Gynecology

Expert Commentary

Data demonstrate efficacy and safety of the IUD in adolescents. In addition, IUDs (particularly the levonorgestrel-containing IUD) have many noncontraceptive benefits. There is still reluctance, however, among clinicians to use IUDs in adolescents. In a sample of fellows of the American College of Obstetricians and Gynecologists, only 43% considered adolescents appropriate candidates for use of an IUD.¹

Study details

In this retrospective chart review, Kebodeaux and Schwartz sought to compare successful IUD insertion rates on first attempt in 120 sexually active (SA) and 82 never sexually active (NSA) adolescents. The IUD type used for all women was the 52-mg levonorgestrel IUD (Mirena), except for 3 copper IUDs (Paragard) used in the SA group. The primary indications for IUD use were contraception (85.2%) in the SA group and abnormal uterine bleeding (43.9%) and menstrual suppression (24.4%) in the NSA group.

In the NSA group, 82.9% of adolescents had had some type of prior treatment affecting the menstrual cycle, compared with 60.9% in the SA group (P = .001).

Non–office insertion. Either a sedation unit or operating room was utilized in 5.5% of the IUD insertions in the SA group and 47.6% of the NSA group. Among the 39 adolescents in the NSA group undergoing non–office insertion, 19 (48.7%) had special needs (learning or intellectual disabilities, autism/autism spectrum, or physical disabilities, such as cerebral palsy). Only 1 adolescent with special needs in the NSA group had an office insertion compared with 5 out of 6 in the SA group.

The performance of another procedure other than the IUD insertion (including diagnostic laparoscopy and hymenectomy) was common among adolescents undergoing procedures in the sedation unit or operating room who did not have special needs. It is also important to note that adolescents with special needs were routinely offered insertion under anesthesia while SA adolescents were offered insertion under anesthesia only if they were undergoing another procedure as well.

Study strengths and weaknesses

The study’s strengths include IUD insertions performed at a children’s hospital by providers with experience working with adolescent populations. This likely accounts for the high rates of “tolerance of the procedure well” (93.8% in the SA group vs 81.7% in the NSA group; P = .006). The study also included a patient population—adolescents with special needs—that has not been studied relative to IUD use previously.

A significant weakness of the study, however, is that there are no long-term follow-up data, particularly related to continuation rates.

Expert Commentary

Data demonstrate efficacy and safety of the IUD in adolescents. In addition, IUDs (particularly the levonorgestrel-containing IUD) have many noncontraceptive benefits. There is still reluctance, however, among clinicians to use IUDs in adolescents. In a sample of fellows of the American College of Obstetricians and Gynecologists, only 43% considered adolescents appropriate candidates for use of an IUD.¹

Study details

In this retrospective chart review, Kebodeaux and Schwartz sought to compare successful IUD insertion rates on first attempt in 120 sexually active (SA) and 82 never sexually active (NSA) adolescents. The IUD type used for all women was the 52-mg levonorgestrel IUD (Mirena), except for 3 copper IUDs (Paragard) used in the SA group. The primary indications for IUD use were contraception (85.2%) in the SA group and abnormal uterine bleeding (43.9%) and menstrual suppression (24.4%) in the NSA group.

In the NSA group, 82.9% of adolescents had had some type of prior treatment affecting the menstrual cycle, compared with 60.9% in the SA group (P = .001).

Non–office insertion. Either a sedation unit or operating room was utilized in 5.5% of the IUD insertions in the SA group and 47.6% of the NSA group. Among the 39 adolescents in the NSA group undergoing non–office insertion, 19 (48.7%) had special needs (learning or intellectual disabilities, autism/autism spectrum, or physical disabilities, such as cerebral palsy). Only 1 adolescent with special needs in the NSA group had an office insertion compared with 5 out of 6 in the SA group.

The performance of another procedure other than the IUD insertion (including diagnostic laparoscopy and hymenectomy) was common among adolescents undergoing procedures in the sedation unit or operating room who did not have special needs. It is also important to note that adolescents with special needs were routinely offered insertion under anesthesia while SA adolescents were offered insertion under anesthesia only if they were undergoing another procedure as well.

Study strengths and weaknesses

The study’s strengths include IUD insertions performed at a children’s hospital by providers with experience working with adolescent populations. This likely accounts for the high rates of “tolerance of the procedure well” (93.8% in the SA group vs 81.7% in the NSA group; P = .006). The study also included a patient population—adolescents with special needs—that has not been studied relative to IUD use previously.

A significant weakness of the study, however, is that there are no long-term follow-up data, particularly related to continuation rates.

Expert Commentary

Data demonstrate efficacy and safety of the IUD in adolescents. In addition, IUDs (particularly the levonorgestrel-containing IUD) have many noncontraceptive benefits. There is still reluctance, however, among clinicians to use IUDs in adolescents. In a sample of fellows of the American College of Obstetricians and Gynecologists, only 43% considered adolescents appropriate candidates for use of an IUD.¹

Study details

In this retrospective chart review, Kebodeaux and Schwartz sought to compare successful IUD insertion rates on first attempt in 120 sexually active (SA) and 82 never sexually active (NSA) adolescents. The IUD type used for all women was the 52-mg levonorgestrel IUD (Mirena), except for 3 copper IUDs (Paragard) used in the SA group. The primary indications for IUD use were contraception (85.2%) in the SA group and abnormal uterine bleeding (43.9%) and menstrual suppression (24.4%) in the NSA group.

In the NSA group, 82.9% of adolescents had had some type of prior treatment affecting the menstrual cycle, compared with 60.9% in the SA group (P = .001).

Non–office insertion. Either a sedation unit or operating room was utilized in 5.5% of the IUD insertions in the SA group and 47.6% of the NSA group. Among the 39 adolescents in the NSA group undergoing non–office insertion, 19 (48.7%) had special needs (learning or intellectual disabilities, autism/autism spectrum, or physical disabilities, such as cerebral palsy). Only 1 adolescent with special needs in the NSA group had an office insertion compared with 5 out of 6 in the SA group.

The performance of another procedure other than the IUD insertion (including diagnostic laparoscopy and hymenectomy) was common among adolescents undergoing procedures in the sedation unit or operating room who did not have special needs. It is also important to note that adolescents with special needs were routinely offered insertion under anesthesia while SA adolescents were offered insertion under anesthesia only if they were undergoing another procedure as well.

Study strengths and weaknesses

The study’s strengths include IUD insertions performed at a children’s hospital by providers with experience working with adolescent populations. This likely accounts for the high rates of “tolerance of the procedure well” (93.8% in the SA group vs 81.7% in the NSA group; P = .006). The study also included a patient population—adolescents with special needs—that has not been studied relative to IUD use previously.

A significant weakness of the study, however, is that there are no long-term follow-up data, particularly related to continuation rates.

LAS VEGAS – Officially a type of precancerous lesion is known as vulvar intraepithelial neoplasia (VIN); unofficially, an obstetrician-gynecologist calls it something else: “The Great Mimicker.” That’s because symptoms of VIN can fool physicians into thinking they’re seeing other vulvar conditions. The good news: A biopsy can offer crucial insight and should be performed on any dysplastic or unusual lesion on the vulva.

