Salmonella, Meningitis, Teenage Endometriosis – PediaCast 411
- Dr Leslie Appiah visits the PediaCast Studio as we explore teenage endometriosis. Discover the cause, symptoms, work-up, treatment and long-term outlook for those affected. Also reviewed this week: salmonella and meningitis. We hope you can join us!
- Teenage Endometriosis
- Pediatric and Adolescent Gynecology at Nationwide Children’s
- Not Your Typical Menstrual Pain: Endometriosis in Teens (700 Children’s Blog)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome. Once again to PediaCast, it is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital, we're in Columbus, Ohio. It is episode 411 for August 8th, 2018. We're calling this one, Salmonella, Meningitis, and Teenage Endometriosis. Want to welcome you to the program.
We have a full line up for you this week. Salmonella and meningitis, both of them in the news and probably in your social media feeds recently. We'll talk more about those topics in a couple of minutes. Our third topic this week is one that affects teenage girls and it's an important topic because we, and by we I mean, all of us parents, healthcare providers, teenage girls. We may not consider endometriosis when an adolescent girl experiences chronic pelvic and abdominal pain. Especially pain that kind of comes and goes. In fact, there are many out there who may not understand exactly what this disease process entails. Maybe you've heard of endometriosis but you're not exactly sure what it is. So we'll explain that as we move forward. And even if you do understand endometriosis, you know what it is, we tend to think of it as a process that affects adult women and we may not consider it, at least not initially, in the differential diagnosis of pelvic and abdominal pain in teenage girls.
We may think about run-of-the-mill menstrual cramps, or constipation, or irritable bowel syndrome, even urinary tract infections, sexually transmitted diseases, along with many other possibilities and all good things to consider. But we do our teenage patients a disservice if we overlook endometriosis as a possible cause of their symptoms. Dr. Leslie Appiah is a Pediatric and Adolescent Gynecologist here at Nationwide Children's Hospital. She'll swing by the studio and help us understand who, what, when, where, why and how of teenage endometriosis. Again, that's coming up a little bit later in the program.
First though, I did want to talk about salmonella. There's been a lot in the news about this organism because it's been appearing in cereals and snacks. And of course if you hear about it from time to time in produce and meats. And so, there is awareness about salmonella out there and it's been in the news quite a bit, as relates to food. So what exactly is salmonella? It is a bacterial organism, so it's a bacteria and it's one that is spread through what we call the fecal-oral route. I know it's not pleasant necessarily to think of. But bacteria is in our stool and then on the skin around where the stool comes out. So when we wipe after going to the bathroom, you know the bacteria is going to be on the toilet paper and on our hands. So it's really important to wash our hands after we go to the bathroom.
And then as we touch things, the salmonella can spread from our fingers, then to those food products. So folks who are in the food industry, packaging our breakfast cereals, snacks foods, fresh produce, bagged greens, meats; it can get into the food and then when we come along and eat the food of course, we're ingesting it direct then into our bellies, and then the incubation's on salmonella ends up in one day to two weeks. It can take a little time before symptoms appear. Sometimes it's not a symptomatic, so there aren't any symptoms, that can sometimes happen as well. Especially if your immune system is on the ball and takes care of it right away.
But for most folks who gets exposed to salmonella after few days to two weeks, sometimes shorter, used to start have symptoms. And those symptoms typically, are loose watery stools, because there's inflammation in the intestines and it's not working quite right. It kind of speeds the movement of our food through and adds extra water as things you have inflammation. And then that can lead to a blood in the stool along with abdominal cramps, sometimes fever, we get a little more worried about salmonella when there's a high fever present. Vomiting is a possibility, dehydration is possible because you have diarrhea and you're losing water that way. And then you can have invasive disease where the bacteria moves into the bloodstream and causes what we would call, a bacteremia. And that can lead to sepsis which is kind of, overdoing of the immune system that can become life-threatening very quickly because of the way that your immune system is responding to the bacteria in the blood.
So salmonella can be serious. But in most folks, you end up with a watery stool, some blood in the stool and most of the time it gets better on its own. Without actually even needing to treat it with anything other than fluid replacement. Now, there are other things that can cause similar symptoms. So, if you have blood in the stool, there are other microorganisms that can do it. So it's going to be a good idea to see a healthcare provider. Have your stool checked out, there's some test that can be run, some other bacteria that can cause blood in the stool include, Shigella, Yersinia, Campylobacter, C. Diff can do it. Of course, you may just have red stools because you've been eating something red, beets can do that often as can with red-colored juices. Constipation can lead to some blood in the stools, that's usually from pushing then you get a hemorrhoid or fissure that can break.
And you get more of bright red blood in the stool. So it's a good idea if you ever see blood in your stools, see a healthcare provider, let them do an exam, get the history, get what characteristics that you're seeing. They can actually test for blood to see if the blood is really present or it could just be a red color. There's a test for that. And then of course, there are tests for the specific microorganisms like salmonella and shigella. Antigen test, PCR test, that are a little more expensive but you get a good result fairly quickly. The old fashion culture takes a bit longer. So the important thing is, a blood in the stool with diarrhea, or a diarrhea that's lasting for more than a few days or associated with other symptoms like high fever and vomiting, make sure you see a healthcare provider, so they can get the right diagnosis.
