Diagnosis and Treatment of Endometriosis in Adolescents

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Diagnosisandtreatmentofendometriosisinadolescents
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Author
MarcRLaufer,MD
SectionEditors
RobertLBarbieri,MD
AmyBMiddleman,MD,MPH,MS
Ed
DeputyEditor
KristenEckler,MD,FACOG
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2015.|Thistopiclastupdated:May19,2015.
INTRODUCTIONEndometriosisreferstothepresenceofendometrialglandsandstromaoutsidethe
endometrialcavityanduterinemusculature.Theseectopicendometrialimplantsareusuallylocatedinthepelvis,
butcanoccurnearlyanywhereinthebody.Thediseasecanbeassociatedwithmanydistressinganddebilitating
symptoms,oritmaybeasymptomatic.Despitenumerousstudies,considerablecontroversyremainsregardingthe
incidence,pathogenesis,naturalhistory,andoptimaltreatmentofthisdisorder.
Thistopicwilldiscussendometriosisspecificallyinadolescents.Thediseaseinadultsisreviewedseparately:
(See"Endometriosis:Pathogenesis,clinicalfeatures,anddiagnosis".)
(See"Overviewofthetreatmentofendometriosis".)
(See"Diagnosisandmanagementofovarianendometriomas".)
(See"Gonadotropinreleasinghormoneagonistsforlongtermtreatmentofendometriosis".)
(See"Pathogenesisandtreatmentofinfertilityinwomenwithendometriosis".)
(See"Reproductivesurgeryforfemaleinfertility".)
(See"Clinicalfeatures,diagnosticapproach,andtreatmentofadultswiththoracicendometriosis".)
PREVALENCETheprevalenceofendometriosisinthegeneralpopulationisnotknownestimatesvary
dependinguponthepopulationstudied(symptomaticorasymptomatic)andthemethodofdiagnosis(clinical
versussurgical).Thediseasehasbeenreportedin25to38percentofadolescentswithchronicpelvicpain[1,2]
and47percentofthosewithchronicpelvicpainthatundergolaparoscopy[3].Theprevalenceamongadolescents
undergoinglaparoscopyforpelvicpainnotcontrolledwithoralcontraceptivepills(OCs)andnonsteroidalanti
inflammatorydrugs(NSAIDs)is50to70percent[46].
EPIDEMIOLOGYTwothirdsofadultwomenwithendometriosisreportthattheirsymptomsstartedbeforeage
20[7].Althoughithadbeenassumedthatendometriosispresentedonlyaftermanyyearsofmenstruation,this
wasincorrect:symptomaticcaseshavebeendocumentedpriortomenarcheingirlswhohavesomebreast
development,andotherssoonaftermenarche[810].
Someadolescentsmayhaveageneticpredispositiontodevelopingendometriosis.Inonestudyof123patients
withhistologicallyprovedendometriosis,firstdegreefemalerelativesofaffectedpatientsweresignificantlymore
likelytohavebeendiagnosedwithendometriosisthanrelativesofcontrols(7versus1percent)[11].
PATHOGENESISManytheorieshavebeenproposedtoexplaintheetiologyofendometriosis.Nosingletheory
explainsallcases,andallofthetheorieshelptoexplainsomeaspectsofthedisease.Thetypesandfrequencies
ofpathogeneticmechanismsmaybedifferentinadolescentsandpostpubertal/premenarchalendometriosisthanin
adultendometriosis.Itislikelythatthecauseofendometriosisismultifactorial,withcontributionsfromseveralof
theproposedmechanisms.(See"Endometriosis:Pathogenesis,clinicalfeatures,anddiagnosis",sectionon
'Pathogenesis'.)
Thefollowingtheoriesforthepathogenesisofendometriosishavebeenproposed:
Theimplantationorretrogrademenstruationtheorysuggeststhatendometrialtissuefromtheuterusisshed
duringmenstruationandtransportedthroughthefallopiantubes,therebygainingaccessto,andimplanting
http://www.uptodate.com/contents/diagnosisandtreatmentofendometriosisinadolescents?topicKey=OBGYN%2F7415&elapsedTimeMs=9&source=searc
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on,pelvicstructures[12].
Thistheoryissupportedbytheobservationthatendometriosisoccursmostcommonlyinthedependent
portionofthepelvis.Inaddition,obstructivecongenitalanomaliesofthefemalegenitaltractthatenhance
retrogradeflowhavebeenassociatedwithendometriosisintheadolescentpopulation[9,13,14].Asan
example,oneseriesidentifiedsixadolescentswithmlleriananomaliesandendometriosis[13].The
youngestpatientwasa12yearoldwithvaginalatresiaandbicornuateuteruswhodeveloped
hematocolpos,likelyfollowedbyretrogradeflowleadingtoherendometriosis.Repairofthistypeof
obstructiveanomalyhasbeenassociatedwithresolutionofendometriosis[14],butinourexperience,this
hasnotbeentrueinallcases.
Endometriosisinlocationsoutsidethepelvisisexplainedbydisseminationofendometrialcellsortissue
throughlymphaticsandbloodvessels[15].
Thecoelomicmetaplasiatheoryproposesthatthecoelomic(peritoneal)cavitycontainsundifferentiated
cellsorcellscapableofdedifferentiatingintoendometrialtissue[16].Thistheoryisbaseduponembryologic
studiesdemonstratingthatallpelvicorgans,includingtheendometrium,arederivedfromcellsliningthe
coelomiccavity.Supportforthistheoryderivesfromtheobservationofendometriosisinpremenarchalgirls
whohavesomebreastdevelopment[8,17,18].
Thedirecttransplantationtheoryistheprobableexplanationforendometriosisthatdevelopsinepisiotomy,
hysterotomy,andothersurgicalscars.
Thecellularimmunitytheory,whichisthemostrecentlyproposedhypothesis,suggeststhatadeficiencyin
cellularimmunityallowsectopicendometrialtissuetoproliferate[1921].
CLINICALMANIFESTATIONSAppreciationoftheclinicalmanifestationsofendometriosisintheadolescent
maydecreasethelengthoftimebetweenpatientpresentationandclinicaldiagnosis,whichaveragesnineyears
[7].Ideally,earlydiagnosisandtreatmentofendometriosiswillretarddiseaseprogression[22],anddecreasethe
adverselongtermeffectsofthedisease(chronicpain,endometriomas,infertility),andthusimprovethequalityof
lifeofadolescentsandwomenwiththisdisorder.
