Article
Adolescent Endometriosis: Diagnosis and Treatment Approaches

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Abstract

Objectives: To review the etiologies, diagnosis, and treatment options of adolescent endometriosis.

Methods: Review of publications relating to adolescent endometriosis.

Results: Endometriosis occurs in adolescents as young as 8 years of age; furthermore, there have been documented cases of endometriosis occurring prior to menarche. Adolescents presenting with pelvic pain are treated with cyclic combination oral contraceptive pills and nonsteroidal anti-inflammatory agents. If the pain does not respond to these therapies, then in adolescents as in adults, an operative laparoscopy is recommended for the diagnosis and surgical management of endometriosis. The operating gynecologist should be familiar with the appearance of the complete spectrum of various morphologies of endometriosis, as adolescents tend to have clear, red, white, and/or yellow-brown lesions more frequently than black or blue lesions. Subtle clear lesions of endometriosis may be better visualized by filling the pelvis with irrigation fluid so that the clear lesions can be appreciated in a three-dimensional appearance. Young women who are found to have endometriosis by laparoscopy may present with acyclic, cyclic, and constant pelvic pain. Adolescents with pelvic pain not responding to conventional medical therapy have approximately a 70% prevalence of endometriosis. It is known that endometriosis is a progressive disease and since there is no cure, adolescents with endometriosis require long-term medical management until the time in their lives when they have completed childbearing. Psychosocial support is extremely important for this population of young women with endometriosis.

Conclusions: Endometriosis occurs in adolescents, and presenting symptoms may vary from those seen in adult women with the disease. All health care providers must be aware of the existence of adolescent endometriosis. They should also be aware of the presenting symptoms so that the adolescent can be appropriately referred to a gynecologist comfortable with medical and surgical treatment options in this patient population. If laparoscopy is to be undertaken, the gynecologist must be prepared not only to diagnose but to surgically manage endometriosis. In addition, the subtle laparoscopic findings of endometriosis in adolescents must be recognized for an appropriate diagnosis. Long-term medical therapy will hopefully decrease pain and the progression of the disease, thus decreasing the risk of advanced-stage disease and infertility.

Introduction

Adolescents frequently complain of dysmenorrhea and pelvic pain. Studies have shown that 25% to 38.3% of adolescents with chronic pelvic pain have endometriosis.1, 2 Traditionally, nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs) are the first line of treatment; however, many adolescents continue to describe pelvic pain despite these medications. For these young women, it is important to include endometriosis in the differential diagnosis. Endometriosis in adult women is commonly associated with cyclic pelvic pain; however, the symptoms in adolescents may demonstrate acyclic and cyclic pain. It is estimated that 4% to 17% of postmenarchal females have endometriosis.3 Although in the past it was assumed that endometriosis presented only after many years of menstruation, studies have described endometriosis prior to menarche,4 and 15 and 56 months after menarche. Numerous series have shown rates of endometriosis at 50% to 70% of adolescents undergoing laparoscopy for pelvic pain who did not have control of pelvic pain with OCPs and NSAIDs.7, 8, 9

With education of young women, their families, pediatricians, nurse practitioners, family practitioners, gynecologists, and pediatric surgeons, we may be able to decrease the length of time from the onset of symptoms to presentation, and from the time of presentation to diagnosis. In addition, with early diagnosis of endometriosis it may be possible to decrease the long-term effects of the disease (pain, masses, and infertility), and thus improve affected young women's quality of life.

Section snippets

The Origin of Endometriosis

It is important to note that some patients may have a genetic predisposition towards developing endometriosis. This is suggested by the observation that 6.9% of first-degree female relatives of patients with endometriosis are affected, as compared to 1% or less of controls.10 We commonly see young women in consultation who are brought in by their mothers, who have suffered with endometriosis symptoms since adolescence but were not diagnosed until later in life. Although a tendency to develop

Evaluation of Pelvic Pain

In adult women endometriosis is suspected when a patient presents with chronic pelvic pain, dysmenorrhea, dyspareunia, a pelvic mass, or infertility. In adults the pain of endometriosis is most often cyclic pain. In the adolescent endometriosis population, the presenting pelvic pain is often both acyclic and/or cyclic (see Table 1).9 In addition, bowel and bladder symptoms may be common in adolescents found to have endometriosis.9 Ovarian endometriomas are rare prior to the age range of the