And then in terms of treatment as I've mentioned, most cases of salmonella are what we would call, self-limiting. Meaning, the immune system takes care of it. If you have diarrhea with some blood in it for usually you know, a few days to not usually more than a week. So four to seven days kind of in that range. Using an antibiotic, here's the thing: once you don't have symptoms anymore, you may still have the organism in your stool for a while afterward. Even though if you don't have symptoms anymore. So it's always important to wash your hands after you go to the bathroom. Just in case you are a symptomatic, you don't have symptoms, you have or maybe exposed to salmonella at some point in the past and you do have that organism in your stool, it's just not causing symptoms or not causing symptoms anymore, treating with an antibiotic in this mild cases may actually prolong the length of time that the bacteria is shed in the stools. So you're contagious for a longer period of time without symptoms if you use an antibiotic for these mild cases.
Now, if there's evidence of invasive disease or you're immuno-compromised, or you're very young or you're very old with not the greatest immune system, or you have complex medical condition where, getting an infection is going to be more dangerous for you. Then the benefit of using an antibiotic is going to outweigh that risk of prolonged shedding. So we do typically use antibiotics things like, Zithromax, Ceftriaxone, Sefin bactrim, Cipro, especially in older kids and not so much on the littler kids, although sometimes we do. And then of course, supportive care is going to be important too. So lots of fluids. Use Tylenol for fevers that are associated with because you're bleeding in the stool. Maybe, you wouldn't pick Ibuprofen since that can prolong your bleeding a little. Probably just depends on the degree of symptoms. And of course, this is all going to be done under the direction of a healthcare provider.
In terms of preventing salmonella, good hand washing as I've mentioned, since it is that fecal-oral route. Also, be sure that you're following all food storage and handling guidelines. Follow all cooking, heating, and grilling guidelines. With fresh produce, make sure you wash it with a general scrub and rinse. And of course pay attention to those recalls, recalls.gov is a great place to get information. You can also follow the CDC on Twitter. They frequently announce any recalls related to food and infectious organisms as we've been hearing about. So, some places that you can check out and pay attention to those and check your pantry or your refrigerator, and throw out any items that have been recalled.
The other topic that I'd like to talk about before we head to teenage endometriosis with our guest, and that is meningitis. Meningitis has been in the news here recently. For a couple of reasons, we do see sort of, an up tech and viral meningitis cases in the summer time. And then also, there's a lot of prevention efforts around bacterial meningitis in the summer, as we think about back to schooltime because teenagers and older kids, the meningitis vaccine is an important one to get. And in particular, if you have a child heading off to college, you know we always hear stories of the sporadic college student. You know it's not an epidemic but there is the occasional college student that passes away from bacterial meningitis every year. You know, there are case reports every year and it's scattered around the country just enough that you've probably heard of that in your neck of the woods as well.
So I wanted to cover meningitis. First exactly, what is it? The meninges are membranes that surround the spinal cord, and they contain a fluid inside the meninges called, spinal fluid. Or the central spinal fluid or the CSF, and that bades the spinal cord and then travels up into the brain into what we call ventricles, sort of the internal cushioning of the brain. And the meninges then, hold that spinal fluid which is then up against nourishing the actual spinal cord itself. So, that's the spinal fluid.
And then meningitis happens when that fluid and those meninges, those membranes around the spinal cord, get infected. And then there are lots of things that can cause meningitis, but we kind of divide it up to into two big categories. One is going to be viruses. Some of those viruses are summer time viruses that we see like a neural viruses for example, can cause meningitis. And then there are also some viruses that mosquitoes can spread that can cause meningitis encephalitis. So we do see those in the summer, because that's when the mosquitoes are active. And then there's bacterial meningitis, and we do have some vaccines that protect against three different types of bacterial meningitis. One, haemophilus influenza type b, and that's the hep vaccine that we give little babies. Also, the pneumococcus, that particular bacteria can cause meningitis. The pneumococcal or prevnar vaccine that we give to babies that helps to prevent that sort of meningitis. And then the meningococcus, is a very bad nasty bacteria. And I see meningitis as another name for when you get the disease.
And that particular bacteria can cause really severe illness quickly. And that's the one that typically will strike the occasional college student. And they go from just being a little sick to being passed away within a matter of a day or two sometimes. And can cause a really bad rash, bleeding into the skin that's causing the rash. So we really recommend that teenagers get a vaccine against meningococcus, that's the meningitis vaccine you hear about. And in particular, before you head off to college. That's going to be a really important one, to make sure that your child has had.
Now in terms of symptoms of meningitis, it causes fever, muscle aches, vomiting, just like any other viral illness or bacterial illness in the body. And then a headache, a stiff neck, photophobia, not really liking bright lights and that can also lead to an altered mental status. Where kids may not just be as responsive, they may be confused. That's going to be more advanced stages of the disease, and then coma and death would follow that. So you would want to catch these things early. Any headache with a stiff neck, you want to see someone right away so you can get meningitis diagnosed as early as possible.
And then with meningococcus, that bad one that meningitis. That one, does cause the rash with the bleeding into the skin, what we call petechiae. Just little tiny red dots that when you push on, and they don't turn white. And then turn red again when you let go. They just stay red because it's blood in the skin, that's a really dangerous form of meningitis. That's what we're trying to protect against with the meningitis vaccine that we give to older kids. So that sort of rash, we would want see someone right away. That's not something you wait until morning.
In terms of diagnosis, really the best way to diagnose meningitis into differentiate the viral kind versus the bacterial kind, is with a spinal tap or a lumbar puncture. We just go to the lower back in the middle, and it's between vertebrae and the lower back, the lumbar region. It's below where the spinal cord actually stops. So it's just a little sac or some nerves that come off of the spinal cord there, and the fluid and we put a needle in there, we collect the fluid and we analyze it. It's the same place where women get an epidural before child birth.
