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Dr. Shulman:
This is CME on ReachMD, and I'm Dr. Lee Schulman. Here with me today is Dr. Ayman Al-Hendy from the University of Chicago in Chicago.

Ayman, thanks for being here with us today.

Dr. Al-Hendy:
Thank you. It's a pleasure to be with you today. 

Dr. Shulman:
Let's begin, Ayman. can you provide to our learners some insight on your use of GnRH antagonists prior to and following surgery for endometriosis?

Dr. Al-Hendy:
Yeah, I'll be happy to. Beside GnRH antagonists being a great tool for treatment of endometriosis, they are also actually kind of an additional new tool available to us in the pre- and postoperative phase for a patient who will be exposed to surgery for endometriosis. So generally, in that domain, if you look at the Cochrane database about what's available in pre- and post-conservative surgical medical therapy for endometriosis, they did an analysis in 2020 which included about 25 articles on thousands of women who went through surgery for endometriosis. The finding actually was relatively uncertain and inconclusive. Keep in mind this is 2020, so it's before, really, the availability of oral GnRH antagonists, and the value of pre- and postoperative medical therapy in surgical treatment of endometriosis was considered to be limited or uncertain.

However, since the availability of oral GnRH antagonists, I and others have been using them in this particular scenario, pre- and postsurgical treatment of endometrioses with high level of success.

So, for example, let's talk about preoperative preparation of your patient. So you have a patient with endometriosis, typically have the typical endometriosis-related symptoms, the chronic pelvic pain, etc. And through evaluation, both of you decided that she's going to have surgery. Just consenting the patient for surgery for endometriosis doesn't immediately relieve her pain. So I know that's very obvious, but I want to say that in this recording because, for example, in my institution, there's always a delay of about 2 or 3 months from the moment that the decision to do surgery is made to the actual performance of the surgery because of different reasons: the preparation of the patient, finding the right time for everybody, anesthesia, etc. So this patient will have to go through 2-3 months of pain and symptoms and suffering waiting for her surgery. 

I think oral GnRH antagonist is a great tool, easy to use. It's a daily medication that the patient can stop anytime, unlike what we had before, injectable GnRH analogs or agonists, and all the other differences. And it's a great preparation for the patient to give her symptom relief in preparation for the surgery.

Also, many of the endometriosis patients, unfortunately, have also heavy menstrual bleeding, so they have anemia. And of course, we always try to do everything we can to avoid the need for a blood transfusion. And as you know, Lee, typically we would like to take the patient to the OR with the hemoglobin probably above 10 or ideally above 11. So instead of doing other things that maybe have side effects, like iron infusion, etc., I have been using successfully oral GnRH antagonist, again, for that purpose. As you know, the amenorrhea rate with those medications are up to 70% to 80%, so you know the patient will have very little loss of iron, little loss of blood, and their anemia will be corrected by the time of the surgery.

Also, I can tell you anecdotally, again, this is limited experience, but I'm sure with time we'll have more data on that. I find the surgery itself actually less bloody and the blood loss is less when I prepare the patient with oral GnRH antagonist. And I expect more observation and more studies will confirm this in the future.

So that's in the preoperative preparation. Now after you do the surgery, of course, we do as careful and as extensive ablation of endometriosis as possible. But as you know, but I also want our audience to know, endometriosis is a chronic disease, so there is a high rate of recurrence. In premenopausal women, the recurrence rate is up to 70% in 5 years. So we know surgery itself is not a cure. So I've been also using oral GnRH antagonists for up to 2 years after the surgery in my patient, especially a patient with extensive disease where I feel that there probably is residual disease after surgery, and with great success. Again, because these are recent medication, there's limited published work on that, but this is also another something I expect moving forward there will be data on that. 

Dr. Shulman:
You obviously have great experience using this pre- and postsurgically. What do you tell patients about side effects to be aware of?

Dr. Al-Hendy:
Well, I tell patients who are using this medication, in general, for medical therapy of endometriosis, regardless if they are going through a surgery or not, what we found in the clinical trials, for example, the hypoestrogenic side effects, like hot flashes, night sweats, and so on, they were really not that different in the placebo arm versus the arm that used oral GnRH antagonists. I'm talking about the studies that had the add-back therapy, had the estrogen and progesterone. So I assure them that even though these symptoms have been reported in the clinical trial, the chance of this is very limited and was not that different from those who had the sugar pill. The only thing I want to add about using this medication in the context of surgery is, because, especially the newer medication like relugolix combination therapy, they have estrogen and we know, of course, we prefer not to use estrogen very close to the time of a major surgery, so I just ask them to stop it about a week before surgery. But other than that, it's a very easy medication to use in this scenario.

Dr. Shulman:
Ayman, it's been great to have you here today. Thanks so much for really updating us on this very important approach to endometriosis surgical care.

Dr. Al-Hendy:
Thank you.

Dr. Shulman:
This concludes our discussion on the potential use of GnRH antagonists prior to and after surgery for endometriosis. Our time is up, but I want to thank all of you for being here with us today and have a great day.

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