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Comorbidities in Adolescents With Endometriosis
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Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
for treatment of biopsy proven endometriosis, and determine it's efficacy in regards to pain and bleeding on follow up exam. Methods: This was a retrospective chart review of adolescent patients with pathology proven endometriosis who had a LNG-IUS placed for treatment during the time period of October 2009 through June of 2011. Patients were either classified as having the LNG-IUS placed at the time of diagnostic laparoscopy, or after the diagnosis had been made. Hormonal medications used before and after diagnosis of endometriosis were recorded. Follow up visits after LNG-IUS insertion were reviewed for the presence of persistent pain and bleeding. Additional hormonal medications needed after LNG-IUS insertion to control pain and bleeding were also recorded. Results: Eighteen patients, with median age of 16, were identified with pathology proven endometriosis who had a LNG-IUS placed as part of their treatment. Seventeen patients had stage I disease, and one patient had stage II disease. LNG-IUS was placed at time of diagnostic procedure in 8 patients, and the remaining 10 patients had the LNG-IUS placed after diagnosis (mean of 25.6 months). In the eight patients that had an LNG-IUS placed at the time of diagnosis, all but one patient required additional hormonal medications for pain or bleeding suppression. Two patients required GnRHa, and the remaining 5 patients used an oral contraceptive or progestin for an average of 6.6 months. Length of follow up after LNG-IUS was an average of 8.5 months. Time until bleeding cessation was an average 4.2 months in six patients, with the remaining two patients having irregular spotting at the last visit. All eight patients had pain resolution within an average of 4.75 months. In the ten patients that had the LNG-IUS placed after surgery, all had post operative hormonal therapy up until the time of LNG-IUS insertion. Eight patients were treated with GnRHa, while the remaining were treated with an oral contraceptive or progestin. After insertion of the LNG-IUS, five patients needed no additional medication for pain or bleeding, while the other five were treated with an oral contraceptive or progestin (4 patients) or GnRHa (1 patient). Of the patients in this group with at least 3 months of follow up, all had resolution of bleeding by an average of 2.3 months. All but one patient had resolution of pain within an average of 4.8 months. Conclusions: An LNG-IUS is an option for treatment of endometriosis in adolescents. Our study indicates that the majority of patients (67%) will require additional hormonal therapy for pain and bleeding suppression. Average time to pain suppression was similar in both groups (4.8 versus 4.75 months). As pain is the main problem associated with endometriosis, it can be beneficial to consider LNG-IUS placement at the time of diagnostic surgery.
36. Comorbidities in Adolescents With Endometriosis Noam Smorgick-Rosenbaum MD, Msc, Courtney Marsh MD, MPH, Sawsan As-Sanie MD, MPH, Yolanda R. Smith MD, MS, Elisabeth H. Quint MD Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, MI
Background: Endometriosis is a common etiology of pelvic pain in women. In adult women with endometriosis and pelvic pain, comorbidities are frequently identified. The prevalence of comorbidities in teenagers with chronic pain from endometriosis has not been reported. The objective of this study is to determine the frequency of comorbidities in young women with endometriosis and to compare clinical parameters between women with and without comorbidities. Methods: Women treated for surgically diagnosed endometriosis before the age of 21 (either visually or with pathology) from July 2005 to September 2011 were identified by ICD-9 codes. The medical charts were retrospectively reviewed for medical, surgical and pathologic diagnoses. We specifically focused on pain and mood comorbidities common in adults with endometriosis. The Student t-test and Chi square test were used for statistical analysis. The study was approved by the institutional IRB. Results: Eighty-five young women were identified with endometriosis. Mean age at time of endometriosis diagnosis was 17.3 2.1 years, and mean age at their first clinic visit was 18.3 2.4 years. Of those, 56 (65.9%) had one or more comorbid conditions at presentation, including depression (32.9%),
anxiety (18.8%), irritable bowel syndrome (25.9%), chronic headaches (22.6%), interstitial cystitis (15.3%), low back pain (15.3%), vulvodynia (9.4%), chronic fatigue syndrome (4.7%), fibromyalgia (4.7%), and temporomandibular joint disorder (2.4%). Comparing adolescents with and without comorbidities, there were no statistical differences in mean age at endometriosis diagnosis, mean age at first visit, and prevalence of dysmenorrhea, daily pelvic pain or intermittent pelvic pain. Adolescents with comorbidities were more likely to report a history of sexual abuse (12.5% versus 0%, p<.05), dysuria (35.2% versus 3.6%, p<.01), and the use of 3 or more hormonal medications (67.9% versus 41.4%, p<.05). Conclusions: Two-thirds of adolescents with endometriosis report mood and/or pain syndromes. In those with comorbidities a history of sexual abuse was reported in 12.5%. Evaluation for mood and pain disorders, as well as for sexual abuse is essential in adolescents with endometriosis.
