Endometriomas in adolescents and young women

Height and pelvic lesion number: Do they have a positive relationship with postoperative recurrence in adolescent endometriosis?-A retrospective clinical analysis of 89 adolescent endometriosis in China

BACKGROUND

Adolescent endometriosis is a special type of endometriosis. Its diagnosis is often delayed. This study aimed to share the treatment experience of adolescent endometriosis and analyze the clinical manifestation, clinical stage, and risk factors of postoperative recurrence in China.

METHODS

Eighty-nine cases of adolescent endometriosis over 7 years in a single institution were reviewed. Demographic, clinical outcome measures were collected.

RESULT

The cumulative incidence rates of postoperative recurrence at years 1, 2, 3, 4, and 5 were 13.2%, 15.09%, 16.98%, 20.75%, and 20.75%, respectively. The risk factors associated with postoperative recurrence were disease stage, number of lesions, and height. In multivariate analysis, the independent risk factors of postoperative recurrence were height (RR: 1.132, 95% CI: 1.018-1.260) and the number of pelvic lesions (three or more, RR: 4.202, 95% CI: 1.013-17.433).

CONCLUSION

Taller patients and those who had multiple lesion sites (≥3) should receive more attention, because they have a higher possibility of relapse after surgery than their counterparts. This finding can guide the postoperative treatment of adolescent patients with endometrioma.

Adolescent Endometriosis

Importance

Endometriosis is a major health concern in the adolescent population and significantly impacts daily physical and psychosocial functioning. Endometriosis can have differing presentations in this population, and the diagnosis often involves long delays and multiple visits to specialists.

Objective

The aim of this review is to discuss adolescent endometriosis, factors specific to this population, accurate diagnosis, and evidence-based surgical and medical management.

Evidence Acquisition

Computerized searches on the topic of endometriosis and adolescent endometriosis were completed. References from identified sources were then searched manually to allow for a thorough review. Data from relevant sources were synthesized to create the review.

Results

The literature supports endometriosis as a frequent cause of secondary dysmenorrhea. The characteristics of adolescents with endometriosis are shown to differ from those of adults. Initial medical therapy includes nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives, but laparoscopy does have a role in the adolescent population, particularly those who have inadequate response to these treatments. Adolescent endometriosis may have a different appearance and be of all stages. Medical therapies are similar to that of the adult population; however, the benefits of medical and surgical management must be tailored to the adolescent patient.

Conclusions and Relevance

Adolescent endometriosis is likely a more prevalent cause of dysmenorrhea than currently appreciated. A high index of suspicion combined with recognition of risk factors and history-based markers of endometriosis may help identify adolescent endometriosis earlier and avoid delays in diagnosis. Expert opinion supports earlier laparoscopic evaluation in patients with symptoms unresponsive to oral medications, those who have failed initial medical therapy, or those who have evidence of deeply invasive disease, such as an endometrioma. Surgeons should be familiar with the unique appearance of lesions in the adolescent and understand the evidence as it relates to surgical therapy. Postoperative medical management is generally advocated by many, although the efficacy remains unclear at present.

A focus on the distinctions and current evidence of endometriosis in adolescents

Endometriosis (EM) occurring in adolescents presents distinct clinical and histologic characteristics compared to the disease in women. Because the symptoms of EM are nonspecific, often overlapping with those experienced in a range of gynecological and gastrointestinal conditions, the process of reaching a diagnosis of EM is often delayed. The diagnosis of EM is suspected depending on the history and the symptoms and signs, is corroborated by physical examination and imaging techniques, and is finally proved by histological examination of specimens collected during laparoscopy. Currently, there is insufficient evidence to make strong recommendations for management in adolescents who may have EM. This short report reviews some peculiarities of EM in adolescents and provides an update of recent knowledge of the diagnosis and treatment of EM. We hope that the present contribution may help to bring more attention to the clinical diagnosis of EM and consequently aid in decreasing diagnostic delay.

Endometrioma in Adolescents and Future Reproductive Health

There continues to be debate over the nature and progression of ovarian endometriomas in adolescence due to the possibility that they may have a different origin and to the impossibility to be able to predict progress.

The hypothesis of a different origin traces its roots in the phenomenon called “neonatal menstruation” (NUB), occurring in approximately 5% of newborn. The retrograde shedding of neonatal endometrium may contain progenitor cells and stroma that may lie dormant under the peritoneal surface until being activated when estrogens begin to rise.

In teenagers, ovarian endometriomas are often preceded by highly angiogenic implants in the fossa ovarica, with adhesion formation resulting in the invagination of the ovarian cortex and the creation of a pseudocyst.

Use of imaging techniques makes it possible to diagnose even small endometriomas. This is vital to their management, since there is evidence that the disease in an adolescent represents a severe condition, with tendency to progression. In addition, if intervention is decided, the first surgical procedure can determine the ultimate outcome of her reproductive life, because there is a significantly higher risk of inadvertently removing ovarian tissue in the presence of an endometrioma than of other ovarian pathologies. For this reason, techniques avoiding additional trauma to the ovary should be preferred and those who wish to become pregnant should attempt conception as soon as possible; if pregnancy is not sought, hormonal therapy is strongly advised.

Finally, young age at diagnosis may constitute a pivotal factor in considering fertility preservation.

Endometriosis in Adolescents: A Systematic Review

Introduction

The aim of this manuscript is to present a systematic review of characteristics and management of endometriosis in adolescents in order to gain some relevant insight into the most appropriate clinical management of the disease.

