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Although endometriosis affects 1 in 10 women in the United States, it also affects adolescents, with the youngest documented at the age of eight. (Young et al, 2017)

Adolescent 

What is Endometriosis?

Endometriosis is a chronic disease where the endometrial-like tissue (similar to the type that lines inside your uterus) grows outside of the uterus and other organs in your abdomen, and cause inflammation, scarring, damage to nearby structures, intense pain and even infertility.

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Delay in diagnosis

It is shown that teenagers with endometriosis often wait for 4.6 years before seeking advice and another 4.7 years before finally being diagnosed. (Ahn et al, 2017)

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Why early detection is necessary?
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  1. Early clinical diagnosis and treatment of endometriosis and dysmenorrhea/pelvic pain are important as they could drastically improve quality of life, reduce the exacerbation of pain and ensure their reproductive potential. 

  2. Endometriosis can cause anxiety, depression and mental disturbance. (Young et al., n.d.)

  3. Endometriosis can also progress into other types of disease if left untreated.  

  4. The risk of developing a comorbid (overlapping) condition among endometriosis patients was at least twice as large for the following comorbidities: infertility/subfertility, ovarian cyst, uterine fibroids, pelvic inflammatory disorder, interstitial cystitis, irritable bowel syndrome, constipation, ovarian cancer, and endometrial cancer.  (Surrey et al., 2018)

  5. Adolescent and young adult women with endometriosis experienced painful sex twice as often than without endometriosis. (Schneider et al., 2020)

  6. Persistent pain can also develop a sensitized nervous system and develop chronic pelvic pain and other chronic pain syndromes. Intermittent or ongoing pain resulting from disease can produce a sensitized peripheral and central nervous system (peripheral and central sensitization) that becomes maladaptive (centralization of pain). (Katz and Seltzer, 2009).

3 factors contribute to delay diagnosis

  1. Overlapping conditions make diagnosis more difficult.(Surrey et al., 2018)

  2. Adolescents often present with chronic pain instead of pain limited to period. (Laufer et al., 1997)

  3. Lesions in adolescents often appear differently than lesions in adult endometriosis patients. (Laufer et al., 2003). It could be missed if the surgeon is not aware of the difference appearances of adolescent endometriosis. 

It has been found that patients who report symptoms as adolescents are evaluated on average by four or more physicians before receiving a diagnosis of endometriosis. (Ballweg, 2003)

Symptoms

Pain.

The majority of teenagers with endometriosis complain of CPP and dysmenorrhea not responsible to NSAIDS (anti-inflammatory medicine) or birth control pills. Approximately 80 % of adolescent girls with CPP not responding to conventional medical therapy have endometriosis. (Yeung et al., 2017)

Other pain such as painful sex in sexually active adolescents, bladder and bowel pain and constipation. Nausea caused by pain is also commonly seen in adolescents. (Saridogan, 2017)

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The pelvic pain in adolescents is cyclic and/or noncyclic, and the pattern of pelvic pain in adolescents is unpredictable, it can be intermittent, constant or a mix of both. (Laufer et al., 1997)

Mental disturbance.

Depression or anxiety

Young individuals with endometriosis, ages 18–23 years, with endometriosis had a greater risk of moderate to severe psychological distress compared those without a history of this condition. (Ballweg, 2003)

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Diagnosis

Initial Evaluation 

Keep a pain diary to examine the pattern of the pain (cyclic or acyclic) and if it is related to bowel or bladder function

Examine family history. Patients with a family history of endometriosis have an increased risk of endometriosis.

Physical Exam 

Medical treatment might be necessary if the patients complain that the pain has interfered with their daily life (missing schools, unable to participate in normal activities, etc). 

Laboratory Tests 

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Rectal-abdominal exam is sufficient for non sexualy active adolescent. Cul-de-sac tenderness is a common finding on pelvic exam for endometriosis. (Redwine and Yocom, 1990)

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Although pelvic ultrasound is not sufficient to rule out endometriosis, it can examine for pelvic mass and structural anomalies, such as ovarian cysts, torsion, tumors.

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No lab tests are available for endometriosis. 

Using CA-125 as a screening test is not recommended due to its high rate of false positives. (Pittaway and Fayez, 1986)

Laparoscopy  (the gold standard)

If the pain still persists or if the medical treatment is not tolerated, laparoscopy might be required for definitive diagnosis. However, due to the extensive training and skills required to perform laparoscopy, referral to a specialist is recommended for endometriosis. 

The decision for surgical management of endometriosis should be based on clinical evaluation, imaging, and medical treatment response, with restrictive use of laparoscopy for diagnosis. Laparoscopy should  be performed by someone with experience in the atypical appearance of adolescent endometriosis.

Endometriotic implants morphology

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Adolescent.

