Our first lecturer for this morning is Dr. Mark Hoffman. Dr. Hoffman earned his medical degree at the University of Kentucky and completed a residency in obstetrics and gynecology at the University of Chicago. He spent two years as a fellow in minimally invasive surgery and chronic pelvic pain at the University of Michigan with training in advanced laparoscopic and robotic surgery. Dr. Hoffman's primary research interests include uterine fibroids and outcomes following robotic surgery. And he is a member of the American Association of Gynecologic Laparoscopists and the American College of Obstetrics and Gynecology. Dr. Hoffman focuses his practice on medical and surgical treatments of complex gynecologic problems including fibroids, endometriosis, abnormal uterine bleeding, and chronic pelvic pain. In addition to non-surgical treatments, he can offer a minimally invasive approach when surgery is needed. Thank you so much and welcome Dr. Hoffman. Good morning. Thank you, guys. All right, let's see here. Well, it's a pleasure to be here. Thank you for having me very much. I have no financial disclosures. So, goals today, everybody hopefully will be able to evaluate a patient with pelvic pain, recognize signs concerning for endometriosis and formulate a plan for management of endometriosis and endometriosis-related symptoms. And I say endometriosis-related symptoms because, as we'll talk about here in a minute, I'm less concerned about that diagnosis, that surgical diagnosis of endometriosis before we start managing our patients and whom we have concerns. So, as we know, endometriosis is a disease we diagnose surgically. It's a long conversation to have with patients who've been told they have endometriosis and they've never had surgery, not to minimize their symptoms or pain or the possibility that they have it, but just to understand in diagnosing endometriosis, it is a surgical diagnosis. Pathology is better than observation, but certainly, if you see a patient with typical lesions, it's reasonable to diagnose them at that time as well. So, endometriosis is tissue that looks like endometrium tissue inside the uterus growing outside the uterus. Staging, a few different ways to do it, ASRM staging most common, but, as we know, correlation of staging and symptoms is pretty poor. So, you have a patient with terrible pain, you get in there and they've got one tiny dot. General surgeon calls you for another patient who's got appendicitis and their whole pelvis looks like a bomb went off. So, not always correlated. So, not uncommon in our chronic pelvic pain population, the population of patients who come to see me in clinic, one in six-ish, one in seven patients likely have endometriosis. Four million women diagnosed with endometriosis, but we think probably that's only about 40%, so, or rather only about a third of, rather a third of our patients in the country that have endometriosis are probably undiagnosed, or two-thirds. So, an additional six million. So, a lot of patients out there with endometriosis who don't know they have it, whose doctors don't know they have it. So, trying to diagnose or identify patients that have endometriosis prior to surgery is a challenge. Being able to come up with a clinical diagnosis has not yet come to fruition. The delay in diagnosis is common. We hear a lot about that, and one caveat I would say is I have a lot of patients in my clinic that I've been managing for years who have never undergone surgery, who we are managing as if they have endometriosis, who we've never formally diagnosed. So, the delay in diagnosis, in some ways, we have to think about making sure we listen to our patients. We validate their pain, validate their symptoms, but it doesn't always mean that the delay of diagnosis of endometriosis is because we don't care. It's because we can treat them and presume they have it without having to have that formal diagnosis. So, there is a delay, but there are a number of factors. But, yeah, there's a lot of misdiagnosis as well, as well as normalization of symptoms. So, we have to, we have to be putting endometriosis in our differential early on, but in general, the challenges here are that there is no pathognomic features, no biomarkers that we can use to define endometriosis. This is something that can look like a lot of different things. So, you know, a lot of patients are going to present with cyclic chronic pelvic pain, things that are more common with endometriosis. Cyclic menstrual pain can progress over time to daily pelvic pain. Those patients with endometriosis are more likely to have dyskinesia dysuria. Dyspareunia, in general, has low sensitivity in predicting endometriosis, but if they have deep dyspareunia, it can make that diagnosed more likely. Family history, for sure. I had a patient I saw the other day, a young patient, and her grandma was there with her, and she had it, and her mom had it, and the patient's looking at me going, I think I have it, and I said, I think you're right. So, a lot of times when our patients have family history and symptoms are consistent, it's a really high likelihood that they've got it. So, taking a good family history is important, and also if they have infertility. So, diagnosis, you know, physical exam, again, are there certain findings, like in our history, that would help us identify things? It can be. I had a patient I saw the other day that had a vaginal endometriosis lesion, so something I've seen a few times. Make sure you always do a speculum exam in our patients who, in whom we suspect it. She's been followed for years. She's actually in her, I want to say, late 40s, maybe early 