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Surgical Treatment of Endometriosis in Adolescents: Balancing Benefits and Risks
Endometriosis is a challenging condition to manage, particularly in adolescents. The surgical treatment of endometriosis in this population is a topic of ongoing debate, with only small studies providing low-quality evidence currently available in the literature. Despite these limitations, the management of endometriosis in adolescents generally mirrors that in adults, with a focus on optimizing long-term health, reproductive potential, and sexual function.
When to Consider Surgery
In adolescents with endometriosis, surgical removal of endometriotic lesions may be considered, especially when medical treatments have proven ineffective, are contraindicated, or are poorly tolerated. Surgery is also an option for those whose symptoms strongly suggest endometriosis, but where imaging techniques fail to provide a definitive diagnosis and symptoms do not respond to first-line medical therapies.
Diagnostic laparoscopy, in particular, is often offered in such cases. It serves both as a diagnostic and therapeutic tool, allowing for the direct visualization and potential removal of endometriotic lesions.
Outcomes and Recurrence
Following surgery, approximately 80% of patients report an improvement in their painful symptoms, including dysmenorrhea (painful menstruation), dyschezia (painful defecation), and chronic pelvic pain. However, the rate of symptom recurrence is a significant concern, particularly when surgery is not followed by hormonal therapy. Recurrence rates can be substantial, with clinical recurrence—defined as the return of symptoms or the ultrasound detection of ovarian or pelvic endometriosis—occurring in up to 56% of adolescents after at least five years of follow-up.
One of the challenges in managing endometriosis surgically in adolescents is the likelihood of requiring multiple interventions throughout their reproductive years. The age at which the first surgery is performed often correlates with the total number of surgeries a patient may need over her lifetime, making the decision to operate particularly critical in this young population.
Surgical Techniques and Recommendations
International guidelines suggest that if surgery is indicated in adolescents with endometriosis, it should be performed laparoscopically by an experienced surgeon. Complete laparoscopic removal of endometriosis is recommended where possible, as excision tends to yield better outcomes for dysmenorrhea, dyschezia, and chronic pelvic pain compared to lesion ablation.
However, the decision to proceed with surgery must weigh the potential benefits against the risks of the procedure, including postoperative complications and the high likelihood of recurrence. There is no consensus on whether surgery should be minimized in adolescents to avoid multiple interventions or whether it should be performed early and aggressively, aiming to eliminate all visible endometriosis, including deep infiltrating endometriosis (DIE). Importantly, there is no conclusive evidence that surgical intervention in adolescence prevents disease progression or long-term consequences such as infertility.
The Role of Postoperative Hormonal Treatment
Postoperative hormonal therapy is crucial in managing endometriosis after surgery. Hormonal treatment helps to prevent or reduce the risk of recurrence and the progression of the disease, and it is strongly recommended in line with the management strategies employed in adults. This approach helps to sustain the benefits of surgery and provides long-term symptom relief.
Conclusion
The surgical treatment of endometriosis in adolescents is a complex decision-making process that requires careful consideration of the benefits and risks. While surgery can provide significant symptom relief, the potential for recurrence and the need for multiple future interventions are important factors to consider. A multidisciplinary approach, involving experienced surgeons and postoperative hormonal management, is essential to optimize outcomes for adolescents with endometriosis. The lack of consensus on the timing and extent of surgery in this population underscores the need for further research to guide clinical practice.