Background: Endometriosis was formerly described as caucasian disease; with the practice of laparoscopic surgery in Africa it has been shown to concern also Black women.

Objective: To share with the researchers and clinicians a case of pelvic endometriosis in a black virgin adolescent in sub-Saharan Africa’s setting.

Case: Adolescent girl, 20 years old, virgin, managed for chronic pelvic pain with, nonsteroidal anti-inflammatory drugs, combine oral contraceptives, paracetamol and tramadol for eight months with no regression of symptoms. Laparoscopic surgery was used to diagnose and remove endometriotic tissue. Then the administration of a GnRh agonist associated with an add-back therapy permitted effective treatment of the patient.

Conclusion: Pelvic endometriosis exist in black adolescent girls in sub-saharan Africa, and must be excluded in all cases of chronic pelvic pain resistant to nonsteroidal anti-inflammatory drugs, paracetamol, combined oral contraceptives and tramadol.

Keywords: Endometriosis, Adolescent, Sub-saharan Africa

INTRODUCTION

Pelvic endometriosis, long considered a pathology of the Caucasian population, has also been shown to affect black women thanks to the popularization of endoscopy in sub-Saharan Africa over the past 20 years [1]. This pathology is characterized by the existence of endometriotic glandular and stromal tissue in an ectopic area [2]. Long considered a pathology for adult women, literature has proven for at least 2 decades that it is also present in adolescents, in the Caucasian population [3,4]. In presenting this clinical case we would like to share with the medical scientific community the existence of endometriosis in adolescent black girls in sub-Saharan Africa.

CASE

We are reporting a case of adolescent girl of 20 years old, nulligravid who consulted in the gynecology department of the Douala General Hospital (HGD) for chronic pelvic pain of 8 months duration, regardless of the period of the menstrual cycle, of greater intensity (quoted 8/10 on a visual analog scale [5] ) during menstruation, without improvement on antispasmodics, paracetamol, non-steroidal anti inflammatory drugs ( NSAIDs) and tramadol. Gynecological past history revealed menarche at 13 years, a regular menstrual cycle and no coitarche.

She never had a laparotomy. Her general state was good, the abdomen was soft and we did not palpate any mass. The vulva was normal, the hymen was present and the penetration of a cotton swab made it possible to verify the absence of a vaginal 

septum, agenesis of the vagina and stenosis of the cervix; digital rectal examination identified a free and non-tender rectovaginal wall and posterior cul de sac; pelvic ultrasound was normal. We sought the opinion of the gastroenterologist and the digestive surgeon who requested the following examinations (Full blood count, C Reactive Protein, Abdominal ultrasound, Stool examination) whose results were normal. MRI could not be performed because the machine was not functionning. Therefore, we suspected pelvic endometriosis : however after 3 months of monophasic low dose estrogen-progestin pill (Levonorgestrel 0.150 mg and Ethinyl oestradiol 0.030 mg) (MLOP) no improvement was observed. Hence the decision for a laparoscopy for diagnostic and possibly therapeutic purposes. After informed consent  from the patient and her parents on the importance of laparoscopy, followed by a conclusive anesthetic consultation, the operative findings were essentially: a normal but soft and hypervascularized uterus suggestive of adenomyosis; normal appendices; a hematocele of about 150 ml of dark red blood; endometriotic lesions in the pouch of douglas, uterosacral ligament and pelvic peritoneum, consisting of red, white, vesicular micronodules (from 02 to 04 mm); type A left ovaro-peritoneal adhesion [6] (Figure 1). The lesions were classified stage I [7]. The surgical procedures consisted mainly of: Biopsies of the lesions described above for histopathological analysis, aspiration of the hematocele, cauterization of residual micronodules, adhesiolysis and pelvic lavage with Ringer lactate. She came out at the 18^th hour post-operation on MLOP and Celecoxib:100 mg every 12 h during 10 days. She returned for consultation on the 14^th day post-operation with the result of the biopsy analysis which confirmed endometriosis; however, the pelvic pain persisted. Hence, we prescribed a GnRH agonist (Triptorelin LP 3 mg) 3 mg IM / month for 3 months in addition to the MLOP in Add back therapy. This led to a 6-month amenorrhea after the first injection and then return to a normal menstrual cycle. The patient was re-evaluated every 3 months for the two years following the surgery, a period marked by the complete regression of the pain.

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