OBJECTIVE: To quantify physicians’ preferences for attributes of medical treatments for endometriosis-associated pain.
MATERIALS AND METHODS: Obstetricians and gynecologists who treated at least 2 patients with moderate-to-severe endometriosis-associated pain per month in the United States completed an online discrete-choice experiment survey. In a series of treatment-choice questions, physicians were asked to choose the medical treatment they would recommend for a hypothetical patient who is still menstruating, has surgically confirmed endometriosis, and has severe dysmenorrhea, nonmenstrual pelvic pain, and/or dyspareunia that persists despite nonsteroidal anti-inflammatory medications and oral contraceptive pills. Each treatment-choice question contained a pair of hypothetical medical treatments for endometriosis-associated pain characterized by 7 clinically relevant attributes with varying levels: improvement in dysmenorrhea, improvement in nonmenstrual pelvic pain (both from severe to moderate, mild, or no pain), improvement in dyspareunia (from severe to moderate or mild pain, or no improvement), mode of administration (daily oral or monthly injection), risk of pregnancy-related complications if pregnancy occurs during treatment (unknown, 0%, 2%, 7%), increased risk of bone fracture later in life (unknown, 0%, 2%, 5%, 10%), and risk of moderate to severe hot flashes (0%, 30%, 50%, 65%, 85%). A mixed logit model was used to quantify preferences, which were then used to calculate the conditional relative importance (CRI) of each attribute as the difference between the largest and smallest preference weights for that attribute’s levels. Larger values correspond to greater relative importance.
RESULTS: Two hundred and fifty physicians completed the survey. Average respondent age was 53 years, 36% were female, and 72% were both obstetricians and gynecologists. The most important treatment attribute (conditional on the attributes and levels included in the survey) was risk of moderate to severe hot flashes (CRI: 3.34). The relative importance of the remaining attributes in decreasing order of importance is improvement in nonmenstrual pelvic pain (CRI: 2.13), improvement in dyspareunia (CRI: 2.04), improvement in dysmenorrhea (CRI: 1.88), risk of pregnancy-related complications if pregnancy occurs during treatment (CRI: 1.16), increased risk of bone fracture later in life (CRI: 0.62), and mode of administration (CRI: 0.48). Oral treatments were preferred to injections. Most physicians (n = 152; 61%) would prescribe add-back hormonal therapy in addition to the preferred treatment to mitigate vasomotor symptoms.
CONCLUSIONS: In exchange for pain relief, physicians treating women with severe endometriosis-associated pain have relatively lower tolerance for treatment-related risks of moderate to severe hot flashes than less common and less immediate risks of pregnancy-related complications and bone fracture.
IMPACT STATEMENT: This study has revealed the tradeoffs that physicians will accept among the benefits and risks of medical treatments for endometriosis-associated pain.
