{"paper_id":"985da373-af07-4070-a2b9-a7cc4631ab4a","body_text":"Curr Treat Options Peds (2016) 2:143 –155\nDOI 10.1007/s40746-016-0060-x\nPediatric Gynecology (L Breech and K Stambough, Section Editors)\nGynecologic Pain\nin Adolescents\nKate McCracken, MD\nAddress\nPediatric and Adolescent Gynecology, Nationwide Children’s Hospital, 700\nChildren’s Drive, Columbus, OH, 43205-2664, USA\nEmail: kate.mccracken@nationwidechildrens.org\nPublished online: 8 July 2016\n* Springer International Publishing AG 2016\nThis article is part of the Topical Collection on Pediatric Gynecology\nKeywords Gynecologic pain I Adolescents I Dysmenorrhea I EndometriosisI Mullerian anomaliesI Adnexal masses I\nMusculoskeletal pain\nOpinion statement\nGynecologic pain affects a significant number of adolescents. While the differential\ndiagnosis for such pain is often extensive, the treatment goals are the same —to relieve\npain and minimize the effect it has on an adolescent’s daily functioning, and to maximize\ntheir future reproductive potential. For management of acute gynecologic pain—such as\nin cases of adnexal torsion or obstructive anomalies —surgical intervention is often\nwarranted. Pain related to more chronic processes —such as endometriosis —is treated\nboth medically and surgically. Hormonal therapy (either combined estrogen/progestin or\nprogestin-only) is the mainstay of medical therapy. Newer methods, such as the levonor-\ngestrel intrauterine devices (LNG-IUD), show promise as a management option for chronic\nendometriosis-related pain. The LNG-IUD also provides highly effective long-acting re-\nversible contraception, and is a first-line recommended contraceptive method for adoles-\ncents. Other etiologies of gynecologic pain may be infectious and are therefore treated by\nantibiotics. Providers must perform a thorough history and physical exam—with attention\nto patient confidentiality. Establishing a good rapport with both patients and their\ncaregivers is crucial. Regular follow-up to assess treatment efficacy is necessary —as\ncertain conditions may require a stepwise progression of treatment modalities for resolu-\ntion of symptoms. While it is often challenging caring for an adolescent with chronic\ngynecologic pain, it is also extremely important and rewarding. Optimizing the gyneco-\nlogic health of adolescent females will allow them to function at their full potential and\nlead productive, enjoyable lives.\nIntroduction\nGynecologic pain in adolescents is common, and pa-\ntients may present to a variety of care settings —primary\ncare providers, gynecologists, urologists,\ngastroenterologists, emergency care providers, and pedi-\natric surgeons. Gynecologic pain in adolescents may have\nmultiple etiologies—these are listed in Table 1.T h ep a i n\n\nmay be primary (not attributed to pathology) or second-\nary (attributed to a pathologic condition); it may be acute\nor chronic in nature, and cyclic or continuous. Practi-\ntioners must also consider and rule out other non-\ngynecologic etiologies of pain—such as gastrointestinal,\ngenitourinary, musculoskeletal, neurologic, or\npsychologic conditions. While the differential diagnosis\nis extensive, a thorough and multisystem evaluation of\nthe pain will lead the provid er to an accurate diagnosis,\nand help dictate the appropriate treatment.\nTreatment of gynecologic pain is varied and may\nrequire a stepwise progression of treatment and/or\nTable 1. Acute and chronic causes of gynecologic pain in adolescents (adapted from Laufer M. gynecologic pain:\ndysmenorrhea, acute and chronic pelvic pain, endometriosis, and premenstrual syndrome. In: Emans SJ, Laufer\nMr. Emans, Laufer, Goldstein’s pediatric and adolescent gynecology. 6\nth ed. Philadelphia, PA: Lippincott\nWilliams and Wilkins; 2012:239–271.) [4]\nAcute pain Chronic pain\nPregnancy related\n Ectopic pregnancy\n Threatened/spontaneous abortion\nObstructive anomalies\n Imperforate hymen\n Transverse vaginal septum\n Non-communicating uterine horn\nOvarian\n Cyst/mass\n Torsion\nOvarian\n Cyst/mass\n Torsion\nFallopian tube\n Cyst\n Hydrosalpinx\n Torsion\nFallopian tube\n Cyst\n Hydrosalpinx\n Torsion\nVulva\n Vulvovaginitis—infectious or non-infectious\n Lichen sclerosis\n Hair tourniquet\n Contact dermatitis\nVulva\n Vulvovaginitis—infectious or non-infectious\n Lichen sclerosis\n Contact dermatitis\nVagina\n Bartholin’s gland cyst/abscess\n Skene’s duct cyst/abscess\n Vaginismus\nVagina\n Bartholin’s gland cyst/abscess\n Skene’s duct cyst/abscess\n Vaginismus\nInfection\n Pelvic inflammatory disease\n Tubo-ovarian abscess\n Endometritis\nChronic Infection\n Pelvic inflammatory disease/Fitz-Hugh-Curtis\n Tubo-ovarian abscess\n Endometritis\nCyclic pain\n Mittelschmerz\n Dysmenorrhea\n Endometriosis/adenomyosis\n Leiomyoma (fibroids)\n