A longitudinal study of adolescent dysmenorrhoea into adulthood

The relationship between menstrual pain in adolescence and mental health in adolescence and early adulthood

OBJECTIVES

Approximately 70 % of adolescents worldwide experience menstrual pain (dysmenorrhea), with significant impacts on quality of life. This prospective study aimed to explore the relationship between mental health and dysmenorrhea in Australian adolescents.

DESIGN

Female adolescents in a nationally representative sample of Australian children (the Longitudinal Study of Australian Children) recruited in 2004 were included in the Kinder cohort (aged 4-5 years at enrolment).

PARTICIPANTS

Survey data for 1600 participants from Wave 4 (age 10) to Wave 9C2 (age 21) were included in this study. Parents and adolescents completed questionnaires and interviews at each wave.

MAIN OUTCOME MEASURES

For this study, questions included age of menstruation onset, dysmenorrhea severity, symptoms of anxiety and/or depression (parent-report and adolescent-report), and psychological distress (adolescent-report).

RESULTS

Adolescents with dysmenorrhea were more likely to have anxiety (odds ratios 1.75-1.82) and more likely to have depression (odds ratios 2.03-2.89) than adolescents without dysmenorrhea at ages 14, 16, and 18. Adolescents with dysmenorrhea at ages 14, 16, and 18 reported higher levels of psychological distress, with scores 2.99 to 3.34 points higher on a self-report measure (K10) in early adulthood than adolescents without dysmenorrhea (p < 0.001). Longitudinal analyses revealed that adolescents with dysmenorrhea were more likely to develop mental health concerns in later adolescence and early adulthood (χ2 = 17.26, p < 0.001), while those with mental health concerns were not more likely to develop dysmenorrhea (χ2 = 0.49, p = 0.48).

CONCLUSION

This study highlights that adolescents who experience dysmenorrhea are at significantly greater risk of experiencing mental health problems both in adolescence and in early adulthood. Improved treatment for dysmenorrhea, menstrual education, mental health monitoring, and early intervention are essential to reduce this risk.

Natural History of Menstrual Pain and Associated Risk Factors in Early Adolescence

STUDY OBJECTIVE

To determine the natural history of menstrual pain without pelvic pathology, the role of progesterone in its pathophysiology, and associated risk factors in a longitudinal study of early postmenarchal girls in North Carolina.

METHODS

Participants contributed daily urine samples for up to 3.5 years to measure pregnanediol-3-glucuronide (PdG) (mean 589 urines/participant), completed menstrual diaries, and reported menstrual pain using the Menstrual Symptom Questionnaire (MSQ) biannually. MSQ scores were log-transformed and generalized estimating equations assessed associations with gynecologic age, cycle peak PdG, presumed ovulation, physical activity, anxiety, and depression. Models were adjusted for age at menarche, baseline body mass index, race/ethnicity, parental education and employment, and gynecologic age.

RESULTS

Forty-three girls, aged 12.6 ± 1.1 years (mean ± SD) at enrollment with a gynecologic age 0.3 ± 0.2 years, participated. Total MSQ scores were higher for every 1-year increase in gynecologic age (MSQ score ratio: 1.12; 95% CI: 1.08, 1.17; P < .0001). Overall MSQ (ratio: 1.04; 95% CI: 1.02, 1.06; P = .0002) and abdominal pain-specific (ratio: 1.04; 95% CI: 1.01, 10.7; P = .004) scores were higher for every 1000 ng/mg creatinine increase in peak PdG in the preceding cycle. Overall MSQ scores were higher (ratio 1.26; 95% CI: 1.11, 1.44; P = .0005) if the preceding cycle was presumed ovulatory. Menstrual pain was not associated with physical activity, anxiety, or depression.

CONCLUSIONS

In early postmenarchal girls, gynecologic age and PdG were associated with menstrual pain, suggesting a pathophysiologic role for progesterone and other unknown factors in the development of menstrual pain.

Seeking help for menstrual pain during adolescence: A mixed-methods retrospective survey of treatment experiences and preferences

BACKGROUND

Menstrual pain can significantly impact adolescents' well-being and functioning. Despite the prevalence of adolescent menstrual pain, information about adolescents' experiences seeking treatment is limited.

