Complementary and Alternative Therapies

Some patients and families seek complementary and alternative therapies. Adolescents should be asked about what alternative treatments they already may be using. There are promising, although limited, data on the benefits of exercise and heat treatment for the symptoms of dysmenorrhea 28. 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 for which there may be limited evidence to suggest a potential benefit include fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B₁ 29. A recent study of adolescent girls with a mean age of 14.72 years demonstrated a decrease in the prevalence of dysmenorrhea when taking high-dose vitamin D weekly for 9 weeks 30; however, other studies show limited effect of vitamin D. Transcutaneous electrical nerve stimulation, acupuncture, herbal preparations, and yoga have demonstrated improvement in dysmenorrhea in some studies, but current evidence does not support them as first-line complementary and alternative therapies 22. Safety and efficacy data on herbal treatments are unclear.

Surgical Approaches to Management of Primary Dysmenorrhea

Surgical therapies have been proposed for primary dysmenorrhea. However, a systematic review found insufficient evidence to recommend the use of either uterine nerve ablation or presacral neurectomy for dysmenorrhea 31. Definitive and irreversible procedures such as ablation and hysterectomy should not be considered in adolescents.

Follow-Up for Primary Dysmenorrhea

Regardless of chosen therapy, patients with a presumed diagnosis of primary dysmenorrhea should be monitored for response to treatment. Response to treatment of primary dysmenorrhea supports the diagnosis. Tools that can be used for assessing dysmenorrhea at initial presentation as well as in response to treatment include visual analog scales and numerical rating scales. Both scales are reliable, valid, translated into the most frequently spoken languages, and are simple to administer and fulfill 32. When a patient does not experience clinical improvement for her dysmenorrhea within 3–6 months of therapy initiation, her obstetrician–gynecologist should investigate for possible secondary causes and for treatment adherence. Adolescents may be less adherent to medication schedules and may face conflict with parents about medication use. Other barriers may include forgetfulness, disorganization, financial costs, and pharmacy access. A literature review concluded that social support and peer relations were key themes in evaluating medication adherence, noting that adolescents worry about stigma and embarrassment in terms of social deviance, taking medications in front of peers, and having peers find out about their condition 33. An additional theme noted by the review was that medication nonadherence can be related to conflicts between adolescents and their parents. Such conflict could arise from parents who find it challenging to include the adolescent in the decision-making process, thus inhibiting self-management and the transition of treatment responsibilities, or conversely, from parents who show lack of support and involvement 33. Addressing these issues with patients and discussing methods to overcome such potential challenges may be helpful. After confirming treatment adherence, another hormonal method may be tried for an additional 3 months.

Evaluation of Suspected Secondary Dysmenorrhea

Most adolescents who present with dysmenorrhea have primary dysmenorrhea and will respond well to empiric treatment with NSAIDs, or hormonal suppression, or both 34. However, some patients either present initially with symptoms suggesting secondary dysmenorrhea or they fail empiric treatment for primary dysmenorrhea and require further evaluation (see Fig. 1. Additionally, if a patient has pain for 3–6 months, a more comprehensive evaluation of chronic pelvic pain should be performed with a history and focused physical examination to assess potential gastroenterologic, urologic, musculoskeletal, and psychosocial etiologies of pain.

Figure 1.

Approach to the adolescent with dysmenorrhea.

A pelvic examination to evaluate potential etiologies of secondary dysmenorrhea should be considered. With education and support, many adolescents who are not sexually active are able to tolerate a pelvic examination. Findings from a pelvic examination also may indicate other etiologies of secondary dysmenorrhea such as endometriosis, an obstructed reproductive tract anomaly, enlarged or irregularly shaped uterus, cervical friability or discharge (pelvic inflammatory disease), pelvic masses (ovarian cyst), vaginismus, or other pelvic floor disorders.

Pelvic imaging with ultrasonography, regardless of findings on pelvic examination, also should be considered during evaluation for secondary dysmenorrhea. Ultrasonography is the most appropriate initial imaging modality to identify potential etiologies of secondary dysmenorrhea, including obstructive reproductive tract anomalies, uterine myomas, and adnexal masses with endometriomas 35. Ultrasonography can be helpful in the diagnosis of ovarian endometriomas but is not useful for nonovarian endometriotic lesions 35. Although subsequent magnetic resonance imaging may be necessary to further delineate müllerian anomalies, it is not cost-effective as an initial screening tool 36. Although magnetic resonance imaging is likely to be equally as sensitive as ultrasonography in diagnosing ovarian endometriomas, it does not appear to be useful for identifying endometriotic peritoneal lesions or determining the extent of disease 36. A normal pelvic ultrasonography or physical examination does not eliminate the possibility of endometriosis.

