Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea

Obstetrics and Gynecology Journal: Published on October 2021

Endometriosis affects 6–10% of reproductive-aged women and is associated with significant morbidity.

Clinical manifestations are broad and can include dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, dyschezia, and infertility.

The wide range of presentations hinder the ability to make a timely diagnosis; the average time to surgical diagnosis is nearly 7 years from onset of symptoms.

This delay can lead to chronic pain, reduced quality of life, infertility, and significant cost burden to the individual and health system.

Multiple strategies exist for the treatment of endometriosis-related dysmenorrhea, which is defined as cyclic pelvic pain occurring during the menstrual cycle.

Medical therapies include nonsteroidal antiinflammatory drugs (NSAIDs) and hormonal agents such as short-acting reversible contraception, levonorgestrel intrauterine device, and gonadotropin-releasing hormone (GnRH) modulators.

Surgery is frequently performed to confirm the diagnosis and treat endometriosis implants; however, there is not a standardized surgical technique.

TAKE-HOME MESSAGE

In this study, researchers evaluated the cost-effectiveness of sequential medical and surgical therapy for dysmenorrhea caused by endometriosis.

Authors found that using a treatment strategy consisting of NSAIDs followed by short-acting or long-acting reversible contraceptives followed by surgery was associated with the lowest cost.

All sequential medical and surgical strategies were cost-effective compared with surgery alone.

CONCLUSION

The researchers found that the most cost-effective strategy was treatment with NSAIDs, hormonal contraceptives (either short or long acting), and then surgery.

However, delaying surgical management for patients with pain refractory to more than three medications may increase cost and decrease quality of life.

The study confirms standard treatment of women with dysmenorrhea in primary care. When a woman comes in with dysmenorrhea, primary care clinicians will usually start with a scheduled NSAID and/or hormonal contraception. This study confirms that after those two medication trials, it is reasonable and acceptable to refer a woman to the gynecologist to discuss surgery.

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Abstract

Objective: To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea.

Methods: A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18-45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed.

Results: In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach.

Conclusion: All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

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