OBJECTIVES

We examined retrospective reports of help-seeking in adolescence among menstruators to better understand perceptions and experiences of interacting with the healthcare system due to menstrual pain.

DESIGN

This study used an embedded mixed-methods design in which the qualitative and quantitative data were collected concurrently.

METHODS

Young adults aged 18-25 who experienced menstrual pain in adolescence completed an online, mixed-methods survey of help-seeking experiences. Responses were analyzed using descriptive statistics and reflexive thematic analysis.

RESULTS

Across participants (N = 590, Mage = 21.78 years), 41% sought treatment for menstrual pain in adolescence and of these 43% found the treatments they were offered ineffective. Three themes were generated related to why treatment was perceived as unsuitable: "Side effects and risks of pharmacological treatment," "treatment not tailored to the individual," and "treatment seen as a band-aid solution." Participants perceived the treatment options as limited and likely not addressing the underlying cause of their pain. Four themes were generated related to perceived improvements to treatment seeking. Participants recommended that healthcare providers: "Go beyond contraceptives," "share and demonstrate expertise," "investigate menstrual pain," and "listen and do not dismiss." Participants reported that having more information, feeling validated, and understanding treatment recommendations would improve their experience.

CONCLUSION

Participants perceived that their menstrual pain-related treatment needs were unmet in adolescence, despite being offered treatments that align with treatment guidelines for adolescent menstrual pain. Findings suggest that improving explanations about treatment provided to youth, along with improving communication and menstrual education, may lead to more optimal help-seeking experiences among adolescents.

Hysterectomy Rate Following Endometrial Ablation in Ontario: A Cohort Analysis of 76,446 Patients

Background

Endometrial Ablation (EA) is an alternative to hysterectomy for the management of abnormal uterine bleeding (AUB); however, it does not eliminate the need for future surgical re-intervention.

Objectives

The primary objective of this study was to establish long-term clinical outcomes including the risk of hysterectomy in women who had undergone a primary EA.

Materials and Methods

This is a retrospective population-based cohort study utilising administrative data from the Canadian province of Ontario. This study assesses patients undergoing surgery in a publicly funded health care system.

Main outcome measures

We assessed women in Ontario undergoing a primary EA over a 15-year period. The primary outcome was hysterectomy within 5 years of primary EA. Secondary outcomes included myomectomy and repeat EA. All outcomes were also reported for 1, 3, 5, 10 and 15 years of follow-up. Logistic regression was used to establish predictors of hysterectomy within 5 years of primary EA.

Results

A total of 76,446 primary EAs were evaluated from 2002-2017, with 16,480 (21.56%) undergoing a subsequent surgical intervention. The average age of primary EA was 43.8 (+/- 6.3) years. Within 5 years, the evaluable cohort was 52,464, with 8,635 (16.46%) of women having proceeded to hysterectomy, 664 (1.27%) to myomectomy, and 2,468 (2.8%) to repeat ablation. By 15-years follow-up, the evaluable cohort was 1,788, with 28.75% had undergone a hysterectomy, 2.01% a myomectomy, and 5.20% a repeat EA. On logistic regression analysis, advancing age at time of EA was associated with significantly decreased odds of hysterectomy (OR=0.94, 95% CI 0.935-0.944, p<.0001) as was increasing surgical experience (OR=0.997, 95% CI 0.994-1.000, p=.022). Conversely, complex diagnosis (OR=1.102, 95% CI 1.042-1.164, p<.0001) and previous abdominal surgery (OR=1.288, 95% CI 1.222-1.357, p<0.0001) were associated with increased risk of subsequent hysterectomy.

Conclusion

Primary EA is associated with a high risk of progression to subsequent hysterectomy or other surgical intervention, without evidence of plateau of risk with long term follow-up.

What is new?

This study has the longest follow-up assessing hysterectomy outcomes in women undergoing a primary EA, with 28.75% of women having undergone a hysterectomy within 15 years of their EA.

