Heather Appelbaum, MD, FACOG, explains multimodal approach to adolescent endometriosis

A tiered treatment strategy that begins with anti-inflammatory medications and reserves surgery for refractory cases should guide the management of endometriosis in adolescents, according to Heather Appelbaum, MD, FACOG, director of Pediatric and Adolescent Gynecology at K. Hovnanian Children's Hospital at Hackensack Meridian Jersey Shore University Medical Center, associate professor of Obstetrics and Gynecology at Hackensack Meridian School of Medicine, and director of the PMOS Multidisciplinary Program at Jersey Shore University Medical Center.

The discussion builds on Appelbaum's earlier comments distinguishing clinical from surgical diagnosis, drawn from her presentation "Multimodal Treatment for Endometriosis," delivered this year at the North American Society for Pediatric and Adolescent Gynecology (NASPAG).

Appelbaum described an empiric, pattern-based sequence as the foundation of care.

"Our approach to the diagnosis of endometriosis or an exploration for endometriosis in adolescence should always start with a pattern-based diagnosis and pattern-based intervention. What I mean by that is an initial treatment with anti-inflammatory medications, and that should be the first line of defense when a girl is presenting with a constellation of symptoms that are related to pain and the menstrual cycle," she said. "And if that does not work, then the second-line treatment is hormonal therapy."

Patients who fail hormonal therapy, with persistent or breakthrough pain and possibly irregular menses, represent the subset who may warrant surgical evaluation, Appelbaum said. She stressed that diagnostic laparoscopy should not be undertaken without therapeutic capability.

“When we do a surgical evaluation and we engage in doing a laparoscopy, one of the things that I think is very important to focus on is if we are going to do a diagnostic procedure, the surgeon needs to be capable of doing not only a therapeutic laparoscopy at the same time, meaning that you put the camera in, you look, you see endometriosis. Number one, you have to be able to recognize endometriosis in adolescence,” she said, and explained further, “recognizing endometriosis in adolescence is understanding the subtlety of the disease process in younger patients.

“So that is number one. Number two, the surgeon needs to have appropriate skills to be able to excise the endometriosis, and so just making the diagnosis by itself is not very helpful. It is actually part of the treatment plan by removing the endometriosis.”

Appelbaum underscored that surgery alone is not the final piece given the chronic nature of the disease.

"The most skilled surgeon can remove endometriosis, but if we do not continue the patient post-surgery with treatment on a chronic basis, because this is a chronic illness, the endometriosis is going to come back," she said, framing surgery as one component of intervention for patients whose quality of life is severely compromised despite medical therapy.