50s, been managed for years medically. I sort of thought she had it, but speculum exam, I saw a little blue lesion right in that posterior cul-de-sac, posterior, right behind her cervix, and got an MRI and saw she had a pretty significant deep posterior cul-de-sac lesion as well. So, always be thinking about it. I guess it's easier for me to say when that's my whole practice, but certainly there are findings we can find outside as well, which is not as common, but we find it. Let's see. Exam. So, if a patient's got nodularity in their uterus acrals, if they've got a retroverted fixed uterus, there are certainly things that we can find on exam that are more suggestive and predictive of endometriosis, but typically, it's more predictive and suggestive of advanced stage disease. There just aren't any good findings on exam to help us predict whether or not patients have early stage disease, which is what you want, right? That's the ultimate goal is to find earlier stage disease because management typically is easier. Like I said, for those with endometriosis or those with infertility are more likely to be diagnosed, important caveat, interstitial cystitis, painful bladder syndrome, irritable bowel syndrome, make friends with your colorectal surgeons and your GI docs. Make friends with your urologists. These conditions, we call them, you know, the three sisters, three-headed monster. Being diagnosed with IC or IBS significantly increases your chance of having endometriosis. Three commonly co-diagnosed disease processes, chronic pelvic inflammatory conditions of unknown etiology, very common, but most importantly, treating a patient for endometriosis who has IC or IBS, those symptoms can actually improve just from endometriosis treatment, so decreasing the chronic pelvic inflammation, you know, keeps the neighbors a little happier. So the other thing is musculoskeletal pain. You guys all have pelvic floor physical therapy folks that you are on the ready to refer to. I'd say I refer probably a third of my patients or more to pelvic floor PT. Musculoskeletal pain is one of those things that I didn't learn about in residency, certainly not something that was a big part of my resident practice. It wasn't until doing a fellowship in chronic pelvic pain where you realize the pelvic floor, as we know the pelvic floor is muscle, the abdominal wall is muscle, but yet if you have low back pain, shoulder pain, neck pain, you go to PT. It's muscles, but if they have daily pelvic pain, worse with activity, worse throughout the day, well it must be gynecological to start taking out female reproductive organs, and obviously those muscles, those skeletal muscles need to be addressed in the same way that we address skeletal muscles around the rest of the musculoskeletal system, and that's physical therapy. And so you can have that pain as a result of your endometriosis after years of pain. The analogy I use is you spend the night throwing up, the next morning your stomach hurts. It's not your stomach, it's your abdominal wall muscles from doing 100 sit-ups over the toilet. That primary source of your disease, your bad shrimp that you ate the night before is gone, but you still have that pain in your muscles from the result of that pain. So we can treat your endometriosis, we can manage your endometriosis, your cyclic pain, your painful periods may be better, but you've got this daily pelvic pain left over, and you're going, well it didn't work. Well no, we treated the main issue, now we've got this daily pelvic pain we have to address. There's no surgery that can fix that, it's PT, and so making sure that you think about your other organ systems outside of just the gynecologic side. So imaging, we perform a lot of ultrasounds in my office, can be sensitive for advanced findings. Endometrioma is obviously pretty helpful to see those to help us make that diagnosis. Deep endometriosis lesions depending on location, deep pelvic side wall, deep pustular cul-de-sac, our sonographers primarily do obstetrics. We're trying to hire a GYN only sonographer to really focus on doing more advanced ultrasound, but that takes someone who knows what they're doing, it takes someone who's committed to learning how to do that. And so when you say ultrasound findings, it really depends on your sonographers. Are you sending your patients to radiology? Do you have only OBGYN sonographers? And so the quality of ultrasound is going to be highly variable, so understanding who's doing those scans, who's reading those scans is really essential. Do a lot of MRI too. Now, a word about MRI, obviously it's a big expensive test, but as a surgeon who's doing advanced endometriosis surgeries, working with colorectal, these surgeries we're planning for a long time, getting two surgeons in the same room, we want to know what we're getting into. I don't want to say, oh, hey, I'll call you if we need you. Well, if he's got a full day clinic or OR, it's not very available. And so I really want to make sure I use that time more efficiently. So MRI can be very specific for certain things, certainly deep lesions, smaller deep lesions, involvement of the bowel, those things can help us plan for surgery a little better. And also understand how to counsel our patients. Do we need to do surgery? If you're feeling okay, we see this advanced disease, but you're feeling all right, your surgery's going to be pretty tough, might involve bowel resection. That's going to help change our counseling and maybe keep us out of the OR unless we really need to be there. Biomarkers, there are a bunch. There are none that really help us. So quick slide, but yes, there's