{"paper_id":"8660df67-4a45-46c9-a788-cd7a11164c50","body_text":"Endometriosis in Adolescence: Challenges and Opportunities for \nManaging Future Infertility\nPublication History:\nReceived: November 06, 2018\nAccepted: December 17, 2018\nPublished: December 19, 2018\nKeywords:\nAdolescence, Endometriosis, \nTreatment, Fertility\nReview Article Open Access\n*Corresponding Author: Prof. Efthimios Deligeoroglou, Department of \nObstetrics & Gynecolog National and Kapodistrian University of Athens, Medical \nSchool, 145 Michalakopoulou Str., 11527 Athens, Greece, Fax: +302107798111, \n+302107233330; E-mail: deligeoroglou@yahoo.gr\nCitation: Deligeoroglou E, Karountzos V, Tsimaris P, Deligeoroglou E (2018) \nEndometriosis in Adolescence: Challenges and Opportunities for Managing \nFuture Infertility. Int J Gynecol Clin Pract 5: 145. https://doi.org/10.15344/2394-\n4986/2018/145\nCopyright: © 2018 Deligeoroglou et al. This is an open-access article distributed \nunder the terms of the Creative Commons Attribution License, which permits \nunrestricted use, distribution, and reproduction in any medium, provided the \noriginal author and source are credited.\nInternational Journal of\nGynecology & Clinical Practices\nEfthimios Deligeoroglou1*, Vasileios Karountzos1, Pandelis T simaris1 and Evangelia Deligeoroglou1\n1Division of Pediatric-Adolescent Gynecology & Reconstructive Surgery, Athens, Greece\nInt J Gynecol Clin Pract                                                                                                                                                                                          IJGCP , an open access journal                                                                                                                                          \nISSN: 2394-4986                                                                                                                                                                                                       Volume 5. 2018. 145                                    \n                       Deligeoroglou et al., Int J Gynecol Clin Pract 2018, 5: 145\n                       https://doi.org/10.15344/2394-4986/2018/145\nthe ectopic endometrium can explain several other endometriosis \ncases. Theoretically, all women should have been diagnosed with \nendometriosis, due to normal retrograde menstruation at the pelvis \nin every cycle [10]. The above theories, explain why some women \ndiagnosed with endometriosis and others not, paying attention in \nindividual features, such as family history of endometriosis, early \nmenarche and exposure to circulating steroid hormones, body mass \nindex during late childhood and early adolescence. Moreover, lifestyle \ncharacteristics and environmental factors are likely related to the \ndevelopment of the disease playing an epigenetic role. Positive family \nhistory has been reported by many studies [11], even though this \nassociation cannot only be explained by genetic mechanisms. It is \nimportant that the disease among first-degree relatives is six to nine \ntimes higher than in the population [12,13].\nAn early menarche is also positively associated with endometriosis \n[14], due to the fact that these girls are more likely overweight, with \nhigher levels of adipose fat tissue and circulating steroid hormones \n[15,16]. Another factor that seems to play a role in the inverse relation \nbetween childhood and early adolescence body size and the incidence \nof laparoscopically confirmed endometriosis is anovulation due to \ninsulin resistance and hyperinsulinemia in obese pre-adolescent girls \n[17].\nFinally, endometriosis can only be diagnosed by visual inspection \nduring laparoscopy, ideally confirmed by histology and can present  \nIntroduction\nEndometriosis is defined as the presence of endometrial stroma \nand glands outside the normal uterus. As reported in the past by the \nEndometriosis Association Registry a total of 38% of women diagnosed \nwith endometriosis may have symptoms before the age of 15, while a \nmean number of 4.2 physicians have examined the adolescent before \nfinal diagnosis is set [1]. On the other hand, a range between 19% and \n73% of adolescents undergoing laparoscopy for chronic pelvic pain \nare diagnosed with endometriosis. The same was found by a study of \nGoldstein et al. [2] who reported that the prevalence of endometriosis \nfound at laparoscopy in a prospective study of adolescent females with \npelvic pain is 47%, while other studies have shown a prevalence of 25-\n38% for these adolescents. [3,4]. A 66% of adult women have reported \nthe onset of pelvic symptoms before the age of 20 according to the \nEndometriosis Association.