Current approaches to optimizing the treatment of endometriosis in adolescents

Endometriosis can occur in adolescents and this patient group presents particular challenges in terms of differential diagnosis, variable presentation and symptoms, and choice of treatment. Early diagnosis is essential in order to decrease pain and hopefully prevent disease progression and preserve future fertility. Endometriosis surgery is generally cytoreductive rather than curative, and postoperative medical therapy should be initiated regardless of disease stage. Menstrual suppressive therapy with the use of continuous combination estrogen/progestin is the main treatment for most adolescents with endometriosis. For those with a persistence of pain on this therapy Gonadotropin-releasing hormone (GnRH) agonists (with add-back therapy) can be effective in relieving symptoms. GnRH agonist therapy requires special consideration in adolescents due to possible adverse effects on bone mineralization--an important consideration in adolescents who are at a critical age for accrual of bone mineral density (BMD). However, potential problems of bone loss may be avoided with the use of 'add back' therapy. A recent clinical study found that most adolescents with endometriosis receiving a GnRH agonist plus add-back therapy with norethindrone acetate (NA) or estrogen plus NA had normal BMD at the hip. Add-back therapy appears to be a promising adjunct to GnRH agonist therapy for the prevention of bone loss and may allow a longer duration of therapy than with a GnRH agonist alone. BMD should continue to be carefully monitored after the initial 6-8 month period of therapy and then approximately every two years in adolescent patients (over age 16) receiving long-term GnRH agonist with add-back therapy.