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EOE ( Early onset endometriosis) starting at the time of menarche or early adolescence may at times be severe, requiring early diagnosis and proper treatment. Its origin may be different from its adult variant and is attributed to NUB (Neonatal Uterine bleeding)

Pathogenesis:

In a small proportion of female neonates, progesterone withdrawal cause uterine bleeding after birth. This NUB- Neonatal Uterine Bleeding. Secondary to NUB, there is the reflux and seeding of endometrial stem and progenitor cells in the pelvic cavity which quickly attach themselves to the peritoneum. Remaining dormant for years, they get activated around the time of thelarche by factors known to cause endometriosis. This may then progress to highly angiogenic implants, recurrent ectopic bleeding and endometrioma formation.

Clinical features and diagnosis:

The diagnosis in adolescents is often delayed due to non-specific nature of symptoms. Also there is a reluctance among clinicians to subject an adolescent to invasive testing like laparoscopy.

The adolescent girl might present with primary dysmenorrhea, often resistant to NSAIDs and hormonal contraceptive pills. Younger the age of presentation, more severe is the disease.

Symptoms include dysmenorrhea, menorrhagia, abnormal or irregular uterine bleeding, gastro-intestinal and genito-urinary symptoms.

Five practical ways of diagnosing adolescent endometriosis:

1. Never underestimate the pain.
2. Endometriosis must always be considered as a possible cause of severe cyclical pain.
3. Detailed history follows clinical examination and ultrasound.
4. Pain must be treated with hormonal therapies ( Combined oral contraceptive pills or progesterone-only pill) and analgesics.
5. Frequent follow up visits must be planned for evaluating the patient.

Treatment

Medical Treatment: Combined Oral contraceptive pills, NSAIDs, Progesterone only ( Nor-ethisterone 15mgs/day or Medroxyprogesterone acetate 50 mgsm/day or MPA Depot 150 mg once in 3 months) are prescribed. Dioenogest 2mg/day in women over 18 years can also be considered. GnRH agonists with add-back therapy to prevent hypoestrogenism can also be tried. If the dysmenorrhea does not improve within 6 months of NSAIDs and OCPs, then laparoscopy is indicated.

Surgical Therapy: Surgical therapy in an adolescent might increase the risk of premature ovarian failure and promote development of endometriosis. Hence it has to be reserved for carefully selected cases.

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