For many adolescents — and adults — with dysmenorrhea, the cornerstone of successful treatment is hormones. Oral contraceptive pills or other hormone based contraceptives (like implants or patches) will stop the production of prostaglandins and therefore mitigate the cramps, though some parents dislike the idea of adolescents taking hormones, or worry that having contraception may lead teenagers to be sexually active earlier. Again, it’s important for adolescents and their parents to feel comfortable talking this through with the doctor — and with one another.
Dr. Bonny said that she worries more about underlying problems when someone’s first menstrual period is marked by severe pain, because it may be a sign of some structural problem. And when there is progressively worsening pain and hormones don’t help, doctors worry about endometriosis.
The muscular uterine wall — the myometrium, where cramps take place — is lined with the endometrium, which thickens during the cycle and then is shed during menstruation. In endometriosis, cells such as the endometrial cells that normally line the uterus and slough off with every menstrual cycle, cued by the hormone shifts of ovulation, also grow on other organs, including the ovaries and the fallopian tubes.
These tissues also respond to the hormonal signals, but the blood and tissue outside the uterus cannot leave the body and can cause inflammation, pain and, over time, give rise to scar tissue and adhesions. Pelvic pain — including pain with intercourse and pain with bowel movements or urination — is often seen as the hallmark of endometriosis, but it also causes heavy periods.
In order to make this diagnosis, doctors need to do a laparoscopy, inserting a camera through a tiny incision in the abdominal wall to look for the errant endometrial tissue and the damage it may have done; there’s no radiologic study that can substitute. Laparoscopy has risks, and doctors may be especially reluctant to take those risks in adolescents.
Dr. Rosen, who regularly performs such laparoscopies, said that often in teenagers, the trip to the operating room is a last resort, after numerous tries with medical therapy. “It’s very difficult to decide when to take someone to the operating room to look for endometriosis,” she said. But if the hormones don’t help, laparoscopy can also be an occasion for treatment, with surgical removal of the problem tissue. And since other medical treatments for refractory endometriosis carry other risks, that surgical diagnosis is important for confirming the cause of the pain before those other options are tried.