Endometriosis in Adolescents

1. ACOG Committee Opinion Number 310 Endometriosis in Adolescents VOL. 105, NO. 4, APRIL 2005 OBGY R1 LEE EUN SUK

2. 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

3. 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

4. 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

5. 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

6. 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%)

7. 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

8. 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

9. Endometriosis in Adolescents • Diagnosis • Imaging studies and serum markers • Ultrasonography & magnetic resonance imaging → Evaluate anatomical structures • CA125 → very sensitive but not specific

10. 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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12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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