37. Scar Endometriosis After Hysterectomy for Cervical Agenesis Amanda N. Kallen MD, Beth W. Rackow MD Yale University School of Medicine; Department of Obstetrics, Gynecology and Reproductive Sciences; New Haven, Connecticut
Background: A 17 year old young woman with cervical agenesis underwent a laparoscopic hysterectomy and surgical treatment of endometriosis, and two years later presented with a mass of endometriosis at a port site. It should be recognized that some females with endometriosis € llerian anomaly will continue to have endomedue to an obstructive mu triosis despite surgical treatment of the obstruction. Furthermore, as more hysterectomies are performed laparoscopically, the incidence of scar endometriosis may increase, and should be considered in the differential diagnosis of an incisional mass. Case: A 17 year old young woman presented with primary amenorrhea and cyclic pelvic pain; her exam revealed a normal vagina with no visible cervix, and an ultrasound identified a normal uterus. A pelvic MRI confirmed the diagnosis of cervical agenesis. After extensive counseling regarding management options, a laparoscopic hysterectomy was performed. Intraoperative findings included stage 3 endometriosis; the uterus was morcellated and removed through a 10 mm suprapubic port site. For medical management of endometriosis, continuous oral contraceptive pills were prescribed. Postoperatively she was pain-free, and discontinued the pills one year later., Over the following year, she reported a palpable mass and worsening cyclic pain at the suprapubic port site. A pelvic MRI revealed a 2.9 cm focus of endometriosis in the lower abdominal wall and bilateral ovarian endometriomas. She underwent laparoscopic ovarian cystectomies, ablation of endometriosis, and abdominal excision of the port site endometriosis. The 3 cm mass extended through subcutaneous tissue, fascia and rectus muscle; pathology is pending. Comments: Women with cervical agenesis are at high risk of endometriosis due to obstruction-related retrograde menstruation. Management options for cervical agenesis include medications for menstrual suppression, surgical reconstruction of the cervical canal or hysterectomy. After relieving the obstruction, endometriosis tends to resolve. In this case, endometriosis persisted despite aggressive surgical management and postoperative hormonal suppression, and warrants long-term medical treatment. Theories about endometriosis development include retrograde menstruation, venous and lymphatic metastases, coelomic metaplasia and mechanical transplantation. Surgical site endometriosis is reported in 0.03-1.7% of women who undergo abdominal surgery. Symptoms can mimic an incisional hernia, with a palpable subcutaneous mass at the surgical site, or cyclic pain and swelling may occur with menses., Scar endometriosis lesions can measure up to 5 cm in size, and occur on average 21 months after surgery. Although hormonal medications may be effective treatment, surgical excision is the gold standard, and to prevent recurrence, it is important to excise all scar endometriosis. With an increasing number of laparoscopic hysterectomies being performed, one must consider the risk of surgical scar endometriosis when planning removal of the uterine corpus. Additionally, knowledge of the presentation and treatment of scar endometriosis will help clinicians better evaluate postoperative incisional masses.
Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
for treatment of biopsy proven endometriosis, and determine it's efficacy in regards to pain and bleeding on follow up exam. Methods: This was a retrospective chart review of adolescent patients with pathology proven endometriosis who had a LNG-IUS placed for treatment during the time period of October 2009 through June of 2011. Patients were either classified as having the LNG-IUS placed at the time of diagnostic laparoscopy, or after the diagnosis had been made. Hormonal medications used before and after diagnosis of endometriosis were recorded. Follow up visits after LNG-IUS insertion were reviewed for the presence of persistent pain and bleeding. Additional hormonal medications needed after LNG-IUS insertion to control pain and bleeding were also recorded. Results: Eighteen patients, with median age of 16, were identified with pathology proven endometriosis who had a LNG-IUS placed as part of their treatment. Seventeen patients had stage I disease, and one patient had stage II disease. LNG-IUS was placed at time of diagnostic procedure in 8 patients, and the remaining 10 patients had the LNG-IUS placed after diagnosis (mean of 25.6 months). In the eight patients that had an LNG-IUS placed at the time of diagnosis, all but one patient required additional hormonal medications for pain or bleeding suppression. Two patients required GnRHa, and the remaining 5 patients used an oral contraceptive or progestin for an average of 6.6 months. Length of follow up after LNG-IUS was an average of 8.5 months. Time until bleeding cessation was an average 4.2 months in six patients, with the remaining two patients having irregular spotting at the last visit. All eight patients had pain resolution within an average of 4.75 months. In the ten patients that had the LNG-IUS placed after surgery, all had post operative hormonal therapy up until the time of LNG-IUS insertion. Eight patients were treated with GnRHa, while the remaining were treated with an oral contraceptive or progestin. After insertion of the LNG-IUS, five patients needed no additional medication for pain or bleeding, while the other five were treated with an oral contraceptive or progestin (4 patients) or GnRHa (1 patient). Of the patients in this group with at least 3 months of follow up, all had resolution of bleeding by an average of 2.3 months. All but one patient had resolution of pain within an average of 4.8 months. Conclusions: An LNG-IUS is an option for treatment of endometriosis in adolescents. Our study indicates that the majority of patients (67%) will require additional hormonal therapy for pain and bleeding suppression. Average time to pain suppression was similar in both groups (4.8 versus 4.75 months). As pain is the main problem associated with endometriosis, it can be beneficial to consider LNG-IUS placement at the time of diagnostic surgery.
36. Comorbidities in Adolescents With Endometriosis Noam Smorgick-Rosenbaum MD, Msc, Courtney Marsh MD, MPH, Sawsan As-Sanie MD, MPH, Yolanda R. Smith MD, MS, Elisabeth H. Quint MD Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, MI
Background: Endometriosis is a common etiology of pelvic pain in women. In adult women with endometriosis and pelvic pain, comorbidities are frequently identified. The prevalence of comorbidities in teenagers with chronic pain from endometriosis has not been reported. The objective of this study is to determine the frequency of comorbidities in young women with endometriosis and to compare clinical parameters between women with and without comorbidities. Methods: Women treated for surgically diagnosed endometriosis before the age of 21 (either visually or with pathology) from July 2005 to September 2011 were identified by ICD-9 codes. The medical charts were retrospectively reviewed for medical, surgical and pathologic diagnoses. We specifically focused on pain and mood comorbidities common in adults with endometriosis. The Student t-test and Chi square test were used for statistical analysis. The study was approved by the institutional IRB. Results: Eighty-five young women were identified with endometriosis. Mean age at time of endometriosis diagnosis was 17.3 2.1 years, and mean age at their first clinic visit was 18.3 2.4 years. Of those, 56 (65.9%) had one or more comorbid conditions at presentation, including depression (32.9%),
anxiety (18.8%), irritable bowel syndrome (25.9%), chronic headaches (22.6%), interstitial cystitis (15.3%), low back pain (15.3%), vulvodynia (9.4%), chronic fatigue syndrome (4.7%), fibromyalgia (4.7%), and temporomandibular joint disorder (2.4%). Comparing adolescents with and without comorbidities, there were no statistical differences in mean age at endometriosis diagnosis, mean age at first visit, and prevalence of dysmenorrhea, daily pelvic pain or intermittent pelvic pain. Adolescents with comorbidities were more likely to report a history of sexual abuse (12.5% versus 0%, p<.05), dysuria (35.2% versus 3.6%, p<.01), and the use of 3 or more hormonal medications (67.9% versus 41.4%, p<.05). Conclusions: Two-thirds of adolescents with endometriosis report mood and/or pain syndromes. In those with comorbidities a history of sexual abuse was reported in 12.5%. Evaluation for mood and pain disorders, as well as for sexual abuse is essential in adolescents with endometriosis.
