16th Annual Patient Day
Your Mother Should Know, Your Doctor Should Know Better!
Patient Day - March 2, 2025
Einhorn Auditorium
Lenox Hill Hospital, New York City
Scientific Director
Dan Martin, MD
Program Director
Tamer Seckin, MD
So we are moving on. Thank you. I want to confess something. This Einhorn Auditorium we call has never been this happy before. Let me tell you, they told you we have meetings every week here it is never full. Even I come here, I sign and I leave. So this is full today. My next speaker will testify to this because she's been trained in this institution and she is been a lovely and one of the most successful residents we had. And now she's also practicing minimally invasive surgeon doing endometrial surgery. Her name is Dr. Or she's at Mount Sinai, focuses on gynecology surgical aspects of it and she has special interest in endo and ovarian cyst, abnormal bleeding, chronic pelvic pain. I have the pleasure of having Dr.Or
Good morning. I'm very excited to be here. So I am going to be talking about medical management of endometriosis and I'm going to try to figure out is this the way to move the Yes. Okay. I will be using the word women throughout my presentation. I understand that some people with endometriosis, some people with the uterus don't necessarily identify as females or as women, but just for the flow of the presentation, that's what I'm going to be using. And then I'm going to try to or not I, can you help me with this green? Oh, the green one. Okay. Thank you. So when I started putting up this talk, I came to the conclusion that the talk should be divided into three groups of patients. The medical management of women with suspected endometriosis, but not with definitive surgical diagnosis. The medical management of women who had recent surgery and need management after the surgery.
And then medical management of women who had such severe endometriosis that they needed to have their ovaries removed and now suffer because of menopausal symptoms. And so why do we even start with medical management and not go directly to surgery? Surgery has its risks. Surgery has risks of complications during surgery. It has the risk of forming adhesive disease or scar tissue, which can impact future surgeries, not even related necessarily to endometriosis. And it also doesn't have the ability necessarily to treat microscopic lesions that can be missed during surgeries and that's where the medical management of endometriosis can come in. There are downsides of course to medical management. You can have side effects from the medications, you can have the return of pain after the treatment is stopped if the treatment is stopped. It doesn't affect scar tissue. Medical management does not help with scar tissue that may be present even before the initial surgery and doesn't help with blockage of organs such as the bowel or the ureters.
It doesn't improve. Lesions within the ovaries won't make them shrink, it won't make them better and it doesn't improve any infertility issues that women may have and many medications will prevent pregnancy. So if you're interested in pregnancy, that's not a good option. Medical management treatment options are, there's many options. I summarize the most common ones here. It's non-steroidal anti-inflammatory drugs, combination, hormonal contraception, progesterone, hormonal contraception, generate analogs, danzo and aromatase inhibitors. And I'll try to go through them. So what's the best treatment? The answer is there is no best treatment. There is no treatment that has been shown that is better than other treatments, but there are treatments that may be more cost effective and less risk and less risk of side effects. So treatment decisions really should be individualized based on the symptoms of the patient, based on the severity, based on their goals for fertility goals, long-term goals in terms of their health, the age of the patient, the side effects of the medications, and the possible surgical complications.
So the first group that we're looking at is a group that is very readily available. It's very cost effective and that's NSAIDs. NSAIDs are essentially anti-inflammatory medications. There is a long list of medications that go under that group and usually the recommendation is to use it with combination contraception. The difference between the types of NSAIDs sometimes is they work in a different mechanism. So it's actually important to know which mechanism works for side effects and also they can be used alone without combination contraception. If we're looking for pregnancy with a caveat that there are a few of these medications in this group that can actually delay or prevent ovulation, so you really have to be aware of what medication you're taking. The recommendation is to start these medications on the first day of the period and use it for one to three days or for the duration of the pain.
