ACOG Guidance on Evaluation and Management of Endometriosis and Dysmenorrhea in Adolescents

SUMMARY:

ACOG has released recommendations on the diagnosis and management of dysmenorrhea and endometriosis in adolescents.

The goals of therapy include symptom relief, suppression of disease progression, and protection of future fertility. Therapy must be individualized, and obstetrician–gynecologists should consider patient choice, the need for contraception, contraindications to hormone use, and potential adverse effects and counsel the adolescent and her family on treatment options.

Key Definitions

  • Primary dysmenorrhea
    • Painful menstruation in the absence of pelvic pathology
    • Starts 6–12 months after onset of menses
  • Secondary dysmenorrhea
    • Painful menstruation with pelvic pathology or medical condition
    • Most commonly caused by endometriosis
    • Less common causes
      • Aenomyosis | Infection (e.g., PID) | Fibroids | Müllerian structural anomalies leading to outlet obstruction | Ovarian cysts
    • Chronic pelvic pain
      • Pelvic pain ≥6 months
      • Timing: Constant | Intermittent |Cyclic | Acyclic

Symptoms

  • Associated with dysmenorrhea
    • Nausea and vomiting
    • Diarrhea
    • Headaches
    • Muscle cramps
    • Sleep disturbance
    • Premenstrual syndrome
  • Note: Endometriosis in adolescents may be associated with chronic acyclic nonmenstrual pain

Evaluation

Primary dysmenorrhea

  • Evaluation based on thorough history
    • pelvic exam not necessary if symptoms ‘only’ of primary dysmenorrhea

Secondary dysmenorrhea

  • Requires further evaluation and should be considered with the following reported symptoms
    • Severe dysmenorrhea immediately after menarche
    • Progressively worsening dysmenorrhea
    • Abnormal uterine bleeding
    • Mid-cycle or acyclic pain
    • Lack of response to empiric medical treatment
    • Dyspareunia
    • Personal or family history
      • Endometriosis | Genitourinary structural anomalies
      • Family history of endometriosis have up to a 10-fold increased risk
  • Work up for secondary dysmenorrhea
    • Consider pelvic examination
      • With proper education and counseling, “many adolescents who are not sexually active are able to tolerate a pelvic examination”
    • Ultrasound should be used as initial imaging modality
      • MRI may be helpful for follow up, but not as a primary imaging approach
    • If positive findings, manage and treat as appropriate

Note: Pelvic pain that persists for 3 to 6 months warrants further evaluation for other causes of chronic pelvic pain such as GI, GU, MSK or psychological

KEY POINTS:

Management of Primary Dysmenorrhea

Empiric treatment

  • NSAIDS
    • Ibuprofen
      • First Dose: 800 mg
      • Followed by 400-800 q8 mg every 8 hours PRN
    • Naproxen sodium
      • First Dose: 440-550 mg
      • Followed by 220-550 mg every 12 hours PRN
    • Mefenamic acid
      • First Dose: 500 mg
      • Followed by 250 mg every 6 hours PRN
    • Celecoxib (>18 years of age)
      • First Dose: 400 mg
      • Followed by 200 mg every 12 hours PRN
    • Hormonal Therapy
      • (1) Inadequate relief with NSAIDS or (2) Can be considered appropriate as first line therapy
    • Alternative nonpharmacologic therapies
      • “Given the low risk of harm and low cost of heat therapy and exercise, as well as the additional general health benefits of exercise, both options should be encouraged”
      • Dietary supplements (limited evidence)
        • Fenugreek | Ginger | Valerian | Zataria | Zinc sulphate | Fish oil Vitamin B1
        • Vit D: Conflicting evidence
      • TENS (Transcutaneous electrical nerve stimulation) | Acupuncture | Herbal preparations | Yoga
        • Limited evidence does not support use as first line treatment
        • Herbal treatments: Safety and efficacy unclear
      • Surgical therapies
        • Insufficient evidence to support use of surgical therapies for primary dysmenorrhea
        • Recommendation against ablation and hysterectomy

Consider Endometriosis in Refractory Cases

Diagnosis of endometriosis

  • Requires surgical/pathologic diagnosis
  • Patients/family may opt of medical management of endometriosis without surgical confirmation
  • ACOG recommends ‘shared decision making’
    • Benefits of laparoscopy
      • Only way to confirm and treat if endometriosis is the cause (tend to be early stage)
      • Other pathologies may be identified
    • Risks of laparoscopy
      • Typical surgical and anesthesia risks
    • If patient undergoing diagnostic laparoscopy for pelvic pain
      • Consider hormonal IUD at time of laparoscopy (even though not approved by FDA for treatment of endometriosis pain)
      • Evidence for benefit
        • Dysmenorrhea unresponsive to oral contraceptives
        • Endometriosis pain

Management of endometriosis

  • Conservative surgical therapy
  • NSAIDs for pain relief (not narcotics outside specialized pain unit)
  • Suppressive hormonal therapy
    • Continuous combined hormonal contraceptive
    • Progestin-only agent
    • 52 mg (hormonal contraceptive) LNG-IUS
  • If unresponsive to the above, consider
    • GnRH agonist with add back (0.625 mg CEE and 5 mg norethindrone acetate daily) for at least 6 months
      • Dual-energy X-ray absorptiometry scanning not necessary (if using GnRH <12 months)
      • Bone health: Dietary calcium | Vitamin D | Weight-bearing exercise
      • Continuous hormone-suppression therapy after GnRH completed

Learn More – Primary Sources:

ACOG Committee Opinion 760: Dysmenorrhea and Endometriosis in the Adolescent