A Paradigm Shift in the Treatment of UF and Endometriosis

Neil Minkoff, MD: Let me bring Dr. Steven McCarus into the conversation. In a few sentences over the last few minutes, our other two panelists mentioned surgical options. You are the head of the gynecological surgery department, so we invite you to talk about it. If we’re talking about things like uterine fibroids or heavy menstrual bleeding, there’s a pretty significant clinical burden, but it feels like the movement has moved away from surgical treatment to non-surgical treatment to medical treatment. I was wondering if you could touch on some of these things or specifically how they might differ from heavy menstrual bleeding versus endometriosis.

Steven McCarus, MD, FACOG: The clinical burden of endometriosis and uterine fibroids with regard to surgery is real. Surgery is risky. It interferes with someone’s daily activities. This can create a burden not only for the patient, but also for the hospital and the surgeon. There has been a paradigm shift. I am happy to say that through reputable organizations such as the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, instead of seeing surgery as the initial mainstay for severe endometriosis and uterine fibroids, we endorse and promote study treatment medicine prior to surgery. Surgery, at least now in my career, is the last choice for any treatment. It makes sense, although there are times when surgery is indicated.

What we’re trying to do through nationally organized fellowship programs—Ayman can speak to this as well—is look at residency training and fellowship programs, trying to create surgeons of Excellency. It is very unfortunate that many of these patients end up in the emergency room and may end up under the care of someone who is not qualified to treat a case of stage IV endometriosis or a large case of uterine fibroid. Unfortunately, this is a reality that we have to face. Looking at what we have better access to now than a decade ago, such as data pools and outcomes, will help us determine who should be supported or which patients should see one of these qualified surgeons.

It’s delicate. Surgery has changed a lot. We have advanced laparoscopic approaches, robotic approaches, and laparoscopic radiofrequency, which I worked very hard on to get payers to agree and put their coding on so we could do this procedure in Florida. We work together. As stakeholders, it is important that we look at some of these new minimally invasive innovations that can treat fibroids and endometriosis and can create less patient burden and be able to provide patients with alternatives to what we’ve done in the past as far as hysterectomies and more aggressive surgeries.

Neil Minkoff, MD: Allow me to follow you a bit. As a lowly PCP [primary care physician] and emergency department doctor, I might be one of those people that you were saying didn’t understand some of those nuances. Mea culpa. One thing I’m curious to ask you is that, as someone like me – not an expert like you – is trying to assess heavy menstrual bleeding and pelvic pain against endometriosis, what are the different clues that should point us in a certain direction in terms of the early stages of therapy?

Steven McCarus, MD, FACOG: That’s a great question, Neil. We looked at that. We have a family medicine residency program at AdventHealth that I attend. We did a data pool about a year and a half ago of all patients with a diagnosis of pelvic pain who came to the emergency department with a diagnosis of endometriosis and heavy menstrual bleeding with fibroids. The data was quite impressive, showing that patients came to the emergency department, received an IV [intravenous], move to an observation area and receive intravenous pain medication. They would get Dilaudid or something. They almost always had CT scans of the abdomen and pelvis. Because with pelvic and abdominal pain in the emergency room, what is the No. 1 diagnosis that must be ruled out?

Neil Minkoff, MD: Appendicitis. I still remember it.

Steven McCarus, MD, FACOG: They receive CT and IV pain medication, and they are observed for 3 or 4 hours. It always comes back that it is not an appendage. They feel a lot better because they were given intravenous opioids and they are being kicked out with no follow-up. We created a care algorithm that we worked on with our primary care physicians so that we could be on the same page—very often that’s not the case, and that’s what you’ve got alluded to—where we get proper follow-up care and access to care for these discharged emergency department patients. I’m happy to say it works. Maybe another time we can look at this algorithm and see if it’s something other people can use.

It’s important to build pools of data, as I’m sure Dr. Lopes knows, and look at what we’re seeing and what the follow-up care is to get these patients under the care of proper doctors to get medical treatment or surgery for these terrible diseases.

Transcripts edited for clarity.

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