What is the next step for a patient with endometriosis, currently on short-term contraceptives (hormonal contraceptives) and Slinda (mifepristone), who is experiencing severe pain and wishes to avoid pregnancy until after surgery?

From the Guidelines

Your next step is to optimize the patient's pain management while awaiting surgery for endometriosis, focusing on a multimodal approach that includes pharmacological and non-pharmacological interventions. Given the patient's severe pain and the fact that she has been started on Slinda (drospirenone 4mg), a progestin-only pill, which is appropriate for endometriosis pain management 1, you should consider adding other pain relief options. The American College of Obstetricians and Gynecologists (ACOG) recommends that pain caused by endometriosis can be managed medically with progestins, danazol, oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) agonists 1. Key considerations for managing her pain include:

• Prescribing NSAIDs like naproxen 500mg twice daily or ibuprofen 600mg three times daily with food as first-line pain relief.
• For breakthrough pain, consider adding acetaminophen 1000mg every 6 hours as needed.
• If pain remains severe, a short course of tramadol 50mg every 6 hours as needed might be appropriate.
• Non-pharmacological approaches like heat therapy, gentle exercise, and pelvic floor physical therapy can provide supplementary relief. It's also crucial to continue the Slinda as it may take 2-3 months to achieve maximum benefit for endometriosis symptoms 1. Schedule a follow-up in 2-4 weeks to assess pain control and medication effectiveness. Consider advocating for your patient with the gynecology department if her pain significantly impacts her quality of life, as this might warrant reconsideration of her surgical priority 1. This approach addresses immediate pain management needs while maintaining appropriate contraception until her planned surgery.

From the FDA Drug Label

If drospirenone and ethinyl estradiol tablets are first taken later than the first day of the menstrual cycle, drospirenone and ethinyl estradiol tablets should not be considered effective as a contraceptive until after the first 7 consecutive days of product administration Instruct the patient to use a non-hormonal contraceptive as back-up during the first 7 days. Drospirenone and ethinyl estradiol tablets should not be considered effective as a contraceptive until after the first 7 consecutive days of product administration. Instruct the patient to use a non-hormonal contraceptive as back-up during the first 7 days.

The patient has been started on Slinda, which is likely a contraceptive. Since the patient does not want to get pregnant until she has the surgery, it is essential to ensure that the contraceptive is effective.

• The patient should be instructed to use a non-hormonal contraceptive as a back-up during the first 7 days of taking drospirenone and ethinyl estradiol tablets.
• The patient should be advised to take the tablets exactly as directed, in the order directed on the blister pack, to achieve maximum contraceptive effectiveness 2.
• The patient should be informed that drospirenone and ethinyl estradiol tablets should not be considered effective as a contraceptive until after the first 7 consecutive days of product administration 2.

From the Research

Patient's Current Situation

• The patient has endometriosis and is on a category three waitlist for surgery.
• She was advised to start short-term contraceptives due to her plans for pregnancy.
• The patient is currently experiencing severe pain and has been started on Slinda.
• She does not want to get pregnant until after the surgery.

Considerations for Pain Management

• According to 3, labor results in severe pain for many women, and there is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician's care.
• The study 4 suggests that pain experienced during gynecologic exams and procedures is often dismissed, not recognized, and undertreated by some clinicians.
• The patient's severe pain should be addressed, and pain management options should be considered.

Contraception and Pregnancy Planning

• The patient is currently using short-term contraceptives, as advised by her gynecologist, due to her plans for pregnancy 5.
• It is essential to consider the patient's wishes regarding pregnancy and to ensure that her contraceptive method is effective and suitable for her needs.

Next Steps

• Continue to manage the patient's pain effectively, considering her severe pain and the need for individualized care 4.
• Review the patient's contraceptive method and ensure that it is suitable for her needs, given her plans for pregnancy and her current health status 5.
• Monitor the patient's condition and adjust her treatment plan as necessary, taking into account her upcoming surgery and her wishes regarding pregnancy.