Adolescent dysmenorrhoea in general practice: tensions and uncertainties

This Perspectives article reflects on findings from our systematic review about adolescent dysmenorrhoea Q, drawing on sociology of diagnosis theory. We consider tensions and uncertainties between presentation with symptoms of dysmenorrhoea and processes of symptom categorisation and diagnosis in adolescents, tracing these through research and clinical guidance, considering possible implications for clinical practice. We argue that challenges in distinguishing between primary and secondary dysmenorrhoea in research translate into challenges in differentiation in clinical practice. We argue that framing this distinction as clear cut and straightforward belies the well-documented challenges in diagnosis of endometriosis, and that not recognising uncertainty and complexity inherent in this task may benefit neither clinicians nor patients.

Evaluating the development of endometriosis and adenomyosis lesions over time: An ultrasound study of symptomatic women

INTRODUCTION

There is a gap in knowledge regarding development of endometriosis and adenomyosis lesions visible at transvaginal ultrasound. The objectives were to evaluate if women with symptoms suggestive of endometriosis or adenomyosis but normal ultrasound examination develop endometriosis or adenomyosis lesions visible at ultrasound over time and if alterations of symptoms over time are associated with ultrasound findings at follow-up.

MATERIAL AND METHODS

This was a prospective cohort study of 100 symptomatic women with normal initial ultrasound examination during 2014-2017 who underwent follow-up ultrasound examination in 2022. Symptoms suggestive of endometriosis were assessed using visual analog scale at both examinations and minimal clinically important difference of 10 mm was considered as a significant alteration. An examiner with expertise in advanced ultrasound examination of endometriosis performed transvaginal ultrasound examinations in accordance with the consensus protocol by the International Deep Endometriosis Analysis group.

RESULTS

At follow-up ultrasound examination of 100 women, 13 (13% [95% CI 7.1-21.2]) had visible endometriosis or adenomyosis lesions, 8 (8% [95% CI 3.5-15.2]) had endometriosis lesions, and 6 (6% [95% CI 2.2-12.6]) had adenomyosis. At follow-up, women with endometriosis or adenomyosis lesions reported lower intensity of dysmenorrhea and chronic pelvic pain compared to women without lesions (48 mm [IQR 16-79] vs. 73 mm [IQR 46-85] and 45 mm [IQR 26-57] vs. 57 mm [IQR 36-75], p = 0.087 and p = 0.026, respectively). None of the women with endometriosis or adenomyosis lesions reported increased intensity of dysmenorrhea at follow-up, compared to 32/86 women (37%) without lesions (p = 0.008). Increased intensity of chronic pelvic pain tended to be less common in women with lesions compared to those without (3/13 [23%] vs. 35/86 [41%], p = 0.223).

CONCLUSIONS

Our findings suggest that in symptomatic women, endometriosis and adenomyosis lesions visible at ultrasound may develop over time. However, majority of women remain having normal ultrasound examinations despite symptoms. Exacerbation of dysmenorrhea or chronic pelvic pain during follow-up was not associated with the development of endometriosis or adenomyosis lesions visible at ultrasound, suggesting that even women with less severe symptoms might benefit from a follow-up ultrasound when indicated.

Questionnaire-based screening of adolescents and young adult women can identify markers associated with endometriosis

STUDY QUESTION

Do adolescents and young adult women (YAW) with histologically proven endometriosis present a specific clinical history?

SUMMARY ANSWER

Questionnaire screening of adolescents and YAW can identify clinical markers associated with histologically proven endometriosis.

WHAT IS KNOWN ALREADY

Some validated questionaries can contribute to an earlier endometriosis diagnosis in adults. None of these scores, however, have been validated for adolescents or YAW.

