MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.
Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).
Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.
"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."
Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.
Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.
A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."
Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."
The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.
All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.
Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."
Dr. Opoku-Anane said that she had no relevant financial disclosures.