Guideline-Directed Treatment Approach for Endometriosis

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Maria Lopes, MD, MS: Dr Surrey, is there a fault of guidelines and lack of standardization? In your opinion, is this a training or educational issue for physicians? Obviously, patient access to the right specialist is critical, but do you feel that there’s variation? Do you feel there’s opportunity for physician education as well, especially given the newer treatment options?

Eric Surrey, MD: The answer to all of your questions is yes. There are definitely generational differences, but it’s a matter of continued education. As Amber said, you can always add to the toolbox. The toolbox is never closed. It’s a matter of being open minded, because we all evolve in what we do. With laparoscopy alone, we can go back that far. Before 1980, the standard treatment for almost anything was open surgery. That’s almost never done anymore outside cancer cases or severe gynecologic disease.

The nature of training is an issue. As we see in OB-GYN [obstetrics-gynecology], we have fewer surgical procedures to train and more requirements for what our residents need to do, so their time in the OR [operating room] has dropped dramatically. The ability to do more advanced laparoscopic procedures for the average ob-gyn [obstetrician-gynecologist] coming out of residency has declined. There are certainly superb surgeons coming out of residency, but there’s less training and less experience, so that turns you a little away from doing a surgical procedure.

It’s important to be open minded. There’s a whole set of issues that can be addressed. There are so many more ways of treating. These new drugs take away some of the fear of giving injectable drugs that could last for 1 to 3 months. If a patient has adverse effects, what do I do? There are ways around those adverse effects. We’ve published [a lot] of articles on these subjects. But if you can give an oral agent that can reverse pain with minimal adverse effects that has a rapid onset of action and rapid reversibility, that can make the clinician much more comfortable with using it. I’m not sure the primary care physician is going to use these with frequency, but the average women’s health care provider will feel much more comfortable using these drugs.

Maria Lopes, MD, MS: I’d like to take it back to guidelines, because guidelines certainly take time to develop. But in the interim, this is something payers heavily rely on sometimes for decision-making. Regarding the standardization and the approach, do you consult any guidelines or standard practices?

Eric Surrey, MD: I’m happy to comment on that. The problem is there are a host of guidelines. The American Society for Reproductive Medicine [ASRM] has a guideline. ACOG [American College of Obstetricians and Gynecologists] has a guideline. Although most US physicians don’t consult with the Canadian guidelines, they have a separate guideline. ESHRE [European Society of Human Reproduction and Embryology] in Europe has guidelines.

As everybody on this call knows, guidelines aren’t the way one must practice. I look at guidelines as [similar to] when children go bowling and you put bumpers on the sides of the lanes. It’s to keep you in the lane in their recommendations. They aren’t that far apart in what they recommend. Virtually all say that the only way to truly diagnosis endometriosis is pathologically and surgically, and I don’t know that there’s another way to do that with complete accuracy. But they also all say that surgical therapy isn’t required to initiate treatment, and that imaging studies, careful history, and physical [examination] are all appropriate before we begin medical therapy. This is a sea change from what we would have been doing 15 or 20 years ago. There isn’t a huge difference in that general concept for these guidelines.

Not all clinicians are members of ASRM. They aren’t going to know the guidelines if they don’t participate. But any ob-gyn, and certainly nurse midwives and nurse practitioners, tend to be members of ACOG and get those guidelines. It’s easy enough to review them if you have a question. They’re easy to access online. There’s no reason not to consult them.

Maria Lopes, MD, MS: As payers, we draw from guidelines and health sources like UpToDate and literature review, but very much in line with what you outlined in terms of an algorithm approach and a diagnostic approach. Many times, payers will have things like prior authorization, especially for the GNRH agonists and antagonists, requiring that patients try an NSAID [nonsteroidal anti-inflammatory drug], oral contraceptives, maybe progestin because the GNRH products are usually significantly higher cost, so they also may pose patient challenges in terms of affordability. Tara brought this up earlier. It’s certainly a growing challenge in terms of how we escalate the therapy on the payer side as well.

Eric Surrey, MD: Just to interject, the clinician often has to be an advocate for their patient. As a payer, it tends to be relatively monolithic because you have to be. This is the standard way. If you go back 15 years, for many payers, it was required to have a laparoscopy before using a GNRH agonist, which made no sense because it massively increases costs for no good reason. That got turned around by enough clinicians advocating for their patients, and these are new ways of treating patients that may be more cost effective and more efficient for the patients. We all evolve over time.

Transcript edited for clarity.