STUDY DESIGN, SIZE, DURATION

This was an observational cross-sectional study using prospectively recorded data performed between January 2005 and January 2020 in a single university tertiary referral centre for endometriosis diagnosis and management. After a thorough surgical examination of the abdomino-pelvic cavity, women with histologically proven endometriosis were allocated to the endometriosis group, and symptomatic women without evidence of endometriosis were allocated to the endometriosis-free control group. The endometriotic patients were allocated into two sub-groups according to their age: adolescent (≤20 years) and YAW (21-24 years).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Adolescents and YAW ≤24 years of age were operated for a symptomatic benign gynaecological condition with signed informed consent. A standardized questionnaire was prospectively completed in the month before the surgery and included epidemiological data, pelvic pain scores, family history of endometriosis, and symptoms experienced during adolescence. The study searched for correlations by univariate analysis to determine clinical markers of endometriosis in adolescents and YAW compared with endometriosis-free control patients.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 262 study participants, 77 women were adolescents (≤20 years of age) and 185 patients (70.6%) were YAW. The endometriosis group included 118 patients (45.0%) and 144 (55.0%) were assigned to the control group. A family history of endometriosis, absenteeism from school during menstruation, history of fainting spells during menstruation, and prescription of oral contraceptive pills for intense dysmenorrhea were significantly more frequently observed in the endometriotic patients. The prevalence and mean pain scores for dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain and gastrointestinal and lower urinary tract symptoms were significantly greater in the endometriosis group, as was experienced rectal bleeding.

LIMITATIONS, REASONS FOR CAUTION

The study was performed in a single referral centre that treats patients with potentially more severe disease. This questionnaire was evaluated on a population of patients with an indication for endometriosis surgery, which can also select patients with more severe disease. Women with asymptomatic endometriosis were not considered in this study. These factors can affect the external validity of this study.

WIDER IMPLICATIONS OF THE FINDINGS

Patient interviews are relevant to the diagnosis of endometriosis in adolescents and YAW. Combined with imaging and clinical examination, this approach will enable earlier diagnosis and treatment, while remaining non-invasive and rapid.

STUDY FUNDING/COMPETING INTEREST(S)

The study received no funding from external sources. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Menstrual pain in Australian adolescent girls and its impact on regular activities: a population-based cohort analysis based on Longitudinal Study of Australian Children survey data

OBJECTIVES

To determine the proportion of Australian adolescent girls who experience menstrual pain (dysmenorrhea); to assess associations of dysmenorrhea and period pain severity with adolescents missing regular activities because of their periods.

STUDY DESIGN

Prospective, population-based cohort study; analysis of Longitudinal Study of Australian Children (LSAC) survey data.

SETTING, PARTICIPANTS

Female adolescents in the nationally representative cross-sequential sample of Australian children recruited in 2004 for the Kinder cohort (aged 4-5 years at enrolment). Survey data from waves 6 (mean age 14 years), wave 7 (16 years) and wave 8 (18 years) were analysed.

MAIN OUTCOME MEASURES

Severity of period pain during the preceding three months (very, quite, a little, or not at all painful); number of activity types missed because of periods; relationship between missing activities and period pain severity.

RESULTS

Of the 1835 participating female members of the LSAC Kinder cohort at waves 6 to 8, 1600 (87%) responded to questions about menstruation during at least one of waves 6 to 8 of data collection. At wave 6 (14 years), 227 of 644 respondents (35%) reported dysmenorrhea, 675 of 1341 (50%) at wave 6 (16 years), and 518 of 1115 (46%) at wave 8 (18 years). Of the 366 participants who reported period pain severity at all three waves, 137 reported no dysmenorrhea at all three waves (37%), 66 reported dysmenorrhea at all three waves (18%), 89 reported increasing period pain over time (24%), and 38 reported declining pain (10%). At wave 6, 223 of 647 participants reported missing at least one activity because of their periods (34%), 454 of 1341 at wave 7 (34%), and 344 of 1111 at wave 8 (31%). Of the participants who experienced very painful periods, 72% (wave 6), 63% (wave 7), and 65% (wave 8) missed at least one activity type because of their periods, as did 45% (wave 6), 36% (wave 7), and 40% (wave 8) of those who experienced quite painful periods.

CONCLUSIONS

A large proportion of adolescent girls in Australia experience period pain that affects their engagement in regular activities, including school attendance. Recognising adolescent period pain is important not only for enhancing their immediate quality of life with appropriate support and interventions, but also as part of early screening for chronic health conditions such as endometriosis.

Periods Shouldn't Bring Any Adolescents' World to a Full Stop. Period. An Online Survey of Adolescents' Experience of Menstruation

STUDY OBJECTIVE

Few studies have explored what specific outcome measures contained in assessment tools for period and pelvic pain are most relevant to adolescents. Co-design is a valuable method of ensuring input from those with lived experience. The Longitudinal Study of Teenagers with Endometriosis Periods and Pelvic Pain in Australia (LongSTEPPP) Co-Design Periods Survey comprised an anonymous online survey of adolescents' experience of menstruation to inform patient-reported outcome measures for the larger 5-year project.

