Neil Minkoff, MD: One of the things that can be confusing to a primary care physician like myself is that it seems as if many of the treatments for the different conditions we’re discussing revert back to some level of contraception, whether it’s oral contraception, an IUD [intrauterine device], or something like that. Could you talk a little about how you pick the appropriate contraception for the right patient, other differences in terms of what you’re picking for the different diagnoses and so on, combined vs progesterone-only oral contraceptives, or medicated vs non-medicated IUDs? I realize I just threw like a million things at you. But 1 of the things that’s confusing to me as a primary care doctor is trying to figure out some of those levels.

Steven McCarus, MD, FACOG: Here’s my philosophy on medical treatment as far as birth control pills and what you pick. You have to remember that dysmenorrhea is a common symptom that we hear in patients who might have endometriosis. The first line of therapy for dysmenorrhea is nonsteroidal anti-inflammatories or birth control pills, or both for 90 days. Always give the patient a pain diary for 90 days and put her on a combination birth control pill, estrogen and progesterone, low dose. That’s our first treatment. If the patient comes back and is better and her dysmenorrhea is improved, I keep her on her medical therapy.

Here’s where Ayman and I may disagree. I’m a true believer that endometriosis is an estrogen-dependent disease. It needs estrogen to proliferate. If I’m treating endometriosis, I never use an estrogen medication. I don’t switch the pill. I don’t give them any exogenous estrogen. I want to decrease the amount of estrogen that’s present. I would go to a progestin-only pill. IUD and Depo-Provera have been used. There are data that say pain will improve with those medications. But I want to suppress the proliferation of the disease, so I go with a progestin-only pill or some of the newer medications that we’ll probably talk about in a bit.

Neil Minkoff, MD: What about IUD usage?

Steven McCarus, MD, FACOG: I use a hormone-releasing IUD to decrease heavy menstrual bleeding. I don’t use that to treat endometriosis.

Neil Minkoff, MD: You’re treating the symptom of the heavy bleeding rather than the underlying disease state?

Steven McCarus, MD, FACOG: Correct.

Ayman Al-Hendy, MD, PhD: This was the state of the art up until 2018 or early 2019. Then, we started gaining new medical treatment options. For endometriosis, we have elagolix [Orilissa], whether alone or with the add-back therapy. I’m talking about FDA-approved medications published in a high caliber medical journal. For fibroid, we have elagolix, also with add-back therapy, but it’s a different dose than endometriosis. Then, more recently, as of last summer, we have relugolix [Myfembree] with add-back therapy. Can we use their commercial names?

Neil Minkoff, MD: Go ahead. I want to make sure everybody knows what we’re talking about.

Ayman Al-Hendy, MD, PhD: Because it can get a little confusing. Orilissa has been FDA approved for treatment of pelvic pain associated with endometriosis for about 3 to 4 years. For fibroid, we have Oriahnn, which is elagolix with estradiol and norethisterone acetate. It was approved in summer of 2020. Most recently, relugolix was approved in summer last year, which is estradiol and norethisterone acetate. The commercial name is Myfembree. We have to use these new tools.

Maria mentioned guidelines. The ACOG [American College of Obstetricians and Gynecologists] guidelines for fibroids came out in June of 2021. The previous one was probably 2008. That’s about 13 years. It doesn’t identify a first-line therapy, which I wasn’t happy with. But at least they left it up to the doctors and the patient discussion. They put all the medications out there, but they didn’t identify first-line therapy. Of course, I respect everybody’s opinion and practice. In my opinion, the situation to start with birth control pills and so on was totally appropriate up until 2018, when we didn’t have alternatives. Now that we have these new tools after highly well-designed, highly planned phase 3 trials in large numbers of patients, sometimes 800 or 900 patients, with high-quality data, I use these new options as my first-line therapy.

Transcripts edited for clarity.