Pain Levels of Women Diagnosed with Endometriosis: Is There a Difference in Younger Women?

STUDY OBJECTIVE

Early diagnosis and treatment of endometriosis affecting adolescent women are important in preventing chronic pain. Our aim was to analyze the clinical characteristics and severity of symptoms in adolescent patients with endometriosis compared with older patients.

METHODS

This single-center retrospective cohort study in a tertiary referral hospital analyzed women whose first consultation at the certified endometriosis center of Bern University Hospital between January 2017 and December 2020 resulted in the clinical diagnosis of endometriosis. Patients, divided into 2 groups by age, reported visual analog scale (VAS) scores for noncyclic pelvic pain, dysmenorrhea, dyschezia, dysuria, and dyspareunia. The symptom types and severity in the 2 groups were compared. The young patients with endometriosis were analyzed in greater detail, comparing VAS scores and types of endometriosis.

RESULTS

From a total of 826 patients, 144 (17.4%) patients 24 years old or younger and 682 (82.6%) patients over 24 years old were compared. The younger patients reported significantly higher pain scores for dysmenorrhea (VAS 7.3 vs 6.6; P = .015), dyspareunia (VAS 4.6 vs 3.4; P = .001), and noncyclic pelvic pain (VAS 4.3 vs 3.7; P = .032) compared with the older patient collective. Similar results were found when excluding patients with hormonal treatment.

CONCLUSION

Young patients with clinically diagnosed endometriosis have significantly higher dysmenorrhea and dyspareunia pain levels than older patients. By acknowledging and understanding this, early diagnosis and adequate treatment can be promoted. Dyspareunia in adolescents in particular merits clinical attention.

Altered anterior insula functional connectivity in adolescent and young women with endometriosis-associated pain: Pilot resting-state fMRI study

BACKGROUND

Endometriosis is the leading cause of chronic pelvic pain. Alterations in brain functional connectivity have been reported in adult women with endometriosis-associated pain (EAP), however, it is still unknown if similar patterns of changes exist in adolescents.

METHODS

In this pilot study, resting-state fMRI scans were obtained from 11 adolescent and young women with EAP and 14 healthy female controls. Using a seed-to-voxel approach, we investigated functional connectivity between the anterior insula, medial prefrontal cortex, and the rest of the brain. Furthermore, we explored whether potential functional connectivity differences were correlated with clinical characteristics including disease duration, pain intensity, and different psychosocial factors (pain catastrophizing, fear of pain, functional disability, anxiety, and depression).

RESULTS

Our findings revealed that patients with EAP demonstrated significantly decreased connectivity between the right anterior insula and two clusters: one in the right cerebellum, and one in the left middle frontal gyrus compared to controls. Additionally, functional connectivity between the right anterior insula and the right cerebellum was positively associated with pain intensity levels. In patients with EAP, brain changes were also correlated with state anxiety and fear of pain.

CONCLUSIONS

Our results are relevant not only for understanding the brain characteristics underlying EAP at a younger age, but also in enhancing future pain treatment efforts by supporting the involvement of the central nervous system in endometriosis.

Surgical Management of Superficial Peritoneal Adolescent Endometriosis

BACKGROUND

Adolescent endometriosis typically presents as stage I with superficial peritoneal disease and less commonly as stage III or IV with deeply infiltrative disease. Endometriosis lesions can be destroyed (cautery or laser), cutting out the discrete lesion with excision and destroyed, or radically excised with removal of the lesion and surrounding tissue. It has been shown to be beneficial to excise deeply infiltrative disease to improve pain. Radical excision has been promoted by a subset of surgeons and involves removal of large areas of peritoneum with the promise/proposal of a cure and suggestion of no need for medical suppression of endometriosis. The best technique to manage superficial peritoneal disease has not yet been defined.

