Neil Minkoff, MD: One of the things that can be confusing for a primary care physician like me is that it seems like a lot of the treatments for the different conditions that we’re discussing come down to some level of contraception, whether it’s acts as an oral contraceptive, an IUD [intrauterine device], or something like that. Could you talk a bit about how you choose the right contraception for the right patient, other differences in terms of what you choose for different diagnoses, etc., combined oral contraceptives versus progesterone alone, or Medicated versus non-medicated IUD? I realize I just threw a million things at you. But one of the things that confuses me as a primary care physician is trying to understand some of these levels.
Steven McCarus, MD, FACOG: Here is my philosophy on medical treatment when it comes to birth control pills and what you choose. You must remember that dysmenorrhea is a common symptom that we hear in patients who may have endometriosis. The first line of treatment for dysmenorrhea is nonsteroidal anti-inflammatory drugs or birth control pills, or both, for 90 days. Always give the patient a pain diary for 90 days and put her on a combination birth control pill, estrogen and progesterone, in low doses. This is our first treatment. If the patient comes back and is better and her dysmenorrhea improves, I keep her on medical treatment.
This is where Ayman and I may disagree. I sincerely believe that endometriosis is an estrogen-dependent disease. It needs estrogen to proliferate. If I treat endometriosis, I never use estrogen. I don’t change pills. I don’t give them any exogenous estrogen. I want to decrease the amount of estrogen that is present. I would go for a progestin-only pill. IUD and Depo-Provera were used. There is data that indicates pain will improve with these medications. But I want to suppress the proliferation of the disease, so I choose a progestin-only pill or some of the newer drugs that we’ll probably talk about in a moment.
Neil Minkoff, MD: What about the use of the IUD?
Steven McCarus, MD, FACOG: I use a hormone releasing IUD to decrease heavy menstrual bleeding. I do not use it to treat endometriosis.
Neil Minkoff, MD: Are you treating the symptom of heavy bleeding rather than the underlying medical condition?
Steven McCarus, MD, FACOG: To correct.
Ayman Al-Hendy, MD, PhD: It was state of the art until 2018 or early 2019. Then we started getting new medical treatment options. For endometriosis, we have elagolix [Orilissa], either alone or with add-back therapy. I’m talking about FDA approved drugs published in a high caliber medical journal. For fibroids we have elagolix, also with add-on therapy, but it’s a different dose than endometriosis. Then, more recently, since last summer, we have relugolix [Myfembree] with add-back therapy. Can we use their trade names?
Neil Minkoff, MD: Go ahead. I want to make sure everyone knows what we’re talking about.
Ayman Al-Hendy, MD, PhD: Because it can get a little confusing. Orilissa has been approved by the FDA for the treatment of pelvic pain associated with endometriosis for about 3-4 years. For fibroids, we have Oriahnn, which is elagolix with estradiol and norethisterone acetate. It was approved in the summer of 2020. More recently, relugolix was approved in the summer of last year, which is estradiol and norethisterone acetate. The trading name is Myfembree. We must use these new tools.
Maria mentioned the guidelines. AGOG [American College of Obstetricians and Gynecologists] the fibroid guidelines came out in June 2021. The previous one was probably from 2008. That’s about 13 years ago. It does not identify a first-line treatment, which did not satisfy me. But at least they left that up to the doctors and the discussion with the patients. They put all the drugs on the market, but they didn’t identify a first-line treatment. Of course, I respect everyone’s opinion and practice. In my opinion, the situation of starting with birth control pills and so on was quite appropriate until 2018 when we had no alternative. Now that we have these new tools after very well designed and very planned phase 3 trials on a large number of patients, sometimes 800 or 900 patients, with high quality data, I am using these new options as first line treatment .
Transcripts edited for clarity.