Evaluation and Treatment of Endometriosis

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Summarize the symptoms of endometriosis
2. List the medical treatments to reduce pain from endometriosis

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Definitive diagnosis is surgical and made on histology of lesions removed. Lesions can be black powder-burn, red or white
- Imaging studies are useful only in the presence of a pelvic/adnexal mass
- Transvaginal ultrasound is the technique of choice in differentiating an endometrioma from other adnexal masses, and in detecting deeply infiltrating endometriosis of the rectum or rectovaginal septum
- MRI can be used when ultrasound results are equivocal
American Society for Reproductive Medicine (ASRM) classification system is most commonly used, but is not a good correlate with fertility or symptoms
Excision of endometriomas can improve pregnancy rates
Drainage and ablation is less effective

SYNOPSIS:

Endometriosis is a chronic condition. Clinical manifestations vary and are not good predictors of the severity of the disease. Dysmenorrhea, chronic pain, dyspareunia, uterosacral ligament nodularity, and adnexal masses are among the common presentations. Treatment is aimed at optimizing pregnancy rates and minimizing symptoms; definitive treatment remains removal of the ovaries, fallopian tubes and uterus.

KEY POINTS:

Pain associated with endometriosis can be reduced with use of:
- Progestins, combined oral contraceptives (OCs), nonsteroidal anti-inflammatory drugs, gonadotropin-releasing hormone (GnRH) agonists, danazol
- Extended cycle OCs or continuous OCs can be used to limit dysmenorrhea
Nongynecologic causes of pelvic pain such as irritable bowel syndrome, interstitial cystitis and urinary tract pathology should be ruled out with appropriate testing and referral
The levonorgestrel intrauterine device is effective in reducing pelvic pain related to endometriosis
GnRH agonists are FDA approved for up to 12 months
- ‘Add back’ therapy reduces side effects and bone loss and may include (1) progestins alone, (2) progestins and bisphosphonates, or (3) low dose progestins and estrogens
- There is no difference between GnRH agonists and other medical treatments for endometriosis based on a recent Cochrane review, so should not be used as a primary treatment
  - GnRH agonists are, however, first line for extrapelvic endometriosis treatment
Elagolix is FDA approved for up to 6 months
- Normal liver function or mild hepatic impairment: 150 mg once daily for up to 24 months or 200 mg twice daily
- Moderate hepatic impairment: 150 mg once daily for up to 6 months
- Contraindications: Pregnancy | Known osteoporosis | Severe hepatic impairment | Strong organic anion transporting polypeptide (OATP) 1B1 inhibitors
- Potential for Reduced Efficacy with Estrogen-Containing Contraceptives: Use non-hormonal contraception during treatment and for one week after discontinuing elagolix
- Note: For further warnings & precautions and adverse reactions see FDA HIGHLIGHTS OF PRESCRIBING INFORMATION in ‘Learn More – Primary Sources’ below
Aromatase inhibitors such as letrozole or anastrozole appear promising in observational trials but await more data
Patients undergoing surgery for removal of endometriosis should be counseled that they have about a 36% chance of requiring further surgery
Hormone therapy with estrogen is not contraindicated after hysterectomy with bilateral salpingo-oophorectomy for endometriosis
Diagnosis Codes: ICD-10-CM: N80.0-N80.9, depending on location of endometriosis