How to Diagnose and Manage

Adolescent Endometriosis
OVERVIEW
OUTLINE

DIAGNOSTIC
CHALLENGES
• OVERVIEW
• DIAGNOSTIC CHALLENGES
• MANAGEMENT CHALLENGES
MANAGEMENT • TAKE HOME MESSAGES
CHALLENGES

TAKE HOME
MESSAGES
OVERVIEW DEFINITION

DIAGNOSTIC Endometriosis is an inflammatory disease in

CHALLENGES
which ectopic endometrial-like tissue forms
lesions outside the uterus

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
PATHOGENESIS OF EARLY ONSET ENDOMETRIOSIS

Gordts S, et al.Fertil Steril 2017;108:872-85

Life cycle of early onset endometriosis

European Journal of Obstetrics & Gynecology and Reproductive Biology 196 (2016) 57–59
Gordts. Deep endometriosis: Pathogenesis. Fertil Steril 20
OVERVIEW

DIAGNOSTIC
CHALLENGES

There is a delay of diagnosis in

endometriosis
MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
 DELAY OF DIAGNOSIS
OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

REPRODUCTIVE BIOMEDICINE ONLINE 36 (2018) 102–114

 DELAY OF DIAGNOSIS
OVERVIEW

DIAGNOSTIC
CHALLENGES

64% were <30 years

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

Nnoaham KE et al. Fertil Steril 2011; 96: 366–373.

OVERVIEW

DIAGNOSTIC
CHALLENGES RULE #1
Never underestimate the pain

• Menstrual pain should not be minimized

MANAGEMENT
CHALLENGES • Pain should be evaluated and treated to help the girl
with her activities of daily living

TAKE HOME
MESSAGES

PEDIATRIC ANNALS • Vol. 45, No. 9, 2016

OVERVIEW What are the Presenting Symptoms of
Adolescent Endometriosis?

DIAGNOSTIC
CHALLENGES
• Endometriosis can present with cyclic or noncyclic
pain
• It can be associated with gastrointestinal
symptoms such as diarrhea or constipation
MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

J Pediatr Adolesc Gynecol 24 (2011) S13-S17

OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

Rev Assoc Med Bras 2014;60(6):560-564

OVERVIEW

DIAGNOSTIC RULE #2
CHALLENGES
Always consider adenomyosis and
endometriosis

MANAGEMENT
CHALLENGES RULE #3
Obtain a detailed and accurate history
before performing clinical evaluation
TAKE HOME
and pelvic sonography
MESSAGES

PEDIATRIC ANNALS • Vol. 45, No. 9,

 DIAGNOSTIC TOOLS
OVERVIEW

ULTRASONOGRAPHY

LESION SENSITIVIT SPECIFICT PPV NPV

DIAGNOSTIC
CHALLENGES Y Y
ENDOMETRIOM 84% 95,6% 81,8% 96,2%
A
DIE 33,3% 98,9% 60% 96,9%
RECTOSIGMOID
MANAGEMENT
CHALLENGES DIE USL 10% 99,16% 57% 90,7%
ANY ADHESION 79,6% 91,9% 83,8% 89,5%
ON OVARY
ANY ADHESION
*DATA 83,3%
NOT SPECIFIC 97%
FROM ADOLESCENT 83,3% 97%
ENDOMETRIOSIS
TAKE HOME IN POD
MESSAGES

Adapted from Holland et al. BMC Women's Health 2013, 13:43

OVERVIEW

• The majority of adolescents have early stage

DIAGNOSTIC disease
CHALLENGES
• An ovarian endometrioma is the most common
presentation of advanced endometriosis in
adolescents
MANAGEMENT
CHALLENGES
STAGE I STAGE II STAGE III STAGE
IV
TOTAL 47% 18,8% 19,3% 14,9%
TAKE HOME N = 430 (202/430) (81/430) (83/430) (64/430)
MESSAGES

Table adapted from Yeung et al J Endometr Pelvic Pain Disord 2017; 9(1): 17-29
OVERVIEW Ms. 19 years old, dysmenorhea VAS 6
Ultrasound : left ovary, endometrioma size 4
cm
DIAGNOSTIC
She had taken over the counter analgesics
CHALLENGES medications

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
OVERVIEW HOW TO MANAGE

AIM OF ENDOMETRIOSIS MANAGEMENT

DIAGNOSTIC
CHALLENGES

• Treat the clinical problem not the lesion

• Preserve fertility
• Prevent progression to chronic pain
MANAGEMENT
CHALLENGES • Keep surgery to a minimum