If you get that medicine, they just inject into that area. In this case, where taking fluid out of that area, we'll look at the number of the white blood cells, the protein, the glucose, we do cultures, we do PCR test, which looks for the evidence of the genetics of viruses and bacteria. That can help us determine a little more quickly than waiting for culture. What organism and also, just how many white blood cells? What is the protein look like? What is the glucose look like? Can help us determine if this is a viral meningitis versus a bacterial meningitis. For a viral meningitis, most of these are self-limiting. Meaning you just need supportive care, rest, fluids, Tylenol, those sorts of things. And your body's immune system is going to take care of that.
But it's important to differentiate that from bacterial meningitis. Because IV antibiotics would be necessary for that particular form of meningitis. And it's important to identify and treat those bacterial causes early. Complications of meningitis, especially the bacterial kind, you can have disabilities that affect the brain. It could lead to a hearing loss, you could have cognitive effects down the road with issues with thinking, thought processes, motor issues, sensory issues and in particular, when meningitis spreads to the brain itself and causes encephalitis, those things are really high risk for those complications. And then of course, the biggest complication of all, you can die from meningitis. Particularly the bacterial kind and really particularly, the meningococcus ones. So, that's a pretty bad complication, that's why we do want to diagnose meningitis and are fearful of it, and we would want to diagnose it as quickly as possible.
In terms of preventing meningitis, which is really important better to prevent than to be behind the ball and actually have it. Once vaccines, you know the haemophilus influenza vaccine and the pneumococcal vaccines really decreased the numbers of cases of meningitis that we see in young kids. Meningitis used to strike babies and toddlers all the time, the death rate from meningitis used to be really high. And then we had some good vaccines to prevent haemophilus influenza type b and pneumococcal disease. So that's really decreased the numbers of cases in the meningitis. And now with the Menactra and other forms of the meningitis vaccines that your doctor may give to order kids before they head off to college. It's going to be important to get that one to protect your child against that really bad form of meningitis.
Also in the summer time, you know, avoid mosquitoes especially, if meningitis and encephalitis producing viruses are in your area. You know if the health departments are letting you know that mosquitoes in your area have been shown to carry viruses that cause meningitis or encephalitis. Pay attention to those alerts and of course, use insect repellent if you do have to be outside when the mosquitoes are active particularly, if those viruses are in your area. And of course, it's early recognition of symptoms, so you can get the right diagnosis and get treatment going as soon as possible, to prevent those complications. That's going to be important. So again, fever with the headache and the stiff neck, you definitely want to be seen for that as soon as possible.
Alright don't forget, one thing I do want to remind you before we head into our discussion of teenage endometriosis. It's easy to get in touch with me. You know if there's a topic that you'd like us to talk about on PediaCast, we'd love to hear your ideas, love to answer your questions. In fact, our next program next week, we're going to devote to answering some listener questions, will cover some pediatric news along with that. I'd love to get your questions, it's easy to get in touch. Just head over to pediacast.org and click on the contact link.
Dr. Mike Patrick: Dr. Leslie Appiah is a Pediatric and Adolescent Gynecologist at Nationwide Children's Hospital and an Associate Professor of Obstetrics and Gynecology at the Ohio State University College of Medicine. She has a particular interest in helping teenagers who are experiencing pelvic pain and painful periods, which are sometimes caused by endometriosis. That's what she's here to talk about today, endometriosis in teenagers. So let's give a warm PediaCast welcome to Dr. Leslie Appiah. Thanks for stopping by today.
Dr. Leslie Appiah: Thank you Dr. Mike, I appreciate the opportunity to speak today.
Dr. Mike Patrick: Yeah, really appreciate you taking time out of your day to join us. So let's begin with just a definition, what exactly is endometriosis? It's a big work, kindly break it down for us.
Dr. Leslie Appiah: Sure. So endometriosis is an estrogen-dependent inflammatory disease or condition that affects women of a productive age, including adolescents. Endometriosis can occur by several different mechanisms and different individuals may develop endometriosis in very different ways.
Dr. Mike Patrick: Sure. So the word comes from endometrium, which is the lining of the uterus and when you say estrogen-dependent, it's because that tissue responds to estrogen through menstrual cycle and kind of grows and then sheds, correct?
Dr. Leslie Appiah: Correct. So, the most common mechanism of the development of endometriosis is backwards menstrual flow. So all women will have menstrual tissue that flows backwards to the fallopian tubes and then into the pelvis.
Dr. Mike Patrick: So up toward the ovary?
Dr. Leslie Appiah: Correct. And so, most women will have mechanisms that clean up that endometrial tissue in the pelvis. Women with endometriosis don't have that mechanism. And so, that tissue stays in the pelvis, implants and then burrows deep, invading those nerve vessels. And also attract substances that cause pain and scarring. So that's the difference. Its inability to clean up that tissue that's developed through backwards menstruation. That's the most common way. There are other ways of developing endometriosis, but that is the most common.
Dr. Mike Patrick: Sure. Now, how common is it then that you have a female who were, I supposed it's the immune system, is that what's involved in kind of cleaning up any endometrial cells that have gone backwards of the fallopian tubes and now into the pelvis region. How often does that happen that someone who's not able to take care of that?
