Transcription:
Treatments and Management of Endometriosis

Melanie Cole, MS: Thanks so much for tuning into Back to Health, the podcast that brings you up to the minute information on the latest trends and breakthroughs in health, wellness and medical care. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

Host: I'm Melanie Cole. And today, on this Women's Health Wednesday, we're discussing treatments and management of endometriosis. Joining me is Dr. Cynthia Arvizo. She's an Assistant Attending Obstetrician Gynecologist at New York Presbyterian Hospital Weill Cornell Medical Center, and she's an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College Cornell University.

Dr. Arviso, thank you so much for joining us today. As we sort of set the stage here, and the listeners can listen to our previous podcast on endometriosis, but today we're doing a little bit of a different take, but I'd still like you to set the stage for us about endometriosis in general. Tell us what it is, how common it is, and why it's so difficult sometimes to diagnose.

Cynthia Arvizo, MD: Well, thank you first off for having me. Now going into endometriosis, it's a disease where a tissue from within the uterus, endometrium to be more specific, grows outside of the uterus, commonly in the pelvis, such as the ovary, the fallopian tube, and on the walls of the pelvis. It affects up to 10% of reproductive aged women and, in patients with infertility, can be seen up to about 50% of the time and, in patients with chronic pelvic pain, almost 90% of the time. Endometriosis causes pain, infertility, and sometimes can cause no symptoms at all. It is difficult to really diagnose because the diagnosis requires a surgery. People, including physicians and patients, can sometimes be more hesitant to offer that as a first line.

Host: So, are there things that suggest it? As an obstetrician gynecologist, when a woman comes to you and she's having pain and such, are there certain things that you would say, "Okay, maybe we're not going to do the definitive diagnosis surgically, but this would suggest that that's what this is?"

Guest: Yes, there are for sure, especially in a patient's history and clinical course. So, anyone that has pelvic pain or significant pain with periods at an early onset in their teenage years or in their 20s, that should be a strong consideration for endometriosis. Other things that can be seen on imaging such as ultrasound or MRI are specific cysts of the ovary that contain endometriosis cells. Those are called endometriomas, and those can really point to the diagnosis.

Host: So, I'd like you to speak, Dr. Arviso, about your approach as you help women with this condition, and we've heard it's pretty painful. Please tell us about your philosophy of care for them as this can cause a lot of stress, be very worrisome and certainly, as we've said, painful situation.

Guest: In terms of my approach, I think this is one where really shared decision-making and patient-centered approach is optimal because there is such a wide range of options, from expected management or not doing much to medicine to surgery. And everyone comes in with a different goal, a different life. For some people, they want surgery right away. Other people might want to delay it for as long as possible. So, I think that's where it's really important to have these frank discussions and give all the options, and then people can decide what they want to go forward with.

Host: I love that you brought up shared decision-making because it is so important. You know, our doctors are not just in a silo by themselves. There's always this multidisciplinary approach. And working with the patient to see what is best for them is just so important. And we as women must be our own best health advocates. So, that's so important that you brought that up. Tell us about some of those care options that are available for women experiencing endometriosis, any treatments that you might try before considering a surgical procedure? So, let's start with medication intervention first and non-surgical interventions. Tell us about those.

Guest: So, the mainstay for treatment of endometriosis is hormonal therapy. And people, I think, nowadays are more hesitant to try that. I think it's just a change in our culture in general, changing hormones. But those, they work by creating a hypoestrogenic state, meaning there's less estrogen in the body and they then suppress ovulation. And in doing so, you have either no periods or very light ones, and that helps with pelvic pain and pain associated with cramping. And those can be anything from regular birth control pills that contain both estrogen and progestin. There's other ones that we use quite a bit and they also have progestin only. That includes pills, things like the IUD that goes into the uterus. And then, there are other medications called GnRH agonists and antagonists. Orlissa is the GnRH antagonist, and Lupron is a GnRH agonist.

Lupron has been around for a very long time. And has more of the side effects of the bone loss and typically can be used for up to six months, although some situations it's used longer. Orlissa is a little bit newer, but has been around for several years now and can be used depending on the dosing up to two years. Those are pretty much the medical therapies that we have right now. And there's always ongoing research into other medications and, hopefully, more and more will come up as research evolves.

