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What Makes a Center of Excellence in Endometriosis Care? · UF Health MedEd Cast

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  Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shans Hospital.
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  I'm Melanie.
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  Today we're highlighting the UF Health Endometriosis Center of Excellence.
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  Joining me is Dr.
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  Nash Moad.
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  He is a professor and chief in the division of Minimally invasive Gynecologic
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  Surgery, the director of the uf.
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  Centers of excellence in minimally invasive gynecologic surgery
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  and complex endometriosis care.
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  In the Department of Obstetrics and Gynecology at the University of Florida
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  College of Medicine at Gainesville.
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  And Dr.
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  Amira cdo, she's a minimally invasive gynecologic surgeon and
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  an assistant professor in the department of OB GYN at the University
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  of Florida College of Medicine.
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  Doctors, thank you so much for joining us, and Dr.
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  Moad, I'd like to start with you, as we think about endometriosis
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  today, how do you frame it?
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  Give us a little bit of a background, an overview, a table setting, if you will,
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  as a gynecologic condition, a systemic inflammatory disease or something broader.
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  Dr Nash Moawad: Well, first of all, thank you for having me, Melanie.
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  This is a great time to focus on endometriosis as, it's a common disease
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  that's, commonly missed or misdiagnosed, leading to delays of up to 10 years in a
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  lot of women, that keeps suffering with pain for many, many years and seeing
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  multiple physicians and providers.
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  From pediatrician to primary care providers, to gynecologists, to
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  ER physicians And so forth, even GI doctors and general surgeons.
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  And ultimately, it takes that long to get a diagnosis.
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  it's a chronic, systemic inflammatory condition that even though it
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  does start in the pelvis, it can affect the entire body.
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  It can affect the entire individual And the way she functions and
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  carries on her daily life.
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  pain is a highlight of this condition.
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  Typically starts with pain with menstrual cycle, sometimes it can
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  start before the menstrual cycle and extend beyond the menstrual cycle.
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  Sometimes pain will affect other, activities such as, physical
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  activities, pain with sexual activities, pain with bowel movements, pain
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  with urination, and some of those women can suffer with, difficulty
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  conceiving or achieving a pregnancy.
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  Those are some of the common conditions that lead us to
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  suspect Endometriosis is at play.
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  Melanie Cole (Host): Well, thank you so much and, and Dr.
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  Moad, I'd like to stick with you for a minute.
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  Can you tell us a little bit about building a center of excellence in
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  endometriosis care, what's involved in doing this, And what are your visions
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  And we're gonna get to visions near the end as well, but I'd like you to speak
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  about what's involved, what defines experienced care in endometriosis?
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  Dr Nash Moawad: First, the purpose of having a center of excellence really
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  is, making it easier for patient's to know where to go and making it
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  easier for physicians and providers to know where to refer the patient's
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  in whom they suspect endometriosis.
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  So This is the highlight.
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  This is the main purpose of having a center of excellence is to provide.
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  place a location that's easily identifiable for women and
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  families and, providers.
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  To know, know where to go to, what that entails specifically is a group
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  of physicians and group of providers that are highly skilled in addressing
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  endometriosis, diagnosing it first, and addressing it with multiple,
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  medical and surgical options.
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  A multidisciplinary team So, It starts with taking a good
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  history, doing a good exam.
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  specialized GYN ultrasound and sometimes, additional imaging
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  studies like, MRI And the.
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  Discussion of multiple treatment options depending on the
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  patient's symptoms and her goals.
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  So if that's a patient who is suffering with pain, there are options for this.
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  If that's a patient with a big ovarian cyst, for example,
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  there's treatment for this.
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  If that's a patient who's trying to conceive, then the
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  strategy can vary a little bit.
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  So.
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  Typically that multidisciplinary team will start with a minimally
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  invasive GN surgeon with expertise in diagnosing and treating endometriosis.
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  With a specialized ultrasound unit that, has the surgery in mind,
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  has the disease in mind, and know where to look And what to look for.
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  frequently those women will come to us with a normal ultrasound because.
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  Most pelvic ultrasounds, they just look at the uterus And the
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  ovaries and everything looks fine.
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  And then the patient keeps getting moved on hearing that everything's fine, we
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  don't know what's causing your pain.
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  So that's a big problem.
