ASRM2011: Is endometriosis the cause or a by-stander when it comes to pain?

Orlando, 17 October 2011 | by Lone Hummelshoj

The 67th Annual Meeting of the ASRM kicked off with a two-hour plenary session on endometriosis, addressing controversial issues surrounding the disease.

Is endometriosis responsible for all pain – and if so, how do we manage this long-term?

Professors Robert Schenken, John Steege, and Serdar Bulun at the 67th Annual Meeting of the ASRM

Professor John Steege’s key message this morning was that practitioners have become too entrenched with endometriotic implants and staging of the disease.

In his opinion it is time to back-up and look at the woman with endometriosis as a whole, and consider other compounding factors which may contribute to her pain.

He opened the session stressing that the correlation between the extent of endometriosis and the pain experience (and indeed infertility) is low. In fact, it is necessary to distinguish between peritoneal implants vs. ovarian endometriomas vs. peritoneal scarring.

He also advised on exercising caution when using the term “progressive disease” since, in his experience, it is seldom to see Stage I progress to Stage IV disease; in fact, there may very well be biological differences between these “stages of disease” from the very beginning – necessitating different types of care for each individual woman.

Status quo

Today it is often common practice to diagnose endometriosis following a physical exam (with ~75% accuracy) followed by drugs, laparoscopy, laparoscopy, laparoscopy, removal of reproductive organs and, if pain continues to recur, referral to a pain clinic.

However, is it ethical to continue to do laparoscopy upon laparoscopy, or remove healthy organs, without significant pain resolution? (In fact, if a patient has pain all month long, it is unlikely to have anything to do with her reproductive organs, so why remove them?).

Ditto experimenting with different types of drugs when, contrary to popular belief, relief of pain symptoms during hormonal treatments, does not in itself “diagnose” or confirm the presence of endometriosis (according to the ASRM Practice Committee, 2006)?

Preferred practice?

Professor Steege believes that a pain orientated pelvic examination is key in diagnosing endometriosis, along with a thorough medical history, including other pain disorders. He also encourages a recto-vaginal exam in order not to miss any cul-de-sac masses.

This should be followed by a diagnostic and therapeutic laparoscopy – carried out by a surgeon experienced in excising endometriosis – and only then by drugs (if at all?).

There is a known placebo effect of up to 60% following surgical procedures, so it is important to take this into consideration if the woman returns within a year with pain again. It may simply be the placebo effect wearing off, and at this point it may be time to start considering all the factors that may operate within that patient. Thus surgical results should be interpreted with a grain of salt.

Co-travellers and confusing elements

Co-morbidities are not uncommon in endometriosis, and when pain becomes persistent it is important to also consider irritable bowel syndrome, interstitial cystitis, levator spasms/dysfunction, and vulvar vestibulitis. It is therefore important to be mindful of symptoms in neighbouring organs – and to treat these early.

Variations in the types of endometriosis, and the pain associated with the menstrual cycle must not be ignored. For example, recent research has also shown an increase of nerve fibres in the endometrium of women with endometriosis, which may contribute to a higher sensitivity of somatic pain. Furthermore, when you suppress the hypothalamic-pituitary-ovary axis with, for example GnRH-agonists, the somatic pain perception and thresholds in the woman may be altered, which may explain why some women respond poorly after multiple different treatments.

Refractory endometriosis

In his presentation Professor Serdar Bulun focused on stubborn endometriosis.

Despite seeing women with endometriosis in age groups ranging from teens to women in their 40s, his experience shows that almost all of them will tell him that they have had severe dysmenorrhoea since menarche – if they were lucky they may have been treated with oral contraceptives which, incidentally, can reduce nerve fibre density in the endometrium. Unfortunately, most don’t get a laparoscopy (and thus diagnosis) until their late 20s, which is what international studies on the diagnostic delay show also.

One of Professor Bulun’s key messages was that in order to tackle endometriosis surgically, laparoscopies must be carried out by experienced surgeons.

“We see a tremendous variation in the quality of surgeries depending on the surgeon’s experience. This makes a serious difference in how this patients will fare after surgery. It is important to recognise your own skill level – and that of others – and to refer to those!”

said Professor Bulun and continued to list what is NOT effective for refractory endometriosis, including:

endometrial ablation
hysterectomy without oopherectomy
LUNA

with more data needed on in-effective treatments. Refractory endometriosis is best treated with a combination of other treatments.

Experimental treatments

Thus we are left with “experimental treatments”, and aromatase inhibitors in particular. These are typically only used in post-menopausal women, though can be used in pre-menopausal women with endometriosis together with oral contraceptives, progestins, or GnRH-agonists.

“When using drugs in the treatment of endometriosis the key is to educate the patient about what to expect with regards to potential side effects, and that perseverence may pay off in the long term”,

said Professor Bulun, and concluded that in addition to aromatase inhibitors he sees selective progesterone receptor modulators (SPRMs) as the most promising new treatments on the immediate horizon. But for now we need to await further clinical results.

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For more information

A recording of this session can be purchased directly from the ASRM at: http://www.softconference.com/asrm/