Adolescentswithendometriosisusuallyhavebothacyclicandcyclicpain(severe,progressivedysmenorrhea)
(table1)isolatedcyclicpainistheleastcommonpainpresentation[6].Bowelsymptoms(eg,rectalpain,
constipation,painfuldefecationthatmaybecyclic,rectalbleeding)andbladdersymptoms(eg,dysuria,urgency,
hematuria)arealsocommon[6],whileovarianendometriomasandinfertilityarerareinadolescents.
Incontrast,adultswithendometriosiscommonlyhavecyclicpain,andpresentwithdysmenorrhea,dyspareunia,a
pelvicmass,infertility,orchronicpelvicpain.(See"Endometriosis:Pathogenesis,clinicalfeatures,and
diagnosis",sectionon'Clinicalpresentation'.)
DifferentialdiagnosisCausesofpelvicpaininadolescentsincludeappendicitis,pelvicinflammatorydisease,
mllerianabnormalitieswithoutflowobstruction,hernia,boweldisease,andpsychosocialissues.Theetiologyand
evaluationofchronicpaininthispopulationarediscussedindetailseparately.(See"Chronicabdominalpainin
childrenandadolescents:Approachtotheevaluation",sectionon'Etiology'.)
INITIALEVALUATION
HistoryQuestionsthatshouldbeaddressedbythehistoryarelistedinthefigure(table2).Havingthepatient
keepadiarydocumentingthefrequencyandcharacterofherpainwillhelpdeterminewhetherthepainiscyclic,
andifitisrelatedtobowelorbladderfunction.Patientswithahistoryofsexualorphysicalabusemaybeat
increasedriskofdevelopingchronicpelvicpain[23],butthisshouldnotprecludefurtherevaluationfor
endometriosis.
PhysicalexaminationThegoalofthephysicalexaminationistodeterminetheetiologyofthepainandtorule
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outanovariantumororanomalyofthereproductivetract.Theapproachtoabdominopelvicexaminationdepends
onthepatient.Althoughimportant,itmaynotbepossibletoperformacompletepelvicexaminationinall
adolescents.Foradolescentswhoarenotsexuallyactive,rectalabdominalexaminationmaybebettertolerated
thanvaginalabdominal(ie,bimanual)examinationabimanualpelvicexaminationisnotarequirementfor
evaluationofadolescentpelvicpain.AQtipcanbeinsertedintothevaginatodocumentpatencyandexclude
obstructiveorpartiallyobstructiveanomaliessuchasatransversevaginalseptum,imperforateormicroperforate
hymen,vaginalagenesis,oranobstructedhemivagina.Anomaliesarepresentinabout5percentofthesepatients
[24].
Theabdominalexaminationisusuallynormal.Onpelvicexamination,adolescentsrarelyhaveuterosacral
nodularity,acommonfindinginadultswiththedisease,butpainintheculdesaciscommon.Adnexal
enlargementmaybepalpableifanendometriomaispresent,butthesemassesarealsorareinadolescents[25].
Sonographicexaminationshouldbeperformedtoaugmentalimitedphysicalexaminationandidentify/exclude
causesofabdominopelvicpainotherthanendometriosis.(See'Imagingstudies'below.)
Nongynecologicphysicalfindingsthatareobservedmorefrequentlyamongwomenwithendometriosisareredhair
color,scoliosis,anddysplasticnevi[2628].
LaboratoryLaboratoryteststoconsiderinclude:
Completebloodcountanderythrocytesedimentationrate,whichmaysuggestthepresenceofanacuteor
chronicinflammatoryprocess
Urinalysisandurineculturetoidentifypainoriginatingintheurinarytract(eg,cystitis,stone)
Pregnancytestandtestsforsexuallytransmittedinfections(gonorrhea,chlamydia),whenappropriate
CA125ismostcommonlyusedasabiomarkerforovariancancer,butcanbeelevatedinotherconditions,
includingendometriosis.AserumCA125levelisnotausefulscreeningtestduetoitshighrateoffalsepositives
(table3).Ithasbeenusedoccasionallytofollowtheprogressofdiseaseinpatientswhohavehistologicallyor
visuallyconfirmedendometriosisatsurgery[29],butweprefertorelyonthepatient'sreportofsymptomstofollow
endometriosis,anddonotuseCA125inclinicalmanagement.(See"Endometriosis:Pathogenesis,clinical
features,anddiagnosis".)
ImagingstudiesInadultwomenwithendometriosis,sonographycanidentifyanendometrioma,whichisone
ofthepresentationsofthedisease.Imagingislessusefulindiagnosisofendometriosisinadolescentssince
endometriomasrarelyoccurandtypicallesionsofadolescentendometriosiscannotbeappreciatedwith
ultrasound.However,ultrasoundmaybeusefultoidentify/excludeseveralstructuralcausesofpelvicpainin
adolescents,suchasovariantorsionorhemorrhage,tumors,genitaltractanomalies,andappendicitis.(See
individualtopicreviews).
Magneticresonanceimagingcanbehelpfultobetterdefineanabnormalitysuspectedbysonography,butshould
notbeusedasafirstlineimagingtestbecauseofitsexpenseandpoorsensitivityfordetectingperitoneallesions
orstagingendometriosis[3032].Computedtomographyisalsoaninsensitivetestinthediagnosticevaluationof
endometriosis,unlessanendometriomaisidentified.(See"Diagnosisandmanagementofovarian
endometriomas".)
TRIALOFMEDICALTHERAPYFORDYSMENORRHEA
NSAIDsandhormonaltherapyMedicaltreatmentofdysmenorrheaisappropriatepriortoconsideringsurgical
interventionfordiagnosis/treatmentofendometriosisinadolescentswithdysmenorrheaand/orwhohavedifficulty
participatinginnormalactivities,aremissingschool,oravoidingextracurricularactivitiesbecauseofpelvicpain.A
threemonthtrialofnonsteroidalantiinflammatoryagents(NSAIDs)isareasonableapproachwhenthepain
evaluationsuggestsanonacutegynecologicalsource,suchasprimarydysmenorrheaorendometriosis(table4)
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[24].Themedicationshouldbestartedbeforetheexpectedonsetofseverepain,ifpossible.(See"Primary
dysmenorrheainadolescents".)