Ob structive Mullerian anomalies\n Dyspareunia\nChronic pain (cyclic and non-cyclic)\n Dysmenorrhea\n Endometriosis/adenomyosis\n Leiomyoma (fibroids)\n Dyspareunia\n Pelvic adhesions\nTrauma related\n Vulvar or vaginal hematoma\n Genitourinary laceration\n144 Pediatric Gynecology (L Breech and K Stambough, Section Editors)\n\nmultiple modalities. Treatment is dictated by the diagno-\nsis. Currently, treatment may include medication, surgi-\ncal interventions, physical therapy, trigger point injec-\ntions, behavioral and psy chological therapy, and\ncomplementary/alternativemedicine. There may also be\nscenarios in which observation and expectant manage-\nment are the treatment of choice. Timely and accurate\nmanagement of gynecologic pain is crucial to avoid sig-\nnificant negative impact on quality of life and reproduc-\ntive health of the adolescent [1].\nWhen initially evaluating an adolescent with pain,\nestablishing a rapport is paramount. Patient-parent dy-\nnamics, parental involvement, and maintaining confi-\ndentiality are issues that must be navigated by the pro-\nvider. Obtaining a thorough history is the initial step in\nevaluating pain—specifically, providers should elicit in-\nformation about the onset, duration, timing, character,\nquality, location, and radiation of the pain. Any aggra-\nvating, relieving, and associated symptoms should be\ndocumented. It is crucial to obtain a gynecologic history,\nand when applicable, a confidential sexual and psycho-\nsocial history (including substance use/abuse and sexual\nor physical abuse). Asking what the patient attributes her\npain to offers insight into the patient ’s developmental\nstage, coping mechanisms, and perhaps even confidential\nhistory components. How an adolescent responds to and\ncopes with pain may be complicated by psychosocial and\ndevelopmental changes that accompany adolescence [2].\nOften, the patient may be hesitant to discuss their pain, as\nthey may view discussing gynecologic, urologic, or gas-\ntroenterological concerns as embarrassing. Providers\nshould also assess the impact of pain on the patient ’s\nactivities of daily life —school attendance and perfor-\nmance, extracurricular activity involvement, sleep,\nmood/behavior, and family life. It is important to explore\nand document the timeline and response to any prior\ntherapies. Often, the patient has had multiple visits for\ncomplaints of pain and may have been previously treated\nin some manner. A past medical and surgical history, in\naddition to any relevant family history, should be docu-\nmented. Lastly, asking the adolescent and her caregiver to\nindicate their goals of therapy will help ensure that the\nprovider and patient have common goals.\nThe physical exam will be tailored by the differential\ndiagnosis created after obtaining a history. It should also\ntake into account the patient ’sa g e ,m a t u r i t yl e v e l ,a n d\nsexual activity status. Reassuring the patient that she has\nthe right to stop the physical exam at any point provides\nthe adolescent a sense of control and helps solidify the\nrapport established at the beginning of the encounter.\nKey elements of the physical exam include the fol-\nlowing: review of vital signs, height/weight (and if pos-\nsible growth charts), Tanner staging of breasts and pu-\nbic hair, an abdominal exam (note tenderness, masses,\nscars, hernias), a musculoskeletal exam (noting trigger\npoints, posture, scoliosis, leg length discrepancies), an\nexternal genital exam (noting vulvar lesions, congenital\nanomalies, hymenal anatomy, discharge, trauma, ten-\nderness of the vulva/perineum/introitus), and if appli-\ncable, an internal genital exam. A speculum exam is\nuseful to evaluate vaginal patency, the vaginal mucosa\nand cervix, and obtain cultures if there is concern for an\ninfectious process. A bimanual exam is a means to\nevaluate uterine and adnexal size, shape, presence of\nmasses, and tenderness. If a s peculum and/or bimanual\nexam are not feasible, a lubricated cotton swab may be\nused to assess vaginal patency, and a rectoabdominal\nexam may be used to assess the rectovaginal septum\nand posterior cul-de-sac. Often, a rectoabdominal exam\nis better tolerated than a bimanual exam in the young\nand non-sexually active adolescent.\nFurther diagnostic testing may include the following:\npelvic ultrasound, pelvic magnetic resonance imaging\n(MRI), vaginal cultures, labs, and menstrual calendars.\nAp r e g n a n c yt e s tm u s tb ep e rformed in sexually active\nadolescents. Pelvic ultrasound is helpful if the provider\nis unable to perform a pelvic exam or if they suspect a\nmass or congenital anomaly. Pelvic MRI is a particularly\nuseful tool in evaluating congenital anomalies of the\nreproductive tract. Diagnostic laparoscopy is commonly\nused to confirm a diagnosis and provide treatment of\ncertain conditions.