New ACOG guidelines on dysmenorrhea and endometriosis in adolescents

The American College of Obstetricians and Gynecologists (ACOG) has published a new committee opinion on dysmenorrhea and endometriosis in adolescents.

Dysmenorrhea, or menstrual pain, is the most common menstrual symptom among adolescent girls and young women. Prevalence rates vary but range from 50% to 90 %. Most adolescents experiencing dysmenorrhea have primary dysmenorrhea, defined as painful menstruation in the absence of pelvic pathology. Secondary dysmenorrhea refers to painful menses due to pelvic pathology or a recognized medical condition. Endometriosis is the leading cause of secondary dysmenorrhea in adolescents.

Following are the Major Recommendations:

• Most adolescents experiencing dysmenorrhea have primary dysmenorrhea, defined as painful menstruation in the absence of pelvic pathology. Primary dysmenorrhea characteristically begins when adolescents attain ovulatory cycles, usually within 6–12 months of menarche.


• Secondary dysmenorrhea refers to painful menses due to pelvic pathology or a recognized medical condition.


• The most common cause of secondary dysmenorrhea is endometriosis.


• Most adolescents who present with dysmenorrhea have primary dysmenorrhea and will respond well to empiric treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal suppression, or both. However, some patients either present initially with symptoms suggesting secondary dysmenorrhea or they fail empiric treatment for primary dysmenorrhea and require further evaluation.


• Pelvic imaging with ultrasonography, regardless of findings on pelvic examination, also should be considered during evaluation for secondary dysmenorrhea.


• Any obstructive anomaly of the reproductive tract, whether hymenal, vaginal, or müllerian, can cause secondary dysmenorrhea.


• Although the true prevalence of endometriosis in adolescents is unknown, at least two-thirds 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.


• The appearance of endometriosis may be different in an adolescent than in an adult woman. In adolescents, endometriotic lesions are typically clear or red and can be difficult to identify for gynecologists unfamiliar with endometriosis in adolescents.


• If a patient is undergoing a diagnostic laparoscopy for dysmenorrhea or chronic pain, or both, consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the time of laparoscopy to minimize the pain of insertion.


• The recommended treatment for endometriosis in adolescents is conservative surgical therapy for diagnosis and treatment combined with ongoing suppressive medical therapies to prevent endometrial proliferation.


• Patients with endometriosis who have pain refractory to conservative surgical therapy and suppressive hormonal therapy often benefit from at least 6 months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.


• Nonsteroidal anti-inflammatory drugs should be the mainstay of pain relief for adolescents with endometriosis.


• Adolescents should not be prescribed narcotics long-term to manage endometriosis outside of a specialized pain management team.