Welcome to part three of our endo series. Today I’m going to talk about a topic that’s very close to my heart, and that’s the adolescence with pelvic pain. I’m a pediatric adolescent gynecologist, so I see lots and lots of girls who have pelvic pain as an adolescence. Unfortunately, it’s really hard to diagnose endometriosis in this population, and we’re really uncertain as to whether the endometriosis or the pelvic pain they had during their adolescence is going to translate into ongoing symptoms in their adult life. That’s mainly because there’s a condition called primary dysmenorrhea, which affects adolescence causing them pelvic pain, and this occurs in the first few years when a woman, or a young woman, starts to get her period.

Often this occurs when the menstruation becomes regular because it tends to occur with an ovulatory cycle. When an adolescent to young girl, first starts getting her periods, the first couple of years are often plagued with irregular cycles, and that’s a completely normal thing for the start of periods. But as a teenager grows up, those periods start to slowly regulate, and that occurs because ovulation tends to occur with a lot more regularity during after those first couple of years. In that time, often periods become more and more painful, and then gynecologist are in a quandary as to whether, in fact, that teenager has endometriosis or not. And it’s quite tempting at that time to do surgery on a young woman, and we’re not actually sure whether surgery will improve their symptoms or in fact make symptoms worse.

I’m actually doing a study at the moment, looking at adolescent and young adult women through The World Hospital of Women, and UNSW. We’re looking at women who are under 25 years of age with pelvic pain, and menstrual pain, as to whether laparoscopy truly does help with long term symptoms of endometriosis or not. And that’s because, as I mentioned in the last series, doing surgery and removing endometriosis, tends to improve a woman’s pain with endometriosis, but unfortunately once you finish surgery, the woman will keep having menstruations. And that hormonal drive will keep driving those endometrial deposits, and keep causing pain to that young girl. And when you are 13, 14, 15, you’ve got many, many years of menstrual life ahead. And if you have one surgery, does that make you more likely to have many, many surgeries within your life? And as we all know, with multiple surgeries, we are exposing ourselves to excess risk that is associated with surgery. So we don’t want to do surgeries every one or two years on these young women because I don’t think that that’s necessarily good medical practice either.

When should you be concerned about a woman, a young woman, with really excessive menstrual pain? So if there is a teenager who is really suffering with their periods, the first line of treatment that I generally advise is, well, good diet and exercise, and then for pain management when it’s initially painful, using heat packs and simple analgesia. So simple analgesia principally being things like ponstan or nurofen which is very, very good for the crampy pain that goes with periods. And if you start using these treatments from the day before periods occur, throughout the bleeding days, then this should reduce a teenage girl’s pain by 20 to 50%, depending on the level of pain. And this is always the first line management to sort of general lifestyle advice and simple analgesics.

If this doesn’t help, the next line is to use some hormonal therapy. And hormonal therapy can be quite helpful for young women. Although we always start with a non-hormonal therapy, looking at the other risk factors, and whether they’re able to take hormones. But by far and away, as a general rule, hormones are safe for the adolescent population. We can use a single hormone, such as a progesterone hormone. And sometimes we use this to, with the view of taking the periods away. Alternatively, we can use hormones that are probably more commonly used in the community, such as the oral contraceptive pill. Using it to manage the periods, rather than using it as a contraceptive per se.

And we find that girls who go on the contraceptive pill have very, very good results in reducing their menstrual pain, and the other benefit of doing this is we can actually take periods away for young girls, and this in itself is just a complete relief for the young girl who can’t make it to school because she’s just absolutely suffering with her periods.

If none of those measures work, then often we will consider doing surgery, knowing that surgery is not without risks. And that’s principally what my study is looking at, at what stage is it optimum time to do surgery? Because quite often after surgery, the woman will still need ongoing hormonal medications or painkillers because the symptoms recur, or we just want to reduce the symptoms overall, of the hormones which the disease of endometriosis.

Another fantastic treatment is the IUD. So the Mirena IUD has got progesterone in it, which is one of the hormones that I was referring to and that, for 85% of women, takes periods away at the 12-month mark after inserting it. Unfortunately this is hard to insert as an adolescent because quite often they need to have an aesthetic to have it placed, but once it is in, often woman have real relief and it can be a very good treatment for adolescence who we really can’t help with basic painkillers or oral contraceptive pills and other hormonal treatments.

So I hope you’ve found my third session on adolescence useful. I’d be very interested in your feedback. You can find me on, find me at Woollahra Health and Beauty, and please do let me know if there are other topics you’d like me to discuss at further episodes within this series. Thank you.

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