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  relying a hundred percent on ultrasounds that are poorly performed,
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  and not knowing what to look for.
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  So a specialized ultrasound is very important.
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  And like I said, MRI is also a modality we use frequently.
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  When we suspect involvement of other organs, for mapping of the disease and
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  surgical planning, those patient's do also need, sometimes other physicians
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  from other specialties such as colorectal surgeons, if there's bowel involvement,
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  urologists if there is a bladder or urethral involvement, obstruction
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  where some reconstruction is needed.
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  pelvic floor, physical therapy is a big component of a center of excellence.
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  As many of those patient's as a result of suffering for many years, and having pain,
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  they end up having muscle problems, spasm of the muscles and inflammation of the
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  muscles causing, muscle pain as a result.
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  And that's in the pelvic floor and it's pretty hard to, Consider it's
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  different from your, shoulder and neck muscles that are easy to tell, okay?
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  Those are hurting.
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  So I need attention.
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  The pelvic floor muscles, it's hard for patient's And for primary care providers
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  to identify that This is a problem.
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  other important components of a center of excellence are, pain psychology.
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  we know, pain cannot be treated in isolation.
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  A lot of those patient's have been suffering with pain for many years.
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  And that can be, a factor in either affecting their mental health
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  or the pain perception itself.
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  And the coping mechanisms can be impacted by mental health issues.
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  So, it's important to address that part.
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  sadly, Common problem is history of sexual abuse, And that can lead
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  to a lot of, either myofascial components or muscle component and
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  a mental health component that does need to be addressed along with the
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  endometriosis And the pelvic vein itself.
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  So when you think of a center of excellence, you need to have
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  all those components in play.
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  the part That is sort of at the center of all this.
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  Is a surgeon who's able to diagnose endometriosis and treat complex disease
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  because you wouldn't wanna do a diagnostic laparoscopy, find endometriosis,
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  And then not treat it, or treat just a typo iceberg, or do some brief
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  ablation or burning of the lesions.
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  and when that happens, then you're leaving all the lesions on the
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  vital structures like the bowel, the bladder, the ureters, the tubes.
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  Those are untouched.
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  And the patient continues to suffer and gets another surgery or another surgery.
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  it's not uncommon for us to see patient's in their teens and twenties who have
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  lost an ovary because they had surgery, as an emergency or by a physician who's
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  not trained to handle endometriosis.
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  So for us, our.
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  Mindset is always conservatives, surgery.
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  So we wanna save the organs, spare the organs.
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  A lot of those women are young and wanna have children.
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  So, uterine preservation and ovarian preservation and tubal preservation are
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  prime goals for us when we do surgery.
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  Melanie Cole (Host): Thank you.
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  It's certainly a comprehensive, multidisciplinary approach.
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  And Dr.
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  Cado, I'd like you to speak about early referral.
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  And letting other providers know when it's so important to refer
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  suspected endometriosis patient's.
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  But while you're doing that, tell us when you get these patient's,
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  what's the first-line medical treatments for their symptoms?
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  Are you working on the underlying condition symptom management?
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  Speak to other physicians now about when to refer And what you're going
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  to do with their patient's first.
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  Dr Amira Quevedo: Thank you Melanie, and again, thank you for this kind invitation.
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  Yes.
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  Referral, is definitely something that sometimes gets missed, like Dr.
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  Moad was alluding to, there's a, a big diagnostic gap and from
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  the time that patient's get.
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  symptoms usually around, very close to menstruation shortly thereafter.
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  And then when they actually get diagnosed, sometimes, on average it's
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  between seven and 12 years, depending on, the studies that you look at.
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  And these are in.
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  Developed countries.
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  So we're not talking about, underdeveloped or third world countries.
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  We're talking about countries that have very sophisticated, diagnostic
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  procedures like MRI and ultrasound.
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  And so, the imaging really shouldn't deter, physicians from
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  referring these patient's early.
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  And, the main thing is.
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  That we see a lot of patient's going to their family medicine doctors
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  or their internal medicine doctors.
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  They're seeing, the primary care providers first and they're having
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  these symptoms, but because there's a little bit of a lack of awareness of.
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  What normal menstruation is supposed to be.
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  patient's either feel stigmatized or they feel like at times the diagnosis
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  isn't thought of, early enough.
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  And so usually they present, early, after menstruation starts.