Courtesy Cashman Photo

Amanda Nickles Fader, MD, of Johns Hopkins Hospital in Baltimore, offered this advice and other tips about this type of precancerous vulvar lesion in a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

According to Dr. Nickles Fader, vulvar cancer accounts for 5% of all gynecologic malignancies, and it appears most in women aged 65-75 years. However, about 15% of all vulvar cancers appear in women under the age of 40 years. “We’re seeing a greater number of premenopausal women with this condition, probably due to HPV [human papillomavirus],” she said, adding that HPV vaccines are crucial to prevention.

The VIN form of precancerous lesion is most common in premenopausal women (75%) and – like vulvar cancer – is linked to HPV infection, HIV infection, cigarette smoking, and weakened or suppressed immune systems, Dr. Nickles Faber said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

VIN presents with symptoms such as pruritus, altered vulvar appearance at the site of the lesion, palpable abnormality, and perineal pain or burning. About 40% of cases do not show symptoms and are diagnosed by gynecologists at annual visits.

It’s important to biopsy these lesions, she said, because they can mimic other conditions such as vulvar cancer, condyloma acuminatum (genital warts), lichen sclerosus, lichen planus, and condyloma latum (a lesion linked to syphilis).

“Biopsy, biopsy, biopsy,” she urged.

In fact, one form of VIN – differentiated VIN – is associated with dermatologic conditions such as lichen sclerosus, and treatment of these conditions can prevent development of this VIN type.

As for treatment, Dr. Nickles Faber said surgery is the mainstay. About 90% of the time, wide local excision is the “go-to” approach, although the skinning vulvectomy procedure may be appropriate in lesions that are more extensive or multifocal and confluent. “It’s a lot more disfiguring.”

Laser ablation is a “very reasonable” option when cancer has been eliminated as a possibility, she said. It may be appropriate in multifocal or extensive lesions and can have important cosmetic advantages when excision would be inappropriate.

Off-label use of imiquimod 5%, a topical immune response modifier, can be appropriate in multifocal high-grade VINs, but it’s crucial to exclude invasive squamous cell carcinoma. As she noted, imiquimod is Food and Drug Administration–approved for anogenital warts but not for VIN. Beware of toxicity over the long term.

Dr. Nickles Fader reported no relevant financial disclosures.

LAS VEGAS – Officially a type of precancerous lesion is known as vulvar intraepithelial neoplasia (VIN); unofficially, an obstetrician-gynecologist calls it something else: “The Great Mimicker.” That’s because symptoms of VIN can fool physicians into thinking they’re seeing other vulvar conditions. The good news: A biopsy can offer crucial insight and should be performed on any dysplastic or unusual lesion on the vulva.

Courtesy Cashman Photo

Amanda Nickles Fader, MD, of Johns Hopkins Hospital in Baltimore, offered this advice and other tips about this type of precancerous vulvar lesion in a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

According to Dr. Nickles Fader, vulvar cancer accounts for 5% of all gynecologic malignancies, and it appears most in women aged 65-75 years. However, about 15% of all vulvar cancers appear in women under the age of 40 years. “We’re seeing a greater number of premenopausal women with this condition, probably due to HPV [human papillomavirus],” she said, adding that HPV vaccines are crucial to prevention.

The VIN form of precancerous lesion is most common in premenopausal women (75%) and – like vulvar cancer – is linked to HPV infection, HIV infection, cigarette smoking, and weakened or suppressed immune systems, Dr. Nickles Faber said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

VIN presents with symptoms such as pruritus, altered vulvar appearance at the site of the lesion, palpable abnormality, and perineal pain or burning. About 40% of cases do not show symptoms and are diagnosed by gynecologists at annual visits.

It’s important to biopsy these lesions, she said, because they can mimic other conditions such as vulvar cancer, condyloma acuminatum (genital warts), lichen sclerosus, lichen planus, and condyloma latum (a lesion linked to syphilis).

“Biopsy, biopsy, biopsy,” she urged.

In fact, one form of VIN – differentiated VIN – is associated with dermatologic conditions such as lichen sclerosus, and treatment of these conditions can prevent development of this VIN type.

As for treatment, Dr. Nickles Faber said surgery is the mainstay. About 90% of the time, wide local excision is the “go-to” approach, although the skinning vulvectomy procedure may be appropriate in lesions that are more extensive or multifocal and confluent. “It’s a lot more disfiguring.”

Laser ablation is a “very reasonable” option when cancer has been eliminated as a possibility, she said. It may be appropriate in multifocal or extensive lesions and can have important cosmetic advantages when excision would be inappropriate.

Off-label use of imiquimod 5%, a topical immune response modifier, can be appropriate in multifocal high-grade VINs, but it’s crucial to exclude invasive squamous cell carcinoma. As she noted, imiquimod is Food and Drug Administration–approved for anogenital warts but not for VIN. Beware of toxicity over the long term.

Dr. Nickles Fader reported no relevant financial disclosures.

LAS VEGAS – Officially a type of precancerous lesion is known as vulvar intraepithelial neoplasia (VIN); unofficially, an obstetrician-gynecologist calls it something else: “The Great Mimicker.” That’s because symptoms of VIN can fool physicians into thinking they’re seeing other vulvar conditions. The good news: A biopsy can offer crucial insight and should be performed on any dysplastic or unusual lesion on the vulva.

Courtesy Cashman Photo

Amanda Nickles Fader, MD, of Johns Hopkins Hospital in Baltimore, offered this advice and other tips about this type of precancerous vulvar lesion in a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.

According to Dr. Nickles Fader, vulvar cancer accounts for 5% of all gynecologic malignancies, and it appears most in women aged 65-75 years. However, about 15% of all vulvar cancers appear in women under the age of 40 years. “We’re seeing a greater number of premenopausal women with this condition, probably due to HPV [human papillomavirus],” she said, adding that HPV vaccines are crucial to prevention.

The VIN form of precancerous lesion is most common in premenopausal women (75%) and – like vulvar cancer – is linked to HPV infection, HIV infection, cigarette smoking, and weakened or suppressed immune systems, Dr. Nickles Faber said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

VIN presents with symptoms such as pruritus, altered vulvar appearance at the site of the lesion, palpable abnormality, and perineal pain or burning. About 40% of cases do not show symptoms and are diagnosed by gynecologists at annual visits.

It’s important to biopsy these lesions, she said, because they can mimic other conditions such as vulvar cancer, condyloma acuminatum (genital warts), lichen sclerosus, lichen planus, and condyloma latum (a lesion linked to syphilis).

“Biopsy, biopsy, biopsy,” she urged.

In fact, one form of VIN – differentiated VIN – is associated with dermatologic conditions such as lichen sclerosus, and treatment of these conditions can prevent development of this VIN type.

As for treatment, Dr. Nickles Faber said surgery is the mainstay. About 90% of the time, wide local excision is the “go-to” approach, although the skinning vulvectomy procedure may be appropriate in lesions that are more extensive or multifocal and confluent. “It’s a lot more disfiguring.”

Laser ablation is a “very reasonable” option when cancer has been eliminated as a possibility, she said. It may be appropriate in multifocal or extensive lesions and can have important cosmetic advantages when excision would be inappropriate.

Off-label use of imiquimod 5%, a topical immune response modifier, can be appropriate in multifocal high-grade VINs, but it’s crucial to exclude invasive squamous cell carcinoma. As she noted, imiquimod is Food and Drug Administration–approved for anogenital warts but not for VIN. Beware of toxicity over the long term.

