Dr Linda D. Bradley on Inequities in Treating Endometriosis and Uterine Fibroids

Optimal care that should be offered to all patients includes not only pain relief but also a complete pelvic exam and a discussion about the many options that are available for fibroids and endometriosis, including minimally invasive, organ-conserving surgery, said Linda D. Bradley, MD, professor of Obstetrics and Gynecology and Reproductive Medicine, Cleveland Clinic.

Part 2 of this discussion with The American Journal of Managed Care^® (AJMC^®) continues here. Read part 1 here.

AJMC®: What are some examples of uterine-saving procedures and treatments that we might use in the treatment and management of uterine fibroids? Are there any inequities or disparities with respect to these procedures? Do we see different groups having access to them disproportionately from other groups?

Bradley: Well, I think I would always want to start with, yes, I am a surgeon, but I always start with baby steps. Many diseases don't require any surgery, or extra pain of surgery. The first thing is to see, are there medications? Let's just look at symptoms.

Lumping them together, both disease states can cause pain. Can we come up with a safe, non-narcotic pain regimen that would be tolerated and treat the symptoms?

We know that women of color do not get offered pain therapy. And I'm not even speaking about narcotics. We see this in the hospitals after surgery, that women of color are less likely to even go home after a major surgery with as many pills as a white person, and even when we know that they're not drug-seeking people.

The first thing is pain medicine: optimizing, explaining, using multiple modalities. For instance, we might use—if we're seeing someone without allergies—a really good [nonsteroidal anti-inflammatory drug] NSAID. I tell patients, acetaminophen or Tylenol—I'm just making a name up—Motrin, they work differently on pain receptors. And we have to be convincing. Many patients say, “Oh, Tylenol never works,” but sometimes, when we bridge it with, or combine it with, an NSAID, this may work.

And I think the other thing is to have a fixed period of time that the patient should be better. I'm not going to see her January 1, severe pain, the visual analogue, “What's your pain, from zero to 10?” I go through, “OK, how many days do you bleed? When do you have the pain?” And “What do you take?”

A lot of patients say, “Well, the doctor just gives me what I'm already taking.” Well, that's wrong. OK, you've been on this, let's try something different. What things may help?

Some patients are very into things like yoga, acupuncture, a heating pad, massage if they can afford it. Those kinds of things. I want to work with a patient—different teas, different things. I'm not trained in that area but multiple modalities and their belief system, we should work with them, not against them.

The first is to see something on a non-narcotic route. I think imaging is very important, like ultrasound, as is the first thing that's most important is a pelvic and abdominal exam, the old-fashioned hands-on touch. We are very high tech with patients but very low touch these days. I think it's unfair. I'll have patients come to me and say to me, "You know, Dr. Bradley, I've been seeing somebody, a health care provider, for years. They've never done a pelvic exam."

That to me is wrong. Unless there is a religious reason, like they can't be examined on their period or if there is an issue. If there is some reason, you have to respect that. But if someone's come to me multiple times and there's no pelvic [exam], that's not right. We start with that.

Sometimes patients with obesity, you may not feel the pelvic anatomy as well. Then you go to the next step, a transvaginal ultrasound, if it's looking for pain. If she has a huge ovarian endometrioma—again, the normal ovary is the size of a walnut—if her ovary is swollen with blood to the size of an orange or an egg, or you name the fruit, that's not going to be NSAIDs only and Tylenol. That’s surgical treatment.

Then when they go to surgical treatment, even if they don't want children, we should not remove ovaries. Ovaries are an important source of hormones. Get the best doctor who can offer minimally invasive techniques, and that's ovarian conservation. If it's fibroids, for uterine conservation, meaning just removing the myomas. I liken this to having a bad tooth. You go to a dentist. We don't have a patient leave with all of their teeth pulled. They fix a crown, put a cap over it, they do something.

I think in gynecology we have been unfortunately taught to just remove organs. Again, there is that social stigma for black women. "They have had children, they don't need any more children." Or just remove the uterus because they say they're not going to have a child. Or, at that time, we are, as black women, less married than white women, so black women may have partnerships with either marriage or a partner who are wanting children later in life.

I think it's sad for us to just think a 32-year-old that's not in a relationship never wants to be a mother. We have to also listen to our patients. Some women have just suffered so much, and the doors are revolving for them, that when offered surgery, they'll just say, “take it all out.” We have to step back and say, “no, let's see what we can do to treat the symptoms at hand.” The uterus, in particular, has many functions besides menstruation. The ovaries have many functions. I think we should do like a dentist, treat what only needs to be treated and not go in taking out all these different organs. It would be rare in 2022/2023 to have to do that. There are just many, many options and ways we can reassure patients and follow patients.

Even medicines like continuous low-dose contraception for menstrual suppression, use of intrauterine devices, again I'm just naming things. Everybody can't have it, but these are things that we think about. They're not even new but antifibrinolytics like Lysteda for heavy menstrual bleeding.

We just slowly, slowly go up. I try to have a fixed time. If you have heavy bleeding and I put you on a antifibrinolytic, if it's going to work, it's going to work in one period, the next period. If you're not better, then we stop that and we start something else. I think the partnership I have with my patients is we talk, tell me- I always use the work rank, R-A-N-K order what bothers you the most. What can we fix? What's really on the top of your list? I say I'm going to try to fix everything, but I have to make sure when you're leaving that I've heard you tell me what's the top two things? Then we work on that.

Then we can make a follow up. That could be a follow up telephone call. Those who can access their EPIC on the computer, their MyChart, I always say send me a note and tell me how this next period was, or the next couple periods, depending on what we have tried. I don't want to see a patient back in 6 months to a year and they are still at the same point because we wasted time and they've lost precious time.

I saw a lady yesterday missing 3 to 4 days of work a month. I couldn't miss that many days a month and still be employed. Those women, not only do they lose their jobs, they are sometimes hourly workers. If you don't work, you don't get your full paycheck.

We need to have to have templates for the time. When am I going to see you back? When do I need to hear from you? What are your concerns? We have to listen to her story and what bothers her the most. What does she want the most? As physicians, if we don't provide those services, if you're not a minimally invasive surgeon, we still need to know that certain procedures are available. If you don't do them, but only cut women open like the old days, that's inappropriate. Most surgeries now, for most people, should be minimally invasive, tiny incisions, they go home in a few hours. They are off work less time. There are so many more benefits of minimally invasive [gynecological] GYN surgical procedures and that's the direction that women need to know, and also how to find those kinds of physicians for surgery.