Host: So, when does surgery become that discussion and what are some of the surgical treatment options?

Guest: When I counsel a patient, if they haven't had the diagnosis, but we suspect it, I do offer surgery because it can help with, of course, diagnosing, but can also treat symptoms. There's a big question about people with endometriosis will many times need more than one surgery in their lifetime and then, that's when it becomes more of a discussion with the patient of when to do that. And most of the time, people will know. They'll know that the medications that they're trying, they've now tried a couple again, and they're still having significant pain or their imaging findings will show a larger cyst or more in deep disease. And surgery is an option at that point. But hopefully, with hormonal suppression, we're able to decrease the time between surgeries.

Host: What about hysterectomy? When does that become the discussion?

Guest: Again, I think it comes up with patience and what their goals are. I think if they are really trying to treat the pain, don't have any desire to preserve the uterus or preserve fertility in the future, it's always an option. And some people I think listening or other physicians might disagree, but do think that it's ultimately up to the patient to decide if that option is right for them. Even with a hysterectomy, there is a chance of having to have surgery again in the future depending on age, so that's something to consider as well.

Host: Can you tell us about any homeopathic or natural ways, complementary medicine that women might be able to try to treat their endometriosis and the symptoms that go with it?

Guest: Yes, that's a great question, especially as patients sometimes really want to avoid any medications. There are things, and I suggest them for everybody. We know things like diet changes, exercise, acupuncture, TENS units. And a very big one is pelvic floor physical therapy because many times people with endometriosis have pain with intercourse and have what's called pelvic floor dysfunction, and that is very helpful.

Another alternative is psychotherapy. And that is very helpful for people with chronic pain. And then, we also offer injections with our anesthesia colleagues and referrals to other services because endometriosis can be associated with other pain conditions.

And I forgot to mention earlier that people with chronic pain will start to have more like central sensitization of pain, and sometimes treatment with other things like gabapentin or Lyrica is helpful in minimizing what we call hyperalgesia or an oversensitization to pain itself.

Host: This is such an interesting topic. And so many women, including my sister, suffer from the pain of endometriosis. Dr. Arvizo, before we get ready to wrap up, you speak to women every day and you speak to them about this and about shared decision-making and being their own health advocate. What would you like to tell them about the pain, the symptoms, living life with endometriosis? Because it doesn't have to be as painful. And some women are quiet about these things and they don't always talk to their providers. I'd like you to speak to them now and say what you do say to them every day in your office when you would like them to speak up, ask questions, and get this taken care of.

Guest: I really love that question. Many times we'll tell people in that room they're the ones in pain and they're the ones that know how it is affecting their life. And I'm many times meeting them for a brief 30, 45 minutes of their lifetime, I get a little snapshot of how this is affecting them. But I think it's essential to advocate, ask the questions. I think many times women are essentially told to normalize the pain that they're undergoing, and it's horrific. I mean, they're missing work. They're letting their periods dictate their lives. They don't go on trips. They don't enjoy life. it's not a way to go about, and I think people will agree when they're have endometriosis that it's so difficult to get someone to listen. And I think sometimes it takes several doctors, but essentially, if you don't feel like it's the right person, go to somebody else and you'll eventually will find somebody. And I think another big component that we have now is a lot of support groups online and there are ways to find the correct people to treat endometriosis and pelvic pain that way now. So if you don't feel that your physician adequately treating it or something, you can go online and find somebody who will, but keep looking until you find someone that you really jive with.

Host: I love that you said that and you are lovely. So, I imagine your patients feel the same way, and I can hear the passion in your voice when you speak about patients and helping themselves. Thank you so much, Dr. Arviso, for joining us today and sharing your philosophy of care and the treatment options available for women with endometriosis.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. We're so glad you joined us for Women's Health Wednesday. We hope you'll tune in and become part of a community and a fast-growing audience of women looking for knowledge, insight, and real answers to hard questions about our bodies and our health. Please download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify and Google Podcast. And for more health tips, please visit weillcornell.org and search podcasts. Parents, definitely don't forget to check out Kids Health Cast. I'm Melanie Cole. Thanks so much for tuning in today.

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