ACOG updates its recommendations for treatment of Dysmenorrhea and Endometriosis in the Adolescent

The American College of Obstetrics and Gynecology (ACOG) has issued new guidance on diagnosing and relieving dysmenorrhea in adolescents, published in December issue of Journal Obstetrics and Gynecology.

Obstetrician and gynecologists frequently come across adolescents with dysmenorrhea in their practice due to high prevalence ranging between 50% to 90%. It is also responsible for recurrent short-term school absenteeism and reduced quality of life.

Most of the adolescents suffering from dysmenorrhea have primary dysmenorrhea–– painful menstruation in the absence of pelvic pathology.

If the physician suspects it to be primary dysmenorrhea, no pelvic examination or ultrasound is indicated in the initial evaluation. The patient should be put on empirical therapy after a careful history and physical examination.

If the patient does not respond to empirical therapy with NSAIDs and hormonal treatment in 3-6 months, she should be investigated for secondary causes or irregular treatments.

The most common cause of secondary dysmenorrhea is endometriosis, the other being obstructive anomaly of the reproductive tract (hymenal, vaginal, or Mullerian), uterine fibroids and polyps, adenomyosis, cervical stenosis, and adhesions.

Patients who do not respond to treatment for primary dysmenorrhea should be investigated for secondary causes which include pelvic examination and pelvic ultrasound. If pathology is detected, treatment of the cause is warranted.

If no pathology is seen, suspect endometriosis and consider a diagnostic laparoscopy. About 75% of adolescents and young adults with dysmenorrhea who do not respond to NSAIDs and hormonal therapy have endometriosis as the primary pathology. 

Endometriotic lesions present a different appearance in adolescents as compared to a young woman and are typically transparent or red and are challenging to diagnose.   

If a young woman is diagnosed with endometriosis, treatment consists of biopsy of the lesions along with destruction, ablation, or excision of the visible lesions at the time of initial laparoscopy. The patient should also be started on suppressive medical therapy to prevent further endometrial proliferation.

Consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the of diagnostic laparoscopy to minimize the pain of insertion later. 

If patients do not respond to conservative surgical therapy and suppressive hormonal therapy, they often benefit from at least six months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.

NSAIDs are the principal medications used for pain relief in endometriosis, and there is no role of long-term opioids in the management of endometriosis, besides being used by a specialized pain management team.

ACOG committee opinion No. 760

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Video presentation of diagnosis and management of Robert’s uterus

Robert’s uterus is an extremely rare Mullerian duct malformation which is characterized by a septate uterus with obstruction of one of the cavities. The three triads of Robert’s uterus include Blind hemicavity/uterine horn with hematometra, Contralateral Unicornuate uterine cavity and normal uterine fundus with a small indentation.  Only a few cases are reported in the literature since it’s first diagnosis by Robert’s in 1970.

Patients usually present with severe dysmenorrhea at the time of menstruation because of accumulation of menstrual blood in the non-communicating horn, reproductive failure, and dyspareunia. Three different type of Robert’s Uteri have been described: Type 1 is with large hematometra, Type 2 is with no hematometra while Type 3 is with small hematometra.

Classification of this anomaly is debatable, the European Society of Human Reproduction and Embryology–European Society for Gynaecological Endoscopy (ESHRE‐ESGE) classification describes this anomaly as a complete septate uterus with partial cervical aplasia; however, no explanation is given for diagnosing ‘unilateral cervical aplasia.’ The American Society of Reproductive Medicine classification system classifies it as a rare obstructive form of class VB anomalies.

Diagnosis is made based on history, physical examination and a combination of modern imaging techniques like 3D sonography, MRI, three‐dimensional sonohysterography with volume‐contrast imaging, HDLive rendering mode and automatic volume calculation (SonoHysteroAVC). HSG is often misleading and only depicts the Unicornuate horn.

Previous treatments include invasive horn resection surgery or endometrectomy via laparoscopy or laparotomy, which resulted in a loss of normalization of uterine volume and shape, abdominal metroplasty or by combining hysteroscopy/laparoscopy.

This video demonstrates successful management of all three types of Robert’s uterus using:

• Three-dimensional (3D) ultrasound in diagnosing and surgical management
• Hysteroscopic metroplasty transrectal ultrasound guidance
• Sequential balloon therapy to prevent adhesions
• Three-dimensional ultrasound for postoperative assessment of the cavity

In the end, a successful unification of non-communicating and communicating uterine cavity parts during surgery, better shape and several times higher volume of the uterine cavity, and total elimination of pain associated with obstruction after healing period were recorded.

Abstract

Here is the video presentation of Pre-, Intra- and Postoperative Management of Robert's Uterus

News from ACOG 2018: Elagolix promises long-term safety and efficacy in the treatment of Endometriosis

Elagolix, The first oral drug Elagolix showed promising results in the treatment of three types of pain in endometriosis reports the results of a study presented at the annual clinical and scientific meeting of the annual American College of Obstetricians and Gynecologists at Austin, Texas.

Elagolix, is a gonadotropin-releasing hormone (GnRH) receptor antagonist manufactured by AbbVie, a global research and development-based biopharmaceutical company in cooperation with Neurocrine Biosciences, Inc.

“There have been no new medications approved for a long time for systematic endometriosis and there is a huge gap because the current options are expensive, and they are often injectable drugs,” said presenter Dr. Surrey.

In this extension of an earlier phase3 trial, women with moderate to severe endometriosis-related pain who participated in the initial randomized, placebo-controlled trial were given either a 150- or 200-mg dose of Elagolix (NCT01620528).

About 569 women from 149 locations continued the treatment during the extension phase of 12 months to study the safety and efficacy of Elagolix over prolong period.

The average age of each patient group was between 31 and 34 years, and all groups were majority white, with a mean length of time from surgical diagnosis ranging from 45.5 to 56.6 months.

Patients reported a decrease in daily analgesic use by 46%-77% and improvement in dysmenorrhea and chronic pelvic pain by 49%-53% with 150 mg dose and by 82% for those at 200 mg.

Common side effect reported during the extension period was hot flashes, but they were not as severe as GnRH analogs and did not require any additional treatment. GnRH analogs are current gold standard for endometriosis and cause severe hot flashes requiring additional treatment.

The drug is also being evaluated in the treatment of uterine fibroids.

FDA is already on Elagolix and has announced April 2018 that it requires extended time to review additional information regarding the results of liver function tests provided by AbbVie in connection with its New Drug Application (NDA) for Elagolix in endometriosis-associated pain.

" We are pleased with the outcomes of the pivotal trials thus far. AbbVie will continue to pursue Elagolix as a potential new treatment for the disease's most common symptoms, including pain related to menstruation and chronic pelvic pain throughout the menstrual cycle," said Michael Severino, the chief scientific officer at AbbVie, at the time.

Abstract

FDA release 

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