Dr. Anna Reinert, M.D., Endometriosis Specialist, Gynecologist, Minimally Invasive Gynecologic Surgeon
City: Los Angeles, CA, USA
Philosophy: Endometriosis is such a varied disease. I think that the relative contributions of different pathogenic mechanisms vary between patients. For most patients, I find that the greatest burden of disease is present at initial surgery, with much less recurrence over time, which suggests an in situ disease theory. I have seen more aggressive forms of the disease where recurrence happens quickly and in areas where peritoneal resection was recently performed, suggestive of a retrograde menstruation mechanism. In patients seeking surgery who are done with childbearing, I recommend hysterectomy – but if a patient does not desire hysterectomy, I recommend bilateral salpingectomy to try to minimize the risk of retrograde menstruation. I also recommend hormonal menstrual suppression as part of symptom control in women desiring future fertility.
I am hopeful that over time, the inflammatory cytokine cascades involved in endometriosis pathogenesis will be elucidated, and that we would be able to treat women with a small molecule inhibitor medication, similar to what is being used to prevent ovarian cancer recurrence, as part of post-surgical medical management of endometriosis.
Medication: I frequently recommend the use of hormonal contraceptive medications to suppress menstruation in women not seeking immediate fertility (combined OCPs, Depo-Provera, Kyleena IUD placement), both pre-operatively and post-operatively. I do not routinely recommend GnRH agonists or antagonists, but may consider these for refractory pain after surgery in specific patients, or for temporary symptom management if surgery needs to be delayed and symptoms have persisted despite the use of hormonal contraception and other non-hormonal pain medications.
I also take a multimodal approach to pain management including the use of oral and vaginal muscle relaxants, lidocaine patches, NSAIDs, and Tylenol.
Approach to Persistent Pain After Surgery: Prior to surgery, I perform a comprehensive pelvic pain evaluation to assess for overlapping conditions such as spastic pelvic floor syndrome, interstitial cystitis, irritable bowel syndrome, or vulvodynia, and I look for evidence of central sensitization. Patients identified as having pelvic floor spasm pre-operatively will be referred to pelvic PT as part of their management of chronic pelvic pain, so many patients are referred to work with pelvic PT post-operatively. I prescribe oral and vaginal muscle relaxants for the management of pelvic floor spasms and perform Botox trigger point injection into the pelvic floor muscles when applicable. I will treat interstitial cystitis or IBS with medications and elimination diets. I use topical compounded ointments for vulvodynia including topical gabapentin and hormones.
In patients who have persistent symptoms after surgery that are not specifically related to muscle spasms, IC, or IBS, I will assess for central sensitization and consider the use of duloxetine or a tricyclic antidepressant. I may recommend the use of ketamine, either in the vaginal suppository that I prescribe or as an oral agent prescribed by one of the pain management specialists with whom I collaborate. In specific patients, I may consider the use of GnRH agonists or antagonists as part of post-op pain management.
In addition to physical therapists, I collaborate with occupational therapists that specialize in lifestyle redesign for chronic pain, pain management specialists who understand pelvic pain and offer a variety of interventional procedures, and pain psychologists – and will refer patients to this team of providers as part of managing persistent pain symptoms.