Endometriosis in Adolescents

Abstract Endometriosis is an estrogen-dependent chronic inflammatory disease characterized by the proliferation of endometrial glandular tissue and stroma outside the uterine cavity. It is estimated that 4 to 17% of adolescent girls have the same form of endometriosis, and it is particularly common among those with dysmenorrhea who respond poorly to analgesics or estroprogestins. For those suffering from recurrent and chronic pelvic pain, the percentage rises to 25-38%. Possible explanations for the pathogenesis of endometriosis are: coelomic metaplasia, embryonic Müllerian rests, iatrogenic implantation, vascular and lymphatic metastasis, the genetic theory, and endometrial stem/progenitor cells that represent different hypotheses besides Sampson’s theory, the classic retrograde menstruation, which is the most widely accepted theory to explain the ectopic implantation of endometrium. According to the ESHRE guidelines, suggestive manifestations for endometriosis include early menarche, severe dysmenorrhea, dyspareunia, abnormal uterine bleeding, midcycle or acyclic pain, resistance to empiric medical treatment, and gastrointestinal and genitourinary symptoms. Known risk factors for developing endometriosis include: genetic predisposition; epigenetic variables – prematurity, bottle feeding, exposure to some pollutants with estrogenic activity; dysregulation of the immune and inflammatory response, as well as obstructive anomalies of the reproductive tract. Diagnosis is made by accurate anamnesis – personal and family history, gynecological examination and ultrasonographic evaluation (transabdominal and transvaginal ultrasound). Magnetic resonance can be useful to detect obstructive reproductive tract anomalies and to identify and characterize endometriotic lesions that are difficult to locate by ultrasound. A multidisciplinary diagnostic approach should be considered for a complete evaluation of these patients. Laparoscopic evidence serves as the gold standard for verifying peritoneal endometriosis and determining its stage, spread, and severity. A differential diagnosis of gastrointestinal pathologies, Müllerian anomalies, recurrent infections, and adenomyosis must be made. The treatment of this disease includes medical and surgical interventions, and a combination of both. ESRHE guidelines advise clinicians treating women with endometriosis to prescribe hormonal contraceptives or progestins to reduce endometriosis-associated pain. The use of gonadotropin hormone-releasing hormone agonists is acceptable in adolescents only if the patient with known endometriosis is refractory to other medical therapies or surgical treatments. The goals of medical therapy in the adolescent patient include symptomatic relief, suppression of disease progression, and protection of future fertility.