Reproductive Tract Anomalies

Any obstructive anomaly of the reproductive tract, whether hymenal, vaginal, or müllerian, can cause secondary dysmenorrhea. The true incidence of reproductive tract anomalies is unknown, but they are estimated to occur in 0.1–3.8% of young women. Reproductive anomalies, both obstructive and nonobstructive, also are associated with endometriosis 37. Patients with urogenital sinus abnormalities and anorectal malformations are at increased risk of reproductive tract abnormalities and should be monitored for outflow tract obstructions as they progress through puberty and establish menses.

The goal of treatment in patients with obstructive reproductive tract anomalies is to establish a patent outflow tract to relieve symptoms and to decrease endometriosis and adhesions that can occur secondary to retrograde menses. Endometriosis associated with obstructive anomalies may improve after surgical correction and establishment of a patent outflow tract 37; however, persistent endometriosis after surgical correction of the obstructive anomaly has been reported 38.

Suspected Endometriosis

Endometriosis is the leading cause of secondary dysmenorrhea in adolescents. Endometriosis should be considered in patients with persistent, clinically significant dysmenorrhea despite treatment with hormonal agents and NSAIDs, particularly if no other etiology for chronic pelvic pain or secondary dysmenorrhea has been identified based on history, physical examination, and pelvic ultrasonography. Family history of endometriosis also should raise suspicion because patients with an affected first-degree relative have a 7-fold to 10-fold increased risk of developing endometriosis 39. To assess the effects of the symptoms on functionality in adolescents, it may be helpful to ask if they are missing school or participation in sports or other extracurricular activities.

Endometriosis is the most common finding in young women undergoing laparoscopy for chronic pelvic pain 6. Although the true prevalence of endometriosis in adolescents is unknown, at least two thirds of adolescent girls with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at the time of diagnostic laparoscopy.

Endometriosis remains a surgical and pathologic diagnosis in adolescents requiring the presence of endometrial glands and stroma in the biopsy specimen from a location outside of the endometrial cavity. Patients with persistent dysmenorrhea despite treatment and no other identified etiologies should be counseled about the high likelihood of endometriosis and the risks and benefits of diagnostic laparoscopy. The benefits of laparoscopy include confirmation of the presence or absence of endometriosis or other causes of chronic pain such as adhesive disease. Laparoscopy also presents an opportunity to treat endometriosis with coagulation, ablation, or resection of visible implants and adhesive disease with lysis of adhesions. Risks associated with laparoscopy include adverse effects from anesthesia, venous thromboembolism, bleeding, infection, wound infection, adhesion formation, and injury to surrounding structures. After shared decision making, some patients, together with their families and obstetrician–gynecologists, may opt for medical treatment of suspected endometriosis without having a confirmed pathologic diagnosis to avoid laparoscopy.

Laparoscopy for Endometriosis

The appearance of endometriosis may be different in an adolescent than in an adult woman. In adolescents, endometriotic lesions are typically clear or red and can be difficult to identify for gynecologists unfamiliar with endometriosis in adolescents Fig. 2, Fig. 3. Techniques described to enhance visualization of the lesions include moving the laparoscope within millimeters of the peritoneum (magnification technique) and filling the pelvis with saline and “diving in” with the laparoscope 27. Lesions suspicious of endometriosis should be sampled and biopsied, and visible lesions should be destroyed, ablated, or excised at the time of initial laparoscopy 27. Occasionally, biopsy of a suspicious lesion may not confirm endometriosis and visual diagnosis may suffice so that treatment can be initiated. The American College of Obstetricians and Gynecologists does not recommend “peritoneal stripping” in adolescents based on theoretical concerns (eg, adhesion formation contributing to bowel obstruction or infertility, or both, and persistent pain). In addition, there is a lack of short-term and long-term outcome data about the procedure.

Figure 2.

Red, inflamed adolescent endometriotic implant in the right paraovarian fossa. (Image courtesy of Geri Hewitt, MD, Nationwide Children’s Hospital, Columbus, Ohio.)

Figure 3.

Clear, vesicular adolescent endometriotic implant in the anterior peritoneum. (Image courtesy of Geri Hewitt, MD, Nationwide Children’s Hospital, Columbus, Ohio.)

