As a gynecologist specializing in minimally invasive surgical techniques, what is your involvement in the process for diagnosing endometriosis?
Dr. Lager: At our multidisciplinary endometriosis center, we receive a range of referrals from excellent providers near San Francisco and beyond. As a result, patients will often have had extensive evaluations and multiple treatments. Nonetheless, it is important to take a thorough history, to gain an understanding of the progress of their disease, treatments they have taken and the results or side effects of those treatments, and the goals of the patient in order to guide next steps.
Reviewing previous operative reports, pathology, and surgical photos can also be helpful to guide next steps. Commonly, patients will present with dysmenorrhea, and depending on the severity of associated symptoms, such as dysuria, dyschezia, hematuria, or hematochezia, I may refer patients to our colleagues in urology or GI for further evaluation.
Patients will often have previous imaging such as an ultrasound or CT to evaluate anatomic etiology of the pain, but those studies are often negative. Depending on their history, I may order additional imaging, such as an MRI pelvis, and consideration of vaginal or rectal gel. We have worked closely with our radiologists who have developed a specific endometriosis protocol for deeply infiltrative endometriosis and have a multidisciplinary review committee to discuss complex cases.
Although the gold standard for diagnosis of endometriosis is surgical, this leads to a delay in treatment of 7 to 12 years. [1] So, if a patient presents with symptoms of endometriosis, I will discuss the likely diagnosis and start treatment.
Are there specific techniques that you prefer in your standard practice once a clear diagnosis is determined?
Dr. Lager: As I mentioned, although endometriosis is a surgical diagnosis, there may be findings on imaging which will lead to a diagnosis of endometriosis, including endometriomas, uterosacral thickening, a “kissing ovary” appearance, or hematosalpinx for example.
I discuss a broad range of treatment options based on the patient’s goals, from least invasive treatments to definitive surgery. I discuss dietary changes, integrative medicine (we are fortunate to have an integrative medicine gynecologist here at UCSF Osher Center), and pain psychology. Additionally, I review first-line hormonal management options such as: birth control pills, progestin-only pills, levenogestrol IUD, etonogestrel implant, and medroxyprogesterone acetate injection. In my practice, most patients have already tried initial treatment options, and are most interested in other options. I then review second-line options such as GnRH agonists, antagonists, danazol, and aromatase inhibitors. For patients that have had chronic pelvic pain, I also discuss peripheral and central sensitization, and overlapping diagnoses. Surgical management includes diagnostic laparoscopy and excision or ablation of endometriosis, hysterectomy, and oophorectomy.
Are there specific factors that you look for to help you decide whether surgical management is necessary?
Dr. Lager: There are several reasons why patients decide to proceed with surgical management. First, some patients are reticent to start treatment, particularly if they have had negative experiences with hormonal medications and desire a definitive diagnosis. Other patients choose to proceed with surgery for fertility reasons, and others have severe symptoms that are not managed by medications.
The goal of surgery is to remove all visible endometriotic lesions, restore normal anatomy and for pathologic diagnosis if there is atypical characteristics of an endometrial mass. The pelvic exam and imaging can often be helpful surgical planning. If there is a deeply infiltrative lesion in the bowel or bladder, I consult my urology and colorectal colleagues for surgical planning.
Endometriotic lesions are heterogenous, and can include superficial peritoneal lesions, clear vesicular lesions, “powder burn lesions”, endometriomas, and deep infiltrative lesions.
Additionally, I counsel patients on surgical options depending on the fertility desires. For patients with infertility and symptoms of endometriosis, primary surgery with excision or ablation increases pregnancy rates. One meta-analysis showed that operative laparoscopy improved live births and ongoing pregnancy rates. [2] This was found for the first laparoscopic surgery and not repeat surgery.
Can you talk a little bit more about some of the advancements and the controversies in surgical management, and how that impacts your practice or your treatment?
Dr. Lager: Controversy in surgical management includes excision versus ablation in surgical management of endometriosis. One randomized controlled trial showed an improvement with dyspareunia with excision versus ablation after 5 year follow up. [3] However, a recent meta-analysis from 2021 showed no difference in dysmenorrhea between excision and ablation. [4] I generally perform excision of endometriosis as it can provide a tissue for diagnosis and may allow for complete excision of a lesion that may have an underlying component not easily seen.
We also discussed some of the controversy related to fertility and endometriosis. Management of endometriomas in the face of desired fertility is unclear. Endometriomas that are >3 cm in diameter are associated with decreased anti-Mullerian hormone (AMH) levels, but ovarian cystectomy for endometriomas is also associated with decreased AMH levels. I will counsel patients regarding the risks and benefits of ovarian cystectomy and discuss with the reproductive endocrinologists if they recommend removal to improve oocyte retrieval.
Lastly, conservative versus definitive treatment is an important issue to discuss. Depending on a patient’s goals, conservative surgical management of endometriosis may be the most appropriate procedure. However, if a patient has multiple surgeries, does not desire to have children or has completed childbearing regardless of age and wants to decrease the risk of need for repeat surgery, I will discuss with patients that the risk of reoperation after hysterectomy versus conservative surgery is 8% vs 21% in 2 years and 59% vs 22% after 7 years, respectively. [5] Additionally, the patient may have an overlapping gynecological condition, such as adenomyosis or fibroids, and desire surgical management for those conditions as well. Management ultimately will depend on shared decision making,
You mentioned overlapping diagnosis. What are the impacts and barriers related to misdiagnosis or overlapping diagnosis, and what is your approach to recognizing those signs and symptoms?
Dr. Lager: The classic symptoms of endometriosis can overlap with several medical conditions. In addition to gynecologic issues such as adenomyosis and fibroids that I mentioned previously, symptoms such as pelvic pain, bloating, and dysuria can be associated with gastrointestinal conditions, painful bladder syndrome, neurologic, and musculoskeletal pain conditions. This is complex because the overlapping diagnoses can lead to misdiagnosis, and delay in diagnosis and missing an associated diagnosis can lead to inadequate treatment.
I approach the possibility of overlapping diagnoses in consultation with my colleagues who may recommend further testing, such as endoscopy and colonoscopy. Depending on the diagnoses, several treatments can be started concomitantly to address the multifactorial components of pain. For example, pelvic floor dysfunction related to pelvic pain can affect bowel habits, even without a diagnosis of IBS. Pelvic floor physical therapy can address one component of this. Similarly, even if we surgically or medically manage symptoms of endometriosis, the musculoskeletal pain can lead to persistent or worsening pain. The same goes for pain medicine and peripheral or central pain sensitization or neurological pain.
Was there anything else you’d like to share with your colleagues?
Dr. Lager: Endometriosis is a complex condition that requires a multifactorial approach that takes into consideration a patient’s goals. There is not a one-size fit for all patients with endometriosis due to all the issues we discussed. It will take time to address the varied components of pain and is an iterative process. Minimally invasive surgery has an important role in diagnosis and management of endometriosis but is one of several approaches to treat this complex condition. Thanks for taking the time to discuss this important condition that affects at least 10% of gynecological patients, and potentially more due to delayed and undiagnosed disease.