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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North American Menopause Society (NAMS) video series about important midlife health topics: Nonhormone Prescription Options for Hot Flashes

The North American Menopause Society (NAMS) provides practical information on important midlife health topics for women. All the interviews in the series are hosted by NAM Board of Trustees Member and Immediate Past-President Dr. Marla Shapiro, a Canadian physician who led this exciting initiative. Dr. Shapiro is also the medical consultant for CTV News.

HRT remains the most effective solution for the relief of menopausal hot flashes but not all women want to use hormones, or it may be contraindicated in some as women with breast cancer. Fortunately, there are some non-hormonal therapy that provide some relief, although they may not be as effective as estrogen.

In this informative video of 2018 series, Dr. Shapiro interviews Dr. James Simon, Clinical Professor, Department of Obstetrics and Gynecology, the George Washington University School of Medicine. Dr. Simon explains the efficacy of nonhormone options for hot flashes.

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ASCO 2018: Many women with early-stage breast cancer can safely skip chemotherapy

A majority of women with early-stage breast cancer will not require to undergo chemotherapy says the results of very important clinical trial presented Sunday, June 3, 2018, at the American Society of Clinical Oncology (ASCO) annual clinical meeting in Chicago, Illinois and is also being published simultaneously in the New England Journal of Medicine.

This federally funded phase III randomized clinical trial is a game changer for most women diagnosed with early-stage breast cancer who are hormone receptor-positive, HER2-negative, axillary node-negative and who received a mid-range score on the Oncotype DX gene test.

"Half of all breast cancers are hormone receptor-positive, HER2-negative, and axillary node-negative," noted study author Dr. Joseph Sparano, MD, Associate Director for Clinical Research at the Albert Einstein Cancer Center and Montefiore Health System in New York, and Vice-Chair of the ECOG-ACRIN Cancer Research Group.

"Our study shows that chemotherapy may be avoided in about 70 percent of these women when its use is guided by the test, thus limiting chemotherapy to the 30 percent who we can predict will benefit from it," Sparano said in a news release from the American Society of Clinical Oncology (ASCO).

The Oncotype DX test looks at 21 separate genes in breast tumor cells samples and quantifies the individual risk of recurrence and likelihood of benefits from post-surgical chemotherapy. The test results give patients a "score" based on a continuous scale from 0-100.

Onco-surgeons are using this score since long to guide them about decisions on post-surgical chemotherapy. A woman with a low score (1-10) will only receive hormonal therapy while if she scores high (26-100), she receives additional chemotherapy also to prevent recurrence.

It was not clear how to proceed with treatment decisions for women who received the scores in mid-range 11-25. “The trial was designed to address this question, and provides a very definitive answer,” added Sparano.

The Trial Assigning IndividuaLized Options for TReatment (TAILORx) (ClinicalTrials.gov: NCT00310180) recruited 10,273 women 18-75 years of age diagnosed with hormone receptor-positive, HER2-negative, axillary node-negative breast cancer.

Of those, 6,711 had a mid-range Oncotype DX test score of 11-25 and were randomly assigned to receive hormone therapy alone or hormone therapy and chemotherapy.

After a median follow-up of 7.5 years, it was seen that the rates of overall survival, disease-free survival, or cancer spread beyond the breast was comparable for both the groups.

Adding chemotherapy only benefited a small subgroup of women who scored between 16-25 on the Oncotype DX test and were younger than 50 years.

Based on the results, the researchers concluded:

Chemotherapy can be safely omitted in women with this type of breast cancer who have an Oncotype score under 26 and are older than 50 years (85 % of women with breast cancer in this age group).

Chemotherapy can also be omitted in women who are younger than 50 and have an Oncotype score less than 16 (about 40% of women with breast cancer in this age group).

This study received funding primarily from the National Cancer Institute, part of the National Institutes of Health. Additional support was provided by the Breast Cancer Research Foundation, Komen Foundation, and the U.S. Postal Service Breast Cancer Stamp. The ECOG-ACRIN Cancer Research Group designed and conducted the study.

ASCO press release

Full-Text NEJM

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