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ACOG Committee Opinion Number 310. Endometriosis in Adolescents. VOL. 105, NO. 4, APRIL 2005 OBGY R1 LEE EUN SUK. Endometriosis in Adolescents. Abstract Historically thought of as a disease that affects adults women,

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ACOG Committee Opinion Number 310

Endometriosis in Adolescents

VOL. 105, NO. 4, APRIL 2005

OBGY R1 LEE EUN SUK


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Endometriosis in Adolescents

  • Abstract

    • Historically thought of as a disease that affects adults women,

      endometriosis increasing is being diagnosed in the adolescents population

    • This disorder, which was originally described more than a century ago, still represents a vague and perplexing entity that frequently results in chronic pelvic pain, adhesive disease, and infertility

    • The purpose of this Committee Opinion is to highlight the differences in adolescent and adult types of endometriosis

    • Early diagnosis and treatment during adolescence may decrease

      disease progression and prevent subsequent infertility


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Endometriosis in Adolescents

  • Incidence

    • Goldstein et al : 47% prevalence of endometriosis in adolescent females with pelvic pain

    • 50-70% of adolescents with pelvic pain not responding to combination hormone therapy and NSAIDs have endomeriosis

    • Endometriosis has been identified in premenarcheal girls who have started puberty and have some breast development


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Endometriosis in Adolescents

  • Theory of endometriosis

    • Ectopic transplantation of endometrial tissue

      • Endometriosis caused by the seeding or implantation of endometrial cells by transtubal regurgitation during menstruation

    • Coelomic metaplasia

      • Transformation (metaplasia) of coelomic epithelium into

        endometrial tissue

    • Induction theory

      • Extension of the coelomic metaplasia theory

      • Endogenous (undefined) biochemical factor → undifferentiated peritoneal cells to develop into endometrial tissue


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Endometriosis in Adolescents

  • Incidence

    • 66% of adults women reported the onset of pelvic symptoms before age 20 years

    • As the age of the onset of symptoms decreases, the number of doctors reaching a diagnosis increases

    • With early diagnosis and treatment, it is hoped that disease progression and infertility can be limited


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Endometriosis in Adolescents

  • Presentation and Characteristics

    • Adolescents primarily seek medical attention because of pain rather than a concern for infertility

    • Common symptoms

      • Progressive dysmenorrhea (64-94%)

      • Acyclic pain (36-91%)

      • Dyspareunia (2-46%)

      • Gastrointestinal complaints (2-46%)


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Endometriosis in Adolescents

  • Diagnosis

    • History and Physical examination

      → Differential diagnosis of pelvic pain

      • Appendicitis

      • Pelvic inflammatory disease

      • Mullerian anomalies or outflow obstruction

      • Bowel disease

      • Hernia

      • Musculoskeletal disorder

      • Psychosocial complaints


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Endometriosis in Adolescents

  • Diagnosis

    • Pelvic examination may be difficult, especially in patients who have not had vaginal intercourse

      • Rectal –abdominal examination in the dorsal lithotomy position may be helpful to determine if a pelvic mass is present

      • Cotton-tipped swab to evaluate for the presence of transverse vaginal septum, or agenesis of the lower vagina

    • Ultrasound examination is helpful in evaluation the pelvis of young adolescents who declines a bimanual or rectal-abdominal exam


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Endometriosis in Adolescents

  • Diagnosis

    • Imaging studies and serum markers

      • Ultrasonography & magnetic resonance imaging

        → Evaluate anatomical structures

      • CA125

        → very sensitive but not specific


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Endometriosis in Adolescents

  • Empiric therapy

    • Younger than 18 years

      → Combination hormone therapy and NSAIDs

    • Older than 18 years

      → Empiric trial of GnRH agonist therapy

    • For patients younger than 18 years because of the effects of GnRH agonist medications on bone formation & long-term bone density or who decline empiric therapy

      → Diagnostic and therapeutic laparoscopy



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Endometriosis in Adolescents

  • Surgical diagnosis

    • After a comprehensive preoperative evaluation and trial of combination hormone therapy and NSAIDs

      → Diagnostic and therapeutic laparoscopy

    • Laparoscopic findings

      • Inspection and palpation with a blunt probe of the bowel, bladder, uterus, tubes, ovaries, cul-de-sac, and broad ligament

      • Typical lesions of endometriosis in adolescents : Red, clear, or white as opposed to the powder-burn lesion seen commonly in adults

      • Histologic confirmation of the laparoscopic impression is essential

        for the diagnosis of endometriosis


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Endometriosis in Adolescents

