By: Callie Takahashi, MD
Executive Director’s Note: In this review of endometriosis in adolescents, Callie Takahashi recounts a personal experience from college that stuck in her mind over the years and piqued an interest in this important topic. As she learned more about the diagnosis and management of endometriosis in the FACTS elective, she decided to write a synopsis of an article that addressed this topic in teenagers, “Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review” by Janssen et al. published in Human Reproduction Update in 2013. [1] She hopes this summary helps clinicians to better care for adolescent patients presenting with dysmenorrhea.
Introduction
I will always remember the time when my college roommate collapsed in pain, told me this was normal for her once a month, and asked me to cook her rice soup. She was curled up in a ball on the floor, fatigued, and nauseated, so asking her for a recipe seemed impractical. I instead just hurried off and prepared a bowl of salty rice water and hoped it would help. She politely accepted my concoction and then hobbled over to the kitchen—while clutching a heating pad over her abdomen—to re-make the congee so that she could eat something with the pain-relieving ibuprofen that she so desperately needed. I wished that I could have helped her more. At the time, I knew this was not normal, but I lacked the awareness and wisdom to ask more questions. A few years later, I learned that I was not alone in my thinking. I grew up in the era of emerging reality television and watched celebrities such as Padma Lakshmi speak out about a disease called endometriosis.
Endometriosis is a disorder where endometrial tissue grows outside of the uterus presenting as painful periods and, in some cases, leading to infertility. Although I knew that surgical biopsy was the only way to diagnose endometriosis, I was unfamiliar with laparoscopy in adolescents. This summary highlights the important role of this procedure in making an early and accurate diagnosis.
Methodology
Janssen and colleagues conducted a systematic literature search for articles published between 1980 and 2011 in PUBMED and EMBASE using the keywords “endometriosis,” “laparoscopy,” “adolescents,” and “chronic pelvic pain.” The researchers only included articles reporting original research, written in the English language, published in full text, and that addressed the primary outcome variable—i.e., the prevalence of endometriosis diagnosed by laparoscopy in adolescents. The first authors (EJ and AR) independently assessed the articles using the Critical Appraisal Skills Programme (CASP) for cohort studies, both agreeing to define articles as valid if at least four out of the six CASP validity questions were found to be “yes.” While the initial electronic search produced 1,014 citations, only 15 met the criteria for this review, comprising seven studies conducted in the US, six in Europe, one in New Zealand, and one in Asia.
Results
While the prevalence of endometriosis was highly variable ranging from 25% to 100% among the 15 studies, the overall prevalence of visually confirmed endometriosis was 62% (543/880) in all adolescent girls undergoing laparoscopic investigation. The prevalence was higher in adolescents with chronic pelvic pain resistant to treatment with oral contraceptive pills and non-steroidal anti-inflammatory treatments at 75% (237/314). The prevalence of visually confirmed endometriosis was also higher in adolescents with dysmenorrhea at 70% (102/146). ‘
“The prevalence of endometriosis was higher in adolescents with chronic pelvic pain resistant to treatment with oral contraceptive pills and non-steroidal anti-inflammatory treatments.”
Endometriosis was staged laparoscopically with different classification systems: AFS/ASRM [2] was used in eight of 15 studies, ACOSTA in two of 15, combined AFS/ACOSTA classification, Semm Endoscopic Endometriosis Classification, and Kistner classification in one study each, and no classification was used in two of the 15 studies.
Discussion
This systematic review found nearly two-thirds of adolescents with chronic pelvic pain or dysmenorrhea unrelieved with conventional symptomatic treatment had laparoscopic evidence of endometriosis, including moderate-to-severe disease in about one-third of those cases. A more recent systematic review of endometriosis in adolescents published by Yeung et al. (2017) found an even higher prevalence of endometriosis, with up to 80% of adolescent girls with chronic pelvic pain unresponsive to conventional medical therapy having the disease. [3] These findings call on the need for primary care physicians to be aware of the appropriate diagnosis and management of endometriosis for adolescent patients. While symptomatic treatment may be beneficial to some patients, for patients with unrelenting symptoms, further workup with laparoscopic treatment may be beneficial in treating pain, improving quality of life, and improving future fertility. Through the FACTS elective, I have gained awareness about referral to NaProTECHNOLOGY-trained physicians for diagnosis and treatment of endometriosis in adolescent patients, including with near contact laparoscopy. While I have gained greater insight into treatment options, this awareness is also a limitation in itself, as I now recognize that the need for NaPro-trained surgeons far outpaces their availability.
“Nearly two-thirds of adolescents with chronic pelvic pain or dysmenorrhea unrelieved with conventional symptomatic treatment had laparoscopic evidence of endometriosis.”
Due to limited research and a need for more FABM-trained clinicians, this review has many limitations. First, it includes a low number of papers, highlighting the need for further high quality research in the field. Also, the data collection in the included studies was conducted retrospectively, which may increase selection bias and result in an overestimate of the prevalence of endometriosis among adolescents. Another limitation is in the varying age of adolescents in each study. While the American Academy of Pediatrics defines adolescence as the ages between 11 and 21 years, the World Health Organization definition encompasses adolescents from age 10 to 19 years and includes a separate definition of young adults from 20 to 24.
Finally, the authors identified lack of ethnic diversity among the collective study population as an additional limitation of the study. The main symptom leading to laparoscopic investigation was chronic pelvic pain and despite there being no biological difference between Black and White patients’ perception of pain, racial bias in pain assessment can impact treatment recommendations. In 2016, Hoffman et al. surveyed 222 White medical students and resident physicians and found that about half of those surveyed endorsed false beliefs about biological differences between Blacks and Whites. [4] Furthermore, these clinicians-in-training perceived Black patients as feeling less pain than White patients. Every patient deserves the best evidence-based care, and we must do better in our care of adolescents with endometriosis.
References
[1] Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D’Hooghe TM. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update. 2013 Sep-Oct;19(5):570-82. doi: 10.1093/humupd/dmt016. Epub 2013 May 31. PMID: 23727940.
[2] Lee SY, Koo YJ, Lee DH. Classification of endometriosis. Yeungnam Univ J Med. 2021;38(1):10-18. doi:10.12701/yujm.2020.00444.
[3] Yeung P, Gupta S, Gieg S. Endometriosis in Adolescents: A Systematic Review. Journal of Endometriosis and Pelvic Pain Disorders. 2017;9(1):17-29. doi:10.5301/je.5000264.
[4] Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301. doi: 10.1073/pnas.1516047113. Epub 2016 Apr 4. PMID: 27044069; PMCID: PMC4843483.
ABOUT THE AUTHOR
Callie Takahashi, MD
Callie Takahashi, MD, wrote this piece as a fourth-year medical student at Georgetown University School of Medicine. She enrolled in both components of the virtual FACTS elective after multiple patients she cared for in her clinical rotations asked about natural family planning. She began her Family Medicine residency training in 2021 at Kaiser Permanente in Seattle, Washington.
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