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  And, these are patient's that can start on the first-line therapy.
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  So usually anti-inflammatories.
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  As well as, oral contraceptives or hormonal medications.
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  Hormonal medications are really the first-line, treatments.
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  And so that can include anything from combination birth control
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  to progesterone only pills.
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  And these, are fairly effective for the vast majority of patient's.
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  The only problem is that there's, a certain group of patient's with
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  endometriosis and it's very significant.
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  It can be somewhere up to, 30% that either don't respond well to these medications
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  or they have a lot of side effects.
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  most of them, A refractory in terms of, if they're starting the birth control
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  pill and they've been on it for a period of two or three months, they're
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  still having to stay home from school.
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  They're not going and attending their college classes because
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  of the debilitating pain.
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  And so these are the patient's that usually get referred to us
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  because they are failing the most common in first-line therapies.
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  And, the other group is patient's that.
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  Are trying to conceive.
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  So all of the hormonal therapies that we have available to us to
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  treat endometriosis, also while patient's are taking it, don't
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  allow for them to conceive.
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  So This is a very important group of patient's that we see is patient's
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  that are actively, trying to start their families for the first-time.
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  Or, they've had a family before and they're, having trouble
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  conceiving, their second child.
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  or they're failing multiple rounds of fertility treatments.
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  And so they come to us because they either have pain and
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  infertility or just infertility.
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  So just to, readdress the symptoms of endometriosis.
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  Sometimes patient's don't actually have classic pain symptoms.
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  most patient's do.
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  Most patient's have really debilitating pain, but some patient's just
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  have infertility as their main.
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  Symptom.
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  And so that's a very important group that gets referred to us because the
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  available therapies, can't, address the concerns for fertility and fertility has
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  been shown to be improved after surgery.
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  especially, like Dr.
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  Moad said, when done in the right, setting with the right surgeon because a lot
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  of harm can be done if, the surgery's performed by somebody who doesn't have the
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  skillset, doesn't have the proper training to, preserve the ovaries, preserve the
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  fallopian tubes, take in mind the whole picture of, why the patient is presenting.
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  And a lot of patient's come to us they're at the consultation for a second or third.
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  Opinion because they've been told that the only way that they can get rid of their
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  endometriosis is through a hysterectomy.
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  And Dr.
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  Mo had said like, you can, have the surgery and you can have your uterus
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  removed and you can still have a lot of pain because there's a lot of
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  disease that can be left behind on the bowel or the bladder, the appendix.
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  And so, These are very important, conversations that need to be had
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  about not just, offering patient's, the surgical management, but
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  also the quality of the surgery.
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  And that's what the multidisciplinary team allows us to do, is to really,
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  Be able to offer the patient's top-notch care, in a setting where
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  they're able to meet their priorities, meet the patient's where they're at.
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  and I'd like to add something really unique about the University of
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  Florida in our center of excellence.
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  So as, both Dr.
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  Ma and I being surgeons of excellence in the center for complex
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  endometriosis care, we are also.
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  Really, excited about, being part of research in endometriosis because.
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  the main medications that are available to patient's are hormones, like
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  we said, the limitations of that.
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  And we have a lot of clinical studies involving, patient's with endometriosis
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  and seeing if we can look at other pathways that can treat endometriosis
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  pain and treat the endometriosis lesions either through, looking at the microbiome
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  or looking at the mitochondrial health of, patient's with endometriosis as
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  well as, using the very rich, resources in artificial intelligence and, the
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  strong research infrastructure at the University of Florida to be able to,
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  enroll patient's that may not otherwise have many options for endometriosis.
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  in some of our studies that.
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  We're, so privileged to be a part of.
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  So I think that makes our center of excellence pretty unique.
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  Melanie Cole (Host): Well, it certainly is a very exciting time in your field
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  with so much as you say, research and advancements, and I'd love to give you
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  each a chance for some final thoughts.
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  Before we do that, Dr.
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  Moad, tell us a little bit about the, what the evidence tells us about
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  outcomes when surgery is performed in high volume centers like yours.
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  What are your patient's saying?
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  Dr Nash Moawad: there are so many studies about outcomes and it really depends
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  on what outcomes are you looking for.
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  So when you look at pain, there's a pretty good success rate for complete
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  excision of endometriosis in terms of helping pain, if endometriosis
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  is the only source of the pain.