Dr. Nickles Fader reported no relevant financial disclosures.

Medical science’s broad knowledge of endometriosis notwithstanding, “many questions remain unanswered” about the management of a condition that is often refractory to established therapies, observed Sawsan As-Sanie, MD, MPH, at the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada. Dr. As-Sanie is Associate Professor and Director, Minimally Invasive Gynecologic Surgery Fellowship, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor. How, then, should clinicians approach the challenge of caring for women with this enigmatic disease in the larger context of chronic pelvic pain, in which, as Dr. As-Sanie said, “one size never fits all”?

Complex correlation between endometriosis and CPP

Despite high prevalence and negative impact on the health and quality of life of women who suffer from endometriosis, Dr. As-Sanie emphasized, it remains unclear why only some women with endometriosis develop chronic pelvic pain (CPP) and why there is little, if any, correlation between disease severity and the intensity of pain.

The clinical approach to endometriosis and CPP can be frustrating for several reasons: there is minimal relationship between extent or location of disease with pain symptoms; there is no consistent relationship among inflammatory markers, nerve-fiber density, and pain symptoms; and pain can recur after medical and surgical therapy—often without evidence of recurrent endometriosis. Furthermore, the differential diagnosis of CPP is broad, and also includes adenomyosis, adhesions, chronic pelvic inflammatory disease, uterine fibroids, pelvic congestion, ovarian remnant, and residual ovarian syndrome. Chronic overlapping pain conditions are prevalent, too, including interstitial cystitis, irritable bowel syndrome, and vulvodynia, to name a few.¹

_

CPP is not just a pain disorder

Dr. As-Sanie said that understanding of CPP must extend to include fatigue, memory difficulties, poor sleep, and heightened sensitivity to multiple sensory stimuli (e.g., sound and light).² So what, she asked, do we know about endometriosis, chronic pelvic pain, and the brain? We know that CPP, with and without endometriosis, is associated with increased pain sensitivity and altered central nervous system structure and function.^3-5 Central amplification of pain can lead to chronic pain independent of nociceptive signals, including multifocal, widespread pain; higher lifetime history of pain throughout the body; and pain triggered or exacerbated by stressors. And CPP brings with it other, potentially debilitating problems, including elevated distress, decreased activity, isolation, poor sleep, and maladaptive illness behaviors.

Finding, then addressing, the culprit

Identifying the underlying cause(s) of CPP in the individual woman should guide clinical care. This includes the decision to proceed with, or avoid, surgery. Remember: Patients with centralized pain respond differently to therapy; surgery is less likely to help relieve the pain.

Dr. As-Sanie offered several fundamental guidelines for managing CPP:

• Treat early, to prevent transition from acute to chronic pain; treatment delay increases connectivity between pain regulatory regions.
• Hysterectomy is not definitive therapy for all women with endometriosis or CPP.⁶
• Take a multisystem approach, comprising medical, behavioral, and interventional strategies.
• If an organ- or disease-based diagnostic and treatment approach does not work, reconsider the diagnosis; re-evaluate comorbid psychosocial variables; and consider treating centralized pain.
• Choice of treatment should include consideration of cost and adverse-effect profile.
• If one modality is ineffective, try another.

Continue to: What are the levels of evidence for centralized pain treatment?

Available pharmacotherapeutic agents have modest benefit, possibly because the population of pain patients is heterogeneous, with various underlying mechanisms of pain. And, Dr. As-Sanie pointed out, clinical tools do not currently exist to pre-emptively select the right medicine for individual patients.

Evidence is strong, Dr. As-Sanie noted, for dual reuptake-inhibitor antidepressants, such as tricyclic compounds (amitriptyline, cyclobenzaprine) and serotonin–norepinephrine reuptake inhibitors, and for anticonvulsants with analgesic properties (pregabalin, gabapentin). Evidence is “modest,” Dr. As-Sanie said, for tramadol, gamma hydroxybutyrate, and low-dose naltrexone, and “weak” for cannabinoids, human growth hormone, 5-hydroxytryptamine, tropisetron, and S-adenosyl-L-methionine. There is no evidence for using opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepine and non–benzodiazepine hypnotics, or guaifenesin.⁷

When surgery or pharmacotherapy alone fail to yield the necessary outcome, consider adjunctive nonpharmacotherapy.⁸ For example, there is strong evidence for patient education, aerobic exercise, and cognitive behavior therapy; modest evidence for acupressure, acupuncture, strength training, hypnotherapy, biofeedback, trigger-point injection, and neuromodulation; but only weak evidence for chiropractic, manual and massage therapy, electrotherapy, and ultrasound. ⁷

_

With CPP, “one size never fits all”

Dr. As-Sanie concluded with a reminder that CPP can be the product of any of a range of underlying contributory causes. Pathology might stand foremost as you search for the source of pain and an effective treatment, but keep in mind that genetics, environment, co-existing pain conditions, the patient’s ability to cope, and her resilience and social support might play a role.

Medical science’s broad knowledge of endometriosis notwithstanding, “many questions remain unanswered” about the management of a condition that is often refractory to established therapies, observed Sawsan As-Sanie, MD, MPH, at the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada. Dr. As-Sanie is Associate Professor and Director, Minimally Invasive Gynecologic Surgery Fellowship, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor. How, then, should clinicians approach the challenge of caring for women with this enigmatic disease in the larger context of chronic pelvic pain, in which, as Dr. As-Sanie said, “one size never fits all”?

Complex correlation between endometriosis and CPP

Despite high prevalence and negative impact on the health and quality of life of women who suffer from endometriosis, Dr. As-Sanie emphasized, it remains unclear why only some women with endometriosis develop chronic pelvic pain (CPP) and why there is little, if any, correlation between disease severity and the intensity of pain.

The clinical approach to endometriosis and CPP can be frustrating for several reasons: there is minimal relationship between extent or location of disease with pain symptoms; there is no consistent relationship among inflammatory markers, nerve-fiber density, and pain symptoms; and pain can recur after medical and surgical therapy—often without evidence of recurrent endometriosis. Furthermore, the differential diagnosis of CPP is broad, and also includes adenomyosis, adhesions, chronic pelvic inflammatory disease, uterine fibroids, pelvic congestion, ovarian remnant, and residual ovarian syndrome. Chronic overlapping pain conditions are prevalent, too, including interstitial cystitis, irritable bowel syndrome, and vulvodynia, to name a few.¹

_

CPP is not just a pain disorder

Dr. As-Sanie said that understanding of CPP must extend to include fatigue, memory difficulties, poor sleep, and heightened sensitivity to multiple sensory stimuli (e.g., sound and light).² So what, she asked, do we know about endometriosis, chronic pelvic pain, and the brain? We know that CPP, with and without endometriosis, is associated with increased pain sensitivity and altered central nervous system structure and function.^3-5 Central amplification of pain can lead to chronic pain independent of nociceptive signals, including multifocal, widespread pain; higher lifetime history of pain throughout the body; and pain triggered or exacerbated by stressors. And CPP brings with it other, potentially debilitating problems, including elevated distress, decreased activity, isolation, poor sleep, and maladaptive illness behaviors.

