Endometriosis in Adolescents VOL. 105, NO. 4, APRIL 2005 OBGY R1 LEE EUN SUK ACOG Committee Opinion...

Endometriosis in AdolescentsEndometriosis in Adolescents

VOL. 105, NO. 4, APRIL 2005

OBGY R1 LEE EUN SUK

ACOG Committee Opinion Number 310


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


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


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


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


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%)


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


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


Diagnosis

Imaging studies and serum markers

Ultrasonography & magnetic resonance imaging → Evaluate anatomical structures

CA125 → very sensitive but not specific


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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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


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


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


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


Treatment

Progestins

Antiendometriotic effect by causing initial decidualization of endometrial tissue followed by atrophy

Medroxyprogesterone acetate starting 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


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 dos

e 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


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)


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


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


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


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

Endometriosis in Adolescents VOL. 105, NO. 4, APRIL 2005 OBGY R1 LEE EUN SUK ACOG Committee Opinion...

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