First-Line Therapies for Endometriosis

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Maria Lopes, MD, MS: Dr Surrey, can you please take us through some of the treatment options that are available if you suspect or confirm endometriosis?

Eric Surrey, MD: [This could be] a 6-hour answer, so I’ll try to be succinct. The first part is: What are you treating? That’s a critical piece. This is where you must communicate with the patient, because the clinician may think they know what the patient wants [but doesn’t]. The first question is: Depending on her age, is the primary desire pregnancy or pain relief? Obviously, it’s going to be both. But if the patient says, “I want to get pregnant ASAP,” that’s a very different evaluation and treatment. I won’t go into that today in terms of fertility evaluation, but it’s critical to ask that question.

If it’s pain relief, then the critical piece is, “What’s the thing that’s bothering you the most?” Because if their main concern is, “I’m having painful intercourse, the rest doesn’t concern me,” that’s going to point you in a different direction. You’ve got to talk to the patient. But if we take the [common] patient who comes in with some form of pelvic pain and has never been diagnosed, and you’re the first clinician they’ve seen, which isn’t that likely, you’d typically want to do a full history, physical exam, and appropriate imaging. Standard imaging would be ultrasound. In my view, we do a much better job when the clinician does their own ultrasound because the ultrasound examination is an extension of the pelvic examination. A radiologist, good as they may be, isn’t doing a pelvic exam. There’s some great work on more advanced ultrasound techniques to pick up nodules and points of tenderness that can help you so much.

If we take a patient who has no masses, has classic pain, and doesn’t want to get pregnant right away, the standard first treatment in clinically suspected endometriosis is to use an oral contraceptive. Typically, I’d use that continuously to avoid menses because that avoids dysmenorrhea if you don’t have a period, along with an NSAID [nonsteroidal anti-inflammatory drug]. A big problem we see is when the woman isn’t responding to those. Some folks are on these treatments for months, maybe 8 months. If they aren’t better within 3 months, this has failed, and it’s going to get the patient frustrated and unhappy, and they’ll probably see somebody else. Then you need to talk about second-line therapy.

The definition of second-line therapy has evolved over the years. Classically, this was surgical because that truly is the only way to this day to diagnose endometriosis. It doesn’t mean you need a surgeon to treat it. That’s what has changed in the last 15 years. One avenue is a surgical approach. The other avenue is a second-line therapy, which has included progestins over the years, which can be intrauterine, intramuscular, or oral. Danazol, which is a modified testosterone, is almost never used anymore because of its adverse effects, but it was effective in treating endometriosis. GnRH [gonadotropin-releasing hormone] agonists were the gold standard for the last 15 years. The newer agents, which are very exciting, are oral GnRH antagonists. There are other drugs that have been used primarily in Europe. These are second-line treatments.

If a patient doesn’t respond within 2 to 3 months with those, then you need to move on. These are CliffsNotes of a fairly complex subject, but I’m happy to get back to you if you have questions.

Maria Lopes, MD, MS: When do you decide to do a laparoscopy? Is it before GnRH antagonists? Especially given the implications for maybe some out-of-pocket costs for a patient.

Eric Surrey, MD: Some of this is the mindset of the clinician and the mindset of the patient. I’m not one of these people who believes you must do one thing or another, because frankly, there’s almost nothing in life that has only 1 answer. This is where you have to partner with your patient. There are some folks who say, “I want to know exactly what I have.” Usually, it’s a fear of cancer, which has nothing to do with this disease, but it’s a fear. If that’s the concern, a surgical approach is appropriate, but the role of a diagnostic laparoscopy of just looking inside and saying, “This is what you have,” should never be performed unless the finding is nothing. It should be performed with the goal of treating that disease surgically at the same time.

That’s partnering with the patient. I find that we do this less nowadays. Partly is the panoply of medical therapies that we’ve got. Part is the fact that no one has shown that one is better than the other, including the recurrence rates of both approaches. Clearly, medication is safer than surgery, and sometimes for the patient who doesn’t want to get pregnant right away, this can segue into long-term therapy. Partnering with the patient is what’s best. I have a big concern with clinicians who say that if you can’t treat this surgically, it can’t be treated. That isn’t based on data. The clinicians who state that there’s no place for surgery also don’t have data to base that on. You have to be flexible. It’s like gardening. You can’t do everything with a rake. You have to have a bunch of tools. I look at this management the exact same way.

Transcript edited for clarity.