Dysmenorrhea and pelvic pain in adolescents

Forty-two normomenstruating adolescents with Müllerian obstructive anomalies: Presentation, pitfalls in the dagnosis and surgical management

INTRODUCTION

We analyzed the frequency, presentation and pitfalls in the diagnosis and surgical management of a large group of normomenstruating adolescents with obstructive reproductive tract anomalies.

MATERIAL AND METHODS

Retrospective analysis of prospectively collected data. Of the 143 outpatients referred for severe dysmenorrhea and persistent pelvic pain, 42 (29.3%) young women with obstructive Müllerian anomalies and regular menstrual flow were identified. These patients were divided into four groups: (1) patients with duplicate uterine cavities, obstructed hemivagina and ipsilateral renal agenesis (n = 34); (2) patients with unicornuate uterus and noncommunicating cavitated rudimentary horn (n = 5); (3) patients with accessory cavitated uterine mass (n = 2); (4) patients with partially obstructed transverse vaginal septum (n = 1). All 42 patients were conservatively treated via laparoscopy and 35/42 patients had also vaginal surgery.

RESULTS

Of the four groups, patients in groups 2 and 3 (n = 7) were conservatively managed by laparoscopy alone; for patients in groups 1 and 4 (n = 35), laparoscopy and the vaginal approach were used. Patients of group 1 were treated by resecting the obstructed vaginal septum with drainage of retained collections. In patients in group 2, surgery consisted of the removal of the rudimentary horn. Patients of group 3 were treated by the removal of myometrial neoformations. In the patient in group 4, treatment consisted of removal of the septum. All surgical procedures were successful and no major complications were recorded. Follow-up reports highlighted the disappearance of obstruction and clear improvement in pain symptoms.

CONCLUSIONS

Unilateral obstructive anomalies of the female genital tract are difficult to identify. Early diagnosis allows the preservation of reproductive activity and avoids potential complications.

Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly

OBJECTIVE

This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n = 36). Additionally, we assessed a novel technique known as butterfly resection for severe cases.

METHODS

This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon.

RESULTS

There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P = 0.64).

CONCLUSION

Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques.

CAPSULE

Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Flucrypyrim, a novel uterine relaxant, has antinociceptive and anti-inflammatory effects in vivo

Consequences of primary dsysmenorrhea (PD) can be severe. Increased prostaglandin production leads to uterine contraction and insufficient blood flow to the endometrium causing ischemia and pain symptoms. Protein tyrosine kinase/phosphatase activities contribute to the modulation of uterine contraction. In our previous study, we found the synthetic β-methoxyacrylates compound Fluacrypyrim (FAPM), significantly increased protein tyrosine phosphatases (PTPs) activity, resulting in dephosphorylation of tyrosine kinases. In the present study, we found that FAPM near completely inhibited prostaglandin F2α (PGF_2α)-, oxytocin-, acetylcholine-, and high K⁺-induced uterine contractions in rats in vitro, and decreased rat myometrial myosin light chain (MLC₂₀) phosphorylation induced by PGF_2α. A structure–activity relationship assay indicated that the β-methoxyacrylates structure of FAPM is crucial for the inhibition of PGF_2α-induced uterine contractions. FAPM caused a concentration-dependent parallel rightward shift of the concentration–response curve induced by oxytocin, dose-dependently reduced the number of abdominal constrictions and increased the latency time in PGF_2α- and acetic acid-induced writhing test in mice in vivo. Furthermore, FAPM considerably inhibited the development of Carr-induced rat paw edemas and thexylene-induced mouse ear edemas. Taken together, our results indicate that FAPM exerts antinociceptive and anti-inflammatory effects in vivo with considerable potential as a novel uterine relaxant.

Characteristics of the menstrual cycle in 13-year-old Flemish girls and the impact of menstrual symptoms on social life

This study aimed to investigate the characteristics of symptoms related to the menstrual cycle and their impact on social activities in young teenage girls. Between March and June 2009, all girls born in 1996 who were residents of eight regions in Flanders (Belgium) received a semi-structured questionnaire, including questions about the age of menarche, characteristics of the menstrual cycle, and its impact on social activities. Participants were 792 13-year-old girls (15.7 % of the target population). Out of 363 (47.2 % of participants) postmenarcheal girls, 41.6 % (95 % confidence interval (CI) 36.4-47.0 %) reported painful menstruations. The proportion of girls with painful menstrual periods decreased approximately 16 % with each year the age at menarche increased (relative risk (RR) = 0.84; 0.73-0.98; p < 0.05) and was positively correlated with the amount of blood loss (RR = 0.33; 0.16-0.67; p < 0.05 when little and 1.85; 1.49-2.31; p < 0.001 when abundant, compared to average). One in four (25.4 %) postmenarcheal girls indicated a negative impact of menstruation on social activities, but this proportion was significantly higher in girls who experienced menstruation as painful (41.3 %) compared to those who did not (14.2 %).