Dr. Leslie Appiah: Sure. So we know that endometriosis or pelvic pain affects about five percent of adolescents who are seeing the gynecology office. We know that for girls who don't respond to the typical treatments for pelvic pains such as, anti-inflammatories, Motrin and Pamprin Midol or birth control pills, 50-70% of those patients will be diagnosed with endometriosis and laparoscopy. So those who fail first line treatments, that is the prevalence of the condition.
Dr. Mike Patrick: Now certainly, you can have painful periods or sometimes they're painful, sometimes they're not. When we talk about chronic pain, at what point do you start searching for other answers because this has gone on too long? How long is 'too long'?
Dr. Leslie Appiah: In children and adolescents, the definition of chronic pain is pain that occurs three or more times in a three-month period. So for any adolescent girl who experiences that duration of pain three episodes in a three-month period were concerned about chronic pelvic pain. And we begin to look for the different causes of that pain.
Dr. Mike Patrick: Yup. And it's important to get to the root of it and do we can to get rid of the pain because chronic pain can affect us in so many other ways, not just the pain itself, but just in terms of school and our jobs, and our social interactions, anxiety and depression can result from chronic pain. So there's all sorts of reasons why beyond just the pain itself, of why we would want to figure out what's going on and treat appropriately.
Dr. Leslie Appiah: Absolutely. We know that chronic pelvic pain cause two billion dollars per year, in both direct and indirect cause. So that's direct in terms of hospital bills and then indirect from loss of employment and then some other things that go with loss of employment, the downstream effects of that. Many of these girls will experience depression and anxiety as you stated, which then affects their ability to have friendships, relationships, go on to pursue higher education and employment.
Dr. Mike Patrick: Since these does have an immune component to it, I would assume that it also runs in families then? Is this inherited thing although, it must be complex in that simple inheritance because you can't trace it necessarily through a family tree. But it is more common in families, right?
Dr. Leslie Appiah: You're absolutely correct, Dr. Mike. So we know that endometriosis is polygenetic, meaning there are many different genes that cause it. We don't know all of the genes that cause it or exactly which ones. We know that it's multifactorial and the thing more importantly, we know that when there is a first-degree relatives. So our mother, our aunt or sister, who has endometriosis. Then that patient is seven times to ten times more likely to have endometriosis. So obtaining an appropriate family history is very important and many times mothers come in and say, "you know my sister has endometriosis" or "I had endometriosis, I'm concerned that my daughter may have it." And then we need to listen to our parents and our families when they say these things because of the high associations, seven to ten times more likely is extremely high.
Dr. Mike Patrick: Yeah. And I would imagine some of those moms, grandmas and aunts may not have been appropriately diagnosed. And so, just hearing a family history of chronic pelvic and abdominal pain, may also clue you in that this is going on even if they've never head of the word endometriosis before.
Dr. Leslie Appiah: You're absolutely correct. And many times once we diagnose endometriosis in the adolescent and the mother would again, speak to their siblings and say, “I wonder if I have that, has it directed me at an early age or chronic pelvic pain. My doctor never knew what it was and I still have pain.” And so you write many times just chronic pelvic pain has gone underdiagnosed and untreated.
Dr. Mike Patrick: Are there other risk factors in sort of the history that would clue us in that this could be going on in terms of things like, what age you start having your period? Or how long your menstrual cycle last? Are there any other risk factors that we should kind of have our attention go up like, 'Hey, this could be endometriosis that's causing this chronic pain?'
Dr. Leslie Appiah: Sure. So, young girls who experience their menses early, so the average age is between 12 and 13. So girls who experience their menses at an early age, girls who have frequent menses, so greater or more often than every 21 days, girls who have flow that longer than 7 days. So heavy flow, frequent flow, early menses, all give us the indication that these patients may be at higher risk. Interestingly, girls who are thinner, tend to have an increased likelihood of endometriosis, and we're not sure what that association is, but we see it anecdotally and in the literature. So that's important to kind of keep an eye out. And then, many times, girls will have associated symptoms such as, pain with bowel movements, irritable bladder, urinary frequency, urgency. Many of these things can be associated with endometriosis.
Dr. Mike Patrick: Yeah. One thing you've mentioned is the backwards menstruation that causes it. And I guess that does it when you think about those risk factors. If you do it early, maybe the cleaning up process maybe isn't that mature yet. Again, this is all hypothesis.
Dr. Leslie Appiah: All of it is a hypothesis.
Dr. Mike Patrick: If you have your periods more flowing backwards or if they lasts longer, or they're more frequent at all, place into that for sure.
Dr. Leslie Appiah: Yes.
Dr. Mike Patrick: But there are, as I'm researching this, there are some other possible causes other than backward flow of menstruation. Can you comment on some of those? Because they're kind of interesting.
Dr. Leslie Appiah: They are. So, coelomic metaplasia is one of the other mechanisms of development of endometriosis. And that involves a change in the normal tissue lining of the pelvis. So not endometrial tissue at all, normal tissue that we have changes into endometrial tight tissue. So that's coelomic metaplasia. The other mechanism is hematogenous and lymphatic spreads. So we know that endometrial type cells could spread through the vascular, through the blood vessels, and also through those vessels that holds fluid in our body. So, endometriosis has been identified in the lung, in the brain, in the diaphragm. So, places where retrograde or backwards menstruation would not cause endometriosis. So you're correct. There are other mechanisms, those two would be the most next common.
Dr. Mike Patrick: What about, this is going to be more on the adult population. But if you had GYN surgery in the past, can endometrial tissue gets transplanted because of the surgery?