\nIt is of great importance that 50-70% of adolescents with pelvic \npain, who have received Combined Oral Contraceptives (COCs) \nand/or Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), but no \nresponding to them, have signs of endometriosis during laparoscopy. \nInterestingly, endometriosis has also been identified in premenarcheal \ngirls with some breast development [5,6]. This can be explained by \nthe theory of embryonic müllerian rests or coelomic metaplasia as \nopposed to retrograde menses.\nPathophysiology\nSeveral factors have been incriminated for endometriosis, while \nno single theory can explain the variety of symptoms. Sampson [7] \nwas the first who reported that during menstruation endometrial \ncells regurgitate through the fallopian tubes and implant in the pelvis. \nAnother theory has proposed that metaplastic cells transform into \nendometrial cells, [8] and these metastasize through lymphatic and \nvascular channels, resulting in endometriosis [9]. This theory can \nexplain the findings of endometriosis in other tissues such as the lung, \nbrain, and skin. Other multi-factorial hypotheses with immunological, \nanatomical and genetic mechanisms, leading to dysfunction in\nAbstract\nEndometriosis is defined as the presence of endometrial stroma and glands outside the normal uterus. \nThe prevalence of endometriosis in adolescents undergoing laparoscopy for chronic pelvic pain is reported \nto be between 19% and 73%. Interestingly, endometriosis has also been identified in premenarcheal girls \nwith some breast development. Several factors have been incriminated for endometriosis, while no single \ntheory can explain the variety of symptoms. Genetic factors seem to play a role, while lifestyle characteristics \nand environmental factors are likely related to the development of the disease. The main symptoms during \ndiagnosis of endometriosis in adolescence, is chronic pelvic pain (27%-96%) and dysmenorrhea (18%-100%). \nMedical history and clinical examination are of great importance, while imaging exams are very helpful \nduring evaluation of these girls, while endometriosis can only be diagnosed by visual inspection during \nlaparoscopy, ideally confirmed by histology. Treatment options include not only medical regimens, with \nNon-Steroidal-Anti-Inflammatory Drugs and Combined Oral Contraceptives been the most common used, \nand other medications such as Danazol, Progestins, GnRH agonists with Add-Back therapy and cyproterone \nacetate, but also surgical treatment. Surgical management alone or in combination with postoperative \nhormonal suppression seems to improve future fertility options of adolescents with endometriosis. \n\nInt J Gynecol Clin Pract                                                                                                                                                                                          IJGCP , an open access journal                                                                                                                                          \nISSN: 2394-4986                                                                                                                                                                                                       Volume 5. 2018. 145                                    \nCitation: Deligeoroglou E, Karountzos V , Tsimaris P , Deligeoroglou E (2018) Endometriosis in Adolescence: Challenges and Opportunities for Managing Future \nInfertility. Int J Gynecol Clin Pract 5: 145. https://doi.org/10.15344/2394-4986/2018/145\n                  Page 2 of 6\nas peritoneal disease with typical or subtle lesions, ovarian \nendometriotic cysts or deeply infiltrative disease or as a combination \nof these features. Different Classification systems have been used \nat the past in order to set different stages of the disease. The degree \nof endometriosis can be staged by laparoscopy as minimal, mild, \nmoderate or severe according to the classification of the American \nSociety of Reproductive Medicine [ASRM-former American Fertility \nSociety (AFS)] [18]. Studies regarding the ASRM classification \nsystem have shown that adolescents with endometriosis, hadeither \nminimal (50%), mild (27%), moderate (18%) or severe (14%) disease. \nOther classification systems include the Endoscopic Endometriosis \nClassification I-IV by Semm (EEC I-IV) [19], the Acosta classification \n[20] or the staging system proposed by Kistner et al. [21] with a scale \nof I-IV . The variety of studies and classification systems agree that the \nprevalence and severity of the endometriosis is believed to significantly \nincrease with age therefore is considered as a progressive disease [22].