METHODS

Adolescents aged 12-18 years whose periods had commenced at least 3 months previously and with demonstrated capacity to consent were invited to participate in an online survey. Recruitment was primarily via social media channels.

RESULTS

Of the 1811 adolescents who participated, 85% reported that periods had a "moderate" or greater impact on their life. Pain (90.7%), heavy flow (56.2%), and worry about leakage (49%) were common reasons for missed activities. Menstrual symptoms were wide-ranging and included cramping, nausea, poor energy, and impacts on mood. When asked where adolescents sought assistance with their periods, 39.8% had seen their general practitioner, 21.3% their school nurse, and almost 1 in 10 had consulted a mental health practitioner (9.3%). To manage menstrual symptoms, heat packs (66.0%), over-the-counter medications (55.8%), and prescription medications (28.6%) were used.

CONCLUSION

We found a lack of menstrual health awareness in adolescents. Periods had a significant effect on their lives, and adolescents commonly missed activities. In managing menstruation, a wide range of practitioners were consulted. Nearly a third were prescribed medication to manage their periods. These findings have directed the longitudinal study as to how best to capture outcome measures that reflect the impact of periods on adolescents.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.

Trends in pelvic pain symptoms over 2 years of follow-up among adolescents and young adults with and without endometriosis

ABSTRACT

We described trends in pelvic pain characteristics over 2 years of follow-up among adolescents and adults with and without endometriosis participating in the longitudinal observational cohort of the Women's Health Study: From Adolescence to Adulthood, using data reported at baseline and at years 1 and 2 of follow-up. Participants completed a questionnaire at baseline (between November 2012 and May 2019) and annually thereafter that included validated measures of severity, frequency, and life interference of dysmenorrhea, acyclic pelvic pain, and dyspareunia. Our study population included 620 participants with surgically confirmed endometriosis (rASRM stage I/II = 95%) and 671 community-based and hospital-based controls, with median age = 19 and 24 years, respectively. The proportion reporting hormone use varied across the 3 years ranging from 88% to 92% for cases and 56% to 58% for controls. At baseline, endometriosis cases were more likely to report severe, frequent, and life-interfering dysmenorrhea, acyclic pelvic pain, and dyspareunia compared with controls. Among cases, frequency and severity of dysmenorrhea and dyspareunia were relatively static across 2 years. However, acyclic pelvic pain improved. Severe acyclic pain decreased from 69% at baseline to 46% at year 2. Daily pain decreased from 28% to 14%, and life interference from 68% to 38%. Trends among controls remained fairly stable across 2 years. Among endometriosis cases who completed the questionnaire at all 3 time points, 18% reported persistent, severe acyclic pelvic pain at all 3 time points. Over time, different trends were observed by pelvic pain type among endometriosis cases and controls, supporting the importance of assessing multidimensional features of pelvic pain.

Exploring the interface between adolescent dysmenorrhoea and endometriosis: a protocol for a cohort and nested case-control study within the QResearch Database

INTRODUCTION

Dysmenorrhoea affects up to 70%-91% of adolescents who menstruate, with approximately one-third experiencing severe symptoms with impacts on education, work and leisure. Dysmenorrhoea can occur without identifiable pathology, but can indicate underlying conditions, including congenital genital tract anomalies or endometriosis. There is a need for evidence about the management and incidence of dysmenorrhoea in primary care, the impact of treatments in adolescence on long-term outcomes and when to consider the possibility of endometriosis in adolescence.

