Will new endometriosis guidance put an end to treatment delays?

Endometriosis patients may soon be getting faster relief from their chronic, painful symptoms.

In an effort to reduce delays in treatment, the American College of Obstetricians and Gynecologists (ACOG) published new guidance on the evaluation and diagnosis of endometriosis, reports Dr. Joseph Nassif, professor of obstetrics and gynecology at Baylor College of Medicine and a minimally invasive gynecologic surgeon at the Endometriosis Center at Texas Children’s Pavilion.

The ACOG recommendations state that a clinical diagnosis of endometriosis (made through a symptom-based assessment, physical examination or both) is sufficient to initiate medical treatment. Also, diagnostic laparoscopy can be considered in patients with suspected endometriosis to confirm the diagnosis, even if the results of physical examination and imaging are negative. However, diagnostic laparoscopy is not required to initiate empiric medical treatment.

That’s a significant departure from the past, where patients underwent surgery to remove a tissue sample (biopsy) and confirm the presence of endometriosis.

Today, ACOG considers a clinical diagnosis of endometriosis based on the patient’s symptoms, a physical exam or both to be sufficient to initiate medical treatment, enabling more timely access to care.

Creating crucial awareness

Endometriosis occurs when cells similar to the lining of the uterus grow in other areas, typically the pelvic region, causing chronic, often debilitating pain, inflammation and infertility, among other issues.

According to ACOG, it takes patients, an average of 4 to 11 years after symptoms begin to receive a diagnosis.

Why the long delay? In part because the disease itself is so “enigmatic,” according to Nassif. Inadequate education and training in the recognition of endometriosis are also to blame, leading to underdiagnosis, misdiagnosis, and delayed referral for specialist care.

“This new guidance includes detailed information on the signs and symptoms that should lead to a suspicion of endometriosis,” Nassif said. “That’s crucial for raising awareness.”

“It encourages providers to think about endometriosis when they see patients with symptoms like cyclical or non-cyclical pelvic pain, pain with intercourse, pain with urination or with bowel movements, or infertility in conjunction with one or more of these other symptoms. That awareness may drive the doctor to order an ultrasound or an MRI to detect endometrioma or even do a laparoscopic diagnosis, instead of accepting the pain or other symptoms as normal with the cycle. We don’t accept that anymore.”

“We also need to put endometriosis in medical school curricula so students learn to recognize the symptoms and better understand the disease and its impact on the patient’s life, not just as a cause of pelvic pain,” Nassif said.

Driving change

Nassif has been keeping up with the latest on endometriosis for more than two decades. He was part of the first groups of physicians to complete an endometriosis surgery fellowship back in 2008, as highlighted in a recent article on the growing interest in endometriosis research.

“It’s not enough to do a fellowship, you have to stay up to date in the field and try to make an impact through research,” said Nassif, who has published multiple articles on endometriosis. “Research changes the way we diagnose and treat endo.”

His current research at Baylor College of Medicine includes a study with the Department of Radiology on the use of AI with imaging, particularly ultrasound and MRI imaging, to improve the detection of endometriosis.

“ACOG recommends that we don’t rely on biomarkers or blood tests today to detect endometriosis,” noted Nassif. While more than 1,000 biomarkers have been studied to date, none have been shown to be as accurate as diagnostic laparoscopy or of added benefit, reports ACOG.

“We’re also working on a study with Dr. Xiaoming Guan on surgical mapping of endometriosis and the correlation between surgical findings and pathologic findings after surgery, to determine if there is a predilection for where to find endometriosis,” he added. Guan is a professor of obstetrics and gynecology at Baylor with a focus on complex benign gynecologic surgery.

Know your options

Minimally invasive surgical excision remains the gold standard for treatment of endometriosis, Nassif noted, reducing disease recurrence, improving fertility rates and providing long-term symptom relief. Nonsurgical therapies include hormonal and nonhormonal treatments such as birth control, IUDs and Lupron, which might help in controlling painful symptoms.

“If other treatments fail to provide relief and surgery is needed, make sure your surgeon is highly experienced in endometriosis excision and has the team of specialists required to treat this condition when multiple organs are involved,” Nassif advised.

“Our endometriosis team includes urology, colorectal surgery and other specialties that are critical in these complex surgeries. We’re also minimizing the risks of complications through procedures like nerve-sparing bladder surgery and transluminal endoscopic surgery, a fluorescence-guided technique that improves visualization and protection of the ureters.”

Nassif calls the new endometriosis guidance, which includes 10 recommendations, useful reading for every OB/GYN and primary provider today. “We all need to be looking for endometriosis to ensure adult and adolescent patients get the timely treatment they deserve.”

By Sharon Dearman, writer in the Department of Obstetrics and Gynecology