Finding, then addressing, the culprit

Identifying the underlying cause(s) of CPP in the individual woman should guide clinical care. This includes the decision to proceed with, or avoid, surgery. Remember: Patients with centralized pain respond differently to therapy; surgery is less likely to help relieve the pain.

Dr. As-Sanie offered several fundamental guidelines for managing CPP:

• Treat early, to prevent transition from acute to chronic pain; treatment delay increases connectivity between pain regulatory regions.
• Hysterectomy is not definitive therapy for all women with endometriosis or CPP.⁶
• Take a multisystem approach, comprising medical, behavioral, and interventional strategies.
• If an organ- or disease-based diagnostic and treatment approach does not work, reconsider the diagnosis; re-evaluate comorbid psychosocial variables; and consider treating centralized pain.
• Choice of treatment should include consideration of cost and adverse-effect profile.
• If one modality is ineffective, try another.

Continue to: What are the levels of evidence for centralized pain treatment?

Available pharmacotherapeutic agents have modest benefit, possibly because the population of pain patients is heterogeneous, with various underlying mechanisms of pain. And, Dr. As-Sanie pointed out, clinical tools do not currently exist to pre-emptively select the right medicine for individual patients.

Evidence is strong, Dr. As-Sanie noted, for dual reuptake-inhibitor antidepressants, such as tricyclic compounds (amitriptyline, cyclobenzaprine) and serotonin–norepinephrine reuptake inhibitors, and for anticonvulsants with analgesic properties (pregabalin, gabapentin). Evidence is “modest,” Dr. As-Sanie said, for tramadol, gamma hydroxybutyrate, and low-dose naltrexone, and “weak” for cannabinoids, human growth hormone, 5-hydroxytryptamine, tropisetron, and S-adenosyl-L-methionine. There is no evidence for using opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepine and non–benzodiazepine hypnotics, or guaifenesin.⁷

When surgery or pharmacotherapy alone fail to yield the necessary outcome, consider adjunctive nonpharmacotherapy.⁸ For example, there is strong evidence for patient education, aerobic exercise, and cognitive behavior therapy; modest evidence for acupressure, acupuncture, strength training, hypnotherapy, biofeedback, trigger-point injection, and neuromodulation; but only weak evidence for chiropractic, manual and massage therapy, electrotherapy, and ultrasound. ⁷

_

With CPP, “one size never fits all”

Dr. As-Sanie concluded with a reminder that CPP can be the product of any of a range of underlying contributory causes. Pathology might stand foremost as you search for the source of pain and an effective treatment, but keep in mind that genetics, environment, co-existing pain conditions, the patient’s ability to cope, and her resilience and social support might play a role.

Medical science’s broad knowledge of endometriosis notwithstanding, “many questions remain unanswered” about the management of a condition that is often refractory to established therapies, observed Sawsan As-Sanie, MD, MPH, at the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada. Dr. As-Sanie is Associate Professor and Director, Minimally Invasive Gynecologic Surgery Fellowship, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor. How, then, should clinicians approach the challenge of caring for women with this enigmatic disease in the larger context of chronic pelvic pain, in which, as Dr. As-Sanie said, “one size never fits all”?

Complex correlation between endometriosis and CPP

Despite high prevalence and negative impact on the health and quality of life of women who suffer from endometriosis, Dr. As-Sanie emphasized, it remains unclear why only some women with endometriosis develop chronic pelvic pain (CPP) and why there is little, if any, correlation between disease severity and the intensity of pain.

The clinical approach to endometriosis and CPP can be frustrating for several reasons: there is minimal relationship between extent or location of disease with pain symptoms; there is no consistent relationship among inflammatory markers, nerve-fiber density, and pain symptoms; and pain can recur after medical and surgical therapy—often without evidence of recurrent endometriosis. Furthermore, the differential diagnosis of CPP is broad, and also includes adenomyosis, adhesions, chronic pelvic inflammatory disease, uterine fibroids, pelvic congestion, ovarian remnant, and residual ovarian syndrome. Chronic overlapping pain conditions are prevalent, too, including interstitial cystitis, irritable bowel syndrome, and vulvodynia, to name a few.¹

_

CPP is not just a pain disorder

Dr. As-Sanie said that understanding of CPP must extend to include fatigue, memory difficulties, poor sleep, and heightened sensitivity to multiple sensory stimuli (e.g., sound and light).² So what, she asked, do we know about endometriosis, chronic pelvic pain, and the brain? We know that CPP, with and without endometriosis, is associated with increased pain sensitivity and altered central nervous system structure and function.^3-5 Central amplification of pain can lead to chronic pain independent of nociceptive signals, including multifocal, widespread pain; higher lifetime history of pain throughout the body; and pain triggered or exacerbated by stressors. And CPP brings with it other, potentially debilitating problems, including elevated distress, decreased activity, isolation, poor sleep, and maladaptive illness behaviors.

Finding, then addressing, the culprit

Identifying the underlying cause(s) of CPP in the individual woman should guide clinical care. This includes the decision to proceed with, or avoid, surgery. Remember: Patients with centralized pain respond differently to therapy; surgery is less likely to help relieve the pain.

Dr. As-Sanie offered several fundamental guidelines for managing CPP:

• Treat early, to prevent transition from acute to chronic pain; treatment delay increases connectivity between pain regulatory regions.
• Hysterectomy is not definitive therapy for all women with endometriosis or CPP.⁶
• Take a multisystem approach, comprising medical, behavioral, and interventional strategies.
• If an organ- or disease-based diagnostic and treatment approach does not work, reconsider the diagnosis; re-evaluate comorbid psychosocial variables; and consider treating centralized pain.
• Choice of treatment should include consideration of cost and adverse-effect profile.
• If one modality is ineffective, try another.

Continue to: What are the levels of evidence for centralized pain treatment?

Available pharmacotherapeutic agents have modest benefit, possibly because the population of pain patients is heterogeneous, with various underlying mechanisms of pain. And, Dr. As-Sanie pointed out, clinical tools do not currently exist to pre-emptively select the right medicine for individual patients.

Evidence is strong, Dr. As-Sanie noted, for dual reuptake-inhibitor antidepressants, such as tricyclic compounds (amitriptyline, cyclobenzaprine) and serotonin–norepinephrine reuptake inhibitors, and for anticonvulsants with analgesic properties (pregabalin, gabapentin). Evidence is “modest,” Dr. As-Sanie said, for tramadol, gamma hydroxybutyrate, and low-dose naltrexone, and “weak” for cannabinoids, human growth hormone, 5-hydroxytryptamine, tropisetron, and S-adenosyl-L-methionine. There is no evidence for using opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepine and non–benzodiazepine hypnotics, or guaifenesin.⁷

When surgery or pharmacotherapy alone fail to yield the necessary outcome, consider adjunctive nonpharmacotherapy.⁸ For example, there is strong evidence for patient education, aerobic exercise, and cognitive behavior therapy; modest evidence for acupressure, acupuncture, strength training, hypnotherapy, biofeedback, trigger-point injection, and neuromodulation; but only weak evidence for chiropractic, manual and massage therapy, electrotherapy, and ultrasound. ⁷

_

With CPP, “one size never fits all”

Dr. As-Sanie concluded with a reminder that CPP can be the product of any of a range of underlying contributory causes. Pathology might stand foremost as you search for the source of pain and an effective treatment, but keep in mind that genetics, environment, co-existing pain conditions, the patient’s ability to cope, and her resilience and social support might play a role.