\nTreatment\nAs previously mentioned, the differential diagnosis of gynecologic pain in the\nadolescent can be extensive—as can the corresponding treatment options. The\ncourse of treatment is dictated by the suspected diagnosis, and in some cases,\nproviders may move through several modalities before the desires treatment\nGynecologic Pain in Adolescents McCracken 145\n\neffect is obtained. We will begin our discussion of treatment options with\npharmacologic therapies.\nPharmacologic treatment\nNon-steroidal anti-inflammatory medications\nInitial therapy for dysmenorrhea—severe cramping lower abdominal pain that\noccurs during and/or prior to menses—is typically non-steroidal anti-inflam-\nmatory drug (NSAID). NSAIDs inhibit prostaglandin synthesis. They have both\nanalgesic and anti-inflammatory properties. A meta-analysis of 63 randomized\ncontrolled trials found that NSAIDs were significantly more effective for pain\nrelief than placebo [3]. Typically, patients are instructed to take NSAIDs on an\nas-needed basis when they experience dysmenorrhea. However, in some pa-\ntients, it may be beneficial to schedule dosing —starting at the onset of menses\nand continuing as long as they experience cramping. Commonly used NSAIDs\ninclude ibuprofen, naproxen, and mefenamic acid. The response to NSAIDs is\nvariable, and lack of response to one NSAID should prompt the provider to\nprescribe an alternate NSAID [4]. Patients should be counseled that side effects\nmay include gastrointestinal irritation, heartburn, nausea, vomiting, headache,\nand allergic reactions. Adolescents with known/suspected peptic ulcer disease,\nGI bleeding, clotting disorders, renal disease, or known allergies to this class of\nmedication should avoid NSAID use.\nCombined hormonal contraceptives\nCombined hormonal contraceptives (CHCs) are a mainstay of treatment in\ncases of primary dysmenorrhea and secondary dysmenorrhea—especially in the\ncase of endometriosis. They are also used for ovulation suppression to reduce\nthe frequency of physiologic ovarian cysts.\nCHCs inhibit ovulation by suppression gonadotropin secretion. Specifically,\nthe progestin component in the pill suppresses the luteinizing hormone (LH)\nsurge that is necessary for ovulation, while the estrogen component suppresses\nfollicle-stimulating hormone (FSH) and therefore, suppresses follicular devel-\nopment. Estrogen also potentiates the action of progestin and stabilizes the\nendometrium [5]. The proposed mechanism of action for treatment of endo-\nmetriosis with a CHC is decidualization followed by atrophy of the endometrial\ntissue [6].\nMost adolescents are overall healthy and will not have contraindications to\nthe use of CHC. However, it is imperative to review the patient ’sp a s tm e d i c a l\nhistory and family history for any possible contraindications to an estrogen-\ncontaining pill prior to initiation. The Centers for Disease Control (CDC) has\ncompiled a useful guide outlining the medical eligibility criteria for contracep-\ntive use [7].\nCombined hormonal therapy is the first-line treatment of endometriosis.\nCHCs may be administered in a cyclic or continuous fashion. Typically, patients\nwith endometriosis have greater reduction in their symptoms with a continuous\nCHC. A progestin-dominant monophasic pill is preferred [4].\nIt is important to note that postoperative management of endometriosis in\nan adolescent is crucial for pain control, ensuring participation in school and\nactivities, and preservation of fertility. The importance of treating endometriosis\nin adolescents cannot be overstated—as studies have shown that early diagnosis\n146 Pediatric Gynecology (L Breech and K Stambough, Section Editors)\n\nand treatment (both medically and surgically) decrease disease progression,\nand without treatment, endometriosis will progress [8, 9].\nAs mentioned above, CHCs are also frequently used for patients with a\nhistory of benign functional cysts. While typical low-dose ( ≤35 μge t h i n y l\nestradiol) may not be as protective against benign ovarian cysts compared to the\noriginal 50-μgE Ep i l l s—studies do show decreased formation of functional\ncysts 93 cm with monophasic pills [ 10]. It is important to note that CHCs do\nnot help resolve an already formed ovarian cyst.\nProgestin-only therapy\nProgestins may also be used for treatment of dysmenorrhea and endometriosis-\nrelated pain. Commonly used progestins include norethindrone acetate (5–\n15 mg orally per day), depo-medroxyprogesterone acetate (150 mg intramus-\ncularly every 12 weeks), and the levonorgestrel intrauterine device (delivers\n20 μg/day over 5 years).