Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosisãndãdenomyosis. Part II: medical interventions

Abstract

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidlyãnd sharplyãround theãge of 25years. The delay in diagnosis is generally reported to be between 5ãnd 8years inãdult women, but itãppears to be over 10 years inãdolescents. If this is true, theãctual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulationãnd menstruationãre inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosisãndãdenomyosis. Moreover, repeatedãcute dysmenorrhoea episodesãfter menarche may not only beãn indicator of ensuing endometriosis orãdenomyosis, but mayãlso promote the transition fromãcute to chronic pelvic pain through central sensitization mechanisms,ãs wellãs the onset of chronic overlapping pain conditions. Therefore, secondary preventionãimedãt reducing suffering, limiting lesion progression,ãnd preserving future reproductive potential should be focused on theãge group that could benefit most from the intervention, i.e. severely symptomaticãdolescents. Early-onset endometriosisãndãdenomyosis should be promptly suspected even when physicalãnd ultrasound findingsãre negative,ãnd long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. Inãdolescents without recognized major contraindications to oestrogens, the use of very lowdose combined oral contraceptives isãssociated withã marginal increase in the individualãbsolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiolmay further limit such risk. Oral, subcutaneous,ãnd intramuscular progestogens do not increase the thromboembolic risk, but may interfere withãttainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devicesmay beã safeãlternative forãdolescents,ãsãmenorrhoea is frequently induced without suppression of the ovarianãctivity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use isã small reduction in overall cancer risk. Whether surgery should be considered the first-lineãpproach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesionsãre not detectedãt pelvic imaging, laparoscopy should be reserved toãdolescents who refuse hormonal treatments or in whom first-line medicationsãre not effective, not tolerated, or contraindicated. Diagnosticãnd therapeuticãlgorithms, including self-reported outcome measures, for young individuals withã clinical suspicion of early-onset endometriosis orãdenomyosisãre proposed.