Dr. Leslie Appiah: Yes, in our older patients we would have cesarean sections or laparoscopic surgery. Any type of surgery where we invade the uterus, and then invade the endometrial and then track that tissue up and through the body, these patients can have ectopic endometrial implants. And we see that many times when there's a bulge in the abdomen underneath the skin, that's cyclical. And they have pain there, and imaging will show endometriosis.
Dr. Mike Patrick: Very interesting.
Dr. Leslie Appiah: Yes.
Dr. Mike Patrick: Just so our listeners would have it in their mind what's happening here is that, if there's a tissue cells within that divide and if you have more of them together, you're going to have the endometrial lining and little pockets outside of the uterus. And so, during your monthly cycle, that grows just like it would inside the uterus and then, it also kind of breaks down and then breaks apart just like what you would shed out the lining of your uterus when you have your menstrual period. But that same thing is happening wherever these little implants are located. And then because of those are there, the body's immune system is going to come in and cause inflammation because it doesn't do it effectively, but it's trying to get rid of those things. And that's how we get the pain and kind of come and go depending on whether those little implants are growing, or they're dissolving or what exactly they're doing. I'm trying to put it in simple terms, but is that the gist of it?
Dr. Leslie Appiah: Sure. So, as you described, what happens is tissue is implanted, and then we have adherence. So, it sticks and then invasion into the underlying tissue. We then have proliferation, where we have other cells that are attracted to it macrophages side of kinds. Those are cells that are trying to help clean it up. Androgenesis, we have a development of new blood vessels that actually feed those tissues. And all of those processes lead to pain, scarring, development of scar tissue and adhesion formation. Yes, you're correct.
Dr. Mike Patrick: And then the other interesting thing, the other thing that I came across and maybe see you see this in the clinical practice, that the pain does not always correlate with the severity of the disease. Speak on that.
Dr. Leslie Appiah: Thank you for bringing that up because I think that is very important for the individuals to understand both, I think more important for providers to understand. That, there is a negative correlation or inverse correlation, where patients with early stage minimal disease have more pain than patients with later stage, more invasive disease. And we don't know exactly why that is, but one can hypothesize that earlier disease, the nerves are affected. They've never been stimulated by these side of kinds. So, that's more kind of exasperated presentation.
It's also important to know that there are several different types of endometriosis. So there is peritoneal endometriosis, where the implants are just superficially in the pelvic tissue. There is deep invasive endometriosis and there is ovarian. It is the peritoneal endometriosis that is the most painful because there are more inflammatory cells lining the pelvis. So yes, absolutely.
Dr. Mike Patrick: Yeah, very interesting. Now, when we think about endometriosis, pain is the first symptom that comes to mind and you've also talked about pain with sometimes with stool, and constipation can sometimes get confused with endometriosis. Or they can be present together in the same patient. Are there other signs and symptoms of endometriosis that we should be on the lookout for?
Dr. Leslie Appiah: I think one of the things that providers should pay attention to is that typically, the pain will begin 1-2 weeks before menses. So with ovulation and production have higher doses of hormones will begin to see that pain. The pain can be both cyclic and non-cyclical. I think that's important to know because, many times if a patient is having pain with just their periods, we assume it's menstrual pain only. But patients can have monthly pain that's endometriosis or pain between periods that is endometriosis. So that is the thing that I think, we need to understand best. And then, as you stated, abdominal pain can be associated with endometriosis. Low back pain, pain that shoots down the leg. Pain that is in the groin. It can be in many different places and be endometriosis. Some of that because we're involved in our accessory muscles to help protect that area of pain. Other part of that is just, inflammatory mediators that are causing pain.
Dr. Mike Patrick: And painful intercourse and tearing sex is also, because you can get the hormones while these tissues responds to that, I'm guessing that would be why I saw that painful intercourses are something to consider, too.
Dr. Leslie Appiah: And we see that in patients who have a little bit more of progressive disease as we begin to have larger nodules or larger implants in the pelvis, you can feel that during in the pelvic exam. And with intercourse, individuals would have pain, mostly with deep penetration. To your point, inflammation and just a hypersensitivity of the nerves can cause pain with entry as well.
Dr. Mike Patrick: Yeah, that makes sense. And then the constitutional symptoms that go on along with this. When you have chronic pain, you can see fatigue, bloating could go along with it, nausea and all these sorts of things.
Dr. Leslie Appiah: Correct.
Dr. Mike Patrick: And so, as we're describing this, pelvic and abdominal pain and nausea, bloating and fatigue, there's a lot of other things that can cause this. And I think as providers, we're always thinking of differential diagnosis. For a parent who listens to this and you hear this sequence, this compilation of symptoms, it's not always going to be endometriosis, right? What are some other things that can cause similar pain?
Dr. Leslie Appiah: Here at Nationwide Children's, we approach this through a multi-disciplinary approach because we know that the differential is broad. And so, we want to make sure that patients have been evaluated by the necessary provider. So, bowel or GI causes are the most common cause of abdominal pelvic pain. About 40% of patients with abdominal pelvic pain would have GI ideology or GI-caused. And that can be diverticulosis, irritable bowel syndrome, inflammatory bowel disease. Urologic causes would be secondary, so painful bladder syndrome, kidney stones, chronic osteitis. And then we have our gynecologic causes. And even in the gynecologic causes, we have to rule out other things, primary dysmenorrhea ovarian cyst torsion. These sorts of things could present with pain. So to your point, it involves a multi-disciplinary approach, physical therapy is also very important in evaluation because some patients have sports injuries or muscular skeletal causes of their pain, and we need to rule that out before we proceed to surgery or other things for diagnosis.