At the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada, Tommaso Falcone, MD, Chief of Staff, Chief Academic Officer, and Medical Director at Cleveland Clinic London, England, addressed the status of tissue morcellation in hysterectomy and myomectomy after several years’ controversy—noting that the specialty’s professional societies all support use of the technique, with precautions and in selected patients.

Morcellation history

Should electromechanical (‘power’) morcellation of tissue be a tool for performing minimally invasive hysterectomy and myomectomy? If so, what are the risks and benefits of using this tool, first approved by the US Food and Drug Administration (FDA) in 1995?

The matter came under intense scrutiny and debate in 2014 as concerns rose about the potential of power morcellation to disseminate intraperitoneal malignancy in women with occult cancer (an estimated 1 in 370 women who undergo power morcellation during a minimally invasive hysterectomy have uterine cancer¹). Early that year, the FDA moved to strongly discourage use of power morcellators for removing uterine fibroids.²

The aftermath, however, was that there were problems with the FDA’s [2014] statement, Dr. Falcone pointed out. In a study by Siedhoff and colleagues of a hypothetical cohort of 100,000 women with fibroids, for example, an abdominal approach resulted in more hysterectomy-related deaths and surgery-related complications than did a laparoscopic procedure with morcellation.³

Balancing risks and benefits of MIS

After continuing study of the risks presented by morcellation, the question today is: How do we balance preventing dissemination of cancer against diminishing the significant benefits of minimally invasive surgery, as surgical technique has been modified to avoid morcellation—including, Dr. Falcone said, by increased use of mini lap (i.e., extending the laparoscopy incision) tissue extraction, decreased use of supracervical hysterectomy, and a move to open approaches.

In fact, Dr. Falcone noted, power morcellation is banned in many institutions, having been replaced by scalpel, extraperitoneal, or in-bag morcellation. Last year, after further analysis, the FDA reiterated its recommendation against use of power morcellators to remove fibroids in most women.⁴
 

Continue to: Morcellation decisions

Dr. Falcone pointed out that, at the Cleveland Clinic, morcellation is not performed in postmenopausal women, and for several other contraindications, including a history of >2 years of tamoxifen therapy; history of pelvic radiation; history of childhood retinoblastoma; personal history of hereditary leiomyomatosis or renal cell carcinoma; and the presence of a cancer-positive tissue specimen. Morcellation is not performed unless endometrial adenocarcinoma has been ruled out. The decision-making process when electing to use tissue extraction includes whether to use contained or noncontained morcellation; whether to favor knife excision over power morcellation; and, when using a mini lap approach, whether to proceed via the umbilicus or suprapubically.

Complications of morcellation include direct injury by the morcellator; dissemination, as noted, of tissue; ‘upstaging’ of uterine sarcoma, with a worsening prognosis; seeding of parasitic fibroids; and reoperation with laparotomy and extensive multi-organ resection to clear disease (3 patients in a published report).⁵

An important advancement in the use of morcellation in minimally invasive hysterectomy or myomectomy has been the development of contained systems for morcellating—generally a plastic specimen bag, sometimes pulled through the port and insufflated. Dr. Falcone’s presentation included video presentations of this important, and still evolving, technology. Whether these contained systems improve survival, and whether using them in a vaginal approach makes any difference, remain uncertain, however. Furthermore, some spillage from bags is inevitable—although how much spillage is clinically significant is open to question.

Takeaways

Dr. Falcone concluded with key points to guide the surgeon’s decision on whether to proceed with morcellation:

• There are no comparative data on which technique [of tissue removal] is best.
• Tissue spill will occur in uncontained morcellation—this is intrinsic to the device.
• Even with the current generation of tissue bags, leakage is common and puncture is possible.

If you choose to continue to use power morcellation, your decision is supported by the fact that all the professional societies still support it, Dr. Falcone noted. Furthermore, he pointed out that it is important to look to the standard of care in your community regarding risks and benefits before proceeding.

Last, the advantages and risks of morcellation in hysterectomy and myomectomy should be part of an in-depth discussion between patient and surgeon prior to the procedure. And you must, Dr. Falcone emphasized, obtain specific informed consent.

At the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada, Tommaso Falcone, MD, Chief of Staff, Chief Academic Officer, and Medical Director at Cleveland Clinic London, England, addressed the status of tissue morcellation in hysterectomy and myomectomy after several years’ controversy—noting that the specialty’s professional societies all support use of the technique, with precautions and in selected patients.

Morcellation history

Should electromechanical (‘power’) morcellation of tissue be a tool for performing minimally invasive hysterectomy and myomectomy? If so, what are the risks and benefits of using this tool, first approved by the US Food and Drug Administration (FDA) in 1995?

The matter came under intense scrutiny and debate in 2014 as concerns rose about the potential of power morcellation to disseminate intraperitoneal malignancy in women with occult cancer (an estimated 1 in 370 women who undergo power morcellation during a minimally invasive hysterectomy have uterine cancer¹). Early that year, the FDA moved to strongly discourage use of power morcellators for removing uterine fibroids.²

The aftermath, however, was that there were problems with the FDA’s [2014] statement, Dr. Falcone pointed out. In a study by Siedhoff and colleagues of a hypothetical cohort of 100,000 women with fibroids, for example, an abdominal approach resulted in more hysterectomy-related deaths and surgery-related complications than did a laparoscopic procedure with morcellation.³

Balancing risks and benefits of MIS

After continuing study of the risks presented by morcellation, the question today is: How do we balance preventing dissemination of cancer against diminishing the significant benefits of minimally invasive surgery, as surgical technique has been modified to avoid morcellation—including, Dr. Falcone said, by increased use of mini lap (i.e., extending the laparoscopy incision) tissue extraction, decreased use of supracervical hysterectomy, and a move to open approaches.

In fact, Dr. Falcone noted, power morcellation is banned in many institutions, having been replaced by scalpel, extraperitoneal, or in-bag morcellation. Last year, after further analysis, the FDA reiterated its recommendation against use of power morcellators to remove fibroids in most women.⁴
 

Continue to: Morcellation decisions

Dr. Falcone pointed out that, at the Cleveland Clinic, morcellation is not performed in postmenopausal women, and for several other contraindications, including a history of >2 years of tamoxifen therapy; history of pelvic radiation; history of childhood retinoblastoma; personal history of hereditary leiomyomatosis or renal cell carcinoma; and the presence of a cancer-positive tissue specimen. Morcellation is not performed unless endometrial adenocarcinoma has been ruled out. The decision-making process when electing to use tissue extraction includes whether to use contained or noncontained morcellation; whether to favor knife excision over power morcellation; and, when using a mini lap approach, whether to proceed via the umbilicus or suprapubically.

Complications of morcellation include direct injury by the morcellator; dissemination, as noted, of tissue; ‘upstaging’ of uterine sarcoma, with a worsening prognosis; seeding of parasitic fibroids; and reoperation with laparotomy and extensive multi-organ resection to clear disease (3 patients in a published report).⁵

An important advancement in the use of morcellation in minimally invasive hysterectomy or myomectomy has been the development of contained systems for morcellating—generally a plastic specimen bag, sometimes pulled through the port and insufflated. Dr. Falcone’s presentation included video presentations of this important, and still evolving, technology. Whether these contained systems improve survival, and whether using them in a vaginal approach makes any difference, remain uncertain, however. Furthermore, some spillage from bags is inevitable—although how much spillage is clinically significant is open to question.

