Endometriosis can occur in adolescents and this patient group presents particular challenges in terms of differential diagnosis, variable presentation and symptoms, and choice of treatment. Early diagnosis is essential in order to decrease
pain and hopefully prevent
disease progression and preserve future fertility.
Endometriosis surgery is generally cytoreductive rather than curative, and postoperative medical
therapy should be initiated regardless of disease stage. Menstrual suppressive
therapy with the use of continuous combination
estrogen/
progestin is the main treatment for most adolescents with
endometriosis. For those with a persistence of
pain on this
therapy Gonadotropin-releasing hormone (
GnRH) agonists (with add-back
therapy) can be effective in relieving symptoms.
GnRH agonist
therapy requires special consideration in adolescents due to possible adverse effects on bone mineralization--an important consideration in adolescents who are at a critical age for accrual of bone mineral density (BMD). However, potential problems of bone loss may be avoided with the use of 'add back'
therapy. A recent clinical study found that most adolescents with
endometriosis receiving a
GnRH agonist plus add-back
therapy with
norethindrone acetate (NA) or
estrogen plus NA had normal BMD at the hip. Add-back
therapy appears to be a promising adjunct to
GnRH agonist
therapy for the prevention of bone loss and may allow a longer
duration of therapy than with a
GnRH agonist alone. BMD should continue to be carefully monitored after the initial 6-8 month period of
therapy and then approximately every two years in adolescent patients (over age 16) receiving long-term
GnRH agonist with add-back
therapy.