#760 Dysmenorrhea and Endometriosis in the Adolescent

Question 1

What is primary dysmenorrhea?

Answer 1

Painful menstruation in the absence of pelvic pathology

Question 2

What is secondary dysmenorrhea?

Answer 2

Painful menstruation in the presence of pelvic pathology or recognized medical condition.

Question 3

What is the leading cause of secondary dysmenorrhea in adolescents?

Answer 3

Endometriosis

Question 4

How do endometriotic lesions often appear like in adolescents?

Answer 4

endometriotic lesions are typically clear or red

Question 5

What are the goals of treatment for endometriosis?

Answer 5

symptom relief, suppression of disease progression, and protection of future fertility

Question 6

What is empiric treatment for primary dysmenorrhea?

Answer 6

NSAIDs, hormonal suppression

Question 7

What fraction of adolescent girls with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at the time of diagnostic laparoscopy?

Answer 7

Two thirds

Question 8

What is the next potential therapy for a patient with endometriosis with pain refractory to conservative surgical therapy and suppressive hormonal therapy?

Answer 8

At least 6 months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.

Question 9

What is the pathophysiology behind primary dysmenorrhea?

Answer 9

Prostaglandins and leukotrienes, both mediators of inflammation

Question 10

What is the definition of chronic pelvic pain?

Answer 10

pain in the pelvic area that lasts 6 months or longer and can be constant, intermittent, cyclic, or acyclic

Question 11

What % of women age 14-20 will miss days of work or school each month due to dysmenorrhea?

Answer 11

12%

Question 12

What are causes of secondary dysmenorrhea?

Answer 12

Endometriosis
Congenital obstructive mullerian malformations
Cervical stenosis
Ovarian cysts
Uterine polyps
Uterine leiomyomata
Adenomyosis
Pelvic inflammatory disease
Pelvic adhesions

Question 13

What in a patient’s history makes you more suspicious of secondary dysmenorrhea?

Answer 13

Severe dysmenorrhea immediately after menarche or progressively worsening dysmenorrhea, AUB (both HMB and irregular bleeding), mid-cycle or acyclic pain, infertility, lack of response to empiric medical treatment, FH of endometriosis, a renal anomaly, other congenital anomalies (spine, cardiac, or gastrointestinal), or dyspareunia.

Question 14

How do NSAIDs work?

Answer 14

NSAIDs interrupt cyclooxygenase-mediated prostaglandin production

Question 15

When during the menstrual cycle should you advise patients with primary dysmenorrhea to take NSAIDs?

Answer 15

Medication use is most effective when started 1–2 days before the onset of menses and continued through the first 2–3 days of bleeding

Question 16

Are opioids appropriate pain therapy for adolescents with primary dysmenorrhea? Why or why not?

Answer 16

No. Risk of addiction with opioids as few as 7 days and risk of dependence/withdrawal. Risk of hyperalgesia.

Question 17

What is the mechanism action of hormonal suppression for primary dysmenorrhea?

Answer 17

The mechanism of action for hormonal methods is likely related to prevention of endometrial proliferation or ovulation, or both, thus decreasing prostaglandin and leukotriene production

Question 18

How long should you trial empiric therapy for primary dysmenorrhea prior to investigating caus?es for secondary dysmenorrhea?

Answer 18

3-6 months

Question 19

What is the risk of endometriosis in a patient with a first-degree relative with endometriosis?

Answer 19

7 to 10-fold risk

Question 20

What are the benefits of performing laparoscopy for chronic pelvic pain?

Answer 20

The benefits of laparoscopy include confirmation of the presence or absence of endometriosis or other causes of chronic pain such as adhesive disease. Laparoscopy also presents an opportunity to treat endometriosis with coagulation, ablation, or resection of visible implants and adhesive disease with lysis of adhesions.

Question 21

Are stage and location of endometriosis correlated with frequency and severity of symptoms?

Answer 21

No

Question 22

Is there a role for LNG-IUD in patients who have failed to improve with OCPs for dysmenorrhea?

Answer 22

Yes, can improve dysmenorrhea and pain associated with endometriosis

Question 23

Is endometriosis a progressive disease or stable disease?

Answer 23

Potential to progress

Question 24

Can endometriosis be cured?

Answer 24

No, chronic disease

Question 25

Why use add back therapy with GnRH agonist therapy?

Answer 25

prevent bone loss and avoid the onset of menopausal symptoms