Takeaways

Dr. Falcone concluded with key points to guide the surgeon’s decision on whether to proceed with morcellation:

• There are no comparative data on which technique [of tissue removal] is best.
• Tissue spill will occur in uncontained morcellation—this is intrinsic to the device.
• Even with the current generation of tissue bags, leakage is common and puncture is possible.

If you choose to continue to use power morcellation, your decision is supported by the fact that all the professional societies still support it, Dr. Falcone noted. Furthermore, he pointed out that it is important to look to the standard of care in your community regarding risks and benefits before proceeding.

Last, the advantages and risks of morcellation in hysterectomy and myomectomy should be part of an in-depth discussion between patient and surgeon prior to the procedure. And you must, Dr. Falcone emphasized, obtain specific informed consent.

At the 2018 Pelvic Anatomy and Gynecologic Surgery Symposium meeting in Las Vegas, Nevada, Tommaso Falcone, MD, Chief of Staff, Chief Academic Officer, and Medical Director at Cleveland Clinic London, England, addressed the status of tissue morcellation in hysterectomy and myomectomy after several years’ controversy—noting that the specialty’s professional societies all support use of the technique, with precautions and in selected patients.

Morcellation history

Should electromechanical (‘power’) morcellation of tissue be a tool for performing minimally invasive hysterectomy and myomectomy? If so, what are the risks and benefits of using this tool, first approved by the US Food and Drug Administration (FDA) in 1995?

The matter came under intense scrutiny and debate in 2014 as concerns rose about the potential of power morcellation to disseminate intraperitoneal malignancy in women with occult cancer (an estimated 1 in 370 women who undergo power morcellation during a minimally invasive hysterectomy have uterine cancer¹). Early that year, the FDA moved to strongly discourage use of power morcellators for removing uterine fibroids.²

The aftermath, however, was that there were problems with the FDA’s [2014] statement, Dr. Falcone pointed out. In a study by Siedhoff and colleagues of a hypothetical cohort of 100,000 women with fibroids, for example, an abdominal approach resulted in more hysterectomy-related deaths and surgery-related complications than did a laparoscopic procedure with morcellation.³

Balancing risks and benefits of MIS

After continuing study of the risks presented by morcellation, the question today is: How do we balance preventing dissemination of cancer against diminishing the significant benefits of minimally invasive surgery, as surgical technique has been modified to avoid morcellation—including, Dr. Falcone said, by increased use of mini lap (i.e., extending the laparoscopy incision) tissue extraction, decreased use of supracervical hysterectomy, and a move to open approaches.

In fact, Dr. Falcone noted, power morcellation is banned in many institutions, having been replaced by scalpel, extraperitoneal, or in-bag morcellation. Last year, after further analysis, the FDA reiterated its recommendation against use of power morcellators to remove fibroids in most women.⁴
 

Continue to: Morcellation decisions

Dr. Falcone pointed out that, at the Cleveland Clinic, morcellation is not performed in postmenopausal women, and for several other contraindications, including a history of >2 years of tamoxifen therapy; history of pelvic radiation; history of childhood retinoblastoma; personal history of hereditary leiomyomatosis or renal cell carcinoma; and the presence of a cancer-positive tissue specimen. Morcellation is not performed unless endometrial adenocarcinoma has been ruled out. The decision-making process when electing to use tissue extraction includes whether to use contained or noncontained morcellation; whether to favor knife excision over power morcellation; and, when using a mini lap approach, whether to proceed via the umbilicus or suprapubically.

Complications of morcellation include direct injury by the morcellator; dissemination, as noted, of tissue; ‘upstaging’ of uterine sarcoma, with a worsening prognosis; seeding of parasitic fibroids; and reoperation with laparotomy and extensive multi-organ resection to clear disease (3 patients in a published report).⁵

An important advancement in the use of morcellation in minimally invasive hysterectomy or myomectomy has been the development of contained systems for morcellating—generally a plastic specimen bag, sometimes pulled through the port and insufflated. Dr. Falcone’s presentation included video presentations of this important, and still evolving, technology. Whether these contained systems improve survival, and whether using them in a vaginal approach makes any difference, remain uncertain, however. Furthermore, some spillage from bags is inevitable—although how much spillage is clinically significant is open to question.

Takeaways

Dr. Falcone concluded with key points to guide the surgeon’s decision on whether to proceed with morcellation:

• There are no comparative data on which technique [of tissue removal] is best.
• Tissue spill will occur in uncontained morcellation—this is intrinsic to the device.
• Even with the current generation of tissue bags, leakage is common and puncture is possible.

If you choose to continue to use power morcellation, your decision is supported by the fact that all the professional societies still support it, Dr. Falcone noted. Furthermore, he pointed out that it is important to look to the standard of care in your community regarding risks and benefits before proceeding.

Last, the advantages and risks of morcellation in hysterectomy and myomectomy should be part of an in-depth discussion between patient and surgeon prior to the procedure. And you must, Dr. Falcone emphasized, obtain specific informed consent.

LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And take a lesson from French fry portions at fast-food restaurants: Don’t “super-size” opioid prescriptions.

Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
 

Try acetaminophen and an NSAID

In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.

She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).

Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
 

Consider gabapentin, but not postoperatively

Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).

Consider neuropathics for minimally invasive hysterectomy

Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
 

Educate patients about postop painkiller use

Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”

It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
 

Don’t over-prescribe opioids

For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).

Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”

Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.

Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.

LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And take a lesson from French fry portions at fast-food restaurants: Don’t “super-size” opioid prescriptions.

Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
 

Try acetaminophen and an NSAID

In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.

She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).

Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
 

Consider gabapentin, but not postoperatively

Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).

Consider neuropathics for minimally invasive hysterectomy

Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
 

Educate patients about postop painkiller use

Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”

It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
 

Don’t over-prescribe opioids

For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).

Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”

Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.

Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.

LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And take a lesson from French fry portions at fast-food restaurants: Don’t “super-size” opioid prescriptions.

Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
 

Try acetaminophen and an NSAID

In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.

She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).

Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
 

Consider gabapentin, but not postoperatively

Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).

Consider neuropathics for minimally invasive hysterectomy

Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
 

Educate patients about postop painkiller use

Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”

It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
 

Don’t over-prescribe opioids

For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).

Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”

Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.

Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.

LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.

M. Alexander Otto/MDedge News

Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.

Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.

After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.

“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.

So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.

The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.

Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.

Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm³ and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.

The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.

There was no external funding for the work, and Dr. Movilla had no disclosures.

aotto@mdedge.com

SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.

LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.

M. Alexander Otto/MDedge News

Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.

Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.

After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.

“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.

So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.

The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.

Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.

Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm³ and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.

The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.

There was no external funding for the work, and Dr. Movilla had no disclosures.

aotto@mdedge.com

SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.

LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.

M. Alexander Otto/MDedge News

Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.

Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.

After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.

“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.

So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.

The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.

Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.

Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm³ and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.

The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.

There was no external funding for the work, and Dr. Movilla had no disclosures.

aotto@mdedge.com

SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.

LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.