  • Mullerian Anomalies and Endometriosis

    • Incidence of anomalies of the reproductive system

      • Most studies quote the rate of 5-6%

    • Clinical outcome in patients with outflow tract obstructions

      differ from those without such obstructions

      • Because regression of disease usually has been observed

        once surgical correction of the anomaly has been accomplished


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Endometriosis in Adolescents

  • Treatment

    • Surgery, hormonal manipulation, pain medications, mental health

      support, complementary and alternative therapies, and education

    • For patients younger than 18 years with persistent pelvic pain

      • Combination hormone therapy & laparoscopic procedure

      • Only procedures that preserve fertility options should be applied

      • After surgery adolescents should be treated with medical therapy

        until childbearing

    • The goal of therapy

      • Suppression of pain

      • Suppression of disease progression

      • Preservation of fertility


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Endometriosis in Adolescents

  • Treatment

    • First-line treatment modalities → NSAID & hormone therapy

    • Continuous combination hormone therapy

      • OCPs, combinations hormonal contraceptive patch, or vaginal ring

        for menstrual suppression

      • Oral contraceptives

        • Low dose monophasic combination contraceptives (one pill per

          day for 6 to 12 months) to induce 'pseudopregnancy' caused by

          the resultant amenorrhea & decidualization of endometrial tissue


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Endometriosis in Adolescents

  • Treatment

    • Progestins

      • Antiendometriotic effect by causing initial decidualization of

        endometrial tissue followed by atrophy

      • Medroxyprogesterone acetatestarting at a dose of 30mg/day

        • Increasing the dose based on the clinical response

          & bleeding patterns

      • Side effect : nausea, weight gain, fluid retention, breakthrough

        bleeding due to hypoestrogenemia


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Endometriosis in Adolescents

  • Treatment

    • Danazol ( Androgenic & antiestrogenic agents)

      • Suppression of GnRH or gonadotropin secretion

      • Direct inhibition of steroidogenesis

      • Direct antagonistic and agonistic interaction with endometrial androgen & progesterone receptors

      • Dose : absence of menstruation is a better indicator of response

        than drug dose start with 400mg daily (200mg twice a day) & increase the dose to achieve amenorrhea and relieve symptoms

      • Side effect : weight gain, fluid retention, acne, oily skin, hirsuitism,

        hot flashes, atrophic vaginitis, reduced breast size, reduced libido,

        fatigue, nausea, muscle cramps, emotional instability


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Endometriosis in Adolescents

  • Treatment

    • GnRH agonists

      • Hypoestrogenic state by down-regulating hypothalamic-pituitary axis

      • Cause a loss of pituitary receptors & downregulation of GnRH activity,

        resulting in low FSH & LH level → pseudomenopause

      • Limited to 6 months because of resultant profound hypoestrogenic state & subsequent effect on bone mineralization

      • Side effect : hot flashes, vaginal dryness, ↓libido, osteoporosis

        (add-back regimen)


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Endometriosis in Adolescents

  • Treatment

    • GnRH agonists

      • Add-back therapy

        • Norethindrone acetate (15mg per day) or conjugated estrogens/ medroxyprogesterone acetate (0.625/2.5mg per day) to reduce bone loss related to a hypoestrogenic state

          → Preserve bone density


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Endometriosis in Adolescents

  • Surgery for the management of endometriosis-related pain

    • Important option for adolescents, but clearly, radical procedures (oophorectomy, bilateral oophorectomy, or hysterectomy)

      should be avoided in this age group

    • In patients with severe endometriosis

      • Surgical treatment be preceded by a 3 month course of medical

        treatment to reduce vascularization and nodular size

    • Postoperative hormone replacement with estrogen& progesterone

      • Required after bilateral oophorectomy

      • The risk of renewed growth of residual endometriosis

        → Hormonal replacement therapy withheld until 3months after surgery


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Endometriosis in Adolescents

  • Summary

    • Adolescent patients typically present with progressive and severe

      dysmenorrhea, but also may present with acyclic pelvic pain

    • Standard therapy (combination hormone therapy and NSAIDs)

      for dysmenorrhea should be initiated, if symptoms do not resolve

      after 3 months further evaluation for endometriosis is indicated

    • A bimanual pelvic examination may be difficult

      : cotton-tipped swab to evaluate for the presence of transverse

      vaginal septum, or agenesis of the lower vagina

      : ultrasound exam in evaluation the pelvis of adolescents

    • Endometriosis in adolescents typically presents as early disease

      & clear, red, and white lesions are the most common


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Endometriosis in Adolescents

  • Summary

    • Treatment should focus on conservative measures with surgical

      & medical interventions

    • Only procedures that preserve fertility options be applied

    • Because there is no cure for endometriosis, long-term treatment should continue until desired family size is reached or fertility no longer needs to be preserved


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