Dr. Mike Patrick: Yeah, urinary tract infection, sexually transmitted infections, appendicitis. All sorts of things that can be there. So how do you go about narrowing it down? How do you make the diagnosis of endometriosis?
Dr. Leslie Appiah: Sure. Again, our multi-disciplinary approach. So, when we see a patient, we take a very thorough history to better understand where that pain maybe originating from. We refer our patients to our guest urinology team, so that they may do assessment based on some of the initial questioning that we have. We also refer our patients to urology, if we feel that there's a bladder component. And then physical therapy. We also begin with anti-inflammatory treatments. So we'll recommend that our patients start with that to help treat the inflammatory process that are related to dysmenorrhea or menstrual cramping. Many of our patients will use hormonal treatments as kind of the initial presentation of the initial treatment of their pelvic pain, that's birth control pills. We use birth control pills for non-contraceptive reasons. And this is one of those reasons. When a patient fails three months of anti-inflammatories and three months of hormonal therapies, and they've been to these other practitioners to rule out these causes, we need to have a strong suspicion for endometriosis, and we need to proceed with the next step, which is typically a laparoscopic or minimally invasive procedure to diagnose and to treat the endometriosis.
Dr. Mike Patrick: So, that all makes sense. I would imagine that there are some girls with endometriosis who do respond to nonsteroidal anti-inflammatory things like ibuprofen and to hormonal therapy. So, in some cases and this is not very satisfying for parents, but sometimes using those things helps the pain but you still can't say for sure what was causing the issue. And parents of course, want to know like, I want a name, right?
Dr. Leslie Appiah: Exactly and so to your point, anti-inflammatories and hormonal contraceptives can be a treatment for endometriosis. So, a patient may have endometriosis and be treated or managed with these therapies. And the important thing for them to know is they need to continue these therapies until they're ready to approach their childbearing because when they stop these therapies temporarily, the pain may resume. And again, pain is an indication of a process. So we know that they're progressing with scar tissue and that can lead to infertility down the line. So, we educate are patients that if you stop these therapies and the pain resumes, you need to be evaluated because there maybe endometriosis going on that you have not yet diagnosed.
Dr. Mike Patrick: Yeah and even if you get to the point where these things are helping doesn't mean that they're going to continue to help in the future. So, it could help a year later or you could start your pain back again despite continuing to do the nonsteroidals and the hormone birth control pills.
Dr. Leslie Appiah: Exactly. And I think also important to remember is that, pain that is 10 out of 10 that is decreased to 5 to 6 out of 10 is an improvement, but there's still some area. There's room for improvement. So, we always want families to be cognizant that, you're not better. You're better but not where you really should be if you're on this therapy. So if you're on these therapies and if you're improving but not substantially, that is another indication that we need to continue to pursue the diagnosis. And I fortunately see that where patients that have been on this hormonal treatments for years. And although they're better, there's still insignificant pain.
Dr. Mike Patrick: Yeah and even though it's better, it's interfering with their quality of life. Maybe they're not running track like they did a couple of years ago. Or they're not doing the things that they typically love to do, and then we could be better.
Dr. Leslie Appiah: That's why it has still affected their quality of life. And that is the goal of treatment, to improve the quality of life with these patients and to minimize progression to infertility and early hysterectomy and those things that occur. Multiple surgeries, we want to minimize the number of surgeries these patients have.
Dr. Mike Patrick: Now, when you do resort to surgery, and you said it's minimally invasive. You're just trying to take out the pockets of cells that are causing the ones we think are causing the problems. But this process of the menstruation going the other way, and your body not taking care of it, still continuing to happen. So, even with surgery, it can reset again.
Dr. Leslie Appiah: Correct. We know that patients improve with medical therapies, and they improve with surgeries. What we need patients and providers to understand is that, progression of disease and long-term improvement occurs when we combine surgery and medical therapies. So, we use surgery to diagnose and to initially treat. So, resect and remove implants but patients need to remain on a hormonal therapy after surgical procedure to stop menstrual flow. And thus doing so, decrease the pain and progression of disease. So, patients need to be on some sort of hormonal therapy, whether its combined birth control pills, progesterone-only therapies. Many times we'll use a progesterone IUD, the levonorgestrel IUD, and then there are other third line treatments that we would use. But the message in it has to be the surgery alone, is not the main stay of treatment. It is the main stay of diagnosis, but treatment should involve both surgery and medical therapy for those patients who don't improve on medical therapy alone.
Dr. Mike Patrick: Yeah. You've mentioned some different options for hormonal therapy. Are there ones that work better for endometriosis than others?
Dr. Leslie Appiah: No one therapy is known to work better any one individual. We know that, different therapies work better for different people. Any therapy that stops menstruation completely, is going to be kind of the goal. But some patients would do well with just combined birth control pills, and those patients sometimes never go to surgery. Progesterone-only therapy seem to be one of the better treatments, and then preventing the body from making estrogen in the first place, is also a good treatment. So good at it in releasing hormonal therapy, which is an injection that a young girl would receive even monthly or every three months to prevent the ovary from making estrogen. That is the therapy that we know works very well.
And as I stated that the intrauterine device, is a progesterone-only therapy that is placed inside of the uterus, which thins out the lining of the uterus. So, it prevents backwards menstruation, it prevents any menstrual tissue from forming and that treats endometriosis. And also, because it is a progesterone therapy. Shrinks the endometrial implants that are in the pelvis and decreases the number of estrogen receptors in the endometrium and in the pelvis.