Hormonaltherapy,suchasacycliclowdosecombinationestrogen/progestinoralcontraceptivepill(OC),or
progestinonlytherapy(oral,injectable,orimplantable),shouldbegivenwiththeNSAIDs[24].Useofhormonal
therapyleadstodecidualizationandsubsequentatrophyofectopicandeutopicendometrialtissue,thereby
decreasingbleedingand,inturn,reducingbleedingrelatedpain.Theseagentsareparticularlyusefulin
adolescentsalsoneedingcontraception.Thevaginalringandtransdermalcontraceptivepatchareotherexamples
ofmethodsofcombinedhormonalcontraceptionandareacceptablealternativestoOCs.Allofthesemethodsare
safeandeffectiveifgivencyclicallyorinanextendedorcontinuouscycle[3335].Theextendedcycleregimen
hasbeensuccessfulinwomenwhosepaindidnotrespondtocyclictherapy,butisassociatedwithmore
unscheduledbleeding.(See"Overviewofthetreatmentofendometriosis",sectionon'Estrogenprogestinoral
contraceptives'and"Overviewofthetreatmentofendometriosis",sectionon'Initialapproach'and"Hormonal
contraceptionforsuppressionofmenstruation"and"Contraception:Overviewofissuesspecifictoadolescents",
sectionon'Extendedcycleorcontinuouspilluse'.)
IfthepaindoesnotresolvewithNSAIDsandhormonaltherapy,thenfurtherevaluationisnecessarytodetermine
whetherendometriosisistheetiologyofthepain.
GonadotropinreleasinghormoneagonistsForadultwomeninwhomendometriosisisthesuspectedcause
ofthepain,anexpertpanelopinedthatatrialofmedicaltherapywithaGnRHagonistisjustifiedprovidedthat
therearenootherindicationsforsurgery(eg,suspiciousadnexalmass)[36].Theempiricutilizationofa
gonadotropinreleasinghormone(GnRH)agonistallowspatientswithchronicpelvicpainandahighprobabilityof
endometriosistoavoidadiagnosticsurgicalprocedurebeforebeginningthistherapy.Dosesaredescribedbelow
(see'GnRHagonists'below).
Placebocontrolledrandomizedtrialshaveconfirmedtheefficacyofthisapproach[37].Theonlyrandomizedtrial
thatdirectlycompareduseofaGnRHagonist(goserelin)tolowdosecyclicOCsinadultwomenwithpelvicpain
associatedwithendometriosisshowedthatbothdrugsprovidedsignificantreliefofpain,butgoserelinwas
superiorfortreatmentofdyspareunia[38].
WedonotutilizeempiricGnRHagonistsforadolescents18yearsofageoryoungerbecausewehaveconcerns
aboutpotentialadverselongtermeffectsonboneformationandbonemineraldensity[39].Additionally,some
parentsarenotcomfortablewithatrialofempirictherapyduetoworriesaboutusingamedicationwithadverse
sideeffectswithoutadefinitivediagnosis.TheAmericanCollegeofObstetriciansandGynecologistsdoesnot
endorsetheuseofempiricGnRHagonisttherapyfortreatmentofpresumedendometriosisinyoungwomenunder
age18,butconsidersitanoptionforconsentingwomenage18orover[24].Mostbonemassinfemaleshas
accumulatedbyage18[40].
PATIENTSWHOFAILTHERAPYFORDYSMENORRHEAAdefinitivediagnosisshouldbeestablished
beforeadministeringfurthertreatmenttoadolescentswhohavepersistentpainafterthreetosixmonthsof
hormonaltherapyandNSAIDSforthetreatmentofdysmenorrhea[24].Laparoscopyisthegoldstandardfor
diagnosisofendometriosis.
Whenpainpersistsdespitedysmenorrheatherapy,wetalkwiththeadolescentandherfamilytodeterminethe
amountofpainthatsheisexperiencing.Wesuggestthatifherpaininterfereswithherdailylife'sactivitiesor
placesheratadisadvantageinacademics,sports,orsocialactivitiescomparedwithothers,thensheshould
undergolaparoscopyfordefinitivediagnosis.Typically,laparoscopyisperformedafterthreetosixmonthsofpain
[24],butwaitingthislongmayinterferewithschoolandsocialactivities.Therefore,itmaybenecessaryto
proceedwithlaparoscopicevaluationsooner.Atsurgery,upto70percentofadolescentswithchronicpelvicpain
thathasnotrespondedtoatrialofNSAIDsandcyclicOCsarefoundtohaveendometriosis[6].Thesedataare
fromstudiesintheearly1990s.Basedonadvancesinlaparoscopicimagingwithhighdefinitiondigitaltechnology,
thecurrentrateislikelyhigher.
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Diagnostic(andtherapeutic)laparoscopyIfagynecologistperformsthelaparoscopy,heorshemusthave
experienceoperatingonpatientsinthisagerange,otherwiseapediatricgynecologistorpediatricsurgeonshould
beconsulted.Adiagnosticlaparoscopywithsubsequentreferraltoaspecialistfordefinitivesurgeryplacesthe
patientatundueriskfromtwoanesthesias.Therefore,thesurgicalprocedureshouldbebothdiagnosticand
therapeutic,withsurgicalmanagementoftheendometriosis.
Itisespeciallyimportanttoachieveagoodcosmeticresultinadolescents.Tominimizevisiblescarring,the
laparoscopetrocarcanbeplacedthroughaverticalincisiondirectlyintheumbilicus.Additionaloperativeports
shouldbeplacedsymmetrically1to2cmabovethepubicsymphysissothatthepubichairwillgrowoverthe
incisionsite(s).
Thegynecologistoperatingonanadolescentwithpelvicpainmustbefamiliarwiththeappearanceof
endometriosisimplantsinthisagegroup.Theimplantshavevariablemorphology(picture1),whichhasbeen
describedintherevisedAmericanSocietyofReproductiveMedicine(ASRM)ClassificationofEndometriosis[41].
Theonlyseriesthatobjectivelycomparedendometriosislesionsinadolescentstothoseinadultsfoundredflame
lesionsweremorecommonandpowderburnlesionslesscommoninadolescentsthaninadultpatients[42].This
isconsistentwiththepresumptionthatpowderburnlesionsrepresentolder,moreadvancedimplants.Clearand
redlesionsmaybethemorepainfullesionsofendometriosis(table5)[43].Peritonealwindowsordefectsarealso
commoninadolescentsandshouldberecognizedasdiagnosticofendometriosis.
Caremustbetakentoidentifysubtleendometrioticlesionsthatoftenappearasclear,shinyperitonealvesicles.