a lot of things people are looking at. Not anything that I would write down, not anything that I would remember because right now, not super useful. We get all those elevated CA125s in middle-aged women who have endometriosis. We're going, what do we do with that? It's probably not cancer. It's probably related to endometriosis. But so just, you know, again, careful what test you order because you're going to have to follow up on them. You're going to have to do something with them typically. So more and more push, at least in my world, is focusing on managing endometriosis after initial diagnosis, after initial medical management failure of thinking about putting together an endometriosis team, a multidisciplinary team. Thinking more about endometriosis as cancer, as long-term chronic progressive diseases that are multisystem in their effect. I'm very lucky. I've got a colorectal surgeon in my institution who is actually interested in endometriosis, interested in doing those surgeries, interested in seeing those patients. It took me only about 10 years to find that person. But creating endometriosis centers, in effect, to allow you to take care of these patients who have really complex symptoms, really complex histories, really complex surgical plans that have to be made for these folks. But if their symptoms are cyclic, certainly, those are the ones you need to see colorectal ahead of time. Quick note about bleeding. If you have bleeding per rectum or hematuria, and so we'll talk about both of these things, it's more likely to be primarily bladder disease if they have blood in the urine. If they have blood per rectum, it's more likely to be primarily a GI disease. So, we don't want to ignore or rule those things out. Certainly, you can have transmural disease, endometriosis that works through the bowel wall, that works through the bladder wall. It's rare. It happens when we see it, but that shouldn't be your first suspicion. Certainly, if it's cyclic, it can raise your suspicion as well. It only happens during cycles. Also, PT, we talked about pain psych, and you have to be very careful in counseling patients. We're not telling you you're crazy. We're saying pain is really hard and can be challenging on people's lives. And so, it's important to make sure we involve a patient's entire care team. and having a primary care doc as their quarterback in a sense during all this can be really helpful as well. So, think someone may have it. Empiric treatment, okay. Just because they responded, doesn't mean they have it. I have all these patients who got Lupron years ago and the pain got better and they said, oh, well, my doctor told me I have endometriosis. Not diagnostic, just because you responded doesn't mean you have it. It's a chronic disease requiring sustained treatment. And this is a conversation I have again and again and again. I don't wanna do hormones. I wanna be treated without hormones. And I say, okay, so, okay. I get that diabetics don't wanna take insulin. I'm not saying it's easy or nice to be on birth control pills. I've never had to take them. It'd be nice if we didn't have to take, to treat anybody with any medication, but we have a disease that over time can get worse, it can progress and become more difficult to treat. And we have a solution that might actually lower your risk of disease progression. Well, just do surgery. Well, what surgery are we talking about? We'll just take the uterus out. Well, taking the uterus out's not a solution for endometriosis treatment. You still have your ovaries, it's extraneous disease. You're still gonna have to be on hormones. We'll just do the laparoscopy to see if it's there. If we see it's there, we're gonna say birth control pills. If it's not there, we're gonna say birth control pills. So if the answer's the same, let's not do the surgery. Let's try the treatment first. And so typically after a long conversation, oh, take it all out. Okay, now we're gonna have you on HRT because you're 30 years old and don't have any ovaries. So if the answer's always hormones, let's start with it and avoid all this big surgery. So obviously a conversation I've had quite a bit, but I understand concerns and why people would prefer not to be on them, but it's something that we always think about starting off first because without suppression, the risk of disease recurrence is super high and something that we need to be thinking about. Just like with cancer, there were cancer surgeons for many years who thought they could solve the world's problems with a knife. Now much of what GYN oncology does is neoadjuvant, chemo, radiation, targeted therapies and those things. So I think understanding at the cellular level that we understand very little about endometriosis. There's a lot more to learn, but thinking that we can solve all the world's problems with a knife is probably a little bit of hubris, which is not shocking to hear from a surgeon. But we think about long-term treatment. We think about long-term use needs to be safe and well-tolerated. And for most women, birth control pills are those things, or at least hormonal suppression. So anti-inflammatories and OCPs, everybody gets them. Important to understand when people say, oh, I tried, it didn't work. How are they using them? Is it cyclic, traditional cyclic management? So they're having their withdrawal week. Do we all know why there's a withdrawal week in birth control pills? Because John Rock was Catholic and was trying to get the birth control pill approved from the Vatican. So that's why there's a withdrawal week. So we can tell our patients there's no clinical need for withdrawal