Dr. Mike Patrick: So, decreasing or getting rid of menstrual flow completely, is going to prevent further progression because you don't have that backward flow, but then that's also a sign that if the endometrium, the lining of the uterus is not active, then those implants are not going to be active either.
Dr. Leslie Appiah: Correct.
Dr. Mike Patrick: Got you. You mentioned infertility. That's the scary prospect, I think for a lot of teenagers and families. How big of the risk is that and what can be done to minimize the risk of infertility down the road?
Dr. Leslie Appiah: Sure. So, we know that about 50 percent of patients with infertility will have infertility from endometriosis. And so, it can be quite problematic and the mechanism is scar tissue formation, as well as just the disruption of ovulation because of those implants and the kind of hormonal stimulation that they produce or cause. So, scarring of the tubes, scarring of the ovary and then inhibiting the eggs from being released in a reliable fashion, both of those are mechanisms for infertility in patients with endometriosis.
Dr. Mike Patrick: Yeah. And is there a correlation between catching this early and then lower risks of infertility down the road or is the risk remain the same regardless of when this gets diagnosed?
Dr. Leslie Appiah: Sure. So, endometriosis can either be progressive or it can be, stable. So, some patients never progress in their disease and remain kind of the same level of disease. But treating patients minimizes the development of the scar tissue, that affects the fallopian tubes in the ovary. So, we know that if a patient has endometriosis, and we treat the patient effectively, we can decrease the likelihood of infertility. So, it's not kind of a death and is to say, “You have endometriosis and therefore, you will be infertile.” We do know that treating endometriosis can minimize the likelihood of infertility down the line.
Dr. Mike Patrick: Yeah, and there's still other options for in vitro fertilization? I mean, it's infertility when you're trying to create a baby the natural way. But are there other things that can be done that's beyond the scope of this podcast, to help those folks who are experiencing infertility secondary to endometriosis.
Dr. Leslie Appiah: Correct. The definition of infertility is inability to conceive with continuous and timed intercourse over 12-month period. So, we know that if patients meet that definition because of endometriosis, there are still therapies that we can use to help them overcome their infertility. Yes.
Dr. Mike Patrick: What about ovarian cancer? Is there an association between endometriosis and ovarian cancer down the road?
Dr. Leslie Appiah: There is. There is an association between both endometrial cancer and ovarian cancer. We don't quite understand the mechanisms for the development of those types of cancer from endometriosis, but we do know that patients can go on to develop both endometrial cancer as well as ovarian cancer with endometriosis. And it's unclear whether treatment is going to decrease the likelihood of that. One can imagine if you're not developing menstrual tissue and it's inactive, then you're less likely to have a progression to malignancy. Similarly, when we stop the ovary from producing estrogen, we're also preventing ovulation. And we know that, ovarian cancer likelihood is increased with more ovulation that a patient has. So, just a treatment preventing ovulation, preventing estrogen production and keeping the lining of the endometrium inactive, is more likely going to prevent development of these cancers.
Dr. Mike Patrick: Yeah, it makes sense. Is there a way to prevent endometriosis from happening in the first place?
Dr. Leslie Appiah: Unfortunately, there is not. Again, it's multifactorial and polygenetic. We don't know and there's no way to prevent it. There's also no known association between lifestyle behaviors and exercise in terms of developing endometriosis. We do know that certain dietary changes and exercise can help minimize the pain that individuals experience. But in terms of preventing development of endometriosis, there is nothing that we know of that can prevent that.
Dr. Mike Patrick: And then, in terms of long-term outlook, sort of prognosis down the road years away. Is this something that these women continue to deal with their whole lives or does it kind of shut down at some point?
Dr. Leslie Appiah: Sure. So endometriosis is considered a chronic, life-long condition because the majority of patients will either maintain the same stay level of endometriosis or progress, if untreated. Endometriosis should improve with a menopause, because at that point we're no longer making estrogen. And therefore, not stimulating any endometrial and tissue to grow, and not stimulating the adhesion formation. We hope that most women don't suffer until the menopause. And so, treating the endometriosis is important until you reach that stage.
Dr. Mike Patrick: And you'd be an advocate for getting these kids into see pediatric and adolescent gynecology professional if they are having chronic abdominal pain. You know, as a primary care doc, you may try hormonal therapy. And if that helps their pain, fantastic. But if it's really not improving it completely, you really do want to make that referral sooner rather than later so you can get to the bottom of what's going on.
Dr. Leslie Appiah: Absolutely. So, the American College of Obstetrics and Gynecology recommends that all young girls see a gynecologist around the age of 13. And the purpose of that visit is to establish a relationship and so, that we can discuss some of these conditions that may be occurring that the patient thinks is normal. Her mother had painful menses, so she assumed she should. And so, this initial visit allows us to identify problems that have gone unidentified. I think it's important for parents and providers to hear that this visit does not involve a pelvic exam, it does not involve a specimen exam or something invasive about this first visit. It is an information gathering visit and an opportunity for us to educate girls about their growing bodies. For pediatricians and family practitioners who see these patients, we recommend that if a patient has been on an anti-inflammatory and or birth control pill for three months and is not improving significantly, then they need to be referred.
Dr. Mike Patrick: Yeah, that totally makes sense. And I love this significantly part. And when you put it that way, “Well, my mom had it, my grandma had it.” Don't look at this as a riddle passage, right? Just get help because we know more now.
Dr. Leslie Appiah: That's right. We know more now, thank you.