\nGiven the potential side effects of progestin therapy—irregular menstrual\nbleeding, weight gain, acne, bloating, and emotional ability—progestin therapy\nis often used in patients who have contraindications to combined hormonal\ncontraception. Patients using depo-medroxyprogesterone acetate (DMPA)\nshould be counseled that the U.S. Food and Drug Administration has issued a\nBblack box warning^—that DMPA should be used as a long-term birth-control\nmethod (e.g., longer than 2 years) only if other birth control methods are\ninadequate^ [5]. It is important to note that the loss in bone mineral density is\nmost rapid within the first 2 years of use, then slows, and bone density is\nrestored within G3 years after the discontinuation of DMPA. Furthermore, there\nis no need to obtain bone mineral density testing in adolescents using DMPA.\nProviders should weigh the risks and benefits of DMPA use and counsel patients\nelecting to use DMPA on the need for adequate calcium and vitamin D intake.\nRecently, there has been increased research on the utility of the levonorges-\ntrel intrauterine device (LNG-IUD) for the management of endometriosis-\nrelated pain [11, 12]. The LNG-IUD has the advantages of avoiding compliance\nwith a daily medication and offering highly efficacious long-acting reversible\ncontraception. Studies have randomized women with known endometriosis to\nLNG-IUD or gonadotropin-releasing hormone agonists, and both treatments\nwere found to be effective for pain control [ 13, 14], while the LNG-IUD had\nhigher continuation rates and lower pain scores at 3 years [15]. Future research\nevaluating the efficacy of LNG-IUD for adolescents with gynecologic pain is\nneeded.\nGonadotropin-releasing hormone agonists\nSecond-line therapy for endometriosis consists of gonadotropin-releasing hor-\nmone agonists (GnRHa) with add-back therapy (typically an oral progestin).\nGnRHa bind to pituitary receptors which results in the down-regulation of the\npituitary-ovarian axis and a reversible hypoestrogenic state—which in turn\nresults in amenorrhea and endometrial atrophy. These medications have been\nwell studied, and their use in adolescents is supported [ 4].\nGnRHa therapy is available in injectable forms, nasal spray, and implants.\nCommonly used doses include depot leuprolide 11.25 mg administered every\n3 months or depot leuprolide 3.75 mg every 4 weeks.\nGynecologic Pain in Adolescents McCracken 147\n\nBecause a stimulatory phase occurs prior to the down-regulation of the\npituitary-ovarian axis, patients should be counseled to expect a Bflare^ in\nsymptoms accompanied by a withdrawal bleed approximately 21–28 days after\nadministration of the initial GnRHa dose.\nCommonly reported side effects are related to the hypoestrogenic state—hot\nflushes, vaginal dryness, decreased libido, mood swings, and bone mineral\ndepletion. Given the concern about decrease in bone density, the FDA has\nlimited the use of GnRHa to courses not lasting longer than 6 months [ 4]. The\nuse of GnRHa in adolescents is of concern, given that adolescence is a period of\nnormal bone acquisition. For that reason, GnRHa therapy is not recommended\nfor patients younger than 16 years [ 16, 17].\nThe goal of add-back therapy is to reduce the negative effects of GnRHa therapy\n(i.e., bone density loss and hot flushes) without stimulating endometriosis growth\nand related pain. The utility of add-back therapy lies within the principle of an\nBestrogen threshold hypothesis^—that the amount of estrogen necessary to pre-\nvent bone loss, hot flushes, and other hypoestrogenic symptoms is less that the\namount of estrogen that would stimulate endometriosis [18]. Add-back therapy\ntypically consists of norethindrone acetate 5 mg daily or conjugated estrogens\n(0.625 mg) taken with medroxyprogesterone acetate 10 mg or norethindrone\nacetate 5 mg daily. Optimization of calcium and vitamin D is also important.\nAntibiotic therapy\nIn cases of pelvic inflammatory disease (PID) and tubo-ovarian abscesses,\nantibiotic therapy is the mainstay of treatment. PID is a common etiology of\ninfectious morbidity in adolescent females. PID is an acute inflammatory\ninfection of the upper genital tract in women —which may involve the uterus,\nfallopian tubes, ovaries, and other pelvic structures. If untreated, it may result in\nsignificant sequelae—chronic pelvic pain, pelvic adhesive disease, increased risk\nof ectopic pregnancy, and increased risk of infertility. Endometritis, salpingitis,\ntubo-ovarian abscesses, and pelvic peritonitis may occur in the setting of PID.\nPID antibiotic therapy includes broad-spectrum coverage, whileNeisseria\ngonorrhoeaeand Chlamydia trachomatisare commonly implicated in PID cases; mul-\ntiple microorganisms that comprise vaginal flora have been associated with PID [19].