Visualizationthroughaliquidmedium,suchassaline,mayfacilitateidentification[44].Afterallthelesionshave
beenlocated,thefluidisremovedsothatthelesionscanbeablatedorexcised.
Ifnoevidenceofendometriosisisidentified,aposteriorculdesacbiopsytoexcludethepresenceofmicroscopic
diseaseshouldbeperformedandmayidentifylesionsnotvisualizedonlaparoscopy.Onestudyofnondirected
biopsiesfoundalowprevalenceofmicroscopicendometriosis[45],whileanotherreportedasignificantratein
adults[46].OurexperienceatChildren'sHospital,Boston,isthatwefindmicroscopicendometriosisin3percent
ofadolescentgirlswithchronicpelvicpainunresponsivetoconventionaltherapyandwithavisuallynormalpelvis
[6].
EndometriosisshouldbestagedaccordingtotherevisedASRMClassificationofEndometriosis(figure1)to
facilitatefollowupandcomparisoniffuturesurgeryisperformed[41].Althoughmostadolescentspresentwith
StageItoIIdisease,inoneseries,11of36adolescentswithendometriosishadstageIVdisease[42].Ingeneral,
thestageofdiseasedoesnotcorrelatewithdegreeofpain.Whencounselingpatientspostoperatively,itis
importanttorememberthattheseverityofsymptomsdoesnotcorrelatewiththeextentorlocationoflesions
(table6)[47].
SurgicaltreatmentMostadultwomenexperienceareductioninpainaftersurgicaltreatment[48,49].Thereare
nolargestudiesinadolescents.
Electrocautery,endocoagulation,orlaserablationorresectionofimplantsshouldbeperformedatthetimeof
diagnosticlaparoscopy[50].InadultswithStageIorIIdisease,thereisnodifferenceinoutcomewithexcision
versusablationofendometriosis[51].Lysisofadhesionsisalsoperformedatthetimeofsurgery.Laparotomyis
rarelyrequired.Anylargeendometrioticcystsshouldberemoved,withpreservationofasmuchovariantissueas
possible.Caremustbetakentoavoiddamagetotheureters,majorbloodvessels,bowel,andbladder.(See
"Endometriosis:Surgicalmanagementofpelvicpain",sectionon'Laparoscopicexcisionorablation'.)
However,surgeryaloneisnotadequatetreatmentforendometriosisastherecanbemicroscopicresidualdisease
thatmustbesuppressedwithmedicaltherapy[36].Symptomswillreturnwithinoneyearinapproximately50
percentofadultwomenwhoreceiveonlysurgicaltherapy[36,48,52,53].
POSTOPERATIVEMEDICALTREATMENTTherearenolongtermfollowupdatadescribingthenatural
historyofuntreatedendometriosisfirstdetectedinadolescentswedonotknowtheproportionofendometriosis
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thatwillprogresstomoreadvanceddiseaseifleftuntreated.
Thegeneralconsensusisthatadolescentswithhistologicallyconfirmedendometriosisshouldreceivemedical
treatmentaftersurgicalablation/resectionuntiltheyhavecompletedchildbearing[24].Comparedtoeutopic
endometrium,endometrioticimplantsarecharacterizedbyoverproductionofprostaglandinsandlocalproductionof
estrogensandcytokines,whichsynergizetheactivitiesofeachother,promoteimplantationofectopic
endometrium,andcausethepainassociatedwithendometriosis.Therationaleformedicaltherapyisinhibitionof
prostaglandinsynthesis,decidualizationandsubsequentatrophyofresidualectopicendometrialtissue,and
reductionofovarianestrogenproduction,therebyinhibitingthegrowthandactivityoftheectopicendometrium.
Thegoalofmedicaltherapyistomanagepainduetoresidualdisease,allowthepatienttofunctioncomfortablyin
herdailyactivities,andsuppressdiseaseprogression,whichcouldimpairfertility.Longtermfollowupdatain
adolescentsshowthatendometriosisthatissurgicallyidentifiedanddestroyedandthenfollowedbymedical
therapytendsnottoprogress[22,54].Therearelimiteddataonthecourseofadolescentswhoundergocomplete
excisionofvisibleendometriosisbutdonotundertakepostoperativehormonalsuppression[55].
Treatmentefficacyshouldbeassessedregularlybyaskingthepatienttorateherpainonascaleof0to10at
eachvisit.Sheshouldbeawarethatshemaynotbecomepainfree,buthermedicationscanbeadjustedto
maximizepainreliefandpromoteparticipationinschoolandsocialactivities.Supportgroupsforadolescentswith
endometriosisareavailableandcanbeuseful(www.youngwomenshealth.org).
Severalmedicaltherapiesareavailable,eachwithdifferingrisks,benefits,andsideeffectprofiles[56].Thechoice
oftreatmentdependsupontheseverityofthepatient'ssymptoms,theextentofdisease,andcompliance.
Althoughnumerousoptionshavebeendescribedforthetreatmentofendometriosis[4,39],combinationhormonal
therapyorGnRHagonistsareusuallyusedforfirstlinetherapy.Foradolescentswithconfirmedendometriosis,
weofferboththerapiestothoseages16orover,butuseonlycontinuouscombinationhormonaltherapyinthose
under16yearsofageoutofconcernabouttheeffectsofGnRHagonistsontheformationofnormalbonesand
bonedensity[57].
ContinuoushormonaltherapyUseofcontinuoushormonaltherapyaftersurgerymayretardprogressionof
diseaseandcontrolanyremainingpain[34].(See'NSAIDsandhormonaltherapy'above.)
Combinationestrogen/progestinsCombinationtherapycanbeusedtosuppressmenstruationandinduce
apseudopregnancystateforsuppressionofendometriosisandendometriosisassociatedpain.Amonophasic
progestindominantpillismosteffectiveforthesuppressionofmenses.Itisimportantforadolescentstobe
remindedthat,forthistreatmenttobesuccessful,thepillmustbetakenatthesametimedaily.Wetypically
recommend6:00pm,7:00pm,or8:00pm.Werecommendthatthepillnotbetakenuponwakening,asmost
adolescentsdonotgetupatthesametimeonweekdaysandweekends.Ifthepillistakenlate,thereappearsto
beanincreasedriskofbreakthroughbleeding.