METHODS AND ANALYSIS

This study aims to improve the evidence base for adolescents presenting to primary care with dysmenorrhoea. It comprises three interlinked studies. Using the QResearch Database, the study population includes all female at birth participants aged 10-19 years any time between 1 January 2000 and 30 June 2021. We will undertake (1) a descriptive study documenting the prevalence of coded dysmenorrhoea in primary care, stratified by demographic variables, reported using descriptive statistics; (2) a prospective open cohort study following an index cohort of all adolescents recorded as attending primary care with dysmenorrhoea and a comparator cohort of five times as many who have not, to determine the HR for a diagnosis of endometriosis, adenomyosis, ongoing menstrual pain or subfertility (considered singly and in combination) anytime during the study period; and (3) a nested case-control study for adolescents diagnosed with endometriosis, using conditional logistic regression, to determine the OR for symptom(s) preceding this diagnosis.

ETHICS AND DISSEMINATION

The project has been independently peer reviewed and received ethics approval from the QResearch Scientific Board (reference OX46 under REC 18/EM/0400).In addition to publication in peer-reviewed academic journals, we will use the combined findings to generate a resource and infographic to support shared decision-making about dysmenorrhoea in community health settings. Additionally, the findings will be used to inform a subsequent qualitative study, exploring adolescents' experiences of menstrual pain.

miR-424-5p combined with miR-17-5p has high diagnostic efficacy for endometriosis

PURPOSE

Endometriosis (EMT) is a chronic benign disease with high prevalence. This study investigated the diagnostic value of serum miR-17-5p, miR-424-5p, and their combined expressions for EMT.

METHODS

Total 80 EMT patients of reproductive age who underwent laparoscopy or laparotomy and were confirmed by pathological examination were included as the study subjects, and another 80 healthy women of reproductive age receiving gynecological examination and ultrasonography with no pelvic abnormalities were selected as the control group. The whole blood samples of enrolled subjects were collected and clinical characteristics were recorded. The miR-17-5p, miR-424-5p, VEGFA, IL-4, and IL-6 levels in the serum were measured. ROC curve was used to evaluate the diagnostic efficacy of miR-17-5p and miR-424-5p expressions for EMT. Pearson correlation was performed to analyze the correlation of miR-17-5p and miR-424-5p with clinical indexes in EMT patients.

RESULTS

miR-17-5p and miR-424-5p were downregulated in EMT patients. For diagnosing EMT, the AUC of miR-17-5p was 0.865 and cutoff value was 0.890 (91.3% sensitivity and 85% specificity), the AUC of miR-424-5p was 0.737, and cutoff value was 0.915 (98.8% sensitivity and 61.2% specificity), and the AUC of miR-424-5p combined with miR-17-5p was 0.938 and cutoff value was 2.205 (93.8% sensitivity and 88.7% specificity), with the diagnostic efficacy higher than miR-424-5p or miR-17-5p alone. miR-17-5p and miR-424-5p expressions were negatively correlated with dysmenorrhea, infertility, pelvic pain, and rASRM stage, but not with age, BMI, menstrual disorder, and nulliparity. VEGFA, IL-4, IL-6, and CA-125 were increased in EMT patients and were inversely associated with miR-17-5p and miR-424-5p.

CONCLUSION

miR-424-5p combined with miR-17-5p has high diagnostic efficacy for EMT.

Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of the Literature

The majority of young women will experience discomfort associated with menstrual cycles and miss out on education and social opportunities. Endometriosis, the presence of endometrial glands and stroma outside of uterus, is the most common cause of secondary dysmenorrhea and characterized by pain despite treatment with nonsteroidal anti-inflammatory drugs and hormonal agents. The true prevalence of adolescent endometriosis is not clear. Delay in diagnosis leads to persistent pain, affects quality of life, and potentially contributes to disease progression and subfertility. A laparoscopic diagnosis is the gold standard, but the surgical appearance may differ from adults, as endometriotic lesions are usually red or clear, making their identification a challenge for gynecologists who are unexperienced with endometriosis in adolescents. A personalized medical–surgical treatment is regarded as the most effective therapeutic strategy to achieve remission of symptoms, suppress disease progression, and protect future fertility. Studies have demonstrated how adolescent endometriosis negatively affects patients’ quality of life and psychosocial functioning. Development of therapeutic interventions targeting psychosocial function and quality of life is imperative for adolescent patients.

Menstrual Health Literacy and Management Strategies in Young Women in Australia: A National Online Survey of Young Women Aged 13-25 Years

STUDY OBJECTIVE

To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education.

DESIGN

Cross-sectional online survey.