\nOutpatient PID therapy is typically appropriate—unless the patient meets any of the\nfollowing criteria (Table2)—in which case, inpatient management is suggested.\nOf note, there is no evidence that adolescents benefit from hospitalization for\nPID treatment—the decision to hospitalize or not should be based upon the clinical\npicture, not the patient’s age.\nTable 2. Indications for inpatient PID treatment (modified from Workowski KA, Bolan GA [ 44])\nSurgical emergency cannot be excluded (i.e., appendicitis)\nPregnant patient\nFailed outpatient oral antibiotic therapy\nPatient unable to comply or tolerate outpatient oral antibiotic therapy\nSevere illness—nausea/vomiting, high fever\nPresence of a tubo-ovarian abscess\n148 Pediatric Gynecology (L Breech and K Stambough, Section Editors)\n\nIt is important to counsel adolescents to notify their partners if possible, to\nencourage partner testing/treatment, and to abstain from sexual intercourse until\ntherapy is completed, their symptoms have resolved, and their partners have been\ntreated. Patients should be offered testing for other sexually transmitted\ninfections—in particular HIV. Patients should have close follow-up (ideally within\n3 days of initiating oral outpatient therapy). Adolescents may be at increased risk for\npoor adherence to the CDC recommendations [20]. Assessment of patient safety, any\nforced intercourse, access to condoms, and access to contraceptive methods should\noccur in a confidential manner.\nRecommended treatment regimens for outpatient and inpatient therapy are listed\nbelow in Table3.\nSurgery\nLaparoscopy\nLaparoscopy is useful in both establishing the diagnosis and providing a means\nof treatment for gynecologic pain. In addition, laparoscopy is associated with\ndecreased morbidity and shorter length of hospital stays compared to laparot-\nomy [21, 22].\nThe management of adnexal masses—both benign and malignant—is be-\nyond the scope of this paper. Adnexal masses may be an etiology for both acute\nand chronic gynecologic pain; thoughtful preoperative assessment and risk\nstratification is necessary to determine the safest and most effective surgical\ntreatment course. Given the low risk of malignancy in the pediatric and ado-\nlescent population, in the majority of cases, laparoscopy is a wise choice, and\nthe gold standard for the management of adnexal masses. In many patients with\nadnexal cysts, a laparoscopic procedure is not emergent—however, in cases of a\nruptured hemorrhagic ovarian cyst if the patient is hemodynamically unstable,\nemergent surgical intervention should be undertaken. Hemoperitoneum is not\na contraindication to laparoscopy [4].\nOther indications for laparoscopy include the following: progressive dys-\nmenorrhea, dysmenorrhea unresponsive to medical therapy, suspected endo-\nmetriosis, or suspected chronic PID [23].\nIf an adolescent has not responded to treatment with NSAIDs and estrogen/\nprogestin or progestin-only therapy after 3–6 cycles of pills, and pain is ad-\nversely affecting her quality of life, then further assessment is needed [ 24].\nLaparoscopy is the cornerstone of diagnosing endometriosis. Any suspicious\nlesions should be biopsied. It is important that a surgeon well versed in\nrecognizing and treating adolescent endometriosis performs the laparoscopy.\nEndometriosis lesions in adolescents may appear differently than in adults.\nSpecifically, adolescents are more likely to have red lesions, clear vesicles, white\nimplants, small hemorrhagic peritoneal spots, or peritoneal defects/windows,\nrather than Bclassic^ brown, black, or Bpowder burn^ lesions that are seen in\nadults [4]. The Bnon-classic^ lesions may be best visualized by placing the\nlaparoscope within millimeters of the peritoneum or filling the pelvis with\nsaline and placing the laparoscope Bunder water.^ While the optimal surgical\ntechnique for treating endometriosis has not yet been established, the data does\nindicate the women with symptoms of pelvic pain who have visible endome-\ntriosis at the time of laparoscopy should be treated. Furthermore, women with\nendometriomas should have complete excision of the endometrioma cyst wall,\nGynecologic Pain in Adolescents McCracken 149\n\nas there is a lower risk of recurrence with cyst wall excision compared to\nfenestration and ablation of the cyst wall [ 6]. All adolescents with endometri-\nosis should be treated medically after surgical intervention. This will reduce the\nprogression of symptoms and avoid recurrence.