\nDiagnosis\nThe main symptoms during diagnosis of endometriosis in \nadolescence, is chronic pelvic pain (27%-96%) and dysmenorrhea \n(18%-100%) [23,24]. Acyclic pain seems to be more common in \nadolescents than in adults. Other symptoms that can support diagnosis \nare gastrointestinal symptoms, urinary symptoms, irregular menses, \ndyspareunia, pelvic mass, subfertility, constitutional symptoms and \ndepression/anxiety [23]. In all adolescents is offered apain diary, in \norder to document frequency and all characters of pain. Smorgick \net al. have reported that the prevalence of comorbid chronic pain \nsyndromes (56%) and mood disorders (48%) in adolescents suffering \nfrom endometriosis is not uncommon, while irritable bowel \nsyndrome, interstitial cystitis/painful bladder syndrome and chronic \nheadaches can be found in up to 25%, 16% and 19% respectively in \nthese adolescents [24].\nIn a study by Laufer et al. [25], 90.6% of adolescents with \nendometriosis had acyclic pain versus 69% in the adult population \nas reported above [26]. Müllerian anomalies, especially those with \noutflow tract obstructions, are statistically significantly positively \ncorrelated with endometriosis, being an independent risk factor. This \nwas shown by a study be Y ang et al [27] who reported that genital tract \nmalformations can present in up to 24%of patients with endometriosis. \nThe majority of adolescents have early stage disease, but up to 33% of \nthem have advanced disease. Fedele et al. [28] found no correlation \nbetween severity of pain symptoms and stage of the disease or site of \nthe endometriotic lesions, while an ovarian endometrioma is the most \ncommon presentation of advanced endometriosis in adolescents. \nRecent studies have report a large number of cases of adolescents with \nStage III and IV endometriosis. The adult literature reports Stage I \ndisease in 30%-39%, Stage II in ~12%-13%, Stage III in 27%-35% and \nStage IV in 13%-28% [29,30]. Even though adolescents may present \nwith advanced stages of endometriosis, these number are fewer \ncomparing with adults.\nRed lesions are the most common lesions seen in adolescents, with \natypical lesions being common as well. Two studies, one by Davis et \nal [31] and another by Reese et al [32] showed that the vast majority \nof lesions in adolescent populations with endometriosis are red \nlesions, while a large number of these lesions were correlated with \nsevere dysmenorrhea, with complaints of abdominal pain, nausea, \nconstipation and diarrhea. Another study reported atypical red \nvascular lesions in 60% of adolescents compared to only 20% of non-\nadolescents [30]. Clear lesions are common in adolescent endometriosis \nbut often difficult to visualize and evaluate. Peritoneal defects, or \nwindows, which are possible manifestations of endometriosis, \nare very common in adolescents. The reported incidence in \nadolescents is around 10%-18.4% as quoted in several studies [33].\nPast medical history, family history and physical examination \nare mandatory during evaluation and management of adolescents \nwith a possible endometriosis. Several other pathologies, such as \nappendicitis, pelvic inflammatory disease, müllerian anomalies \nor outflow obstruction, bowel disease, hernias, musculoskeletal \ndisorders, and psychosocial complaints should be excluded in order \nto set the diagnosis. Inspection of the girl for a possible estrogen-\ndominant body configuration with peripheral fat distribution and \nfor breast and pubic hair development according to the Tanner \nclassification system is of great importance [23].\nA patent outflow should be performed in all adolescent by placing \na Q-tip into the vaginal canal. This is very helpful, in order to exclude \na possible transverse vaginal septum, vaginal agenesis, or agenesis of \nthe lower vagina. For virgo adolescents pelvic examination cannot \nbe performed, therefore, a rectal-abdominal examination, even \ndiscomfort for adolescents, in the dorsal lithotomy position, may be \nhelpful to determine if a pelvic mass is present. Attention should be \ngiven in the existence of both diffuse and focal pelvic tenderness [23].\nImaging exams are very helpful during evaluation of these girls. \nUltrasonography and magnetic resonance evaluate anatomical \nstructures, but are not specific for diagnosing of endometriosis. \nAccording to some studies, MRI can detect endometrial implants with \na sensitivity as high as 60%, while this method can be used in order \nto follow up adolescents’ response to treatment, even though its cost \nis high [34]. Blood tests, such as CA 125, are very sensitive, but it is \nnot specific and, thus, is not helpful in the diagnosis of adolescent \nendometriosis. No data exist regarding the use of CA 125 to monitor \nthe clinical progression or regression of disease in adolescents with \nendometriosis [35].