Methods

The literature review was done using electronic database PubMed focusing on the terms ‘adolescents’, ‘endometriosis’, ‘teenagers’, ‘pain’, ‘infertility’, ‘quality of life’, ‘medical’ and ‘surgical management’ from 1980 onward and was limited to articles in English. Articles were only included if they reported original relevant research.

Results

The 24 studies selected for review included 1148 adolescents with laparoscopic proven endometriosis. The diagnosis of endometriosis was histologically confirmed in 39.02% (448/1148) of cases. The results from trials have been tabulated and main results presented in a question and answer format.

Conclusions

The majority of adolescent girls with chronic pelvic pain not responding to conventional medical therapy have endometriosis (up to 80%). Laparoscopy with biopsy is the only way to diagnose endometriosis in the adolescent population, and depends on recognition of atypical manifestations of the disease. Surgical management (especially by an expert surgeon) has been shown to be beneficial in reducing pain, improving infertility, and preventing progression or recurrence of disease. Postoperative hormonal suppression helps reduce pain symptoms and recurrence of endometriomas, but it does not seem to prevent disease recurrence or progression of peritoneal endometriosis, and has not been shown to improve future fertility. Postoperative suppression until pregnancy is based on expert opinion only. There is a need for good quality properly randomized trials.

Ovarian endometrioma in the adolescent: a plea for early-stage diagnosis and full surgical treatment

The incidence and severity of endometriosis in adolescent are comparable with the incidence in adult women. The mean delay between the onset of symptoms and the final diagnosis varies between 6.4 and 11.7 years. The longer the diagnosis is delayed, the more the endometriosis can progress to a more severe stage certainly in the group of patients with pelvic pain. The evolution of endometriosis and its progressivity are not predictable, and the severity of the disease is not directly related to the degree of pain. Endometriotic cysts have a detrimental effect on the ovarian reserve by the evolution in time and the surgical excision technique. Already, in small endometriotic cysts (<4 cm), loss of follicular reserve is present together with the formation of fibrosis in the cortex of the ovary. Early diagnosis of endometriosis in the adolescent deserves our full attention. Non-invasive imaging techniques like 2-D and 3-D ultrasound are helpful in the early diagnosis. Early ablative surgery is recommendable. Although laparoscopy is traditionally recommended, transvaginal laparoscopy has been shown to be most effective in ablating endometriomas with a maximum diameter of 3 cm. Early detection and intervention will contribute to a better quality of life in these adolescents and also to a lower damage of the ovarian tissue by a less invasive ablative surgery.

Reproductive outcome following hysteroscopic treatment of uterine septum

BACKGROUND

Septate uterus is the most common uterine anomaly and a cause for miscarriage and infertility. Existing data suggested a better reproductive outcome of uterine septum following hysteroscopic septum resection.

OBJECTIVE

Current study was administered to share our experience in hystroscopic septum resection for reproductive outcome following hysteroscopic treatment of uterine septum and specifically focusing on different treatment protocols after hysteroscopic septum resection.

METHODS& MATERIALS

This study was a cross-sectional study based on secondary data that was obtained from medical records of infertile women who had undergone transvaginal hysteroscopy and used different treatment protocols after hysteroscopic correction of uterine septum in Infertility and Reproductive Health Research Center between April 2005 and February 2014.

RESULTS

The total number of infertile women underwent hysteroscopy uterine septoplasty was 106. The hysteroscopy septoplasty resulted in an overall pregnancy rate of 67% and a live birth 57.5%. Pregnancy rate for patients who had not male infertility was 92.1%. The chi-square test did not reveal any statistically significant difference in side affect, pregnancy, live birth, abortion, preterm deliveries, and term deliveries rate between these patients either with consistent hormone therapy plus IUD insertion or with alternate hormone therapy plus IUD after hysteroscopic metroplasty.

CONCLUSION

The findings of the present study indicated hysteroscopic septum resection to remove a uterine septum in women with infertility is safe and may be an efficacious procedure. Treatment following hysteroscopic septum resection, either the consistent or the alternate protocol is both beneficial to improve pregnancy rate.

Advanced stage endometriosis in adolescents and young women

STUDY OBJECTIVE

To describe the prevalence and characteristics of advanced stage endometriosis in adolescents and young women treated in a tertiary referral center.

DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

86 adolescents and young women (≤22 y) who underwent surgery for endometriosis. The operative reports were reviewed for endometriosis stage, surgical findings, surgical procedures, and pathology.

MAIN OUTCOME MEASURES

Endometriosis stage reported according to the revised American Fertility Society classification.

RESULTS

Early stage endometriosis (stage I or II) was found in 66 (76%) and advanced stage endometriosis (stage III or IV) in 20 (23%). The surgical findings in the 20 patients with advanced stage endometriosis included ovarian endometriomas in 14 cases, rectovaginal nodule in 1 case, and diaphragmatic and pulmonary endometriosis in 1 case. Women with advanced stage endometriosis were found to be slightly older at time of diagnosis than those with early stage disease (mean age 20.4 ± 1.4 y vs 18.7 ± 2.2 y respectively, P < .001).

CONCLUSION

In adolescents and young women with endometriosis, advanced stage disease is not uncommon. The main presentation of advanced stage endometriosis in this age group is ovarian endometriomas rather than extensive peritoneal or adhesive disease.