Improving Care for Adolescents and Young Women With Pelvic Pain: Highlights From New ACOG Guidelines

Dysmenorrhea, or painful menses, is the most common menstrual abnormality in teens. Most cases are due to increased production of inflammatory agents and not underlying pelvic pathology. Dysmenorrhea usually presents after regular, ovulatory cycles are established about 6-12 months after menarche. Pain does not typically present with the onset of menarche.

For teens who present with typical dysmenorrhea symptoms, empiric treatment can be initiated with either NSAIDs and/or hormonal contraceptives. Neither a pelvic exam nor ultrasound are indicated. No particular NSAID or hormonal contraceptive is most effective for symptom relief. Therefore, patient and clinician preference or medical contraindications should lead decision making. Complete menstrual suppression with hormonal contraception is a reasonable option to help alleviate symptoms.

If the patient has persistent symptoms despite adherence with NSAIDs and hormonal contraceptives, further investigation is indicated to rule out underlying pelvic pathology. Most teens are able to tolerate a pelvic exam with support. Sexually active teens should be screened for sexually transmitted infections (STIs). Patients with persistent symptoms require a pelvic ultrasound to evaluate for menstrual obstruction due to an abnormal uterus or outflow tract. While uncommon, other potential pelvic pathologies identified by ultrasonography include uterine fibroids and ovarian or tubal masses.

Patients with ongoing pain despite empiric treatment and reassuring evaluation may have endometriosis. Girls who have first-degree relatives with endometriosis are at increased risk.

If a patient has suspected endometriosis, she may benefit from a diagnostic laparoscopy for both diagnosis and treatment. A surgical biopsy confirming endometrial glands and stroma found outside of the uterine cavity remains the gold standard for endometriosis diagnosis.

Most teens have early-stage endometriosis with clear vesicles, which may be difficult for adult gynecologist to identify if unfamiliar with adolescent endometriosis. The advantages of diagnosing endometriosis early include improvement in symptoms due to broader therapeutic interventions and preservation of fertility. At least two-thirds of girls undergoing laparoscopy for suspected endometriosis will be diagnosed with endometriosis at the time of surgery. A normal laparoscopy result for girls with chronic pain is clinically beneficial as well, allowing patients and their families to focus on non-gynecologic etiologies of chronic pelvic pain.

Once a teen is surgically diagnosed with endometriosis, she should remain on medical, suppressive therapy unless she is trying to become pregnant. Endometriosis is an inflammatory condition that responds to estrogen stimulation. Treatments commonly used in teens to suppress endometrial implants include:

• progestin intrauterine systems
• oral progestins
• hormonal contraceptives

Older teens can also be treated with GnRH agonists with add-back hormonal therapy to prevent hot flashes and protect from bone loss.

For pain relief, patients with endometriosis should primarily rely on NSAIDs. Outside of a specialized pain service, they should not be prescribed narcotics. Patients benefit from ongoing education and support as well as multidisciplinary modalities including acupuncture, biofeedback, physical therapy and herbal therapy to optimize their quality of life.

Pediatrician and primary care doctors caring for teens are able to have a tremendous impact on improving the quality of life in girls with dysmenorrhea by providing effective therapy. Recognizing the potential for more significant pathology, such as anatomic abnormalities or endometriosis, and facilitating appropriate referral not only leads to improved symptom relief and quality of life but also helps protect reproductive potential.

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