1. Endometriosis in Adolescents
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

11. 표

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 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

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