\nSymptomatic adolescents should be evaluated laparoscopically \nwhen standard treatment of pelvic pain or dysmenorrhea is not \neffective. Endometriosis should be staged using the revised criteria \nof the American Society of Reproductive Medicine point-based \nclassification system as mentioned above [18]. Biopsying during \nlaparoscopy sites of apparent endometriosis, especially atypical \nlesions, in order to confirm the diagnosis and avoid mislabeling a \npatient is of great importance, while biopsying normal appearing \nperitoneum should be left at the surgeon's discretion because it is \nsomewhat controversial [36].\nProgression of the disease in adolescents has been a topic of \nargument among researchers. In 2010, Unger and Laufer [37] \npublished the case reports of three adolescents, aged between 13 and \n16 years, suffering from severe pelvic pain and diagnosed with Stage \nI endometriosis at the time of laparoscopy. Reese et al. [32] presented \n39 adolescents, with 4 patients (18%), in the two older age groups (16-\n17 and 18-20 years), suffering from Stage III or IV . Tandoi et al. [38] \nstudied 57 women aged 21 years or younger over a 5-year period and \nin 32 (56%) observed a recurrence of the disease after surgery. Its rate \nincreased with time from surgery, with no apparent association with \nsite or stage of the disease, type of surgery, and post-surgical medical \ntreatment. Y ang et al. [27] reported that 45.7% of 35 adolescents \nincluded in the study, suffered from disease recurrence with an \naverage time of recurrence of 33.4 months.\nTreatment\nTreatment algorithm for adolescents presenting with dysmenorrhea \naccording to the American College of Obstetricians and Gynecologists \nis summarized in Figure 1 [39].\nRecommendations include initiation of treatment with NSAIDs \nand COCs. In case of symptoms persistence, after 3 months, a\n\nInt J Gynecol Clin Pract                                                                                                                                                                                          IJGCP , an open access journal                                                                                                                                          \nISSN: 2394-4986                                                                                                                                                                                                       Volume 5. 2018. 145                                    \nCitation: Deligeoroglou E, Karountzos V , Tsimaris P , Deligeoroglou E (2018) Endometriosis in Adolescence: Challenges and Opportunities for Managing Future \nInfertility. Int J Gynecol Clin Pract 5: 145. https://doi.org/10.15344/2394-4986/2018/145\n                  Page 3 of 6\ndiagnostic laparoscopy should be offered for these girls [39]. As \nreported above, lesions seen in adolescents’ pelvis, during laparoscopy \nare different from the typical powder burn lesions seen in adults [40]. \nEndometriosis symptoms control, prevention of disease progression \nand preservation of fertility are primary goals of treatment. \nMedical and surgical options are available for the management of \nendometriosis.\nMedical management\nNSAIDs\nNSAIDs can be used as empiric treatment during management \nof dysmenorrhea in adolescents, even though the diagnosis of \nendometriosis has not been set yet.\nCombined oral contraceptives (COCs)\nCOCs are typically the first line treatment and can be used as well \nas empiric treatment. Acting by ovulation inhibition, they decrease \ngonadotropin levels and therefore reduce menstrual flow and cause \ndecidualization of endometriotic implants. Another role of COCs is \nthe decrease of cell proliferation, as well as the reduction of eutopic \nendometrium. COCs can be used as continuous treatment in order \nto induce amenorrhea, with therapy being suppressive and not \ncurative, while stopping treatment for more than 6 months, can lead \nto symptoms recurrence. Finally, according to Cochrane Database of \n2007 there are no sufficient data regarding long-term benefits of COC \nin the treatment of endometriosis [41].\nProgestins\nProgesterone agents include medroxyprogesterone acetate (MPA) \nand 19 nortestosterone derivatives, such as norethindrone and \nnorgestrel. These agents lead to decidualization and atrophy not only \nin ectopic, but as well in eutopic endometrial tissue. 