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

Evaluation and Treatment of Endometriosis

SYNOPSIS:

Endometriosis is a chronic condition that results in infertility and chronic pain. Clinical manifestations vary and are not good predictors of the severity of the disease. Dysmenorrhea, chronic pain, dyspareunia, uterosacral ligament nodularity, and adnexal masses are among the common presentations. Treatment is aimed at optimizing pregnancy rates and minimizing symptoms; definitive treatment remains removal of the ovaries, fallopian tubes and uterus.

KEY POINTS:

Symptoms

  • Dysmenorrhea
  • Chronic pelvic pain
  • Dyspareunia
  • Uterosacral ligament nodularity
  • Adnexal masses
  • Bowel and bladder symptoms, such as dyschezia, hematochezia, hematuria, dysuria
  • Symptoms do not correlate with severity of disease

Diagnosis

  • Definitive diagnosis is surgical and made on histology of lesions removed.  Lesions can be black powder-burn, red or white
    • Imaging studies are useful only in the presence of a pelvic/adnexal mass
    • Transvaginal ultrasound is the technique of choice in differentiating an endometrioma from other adnexal masses, and in detecting deeply infiltrating endometriosis of the rectum or rectovaginal septum
    • MRI can be used when ultrasound results are equivocal
  • American Society for Reproductive Medicine (ASRM) classification system is most commonly used, but is not a good correlate with fertility or symptoms

Treatment

Medical Management

  • Pain associated with endometriosis can be reduced with use of:
    • Progestins, combined oral contraceptives (OCs), nonsteroidal anti-inflammatory drugs, gonadotropin-releasing hormone (GnRH) agonists, danazol
    • Extended cycle OCs or continuous OCs can be used to limit dysmenorrhea and reduce recurrence of endometriomas
  • Nongynecologic causes of pelvic pain such as irritable bowel syndrome, interstitial cystitis and urinary tract pathology should be ruled out with appropriate testing and referral
  • The levonorgestrel intrauterine device is effective in reducing pelvic pain related to endometriosis
  • GnRH agonists are FDA approved for up to 12 months
    • A 3 month course can be empirically started after treatment failure with OCs and NSAIDs
    • ‘Add back’ therapy reduces side effects and bone loss and may include (1) progestins alone, (2) progestins and bisphosphonates, or (3) low dose progestins and estrogens
    • There is no difference between GnRH agonists and other medical treatments for endometriosis based on a recent Cochrane review, so should not be used as a primary treatment
      • GnRH agonists are, however, first line for extrapelvic endometriosis treatment
  • Elagolix (GnRH antagonist) is FDA approved for management of moderate to severe pain associated with endometriosis
    • Normal liver function or mild hepatic impairment: 150 mg once daily for up to 24 months or 200 mg twice daily
    • Moderate hepatic impairment: 150 mg once daily for up to 6 months
    • Contraindications: Pregnancy | Known osteoporosis | Severe hepatic impairment | Strong organic anion transporting polypeptide (OATP) 1B1 inhibitors
    • Potential for Reduced Efficacy with Estrogen-Containing Contraceptives: Use non-hormonal contraception during treatment and for one week after discontinuing elagolix

Note: For further warnings & precautions and adverse reactions to elagolix see FDA HIGHLIGHTS OF PRESCRIBING INFORMATION in ‘Learn More – Primary Sources’ below

  • Aromatase inhibitors such as letrozole or anastrozole
    • Appear promising in observational trials but await more data

Surgical Management

  • Excision of endometriomas can improve pregnancy rates; drainage and ablation of cyst is less effective
  • Patients undergoing surgery for removal of endometriosis should be counseled that they have about a 36% chance of requiring further surgery
  • In women who do not desire future fertility, definitive therapy is hysterectomy, bilateral salpingo-oopherectomy
  • Hormone therapy with estrogen is not contraindicated after hysterectomy with bilateral salpingo-oophorectomy for endometriosis
  • Diagnosis Codes: ICD-10-CM: N80.0-N80.9, depending on location of endometriosis

Learn More – Primary Sources:

ACOG Practice Bulletin No. 114: Management of Endometriosis 

ASRM: Treatment of Pelvic Pain Associated with Endometriosis: A Committee Opinion

Optimal Management of Endometriosis and Pain

Endometriosis: Where Are We and Where Are We Going?

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for ORILISSA