Endometriosis in adolescents

Early diagnosis and treatment of endometriosis critical in adolescents

Key Points

Highlights:

• Endometriosis represents an opportunity for early intervention in adolescents, with its wide constellation of pain symptoms. 
• Research on complex proinflammatory pathways and utilizing GnRH antagonists, SERMs, SPRMs, aromatase inhibitors, progesterone antagonists, statins, angiogenic inhibitors, and botanicals may offer new treatment options.

Importance:

• Awareness of endometriosis symptoms is low among adolescents. Their symptoms are usually normalized and there is usually a delay in diagnosis
• Early recognition and intervention of endometriosis in adolescents are very important to avoid the severe emotional, physical and social impact.

Key Results:

• Researchers observed no relationship between the extent or location of disease and the severity of pain.
• Medical management aimed at cessation of menses is very important. If the patient needs laparoscopy, the goal is maximal excision.
• Research on new treatment options such as GnRH antagonists, selective estrogen receptor modulators, selective progesterone receptor modulators, progesterone antagonists, statins, angiogenic inhibitors, and botanicals goes on.

What’s Done Here:

• This article reviews the molecular mechanisms underlying adolescent endometriosis and advances in both medical and surgical management.

Limitations of the Study

• There is a need for prospective studies describing the long-term benefits of hormonal suppression presurgery and postsurgery, utilizing combined oral contraceptives and progestins.

Lay Summary

Dr. Mama S. T. from Cooper University Hospital, Camden, New Jersey, USA, recently has published his review on advances in the management of endometriosis in the adolescent in the journal “Current Opinion Obstetrics and Gynecology”.

In adolescence, there is a significant delay in the diagnosis of endometriosis, often because physicians dismiss their symptoms. If the molecular mechanisms underlying progression of endometriosis are better understood, early diagnosis and use of maximum combined medical-surgical treatment can decrease the symptoms of the disease, including infertility risk.

Endometriosis is correlated with increased exposure to menstruation, decreased parity, lean body size, and obstructed Mullerian anomalies. Risk factors for the development of endometriosis are exposure to polychlorinated biphenyl or bisphenol A, alcohol intake, red meat intake, prematurity, low birth weight, formula feeding, increased skin sun sensitivity with increased moles and freckles, and light eye color. More than 4 hours of exercise per week, greater intake of green vegetables, fruits particularly citrus and isoflavones, pregnancy, increased parity, prolonged breastfeeding, or a hypoestrogenic state decrease the risk of endometriosis.

Molecular and cellular features of endometriotic lesions are different from the eutopic endometrium. Altered estrogen-mediated cell signaling, proinflammatory pathways develop in the local microenvironment, impaired cellular immunity and growth factors, cytokines, and angiogenic factors play a very important role in the pathogenesis of endometriosis. This leads to proliferation and invasion by ectopic endometrial tissue. The immune system fails to clear them naturally. Symptoms such as dysmenorrhea, pelvic pain, and dyspareunia compromise the quality of life. They are caused by the inflammation, scarring, and adhesions.

Pelvic pain which is often acyclical progresses to be present throughout the month in adolescents. There is an association between the depth of the lesion and increased level of pain. The wide range of symptoms include dysmenorrhea, heavy bleeding, stabbing cyclic premenstrual and acyclic pelvic pain, debilitating cramps, dyspareunia if sexually active, gastrointestinal pain, associated nausea and vomiting, rectal pressure with increased frequency of bowel movements, conversely dyschezia and tenesmus, urinary symptoms including frequency and pain with micturition, and abnormal uterine bleeding. Endometriosis with associated fibrosis and scarring is seen in up to 70% of young patients with peritoneal defects.

Careful history-taking and reviewing the symptoms are critical in the diagnosis of endometriosis in adolescents. Ultrasound or MRI exclude pelvic masses, including endometriomas, and structural anomalies. To recognize the pain patterns, diaries for recording pain, mood, menses, diet, medication, and bowel history are necessary. Surgery is the gold standard for diagnosis of endometriosis. If there is no relief after conservative maximal medical management for 3–6 months, the patient undergoes diagnostic laparoscopy with excision of endometriosis. In most of the adolescents, the color of lesions is white, yellow-brown or red-pink unlike the blue-black lesions in adult women. Most adolescents present with early-stage disease. Genome-wide association studies suggest that early versus advanced stage disease represent different entities.

A combined medical-surgical intervention aimed at menstrual cessation is necessary to prevent recurrence and disease progression. It is tailored according to the severity of patient symptoms, the extent of disease, and compliance.

GnRH antagonists, selective estrogen receptor modulators, selective progesterone receptor modulators, progesterone antagonists, aromatase inhibitors, statins, angiogenic inhibitors, and botanicals are future treatment options for endometriosis symptoms. Botanicals under investigation are Chinese multiherb Yiweining, Chinese angelica, cinnamon, peach kernel, red sage root, corydalis, frankincense, myrrh, persica, prunella vulgaris, red peony, and white peony.

To conclude, the wide range of pain symptoms in adolescents with endometriosis creates an opportunity for early intervention with proper diagnosis and combined medical-surgical treatment. There is a hope for new treatment options regarding the altered/impaired cellular immunity or hormonal control for this chronic disease in the future.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30153130