37. Scar Endometriosis After Hysterectomy for Cervical Agenesis Amanda N. Kallen MD, Beth W. Rackow MD Yale University School of Medicine; Department of Obstetrics, Gynecology and Reproductive Sciences; New Haven, Connecticut
Background: A 17 year old young woman with cervical agenesis underwent a laparoscopic hysterectomy and surgical treatment of endometriosis, and two years later presented with a mass of endometriosis at a port site. It should be recognized that some females with endometriosis € llerian anomaly will continue to have endomedue to an obstructive mu triosis despite surgical treatment of the obstruction. Furthermore, as more hysterectomies are performed laparoscopically, the incidence of scar endometriosis may increase, and should be considered in the differential diagnosis of an incisional mass. Case: A 17 year old young woman presented with primary amenorrhea and cyclic pelvic pain; her exam revealed a normal vagina with no visible cervix, and an ultrasound identified a normal uterus. A pelvic MRI confirmed the diagnosis of cervical agenesis. After extensive counseling regarding management options, a laparoscopic hysterectomy was performed. Intraoperative findings included stage 3 endometriosis; the uterus was morcellated and removed through a 10 mm suprapubic port site. For medical management of endometriosis, continuous oral contraceptive pills were prescribed. Postoperatively she was pain-free, and discontinued the pills one year later., Over the following year, she reported a palpable mass and worsening cyclic pain at the suprapubic port site. A pelvic MRI revealed a 2.9 cm focus of endometriosis in the lower abdominal wall and bilateral ovarian endometriomas. She underwent laparoscopic ovarian cystectomies, ablation of endometriosis, and abdominal excision of the port site endometriosis. The 3 cm mass extended through subcutaneous tissue, fascia and rectus muscle; pathology is pending. Comments: Women with cervical agenesis are at high risk of endometriosis due to obstruction-related retrograde menstruation. Management options for cervical agenesis include medications for menstrual suppression, surgical reconstruction of the cervical canal or hysterectomy. After relieving the obstruction, endometriosis tends to resolve. In this case, endometriosis persisted despite aggressive surgical management and postoperative hormonal suppression, and warrants long-term medical treatment. Theories about endometriosis development include retrograde menstruation, venous and lymphatic metastases, coelomic metaplasia and mechanical transplantation. Surgical site endometriosis is reported in 0.03-1.7% of women who undergo abdominal surgery. Symptoms can mimic an incisional hernia, with a palpable subcutaneous mass at the surgical site, or cyclic pain and swelling may occur with menses., Scar endometriosis lesions can measure up to 5 cm in size, and occur on average 21 months after surgery. Although hormonal medications may be effective treatment, surgical excision is the gold standard, and to prevent recurrence, it is important to excise all scar endometriosis. With an increasing number of laparoscopic hysterectomies being performed, one must consider the risk of surgical scar endometriosis when planning removal of the uterine corpus. Additionally, knowledge of the presentation and treatment of scar endometriosis will help clinicians better evaluate postoperative incisional masses.