And if you have really severe pain, you can start it even earlier. You can start it one to two days before the onset of menstruation and use it throughout the menstruation. And like I said, it can be used alone For women who want to conceive hormonal contraception can be either a combination of estrogen and progesterone medication or progesterone only contraception. The goal of these medications is both to decrease the amount of estrogen circulating in the body that can affect the lesions of endometriosis. And the other goal is to use the progesterone within these medications to deactivate the endometriosis lesions. And so combination hormonal contraceptions can come in the form of a pill patch in the vaginal ring where the pill is the one that is actually FDA approved officially. They are good in the way in the sense that they can be used, they're inexpensive, they're very easy to use, and their added benefit is that they decrease the risk for future ovarian and uterine cancer, which is nice.
And again, the question is, so which combination should I use? And there is no preferred combination and because there is no preferred combination, we would prefer to start with a low dose estrogen combination with some form of progesterone. They should be taken continuously because what happens is when you take them continuously, you will not menstruate. And not menstruating means you won't have pain during your period. It can help with pain with a disease that is caught between the vagina and the rectum, which is another thing that is something that a lot of women with endometriosis will suffer from.
The downsides of using combination contraception is that first of all, it's unclear whether it can cause regression or even if it stops progression of those endometriosis lesions and there are risks of clots in the lungs that are increased with anything that has estrogen in it. Those clots can travel to the lungs and once you stop these medications, you can have the return of pain. In general, my rule of thumb for follow-up after patients started combination contraception is seeing them in the office three or four months after the initiation of the contraception and we continue the contraceptives. If they work for a long period of time, either until pregnancy is desired or until the average age of menopause, which is roughly 52 in the United States. If there's no improvement with the medication, then we can try a different type of combination contraception that has a different type of progesterone in it or we can try a progestin only medication.
In terms of progesterone only. Progesterone only. What it does is it stops the growth of endometrial tissue, so essentially deactivates the endometrial tissue both inside the uterus where it's supposed to be and also outside of the uterus for endometriosis where it's not supposed to be. The benefits of progesterone only medication is that it decreases the risk of clots. It's relatively cheap so it's readily accessible. It again helps with pain endometriosis that is between the rectum and the vagina and it can be used for patients who cannot or do not want to use any estrogen containing products. There are a lot of side effects. Most of them are mild side effects, but we can see all of these things. The two things that I want to point out are the weight gain and the bone loss, and those are specifically more common with the injectable medication In terms of contraceptive options that are short term.
There is the north syndrome pill or the sperone pill that can be taken every day or there's the medroxyprogesterone acetate, which is the injection, and that's the one that increases the risk, a little bit of bone loss. The other downside of this medication is that if a patient is interested in pregnancy, they have to know that after a long-term use of this medication, it can take up to a year and a half to get pregnant once this is stopped. So that's a long period of time in terms of non contraceptive medications that are short term. And when I say short term, I mean it's a pill that you take every day. It's not like a medication that you can put somehow and then not do anything for a while. You can use the North syndrome acetate pill or the hydroxy progesterone acetate pill and those help with pelvic pain, with pain with menstruation in general, it can help with pain with intercourse, it can help with a wide variety of symptoms that endometriosis patients suffer from other progestins that are contraceptives and are considered long-term acting contraceptives are either the implant or the IUD.
The benefit of the high dose IUD is that it's more local. It has a really, really good control of lesions within the pelvis with less systemic effects. So that's a big advantage for that. The next group is the generate analogs and those work by suppression of the hormone production and the pituitary gland. And essentially what it does is it suppresses the ovary and therefore it decreases the production of estrogen. And so what we see is we see regression in the implants of endometriosis in the pelvis outside of the pelvis. But the problem with these medications is because it decreases the hormones, the estrogen to a menopausal level, you can have menopausal side effects, you can have hot flashes, you can have vaginal dryness, night sweats, and you can have decreased bone density and increased cholesterol. There's no increased risk for any heart disease, diabetes, all these types of considerations. So the first group in these types of medications is the general H agonists.