Dr. Mike Patrick: Yeah, absolutely. Tell us about pediatric and adolescent gynecology services here at Nationwide Children's. What are some of the other things that you folks treat?
Dr. Leslie Appiah: Sure. So, we have a comprehensive and amazing program Dr. Geri Hewitt, who's a division chief and has a done an amazing job in growing this division with over the last several years. Dr. Kate Mccracken, is our other partner who is extremely talented and sees a wide range of conditions. And we have an amazing addition to our team, Dana LeNoble, who is our nurse practitioner for pediatric and adolescent gynecology. She sees all of these patients, both as new visits and follow-up, to help us manage patient population. She also helps lead our endometriosis support group. So quarterly, we have a support group where we meet with patients and their families about their endometriosis and spend sometime with each group separately so that we can help them better understand their condition and how to cope with it.
And so, we see patients for all gynecologic concerns including, ovarian masses, uterine and vaginal abnormalities, we have a collaborative program with the colorectal team and the urology team in caring for children with abnormalities of the urinary reproductive and GI tract. So, cloacal abnormalities. We have a collaborative program with the endocrinology department in caring for patients with differences in development. So, XY differences in development. And so, we care for a spectrum of conditions, and we collaborate very well with other disciplines within the children's hospital.
Dr. Mike Patrick: Yeah, and the psychology services, especially as we're talking about chronic pain and anxiety and depression, those things that can go along with it. And of course, social work to help with any resources that families may need. So, I'd love all the multi-disciplinary approach and really getting folks the help they need in one place.
Dr. Leslie Appiah: Absolutely.
Dr. Mike Patrick: I've happened to see, a bunch of appointments.
Dr. Leslie Appiah: And to your point, the literature shows that patients will see seven to ten different providers, and there is a delay in up to five years from the time they present with abdominal or pelvic pain to diagnosis. And so, the purpose of our multi-disciplinary program here, is to streamline care for these patients. So once we see them, we quickly get to them into see other disciplines and then as a group, we care for these patients. Our physical therapist, Cristina Mansville, is amazing. She has additional training in pelvic floor PT and in patients with endometriosis. And so, every patient with pelvic pain sees Crissy, whether or not they have endometriosis because it is so beneficial. And I here patients say every single time that physical therapy has helped them tremendously. Our behavioral medicine team, is also intimately involved in our program because patients need to learn how to cope with this chronic illness.
When you say that you have endometriosis, that's a chronic illness. It changes how you relate to your family and friends. For your friends who don't have endometriosis, they couldn't possibly understand what you were experiencing. And so, part of that is being able to develop this coping mechanisms and learning ways to help educate your peers as to what you're going through. So, pelvic floor for physical therapy, the behavioral medicine team and then our chronic pain team. We want our patients to understand that narcotics are not the treatment for pelvic pain, and we want to use many different modalities to help with that pain whether it's biofeedback, tens units, different types of neuromodulator therapies. And so, we rely on all of these different disciplines to help us to care for these patients because it's multifactorial.
Dr. Mike Patrick: Yup, absolutely. In order for families and providers get in touch with you, I will put a link in the show notes to the Pediatric and Adolescent Gynecology Services at Nationwide Children's. That will be in the show notes for this episode 411 over pediacast.org. Just so folks can find you and get in touch, get those referrals and see you as quickly as possible. And then, you also wrote a blog post for 700 Children's Blog called, 'Not Your Typical Menstrual Pain: Endometriosis in Teens.' Very well-written and I'll put a link to that in the show notes as well so folks can take a look at it and share it with others in their own social media channels.
Dr. Leslie Appiah: Thank you, Dr. Mike. It's been my pleasure speaking with you, I feel as if we should make you our honorary gynecologist because you know so much about this topic, and we greatly appreciate you helping me to get the word out so young girls don't suffer needlessly with this condition.
Dr. Mike Patrick: Yeah, absolutely. Well, thank you Dr. Leslie Appiah. Thank you so much for stopping by today.
Dr. Leslie Appiah: Absolutely. Take care and have a great day.
Dr. Mike Patrick: We are back with just enough time to say thanks to all of you, for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guest this week, Dr. Leslie Appiah, with Pediatric and Adolescent Gynecology here at Nationwide Children's Hospital. Really appreciate her sharing her expertise with us on teenage endometriosis. Don't forget you can find PediaCast in all sorts of places. Maybe a place that's easier than where you found us today. We're in the Apple Podcast App, iTunes, Google Play, iHeartRadio, Spotify, and most other mobile podcast apps.
We're also part of Parents On Demand Network at parentsondemand.com, it's a collection of podcast for moms and dads and that collection does include PediaCast along with many other terrific podcasts for parents. One of the shows I enjoy listening to is the Parent Savers Podcast with hosts, Johner, Erin and KC. They're all seasoned parents and communicators. It's a round-table style show with expert guests, and they cover a variety of topics, in and quote, "Empowering New Parents", providing practical tips and preserving your sanity. Which is very important. Just some recent topics they've covered: internet safety, overexposing our kids and sharing of photo and stories online, that was with Detective Damian Jackson, law enforcement officer. So, if you think about how much do you let the internet know about your kids? That's what they talk about there. They also have shows about picky eaters, speech development, toddlers, baby rashes, baby names and baby name remorse. What do you do if you don't like the name you chose? And newborn screening test, that's another one. So, it's a terrific podcast, I highly recommend it. Again, that is the Parent Savers Podcast and I'll put a link to that in the show notes of this episode 411 over at pediacast.org.
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Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.