ProgestinsProgestinsinhibitendometriotictissuegrowthbycausinginitialdecidualizationandeventual
atrophy.Theyalsoinhibitpituitarygonadotropinsecretionandovarianhormoneproduction,resultinginamildly
hypoestrogenicstaterelativetonormal.
Themostcommonlyusedprogestationalagentsare:
Norethindroneacetate(5to15mgdailybymouth)
Medroxyprogesteroneacetate(30to50mgdailybymouth)
Depotmedroxyprogesteroneacetate(150mgintramuscularlyeveryonetothreemonths)
Eachofthesetherapiesimprovessymptomsinapproximately80to100percentofpatientswithendometriosis
[5861].Theetonogestrelsubdermalimplanthasalsobeenusedsuccessfullybutexperienceislimited[6265].
(See"Overviewofthetreatmentofendometriosis".)
Potentialbothersomesideeffectsofprogestinsincludeweightgain,bloating,depression,andunscheduled
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bleeding[7]however,manypatientstoleratethistherapyverywell[61].Oralprogestintherapyshouldbe
consideredpriortolongtermintramuscularinjectionssothatsideeffectscanbeidentifiedandaddressedorthe
medicationeasilydiscontinued.
Thelongtermutilizationofdepotmedroxyprogesteroneacetatehasbeenshowntoresultinlossofbonedensity,
whichisreversibleafterdiscontinuationoftheprogestin.(See"Depotmedroxyprogesteroneacetatefor
contraception",sectionon'Reductioninbonemineraldensity'.)
GnRHagonistsGnRHagonistscanbeprescribedforadolescents,withlaparoscopicallyconfirmed
endometriosis,whoareatleast16yearsold.Ourpreferenceisdepotleuprolideacetate(11.25mgintramuscularly
everythreemonths)itisalwaysgivenwithaddbacktherapy.Weusethethreemonthformulationtoimprove
compliancewiththerapy.Somepatientswhoreceiveaonemonthformulationexperiencetheexpectedflare
effect(increasedpainandbleeding)andthendonotreturnfortheirsecondonemonthinjection.Withthethree
monthformulation,patientswhohaveincreasedpainandbleedingwiththeflareeffectwillhavetheGnRHagonist
intheirsystemforthreemonthsandthuscontinuetobenefitfromthesubsequentsuppression.Nafarelinnasal
spray(onepufftwicedailyintranasally)isanalternativeGnRHagonisthowever,complianceisoften
unpredictableintheadolescentpopulation.(See"Gonadotropinreleasinghormoneagonistsforlongtermtreatment
ofendometriosis".)
Over90percentofpatientswillbecomeamenorrheicandhypoestrogeniconthisdoseofleuprolide[66].Side
effectsincludehotflashes,headaches,difficultysleeping,moodswings,depression,andvaginaldryness
therefore,wedonotutilizeGnRHagonisttherapywithoutaddbacktherapy.Mensestypicallyreturn60to90days
aftercessationofintramuscularleuprolidetherapy.
Generally,initialtreatmentwithaGnRHagonistiscontinuedforsixmonths.Uponcompletionofthisinitialsix
monthcourseofGnRHagonisttherapy,thepatientmustthenchooseatreatmentcourse.Shecanreturntoa
continuouscombinedhormonalcontraceptive,asdescribedabove.Ifsheisnotabletotoleratecontinuous
combinationhormonalorprogesteroneonlytherapy,thenlongtermutilizationofaGnRHagonistwithaddback
canbeprescribed(seebelow).Abaselinebonedensityassessmentisobtainedaftertheinitialsixtoninemonths
oftherapyandisthenrepeatedeverytwoyears.Ifbonedensityremainsstable,thentheassessmentisrepeated
everytwoyearswhilethepatientisreceivingGnRHagonists.
AddbacktherapyTheutilizationofaddbacktherapycanhelpalleviatethesideeffectsofGnRHagonists
withoutreducingtheirefficacy,aslongastheaddbackregimendoesnotinvolvehighdosesofestrogen[67].
Addbacktherapyisbaseduponthe"estrogenthresholdhypothesis,"whichisdemonstratedinthefigure(figure2)
[68].Basically,adequatesexsteroid(estrogenplusprogestin,orprogestinalone)isprovidedtopreventsignificant
bonedemineralization,butnotenoughtostimulategrowthofendometriotictissue.
Optionsforsexsteroidaddbacktherapyusedinadultwomeninclude[69,70]:
Norethindroneacetate(5mgdaily)alone,or
Conjugatedestrogen(0.625mg)pluseithernorethindroneacetate(5mg)ormedroxyprogesteroneacetate(5
mgdaily)
Patientsatisfactionishigherwithuseofnorethindronecomparedwiththeotheroptions(table7)[69].
SafetyThesafetyoflongtermuseofaGnRHagonistwithaddbacktherapyinadolescentsisunder
investigation[57].Onestudyperformedserialbonemineraldensityexaminationsin36adolescentsreceivinga
GnRHagonistwithnorethindroneacetateaddback[71].Bonedensitywaspreservedwiththistreatmentoveran
11monthmeantreatmentperiod,butpreservationofbonedensitywasbetteratthehipthanatthespine.Atthe
hip,6subjectshadaBMDZscorebetween1.0and2.0SD,while2hadaZscore2.0SD.Atthespine,11
subjectshadaBMDZscorebetween1.0and2.0SD,while3hadaZscore2.0SD.
DanazolDanazolisa17alphaethinyltestosteronederivativethatcreatesanacyclicenvironment.Its
mechanismsofactionincludeinhibitionofpituitarygonadotropinsecretion,directinhibitionofendometrioticimplant
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growth,anddirectinhibitionofovarianenzymesresponsibleforestrogenproduction.(See"Overviewofthe
treatmentofendometriosis",sectionon'Danazol'.)
Danazol'sefficacyintreatingmildtomoderateendometriosisisequivalenttothatofavarietyofGnRHagonists
[7278].Over80percentofpatientsexperiencerelieforimprovementofpainsymptomswithintwomonthsof
treatment[79].Largeendometrioticcystsandadhesionsdonotrespondwellsurgeryisthepreferredtherapyfor
theselesions.
Mostwomentakingdanazolhavesideeffectsthataredosedependent.Sideeffectsincludeweightgain,muscle
cramps,decreasedbreastsize,acne,hirsutism,oilyskin,decreasedhighdensitylipoproteinlevels,irreversible
deepeningofthevoice,increasedliverenzymes,hotflashes,moodchanges,anddepression[80].Androgenic
sideeffectsarerelatedtodecreasedsexhormonebindingglobulinlevels,resultinginanincreaseoffree
testosterone.