Courtesy Cashman Photo

“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”

Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:

Test for stress incontinence

Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”

If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
 

Ask the right questions

When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.

A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”

Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
 

Beware of acute incontinence cases

“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

Discuss the many treatment options

In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”

She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”

Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.

LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.

Courtesy Cashman Photo

“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”

Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:

Test for stress incontinence

Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”

If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
 

Ask the right questions

When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.

A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”

Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
 

Beware of acute incontinence cases

“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

Discuss the many treatment options

In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”

She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”

Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.

LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.

Courtesy Cashman Photo

“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”

Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:

Test for stress incontinence

Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”

If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
 

Ask the right questions

When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.

A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”

Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
 

Beware of acute incontinence cases

“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

Discuss the many treatment options

In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”

She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”

Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.

LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.

Courtesy Cashman Photo

Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”

Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.

“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”

As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).

Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.

Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.

Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.

Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.

Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”

Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”

Dr. Nickles Fader reported consulting for Ethicon Endosurgery.

LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.

Courtesy Cashman Photo

Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”

Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.

“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”

As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).

Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.

Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.

Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.

Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.

Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”

Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”

Dr. Nickles Fader reported consulting for Ethicon Endosurgery.

LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.

Courtesy Cashman Photo

Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”

Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.

“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”

As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).

Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.

Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.

Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.

Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.

Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”

Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”

Dr. Nickles Fader reported consulting for Ethicon Endosurgery.

LAS VEGAS – Vaginal trial of labor is safe after myomectomy, at least if the uterine cavity wasn’t entered, according to investigators from Northwestern University, Chicago.

M. Alexander Otto/MDedge News

The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.

Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.

Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.

The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*

He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.

Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.

The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.

Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).

There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.

Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.

There was no external funding for the work, and Dr. King didn’t have any disclosures.

aotto@mdedge.com

SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.

*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
 

LAS VEGAS – Vaginal trial of labor is safe after myomectomy, at least if the uterine cavity wasn’t entered, according to investigators from Northwestern University, Chicago.

M. Alexander Otto/MDedge News

The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.

Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.

Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.

The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*

He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.

Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.

The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.

Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).

There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.

Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.

There was no external funding for the work, and Dr. King didn’t have any disclosures.

aotto@mdedge.com

SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.

*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
 

LAS VEGAS – Vaginal trial of labor is safe after myomectomy, at least if the uterine cavity wasn’t entered, according to investigators from Northwestern University, Chicago.

M. Alexander Otto/MDedge News

The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.

Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.

Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.

The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*

He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.

Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.

The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.

Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).

There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.

Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.

There was no external funding for the work, and Dr. King didn’t have any disclosures.

aotto@mdedge.com

SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.

*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
 

Dienogest as an option for endometriosis pain

For treatment of endometriosis-related pain, what about the drug dienogest and the cyclic oral contraceptive Qlaira, which contains dienogest?

Chow Kah Kiong, MBBS
Singapore

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Norethindrone’s conversion to ethinyl estradiol

Dr. Barbieri’s editorial on the medical treatment of endometriosis is excellent! Does norethindrone acetate metabolize to ethinyl estradiol in a higher percentage when the dose is higher, or is it still 1%? We were taught that at doses of greater than 15 mg daily, norethindrone can contribute significant amounts of estrogen.

Lauren Barnes, MD
Albuquerque, New Mexico

Endometriosis is a surgical, not a medical, disease

I read with some dismay Dr. Barbieri’s editorial on medical treatment of endometriosis. As a long-time disciple of the eminent Dr. David Redwine, I have dedicated my practice focus over the past 28 years to minimally invasive curative solutions to many gynecologic problems. The data on the histology, qualitative hormonal differences, and inconsistent and poor long-term response of endometriosis to traditional hormonal suppressive therapies falls strongly in favor of complete and thorough laparoscopic excision—not “biopsy”—as the only truly curative treatment, certainly not medical therapy. Endometriosis is a surgical disease. The experience of the dedicated few in our field who have taken the time and effort to become experts in excision (not ablation) of endometriosis bears this out.

The tragedy is that the only Current Procedural Terminology code that is usable for reimbursement is 58662. Sadly, this code was assigned a resource-based relative value scale “value” many years ago, when the operation consisted of putting a scope in the abdomen and taking a sampling biopsy (which took all of 10 minutes). Of course, we know that a prolonged, delicate procedure requiring retroperitoneal dissection, ureterolysis, excision of deeply infiltrating rectovaginal septum endometriosis, and discoid or segmental bowel resection requires the kind of surgical expertise developed only by those who put in the time and effort to get good at this type of surgery. The majority of ObGyns who have a full obstetric practice and low surgical volumes simply are not going to struggle in the operating room over the many cases that it takes to become good, and safe, at this procedure only to receive an insulting reimbursement.

It is emblematic of this travesty that many of the best minimally invasive surgery practitioners do not accept insurance or other thirdparty payment such as Medicaid as they would otherwise not cover their overhead.

Putting premenopausal women into a severely hypoestrogenic state with medication is cruel and, even worse, does not cure the disease.

Balanced information on surgical management should have been presented in the article. And physicians who are not capable of proper laparoscopic excision should refer the patient.

Hugo Ribot, MD
Cartersville, Georgia

Continue to: Dr. Barbieri responds

I thank Drs. Chow, Barnes, and Ribot for their interest in my recent editorial on the medical treatment of endometriosis. I agree with Dr. Chow that dienogest, a synthetic progestin, is effective in the treatment of pelvic pain caused by endometriosis. In one observational study, norethindrone acetate 2.5 mg daily and dienogest 2 mg daily had similar efficacy in the treatment of pelvic pain. Dienogest treatment was associated with fewer side effects but was much more expensive than norethindrone acetate.¹ The US Food and Drug Administration has approved a combination estradiol- progestin pill (Natazia, Qlaira) as a contraceptive, and I have occasionally used this medication in my practice for women with pelvic pain caused by endometriosis. Dienogest monotherapy is not available in the United States.

Dr. Barnes reminds us that norethindrone is a substrate for the aromatase enzyme system and can be converted to ethinyl estradiol.² The conversion occurs at a very low rate, likely less than 0.4%.³ At a norethindrone acetate dose of 5 mg daily, aromatization would result in the production of less than 2 μg of ethinyl estradiol daily.

Dr. Ribot advocates for surgery as the primary treatment of pelvic pain caused by endometriosis. I agree with Dr. Ribot that, for severe pain caused by deep infiltrating endometriosis, surgery is an optimal approach. However, for women with pelvic pain and Stage I endometriosis, hormonal treatment after initial surgical diagnosis and treatment reduces pain recurrence and repetitive surgical procedures.⁴

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Dienogest as an option for endometriosis pain

For treatment of endometriosis-related pain, what about the drug dienogest and the cyclic oral contraceptive Qlaira, which contains dienogest?

Chow Kah Kiong, MBBS
Singapore

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--

Norethindrone’s conversion to ethinyl estradiol

Dr. Barbieri’s editorial on the medical treatment of endometriosis is excellent! Does norethindrone acetate metabolize to ethinyl estradiol in a higher percentage when the dose is higher, or is it still 1%? We were taught that at doses of greater than 15 mg daily, norethindrone can contribute significant amounts of estrogen.