\nIn cases of suspected adnexal torsion, urgent surgical intervention is the\nmainstay of therapy. With the rotation of the ovary or fallopian tube on its\npedicle, blood supply is compromised; this leads to venous congestion, impaired\narterial supply, ischemia, pain, and if untreated, necrosis and loss of the adnexa\n[25]. Patients typically present with acuteo n s e to fp a i nw i t ha s s o c i a t e dn a u s e a\nand vomiting. Adnexal masses—such as ovarian or paratubal cyst—may predis-\npose the patient to adnexal torsion. Normal ovaries may also torse. Standard\nTable 3. CDC recommendations for PID treatment [ 44]\nIntramuscular/oral regimens\nCeftriaxone 250 mg IM × one dose\nPLUS\ndoxycycline 100 mg PO BID × 14 days\nWITH OR WITHOUT\nmetronidazole 500 mg PO BID × 14 days\nCefoxitin 2 g IM × one dose AND Probenecid 1 g PO × one dose administered concurrently\nPLUS\ndoxycycline 100 mg PO BID × 14 days\nWITH OR WITHOUT\nmetronidazole 500 mg PO BID × 14 days\nThird generation cephalosporin (e.g., ceftizoxime or cefotaxime)\nPLUS\ndoxycycline 100 mg PO BID × 14 days\nWITH OR WITHOUT\nmetronidazole 500 mg PO BID × 14 days\nParenteral regimens\nCefotetan 2 g IV Q12 hours\nPLUS\nDoxycycline 100 mg PO or IV Q12 hours\nC e f o x i t i n2gI VQ 6h o u r s\nPLUS\nDoxycycline 100 mg PO or IV Q12 hours\nClindamycin 900 mg IV Q8 hours\nPLUS\nGentamicin loading dose IV or IM (2 mg/kg), then maintenance dose (1.5 mg/kg) Q8 hours\nAmpicillin/sulbactam 3 g IV Q6 hours\nPLUS\nDoxycycline 100 mg PO or IV Q12 hours\n150 Pediatric Gynecology (L Breech and K Stambough, Section Editors)\n\nlaparoscopic surgical technique is used in cases of suspected adnexal torsion.\nRecent data has indicated that an emphasis on detorsion of the adnexa and\novarian preservation, rather than removal of adnexal structures, is the standard of\ncare [4]. Fertility-sparing procedures are of the utmost importance in adolescents.\nIn some cases, it is useful to make an incision in the ovarian cortex to essentially\nbivalve the ovary and decrease the intraovarian pressure [26].\nLaparoscopy is also useful in the removal of non-communicating uterine\nhorns that contain functional endometrium. The shorter hospital stay, reduced\npostoperative pain, and improved cosmesis make laparoscopy an attractive\noption. In patients with mullerian anomalies—and uterine\nremnants—laparoscopy is a safe and effective means for removal if careful\nsurgical consideration is given to the patient’s unique anatomy (i.e., associated\nurinary tract anomalies, possible endometriosis, and adhesive disease) [27].\nIn cases of chronic pelvic inflammatorydisease or non-resolving tubo-ovarian\nabscesses, surgical intervention may be undertaken. Laparoscopy may be useful\nin patients who have repeatedly been diagnosed with PID, but who have not\nseemed to respond to standard treatment. In such cases, evaluation for other\netiologies of pain, such as endometriosis, may be found during laparoscopic\nevaluation. Laparoscopy may also be used for management of PID sequelae such\nas pelvic adhesions. Pelvic adhesions mayresult from etiologies other than PID;\nthey may be present in cases of endometriosis, secondary to prior surgical\nprocedures or from ruptured appendicitis. Adhesions do not always produce\npain. The data is mixed on whether lysis of adhesions provides therapeutic\nbenefit [2, 28]. In some cases of non-resolving tubo-ovarian abscesses, interven-\ntional radiology placement ofa pelvic drain may be useful.\nSurgical procedures for obstructive anomalies\nPatients with an obstructive anomaly, such as an imperforate hymen, transverse\nvaginal septum, obstructed hemivagina, distal vaginal atresia, vaginal agenesis,\nor non-communicating functional uterine horn, may present with either acute\nor chronic pain related to obstructed menstrual outflow and development of\nhematometra or hematocolpos. In cases of an imperforate hymen or transverse\nvaginal septum, patients may also present with acute urinary retention. Primary\namenorrhea with abdominal or pelvic pain should raise concern for an ob-\nstructive anomaly. Additionally, in patients with menstrual flow, but progres-\nsive or non-responsive dysmenorrhea, a partial obstruction must be considered.\nThe diagnosis is often delayed in these cases [ 29]. Accurate diagnosis of an\nobstructive anomaly is essential—as there is a difference in surgical manage-\nment techniques for imperforate hymen versus transverse vaginal septum versus\ndistal vaginal atresia. MRI is useful in delineating the anatomy pre-operatively.\nAn imperforate hymen with symptomatic hematocolpos is usually managed\nemergently. While under anesthesia, excision of excess hymenal tissue is performed,\nthe hematocolpos is drained, and the patient experiences immediate pain relief.\nOnce excised, hymenal tissue does not regenerate; thus, there is no risk of stenosis.