There's two downsides to these medications. One is that most of them are injectable, and the second one is that the first seven to 14 days when start these medications, the first thing that happens is that estrogen goes up and then it goes down. So when it goes up, it can actually cause exacerbation in the symptoms of endometriosis, more pain. But what we see is that about 75% of women will have menopausal levels within three to four weeks, and then 98% of women will have menopausal levels of estrogen within eight weeks. When we stop these medications, it'll take two to three months and then periods will start again. The limit of use for these is technically six months to one year, and we'll talk about it in a second. So the medications, this is a list of common medications that are approved in the United States. You see that there's three injectable ones and then there's one that is used nasally and that's a daily medication.
When we talk about the symptoms that come with these medications, we can do add-back therapy. The add-back therapy is essentially hormones that we give same as we would give for menopausal patients. And essentially what the goal is, one, to decrease the side effects and two, to increase the bone health for these patients. And so these should be started with the initiation of the GNRH agonists and these are very, very helpful in controlling symptoms and help to protect the bones. As you can see, there's a long list. They can be progesterone only medications, it can be a combination of estrogen and progesterone. The one that I highlighted there is the one that is actually best protective for the bones. And then there can be topical vaginal estrogen that can be used. It comes in very low doses. So for those who have vaginal symptoms, they can use this without any concern that it'll get absorbed into the system and have negative effect on their endometriosis.
And so alternative to add back medications is either to decrease the daily dose or increase the interval of the injectable medications or treat symptoms with non-hormonal medications like antidepressants that have positive effect on hot flashes and night sweats. We can also use bone medications, but those are a little bit more of a problem because they can get absorbed into the bones and slowly be released over time from the bones. And if someone wants a pregnancy, it may affect the fetus in terms of malformations in the fetus. So that's a consideration. Degeneration antagonists are similar to the agonists, but they actually work immediately. They are oral, so that's nice. You don't have to get an injection. They're relatively newer medications and they do show that there is a decrease in use of addictive pain medications. There is two marketed medications. There's actually three, but one of them is technically four fibroids.
One of them doesn't have add back in it, so you can add back from the outside and the other does have add back to it within the medication itself. The only downside to that is that you can't use it in patients who have history of clots in the legs or in the lungs or who are smokers over the age of 35 or have history of uncontrolled high blood pressure. The next group is aromatase inhibitors. Those are never first line. They are an off-label indication. They work in decreasing the estrogen production in all of the tissues and that's how they affect the endometriosis lesions. But they can cause bone loss and some symptoms in terms of menopausal symptoms and they have to be taken with either a combination contraception or progesterone or G RH because they can increase the risk of ovarian cysts. Those are the two common medications that we can use.
And then ol is the last one that I will be explicitly talking about. It's an androgen, so it works great, but the problem is that it can have a lot of androgen effects such as it can cause hair growth. It can cause deepening of the voice that is not reversible. It can cause a lot of things as you can see that women don't want to have as females. It does decrease the size of the lesions of endometriosis. But the problem is that once you stop this medication, it can come back. Those are the three options for dosing for mild endometriosis, severe endometriosis and vaginal preparations for endometriosis. With rectal lesions, it can be used three to six months, can it be extended to nine months? And the point is to make sure that you are without any period and then use the lowest dose that will keep you without a period.
Once we stop it, the lesions can come back, so if there's recurrence of pain, we can restart the medication. In terms of non-hormonal medications, I'm not going to talk about them. I just put them there because there is not enough time. But there are neuropathic pain medications when we use mild and strong opiates, but we prefer not to, of course be those can be addictive. And then medical treatment after surgery essentially is similar to the medical treatment before surgery. The reason to treat is because we see 21.5% recurrence after two years and 40 to 50% recurrence of symptoms after five years. Menopausal symptom management, again, no time, but their recommendations are for women with menopausal symptoms because of surgery or because of medical treatment to be treated with either hormonal or non-hormonal combinations in order to prevent the symptoms and possibly prevent side effects that are significant like bone loss. That's it. Thank you.