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  But a big component of That is really in the pre-op assessment.
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  So in our pre-op evaluation, really need to get to the bottom of things.
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  'cause it frequently isn't just endometriosis, it's endometriosis along
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  with, muscle component in the pelvic floor, there may be a GI component,
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  there may be other issues going on.
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  There may be a bladder component, or a urologic component.
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  There may be, some mental health issues that need to be
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  addressed and, taken care of.
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  So it's really about comprehensive and a whole person approach, not
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  just, you're here for endometriosis, pain, let's do surgery.
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  And that takes care of all problems.
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  So it's really important to, make all the diagnoses and address each one of them.
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  separately, the outcomes are pretty good in terms of, pain relief, good
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  in terms of improving fertility and recurrence rates are low when surgeries
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  are performed by high volume surgeons and specialized centers of excellence.
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  the rate of preserving organs is much higher when surgery is done.
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  properly in those centers.
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  So it's extremely rare where we have to remove an organ for endometriosis,
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  unless it's the appendix, for example.
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  but the vast majority of the time we're able to preserve all organs and
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  just treat the endometriosis without removing end reproductive organs, organs.
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  Melanie Cole (Host): Well, thank you for that.
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  And Dr.
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  Cado, if you could change one thing.
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  About how endometriosis is taught in medical training because of the
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  difficulty in diagnosis And the time factor involved, And the fertility
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  And the quality of life And the pain, all that goes into this condition.
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  What would you tell medical students about this condition?
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  Dr Amira Quevedo: we actually have, a whole curriculum around,
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  endometriosis and, dysmenorrhea and, chronic pelvic pain.
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  but I actually never received that when I was in medical school, so I
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  think definitely starting earlier.
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  definitely helps in just having a standardized approach in medical,
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  school education because This is something, that affects.
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  probably more than 200 million women around the globe at this point.
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  These are, publications that are now several years old.
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  so I think starting earlier, and it doesn't really have
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  to start in medical school.
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  I mean, this should be something that should be broadcasted, on the
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  local news, it should be part of high school education, because that's.
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  Really when patient's start to really have a lot of disturbing
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  and disabling symptoms.
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  So, I say let's even broaden the scope to middle schools and high schools and
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  have that be part of health education.
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  and just having patient's know what, normal menstruation is supposed to, be
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  like And what menstrual health really is.
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  Dr Nash Moawad: And I would like to add something, Melanie, as, a
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  message to patient's and a message to, pediatricians and primary care providers.
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  Uh, a key part of the success of treating endometriosis is early diagnosis.
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  When women suffer for many, many years, it's difficult to get
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  them back on track very quickly just with, surgical management.
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  So I would recommend for any young woman and her family and her
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  pediatrician And the primary care providers And the ER physicians.
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  if the patient is suffering with severe pain with her cycles, that's
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  affecting her life, keeping her from performing her fun activities and going
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  to school and, doing all her hobbies and getting together with her friends.
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  the pain is lasting longer and longer and getting progressively worse.
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  Pain has not responded to typical medical management options like
• 19:03
  ibuprofen and, napper and birth control pills And the usual hormones.
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  pain affecting bowel movements or affecting, urination, pain
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  affecting, sexual activity.
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  Difficulty having babies.
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  it's best to seek her early and it's best to seek care at specialized, endometriosis
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  centers of accidents, especially if.
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  Surgery is proposed.
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  If surgery is proposed, I highly recommend, either seeking care at a center
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  of excellence or getting a second opinion.
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  There is nothing negative at all about seeking a second and a third opinion
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  before you have that first surgery.
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  'cause if we can maximize our outcomes from that first surgery,
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  we can decrease the number of surgeries And the complications of
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  surgeries And what that leads to.
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  Melanie Cole (Host): What great information you both
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  have shared with us today.
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  Thank you so much for really sharing your incredible expertise And the center of
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  excellence at UF Health Shans Hospital.
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  And to learn more about endometriosis care at UF Health Shans Hospital,
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  please visit uf health.org/conditions
• 20:13
  and treatments slash endometriosis.
• 20:16
  And for more information, you can always go to innovation dot uf health.org.
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  That concludes today's episode of UF Health Med EdCast with
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  UF Health Chance Hospital.
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  I'm Melanie Cole.