Lauren Barnes, MD
Albuquerque, New Mexico

Endometriosis is a surgical, not a medical, disease

I read with some dismay Dr. Barbieri’s editorial on medical treatment of endometriosis. As a long-time disciple of the eminent Dr. David Redwine, I have dedicated my practice focus over the past 28 years to minimally invasive curative solutions to many gynecologic problems. The data on the histology, qualitative hormonal differences, and inconsistent and poor long-term response of endometriosis to traditional hormonal suppressive therapies falls strongly in favor of complete and thorough laparoscopic excision—not “biopsy”—as the only truly curative treatment, certainly not medical therapy. Endometriosis is a surgical disease. The experience of the dedicated few in our field who have taken the time and effort to become experts in excision (not ablation) of endometriosis bears this out.

The tragedy is that the only Current Procedural Terminology code that is usable for reimbursement is 58662. Sadly, this code was assigned a resource-based relative value scale “value” many years ago, when the operation consisted of putting a scope in the abdomen and taking a sampling biopsy (which took all of 10 minutes). Of course, we know that a prolonged, delicate procedure requiring retroperitoneal dissection, ureterolysis, excision of deeply infiltrating rectovaginal septum endometriosis, and discoid or segmental bowel resection requires the kind of surgical expertise developed only by those who put in the time and effort to get good at this type of surgery. The majority of ObGyns who have a full obstetric practice and low surgical volumes simply are not going to struggle in the operating room over the many cases that it takes to become good, and safe, at this procedure only to receive an insulting reimbursement.

It is emblematic of this travesty that many of the best minimally invasive surgery practitioners do not accept insurance or other thirdparty payment such as Medicaid as they would otherwise not cover their overhead.

Putting premenopausal women into a severely hypoestrogenic state with medication is cruel and, even worse, does not cure the disease.

Balanced information on surgical management should have been presented in the article. And physicians who are not capable of proper laparoscopic excision should refer the patient.

Hugo Ribot, MD
Cartersville, Georgia

Continue to: Dr. Barbieri responds

I thank Drs. Chow, Barnes, and Ribot for their interest in my recent editorial on the medical treatment of endometriosis. I agree with Dr. Chow that dienogest, a synthetic progestin, is effective in the treatment of pelvic pain caused by endometriosis. In one observational study, norethindrone acetate 2.5 mg daily and dienogest 2 mg daily had similar efficacy in the treatment of pelvic pain. Dienogest treatment was associated with fewer side effects but was much more expensive than norethindrone acetate.¹ The US Food and Drug Administration has approved a combination estradiol- progestin pill (Natazia, Qlaira) as a contraceptive, and I have occasionally used this medication in my practice for women with pelvic pain caused by endometriosis. Dienogest monotherapy is not available in the United States.

Dr. Barnes reminds us that norethindrone is a substrate for the aromatase enzyme system and can be converted to ethinyl estradiol.² The conversion occurs at a very low rate, likely less than 0.4%.³ At a norethindrone acetate dose of 5 mg daily, aromatization would result in the production of less than 2 μg of ethinyl estradiol daily.

Dr. Ribot advocates for surgery as the primary treatment of pelvic pain caused by endometriosis. I agree with Dr. Ribot that, for severe pain caused by deep infiltrating endometriosis, surgery is an optimal approach. However, for women with pelvic pain and Stage I endometriosis, hormonal treatment after initial surgical diagnosis and treatment reduces pain recurrence and repetitive surgical procedures.⁴

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Dienogest as an option for endometriosis pain

For treatment of endometriosis-related pain, what about the drug dienogest and the cyclic oral contraceptive Qlaira, which contains dienogest?

Chow Kah Kiong, MBBS
Singapore

-- 

--

Norethindrone’s conversion to ethinyl estradiol

Dr. Barbieri’s editorial on the medical treatment of endometriosis is excellent! Does norethindrone acetate metabolize to ethinyl estradiol in a higher percentage when the dose is higher, or is it still 1%? We were taught that at doses of greater than 15 mg daily, norethindrone can contribute significant amounts of estrogen.

Lauren Barnes, MD
Albuquerque, New Mexico

Endometriosis is a surgical, not a medical, disease

I read with some dismay Dr. Barbieri’s editorial on medical treatment of endometriosis. As a long-time disciple of the eminent Dr. David Redwine, I have dedicated my practice focus over the past 28 years to minimally invasive curative solutions to many gynecologic problems. The data on the histology, qualitative hormonal differences, and inconsistent and poor long-term response of endometriosis to traditional hormonal suppressive therapies falls strongly in favor of complete and thorough laparoscopic excision—not “biopsy”—as the only truly curative treatment, certainly not medical therapy. Endometriosis is a surgical disease. The experience of the dedicated few in our field who have taken the time and effort to become experts in excision (not ablation) of endometriosis bears this out.

The tragedy is that the only Current Procedural Terminology code that is usable for reimbursement is 58662. Sadly, this code was assigned a resource-based relative value scale “value” many years ago, when the operation consisted of putting a scope in the abdomen and taking a sampling biopsy (which took all of 10 minutes). Of course, we know that a prolonged, delicate procedure requiring retroperitoneal dissection, ureterolysis, excision of deeply infiltrating rectovaginal septum endometriosis, and discoid or segmental bowel resection requires the kind of surgical expertise developed only by those who put in the time and effort to get good at this type of surgery. The majority of ObGyns who have a full obstetric practice and low surgical volumes simply are not going to struggle in the operating room over the many cases that it takes to become good, and safe, at this procedure only to receive an insulting reimbursement.

It is emblematic of this travesty that many of the best minimally invasive surgery practitioners do not accept insurance or other thirdparty payment such as Medicaid as they would otherwise not cover their overhead.

Putting premenopausal women into a severely hypoestrogenic state with medication is cruel and, even worse, does not cure the disease.

Balanced information on surgical management should have been presented in the article. And physicians who are not capable of proper laparoscopic excision should refer the patient.

Hugo Ribot, MD
Cartersville, Georgia

Continue to: Dr. Barbieri responds

I thank Drs. Chow, Barnes, and Ribot for their interest in my recent editorial on the medical treatment of endometriosis. I agree with Dr. Chow that dienogest, a synthetic progestin, is effective in the treatment of pelvic pain caused by endometriosis. In one observational study, norethindrone acetate 2.5 mg daily and dienogest 2 mg daily had similar efficacy in the treatment of pelvic pain. Dienogest treatment was associated with fewer side effects but was much more expensive than norethindrone acetate.¹ The US Food and Drug Administration has approved a combination estradiol- progestin pill (Natazia, Qlaira) as a contraceptive, and I have occasionally used this medication in my practice for women with pelvic pain caused by endometriosis. Dienogest monotherapy is not available in the United States.

Dr. Barnes reminds us that norethindrone is a substrate for the aromatase enzyme system and can be converted to ethinyl estradiol.² The conversion occurs at a very low rate, likely less than 0.4%.³ At a norethindrone acetate dose of 5 mg daily, aromatization would result in the production of less than 2 μg of ethinyl estradiol daily.

Dr. Ribot advocates for surgery as the primary treatment of pelvic pain caused by endometriosis. I agree with Dr. Ribot that, for severe pain caused by deep infiltrating endometriosis, surgery is an optimal approach. However, for women with pelvic pain and Stage I endometriosis, hormonal treatment after initial surgical diagnosis and treatment reduces pain recurrence and repetitive surgical procedures.⁴

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.