\nIn cases of transverse vaginal septa, the first consideration is the level of the\nseptum within the vagina (low, middle, high). Second, the thickness of the septum\nmust be established. MRI is a useful tool for both pieces of information. If the\nseptum is thin, it may be resected, and the vaginal mucosa is then reapproximated\nprimarily. However, in cases of thick septa, the reapproximation of vaginal mucosa\nGynecologic Pain in Adolescents McCracken 151\n\nis more challenging. If the upper vagina is well distended, it may be possible to\nmobilize normal upper vaginal mucosa so that it can be brought together with the\ndistal vaginal mucosa without the anastomosis being under undue tension. How-\never, if this is not possible, other techniques may be utilized, such as using the\nvaginal septum to make flaps for a bridgeof vaginal tissue between the upper and\nlower vagina [29, 30]. Vaginal stenosis is common after resection of transverse\nvaginal septa—thus, vigilant surveillance for this complication and liberal use of\nvaginal dilators is important.\nA challenging case may be that of the obstructed hemivagina. In this case, the\npatient typically has a didelphic uterus with duplicated cervices and septal tissue\nobstructing menstrual flow from one cervix. This results in hematometrocolpos and\ncervical distension on the obstructed side. Complete resection of the septal tissue\nwithout damage to the distended cervix is crucial. Once the septum is excised, the\nvaginal mucosa is reapproximated in an interrupted fashion. There are some cases\nin which an obstructed hemivagina is present and there is a microperforation in the\ntissue—this is challenging because the septum may not be distended and the\nboundaries of the septum are difficult to discern. Stay sutures or a catheter threaded\ninto the microperforation and pulled downward is helpful to provide traction so\nthat the septum can be resected without damage to the cervix above [29, 30].\nDistal vaginal atresia refers to cases in which an upper vagina is present, but the\ndistal vagina has not developed and instead is replaced by fibrous tissue. It is\nimportant to distinguish this case from that of a thick low transverse vaginal\nseptum. With distal vaginal atresia, a vaginal pull-through is performed. In this\nprocedure, dissection of the vesicovaginal and rectovaginal spaces is performed to\nlocate the upper vagina; then, the normal vaginal mucosa is mobilized to the\nperineum to join the upper vagina to the lower vaginal dimple [29, 31, 32].\nTreatment of obstructive anomalies is important as there are higher rates of\nendometriosis, hematosalpinx, pelvic inflammatory disease, and adhesive disease\nrelated to menstrual backflow in these adolescents [29].\nIncision, drainage, and word catheter use\nVulvar abscesses do occur in adolescent patients. Conservative therapy with\nantibiotics may be considered; however, in many cases, a surgical incision and\ndrainage of the abscess is necessary. Standard technique is used in which the\nfluctuant area of the abscess is identified and a scalpel is used to make in\nincision into the abscess cavity, followed by irrigation of the abscess and\nmechanical destruction of any loculations. A culture of the purulent abscess\ncontents should be obtained. Packing of the abscess and the use of a drain\ndepend on the size of the abscess, location, and hemostasis. In adolescents, this\nprocedure is usually performed under anesthesia, but in some situations, local\nanesthesia may be utilized. In cases of a Bartholin’s gland cyst and/or abscess, a\nWord catheter is left in place for a period of time to promote epithelialization.\nDiet, lifestyle, and exercise\nPatients with dysmenorrhea should be encouraged to exercise regularly (goal\n30 min of cardiovascular activity per day), make healthy food choices, and\nfollow stress-reduction strategies. Adolescence is a stressful time, and poor sleep\nhygiene, unbalanced diets, and lack of regular exercise may exacerbate primary\n152 Pediatric Gynecology (L Breech and K Stambough, Section Editors)\n\nor secondary dysmenorrhea. Providers should assess these lifestyle components\nand assist in making recommendations for behavioral changes as necessary.\nSeveral complementary and alternative medicine therapies have been pro-\nposed as helpful for dysmenorrhea symptoms. However, randomized con-\ntrolled trials and studies with adolescent cohorts are limited. Dong Quai,\nevening primrose oil, and chaste tree berry are commonly marketed for relief of\nmenstrual discomfort. Data is mixed on their efficacy [ 33]. Some studies show\nthat following a low-fat diet and consuming a fish oil supplement may relieve\ndysmenorrhea symptoms [33].\nAcupuncture has been well studied and appears to reduce pain in both\nprimary dysmenorrhea and endometriosis patients [1, 4, 34–37]. Adolescents\nmay benefit from acupuncture therapy from a trained, certified provider.\nLastly, yoga may be beneficial for dysmenorrhea symptoms. A ran-\ndomized controlled trial of 92 adoles cents found that practicing yoga\nreduced both the severity and duration of primary dysmenorrhea com-\npared to controls [ 38].