Endometriosis In Adolescents

Endometriosis is a chronic, frequently painful disorder that primarily affects the pelvic area and is characterised by tissue that resembles the lining of the uterus growing outside of it. Numerous symptoms, including infertility and painful periods, can result from this illness.

Endometriosis can affect teens as well, however diagnosing it at this point can be difficult. It primarily affects fertile people assigned female at birth. Adolescent endometriosis raises special considerations because of its possible effects on social, emotional, and physical development. It takes early detection, all-encompassing management techniques, and awareness to address endometriosis in teenagers in order to provide this susceptible group with the right support and care.

Introduction

Endometriosis is a chronic condition involving issues with the endometrial tissues in the female reproductive system. Often, it presents with ectopic Mullerian tissue implantation found lining the uterus (including the endometrial glands and stroma) and the outside of the uterine cavity. It can also be implanted in the ovaries, which results in “chocolate cyst” formation, and/or also found in the uterosacral ligaments, fallopian tubes, or less often in the pericardium or central nervous system.¹

However, the clinical presentation of endometriosis differs between people assigned female at birth, depending on their circumstances. For instance, the symptoms of adolescents are often overlooked, resulting in delayed diagnosis and treatment. This could cause potential progression of the disease, fibrosis, and even infertility.² It is important to take note of endometriosis conditions on a case-by-case basis as each individual may present different manifestations. 

Understanding endometriosis

Essentially, endometriosis clinically presents with endometrial tissues that supposedly line the womb, but show up lining unprecedented places like the ovaries, fallopian tubes, and even outside the uterine cavity.³ It also has lesions and nodules in these unprecedented places that largely cause the pain and discomfort that often accompany the endometriosis condition.¹ Typically, it is a long-term chronic pain condition which could be detrimental to maintaining a productive lifestyle. 

While the actual cause of endometriosis is unknown, there are several factors that can come into play such as genetics and diet. On top of these factors, the following theories could be reasons for the acceleration of its development.

The ectopic endometrial tissues found in unprecedented places are theorised to be the atypical migration and differentiation of Mullerian remnants (a type of ectopic cell involved in the embryologic development of the internal genital portions of the female) in the poster pelvic floor.⁴

The stem cell theory supports this claim of the pathogenesis of the endometrial tissue. Another theory is that endometrial tissue has the ability to enter the lymphatic and vascular systems and travel to far-off areas such as the brain, pleura, or retroperitoneum.⁵ 

Symptoms of endometriosis in adolescents

The clinical presentation is often categorised as dysmenorrhea (painful menstruation) with a duration from the beginning to the last day of the menstrual cycle. Dysmenorrhea is often accompanied by nausea, muscle cramps (oftentimes in the abdomen or lower back), vomiting, headaches, and more.

It can be noted that these symptoms are physical, albeit it is often overlooked due to medical negligence. The urine of dysmenorrheic women shows higher levels of PGF2a activity (a type of prostaglandin) and leukotrienes (lipid mediators for inflammation). These two substances are inflammatory mediators and when combined alongside vasoconstriction, it is considered the main reason for elevated levels of pain.⁶ 

Typically the clinical presentation of endometriosis in all women can be characterised as any of the following:

• headaches
• lightheadedness
• low energy
• heavy menstrual bleeding
• low back pain
• stomach discomfort
• persistent pelvic pain
• and mental difficulties⁷

As for cases of adolescents with endometriosis, these characteristics could be more or less severe. A study also found that in adolescents with endometriosis prior to surgery, 56% of patients experienced at least one gastrointestinal symptom and 52% had one or more genitourinary symptoms.⁸

Diagnosis of endometriosis in adolescents

The challenge in the diagnosis of adolescent endometriosis cases is that the disease is very easily overlooked. Dysmenorrhea is normalised and frequently dismissed with prescriptions for pain relief drugs. In addition, society also has a stigma surrounding menstrual symptoms, partially contributing to discrimination occurring in the healthcare setting. Although these cases are often disregarded, teenagersare always deemed as “dramatic” by society and symptoms are automatically dismissed by healthcare professionals who have biases. 

The most common initial imaging method is an ultrasound examination, which can rule out pelvic masses or structural abnormalities and allows for a thorough investigation of the pelvis. However, another challenge is that endometriosis masses are not easily visualised in adolescents. More information on identifying masses follows under diagnostic procedures. 