CONCLUSION

Early menstrual complaints are common in young adolescent girls and the likelihood of pain increased significantly with lower menarcheal age. What is Known? • Menstrual cycle-related symptoms may negatively interfere with school absence and social activities. • Early menarche and severe dysmenorrhea are correlated with endometriosis. What is New? • In this large population-based study on the characteristics of the menstrual cycle in young teenage girls at or shortly after menarche, painful menstruation was highly prevalent (41.7 %), but related school absenteeism was low (3.2 %). The likelihood of pain increased significantly with lower menarcheal age. • The findings support the need for a systematic evaluation of the characteristics of the menstrual cycle shortly after menarche.

Emotional labor and dysmenorrhea in women working in sales and call centers

Objectives

This study was conducted to investigate the association between emotional labor and dysmenorrhea among women working in sales and call centers in Seoul, South Korea.

Methods

Working women in sales jobs and call centers in Seoul were interviewed face-to-face by well-trained interviewers. In total, 975 participants were analyzed in the final model. Emotional labor was measured using a constructed questionnaire with two components: an emotive effort component with three questions and an emotive dissonance component with five questions. To examine the association between emotional labor and dysmenorrhea, chi-squared tests and logistic regression were applied.

Results

The prevalence of dysmenorrhea among sales workers and call center workers were 43.0% and 61.1%, respectively. The adjusted odds ratios (OR) of emotive effort and emotive dissonance for dysmenorrhea in call center workers were 1.88 (95% confidence interval [CI], 1.07–3.28) and 1.72 (95% CI, 1.13–2.63), respectively. The adjusted OR of emotive effort and emotive dissonance for dysmenorrhea in sales workers were 1.71 (95% CI, 0.92–3.16) and 1.15 (95% CI, 0.67–1.98), respectively.

Conclusions

Emotional labor was found to be associated with dysmenorrhea in call center workers. Further studies to investigate other factors, such as management strategies and the relationship between emotional labor and dysmenorrhea, are needed to support interventions to prevent dysmenorrhea that will further promote the quality of health and life of working women.

Adolescent Endometriosis: Review of Clinical Presentation and Long-Term Issues

Endometriosis may affect adolescent girls. The scientific literature on endometriosis in adolescents is limited, and many aspects are still uncertain despite a growing number of related reports. The prevalence of endometriosis in adolescents is unknown, but in selected groups of patients undergoing laparoscopy, it has been found to be higher than 50%. The physiopathology of adolescent endometriosis has not been specifically shown. However, the presence of a family history and associated genital malformations are more frequently identified in adolescents with endometriosis. The clinical presentation of the disease in adolescents has been assessed by numerous prospective and retrospective studies, and the risk factors for the development of endometriosis are well-known. The recommended diagnostic strategy is actually well-characterized, even if an early diagnosis is hardly ever made. The therapeutic management is also more consensual, but not definitive because of a lack of prospective studies evaluating either short- or long-term results and the impact on the natural history of the disease. Finally, the long-term sequelae are still a burden, and many questions are unanswered, despite new insights provided by a few recent reports evaluating the progression of the disease and its effects on subsequent fertility. Further studies are needed to better assess these issues.

Effects of noninvasive electroacupuncture at Hegu (LI4) and Sanyinjiao (SP6) acupoints on dysmenorrhea: a randomized controlled trial

BACKGROUND

This study aimed to evaluate the effects of noninvasive acupoint stimulation therapy with middle-frequency electrical waves on dysmenorrhea in young women.

METHODS

This randomized controlled trial enrolled 66 gynecology patients who had primary dysmenorrhea, which was defined as painful menstruation without pelvic pathology (secondary dysmenorrhea). Pathology was ruled out by gynecological ultrasound examination and serum concentration of CA-125. Subjects were randomly assigned to an experimental group (n=34) and control group (n=32). Main outcome measures included McGill Questionnaire Short-form and numerical rating scale for pain intensity. Acupuncture-like trancutaneous electrical nerve stimulation (AL-TENS) of middle-frequency (1000 Hz-10,000 Hz) was applied at Hegu (LI4) and Sanyinjiao (SP6) points in the experimental group twice weekly for 8 weeks; the control group received AL-TENS on nonacupoints. Pre- and postintervention results were recorded.

