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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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endometriosis in adolescents

ACOG Committee Opinion Number 310

Endometriosis in Adolescents

VOL. 105, NO. 4, APRIL 2005

OBGY R1 LEE EUN SUK

endometriosis in adolescents2
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

endometriosis in adolescents3
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
endometriosis in adolescents4
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
endometriosis in adolescents5
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
endometriosis in adolescents6
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%)
endometriosis in adolescents7
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
endometriosis in adolescents8
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
endometriosis in adolescents9
Endometriosis in Adolescents
  • Diagnosis
    • Imaging studies and serum markers
      • Ultrasonography & magnetic resonance imaging

→ Evaluate anatomical structures

      • CA125

→ very sensitive but not specific

endometriosis in adolescents10
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

endometriosis in adolescents12
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

endometriosis in adolescents13
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

endometriosis in adolescents14
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
endometriosis in adolescents15
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

endometriosis in adolescents16
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

endometriosis in adolescents17
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

endometriosis in adolescents18
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)

endometriosis in adolescents19
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

endometriosis in adolescents20
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

endometriosis in adolescents21
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

endometriosis in adolescents22
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