Lesions that are shown on the left are more common in adolescents. It includes red flame, white, yellow-brown lesions, subtle lesions appear to be clear, shiny peritoneal vesicles etc.

Source: Cabus et al., 1997

Adult.

Black and blue lesions are more common for adults though the above can still occur.

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Source: Cabus et al., 1997

Treatment

Two aims in treating endometriosis: control the symptoms and possibly prevent further progression

However, it is crucial to note that there is no data that supports the suppression of the symptoms as either treating the lesions themselves or slowing the progression. 

1.Non-hormonal therapy

Non-hormonal therapy includes non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen sodium. They are the first-line treatment followed by combined oral contraceptives. (Bedaiwy et al., 2017) NSAIDs are appropriate to use for a short term course to see if it relieves the symptoms preoperatively. However, if the symptoms remain unchanged or become worsened, it is encouraged for patients to seek other medical treatment, preferably surgical excision or a short term course of hormonal contraceptives.

2.Hormonal therapy

Hormonal therapy reduces the production of estradiol to decrease endometriotic growth and stop your period. (Mama, 2018)

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Source: womanlog

Hormonal contraceptives 

Hormonal contraceptives such as birth control pills, patches and vaginal rings are less invasive and can also prevent pregnancy. However, it could result in a late diagnosis.  (Dunselman et al., 2014)

Levonorgesterel IUD

Levonorgesterel IUD delivers daily progesterone to the body and lasts for over five years. This is another hormonal treatment option for adolescent patients other than OCPs. Levonorgestrel causes degeneration of the uterine lining and endometriosis. (Yoost et al., 2013)

GnRH analogs 

They are usually used as a treatment after surgical confirmation of the disease. (Sauvan et al., 2018) Their use is limited to short periods of time since they pose a great danger due to bone density loss(Ofer et al., 2016) After 16 years of age where the bone structure is established, GnRHa treatment may be considered, if all the other possible treatments have failed to improve the patient’s quality of life. (Saridogan, 2017) Due to the menopausal side-effects, it should be given with hormonal treatment add back therapy. (Altshuler and Hillard, 2014)It should also be only used for the short term and if the symptoms continue, surgery should be considered. 

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Progestins 

Progestins such as depo medroxyprogesterone acetate (DMPA) can stop periods and prolonged use may be limited due to a correlation of the drug with lower bone mineral density

3.Surgical excision

Surgical excision and destruction of any visual evidence of endometriosis if pain is unresponsive to medical therapy. 

Complete laparoscopic excision can significantly reduce pain of endometriosis in adolescents. (Yeung et al., 2017). The decision for surgical management of endometriosis should be based on clinical evaluation, imaging modality, and medical treatment response, with restrictive use of laparoscopy for diagnosis. (Hwang et al., 2018) Surgical excision should be performed by someone with experience in the atypical appearance of adolescent endometriosis.

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Source: innovativegyn

4.Combined medical-surgical approach

Current data emphasizes the combination of the medical-surgical approach could also be considered as an option. However, some studies have shown that patients with endometriosis (specifically on adolescent patients) do not need post excision suppression. It should be on a case by case basis specific to the patient and their needs. If the surgeon excises all disease from all areas, GnRH analogs or other medication should not be needed postoperatively. Postoperative hormonal treatment may improve in pain relief from the effects of surgical treatment in the short term, but has not been shown to prevent recurrence of the disease in the long term. (Benagiano et al., 2018) Hormonal therapy such as oral contraceptives or IUD might be helpful postoperatively for those with the pain of uterine origin (non endometriosis conditions such as adenomyosis). 

For sonographic or MRI evidence of severe endometriosis in teenagers, such as bilateral ovarian endometriosis, discussion of cryopreservation ovarian tissue is necessary as primary ovarian failure can occur and the recurrence rate is high. Postoperative medical therapy is recommended as recurrence rates may be higher in adolescents.  (Benagiano et al., 2018)

Risk factors 

Teenagers, with a first degree relative suffering from endometriosis, are more likely to get diagnosed with adolescent endometriosis with a rate of 25–30 %. (Saridogan, 2015)

Early menarche

People with menarche at an age of less than 12.

Chemicals

Environmental chemicals widely used, such as bisphenol A (BPA), found to be a potential cause for endometriosis and have negative impact on fertility in general. (Rashtian, 2019)

Others

Lean body type (low BMI) (Shafrir et al., 2018), intense physical activity, passive smoking exposure and skin sensitivity

Positive family history

You are not alone! We are all here for you. 

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A personal story from a young individual with endometriosis 

My name is Meghan Martin. I am 20 years old and I have endometriosis.

 

I have always had heavy periods. This started when I was 11 years old. I would change my pad or tampon almost every hour and couldn’t sleep through the night without bleeding through a pad. It took my mind away from class wondering if there would be blood on my seat when the bell rings. During soccer games, I’d dread the days we wore white shorts at away games wondering if I would be able to find a bathroom at half time after my coaches’ speech and make it back for the beginning of the second half.

