Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 15 - 18 REVIEW oral contraceptive pill, levenogestrel intrauterine systems or pro- vera. The median follow was 65 weeks. 17 The benefit of postoperative medical therapy following surgery to prevent recurrence or progression of disease is still contro- versial. The recurrence rate of endometriosis in young women appears to be higher than in older women. The case series by Unger and Laufer, concluded that without combined surgi- cal-medical treatment, the disease worsens and places the patient at risk for chronic pelvic pain and infertility. 26 They reported on 3 adolescents with stage 1 disease that had their lesions cauterized. All 3 patients were prescribed hormonal treatment and all were noncompliant. A second look laparoscopy for persistent symptoms showed worsened stage (2 patients had stage 4, and one stage 2). However, progression of disease in these cases might be due to failure to completely treat lesions at surgery or failure of hor- monal treatment. A retrospective cohort of 57 young women who were treated initially by excision surgery had a 56% (n=32) rate of recurrence of symptoms during a follow up period of 5 years. A second look laparoscopy was performed in 11 of these patients and confirmed the presence of disease. The postoperative medical therapy did not influence the recurrence rates. 27 A study by Doyle et al, concluded that combined surgical-medical management retards disease progression in adolescents and young adults. No change in stage was observed in 70%, 19% improved by a single stage and only 10% worsened on subsequent laparoscopy. There was a likelihood of improvement in stage at the second laparosco- py with those diagnosed as stage 11/111 disease at initial laparos- copy. 28 The benefit of postoperative medical therapy in conjunction with surgery for endometriosis to improve future fertility has not been evaluated. A range of medical therapies have been prescribed for the treat- ment of endometriosis in the adolescence. The options include es- trogen/progestin combinations, progestins alone, and gonadotro- pin-releasing hormone agonists (GnRHa) with add back therapy. Dysmenorrhoea in adolescence is common and treatment with NSAID’s and/or combined oral contraception is common practice. This approach may improve symptoms and avoid further investi- gations including laparoscopy. However, it is possible that endo- metriosis may progress whilst the symptoms are masked. Hence, there is an urgent need to start prospective research to establish the long term benefits and potential disadvantages of empirical treatment with the above drugs. Gonadotropin-releasing hormone agonist The use of empirical GnRHa without the diagnosis of endome- triosis is contentious in the adolescent. It should be reserved for those with surgically confirmed disease. Their side effect profile makes it a difficult choice and there is also concern of its use in teenagers who are at the critical stage of achieving the peak bone density. It should best be avoided in teenagers less than 17 years of age. A retrospective study by Yang et al, reported a recurrence rate of 55.6% in adolescent patients after excisional surgery with a follow up ranging from 12-98 months. 29 Disease recurred in 46- 50% of patients receiving oral contraceptive pills and progestins. However, no recurrence was seen in patients receiving GnRHa. 29 Two randomized controlled trials assessed the hormonal add-back therapy for adolescent females treated with GnRHa for endometri- osis. Both concluded that hormonal add back therapy successfully preserved bone health and improved QOL during the 12 month of therapy. The combination of norethindrone acetate plus conjugat- ed equine estrogen as add-back appeared to be more effective for increasing bone mineral density, total bone mineral content and QOL health related issues than norethindronate acetate alone. 30, 31 Levenorgestrel intrauterine system The use of the Levenorgestrel intrauterine system (LNG-IUS) for the treatment of endometriosis in the adolescence is extrapolated from data in the adult population. A retrospective cohort study by Yoost et al, reported that the LNG-IUD diminished pain and bleeding in the adolescent patients. 32 A case report using LNG- IUD together with etonogestrel subdermal implant suppressed endometriosis symptoms, however, more data is required for its universal use. 33 Dienogest Dienogest (Visanne®) is a progestin used as a monotherapy at an oral dose of 2 mg once daily for patients with endometriosis. It is highly selective for the progesterone receptor, exhibiting strong progestational effects, moderate antigonadotrophic effects with limited androgenic, glucocorticoid, or mineralocorticoid activi- ty. Its use in the adolescent population with a daily dose over 52 weeks has been reported and showed a decrease in lumbar spine BMD with partial recovery after treatment discontinuation. 34 Hence, its use should be tailored taking into account the expected efficacy on endometriosis associated pain and an individual’s risk factors for osteoporosis. MANAGEMENT OF ENDOMETRIOMAS There is very limited data with regard to management of endo- metriomas in adolescent and young women. Recent studies have reported that advanced stage endometriosis in adolescents present mainly with endometriomas rather than peritoneal or adhesive disease. 19 A retrospective chart review of 63 adolescent patients with endometriomas by Ozyer et al, found that bilateral disease occurred in 14/63 (22.2%). 35 Chronic pelvic pain was the most common symptom (44%) and 55 patients (87%) had <16 points for adnexal adhesions (calculated according to the r-ASRM classifica- tion). The surgery performed was a combined technique of cystec- tomy and cauterization of the capsule. 35 A recent review by Gordts et al, concluded that early ablative surgery can contribute to a lower morbidity, relief of symptoms, and a better QOL. 36 How- ever, recurrence of endometriomas is a challenge. Audebert et al, reported a recurrence rate of 50% for deep infiltrating endometri- osis and 36.84% for endometriomas during a mean follow up 97.5 months after excision and ablation surgery. 18 Lee et al, reported that the cumulative recurrence rate of endometrioma per patient at 24, 36, 60 and 96 months after laparoscopic cyst enucleation for endometriomas was 6.4%, 10%, 19.9% and 30.9% respectively. 37 All patients had stage 3 or 4 disease and surgical characteristics such as diameter of the cyst, rAFS stage, unilateral or bilateral endometriomas and coexistence of deep endometriomas were not associated with recurrence. 37 Seo et al, retrospectively evaluated 176 women who received GnRHa for 3 to 6 cycles followed by oral contraception during a median follow up of 41 months (range 6-159 months) after conservative laparoscopic surgery for ovarian endometrioma. 38 The cumulative proportion of recurrent endome- triomas after 60 months was comparable between the adolescent (5.3%) and adult (8.5%) groups. They concluded that postopera- tive treatment with GnRHa and oral contraception was effective in adolescents for the prevention of endometrioma recurrence. 38 Future developments There is a need for good quality randomized and controlled trials evaluating surgical technique, the use of hypoestrogenic and other hormonal agents in the prevention of disease progression and clinical outcomes. Non-invasive diagnostic methods are urgently needed in the adolescent age group. Molecular pathways associated with disease initiation and progression are being assessed to provide more information to aid in diagnosis and treatment. 39 Future investiga- tions into gene expression profile and epigenetic modifications will give us a better understanding of the disease for novel diag- nostic and treatment interventions. Conclusion Adolescent endometriosis requires long-term management to prevent recurrence of disease. Early diagnosis and cost-effective OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 17