Diagnosis and management of adolescent endometriosis

How and why the management of early onset endometriosis needs to be re-evaluated

Key Points

Highlights:

• Early endometriosis requires early diagnosis and appropriate management using minimally invasive surgery, medical therapy, or both.

Importance:

• Diagnosis of Early-onset endometriosis (EOE) is often delayed due to its non-specific clinical presentation and the reluctance of gynecologists to use invasive laparoscopy for diagnosis. This present review article explains the current understanding of EOE and proposes a minimally-invasive approach to the diagnosis and treatment of EOE.

Key Points:

• A postulated hypothesis for the pathogenesis of EOE is discussed in this opinion article.
• EOE is associated with delayed diagnosis and thus increased the risk of advanced endometriosis and ovarian endometrioma formation.
• EOE has been seen to have an increased risk of recurrence after surgery regardless of the type of operation or site or stage of the initial disease.
• In the author’s proposed workup for adolescent endometriosis:
  • If the ultrasound is negative, medical treatment using NSAIDs or hormonal contraceptives should begin. If pain persists, the presence of endometriosis should be excluded via MRI, and afterward, laparoscopy should be considered.
  • If the ultrasound is positive, depending on the disease, medical treatment of surgery should be considered.

Limitations:

• Readers should keep in mind that the author’s proposed clinical approach to EOE needs to be validated by adequately designed prospective studies.

Lay Summary

Early onset endometriosis (EOE) is characterized by endometriosis that begins around menarche or early adolescence. Recent evidence suggests that this form of endometriosis may have a different pathogenic origin than that of adult-onset endometriosis. This opinion article suggests that early peritoneal reflux from neonatal uterine bleeding could be a potential factor in the development of EOE. They point out that early endometrial progenitor cells can seed into the pelvic cavity and lay dormant until adolescence, where the disease becomes rapidly progressive. Risk factors for the development of neonatal uterine bleeding include low birth weight, preeclampsia, fetal post-maturity, and feto-maternal (ABO or Rh) incompatibility.

Early diagnosis and treatment of EOE are crucial to prevent irreversible damage to reproductive organs. Unfortunately, most cases are diagnosed late due to lack of clear guidelines and proper evaluation. EOE is characterized by drug-resistant, cyclic or acyclic pelvic pain and dysmenorrhea. Patients with the suggestive disease are evaluated by laparoscopy and only then is the diagnosis made. However, a less invasive method for diagnosis needed especially for adolescents. Like the treatment used in adult endometriosis, medical and surgical modalities are used to prevent the development of further disease later in life and minimize the risk of infertility. However, recent studies have shown an increased risk of premature ovarian failure in adolescents who underwent surgery alone. Thus, a thorough pre-operative assessment is needed before beginning surgical treatment. Medical therapy is usually given for adolescents who present symptoms suspicious of endometriosis, usually in the form of estrogen-progesterone combination pills and NSAIDs for six months. If symptoms persist after six months, current guidelines suggest laparoscopy for a definitive diagnosis should be carried out. Authors of this article propose the following less invasive approach to the diagnosis and treatment of adolescent endometriosis:

Authors first explain the need for a thorough history of the patient and the circumstances of their birth. Then, a clinical examination should be performed to rule out uterine anomalies or anatomic pathologies. Imaging should then be done in the form of a transvaginal or abdominal ultrasound.

If the ultrasound is negative, medical treatment using NSAIDs or hormonal contraceptives should begin. If pain persists, the presence of endometriosis should be excluded via MRI, and afterward, laparoscopy should be considered.

If the ultrasound is positive, depending on the disease, medical treatment of surgery should be considered.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/29174167