam and detailed imaging, the element for surprise, such as finding disease that is much more advanced than you had thought, is decreased. Understanding your patient's symptoms as well as how aggressive they want you to be with regards to surgery is of utmost importance. The more accurate the description that I have of the type of disease that we're working with allows me to talk about all possibilities that could occur before the patients get into the operating room so that we can ensure expectations are met, for the patient and for the surgeon.

Q: Do you have any protocols to share with the audience that relate to limiting reoperation for residual disease?

Dr. King: Conducting a thorough history and physical exam in addition to having detailed imaging is crucial to optimize success. That said, there are times when imaging may appear “normal” when endometriosis is actually present, which is why it is of utmost importance to listen to your patient’s history. With deeply infiltrating endometriosis, superficially, if you look at the peritoneum, it can sometimes appear as if the disease is not that invasive. Again, endometriosis is unique in that until you start excising it, sometimes you don’t know the extent of the infiltration. So, having detailed imaging is going to allow for better mapping of the endometriosis beforehand which will allow you to properly focus in on those areas and enhance preoperative counseling.

My second level of advice is to know your limits with regards to surgical complexity and your laparoscopic skills. For instance, if an endometrioma is present on imaging, you will most likely encounter peritoneal disease and fibrosis below that ovary on the pelvic side wall adjacent to the ureter. If you are not comfortable excising this disease, you should consider referring the patient to an advanced pelvic surgeon. When you see certain characteristics on imaging, understanding what the disease process will look like when you get in there and understanding your own skill level at which you can safely and efficiently perform that dissection is very important. And if you do not have that skill level or if you are still working on detailed knowledge of retroperitoneal anatomy, then the opportunity exists to build up your team; consider including another subspecialist within GYN or urology, colorectal surgery, or cardiothoracic surgery, if you are working with diaphragmatic endometriosis. Loading your boat will allow you to safely and efficiently remove as much of the disease as you can and decrease the risk of leaving any behind. You could also consider video based surgical coaching to further enhance your own laparoscopic skills and surgical performance when treating this complex disease.

Q: How do you approach postsurgical management to maximize the pain-free period for patients?

Dr. King: We know that the best intervention for pain relief is complete excision of endometriosis. By performing a complete excision, we know that this procedure will prolong the length of time for pain-free interval. So, getting as close as possible to a complete excision is going to be the first step. It is also important to treat alternate sources of pain that can be impacted by endometriosis such as spasm of the pelvic floor muscles or central sensitization. While it is difficult to say whether recurrent endometriosis pain is secondary to reactivation of residual disease as opposed to new disease, we do know that complete excision provides longer relief. Assuming surgery has relieved a majority of or, all of the endometriosis associated pain, then the main strategy that we can use to postoperatively maximize that pain-free period is to minimize ovulation. This is typically accomplished with hormonal suppression. It is worth nothing that this isn't indicated for all patients and it is not mandatory as we, again, must be mindful of the patient's goals and priorities. But a recent systematic review did find that when we start hormonal suppression within 6 weeks of our endometriosis surgery, there is a significant reduction in recurrent endometriosis pain scores for up to one year postoperative. Currently, there are no non-hormonal medications that we can offer, nor do we have any interventions to alter genetics or immune aspects of the disease, though it is hoped such could possibly become available in the near future. At the current point in time, hormonal suppressive options are typically the best route but again, I want to reiterate that medications are suppressive and are not curative. And with regards to details of medical options, pulling in patient preference, financial aspects, underlying comorbidities, and long-term reproductive plans, are factors that are important to consider when making weighing decision.