Bothersometointolerablesideeffectsareacommonreasonfordiscontinuationofthedrug[80].AlthoughGnRH
agonistsarealsoassociatedwithsideeffects,patientsusingthesedrugsreportabetterqualityoflifethanthose
takingdanazol[81].Giventhesideeffectprofile,danazolwouldlikelybepoorlytoleratedbyadolescents,andthus
isnotutilizedinthemanagementofendometriosisintheadolescentpopulation.
NonsteroidalantiinflammatoryagentsNSAIDsarehelpfuladjuvantagentsforthetreatmentofpelvicpain
associatedwithendometriosis.Inanimalmodelsofsurgicallyinducedabdominal/peritonealendometriosis,
NSAIDsdifferentiallyinhibitedlesionestablishmentandgrowth,resultinginsignificantlyreduceddiseaseburden
[82,83].Thiseffectmayalsooccurinhumans[84,85].Nonsteroidaltherapies,suchasantiinflammatoryand
antiangiogenicdrugs,areanemergingareaofinvestigationintreatmentofendometriosis[86].(See"Overviewof
thetreatmentofendometriosis",sectionon'Analgesics'.)
MANAGEMENTOFRECURRENTPAINEndometriosisisachronicandprogressivedisease,thuspaincan
recurdespitetherapy.Managementoptionsforrecurrentpaininclude:
Changingtoadifferenttreatmentmodality.Ifgirlslessthan16yearsofagehavepersistentpainwhile
takingcontinuouscombinationhormonaltherapy,thenutilizationofGnRHagonistswithaddbacktherapy
maybeneeded.Onecourseofsixtoninemonthsoftherapymaybeadequate,followedbyreturnto
combinationcontinuoushormonaltherapy.
ProlongedutilizationofaGnRHagonistwithaddbacktherapy.Wehavetreatedpatientswithsurgically
diagnoseddiseaserefractorytoothermedicationswithprolongedGnRHagonisttreatmentplusaddback
forover10years.Abaselinebonedensityevaluationshouldbeobtainedpriortostartingretreatmentwitha
GnRHagonistoriftherapyistobecontinuedforoversixtoninemonths.
Weobtainabaselinebonemineraldensityassessmentaftertheinitialsixmonthsoftherapyandthen
repeatittwoyearslater.IfbonedensityisstableonGnRHagonistwithaddbacktherapy,thenthetestis
repeatedeverytwoyearsaslongasthepatientcontinuesonthisregimen.Ifbonedensityisdecreasing
despiteaddbacktherapy,theneithersurgicalablation/excisionorcontinuouscombinationhormonaltherapy
areoptions.Asnotedabove,thelongtermutilizationofaGnRHagonistwithaddbacktherapyhasnot
beenstudiedintheadolescentpopulation[57].
Painthatdoesnotrespondtoaggressivemedicaltherapymaybeduetorecurrentendometriosis,endometriomas,
and/orpelvicadhesionsfromendometriosisorpriorsurgery.Arepeatlaparoscopicprocedureshouldbeconsidered
inthisclinicalsituation.Ifsurgeryistobeundertaken,thenlysisofadhesionsshouldbeperformed
laparoscopically.Allvisiblelesionsofendometriosisshouldbecauterized,laserablated,orresected.Weutilize
adhesionpreventiveagentslaparoscopicallyfollowingsurgicallysisofadhesions.(See"Postoperativeperitoneal
adhesionsinadultsandtheirprevention".)
Amultidisciplinaryapproachtopelvicpain,withtheassistanceofpaintreatmentservicesandcomplementary
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andalternativetherapies,isalsohelpfulforsomeadolescents.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
BeyondtheBasicstopics(see"Patientinformation:Endometriosis(BeyondtheBasics)")
Inaddition,thereisadolescentendometriosisspecificdownloadableinformationhandoutsat
www.youngwomenshealth.orglistedbelow:
Endometriosis:
http://www.youngwomenshealth.org/endoinfo.html
ContinuousHormonalTreatmentforEndometriosis:
http://www.youngwomenshealth.org/endo_cont_horm.html
HormonalTreatmentOptionsforAdolescentEndometriosis:
http://www.youngwomenshealth.org/hormonetherapy.html
MonthlyLiveMonitoredChatRoomsforAdolescentwithEndometriosis:
http://www.youngwomenshealth.org/chat.html
ParentsGuidetoAdolescentEndometriosis:
http://www.youngwomenshealth.org/endo_parent.html
SUMMARYANDRECOMMENDATIONSThegoalsoftherapyaretorelievepain,preventdisease
progression,andpreservefertility.Analgorithmforevaluationandmanagementofadolescentswithchronicpelvic
painisshowninthefigure(figure3).
Symptomaticendometriosisoccursinadolescents,inrarecasesbeforemenarche.(See'Prevalence'above
and'Epidemiology'above.)
Adolescentswithendometriosisusuallyhavebothacyclicandcyclicpain.Bowelsymptoms(eg,rectal
pain,constipation,painfuldefecationthatmaybecyclic,rectalbleeding)andbladdersymptoms(eg,
dysuria,urgency,hematuria)arealsocommon,bututerosacralnodularityandovarianendometriomasare
rare.(See'Clinicalmanifestations'above.)
Forevaluationofpelvicpaininadolescents,wesuggesthistoryandphysicalexamination,paindiary,
laboratoryevaluation(eg,pregnancytest,completebloodcount,erythrocytesedimentationrate,urinalysis,
urineculture,testingforgonorrheaandchlamydia),andultrasonographytoexcludeotheranatomiccauses.
However,abimanualpelvicexaminationshouldnotbeconsideredarequirementforevaluationof
adolescentpelvicpain.(See'Initialevaluation'above.)
Whenthepainevaluationsuggestsanonacutegynecologicalsource,wesuggestmedicaltreatmentof
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dysmenorrhea/endometriosisratherthanlaparoscopyfordiagnosisandtherapy(Grade2C).Wesuggest
nonsteroidalantiinflammatoryagentsandcyclichormonaltherapyforfirstlinetherapy(Grade2C).(See
'Trialofmedicaltherapyfordysmenorrhea'above.)