20 to 30 mg daily \nor the depot form of 150 mg every 3 months of medroxyprogesterone \nacetate can be used in order to treat symptoms of dysmenorrhea or \nadolescents’ endometriosis. It is important that up to 70% to 80% of \ngirls suffering from endometriosis show symptoms improvement. \nOn the other hand the benefits of long-term use of progestin therapy \nneeds to be weighed against impaired bone mineralization secondary \nto the hypoestrogenic environment induced by progestins, with the \nrisk for osteoporotic fractures been yet unknown, as reported also by \nthe U.S. Food and Drug Administration [42,43]. Other side effects \ninclude weight gain, bloating, mood lability and irregular bleeding.\nDanazol\nDanazol is a 17-ethinyl testosterone derivative with an efficacy being \nequivalent to a variety of GnRH agonists in treating endometriosis. \nIts androgenic effects, affecting sex-hormone-binding globulin levels, \nresulting in an increase of free testosterone. Buttram [44] had studied \n220 patients, complaining about weight gain, depression, muscle \ncramps, decreased breast size, flushing, oily skin and hair, acne, \nhirsutism, irreversible deepening of the voice, and skin rash. Among \nthem 7% discontinued the drug secondary to intolerable side effects \nand this is enhanced by the fact that patients using GnRH agonists \nreported a better quality of life compared to them using danazol. \nFinally, due to the fact that this agent is poorly tolerated by adolescents \nis not widely utilized in endometriosis management [45].\nCyproterone acetate\nCyproterone acetate (CPA) is a 17-hydroxyprogesterone derivative \nwith antiandrogenic and antigonadotropic properties. As reported \nin a study by Fedele et al. [46] 27 mg/day oral CPA with 0.035 mg \nethinyl estradiol could be used to treat women with endometriosis \nsuccessfully, while another study by Vercellini et al. [47] including 90 \nwomen, who received either 12.5 mg/day CPA or a daily COC (0.02 mg \nFigure 1: Algorithm for management and treatment of adolescents with pelvic pain and endometriosis. \nAdapted from Laufer MR, Sanfilippo J, Rose G (2003) Adolescent endometriosis: diagnosis and treatment \napproaches. J Pediatr Adolesc Gynecol 16: S3-11.\n\nInt J Gynecol Clin Pract                                                                                                                                                                                          IJGCP , an open access journal                                                                                                                                          \nISSN: 2394-4986                                                                                                                                                                                                       Volume 5. 2018. 145                                    \nCitation: Deligeoroglou E, Karountzos V , Tsimaris P , Deligeoroglou E (2018) Endometriosis in Adolescence: Challenges and Opportunities for Managing Future \nInfertility. Int J Gynecol Clin Pract 5: 145. https://doi.org/10.15344/2394-4986/2018/145\n                  Page 4 of 6\nethinyl estradiol + 0.15 mg desogestrel) for 6 months, showed that \nafter 6 months pain scores were reduced in both groups. This supports \nthe idea that girls in whom estrogens are contraindicated, CPA may be \nan alternative sufficient treatment.\nGnRH agonists\nGnRH agonists are very effecting in treating adolescent \nendometriosis and alleviate symptoms associated with endometriosis. \nActing by inducing menopause with binding to the GnRH receptors \nin the pituitary, they result to cessation of pituitary gonadotropin \nrelease and subsequently to amenorrhea. According to the Cochrane \nGroup reviewed the efficacy of GnRH agonists versus COCs in the \ntreatment of endometriosis, GnRH agonists are more effective than \nCOCs. GnRH agonists include leuprolide acetate, nafarelin, buserelin, \nand goserelin. Leuprolide can be given as a 3.75-mg injection every 4 \nweeks or 11.25-mg injection every 12 weeks. It is of great importance \nto remember that the use of GnRH agonists alone is generally limited \nto patients more than 16 years of age and for a period no more than \n6 months [48].\nAdd back therapy\nIn order to prevent side effects of pseudomenopause associated \nwith GnRH agonist like vasomotor symptoms, vaginal dryness, and \nmood swings, hormonal ‘‘add-back’’ options are recommended. \nThese include norethindrone acetate (5-mg daily) and combined \nconjugated estrogens/medroxyprogesterone acetate (0.625/2.5-\nmg daily). Adolescents accruing bone mass up to the age of 20 \nyears, therefore initiation of GnRH agonists in this age should \nalways begin in combination with add-back therapy, while BMD \nmonitoring should be offered every 2 years. Calcium and Vitamin D \nsupplementation should be given in all these girls in order to avoid \nbone demineralization [49].