Surgical Treatment

Operative laparoscopy is performed for definitive diagnosis, coagulation, ablation, or resection of endometriosis in the least invasive and most cost-effective fashion. Laparotomy is rarely indicated. Removal of lesions of endometriosis may be performed with electrocautery, endocoagulation, or laser.32 Surgery has been shown to reduce pain from endometriosis in rates of 38% to 100% of adult women.33, 34 Regardless of the technique, care must be taken to avoid damage to the ureters, major

Issues for Future Consideration

Early diagnosis of endometriosis and treatment will hopefully suppress progression and advancement of disease. This is an area that needs future investigation. Additionally, there are some areas that are particularly challenging. For instance, how should we treat the adolescent daughter of a woman who had no pelvic pain but who had Stage IV endometriosis and infertility? Should she have an evaluation and treatment even though she has no pelvic pain, in an attempt to avert the silent development

Conclusions

Evaluation of pelvic pain in adolescents begins with a history and physical exam, pain calendar, laboratory evaluation, and possible ultrasound. Empiric treatment of chronic pelvic pain and dysmenorrhea in adolescents may include nonsteroidal anti-inflammatory agents and hormonal therapy. A definitive diagnosis of endometriosis can only be made by laparoscopy. Forty-five to seventy percent of adolescents with chronic pelvic pain have endometriosis diagnosed at the time of laparoscopy. A

References (61)

  • D.E Pittaway et al.

    Use of CA-125 in the diagnosis and management of endometriosis

    Fertil Steril

    (1986)
  • F.W., for the Pelvic Pain Study Group Ling

    Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis

    Obstet Gynecol

    (1999)
  • J.C Gambone et al.

    Consensus statement for the management of chronic pelvic pain and endometriosisproceeding of an expert-panel consensus process

    Fertil Steril

    (2002)
  • G.D Davis et al.

    Clinical characteristics of adolescent endometriosis

    J Adolesc Health

    (1993)
  • L Demco

    Mapping the source and character of pain due to endometriosis by patient-assisted laparoscopy

    J Am Assoc Gynecol Laparosc

    (1998)
  • M.R Laufer

    Identification of clear vesicular lesions of atypical endometriosisA new technique

    Fertil Steril

    (1997)
  • M Nisolle et al.

    Histologic study of peritoneal endometriosis in infertile women

    Fertil Steril

    (1990)
  • L Fedele et al.

    Stage and localization of pelvic endometriosis and pain

    Fertil Steril

    (1990)
  • D.B Redwine

    Conservative laparoscopic excision of endometriosis by sharp dissectionlife table analysis of reoperation and persistent or recurrent disease

    Fertil Steril

    (1991)
  • C Sutton et al.

    Prospective, randomized, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

    Fertil Steril

    (1997)
  • R.W Kistner

    Treatment of endometriosis by inducing pseudo-pregnancy with ovarian hormones

    Fertil Steril

    (1959)
  • L Miller et al.

    Menstrual reduction with extended use of combination oral contraceptive pillsa randomized controlled trial

    Obstet Gynecol

    (2001)
  • S.H Kennedy et al.

    Comparison of nafarelin acetate and danazol in the treatment of endometriosis

    Fertil Steril

    (1990)
  • J.M Wheeler et al.

    Depot leuprolide acetate vs. danazol in the treatment of women with symptomatic endometriosisa multicenter, double-blind randomized clinical trial. II. assessment of safety

    Am J Obstet Gynecol

    (1993)
  • R.W., Zoladex endometriosis study team Shaw

    An open randomized comparative study of the effect of goserelin depot and danazol in the treatment of endometriosis

    Fertil Steril

    (1992)
  • R.W Shaw

    Nafarelin in the treatment of pelvic pain caused by endometriosis

    Am J Obstet Gynecol

    (1990)
  • V.C Buttram et al.

    Treatment of endometriosis with danazolreport of a 6-year prospective study

    Fertil Steril

    (1985)
  • K.A Burry

    Nafarelin in the management of endometriosisquality of life assessment

    Am J Obstet Gynecol

    (1992)
  • P Vercellini et al.

    Depot medroxyprogesterone acetate vs. an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis

    Am J Obstet Gynecol

    (1996)
  • B.A Cromer et al.

    A prospective comparison of bone density in adolescent girls receiving depo-medroxyprogesterone acetate (Depo-Provera), levonorgestrel (Norplant), or oral contraceptives

    J Pediatr

    (1996)
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