\nPhysical therapy\nIn cases of musculoskeletal related pain, physical therapy may be beneficial.\nMusculoskeletal dysfunction may occur as a response to a primary gynecologic\nproblem, or it may be the primary etiology of a patient ’sp a i n[2]. A discussion\non musculoskeletal pain is beyond the scope of this article. However, it is\nimportant to note that musculoskeletal pain must be evaluated and treated.\nPhysical therapy—with an emphasis on pelvic floor physical therapy —is an\neffective treatment for musculoskeletal pain. Physical therapy is also useful in\nthe treatment of adolescent vulvodynia, vaginismus, and endometriois [1, 4,\n37, 39]. The use of biofeedback and self-vaginal dilators may be combined with\npelvic floor physical therapy. While this may be challenging in adolescents, the\ntreatment is effective. In a retrospective review of adolescents with musculo-\nskeletal pain who presented to a pediatric and adolescent gynecology practice,\nphysical therapy resulted in resolution of symptoms in 95 % of patients [ 40].\nOther treatments\nTopical heat\nHeat is a commonly used therapeutic measure. This holds true for adolescents\nwith dysmenorrhea [41]. Low-dose heat application has been shown to reduce\ndysmenorrhea [42, 43]. Heat vasodilates and thus, increases smooth muscle\nperfusion and relaxation. This leads to a decreased perception of pain. Heat is a\nnon-invasive, cost-effective, and low-risk adjunct to other therapeutic measures.\nConclusion\nGynecologic pain in adolescents is a common problem. Obtaining a complete\nhistory and physical allows the provider to develop a differential diagnosis. The\nsuspected diagnosis will guide therapy. Patients with chronic pain may require\nregular visits. It is important to validate the patient ’s pain, offer reassurance\nwhen dangerous pathology has been ruled out, and set realistic treatment goals\nGynecologic Pain in Adolescents McCracken 153\n\n[37]. Encouraging the patient to attend school and participate in normal\nactivities is crucial.\nAs with any treatment modality, future research should focus on well-\ndesigned randomized controlled prospective trials to help establish the most\nefficacious, safe, minimally invasive, and cost-effective option. Treatment of\ngynecologic pain in adolescents ensures that our patients’ reproductive health is\nmaximized and that they can participate fully in life.\nCompliance with Ethical Standards\nConflict of Interest\nThe author declares that she has no conflict of interest.\nHuman and Animal Rights and Informed Consent\nThis article does not contain any studies with human or animal subjects performed by any of the authors.\nReferences and Recommended Reading\n1. Trotman GE, Gomez-Lobo V. Pelvic pain in the ado-\nlescent. Contemporary OB/GYN. 2013;58(1):50–5.\n2. Song AH, Advincula AP. Adolescent chronic pelvic\npain. J Pediatr Adolesc Gynecol. 2005;18(6):371–7.\n3. Marjoribanks J, Proctor MS, Farquhar C. Nonsteroidal\nanti-inflammatory drugs for primary dysmenorrhea.\nCochrane Database Syst Rev. 2003;4:CD001751.\n4. Laufer M. Gynecologic pain: dysmenorrhea, acute and\nchronic pelvic pain, endometriosis, and premenstrual\nsyndrome. In: Emans SJ, Laufer M, editors. 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Japanese-style acupuncture for\nendometriosis-related pelvic pain in adolescents and\nyoung women: results of a randomized sham-\ncontrolled trial. J Pediatr Adolesc Gynecol.\n2008;21(5):247–57.\n37. Damle LF, Gomez-Lobo V. Pelvic pain in adolescents. J\nPe\ndiatr Adolesc Gynecol. 2011;24(3):172–5.\n38. Rakhshaee Z. Effects of three yoga poses (cobra, cat and\nfish poses) in women with primary dysmenorrhea: a\nrandomized clinical trial. J Pediatr Adolesc Gynecol.\n2011;24:192–6.\n39. Clare CA, Yeh J. Vulvodynia in adolescence: childhood\nvulvar pain syndromes. J Pediatr Adolesc Gynecol.\n2013;24(3):110–5.\n40. Schroeder B, Sanfilippo JS, Hertweck SP. Musculoskel-\netal pelvic pain in a pediatric and adolescent gynecol-\nogy practice. J Pediatr Adolesc Gynecol. 2000;13(2):90.\n41. O ’Connell K, Davis AR, Westhoff C. Self-treatment\npatterns among adolescent girls with dysmenorrhea. J\nPediatr Adolesc Gynecol. 2006;19(4):285–9.\n42. Akin M et al. Continuous, low-level, topical heat wrap\ntherapy as compared to acetaminophen for primary\ndysmenorrhea. J Reprod Med. 2004;49(9):739–45.\n43. Potur DC, Komurcu N. The effects of local low-dose\nheat application on dysmenorrhea. J Pediatr Adolesc\nGynecol. 2014;27(4):216–21.\n44. Workowski KA, Bolan GA. Sexually transmitted dis-\neases treatment guidelines, 2015. MMWR Recomm\nRep. 2015;64(RR-03):1–137.\nGynecologic Pain in Adolescents McCracken 155","source_license":"CC0","license_restricted":false}