TAKE HOME
MESSAGES

Society of Endometriosis and Uterine Disorders 1s t Conference. Paris, 2015

 SURGERY AND ADOLESCENT ENDOMETRIOSI
OVERVIEW

if all you have is a hammer

DIAGNOSTIC everything looks like a nail
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
OVERVIEW

DIAGNOSTIC
CHALLENGES
HARM OF SURGERY IN
ENDOMETRIOSIS
MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES
Somigliana et al, Fertil Steril, 2012;98
HISTORY OF SURGERY HAS HIGHER ASRM STAGE AND
OBLITERATION OF DOUGLAS POUCH
Obstet Gynecol 2014;124
OVERVIEW

REPETITIVE SURGERY IS MORE HARMFUL TO CP

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES First surgery

Repetititve surgery
TAKE HOME
MESSAGES

Vercellini P, Fertility Sterility 2009

Fertil Steril 2015;103:738–43
 YOUNGER PATIENT
HAS HIGHER
RECURRENCE RATE

AJOG 2004
OVERVIEW Normogram AMH

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

Wiweko et al, JARG 2013

ENDOMETRIOSIS AND OVARIAN RESERVE : A DOUBLE EDGE SWO

ENDOMETRIOSIS

SURGERY TOXIC CONTENT INFLAMMATION

REMOVAL OF EFFECT OF FIBROSIS LOSS OF VASCULAR

OVARIAN HEMOSTATIC STROMA REMODELLING
TISSUE METHOD

FOLLICLE LOSS REDUCED FOLLICLE LOSS

AMH
 ENDOMETRIOSIS LIFE CYCLE
OVERVIEW

Medical Medical Final

Diagnosis ART
Treatment Treatment Surgery

DIAGNOSTIC
CHALLENGES
DESIRE FOR PREGNANCY

Medical Medical
Diagnosis SURGERY ART
Treatment Treatment
MANAGEMENT
CHALLENGES

DESIRE FOR PREGNANCY

Medical Medical
TAKE HOME Diagnosis ART
Treatment Treatment
MESSAGES

Chapron, Presented at SEUD 2017

OVERVIEW
EMPIRICAL TREATMENT OF PAIN

DIAGNOSTIC
CHALLENGES

• Before starting empirical treatment, other causes of

pelvic pain symptoms should be ruled out
MANAGEMENT
CHALLENGES • Empirically treat them with adequate analgesia,
combined hormonal contraceptives or progestagens.

TAKE HOME
MESSAGES

ESHRE GUIDELINES 2013

 HORMONAL THERAPY IN
OVERVIEW ENDOMETRIOSIS

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

Crosignani et al. Hum Reprod Update, 2006

 OCP Dienogest LNG-IUS DMPA NETA GnRH-a

Dose Variable 2 mg/day 20 mcg/day 150 2.5 mg/day 3.75

mg/month mg/month

Preparation Oral Oral Intra uterine Inject oral Inject

Side effect Minimal Androgenic Minimal Decreased Menstrual Hipoestrogen

Venous- effect BMD, irregularities
arterial Fluid weight gain Androgenic
thrombosis retention

Note Break Difficult for Positive Decreased

through unmarried effect on bone mineral
bleeding women calcium density (BMD)
Amenorhea metabolism Amenorrhea
A bit invasive
OVERVIEW Estradiol level and endometriosis

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

Figure adapted from Barbieri RL. J Reprod Med 1998; 43: 287–292.Klipping C et al. J Clin
Pharmacol 2012; 52: 1704–1713
OVERVIEW

DIAGNOSTIC
CHALLENGES
• POP is proved for reducing pain & suppressing the
anatomic extent of endometriosis lesions
• Dienogest is approved for treating endometriosis and
maybe better than OC pills as a first line therapy
MANAGEMENT
CHALLENGES
• OC pills is not indicated for endometriosis
• Estrogen component of OC pills may be
counterproductive in an estrogen-dependent disease
e.g. endometriosis
TAKE HOME
MESSAGES

Casper RF. Fertil Steril 2017;107:533-6

OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

J Pediatr Adolesc Gynecol 30 (2017) 560-567

OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

J Pediatr Adolesc Gynecol 30 (2017) 560-567

OVERVIEW

DIAGNOSTIC
CHALLENGES

MANAGEMENT
CHALLENGES

TAKE HOME
MESSAGES

J Pediatr Adolesc Gynecol 30 (2017) 560-567

OVERVIEW Take home messages

DIAGNOSTIC
CHALLENGES

• There is a delay of diagnosis in endometriosis

• Do not underestimate pain and always think the
MANAGEMENT possibility of endometriosis as a cause
CHALLENGES
• Medical treatment should be the center of
management in adolescent endometriosis

TAKE HOME
MESSAGES