\nSurgical treatment\nSurgical options in adolescent endometriosis include laparoscopy \nrather than laparotomy. The role is both diagnostic and therapeutic \nand usually a specialized physician in laparoscopy and adolescent \nendometriosis is preferred to perform the procedure. Surgery should \nbe timed in the follicular phase of menstrual cycle, in order to avoid \nfuture possibility of recurrences and adhesions. First port should \nbe intraumbilical and the lateral ports should be placed close to the \npubic bone for cosmetic superiority. The goal of surgical treatment \nis to remove visible areas of endometriosis and restore normal \nanatomy by lysis ofadhesions. The procedure seems to improving \nendometriotic symptoms in 38% to 100% of adolescents [50]. Laser \nvaporization, unipolar or bipolar coagulation, and endocoagulation \nare the methods used, with no one technique has been shown to be \nsuperior to any other.\nSurgical treatment seems to improve pain in adolescents with \nendometriosis. This was summarized in a meta-analysis by Janssen \net al. [51], in which girls were treated either with ablation or excision \nof endometriosis and pain improvement was shown. Furthermore, \nY ang et al. [27] concluded that there was a decrease in chronic pelvic \npain (by 23.5%) and dyspareunia (by 11.8%) after complete excision \nof endometriotic lesions, while in a study be Dun et al. [23], 64% \nreported resolved pain and 16% reported improvement of pain at 1 \nyear after the laparoscopic excision and ablation of lesions.\nSurgical treatment can also improve fertility options in adolescence. \nIn a retrospective case series to assess the long-term fertility outcomes \nin young women after laparoscopic surgery (excision and ablation) for\nendometriosis, a long-term pregnancy rate of 71.4% of which >80% \nwere achieved without assisted reproductive technology (ART) was \nshown, with most of the patients who conceived had Stage I/II disease \n[52].\nSurgery is also very helpful in reducing disease progression and/\nor recurrence. In some studies is reported that complete laparoscopic \nexcision by experts can significantly reduce the recurrence rates of \nendometriosis in adolescents, while Y ang et al. [27] found zero rate \nof recurrence (diagnosed visually or histologically) after complete \nlaparoscopic excision of the disease in teenagers at a repeat \nlaparoscopy for pain. Even though the frequency of adolescents \nundergoing laparoscopy for persistent recurrent pain is 47.1% the rate \nof endometriosis found at surgery was zero [53].\nOn the other hand, postoperative hormonal suppression should \nbe offered to adolescents in order to treat symptoms and to prevent \nprogression and/or recurrence of the disease, while the role of \npostoperative medical therapy in conjunction with surgery in \nimproving future fertility of adolescents with endometriosis has \nnot been evaluated. Moreover, the conjunction of surgery with \npostoperative medical therapy does not seem to slow disease \nprogression and/or recurrence. The recurrence rate of endometriosis \nin young women appears to be higher than in older women. In a \nretrospective cohort study of 57 women, aged ≤21 years, who were \ntreated initially by excisional surgery, was shown that the rate of \nrecurrence of symptoms during a follow up-period of 5 years was \n56%. The study also showed that the postoperative medical therapy \ndid not influence the recurrence rates [38].\nAs reported above, a variety of medical therapies have been \nused in treating endometriosis during adolescence. Even though \nfurther studies needed, in order to conclude which medical therapy \nis superior to another, GnRH agonists seem to be more effective \ncompared with COCs and progestins to prevent disease recurrence. \nCombination norethindrone acetate plus conjugated equine estrogens \nas add-back therapy, appears to be more effective for increasing \ntotal bone mineral content, bone mineral density and lean mass \nthan norethindrone acetate monotherapy [54,55]. Levonorgestrel \nintrauterine system (LNG-IUS) is accepted for use in the adolescent \npopulation for contraception and menorrhagia, but there are not \nenough data regarding its effectiveness in the treatment of adolescent \nendometriosis.\nEndometrial cysts\nThere are very few data about endometriosis and endometriomas \nin adolescents and young women. A study reviewing 15 years of \novarian masses in infants, children and adolescents reported no \nendometriomas [56]. Ovarian endometriomas are usually correlated \nwith more advance stage of the disease.