Many adolescents experience discomfort with periods but more severe pain can be a symptom of endometriosis. By Kirsten Braun
What is endometriosis?
Endometriosis is a condition where tissue similar to that which normally lines the uterus grows in other parts of the body, mainly in the pelvis. This stray tissue responds to hormones in the same way as the tissue in the uterus, by releasing chemicals that can cause irritation and inflammation to the surrounding tissue and organs. In addition, over time scar tissue forms around the lesions which can result in pelvic organs becoming stuck to each other (referred to as adhesions). Adhesions can make sexual intercourse, ovulation or going to the toilet painful.
What are the symptoms?
In adolescents the main symptom is painful periods but they may also experience pelvic and/or abdominal pain outside of menstruation. Other symptoms include abnormal bleeding (heavy periods, irregular periods, spotting), pain during sex, bowel disturbances (painful bowel movements, diarrhoea) and painful urination. The type of symptoms women experience depends on where the stray tissue is located.
How many adolescents have endometriosis?
Studies suggest that between 5-10% of menstruating women in Australia are affected by endometriosis. Most women who have been diagnosed with endometriosis report that their symptoms started during adolescence.
What do endometriosis lesions look like?
There are several different types of lesions. Early stages of endometriosis tend to be red or clear in colour. As endometriosis progresses the lesions are often black, brown or white in colour. Adolescents are more likely to have lesions that are clear or red in colour and because of this they are sometimes harder to detect.
What is the difference between just painful periods and endometriosis?
Many women experience discomfort at the time of their menstrual period. One of the main causes of this type of pain is prostaglandins. Prostaglandins are a chemical in the body that makes the uterus contract during periods to help with the shedding of the uterine lining. These uterine contractions can cause pain.
It can be difficult for adolescents to distinguish between what is normal period pain and what is something more serious as they are still getting used to their periods. The limited number of periods they have experienced means that they have little as a means of comparison.
However, there are a number of indications that the pain being experienced is not normal:
• If the pain is occurring more than on the first 1-2 days of the period
• If the pain cannot be effectively managed with the use of antiprostaglandins or oral contraceptives (see following sections)
• If the pain worsens over time
How can endometriosis be diagnosed?
Unfortunately endometriosis can only be definitively diagnosed by a laparoscopy, a surgical procedure which involves inserting a long, thin telescope (laparoscope) into the abdomen through an incision near the navel. Even when a laparoscopy is performed the endometriosis can be more difficult to detect in adolescents and so can be missed.
As medical professionals do not want to perform a surgical procedure unnecessarily they will firstly determine the probability of endometriosis through taking a thorough history of the pain and other symptoms. They may also ask about a family history of endometriosis as it is known that having a family member with endometriosis increases the chances of also having the condition. They will then trial some treatment strategies to see how the period pain responds.
The first treatment option for adolescents experiencing painful periods is to try taking an antiprostaglandin, also known as non-steriodal anti-inflammatory drugs (NSAIDs). Antiprostaglandins include ibuprofen, naproxen, diclofenac, indomethacin and mefenemic acid. Antiprostaglandins inhibit the production of prostaglandins, thus reducing uterine contractions and associated pain. Antiprostaglandins can often be very effective in relieving period pain and may be effective at managing milder forms of endometriosis. However, while they may provide pain relief initially, if endometriosis is the culprit it may progress to a stage where the antiprostaglandins are no longer effective.
For antiprostaglandins to be successful for period pain they must be taken at the earliest opportunity. They work by blocking the prostaglandins from being produced initially but, therefore, have limited effect on prostaglandins once they are already present. If an adolescent's menstrual cycle is predictable taking an antiprostaglandin one or two days before the start of the period is the most effective. Alternatively, they need to be taken at the first sign of period pain. Side effects can include nausea, diarrhoea and stomach upsets but these can be reduced by taking the medications with food or milk.
Try the Pill
If antiprostaglandins do not provide enough relief from the symptoms then an oral contraceptive pill (the Pill) will usually be prescribed. Some parents may be reluctant to allow their daughters to go on the Pill, fearing that it will encourage them to become sexually active earlier. They may also have concerns about exposing them to hormonal drugs at such an age. Parents may find it helpful to think of the Pill as just a medication that assists with endometriosis rather than a contraceptive as in this case it is not being prescribed for contraceptive purposes. Like antiprostaglandins, the Pill works by reducing pain from prostaglandins. As well as reducing pain, the Pill can slow the progression of endometriosis. After antiprostaglandins, the Pill is the most tolerable type of drug treatment for endometriosis.
A Pill that has a higher dose of progestogen than estrogen appears to be the most effective. A low dose, monophasic (same dose of hormones in each active pill) oral contraceptive is usually prescribed. A monophasic Pill allows women to take the Pill continuously for a length of time. This involves skipping the dummy or sugar pills at the end of a packet and immediately starting the active pills in the next packet, thereby not having a withdrawal bleed or 'period'. Skipping periods is helpful for women with endometriosis as it reduces the number of periods and, therefore, pain and inhibits the growth of the lesions.
As well as the Pill, another hormonal contraceptive that is effective at treating endometriosis is the Mirena intrauterine contraceptive device (IUCD). Mirena is a small plastic device that is inserted into the uterus and delivers the hormone progestogen. Mirena is effective at making periods lighter and less painful. The main side effect of Mirena is irregular bleeding and cramp like pain, although this often settles in time. For young women and/or virgins it is usually recommended that Mirena is inserted under anaesthesia. While Mirena is an effective treatment for endometriosis, young women and/or their parents may not be agreeable to using an IUCD.
The role of exercise
Gentle exercise can play an important role in pain management. Endorphins, the brain chemicals we produce when we exercise, combat pain and alleviate feelings of depression and stress, which can be common in those experiencing pain. Types of exercise that are suitable include walking and swimming.
If the pain persists
If conservative treatment options do not help with the pain then a laparoscopy will most likely be recommended. If endometriosis is discovered during a laparoscopy it will also be removed at that time. A surgeon well experienced in treating endometriosis is recommended as it is harder to recognise the condition in adolescents and therefore, a less experienced surgeon may miss lesions. The Pill, IUCD and other drug treatments are commonly used following surgery to reduce symptoms and prevent endometriosis from recurring.
Period pain in adolescents should not be ignored or considered simply part of becoming a woman. It is important that specialised medical attention is sought for adolescents with continued period pain. If left untreated endometriosis can lead to long term consequences such as adhesions, fertility problems as well as emotional and mental health issues.
Last Updated: April 2015
© Women's Health Queensland Wide Inc. This article was written by Kirsten Braun and reviewed by the Women's Health Queensland Wide editorial committee. It was published in Health Journey 2015 Issue 1.