SETTING

Australia-wide.

PARTICIPANTS

A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781).

INTERVENTIONS

Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation.

MAIN OUTCOME MEASURES

Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis.

RESULTS

The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as "abnormal" (P < .0001) but not more likely to consult a doctor (P = .13). Only 53% of those at school had heard of endometriosis.

CONCLUSION

Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

The Prevalence of Endometriosis in Adolescents with Pelvic Pain: A Systematic Review

STUDY OBJECTIVE

Endometriosis is a recognized cause of pelvic pain in adolescents with menstrual symptoms that significantly affect education, activity, and social interactions. We aim to provide an updated systematic review of the prevalence of endometriosis in adolescents with pelvic pain presenting for gynecological investigation.

DATA SOURCES

We searched Medline, Embase, and Cinahl from 2011 to July 2019.

METHODS OF STUDY SELECTION

We included cohort studies of adolescents with pelvic pain undergoing gynecological investigation. Two authors independently selected studies and extracted study characteristics and prevalence data. Methodological quality was assessed using the Critical Appraisal Skills Program for cohort studies.

RESULTS

This updated systematic review evaluated a total of 19 studies including 1243 symptomatic adolescents. In all, 648 of 1011 (64%) adolescents undergoing laparoscopy were found to have endometriosis. The prevalence ranged from 25% to 100%, with a mean prevalence of 64%. Thirteen studies including 381 participants categorized disease severity using the revised American Society of Reproductive Medicine classification. Among these, 53% of participants (201/381) had stage I, 28% (105/381) had stage II, 20% (76/381) had stage III, and 13% (49/381) had stage IV disease.

CONCLUSIONS

The prevalence of endometriosis among adolescents with pelvic pain symptoms is high. Endometriosis is treatable, and prompt recognition will help to ensure that adolescents are signposted earlier to appropriate specialists. The management of adolescents with suspected endometriosis should be consistent with best practice guidance. Despite recommendations to increase the awareness and knowledge of endometriosis in adolescence, minimal research has followed.

The impact of menarche on health-related quality of life in a sample of Italian adolescents: evidence from school-based AVATAR project

Adolescence is a period characterized by rapid physical maturation, involving bodily changes that often necessitate a reorganization of self-perception. The current study investigated the impact of menarche on the determinants of quality of life in healthy female adolescents. Data were collected from 361 healthy female adolescents divided into two groups: pre- and post-menarcheal event. Participants, according the AVATAR project, completed Italian version of KIDSCREEN-52 questionnaires on health-related quality of life. Pre-menarcheal females had the higher score in psychological well-being and mood than post-menarcheal females. As concerns self-perception, post-menarcheal females exhibited lower score compared to pre-menarcheal females. In social context, pre-menarcheal females perceived a better school environment, also when we considered it in terms of social acceptance.Conclusion: Menarche event affects all the components of quality of life, from mood, self-esteem to social relationships, underlining how this hormonal variation is responsible of psychological and emotional changes, opening up the opportunity for preventive approaches aimed not only at traditional risk factors but according a more integrated perspective.What is Known:• Adolescence is a time of increasing behavioural divergence between males and females, probably due to the different hormonal development.• There is a possible link between menarche and the health-related quality of life variables.What is New:• Menarche condition affects all the components of quality of life, from mood to social relationships.• Post-menarcheal condition is associated to psychosocial and emotional changes, with possible multiple pathways to post-pubertal depressive symptoms.

Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents

Most adolescents will experience discomfort during menstruation. Due to normalization of dysmenorrhea, there is delay to diagnosis and treatment. Non-steroidal anti-inflammatories are a first line treatment. Adolescents can safely be offered menstrual suppression with combined hormonal contraception, and progestin-only options. When the above are ineffective, gonadotropin releasing hormone agonists with add back treatment can be considered. Transabdominal ultrasound is indicated when first line treatments do not improve symptoms. Endometriosis should be considered in adolescents who experience ongoing pain despite medical treatment. If laparoscopy is performed and endometriosis visualized, it should be treated with either excision or ablation. Women with endometriosis should be counselled on menstrual suppression until fertility is desired. Management of chronic pain requires the involvement of a multi-disciplinary team.