\nAs it is easily understood, these girls are present with more frequent \npain. A retrospective study of 63 adolescents with endometrioma \nfound bilateral disease in 22.22%, while endometrioma in the right \novary seems to be more frequent than a left endometrioma (65% vs. \n57%). In these cases the preferable surgery is a combined technique \nof cystectomy and cauterization of the capsule [57]. Interestingly, in \na review by Gordts et al. [58] was found that early ablative surgery \ncan contribute to a lower morbidity, relief of symptoms, and a better \nquality of life, while in another recent published study have reported \nrecurrence rates of endometrioma per patient at 24, 36, 60 and 96 \nmonths after laparoscopic cyst enucleation for ovarian endometrioma \nbeing 6.4%, 10%, 19.9% and 30.9%, respectively. All these adolescents \nhad stage III or IV of the disease.\n\nInt J Gynecol Clin Pract                                                                                                                                                                                          IJGCP , an open access journal                                                                                                                                          \nISSN: 2394-4986                                                                                                                                                                                                       Volume 5. 2018. 145                                    \nCitation: Deligeoroglou E, Karountzos V , Tsimaris P , Deligeoroglou E (2018) Endometriosis in Adolescence: Challenges and Opportunities for Managing Future \nInfertility. Int J Gynecol Clin Pract 5: 145. https://doi.org/10.15344/2394-4986/2018/145\n                  Page 5 of 6\nFuture Trends\nSelective estrogen receptor modulators (SERMS) and selective \nprogesterone receptor modulators (SPRMs) are the new treatment \noptions for adolescent endometriosis. However, we have not yet human \nstudies for both drug groups. Both are acting by suppressing estrogen \ndependent endometrial growth without the adverse systemic effects \nof hypoestrogenism, like vasomotor symptoms and loss of BMD. \nAnother treatment options, is the use of aromatase inhibitors. This is \na key enzyme in estrogen biosynthesis, appears to be over-expressed \nin sites of endometriosis. This drug acting by reducing ovarian and \nlocal production of estrogens, therefore can be used in treatment of \nadolescent endometriosis. Finally, autoimmune modulators may be an \neffective method of disease treatment, with anti-tumor necrosis factor \ntherapies have been already successfully used to reduce endometriotic \ngrowth in animal models, being a promising future treatment method \n[59,60].\nFollow-up\nA careful follow-up of adolescents with endometriosis is \nmandatory, due to the fact that it can be a life-long disease. Patient \nshould be examined every 3 to 6 months. During this time, a pain \ncalendar should be used in order to monitor the pain, while concerns \nregarding future fertility and quality of life should be addressed. \nUnless contraindicated, most patients should be put on COCs after \nsurgery. If the patient does not respond to surgery or has recurrence \nof symptoms, other treatment modalities should be considered. \nA multidisciplinary approach is usually needed, including a \ngastroenterologist, psychologist and urologist.\nIssues for Future Consideration\nFuture studies should be focused on the role of early diagnosis of \nendometriosis and treatment in progression and advancement of the \ndisease. Question remaining regarding, how the adolescent daughter \nof a woman, who had no pelvic pain, but stage IV endometriosis and \ninfertility should be treated. Is it important for that girl to be evaluated \nand treated, even though she has no pelvic pain, in order to exclude \nthe possibility of endometriosis.\nConclusions\nAdolescent endometriosis is not uncommon being a progressive \ndisease. Pain is the main symptom, especially dysmenorrhea and \nchronic pelvic pain. NSAIDs and COCs can be used as first line medical \ntreatment during management of adolescent endometriosis, but in case \nof symptoms persistence, the girl should undergo a laparoscopy, with \nthe likelihood of endometriosis during laparoscopy being up to 50%. \nThe appearance of lesions found at laparoscopy in adolescents may \ndiffer from that in adults, while COCs, DMPA, GnRH agonists and \nsurgical ablation tend to be the practical treatment modalities in this \nage group. Primary goals are alleviation of pain symptoms, avoidance \nof disease recurrence and assurance of future fertility preservation. \nA multidisciplinary approach to pelvic pain with the assistance of \npain treatment services is usually recommended, while future work \nfor adolescents should focus on developing safe, minimally invasive, \ntreatment techniques.\nCompeting Interests\nThe author declare no competing interests.\nReference\n1. 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