RESULTS

Prior to AL-TENS intervention, no significant differences were found in pain scale and pain intensity between experimental and control groups. After AL-TENS intervention, average total pain score in the experimental group was significantly lower than in the control group (experimental group 2.9±1.2, control group 5.4±2.2; p<0.001). Significant differences were observed between experimental and control groups in average change in pain scores between pre- and postintervention (experimental group 4.5±1.9, control group 1.39±2.0; p<0.001). Pain severity at postintervention was also significantly different between groups (p<0.001).

CONCLUSIONS

Noninvasive electro-acupuncture stimulation therapy with middle-frequency electric waves applied at both Hegu (LI4) and Sanyinjiao (SP6) acupoints mitigates pain in dysmenorrhea.

Does past pain influence current pain: biological and psychosocial models of sex differences

Previous studies have generally indicated sizeable sex differences for both laboratory pain reactivity and clinical pain reports. Numerous biological and psychosocial models have been invoked to account for these findings, but the laboratory and clinical findings have generally been examined in isolation. This paper reviews data which show a relationship between past clinical pain experiences and current responses to experimentally induced pain. Individuals with a greater pain history tend to show lower pain tolerance. Since women often have high pain experience levels and lower pain tolerance, one might ask whether the two factors are related. We review several models, based upon concepts of neonatal differences in pain reactivity, hypervigilance following early pain experiences, and concepts of peripheral and central sensitization or plasticity which might help to bridge the gap between clinical and experimental findings.

Management of Primary Dysmenorrhea by School Adolescents in ILE-IFE, Nigeria

Dysmenorrhea is a problem that girls and women face and often manage themselves with or without support from health professionals. A cross-sectional, descriptive study was conducted among adolescents with dysmenorrhea ( N = 150) in Ile-Ife, Nigeria. The aims of the study were to determine their knowledge of menstruation and primary dysmenorrhea, assess the severity of pain they experienced during an episode of primary dysmenorrhea, and determine the management strategies they adopted. A pre-tested semi-structured questionnaire was used to collect data. Findings revealed the adolescents had a knowledge deficit regarding menstruation and dysmenorrhea, 58% of respondents reported pain between face 4 and face 10 on the Faces Pain Scale and the majority used inappropriate methods to manage primary dysmenorrhea. School nurses are able to assist adolescents and their mothers in proper management of primary dysmenorrhea.

Interstitial cystitis is an etiology of chronic pelvic pain in young women

STUDY OBJECTIVE

The prevalence of interstitial cystitis (IC) in young women, especially in those 18 years old or younger, is not well defined. This case series was performed to investigate IC as a cause of chronic pelvic pain (CPP) in young women.

DESIGN

Case series.

SETTING

University medical center.

PARTICIPANTS

Twenty-eight women with CPP, ages 13 to 25, who underwent concomitant laparoscopy and cystoscopy.

INTERVENTIONS

All subjects underwent concomitant diagnostic laparoscopy and cystoscopy with hydrodistension for evaluation of CPP. Charts were reviewed to discern preoperative symptoms, operative findings, and postoperative diagnoses.

MAIN OUTCOME MEASURE

Diagnosis of IC based on symptoms and cystoscopic findings.

RESULTS

All 28 women had CPP, 23 (82%) had dysmenorrhea, and 12 of 25 (48%) sexually active subjects had dyspareunia. Twenty-six subjects (93%) had urinary symptoms including frequency (75%), nocturia (32%), urgency (25%), and dysuria (18%). Eleven (39%) subjects were diagnosed with IC and 18 (64%) with endometriosis, including 7 (25%) subjects with both IC and endometriosis. Laparoscopic findings were normal in 6 (21%) subjects. Of the 26 subjects with urinary symptoms, 21 (81%) had findings on laparoscopy or cystoscopy. In this cohort of young women with chronic pelvic pain, urinary frequency and dyspareunia were significantly associated with the diagnosis of IC.

CONCLUSIONS

The results of this study suggest that interstitial cystitis is an etiology of CPP in young women. Evaluation of the bladder as an origin of pelvic pain is warranted in young women with CPP and urinary frequency or dyspareunia.

Laparoscopic treatment of endometriosis in teenagers

OBJECTIVES

To determine the frequency and severity of endometriosis in adolescent and teenager girls with chronic pelvic pain (CPP) who fail to respond to medical treatment and to evaluate the outcome of radical laparoscopic surgery for severe endometriosis.

