Managed Care Perspectives: Optimizing Women’s Reproductive Health - Episode 8

Diagnosis and Treatment Goals: Endometriosis and Uterine Fibroids

Dr Ayman Al-Hendy discusses the diagnosis of uterine fibroids and endometriosis along with treatment goals.

Neil Minkoff, MD: Let me keep pushing a little. I want to open this up to everybody. I’m not trying to pick on you, Steve. I’m the primary care doctor. I’m the emergency department [ED] doctor. I’m seeing patients in my clinic or in my emergency department for heavy menstrual bleeding and pelvic pain. Maybe this is too simple a question. When should I be thinking about endometriosis vs fibroids? What should help drive me in 1 direction or the other in terms of doing my workup?

Ayman Al-Hendy, MD, PhD: I agree 100% with Steve that endometriosis is a real challenge. As he said, there’s a huge delay, but this is a real scientific challenge. We don’t have a good diagnostic tool for endometriosis. The only definitive diagnosis is a pathology confirmed by biopsy. Biopsy means you’ve done laparoscopy to do the biopsy. That’s very invasive and usually comes late in the patient journey. I can appreciate the challenge there. Steve covered the options to do tentative or empirical diagnosis and even start empirical treatment. If the patient gets better, that’s indirect evidence. We’ll get into that later.

However, I don’t see any excuse for missing fibroids. Fibroids are easy to diagnose, and there’s a lead time. It’s much less than endometriosis, but most of the studies average more than 3 years, 3.2 years. That’s inexcusable, in my opinion. Most of the time, what happens is the patient goes to the ED or the clinic of the primary care doctor and says, “I have heavy menstrual bleeding.” Before she finishes the sentence, she has a prescription in her hand for ibuprofen or maybe birth control, and she’s out of the door. Do an ultrasound. Order a transvaginal ultrasound. A lot of fibroid gets delayed in diagnosis because of that, and it’s very easy to diagnose. I agree that endometriosis is a real challenge, and hopefully we’ll have a chance to cover different approaches, but fibroids are easy to diagnose. Then, of course, you can treat it.

Neil Minkoff, MD: I want to come back to those choices in 1 second, but let me ask you 1 more question before I do that. Are there different treatment goals from the way you’re looking at a patient with fibroid vs endometriosis in terms of controlling pain or menstrual bleeding? How would you define those differences?

Ayman Al-Hendy, MD, PhD: Yes. Heavy menstrual bleeding is the No. 1 symptom for fibroids. Most patients with fibroids, about 85%, will come and complain about heavy menstrual bleeding. The other 15% complain about the so-called bulk symptoms, especially the basketball fibroid that Kevin talked about. They complain about a mass if they’re thin. They complain about feeling a mass, a protrusion, or a bulge. Or they complain about urinary symptoms, going to the bathroom frequently, because the fibroid is putting pressure on the bladder, or constipation and discomfort during bowel movements because the fibroid is putting pressure on the bowel or colon. About 15% have primary bulk symptoms.

Severe pain isn’t a typical symptom. There’s some cramping, some dysmenorrhea, that kind of thing, but severe excruciating pain isn’t a typical symptom for fibroids unless there are issues like degeneration or a pedunculated fibroid getting twisted. It’s different from endometriosis. It’s almost the opposite. Pain is the primary symptom of endometriosis, that severe pain that Steve was talking about, almost career-ending, where some patients don’t finish college or can’t maintain a job. That quality of pain, severe degree of pain, is typical of endometriosis. Heavy menstrual bleeding can also be present in a patient with endometriosis, but definitely less than in a patient with fibroids. The goals of treatment are a little different.

Transcripts edited for clarity.