CASE

A 15-year-old young woman with a history of 2 previous laparoscopies for pain and an ovarian cyst who underwent removal of a mucinous cystadenoma, presented to a local gynecologist with chronic pelvic pain. She underwent a third laparoscopy and was found to have superficial peritoneal endometriosis and filmy adhesions believed to be due to the previous ovarian surgery. The endometriosis was surgically destroyed with the use of cautery and the filmy adhesions were lysed. Months later she had a return of pain and was advised to have a fourth laparoscopy with radical excision by an "excisionalist" gynecologist. She was found to have superficial peritoneal disease with ASRM-defined stage I endometriosis and underwent radical excision of the peritoneum of the anterior cul de sac, posterior cul de sac, and both pelvic side walls. She was informed that she had been cured of her endometriosis and was thus not treated with postoperative hormonal suppression. Her pain did not improve and in fact worsened after the radical excisional surgery. She self-referred for care. She started menstrual suppression treatment with continuous estrogen/progestin therapy for medical treatment of endometriosis but after 6 months she was still having severe pain without bleeding. Eight months after the radical excisional surgery she elected to have a fifth laparoscopy to address potential adhesions. At that time she was found to have extensive pelvic adhesions with the uterus adherent to the anterior cul de sac, and adhesions in the posterior cul de sac. In addition, both ovaries were involved with adhesions and adherent to the pelvic side walls. She was found to have clear and red lesions of superficial peritoneal endometriosis. She underwent a lysis of adhesions, and excision of lesions, and destruction of endometriosis. Her pain improved postoperatively; menstrual suppression was continued and she has remained with a continued excellent quality of life with over 2 years of follow-up.

SUMMARY AND CONCLUSION

For this patient, radical excisional surgery resulted in increased pain and extensive adhesion formation. It was not curative because endometriosis was documented on follow-up surgery. In a previously published long-term follow-up report of adolescents with recurrent pain 2-10 years after destruction of superficial peritoneal disease, it was reported that there were no increased adhesions and no trend toward disease progression. Excisional gynecologists who perform this procedure should not suggest that radical excisional surgery is helpful and without increased risk, until studies have shown long-term benefit in the surgical management of superficial peritoneal endometriosis.

Endometriosis in Adolescent and Young Girls: Report on a Series of 55 Cases

STUDY OBJECTIVE

The aim of this retrospective study was to evaluate endometriosis in adolescent and young girls and further to review the menstrual, reproductive characteristics, and risk factors.

DESIGN AND SETTING

We reviewed the medical records of adolescent and young girls with endometriosis from 2 different countries. Data were collected and analyzed from charts of 900 patients with endometriosis.

PARTICIPANTS AND INTERVENTIONS

Fifty-five female adolescents aged between 13 and 21 years (mean age 18.3 years) participated in our series. This study was conducted in the Obstetric and Gynecology Department of Venizeleio General Hospital of Crete and involved all patients diagnosed with endometriosis between 1996 and 2016.

MAIN OUTCOME MEASURES

Statistical methods included χ² and Mann-Whitney U test.

RESULTS

Of 900 patients with endometriosis we found 55 female adolescents (6.1%). The mean age was 18.3 ± 2.3 years, significantly younger compared with the advanced endometriosis patients (32.7 ± 7.2; P < .001). Regarding the menstrual reproductive and others characteristics, we observed several differences in adolescent young girls compared with the advanced age endometriosis group. The factors associated with an increased risk for young women include age at menarche, dysmenorrhea, history of asthma, and a positive family history of endometriosis. Additionally, we report on 16 of 55 (32%) adolescent women with endometriosis and congenital malformations (P < .01) and 5 patients who were diagnosed with dry eye syndrome.

CONCLUSION

There is an association between endometriosis in adolescent and young women and risk factors including early menarche, early onset of dysmenorrhea, history of asthma, previous surgical procedures, obstructive genital anomalies, and family history of endometriosis.

Endometriosis in adolescents

Background and Objectives:

Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes.

Methods:

We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery.

Results:

The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain.

Conclusions:

Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.

Clinical significance of neonatal menstruation

Past studies have clearly shown the existence of a spectrum of endometrial progesterone responses in neonatal endometrium, varying from proliferation to full decidualization with menstrual-like shedding. The bleedings represent, similar to what occurs in adult menstruation, a progesterone withdrawal bleeding. Today, the bleeding is completely neglected and considered an uneventful episode of no clinical significance. Yet clinical studies have linked the risk of bleeding to a series of events indicating fetal distress. The potential link between the progesterone response and major adolescent disorders requires to be investigated by prospective studies.