In addition, with the current state of education, teenagers typically do not have sufficient information about the condition that comes with endometriosis, hence they are more hesitant to undergo gynecologic checkups and treatment. It can also be daunting to inform parents or caretakers about their condition, leading to a tendency to ignore or brush off the symptoms and pain. 

Diagnostic procedures 

For accurate diagnosis of endometriosis in adolescents, the American College of Obstetricians and Gynecologists (ACOG) recommends laparoscopy (keyhole surgery). This surgery allows the visualisation of lesions and cysts. The physical appearance of the following lesions is commonly associated with adolescents with endometriosis and causes a great amount of pain:

• white
• yellow-brown
• red-pink lesions
• and/or clear shiny vesicular lesions

These lesions are usually identified by gynaecologists performing the surgery. In addition to identifying the lesions, laparoscopy also allows intraoperative treatment, where biopsies or direct removal of lesions are performed. 

Impact of endometriosis on adolescents

The condition of endometriosis is usually presented as chronic pain throughout menstruation, sexual intercourse, bowel movements and/or urination. Although it may depend on each individual, it can be assumed that pain would be one of the most physically taxing symptoms that can lead to stress.

Pain can decrease quality of life due to severe pain, fatigue, depression, anxiety and infertility. In addition to that, stress itself can also cause numerous other bodily complications, which could be detrimental to a developing adolescent. 

Teens may also find it difficult to talk openly about their illness because of the social stigma associated with menstruation-related problems. Teenagers may experience a decline in their academic performance and social participation chances if they leave school regularly owing to incapacitating symptoms, which can also negatively impact their educational goals. These effects highlight how critical it is to build support systems and raise awareness in order to meet the particular difficulties faced by young people with this illness. 

As the condition does not develop from a specific known cause, the situation can also feel hopeless. The physical pain and emotional impact combined can oftentimes be debilitating to leading a so-called normal productive life. Early detection allows prevention of the development of more severe lesions which results in further stages of endometriosis. On this note, it is important to note that seeking help whether it be from loved ones or from professionals like counsellors is recommended, and that it is important to spread awareness and educate more people on reproductive health in general. 

Treatment options

Pharmacological approach

There is not a specific cure for endometriosis but medications are typically administered to help with the symptoms that come with endometriosis. Pain relievers (NSAIDs) like ibuprofen or paracetamol are prescribed to relieve pain, or other non-steroidal anti-inflammatory drugs and progestins for hormonal therapy.³

Hormone therapy

Essentially, hormonal contraceptives are administered to lower the levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Contraceptives promote decidualization and endometrial atrophy by lowering oestrogen to shrink endometriosis tissue because oestrogen encourages endometrium shedding.

Hormonal therapy also includes ingesting combined hormonal contraceptives and/or progestogens. Combined hormonal contraceptives stop eggs from being released (ovulation), while progestogens prevent the lining of your womb and any endometriosis tissue from growing quickly as mentioned previously.¹

Laparoscopy

As mentioned under Diagnostic Procedures, laparoscopy is recommended not only to check for lesions but also to allow intrasurgical procedures of removing the cysts physically. They do this by applying heat, special gas, and laser for precise removal during surgery.

Lifestyle modifications

Body composition factors based on age, race, and body mass index, as well as lifestyle factors such as alcohol use and cigarette smoking are associated with the risk of developing and severity of endometriosis.⁹ Smoking cigarettes which have carcinogens increases the risk of endometriosis development exponentially.

It is also important to note that cigarettes not only increase the risk for endometriosis but also various other health complications. With healthy lifestyle habits including exercising regularly, getting sufficient quality sleep, and a balanced diet, the risk of developing endometriosis is decreased and also improves the existing condition. 

Summary

Endometriosis management is still a difficult task, especially for adolescents. The significant delay in identification highlights the urgent need for increased public and professional understanding of the signs and consequences of endometriosis. This problem is being addressed by ongoing research on endometriosis in teenagers, which aims to improve prognosis and shorten diagnosis delays.

Thanks to technological developments and an increasing understanding of the underlying mechanics of the illness, promising treatments are on the horizon. It is becoming more likely that alternative treatments will be developed that are more successful as research continues. However, early intervention—which can only be attained by increased knowledge and proactive healthcare practices—is the key to lessening the burden of endometriosis.

By putting an emphasis on early detection and awareness, we can enable those who are impacted by endometriosis to get treatment on time and live better lives. Resources like the Endometriosis UK research page offer helpful insights and updates on current research as well as developments in the treatment of endometriosis.