Endometriosis in Adolescents

Posted by e-Medical PPT Wednesday, August 3, 2011
Theory of endometriosis
Ectopic transplantation of endometrial tissue
 Endometriosis caused by the seeding or implantation of endometrial cells by transtubal regurgitation during menstruation
Coelomic metaplasia
 Transformation (metaplasia) of coelomic epithelium into endometrial tissue
Induction theory
 Extension of the coelomic metaplasia theory
 Endogenous (undefined) biochemical factor → undifferentiated peritoneal cells to develop into endometrial tissue

Incidence
66% of adults women reported the onset of pelvic symptoms before age 20 years
As the age of the onset of symptoms decreases, the number of doctors reaching a diagnosis increases
With early diagnosis and treatment, it is hoped that disease progression and infertility can be limited

Presentation and Characteristics
Adolescents primarily seek medical attention because of pain rather than a concern for infertility
Common symptoms
Progressive dysmenorrhea (64-94%)
Acyclic pain (36-91%)
Dyspareunia (2-46%)
Gastrointestinal complaints (2-46%)

Differential diagnosis of pelvic pain
Appendicitis
Pelvic inflammatory disease
Mullerian anomalies or outflow obstruction
Bowel disease
Hernia
Musculoskeletal disorder
Psychosocial complaints

Diagnosis
Pelvic examination may be difficult, especially in patients who have not had vaginal intercourse
Rectal –abdominal examination in the dorsal lithotomy position may be helpful to determine if a pelvic mass is present
Cotton-tipped swab to evaluate for the presence of transverse vaginal septum, or agenesis of the lower vagina
Ultrasound examination is helpful in evaluation the pelvis of young adolescents who declines a bimanual or rectal-abdominal exam

Surgical diagnosis
After a comprehensive preoperative evaluation and trial of combination hormone therapy and NSAIDs
      → Diagnostic and therapeutic laparoscopy
Laparoscopic findings
Inspection and palpation with a blunt probe of the bowel, bladder, uterus, tubes, ovaries, cul-de-sac, and broad ligament
Typical lesions of endometriosis in adolescents : Red, clear, or white as opposed to the powder-burn lesion seen commonly in adults
Histologic confirmation of the laparoscopic impression is essential
      for the diagnosis of endometriosis

Empiric therapy
Younger than 18 years
      → Combination hormone therapy and NSAIDs
Older than 18 years
      → Empiric trial of GnRH agonist therapy
For patients younger than 18 years because of the effects of GnRH agonist medications on bone formation & long-term bone density or who decline empiric therapy
      → Diagnostic and therapeutic laparoscopy

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