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When to suspect endometriosis in an adolescent

At the early stage of endometriosis, patients will describe cyclical pain symptoms including dysmenorrhea (painful periods), dyspareunia (pain during or after sex), dyschezia (painful defecation), dysuria (painful urination), rectal bleeding, shoulder pain, cyclical lung conditions, chest pain, cough, hemoptysis and fatigue.

As the disease progresses, pain can become chronic, independent of the menstrual cycle. The severity of pain is measured using the visual analogic score (VAS) and if untreated can impact daily activities. Recording symptoms in a diary or app is recommended. When suspecting endometriosis clinical and vaginal examination to check for tenderness, nodules, or swelling is recommended. If the examination is inconclusive, ultrasound or MRI is advised.

Role of healthcare professionals

Endometriosis profoundly affects women’s physical, psychological and social well-being. This feeling is often exacerbated by insufficient knowledge and insensitivity from healthcare professionals. Patients report feeling misunderstood, highlighting the need for better education among physicians. Early involvement of general practitioners, nurses and specialists can improve diagnosis and treatment.

A multidisciplinary approach, involving gynecologists, gastroenterologists, psychologists, radiologists, urologists, nutritionists and any other specialized professional potentially involved is essential. Dedicated referral centers with trained professionals offer standardized, high-quality care, addressing all aspects of the disease and significantly improving patients’ quality of life.

MRI (Magnetic resonance imaging)

In adolescents where gynaecological exams and transvaginal ultrasound can be challenging, magnetic resonance imaging (MRI) serves as a valuable non-invasive tool for detecting endometriosis and its manifestations. While ultrasound remains the first choice, MRI offers 90% sensitivity and 98% specificity for typical endometriomas, and provides additional insights for atypical lesions.

MRI is especially useful for evaluating intestinal and urinary symptoms, covering a broader pelvic area compared to ultrasound. Studies show MRI’s high sensitivity (94%) and specificity (77%) for diagnosing deep pelvic endometriosis, particularly in rectosigmoid implants. Additionally, MRI can detect adenomyosis in adolescents with chronic pelvic pain or dysmenorrhea, despite it being more common in older women

Physicial examination

The presentation focuses on the importance of physical examination in diagnosing endometriosis in adolescents. It emphasizes that gynecological visits are crucial and should be scheduled alongside pelvic ultrasounds. However, internal pelvic examinations are recommended only for sexually active patients and may not be feasible for all due to anxiety or pain. The presentation outlines the need for clear communication with patients, allowing them to stop the examination if uncomfortable. It highlights specific areas to examine and stresses the importance of pain mapping to guide further diagnostic procedures like ultrasound.

Differential diagnosis

Endometriosis symptoms include painful periods (dysmenorrhea), pain during intercourse (dyspareunia), painful urination (dysuria), defecation (dyschezia), chronic pelvic pain as well as infertility. Diagnosing endometriosis can be challenging due to symptom overlap with other gynecologic and non-gynecologic conditions. A multidisciplinary approach may be necessary.

Other chronic diseases such as Crohn’s, celiac disease, appendicitis and urinary tract cancers should be ruled out. Common gynecologic issues like fibroids, pelvic inflammatory disease, ovarian cysts also mimic endometriosis symptoms. Thorough patient history, symptom assessment, lab tests and imaging by specialists are essential for accurate diagnosis to focus diagnostic laparoscopy to a selected number of patients.

Diagnosing endometriosis early is crucial to
managing pain and preserving quality of life—don’t let silent suffering go unnoticed

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MRI

Magnetic Resonance Imaging (MRI) is a technique that uses magnetic fields to create detailed images of the body’s anatomy and physiological processes. It is not a painful exam, though the machine makes loud tapping sounds. Preparation involves removing metallic items and possibly using an IV for contrast. During the exam, patients lie still in a scanner for about 15-20 minutes, potentially entering feet-first to reduce claustrophobia.

MRI may provide more precise images than ultrasound, especially for broad areas. Although MRI is effective, small lesions in adolescents can be hard to detect. Emerging alternatives include salivary tests analyzing microRNAs for endometriosis diagnosis.

Ultrasonography

Transvaginal ultrasound (TVS) is the gold standard for diagnosing, describing and staging endometriosis, as well as planning laparoscopic surgery. TVS identifies typical ultrasonographic features, maps pelvic disease and assesses extension of the disease. The « pain mapping » technique uses probe pressure to locate painful nodules. TVS systematically scans all pelvic organs and spaces for abnormalities and signs of adenomyosis, which is closely linked to endometriosis.

The IDEA group’s standardized four-step approach enhances diagnostic accuracy. TVS shows high sensitivity and specificity, particularly for rectosigmoid deep infiltrating endometriosis and endometriomas. In adolescents, transrectal or transabdominal approaches may be used if TVS is not tolerated. TVS’s dynamic nature and patient interaction provide advantages over other imaging techniques such as MRI.

Endometriosis classification

Endometriosis is a complex disease with various subtypes and presentations. Over the years, 22 classification systems have been developed to try to understand and manage it better. The revised American Society for Reproductive Medicine (rASRM) score is widely used, categorizing the severity of endometriosis from Stage I (minimal) to Stage IV (severe) based on lesions size and adhesions.

The Enzian classification, introduced in 2003, focuses on deep infiltrating endometriosis using anatomical compartments. The Endometriosis Fertility Index (EFI), published in 2010, predicts pregnancy post-surgical outcomes. The 2021 AAGL Endometriosis Classification System offers an objective, anatomy-based approach, rating surgical difficulty and disease complexity.

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