Patientswhodonotrespondtomedicaltherapywithinthreemonthsshouldundergolaparoscopytomakea
definitivediagnosisandundergoablation/resectionoflesionsand/oradhesions.Fiftyto70percentof
adolescentswithchronicpelvicpainhaveendometriosisdiagnosedatthetimeoflaparoscopy.A
gynecologistfamiliarwiththeappearanceandtreatmentofendometriosisinadolescentsshouldperformthe
surgicallaparoscopicprocedure.Thelaparoscopicappearanceofendometriosismaybesubtle,withred
flamelesionsandclearshinyperitonealvesiclesratherthanpowderburns.(See'Patientswhofailtherapy
fordysmenorrhea'above.)
Formedicalmanagementofconfirmedendometriosisinadolescents16yearsofage,wesuggest
continuoushormonaltherapywitheitheracombinationestrogen/progestinorprogestintherapyalonefor
firstlinetherapy(Grade2C).Gonadotropinreleasinghormoneagonists(withaddbacktherapy)area
secondlineapproach.Foradolescents>16yearsofage,wesuggesteithercontinuouscombinedhormonal
contraceptionorgonadotropinreleasinghormoneagonistswithaddbacktherapyasfirstlinetherapy(Grade
2C).(See"Overviewofthetreatmentofendometriosis"and'Postoperativemedicaltreatment'above.)
UponcompletionofGnRHagonistwithaddbacktherapyforsixtoninemonths,thepatientbeginsa
continuouscombinedhormonalcontraceptive.Ifsheisnotabletotoleratecontinuouscombination
hormonaltherapy,thenwesuggestlongtermutilizationofaGnRHagonistwithaddback(Grade2C).(See
'GnRHagonists'above.)
Wehavetreatedpatientswithsurgicallydiagnoseddiseaserefractorytoothermedicationswithprolonged
GnRHagonisttreatmentplusaddbackforover10years.Abaselinebonedensityevaluationshouldbe
obtainedpriortostartingretreatmentwithaGnRHagonistoriftherapyistobecontinuedforoversix
months.IfthepatientremainsonGnRHagonistwithaddbacktherapy,abonedensitytestshouldbe
obtainedeverytwoyears.Painthatdoesnotrespondtoaggressivemedicaltherapymaybedueto
recurrentendometriosis,endometriomas,pelvicadhesionsfromendometriosisorpriorsurgery,oranew
anddifferentdiseaseprocess.Arepeatlaparoscopicprocedureshouldbeconsideredfordiagnosisand
therapyinthisclinicalsituation.(See'Managementofrecurrentpain'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic7415Version15.0
http://www.uptodate.com/contents/diagnosisandtreatmentofendometriosisinadolescents?topicKey=OBGYN%2F7415&elapsedTimeMs=9&source=sear
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GRAPHICS
Frequencyofpresentingsymptomsinadolescentswith
endometriosis
Bothacyclicandcyclicpain
63percent
Acyclicpainonly
28percent
Cyclicpainonly
9percent
Gastrointestinalpain
34percent
Urinarysymptoms
13percent
Irregularmenses
9percent
Vaginaldischarge
6percent
AdaptedfromLaufer,MR,Goitein,L,Bush,M,etal.JPediatrAdolescGynecol199710:199.
Graphic72066Version1.0
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Initialhistory
Characteristicsofthepain:Location(diffuseorlocalized,ifsowhere?),onsetsuddenorgradual,
constantorintermittent,magnitude,timing,duration,quality(sharpordull),radiation,
relationshiptovariousactivities(physical,sexual,physiologic,menses)
Ispainassociatedwithsymptomssuchasdysuria,urinaryfrequency,nausea,vomiting,chills,
fever,backacheorothermusculoskeletalpain,orchangeinbowelhabits?
Pastmedical/surgicalhistorywithattentiontosymptomssuspiciousfor,diagnosisof,andtherapy
forendometriosisorpelvicinflammatorydisease(PID),gastrointestinal(GI)orgenitourinary(GU)
problems,infection,musculoskeletalproblems,orpsychiatricconditions.Anypreviousdiagnostic
testsortreatmentsforpain?
Menstrual,contraceptive,sexual,andgynecologichistory
Isthereahistoryofsexualorsubstanceabuse?
Familyhistoryofrelevantclinicalconditions
Howdoespaininterferewithdailyactivities?
Doesanythingmakethepainbetterorworse?
AdaptedfromGambone,JC,Mittman,BS,Munro,MG,etal.FertilSteril200278:961.
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ConditionsassociatedwithanelevatedserumCA125concentration
Gynecologicmalignancies
Nongynecologicconditions
Epithelialovarian,fallopiantube,and
Cirrhosisandotherliverdisease
primaryperitonealcancers
Ascites
Endometrialcancer
Colitis
Benigngynecologicconditions
Diverticulitis
Benignovarianneoplasms
Appendicularabscess
Functionalovariancysts
Tuberculosisperitonitis
Endometriosis
Pancreatitis
Meigsyndrome
Pleuraleffusion
Adenomyosis
Pulmonaryembolism
Uterineleiomyomas
Pneumonia
Pelvicinflammatorydisease
Cysticfibrosis
Ovarianhyperstimulation
Heartfailure
Pregnancy
Myocardiopathy
Menstruation
Myocardialinfarction
Pericardialdisease
Renalinsufficiency
Urinarytractinfection
Recentsurgery
Systemiclupuserythematosus
Sarcoidosis
Nongynecologiccancers
Breast
Colon
Liver
Gallbladder
Pancreas
Lung
Hematologicmalignancies
Datafrom:
