What management options are available during the COVID-19 pandemic?
We encourage individuals in need of help to seek a clinical assessment with their general practitioners (GP), gynaecologists, physiotherapists, and/or complementary medical providers through telehealth avenues. Referral to a gynaecologist with expertise in endometriosis may also be appropriate to offset the new diagnostic and therapeutic challenges faced during this time. Those with an established diagnosis who are seeking help, regardless of their intentions to pursue surgical management, should discuss with their clinician the potential to modify their current medication regimen. Some with suspected endometriosis may accept a clinical diagnosis in the absence of imaging or laparoscopy and empirical medical therapy can be initiated.8
Caution in the use of non-steroidal anti-inflammatory drugs (NSAIDs), commonly used for endometriosis-related pain, is being advised, because increase in angiotensin-converting enzyme 2 (ACE2) may predispose to infection with COVID-19.9 Those at low-risk of exposure may consider the benefits of NSAIDs outweigh potential risk, deciding to continue use when needed. Conversely, those at higher-risk for acquisition (e.g. continuing to attend work outside of their home or having household members whom are high-risk), may benefit from using NSAIDs. Beyond traditional medical therapies, problem-focused interventions such as education, modifying work/school/social life, taking advantage of virtual and telephone support provided by national endometriosis organisations, improving sleep hygiene, low-intensity physical activity (including pelvic exercises, yoga), dietary changes, application of heat, and medical cannabis should be considered, either with the assistance of a healthcare provider via telehealth or independently by patients themselves. Similarly, emotion-focused strategies, which include relaxation/mindfulness, acceptance of chronic illness (e.g. via Acceptance and Commitment Therapy with the help of a clinical psychologist through telehealth), reducing catastrophising, and improving a balance toward positive attitude can be considered. These strategies are not unique to the COVID-19 pandemic and are recognised as an integral part of the usual multidisciplinary treatment of endometriosis.
Patients should be aware that, if they experience acute exacerbations of their chronic pain, they may warrant urgent medical assessment, as such cases, especially those with suspected endometrioma or severe acute recalcitrant exacerbation of pain, may require urgent surgery. However, most pain exacerbations are not life- or organ-threatening and with appropriate counselling and support, a face-to-face consultation in the emergency department may be avoided. Some GPs may find it challenging to confidently reassure patients that they are safe to avoid an emergency department visit, so urgent telehealth consultation with a gynaecologist or pain specialist may be helpful.