ENDOMETRIOSIS AND ADOLESCENCE

1. ENDOMETRIOSIS AND ADOLESCENCE Prof. Dr. Enrique Onetto B. Santiago-CHILE

2. ENDOMETRIOSIS AND ADOLESCENCE • Endometriosis is a disease or better a syndrome that starts around the prepuberal age, flourishing after menarche, with symptoms progressing in intensity and throughout the years. • The main symptoms are progressive dysmenorhea, premenstrual syndrome, changes in basal body temperature during menstruation and dyspareunia. Prof.Onetto Santiago.Chile 2001

3. ENDOMETRIOSIS AND ADOLESCENCE • MITHS AND FALACIES TO BE BURIED: • "The disease is most frequently seen above the age of 30, though not a few cases are encountered in the late twenties” (Novak & Novak.Text book of Gynecology.Page 557. Fifth Edition 1956. • Adolescents with severe dysmenrrhea are given prescriptions of analgesicsor contraceptive pills and are reassured with concepts such as “when you get married pains will stop”or their mothers say “how can a gynecologist see her if she is a virgin”

4. ENDOMETRIOSIS AND ADOLESCENCE • Numerous papers on Adolescence, pelvic pain and laparoscopies (Reese, Vercellini, grupo Emory, Kontoradvis, Chatman, Creatsas, Laufer & others), report a prevalence of endometriosis ranging from 32 to 73%. Reports of normal internal genitaliae range from 20 to 60%. Therefore.... • We believe that invasive procedures should not be used in adolescents with severe dysmenorrhea if their basal body temperature, the so called “Benjamin sign”, has not been investigated. Prof.Onetto Santiago.Chile/2001

5. ENDOMETRIOSIS AND ADOLESCENCE • THE BENJAMIN SIGN:When Basal Body Temperature (BBT) of an adolescent girl, with an endometriotic syndrome, stays high during the menstrual flowor has up and downs during the same and falls only at the end of it, we should strongly suspect endometriosis and go for a laparoscopy. • With this procedure, we shall avoid many laparoscopies with normal internal genitaliae or diagnose other gynecological diseases. Prof.Onetto Santiago.Chile/2001

6. Prof.Onetto Santiago.Chile/2001

7. ENDOMETRIOSIS AND ADOLESCENCEAtypical Benjamin sign Prof.Onetto Santiago.Chile/2001

8. ENDOMETRIOSIS AND ADOLESCENCE Pregnancies occurring among adolescents with endometriosis delay the onset of the disease and its evolution for many years. This fact explains Novak’s error. A relapse has to be considered as an initial case and we believe that this is a carrier. Genetics and inmunology are important factors to keep in mind. It is frequently seen among sisters and much more if they are twins. Prof.Onetto Santiago.Chile/2001

9. ENDOMETRIOSIS AND ADOLESCENCEMatherial and methods BBT was requested whenever endometrio- sis was suspected and recorded at least for 2 times from the first day of the fourth week of the cycle till the end of the flow on 34 adolescents, ages 14 to 24 (79,3% below 23). Surgical laparoscopy was carried out on them, followed by treatment with agonist GnRh or medroxiprogesterone acetate or others for 3 to 6 months. Prof.Onetto Santiago.Chile/2001

10. ENDOMETRIOSIS AND ADOLESCENCE Age groups Prof.Onetto Santiago.Chile/2001

11. ENDOMETRIOSIS AND ADOLESCENCE -PREMENSTRUAL TENSION -CYCLE ALTERATIONS The premenstrual syndrome was present in 53%. Cycle alterations only in 35%. (most of them oligomenorrheas) These 2 items appear to be irrelevant but if one adds them to the others, they turn to be relatively important. We also obtained important data from their sexual activity.(next) Prof.Onetto Santiago.Chile/2001

12. Prof.Onetto Santiago.Chile/2001

13. ACTIVES 27 (71%) Orgasmic 23 (85%) Disfunction 4 (15%) No dyspareunia 3 (48,1%) With dyspareunia 14 (51,9%) INACTIVES 11 (29%) ENDOMETRIOSIS AND ADOLESCENCESexualactivity Prof.Onetto Santiago.Chile/2001

14. ENDOMETRIOSIS AND ADOLESCENCE Dysmenorrhea is to be considered the most important symptom and the most frequent reason for consulting. Cramps progressing in intensity throughout the years, not responding to conventional therapy, with diarrhea, N & V, changes in character, premenstrual tension, dyspareunia etc. were present in most of our adolescents in different degrees of intensity but at a very high level. Prof.Onetto Santiago.Chile/2001

