Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 15 - 18 REVIEW reported that as the age of the onset of symptoms decreases, the number of doctors having to be seen to reach a diagnosis increas- es. 11 An average of 4.2 doctors were seen for patients whose symp- toms began before the age of 15 years as compared with an average of 2.64 doctors for patients whose symptoms began between the ages of 30 and 34 years. 11 Several studies on women undergoing surgery for endometriosis have reported that pelvic pain existed for 6-12 years on average, with time to diagnosis and treatment being independent of health care facilities and cost reimburse- ment. 7 Clinical characteristics of endometriosis in adolescents The main symptoms are chronic pelvic pain (27-96%) and dys- menorrhea (18-100%). 7 Pain in the umbilical area and upper thigh is not an infrequent occurrence. Other presentations include var- ious types of abdominal pain (including bowel related pain), uri- nary symptoms, irregular menses, dyspareunia and pelvic masses. Comorbid mood disorders and depression/anxiety has been reported. Irritable bowel syndrome was found in 25%, interstitial cystitis/painful bladder syndrome in 16% and chronic headaches in 19% of adolescents with endometriosis. 12 The quality of life was described as being awful or poor by 64.75% of patients. 13 Fedele et al, found no correlation between severity of pain symptoms or stage of the disease or site of the endometriotic lesions. 14 Acyclic pelvic pain seems to be more common in adolescents than in adults. Teenagers commonly present with atypical non cyclic pain that maybe a daily occurrence. Laufer et al, reported that 90.6% of adolescents with endometriosis had acyclic pain compared to 69% in the adult population. 15 Surgical characteristics of endometriosis It appears that all stages of endometriosis, including deep infil- trating and ovarian endometriomas are found in teenagers and the condition is not only limited to early stages. With earlier reports, the majority of adolescents had early stage disease. Laufer et al (1997) reported that all 39 girls with endometriosis in their study had stage 1 or 2 disease. 15 However recent reports show that a much higher proportion of young girls have advanced stage endo- metriosis. In a systematic review by Janssen et al, it was reported that 50% of teenagers had minimal endometriosis, 27% mild endometriosis, 18% moderate disease and 14% severe endometri- osis. 16 Stavroulis et al in 2006, reported that 54.5% of young girls with endometriosis had stage 4 disease (2 rectovaginal disease, 2 rectovaginal and uterovesical disease, 1 sigmoid disease, and 1 ureteric disease) and a study from France (2015) showed 40% of 55 adolescents had stage 3 or 4 disease which included 6 patients with deep infiltrating endometriosis. 17, 18 The main presentation of advanced stage endometriosis in adolescents is ovarian endome- triomas rather than extensive peritoneal or adhesive disease. Out of 20 patients with advanced stage disease, 14 (70%) had endo- metriomas, 3 (15%) obliteration of cul-de sac, and 2 (10%) had significant adhesive disease. 19 Characteristics of lesions in endometriosis Atypical lesions are common in adolescents, with red lesions being the most common. Red lesions are recognized to be the most active and highly vascularized. Davis et al, 20 and Reese et al, 21 showed a predominance of red lesions in their adolescent population, and demonstrated that adolescence with severe dysmenorrhea, and those with complaints of abdominal pain, nausea, constipation and diarrhea had the greatest number of red lesions. Redwine reported that clear and red lesions occur at an average of 10 years earlier than black lesions. 22 Clear lesions are not uncommon in adolescent endometriosis, but are often difficult to visualize and evaluate. Black lesions are due to haemosiderin deposit from old blood and are older, more mature and less active than red lesions. They are uncommon in adolescents. Peritoneal defects, peritoneal pockets with endometriosis and deep retraction pockets are reported with adolescent endometriosis and should be excised to achieve optimal excision of the disease. Another major difference is the rarity of the deep or adenomy- otic type of endometriosis as compared to adults. The pathophysi- ology of severe endometriosis in the adolescent remains a mystery. Davis et al, reported that the infiltrating endometriosis occurring in pelvic structures of adolescents was characterized by glands and stroma with associated fibrosis of predominantly of 3-5 mm in thickness. 20 These lesions may suggest early stages of deep endo- metriosis and differ histologically from the deep lesions defined in adults. 20 Progression of disease in the adolescent appears to be characterized by extensive adhesions and endometrioma forma- tion. Role of surgery It is crucial for clinicians to consider endometriosis seriously in adolescent girls presenting with severe pelvic pain to ensure timely diagnosis and appropriate management to alleviate their pain, as well as to prevent progression of the disease. Surgery is beneficial in treating pain with all stages of endometriosis. Improvement in pain, and positive impact on quality of life after surgical excision of lesions have been reported in small series of adolescent endo- metriosis. 17, 23 Yeung et al, concluded that there was a decrease in chronic pelvic pain by 32.5%, dyspareunia by 11.8%, and improve- ment in quality of life by 46.4% after complete excision with a follow up of up to 66 months. 13 There were no large trials and no comparative trials with adults when addressing surgery and pain alleviation. Surgery is also beneficial for improving fertility in adolescents with infertility. A retrospective case series to assess the long term fertility outcomes in young women after laparoscopic surgery (excision and ablation) to treat endometriosis–associated pelvic pain demonstrated a long term pregnancy rate of 71.4% of which >80% were achieved without assisted reproductive technology with a mean follow up of 102.5 months. Most of the patients who conceived had stage 1/11 disease. 24 Audebert et al, reported a live birth rate of 72.2% after surgical treatment (excision and ablation) with 9/13 pregnancies in patients with stage 1/11 disease. 18 Is surgery beneficial in reducing disease progression or recur- rence? There is a paucity of data that addresses this issue. There are few studies that emphasize that complete laparoscopic excision can reduce the recurrence rates of endometriosis in adolescents. Yeung et al, found no recurrences (visually or histologically) after com- plete laparoscopic excision of the disease in teenagers at a repeat laparoscopy for pain. During this period, 47.1% of patients had a subsequent laparoscopy for persistent or recurrent pain. 13 Kalu et al, reported a 3-fold increase in symptom recurrence and the need for reoperation in girls previously operated by generalists as com- pared to those operated by an endometriosis specialist team. 25 In the study by Audebert et al, with a mean follow up of 8 years on 50 patients, 25% reported resolution of their symptoms, recurrence rates was 36%, and a second look laparoscopy was performed in 34% of the patients with persistent pain. 18 Among those treated for deep infiltrating endometriosis, there was a trend for higher rates of recurrences that required repeat laparoscopy. 18 It can be argued that optimal (or complete) laparoscopic excision by expert surgeons might slow disease progression. Role of medical therapy Most published reviews recommend that postoperative hormonal suppression be offered to adolescents to treat symptoms (pain) and to prevent progression and recurrence of disease. The ratio- nale for medical therapy is inhibition of prostaglandin synthe- sis, decidualization and subsequent atrophy of residual ectopic endometrial tissue, and reduction in ovarian estrogen production. This tends to inhibit the growth and activity of the endometriosis. Stavroulis et al, showed good response (completely pain free or greatly improved) in 72.3% of patients when prescribed combined OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 16