Endometriosis in children and adolescents

“In the pediatric population, endometriosis can have a profound effect on the trajectory of a girl’s life,” began Smitha Vilasagar, MD, FACOG, assistant professor of Obstetrics and Gynecology, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, at AAGL’s 50th Global Congress on MIGS in Austin, Texas. In her session, “Endometriosis management in the pediatric/adolescent population,” Vilasagar highlighted the importance of practitioners recognizing the negative impact the disease has on this population, reviewed clinical and surgical presentations of endometriosis in order to reduce delay in diagnosis, and described differences in treatment options for this age group.

Endometriosis is the most common cause of secondary dysmenorrhea in teens, with 40% of patients aged 19 years or less having had these symptoms with pain, a statistic Vilasagar noted, was “Appalling: The negative impacts on quality of life for these children and teens include missed school, poor self-image, chronic pain, and negative impact on relationships.” Plus, there are significant delays in diagnosis (11.8 years in the United States, 6.7 years in the United Kingdom).

Risk factors include family history (first degree relatives), early menarche (before age 12), heavy menstrual bleeding, as well as migraines and an association with asthma. Additionally, White and Asian groups are more at risk than others.

Vilasagar discussed the symptoms doctors should watch out for, including “urinary symptoms—frequency, urgency; gastrointestinal issues—nausea, vomiting, diarrhea; and comorbidities,” which can include migraines, myofascial pain, vulvodynia, depression, and anxiety. Noncyclic/nongynecologic pain symptoms are common in this age group, and something clinicians should also watch out for, advised Vilasagar.

“Clinical diagnosis and evaluation is important,” said Vilasagar. “An open communication with the patient is key, because teens wait three times longer than other groups to report symptoms, due to embarrassment, fear of repercussions and cultural/familial differences. This is why it is so important in a family not to normalize pain symptoms,” said Vilasagar. “The mom might say, 'I had this same pain, my mother had these symptoms. This is just normal in our family.' But the truth is, it is not normal."

Vilasagar suggests starting off treatment with conservative management, including coping skills, support groups, physical therapy for myofascial pain, acupuncture and more. First line therapies should include NSAIDS, combo estrogen/progestin and progestins, and most importantly, “don’t delay initiation.” With an estrogen/progestin combination, the goal, reminded Vilasagar, was menstrual suppression, with pill and ring options and continuous administration of these interventions.

“Choose progestin only if there are contraindications to estrogen, migraines with aura, or personal/family history,” suggested Vilasagar.

When it came to surgical management, “a minimally invasive approach is best,” said Vilasagar. “Between excision or ablation, excision is the goal. Hysterectomy or oophorectomy is NOT recommended for teens.”

With proper surgical goals, a teen can have an improved quality of life, feel a validation of symptoms and condition, and, noted Vilasagar, “ if done early enough, reduce the lifetime number of surgeries.” Postoperative menstrual suppression is recommended, Vilasagar added, to prevent recurrence of symptoms and disease,” and, perhaps, most importantly, “ preserve and optimize future fertility.”

Reference

1. Vilasagar S. Endometriosis management in the pediatric/adolescent population. Presented at AAGL 50th Global Congress on MIGS. November 14, 2021; Austin, Texas.