USA: According to a recent study in the Obstetrics & Gynecology journal, sequential medical and surgical management strategies compared to surgery alone are cost-effective for endometriosis-related dysmenorrhea. This implies that a trial of hormonal management following NSAIDs before surgery may provide cost savings.
Endometriosis is a prevalent and highly morbid condition affecting a total of 176 million women worldwide. The findings of the study may have important implications to help guide management. According to the authors, offering surgical management for the treatment of dysmenorrhea should be strongly considered after two to three medications are tried and failed. Delaying surgical management in those with pain refractory to more than three medications may decrease quality of life and increase the cost.
The objective of the study by Jacqueline Bohn, Department of Obstetrics and Gynecology, Oregon Health & Science University Portland, OR, and colleagues was to evaluate the cost-effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea.
For achieving the objective, the researchers created a cost-effectiveness model to compare three stepwise medical and surgical treatment strategies. 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 as per their strategy firstly non-steroidal anti-inflammatory drugs (NSAIDs) followed by surgery, secondly NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery thirdly 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.
The results of the study were found to be
• Out of a total 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.
Dr Bohn and the team concluded that " All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost-effective when compared with surgery alone."They also stated that 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.
Reference:
Bohn, Jacqueline A. MD; Bullard, Kimberley A. MD, MPH; Rodriguez, Maria I. MD, MPH; Ecker, Amanda M. MD Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea, Obstetrics & Gynecology: October 2021 - Volume 138 - Issue 4 - p 557-564 doi: 10.1097/AOG.0000000000004536