week. Seasonal is not a new idea. Seasonal, these are things that we've been doing for a long time that we just put in a new package. So skip the withdrawal week, continue with OCPs for our patients that have pain during their withdrawal weeks. The other key with OCPs is you can time withdrawal bleed to load up on an NSAID. So counseling folks on how to use birth control pills, how to use NSAIDs, which is something that, yes, we all know how to take Motrin, we all know how to take birth control pills, but understanding how to use them more effectively can really minimize those other more advanced treatments. And so cyclic OCPs, let's try. So monophasic, I don't write for any triphasics anymore. Monophasic pills, continuous dosing. If they have some breakthrough bleeding spotting, load up on ibuprofen, have that withdrawal week, or do a birth control pill taper, things like that to get your bleeding better while you're on birth control pills, but trying to maintain that. It can be very helpful. And then the other one I write for all the time, north endoacetate for those patients who can't take estrogen because of migraines. There's likely some increased risk of VTE. A study just came out this year looking at that. It's probably less than estrogen-containing OCPs, but I have a ton of patients on north endurone. It's got a slight estrogenic component to it that allows, from what we know, less bone loss, less effect versus long-term medroxyprogesterone, so a prescription I write for a lot. Second line, more advanced things like generic agonists with ADVAC, right? So I'm putting folks into menopause, need to support their bones for long-term use. Can be helpful. About 80% plus of patients will respond to birth control pills from GnRH agonists. It's about 80%, so if we're gonna choose one, start with birth control pills. There is a subset of women who will respond to those other drugs, GnRH agonists, GnRH antagonists, aromatase inhibitors, sperms that don't respond, but I don't write for a lot of those other drugs. Once we've determined they don't really do well for birth control pills, most of them end up going to surgery after that, so those are useful also when they're waiting for surgery. I've got a four- to six-month wait to get to the OR right now, so if we can get our patients comfortable in the meantime, that can be helpful. There's just limited long-term data on these drugs as well, so if we're thinking about managing them for 20 years, I don't really know the long-term impact. I don't think anybody does, and we have to be very careful about that, so we'll get moving as well as we're... Short talks are better. We can fit a lot in, so pardon me if I go quick. Laparoscopy's better than laparotomy. Laparotomy's not a failure, but outcomes are better in just about every single metric. My last 10 years for hysterectomy, 99% have been laparoscopic. Patients go home the same day. Less rounding is great for me, but also, patient outcomes are much better. Again, appropriate settings. If you have concerns, this is advanced disease. Just going in to look and saying, oh, yes, it's advanced. Are we providing our patient a benefit by doing that? So understanding what your surgical abilities are, what your practice looks like, and making the decision to find that right surgeon for the patient is really important. Thinking about CT surgery as well, one thing I didn't mention, we've had patients that have diaphragmatic endometriosis as well, so... Excision versus ablation, a lot of talk about it. A few more studies coming out that show maybe some improvement with excision over ablation. The key is to destroy the disease. The one thing with excision over ablation is if it's a lesion on the ureter, sitting right on top of it, I wouldn't ablate that. I would open the sidewall, take the ureter off the sidewall, and excise that peritoneum over top of it. So if it's gonna keep you from doing the surgery you aim to do, which is remove or destroy endometriosis, leaving that behind because you can't excise it is not in the patient's best interest. So excision typically allows you to keep things safe that you wish to keep safe. Back to staging surgically, there's a couple more. AGL has a new one coming out. I don't think it really has been shown to be that much better, but something to look into. The one area where excision probably helps is deep infiltrating endometriosis as well over superficial. So still waiting for that good RCT, having sat on the coding committee, a lot of people want endometriosis codes to change. There's not a whole lot in the way of evidence to suggest that excision is clearly better than ablation, but more and more of the studies are being done right now. Endometriosis, endometriomas, removal can be helpful. The one big thing to talk about here is infertility. Used to be, if there's an endometrioma, take it out. Can't do IVF or any other assisted reproductive technologies but the endometrium is still there. More data shows that if it's less than five centimeters probably benefit to leaving it in because the injury of the ovary, the reduction of ovarian reserve from doing a surgery like an endometrioma is significant enough that in these patients that have infertility, we don't wanna hurt their ovaries even more. So leaving them in can actually likely improve their fertility. So I always include infertility. Infertility is not covered by state law, but there's no state mandates for insurance coverage for infertility in Kentucky. So it's different than being in a place like Illinois where everybody gets IVF if they want it. So understanding your state's practice is important. But other