 

I’m also tired all the time. No matter how much sleep I get, I am always ready for a nap and feel like I can fall asleep wherever I am. But I could deal with that.

 

The pain was what made my period unbearable. While middle school was accompanied by cramps and back pain, my experiences in high school reflects my endometriosis story the best.

 

In high school, I played soccer in the fall and ran distance for track in the winter and spring while playing more soccer with my club team. I loved school, was doing well in my classes, and had supportive, amazing friends that I am still close with four years later. I was eating well, intensively active for about 15 hours a week, and considered myself both physically and mentally healthy. But three weeks out of the month, I was in pain.

 

On the average weekday, I’d go to school, track practice, soccer practice, nap, and do homework or hang out with friends. The pattern stayed the same almost every day, but the pain I experienced depended on my menstrual cycle. During the week of my period, my cramps were so bad, I’d vomit almost every time I’d exercise. I’ve worn body heating pads to get through gym class and was dependent on Pamprin (an over the counter pain medication) for practice and the school day. After participating in soccer and track for the day, I would come home and lie flat on the ground until my back stopped spazzing. I then transitioned to laying in my bed to do my schoolwork because it was the only comfortable position. But this comfort also often led to me falling asleep during my homework because the more pain I was in, the more fatigue my body felt. 

 

I considered the second week of my cycle residue period pain. The back pain was similar, but cramps did not require a heavy dependence on Pamprin. For the third week, the back pain and cramps intensified again mimicking my period, this time only with less nausea. The fourth week was peaceful for the most part. A calm before the storm. Then I would get my period again. This cycle continued for years.

 

I was stubborn when I dealt with my period, not letting it stop me from doing anything, but it came with a toll. I learned how to cope with the pain but not how to thrive. By the time I made it to senior year, I was burnt out from ignoring the pain and putting extra effort into most days to learn in school and enjoy athletics. With all the hard work and determination I had put into being an athlete and my education, I no longer wanted to be a college athlete, something I’ve dreamt of since I was a little girl.

 

My mom didn’t give up on my dream though. Even though I had accepted my periods and how they affected all aspects of my life, my mom knew something was wrong. She knows that I have a high pain tolerance and wouldn’t be complaining of something unless it was bad. She jokes about how when my brothers and I were growing up she could almost always catch swimmers’ ear before it started for my brothers but would never know about mine until it was a double ear infection. She did some googling, as the self-proclaimed internet doctor she is, and determined I had endometriosis. Frustrated and tired, I told her she was crazy. There is no way I had some random disease that I have never heard of before after multiple gynecologists told me that it was normal. Everyone gets cramps.

 

During those gynecologist visits, I was asked: how painful were my cramps? I never knew how to answer. Yeah they were painful, but when I started to express that I was in pain, I remember the doctor questioning my answer. They asked how is it possible to run 8 miles before soccer practice if I was in that level of pain? Why didn’t I miss school because of the pain? The more they probed at my lifestyle, the more I doubted myself. Maybe I was overreacting. 

 

Looking back, I could have easily answered that I was stubborn and had a high pain tolerance, but as a teenager, I did not have the confidence to advocate for myself when I thought periods are supposed to be painful and my doctors were not supportive of my initial concerns.

 

Lucky for me, I get my stubbornness from my mother. She wasn’t willing to give up. She dragged me to an endometriosis specialist and about six months later, during finals week senior year of high school, I got laparoscopic surgery where I was diagnosed with endometriosis and my lesions were removed.

 

I had made the hopeful decision right before my surgery to attend University of Rochester following graduation and play soccer there, hoping surgery would solve my problem. Now, as a senior at U of R, I am grateful to be a captain of my soccer team, to grow in an academically challenging environment, and most importantly to have nearly pain-free periods.

 

Being diagnosed with endometriosis allowed me to physically and mentally pursue my interests and passions. It changed my perspective on pain and taught me that even if I think it is just in my head or since I can’t see it, doesn’t mean it’s not there.

 

I am fortunate to have caught my endometriosis as a teenager. But that does not mean my story ends there. There are still some residual effects of my pain and nerves that come with the uncertainty of endometriosis returning and feeling of dread every time I need to take pain medications for cramping. Will I be able to have kids later on and will they have to endure endometriosis too? Will my constant fatigue ever subside? Why is so little known about the disease?

 

Endometriosis had such a big impact on my life for years before I even knew the disease existed. I am actively learning more about endometriosis and sharing my story because it is often overlooked even though it affects such a wide population of menstruating individuals. One in ten women worldwide is a significant number and more attention needs to be brought to the disease to mitigate years of living with symptoms and improve quality of life for women around the world.

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To learn more about Meghan, visit About us page.

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