In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Isabel Green, fellowship director of MIGS at Mayo Clinic, to speak about persistent pain in endometriosis patients.

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SHOW NOTES

Dr. Green begins by defining endometriosis as endometrium-like tissue that grows outside the uterus, but emphasizes the complexity of the disorder with its varying phenotypes and inadequate knowledge about the disease process. Patients with superficial endometriosis can have terrible pain while others with deep disease may have little pain. It’s also common for people to have comorbid conditions, like IBS, fibromyalgia, migraine, myofascial pain, and central sensitization disorders. This makes it a difficult disease to diagnose and treat, and highlights the need to tailor therapy for individual patients. The doctors discuss the lack of data to support pain medications like gabapentin or amitriptyline, and even the typical treatments of birth control pills or excision surgery can fail to help patients.

The doctors then go on to discuss the pathophysiology of endometriosis. Dr. Green believes it may be different for different people as retrograde menstruation fails to explain all cases of endometriosis. There is research on immune dysregulation and inflammatory cytokines that could show the disease is systemic and not just contained in the pelvis. Additionally, some believe it could be cells transforming similar to a malignancy or even a nervous system issue, but more research is needed on the topic. There is a lot we still don’t know about endometriosis.

Next, Dr. Green explains the challenges in diagnosing endometriosis. Patients have variable symptoms, people may dismiss pelvic pain and normalize the symptoms, and ultrasound/MRI is only good at visualizing deep lesions. It is often years by the time patients go to surgery and endometriosis is visualized.

The episode ends with the doctors discussing how to manage patients long-term, especially if the typical treatment of hormonal and pain medications and excision surgery fail. Listening to the patient’s history, knowing exactly what the patient’s lesions looked like during surgery, repeat imaging, and learning the degree of neural involvement can help tailor the next steps. It’s important to remember that the treatment of endometriosis is a marathon, and it’s necessary to acknowledge the patient’s pain.

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RESOURCES

ACOG Guidelines:
https://www.aafp.org/pubs/afp/issues/2000/0915/p1431.html