surgeries that can happen at the same time, interstitial nerve ablation, no improvement in pain that we know about and presacral norectomies, which I don't do potentially. I think hearing at AGL in the same meeting, one talk about nerve sparing surgery and another talk about nerve ablation. I'm going, well, are we sparing them or are we destroying them? I'm not sure which is helping the pain. So a lot of things being done out there with limited data. Hysterectomy, again, back to my point earlier, hysterectomy is not a treatment for endometriosis. So getting your uterus out does not mean you've addressed the lesions in the pelvis, you've addressed the hormonal issues in terms of disease proliferation and growth. And so yes, it can help for heavy periods. Yes, periods will stop, but you still have to address endometriosis management regardless of whether or not you've had the uterus taken out high risk of pain recurrence after hysterectomy, leaving your ovaries behind. The other important thing to think about is not all people that have painful periods have endometriosis. And this is a study done at Michigan. A lot of women who have a pre-op diagnosis going in don't end up having it on path. So it's a tough disease to manage, but again, reminding us to counsel our patients that hysterectomy is not a solution to your endometriosis. And more importantly, we still have to manage it and taking your ovaries out has a significant risk of bone and heart issues for our patients, especially our young patients. Having that team available, the colorectal surgeons, the urologists available, it can, remember, it can involve those non-gynecological organs. Important to have those centers available and the arguments now that, you know, having folks treated for cancer, cancer centers do better. We're seeing more and more endometriosis centers around the country, and I think those patients have fewer surgeries and more optimal surgeries. And lastly, remember that we have to always counsel our patients in post-op. It's amazing how many patients I have that have had surgeries for endometriosis. We're told they were cured, and then three to five years later, they come back to see me with recurrence of pain, and they were never put on birth control. They were never suppressed. They were never put north into, and it was never discussed with them. And I'm just, it's eternally frustrating. This is a disease we have to manage. There is no surgical cure for endometriosis outside of a complete hysterectomy BSO, and even in those cases, there are still rare post-menopausal patients that have it, but understanding that suppression is gonna have to be a part of that conversation no matter what we do. And lastly, adolescence, keep it in mind. It happens. Young girls have papal periods. It should always be in our minds about that, we should always be thinking about suppression. Talking to kids and parents about birth control pills, not as contraception, but as endometriosis treatment, we should come out with a new pill and just rename it something else so people don't think, oh, I'm giving my kid birth control pills. Just put a new name, a new package. Happens all the time in medicine. An endometriosis pill that is just OCPs, but thinking about starting them early, because that can save their fertility. That can save their need for multiple surgeries. And so considering signs before diagnosis, long-term implications when discussing management, involving specialists early and patients in whom you suspect it, and when doing surgery, remain conservative and data-driven, and especially those patients in whom we suspect it. So thank you very much for your time. We did it just under time. A couple minutes left for questions if anybody's got any. Are there any studies where you can have just mild, you know, endometriosis implants, perhaps in the uterus that are very mild or on the ovaries, and the patient has chronic pelvic pain where you can just remove the ovaries and leave the uterus in place? Can you just remove the ovaries and leave the uterus in place? Again, I think it depends on the patient. So if we're talking about someone who is 52, fine. Or, you know, hormonal suppression again, right? Like if they failed, that'd be a patient in whom I'd be far more suspicious that there was something else going on. So it's, you know, chronic pelvic pain. Is it daily? Is it worse throughout the day? The more they do, the worse it gets. That's musculoskeletal pain. Let's make sure we're not missing things like musculoskeletal pain, because there are patients that have endometriosis that have musculoskeletal pain, and making sure we're not missing something. It is hard because we do find little lesions. We do find those things in patients that have more advanced disease, but part of that full history of what's going on allows us to help figure out, is that what it is? There's a lot of things that can be going on. Taking out just the ovaries, I mean, again, ophorectomies in general are not heart surgeries. The patient's, depends on her age. If she's 30, I would say absolutely not. If she's in her late 40s, early 50s, have that discussion. Again, patient autonomy's important if she wants them out. Like, I'm not gonna, not listen to her, but I'd be, it's a surgery I do, I've probably never done, if that helps, for that indication, so. Any other questions or thoughts? Thank you all for getting up early this morning. I appreciate it, and hopefully that was helpful. All right. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

Dr. Mark Hoffman

obstetrics and gynecology

endometriosis

fibroids

chronic pelvic pain

robotic surgery