At laparoscopy, most adolescents are diagnosed with early-stage endometriosis (American Society of Reproductive Medicine stage 1 or 2) 40, although there are a number of recent reports of young women presenting with more advanced disease 124142. When counseling families about surgical findings, it is important to communicate that the stage and location of endometriosis is not directly related to the frequency or severity of symptoms 43. Although typically diagnosed with earlier stage disease, adolescents may still experience substantial pain because the clear and red lesions are more metabolically active and are associated with greater prostaglandin production and subsequent pain and inflammation than the “powder burn” lesions seen in adult women 22.

If a patient is undergoing a diagnostic laparoscopy for dysmenorrhea or chronic pain, or both, consideration should be given to placing a LNG-IUS at the time of laparoscopy to minimize the pain of insertion. The LNG-IUS has been shown to decrease the pain associated with both dysmenorrhea unresponsive to oral contraceptive pills and dysmenorrhea and pain associated with endometriosis 44, although the LNG-IUS is not approved by the U.S. Food and Drug Administration for treatment of endometriosis-associated pain. Adolescents with endometriosis should not be treated with oophorectomy or hysterectomy.

Management of Endometriosis in Adolescents

Endometriosis in adolescents is considered a chronic disease with potential for progression if left untreated 45. The goals of therapy include symptom relief, suppression of disease progression, and protection of future fertility. There is no cure, nor is there a single best treatment option. 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.

Like endometriosis in adults, endometriosis in adolescents is considered an inflammatory-mediated estrogen-dependent disorder. Estrogen produced by the ovaries, as well as estrogen produced locally by the endometriotic implants due to aromatase activity, promotes increased prostaglandin production, resulting in pain 22. The recommended treatment for endometriosis in adolescents is conservative surgical therapy for diagnosis and treatment combined with ongoing suppressive medical therapies to prevent endometrial proliferation 27. First-line therapy for adolescents with either surgically diagnosed and destroyed endometriosis or presumed endometriosis includes suppressive hormonal therapy using a continuous combined hormonal contraceptive, a progestin-only agent, or 52 mg of LNG-IUS. All of these methods have been shown to be effective 46. Patients may benefit from trying several different types of hormonal suppression until they find their best fit. Because endometriosis is a chronic condition, patients should continue hormonal suppression unless they are actively trying to become pregnant.

Patients with endometriosis who have pain refractory to conservative surgical therapy and suppressive hormonal therapy often benefit from at least 6 months of GnRH agonist therapy with add-back medicine. Limited data exist regarding the long-term effects of GnRH agonist therapy on bone mineralization in adolescent patients. Leuprolide has been used in younger adolescents for the treatment of precocious puberty, obstructive anomalies, and for the care of transgender patients and those undergoing therapies for cancer. The obstetrician–gynecologist and patient should engage in a discussion of potential risks and benefits based on the patient’s individualized needs. Patients treated with GnRH agonists should begin add-back hormone therapy at the initiation of treatment to prevent bone loss and avoid the onset of menopausal symptoms. In a 2017 trial in adolescents, add-back therapy using a combination of conjugated equine estrogen (0.625 mg) and norethindrone acetate (5 mg) daily was superior to norethindrone acetate alone when comparing quality of life outcomes 47 and preservation of bone density 48. Dual-energy X-ray absorptiometry scanning is not needed before initiation of therapy, during GnRH agonist treatment of less than 12 months in duration, or after treatment. Obstetrician–gynecologists should counsel patients on adequate dietary calcium and vitamin D intake and the benefits of weight-bearing exercise during GnRH agonist therapy. After leuprolide is discontinued, patients should begin continuous hormone-suppression therapy.

Although serum CA 125 levels may be increased in patients with endometriosis, the American College of Obstetricians and Gynecologists does not endorse using CA 125 to monitor treatment or screen for endometriosis 49. Nonsteroidal antiinflammatory drugs should be the mainstay of pain relief for adolescents with endometriosis. Adolescents should not be prescribed narcotics long-term to manage endometriosis outside of a specialized pain management team.

Long-term Patient and Familial Education and Support

Adolescents with endometriosis often benefit from ongoing education and support and integration of other multidisciplinary services such as biofeedback, pain management teams, acupuncture, and herbal therapy 27. There is an absence of longitudinal data on fertility rates in adolescents with endometriosis, and early diagnosis and treatment may protect this population’s future fertility. The Endometriosis Foundation of America (www.endofound.org) and The Endometriosis Association (www.endometriosisassn.org) provide resources for adolescents and their families.