ENDOMETRIOSIS AND ADOLESCENCE

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ENDOMETRIOSIS AND ADOLESCENCE
Prof. Dr. Enrique Onetto B. Santiago-CHILE
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ENDOMETRIOSIS AND ADOLESCENCE

• Endometriosis is a disease or better a syndrome
  that starts around the prepuberal age,
  flourishing after menarche, with symptoms
  progressing in intensity and throughout the
  years.
• The main symptoms are progressive dysmenorhea,
  premenstrual syndrome, changes in basal body
  temperature during menstruation and dyspareunia.

Prof.Onetto Santiago.Chile 2001
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ENDOMETRIOSIS AND ADOLESCENCE

• MITHS AND FALACIES TO BE BURIED
• "The disease is most frequently seen above the
  age of 30, though not a few cases are encountered
  in the late twenties (Novak Novak.Text book of
  Gynecology.Page 557. Fifth Edition 1956.
• Adolescents with severe dysmenrrhea are given
  prescriptions of analgesics or contraceptive
  pills and are reassured with concepts such as
  when you get married pains will stopor their
  mothers say how can a gynecologist see her if
  she is a virgin

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE

• Numerous papers on Adolescence, pelvic pain and
  laparoscopies (Reese, Vercellini, grupo Emory,
  Kontoradvis, Chatman, Creatsas, Laufer others),
  report a prevalence of endometriosis ranging from
  32 to 73. Reports of normal internal genitaliae
  range from 20 to 60. Therefore....
• We believe that invasive procedures should not be
  used in adolescents with severe dysmenorrhea if
  their basal body temperature, the so called
  Benjamin sign, has not been investigated.

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE

• THE BENJAMIN SIGN When Basal Body Temperature
  (BBT) of an adolescent girl, with an
  endometriotic syndrome, stays high during the
  menstrual flow or has up and downs during the
  same and falls only at the end of it, we should
  strongly suspect endometriosis and go for a
  laparoscopy.
• With this procedure, we shall avoid many
  laparoscopies with normal internal genitaliae or
  diagnose other gynecological diseases.

Prof.Onetto Santiago.Chile/2001
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Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCEAtypical Benjamin
sign
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE

• Pregnancies occurring among adolescents with
  endometriosis delay the onset of the disease and
  its evolution for many years. This fact explains
  Novaks error.
• A relapse has to be considered as an initial
  case and we believe that this is a carrier.
  Genetics and inmunology are important factors to
  keep in mind. It is frequently seen among sisters
  and much more if they are twins.

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCEMatherial and
methods
BBT was requested whenever endometrio- sis was
suspected and recorded at least for 2 times from
the first day of the fourth week of the cycle
till the end of the flow on 34 adolescents, ages
14 to 24 (79,3 below 23). Surgical laparoscopy
was carried out on them, followed by treatment
with agonist GnRh or medroxiprogesterone acetate
or others for 3 to 6 months.
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
Age groups
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
-PREMENSTRUAL TENSION -CYCLE ALTERATIONS
The premenstrual syndrome was present in
53. Cycle alterations only in 35. (most of them
oligomenorrheas) These 2 items appear to be
irrelevant but if one adds them to the others,
they turn to be relatively important. We also
obtained important data from their sexual
activity.(next)
Prof.Onetto Santiago.Chile/2001
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Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE Sexual activity

• ACTIVES 27 (71)
• Orgasmic 23 (85)
• Disfunction 4 (15)
• No dyspareunia 3 (48,1)
• With dyspareunia 14 (51,9)

• INACTIVES 11 (29)

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
Dysmenorrhea is to be considered the most
important symptom and the most frequent reason
for consulting. Cramps progressing in intensity
throughout the years, not responding to
conventional therapy, with diarrhea, N V,
changes in character, premenstrual tension,
dyspareunia etc. were present in most of our
adolescents in different degrees of intensity but
at a very high level.
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCEDysmenorrhea
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
Intensity of dysmenorrhea and dyspareunia are
not related to the anatomical location of the
lesions. The most frequent are Adenomiosys
combined with uterosacral ligaments, followed by
uterosacral ligaments, Adenomiosys, ovarian and
others that match as faulse positives with other
gynecological pathologies.
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCEAnatomical location
of lesions
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
Variety of endometriotic lesions seen at
laparoscopy


Prof.Onetto Santiago. Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
0varian endometriosis
Prof.Onetto Santiago. Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE Benjamin sign
Uterine Hipoplasia PSOPH Hemorrhagic
Follicle Dydelphus uterus PSOPH
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
-Due to the fact that during the last years
endometriosis has been diagnosed among
adolescents, most of them with no fertility
problems, surgical laparoscopy followed by
medical treatment and a close follow-up to avoid
a relapse, seem to be the ideal steps. -Oral
contraceptives containig gestrinone should be
given after treatment.
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
-Surgical laparoscopy should only be perfor- med
by specialists under general anesthesia with
intubatión. A () Benjamin sign and dysmenorrhea
will indicate when a second look laparoscopy has
to be done during follow-up.
-Costs of in-patients and medication should be
considered.(1shot luprorrelin costs US 200.)
-A relapse of endometriosis should be treated as
an initial case and genetic and inmunological
factors must be considered. Endometriosis is
frequently seen among sisters and twins.
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCEfollow up

• Relapse 8 patients between 1 to 15 years of
  follow up.

• Followup
• 11 are using oral contraceptives
• 9 got pregnant (1 ectopic, 1 aborted)
• 6 are lost for follow up
• 1 fertility workup
• 1 had an in vitro fertilization with results
• 2 underwent histerectomies
• 4 recently finished their medical treatment

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
TREATMENTS
- Iatrogenic Pseudopregnancy (low cost)
-17 alfa derivatif of ethinil testosterone
(danazol) and gestrinone a 19 nor steroid wth
contraceptiv effects Ocasionally used. (middle
costs)
- Medroxiprogesterona acetate 50 to 100 mg.
orally daily for 3 to 6 ms. or depot
100mg.monthly for 6 ms.
-Agonists (GnRh) inducing a reversible
hypogonado- trophic hypogonadism (high cost all
the following)
- Nafarelin acetate Nasal Spray used for 6
monthshigh
- Triptorreline acetate depot 1 3.75mg. i.m.shot
monthly for 3 ms or 1 i.m.depot shot of 11,25mg.
lasting 3meses. High cost
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCECONCLUSIONS

• During the early adolescence endometriosis must
  be pursued and diagnosed as early as possible by
  obgyns, pediatricians or others to avoid severe
  physical and psychological discomfort of these
  girls and their relatives, thus avoiding future
  secuelae causing infertility
• With this procedure, we shall avoid many
  laparoscopies with normal internal genitaliae or
  diagnose other gynecological diseases.

Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCECONCLUSIONS
-Many studies involving inmunology and genetics
are underway and should give us more light in the
near future about this disease.
-Many women have some menstrual flow spilling
into the abdomen through the ampulla, but not all
of them have endometriosis.
New analogues or agonist GnRh should be available
at a very low price
Prof.Onetto Santiago.Chile/2001
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ENDOMETRIOSIS AND ADOLESCENCE
THE END
Prof. Dr. Enrique Onetto B. eonetto_at_yahoo.com
Santiago-CHILE