1. BuamahP.JSurgOncol200075:264.
2. MirallesC,et.al.AnnSurgOncol200310:150.
3. MossEL,etal.JClinPathol200558:308.
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Suggestednonsteroidalantiinflammatorydrug(NSAID)dosesin
primarydysmenorrhea
Drug
Initialdose
Subsequent
dose,asneeded
Maximumdose
perdayin
shorttermuse
(3days)
Propionic(phenylpropionic)acids
Ibuprofen*
400to600mg
400to600mgevery
2400mg
4to6hours
Naproxenbase*
500mg
250mgevery6to8
hours
1250mg
Naproxensodium*
550mg
275every6to8
hours
1375mg
Fenoprofen
200mg
200mgevery4to6
3200mg
hours
Ketoprofen
50mg
25to50mgevery6
to8hours
300mg
Mefenamicacid
500mg
250mgevery6hours
1000mg
Meclofenamate
100mg
50mgevery4to6
hours
400mg
Indomethacin
25mg
25mgthreetimes
daily
150mg
Tolmetin
400mg
400mgthreetimes
1800mg
Fenamates
Aceticacids
daily
Diclofenac
75to100mg
50mgthreetimes
daily
150mg(100mg
beginningonday2in
somecountries)
Etodolac
400mg
200to400mgevery
6to8hours
(immediaterelease)
1000mg(immediate
release)
1000mg
500mgtwicedaily
1500mg
Meloxicam
7.5mg
7.5mgoncedaily
15mg
Piroxicam
20mg
10to20mgonce
20mg
Salicylates(nonacetylated)
Diflunisal
Oxicams
daily
NSAIDsaretakenatthefirstonsetofmensesandcontinuedforonetothreedaysorusual
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durationofpainfulsymptoms.PatientswithseveresymptomsmaybegintakinganNSAID
onetotwodayspriortoonsetofmenses.Alldosesshownarefororaladministrationin
adultoradolescentwomen.Patientsshouldbewellhydratedandwithoutsignificantkidney
disease(CrCl>60mL/minute).
AvoidNSAIDuseinwomenwithahistoryofgastrointestinalbleeding,coagulopathy,
ischemicheartdisease,stroke,heartfailure,liverdisease,oraspirinsensitiveasthma.
Usewithcautionoravoidinpatientsreceivingcomedicationwithanticoagulants,systemic
glucocorticoids,lithium,loopdiuretics,andotherinteractingdrugs.Specificinteractions
maybecheckedbyusingLexiInteractprogramincludedwithUpToDate.
*AvailablewithoutaprescriptioninUnitedStatesandothercountries.Naproxensodiumismorerapidly
absorbedthannaproxenbase.
Minimalornoeffectonplateletfunctioningandgenerallytoleratedbyadultswithasthmaatdailydose
of1000mg.
RelativelyCOX2selectiveandminimaleffectonplateletfunctioningatdailydoseof7.5mg.Rarely
associatedwithseriouscutaneousallergicreactions(eg,StevensJohnsonsyndrome).
Riskofseriousgastrointestinalcomplicationsmaybeelevatedindoses20mgperdayconsider
concurrentpharmacologicgastroprotection.Rarelyassociatedwithseriouscutaneousallergicreactions
(eg,StevensJohnsonsyndrome).
Preparedwithdatafrom:
1. Anon.Drugsforpain.TreatmentguidelinesfromtheMedicalLetter2013.11:31.
2. MajoribanksJ,ProctorM,FarquharC,etal.Nonsteroidalantiinflammatorydrugsfor
dysmenorrhoea(review).CochraneDatabaseSystematicRev(2010).20:1.
3. LexicompOnline.Copyright19782016Lexicomp,Inc.AllRightsReserved.
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Thetop,middle,andbottomseriesarerepresentativeofred,
white,andblackimplants,respectively
Reproducedwithpermissionfrom:RevisedAmericanSocietyforReproductiveMedicine
classificationofendometriosis:1996.FertilSteril199767:817.Copyright1997American
SocietyforReproductiveMedicine.
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Associationbetweenlesiontypeandpain
Lesiontype
Pain,percent
Red
84
Clear
76
White
44
Black
22
AdaptedfromDemco,L.JAmAssocGynecolLaparosc19985:241.
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Examplesoftheclassificationofendometriosis
ModifiedfromtheAmericanSocietyforReproductiveMedicine.
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Percentageofendometriosispatientswithpainaccordingtostageof
disease
Stage
Occurrenceofpain,percent
40
II
24
III
24
IV
12
AdaptedfromFedele,L,Parazzini,F,Bianchi,S,etal.FertilSteril199053:155.
19/23
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Estrogenthresholdhypothesis
Reproducedwithpermissionfrom:Barbieri,RL.Hormonetreatmentofendometriosis:
theestrogenthresholdhypothesis.AmJObstetGynecol1992166:740.Copyright
1992Elsevier.
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GnRHagonistscombinedwithsteroid"addback"
Lowdosesteroid
hormoneregimen
Comment
Investigator
Transdermalestradiolpatch25
mcg/day,plus
medroxyprogesteroneacetate2.5
mgdaily
Thisregimendidnotcompletelyprevent
boneloss.Theestradiolconcentration
achievedisintherangeof30pg/ml.
Howell,1995
Norethindroneacetate5mgdaily
Thisisaveryhighdoseofprogestin,
whichisassociatedwithadecreasein
HDLcholesterol.
Hornstein,1997
Conjugatedequineestrogen
0.625mgplusnorethindrone
acetate5mgdaily
Thisregimenpreventedbonelossand
markedlyreducesthevasomotor
symptomsreported.Painreliefwas
excellent.
Hornstein,1997
Conjugatedequineestrogen
0.625mgplus
medroxyprogesteroneacetate5
mgdaily
boneloss.
Moghissi,1998
Conjugatedequineestrogen0.3
mgplusmedroxyprogesterone
acetate2.5mgdaily
boneloss.
Moghissi,1998
Transdermalestradiol25
mcg/day,plusnorethindrone
acetate5mgdaily
boneloss.
Zupi,2004
GnRHagonisttreatmentcombinedwithlowdosesteroid"addback"causesatrophyin
endometriosis,improvespelvicpainandminimizesvasomotorsymptomsandboneloss.The
lowdosesteroidhormoneregimensthathavebeendocumentedtobeeffectiveinrandomized
clinicaltrialswhenusedincombinationwithaGnRHagonistarelistedabove.
GnRH:gonadotropinreleasinghormoneHDL:highdensitylipoprotein.
CourtesyofRobertL.Barbieri,MD.
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Protocolforevaluationandtreatmentofadolescentpelvic
pain/endometriosis
NSAIDS:NonsteroidalantiinflammatorydrugsCHT:combinationhormonaltherapy(oral
contraceptivepills,estrogen/progestinpatch,estrogen/progestinvaginalring)Progestins:
norethindroneacetate,medroxyprogesteroneacetateGnRH:gonadotropinreleasing
hormoneagonistaddback:estrogen+progestinornorethindroneacetatealone.
Adaptedwithpermissionfrom:Laufer,MR,Sanfilippo,J,Rose,G.Adolescent
endometriosis:diagnosisandtreatmentapproaches.JPediatrAdolescGynecol200316(3
Suppl):S311.Copyright2003NorthAmericanSocietyforPediatricandAdolescent
Gynecology.
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1/17/2016
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