DESIGN

Retrospective review of case records of all girls under the age of 21 years who underwent diagnostic and/or operative laparoscopy for CPP unresponsive to medical treatment between January 2001 and December 2003. The operative findings and the response to surgery were retrospectively reviewed.

RESULTS

Thirty-one girls were referred. No pelvic abnormalities were detected in 11 patients (35.5%). Endometriosis was detected in 11 (35.5%). Six had severe endometriosis. Other diagnoses included: non-functional non-endometriotic ovarian cyst (4 patients), functional ovarian cyst (1 patient), hydrosalpinx (bilateral, 1 patient; unilateral, 1 patient) and obstructed uterine horn (2 patients). Of those with severe disease all six were treated laparoscopically without complications. Five were rendered pain free and one had an improvement in symptoms.

CONCLUSIONS

Endometriosis can occur in adolescent and teenager girls. Laparoscopy should be carried out in all adolescents and teenagers with CPP unresponsive to medical treatment. This the first study reporting the outcome of radical excision treatment for severe endometriosis in this age group and early results are encouraging.

Adolescent chronic pelvic pain

The presentation of chronic pelvic pain in the adolescent can at times be quite daunting. A careful and insightful approach to obtaining the history and physical examination must be implemented while maintaining an appreciation of the various stages of adolescent development. The etiologies can range from gynecologic to nongynecologic causes. The ability to render an early diagnosis and appropriate treatment in this population of patients can significantly improve future reproductive health outcomes. The following minireview will outline a systematic approach to the adolescent with chronic pelvic pain.

Double-blind study to evaluate efficacy and safety of meloxicam 7.5 mg and 15 mg versus mefenamic acid 1500 mg in the treatment of primary dysmenorrhea

OBJECTIVE

Assessment of efficacy and safety of meloxicam 7.5 mg and 15 mg once a day (o.a.d.) compared with mefenamic acid 500 mg three times a day (t.i.d.), over a treatment period of 3-5 days, during three menstrual cycles, for primary dysmenorrhea.

STUDY DESIGN

Multicenter, multinational, double-blind, double-dummy, three parallel groups, randomized trial, phase IIb, 337 patients. Treatment group comparisons of continuous variables were carried out using the Kruskal-Wallis test and Wilcoxon signed rank tests. Efficacy was analyzed using Fisher and chi(2)-tests.

RESULTS

Meloxicam 7.5 mg and 15 mg showed a similar profile in pain reduction and dysmenorrhea symptoms when compared with mefenamic acid. Thirty-five subjects presented with gastrointestinal (GI) adverse events (AEs). Two-thirds of those 35 subjects were in the mefenamic acid group. There were no differences between the safety profiles of the two meloxicam dosages. Laboratory abnormalities did not differ in incidence among the treatment groups.

CONCLUSION

Both of the daily doses of meloxicam tested were comparable to 500 mg mefenamic acid t.i.d. in relieving dysmenorrhea symptoms, and meloxicam seems to have a better gastrointestinal tolerability profile.

An Accessory Uterine Cavity as a Cause of Pelvic Pain

BACKGROUND

Pelvic pain is a common gynecologic problem. We report a case of a noncommunicating accessory uterine cavity as a cause of pelvic pain in a young adolescent.

CASE

A 17-year-old nulligravida presented with worsening pelvic pain. Transvaginal ultrasound revealed a 3-cm cavity within the myometrium. Hysteroscopy revealed a normal uterine cavity. Surgical excision of the accessory cavity just lateral to the normal uterine cavity was achieved through laparotomy. Pathology confirmed endometrial tissue in the accessory cavity. Pelvic pain resolved after surgery.

CONCLUSION

A noncommunicating uterine cavity should be considered in the differential diagnosis of pelvic pain.

Gynecologic issues of the adolescent female solid organ transplant recipient

Advances in the field of transplant medicine are providing adolescent recipients with continual improvements in health and quality of life. With expanding opportunities for normal social and sexual relationships, adolescents require careful attention to their gynecologic and reproductive health (Box 1). Medical considerations vary depending on the type of organ transplanted, underlying and comorbid conditions, and current medication use. Most adolescent girls achieve menarche, however, and irregular cycles should be evaluated and managed with the same considerations applied to healthy young women. The management of menstrual disorders frequently uses hormonal contraceptive methods. Many transplant recipients also are sexually active and require a contraceptive method to prevent a mistimed pregnancy. With careful attention to organ function, other medical problems, and concurrently prescribed medications, many transplant recipients can use safely the currently available methods of hormonal contraception.