Borruto, F.

Bracco, Gian Luca

Bruni, Vincenzina

Coccia, Maria Elisabetta

Comparetto, C.

Rizzello, Francesca

Scarselli, Gianfranco

English

Florence Research

©2006 by MEDIMOND S.r.l. 101G510C0011Endometriosis and Pain in an AdolescentPopulationM.E. Coccia, F. Rizzello, C. Comparetto, F. Borruto*, V. Bruni,G.L. Bracco and G. ScarselliDept Gynaecology Perinatology and Human Reproduction,University of Florence. Florence, Italy*Dept of Obstetrics and Gynaecology, University of Verona, ItalySummaryThe aim of this study is to discuss the clinical features, diagnosis andtreatment options of endometriosis associated with pain in adolescents and toevaluate safety of laparoscopic management. The records of adolescent pa-tients (10-21 years) who were admitted in our Department for diagnostic and/or operative laparoscopy were selected. The symptoms prevalence, operativefindings, and the response to surgery were retrospectively reviewed.Fifty-one teen-agers were submitted to laparoscopy. Endometriosis wasdetected in 16 (31.4%). The majority of patients (50%) presented with stageI. Only one patient presented with stage II (6.3%), 3 with stage III (18.8%),and 4 (25%) with stage IV. Out of the 16 girls, 14 (87.5%) complained ofpain. Of those with severe disease all 4 were treated laparoscopically withoutcomplications. In all cases the symptoms were relieved. There was no mor-bidity or mortality.Adolescent girls with pelvic pain have a high incidence of endometriosis.Severe dysmenorrhoea is the most relevant symptom. Laparoscopy should becarried out in all adolescents and teenagers with chronic pelvic pain unre-sponsive to medical treatment.IntroductionChronic abdominal pain in children is defined as pain of more than twoweeks’ duration. The pain may be persistent or recurrent. It is a frustratingconcern to the child, the parents and the physician. The differential diagnosis102 World Meeting on Gynecological Pelvic Pain and Endometriosisof abdominal pain in children varies with age, gender, genetic predisposition,nutritional exposure and many environmental factors (Lake AM, 1999).Although endometriosis is recognized to be a common cause of chronicpelvic pain of women in the reproductive period, its occurrence in adolescentshas long been underestimated. Adolescent endometriosis is not rare. Docu-mented rates in adolescent pain undergoing laparoscopy for chronic pelvicpain range from 19% to 73% (ACOG 2005).It’s difficult to evaluate the correct incidence of endometriosis, particularlyin I-II stage, because a surgical exploration is required. With the availabilityof laparoscopy and the growing awareness of the possibility of endometriosisin this population, more accurate assessment is becoming available. Laparoscopyplays an important role in managing chronic pelvic pain, not only in confir-mation of the diagnosis, but also in surgical intervention, therapy, and patientreassurance (Hewitt GD et al., 2000).The records of adolescent endometriosis cases in our department werereviewed to evaluate age distribution, diagnosis, clinical stage, and safety oflaparoscopic treatment.Materials and MethodsWe reviewed the incidence, type and clinical stage of endometriosis aswell as the main symptoms leading to diagnosis of endometriosis of 51 girlsaged 10-21 years who were submitted to laparoscopy in our department be-tween 1993- 2003.Each case of endometriosis was staged according to the Revised AmericanFertility Society classification of endometriosis (rAFS).Patients were contacted by telephone and asked to answer a very detailedquestionnaire. Our self developed questionnaire can be used to evaluate recur-rence of painful symptoms (dysmenorrhoea, pelvic pain and deep dyspareu-nia), course of infertility and recurrence of disease in patients with endome-triosis. A VAS (Visual Analogue Scale) was used to assess severity of dys-menorrhoea, dyspareunia, dyschezia and chronic daily pain. The event datesconsidered were the date of operation and the date of reappearance of mod-erate or severe pain or the last menstruation before a positive pregnancy test.SPSS version 13 was used to record and statistically analyse data. Statis-tical analysis was conducted by chi-square and Student’s t-test for independ-ent samples. P < 0.05 was considered significant in all comparisons.ResultsDuring the period from1993 to 2003, 51 teen-agers were submitted tolaparoscopy in our Department and endometriosis was detected in 16 (31.4%).Mean age of patients with endometriosis was 19.8 years (range 16-21 years).Out of the 16 girls, 14 (87.5%) complained of pain (7 with chronic or acutepelvic pain, 11 dysmenorrhoea, 6 deep dyspareunia). In one case endometrio-sis was an incidental finding, without symptoms, during a laparoscopic gona-dectomy for Swyer’s Syndrome. Another girl was submitted to laparoscopy103SEGI Annual Congress – Milan, Italy, May 10-14, 2006for ovarian endometrioma observed at ultrasonography (Table 1).The majority of patients (50%) presented with stage I. Only one patientpresented with stage II (6.3%), 3 with stage III (18.8%), and 4 (25%) withstage IV (Table 2).Superficial red lesions were most commonly observed. Of those with se-vere disease all 4 were treated laparoscopically without complications. Among14 complaining pain, symptomatology was relieved. There was no morbidityor mortality.Regarding the treatment modality, surgery only was performed in 6 cases(37.5%), and medical management following surgery in 10 (62.5%). Surgicaltreatment included ovarian cyst enucleation, bipolar electrocoagulation. Tenpatients (62.5%) followed a medical treatment after laparoscopy. Medicaltreatments included oral contraceptives (2 cases), or GnRHa (8 cases).During this follow-up, 5 patients in search of a pregnancy, 3 became preg-nant.ConclusionsIn the past, endometriosis was considered as a disease of women in theirthird or fourth decade of life. It was not until the 1970s that endometriosiswas found to be a common cause of chronic pelvic pain in adolescents (KleinhausS et al., 1977). In fact, most contemporary articles cite endometriosis as themost common finding at diagnostic laparoscopy in adolescent patients withchronic pelvic pain (Hewitt GD et al., 2000). In this study endometriosis wasdetected in 16 (31.4%) of 51 teen-agers submitted to laparoscopy.Most patients with endometriosis report cyclic or acyclic pelvic pain astheir chief complaint. Other common symptoms include dysmenorrhoea, ir-Symptoms No. of patients (%) Chronic or acute pelvic pain 7 (43.7) Dysmenorrhoea 11 (68.7) Dyspareunia 6 (37.5) No symptoms 2 (12.5) Table 1: Symptom Distribution in 16 Adolescents Stage No. of patients (%) I 8 (50) II 1 (6.3) III 3 (18.8) IV 4 (25) Table 2: Stage Distribution in 16 Adolescents 104 World Meeting on Gynecological Pelvic Pain and Endometriosisregular menses, dyspareunia, abdominal pain and nausea, constipation anddiarrhoea, and urinary complaints. More than 90% of adolescents with en-dometriosis have diffuse or localized tenderness on physical examination (HewittGD et al., 2000). The main symptom among our patients was dysmenorrhoeaas 68.7% of patients suffered of it.Unlike older women, adolescents with endometriosis rarely have adnexalenlargement, cul-de-sac nodularity, or a fixed, retroverted uterus. Most ado-lescents in whom endometriosis is identified at laparoscopy are found to havestage I or II disease (based on AFS guidelines) (Reese KA et al., 1996; LauferMR et al., 1997). Most endometriotic implants seen in adolescents are super-ficial red lesions thought to be precursors to the more typical black lesionsseen in adults (Redwine DB, 1987). The change in the appearance of endometrioticlesions and stages of endometriosis suggests the probable progression ofendometriosis with age. Our data show a 50% with stage I, and 6.3% withstage II. The prevalence of stage III or IV was 43.7 %. The reason for the highpercentage of advanced stage of endometriosis in our adolescents is mostlikely that these girls did not visit a gynaecologist until they had a severepainful symptomatology or a palpable mass.Endometriosis has been diagnosed in patients as young as 11, even beforemenarche (Goldstein DP et al., 1980; Reese KA et al., 1996). Early identifi-cation and treatment of endometriosis not only could improve quality of lifebut also lower risk for long-term sequelae such as pelvic adhesive disease andinfertility.Safe and minimally invasive in adolescents, laparoscopy has become animportant diagnostic tool in evaluating chronic pelvic pain in this patientpopulation. The most common indications for a diagnostic laparoscopy in-clude a mass identified by pelvic exam or ultrasound, progressive dysmenor-rhoea, chronic pelvic pain unresponsive to oral contraceptives or nonsteroidalanti-inflammatory drugs (NSAIDs), painful irregular vaginal bleeding, andany diagnostic dilemma such as suspected chronic PID or chronic appendici-tis (Hewitt GD et al., 2000).Medical therapy therapy can be proposed after an initial optimal surgicalresection or destruction of endometriosis to achieve pain control and hormo-nal suppression of the disease, and to minimize progression. In our practice,oral contraceptive and GnRH agonists in selected cases are the first-line andthe most widely used medical therapy for endometriosis.Endometriosis, among teen-agers, is under diagnosed by gynaecologists.Adolescent patients typically present with progressive and severe dysmenor-rhoea, but also may present with acyclic pelvic pain. Endometriosis should bestrongly suspected in adolescent with chronic pelvic pain especially with noor low response to oral contraceptives and nonsteroidal anti-inflammatorymedicine.Treatment should focus on conservative measures with medical and surgi-cal interventions. Laparoscopic approach is a valuable and effective proce-dure in the diagnosis and management of endometriosis in adolescent pa-tients.105SEGI Annual Congress – Milan, Italy, May 10-14, 2006ReferencesAmerican College of Obstetricians and Gynecologists. ACOG Committee Opinion.Number 310, April 2005. Endometriosis in adolescents. Obstet Gynecol.,105(4):921-7, (2005)Goldstein DP, deCholnoky C, Emans SJ, et al. Laparoscopy in the diagnosis andmanagement of pelvic pain in adolescents. J Reprod Med.,24(6):251-256, 1980.Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents. MedClin North Am.,84(4):1009-25, (2000).Kleinhaus S, Hein K, Sheran M, Boley SJ. Laparoscopy for the diagnosis and treat-ment of abdominal pain in adolescent girls. Arch Surg.,112:1178-1179, (1977).Lake AM. Chronic abdominal pain in childhood: diagnosis and management. Am FamPhysician.,59(7):1823-30, (1999).Laufer MR, Goitein L, Bush M, et al. Prevalence of endometriosis in adolescent girlswith chronic pelvic pain not responding to conventional therapy. J Pediatr AdolescGynecol.,10:199-202, (1997).Redwine DB, Yocom LB. A serial section study of visually normal pelvic peritoneumin patients with endometriosis. Fertil Steril.,48:1062, (1987).Reese KA, Reddy S, Rock JA. Endometriosis in an adolescent population: the Emoryexperience. J Pediatr Adolesc Gynecol.,9:125-128, (1996).

Endometriosis and Pain in an Adolescent population

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Endometriosis and Pain in an Adolescent population

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