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GYN
CMECNE

Evaluation and Treatment of Endometriosis

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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 faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, 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 Jan 25 2023, 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 test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

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

SYNOPSIS:

Endometriosis is a chronic condition that results in infertility and chronic pain. 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:

Symptoms

  • Dysmenorrhea
  • Chronic pelvic pain
  • Dyspareunia
  • Uterosacral ligament nodularity
  • Adnexal masses
  • Bowel and bladder symptoms, such as dyschezia, hematochezia, hematuria, dysuria
  • Symptoms do not correlate with severity of disease

Diagnosis

  • 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

Treatment

Medical Management

  • 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 and reduce recurrence of endometriomas
  • 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
    • A 3 month course can be empirically started after treatment failure with OCs and NSAIDs
    • ‘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
  • GnRH antagonists have been approved by the FDA approved for management of moderate to severe pain associated with endometriosis
    • Elagolix (see below for prescribing information)
    • Relugolix (see below for prescribing information)
  • Aromatase inhibitors such as letrozole or anastrozole
    • Appear promising in observational trials but await more data

Surgical Management

  • Excision of endometriomas can improve pregnancy rates; drainage and ablation of cyst is less effective
  • Patients undergoing surgery for removal of endometriosis should be counseled that they have about a 36% chance of requiring further surgery
  • In women who do not desire future fertility, definitive therapy is hysterectomy, bilateral salpingo-oopherectomy
  • 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

Learn More – Primary Sources:

ACOG Practice Bulletin No. 114: Management of Endometriosis 

ASRM: Treatment of Pelvic Pain Associated with Endometriosis: A Committee Opinion

Pathophysiology, diagnosis, and management of endometriosis

Optimal Management of Endometriosis and Pain

Endometriosis: Where Are We and Where Are We Going?

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for ORILISSA (Elagolix)

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for MYFEMBREE (Relugolix)

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Related ObG Topics:

ACOG Guidance on Evaluation and Management of Endometriosis and Dysmenorrhea in Adolescents
Comparing IUD vs Implant for the Management of Endometriosis
Infertility Evaluation: Who, When and How
Does the Oral GnRH Antagonist Elagolix Improve Endometriosis-Associated Pain?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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