When it comes to chronic pelvic pain (CPP), the two debaters for this year’s ABOG Educational Foundation Lectureship on Patient Safety and Quality Improvement agree that treatment needs to be tailored and individualized based on a broad look into all potential pain generators.
But, which course of action to follow first will be the crux of “Debate: Surgery vs. Medical Management for Primary Approach to Pelvic Pain,” which takes place today from 3:40 – 4:30 pm in Hall D. Both doctors will review the multiple etiologies contributing to CPP and identify evidence gaps concerning medical and surgical management while contrasting potential benefits and harms.
Lee A. Learman, MD, PhD, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, will argue that using medical management primarily benefits the patient more. Magdy Milad, MD, MS, Northwestern University, Evanston, IL, supports a more aggressive approach through surgical management.
Dr. Learman will review many of the different etiologies of CPP. Since CPP is often multi-factorial, clinicians must look very broadly for the causes and not assume that they can be addressed surgically.
Primary medical management is recommended for most etiologies, including suspected endometriosis, Dr. Learman said. Laparoscopy is unlikely to find endometriosis in the majority of patients with CPP, and laparoscopic treatment for endometriosis does not provide long-term benefit without adjuvant medical management.
“The same medications that extend the benefits of laparoscopic treatment for endometriosis also work when used as initial management,” he said. “Laparoscopy can be reserved for patients who have refractory symptoms, infertility, or adnexal masses.”
While treating acute conditions provides a straightforward and powerful sense of satisfaction, Dr. Learman said, diagnosing and treating a chronic condition that impairs quality of life and sexual health connects with ob-gyns’ identity as comprehensive women’s health specialists.
“It makes sense for us to be the team captain as we help patients recover from CPP with colleagues from other disciplines,” he said.
Dr. Milad will argue that a physical evaluation can often be highly inaccurate, and that imaging can lack the sensitivity to determine pain causes. Surgery is often necessary to make or confirm a diagnosis.
Dr. Milad said that surgery offers both a “see and treat” approach.
“It would be a disservice to patients to perform a diagnostic laparoscopy and not make use of that venue to be able to resolve a gynecologic disease that potentially responds to surgical management,” he said. “I hope it happens less and less often that we do a diagnostic laparoscopy and then close the patient so that she can be managed medically or surgically by somebody else.”
Dr. Milad also said that while medical therapy can be useful in the short term, a delay in diagnosis often occurs and the side-effects of long-term suppressive hormonal therapies can reduce compliance.
“Often, we can resolve these things surgically,” Dr. Milad said. “On the other side of that, it may not even be gynecologic, and we’ve delayed the patient’s diagnosis by assuming that it’s gynecologic in origin, based on history and whatever limitations physical exams and imaging can offer. Maybe that patient will be better served by being referred to a gastroenterologist, physical therapist, or neurologist.”