15. ENDOMETRIOSIS AND ADOLESCENCEDysmenorrhea Prof.Onetto Santiago.Chile/2001

16. ENDOMETRIOSIS AND ADOLESCENCE Intensity of dysmenorrhea and dyspareunia are not related to the anatomical location of the lesions. The most frequent are Adenomiosys combined with uterosacral ligaments, followed by uterosacral ligaments, Adenomiosys, ovarian and others that match as faulse positives with other gynecological pathologies. Prof.Onetto Santiago.Chile/2001

17. ENDOMETRIOSIS AND ADOLESCENCEAnatomical location of lesions Prof.Onetto Santiago.Chile/2001

18. ENDOMETRIOSIS AND ADOLESCENCE Variety of endometriotic lesions seen at laparoscopy Prof.Onetto Santiago. Chile/2001

19. ENDOMETRIOSIS AND ADOLESCENCE 0varian endometriosis Prof.Onetto Santiago. Chile/2001

20. ENDOMETRIOSIS AND ADOLESCENCE Benjamin sign *Uterine Hipoplasia PSOPH Hemorrhagic Follicle Dydelphus uterus + PSOPH Prof.Onetto Santiago.Chile/2001

21. ENDOMETRIOSIS AND ADOLESCENCE -Due to the fact that during the last years endometriosis has been diagnosed among adolescents, most of them with no fertility problems, surgical laparoscopy followed by medical treatment and a close follow-up to avoid a relapse, seem to be the ideal steps. -Oral contraceptives containig gestrinone should be given after treatment. Prof.Onetto Santiago.Chile/2001

22. ENDOMETRIOSIS AND ADOLESCENCE -Surgical laparoscopy should only be perfor- med by specialists under general anesthesia with intubatión. A (+) Benjamin sign and dysmenorrhea will indicate when a second look laparoscopy has to be done during follow-up. -Costs of in-patients and medication should be considered.(1shot luprorrelin costs US $ 200.) -A relapse of endometriosis should be treated as an initial case and genetic and inmunological factors must be considered. Endometriosis is frequently seen among sisters and twins. Prof.Onetto Santiago.Chile/2001

23. ENDOMETRIOSIS AND ADOLESCENCEfollow up • Relapse: 8 patients between 1 to 15 years of follow up. • Followup • 11 are using oral contraceptives • 9 got pregnant (1 ectopic, 1 aborted) • 6 are lost for follow up • 1 fertility workup • 1 had an in vitro fertilization with results • 2 underwent histerectomies • 4 recently finished their medical treatment Prof.Onetto Santiago.Chile/2001

24. ENDOMETRIOSIS AND ADOLESCENCE TREATMENTS - Iatrogenic Pseudopregnancy (low cost) -17 alfa derivatif of ethinil testosterone (danazol) and gestrinone a 19 nor steroid wth contraceptiv effects Ocasionally used. (middle costs) - Medroxiprogesterona acetate: 50 to 100 mg. orally daily for 3 to 6 ms. or depot 100mg.monthly for 6 ms. -Agonists (GnRh) inducing a reversible hypogonado- trophic hypogonadism (high cost all the following) - Nafarelin acetate Nasal Spray used for 6 months;high $$ - Triptorreline acetate depot 1 3.75mg. i.m.shot monthly for 3 ms or 1 i.m.depot shot of 11,25mg. lasting 3meses. High cost Prof.Onetto Santiago.Chile/2001

25. ENDOMETRIOSIS AND ADOLESCENCECONCLUSIONS • During the early adolescence endometriosis must be pursued and diagnosed as early as possible by obgyn’s, pediatricians or others to avoid severe physical and psychological discomfort of these girls and their relatives, thus avoiding future secuelae causing infertility • With this procedure, we shall avoid many laparoscopies with normal internal genitaliae or diagnose other gynecological diseases. Prof.Onetto Santiago.Chile/2001

26. ENDOMETRIOSIS AND ADOLESCENCECONCLUSIONS -Many studies involving inmunology and genetics are underway and should give us more light in the near future about this disease. -Many women have some menstrual flow spilling into the abdomen through the ampulla, but not all of them have endometriosis. New analogues or agonist GnRh should be available at a very low price Prof.Onetto Santiago.Chile/2001

27. ENDOMETRIOSIS AND ADOLESCENCE THE END Prof. Dr. Enrique Onetto B. eonetto@yahoo.com Santiago-CHILE