Adolescents and endometriosis: what research shows

Endometriosis is usually described as a condition of adults, yet many people report that their symptoms began in the teenage years, and studies of adolescents who have laparoscopy for pelvic pain find endometriosis in a large share of them. This article summarizes what research and guidelines say about how common endometriosis is in adolescents and young adults, how it tends to present, why diagnosis is often delayed, how it is assessed in this age group, and what is known about treatment results and long-term follow-up. Most of the evidence comes from specialty centers, small retrospective series and expert reviews, so the numbers describe selected groups of young people and cannot be applied to any one person.

Why this age group gets its own research

A 2024 narrative review in Obstetrics & Gynecology states that dysmenorrhea and pelvic pain often begin in adolescence and affect school, daily activities and relationships, that many adolescents experience suboptimal management and significant delay in diagnosis, and that symptoms, laparoscopic findings and treatments may differ from those in adults ^[18].

Most adolescents with painful periods have primary dysmenorrhea, defined by ACOG as painful menstruation without pelvic pathology, and ACOG describes endometriosis as the leading cause of secondary dysmenorrhea in adolescents ^[9]. ACOG also states that endometriosis in adolescents is considered a chronic disease with potential for progression if left untreated, and lists relief of symptoms, suppression of progression and protection of future fertility as goals of therapy ^[9]. As discussed below, the evidence on progression is limited.

An ACOG guideline on the diagnosis of endometriosis, published in 2026, says its recommendations also apply to adolescents unless otherwise specified, and that they rest on limited evidence, extrapolation from adult populations and expert consensus ^[10]. Much of what is applied to adolescents was learned in adults.

How common endometriosis is in adolescents

What "prevalence" means in these studies

There is no reliable figure for the share of all adolescents who have endometriosis. A 2017 review of adolescent endometriosis states that the exact prevalence is unknown, and a 2013 systematic review explains why: symptoms may be atypical, and endometriosis can only be diagnosed visually at laparoscopy, so researchers can only count it in young people who have had surgery ^[1][19]. Almost all published "prevalence" figures therefore describe the proportion of symptomatic adolescents who had laparoscopy and were found to have endometriosis. That proportion depends heavily on who was selected for surgery.

Systematic reviews of laparoscopy studies

A systematic review in Human Reproduction Update by Janssen and colleagues searched the literature from 1980 to 2011 and selected 15 studies ^[1]. Among 880 adolescent girls undergoing laparoscopic investigation, 62% (543 of 880) had visually confirmed endometriosis, with a range of 25% to 100% across studies ^[1]. The proportion was 75% (237 of 314) in girls with chronic pelvic pain resistant to treatment, 70% (102 of 146) in girls with dysmenorrhea, and 49% (204 of 420) in girls with chronic pelvic pain not necessarily resistant to treatment ^[1]. Moderate or severe disease was found in 32% (82 of 259) of those with endometriosis, and the authors state that prevalence or severity may be overestimated because of the quality of the included papers ^[1].

An update by Hirsch and colleagues covered 19 studies from 2011 to July 2019 including 1,243 symptomatic adolescents; of 1,011 who underwent laparoscopy, 648 (64%) had endometriosis, again with a range of 25% to 100% ^[2]. The wide range reflects small studies with different referral patterns and surgical thresholds. These are proportions among adolescents who were already candidates for surgery. They do not say how many teenagers with painful periods have endometriosis, and they should not be read as a risk for any individual.

Studies that used imaging instead of surgery

Two European imaging studies offer a different view, though both come from referral settings. In a retrospective study at a university hospital, 270 women aged 12 to 20 referred for pelvic ultrasound between 2014 and 2019 (transvaginal, or transrectal for those not yet sexually active) were assessed ^[20]. At least one ultrasound feature of endometriosis was identified in 36 (13.3%), rising to about 20% among those with dysmenorrhea; endometriomas were seen in 22 and deep infiltrating endometriosis in 10 ^[20].

In a prospective French study, 345 adolescents aged 12 to 20 with severe dysmenorrhea were referred for magnetic resonance imaging (MRI) between September 2019 and June 2020 ^[21]. Endometriosis was found in 39.3% (121) and adenomyosis in 11.4% (35); among the 121, 20.7% had endometriomas and 88.4% had deep infiltrating endometriosis ^[21]. The odds of finding endometriosis were higher in older groups (odds ratio 2.3 for ages 15 to 18 and 3.3 for ages 18 to 20, each compared with under 15), and pain scores were the same for those with and without endometriosis ^[21]. The two studies reached different percentages, and neither gives the prevalence in teenagers in general ^[20][21].

Stage and type of disease in adolescents who have surgery

Studies of adolescents who had surgery generally find mostly early-stage disease. In 86 adolescents and young women aged 22 or younger who had surgery at a US tertiary center, 76% had stage I or II disease and 23% had stage III or IV; among the 20 with advanced disease, ovarian endometriomas were the main finding (14 cases), and these women were slightly older (mean 20.4 versus 18.7 years) ^[12]. In a US series of 25 patients aged 21 or younger, 68% had stage I, 20% stage II and 12% stage III ^[6], and in a New Zealand cohort of 20 adolescents 85% had stage I or II and 15% stage III or IV ^[11]. All stages occur in this age group, with early stage most common among those who have surgery, and a cautious reading is that advanced disease is uncommon but possible.

How endometriosis presents in adolescents and young adults

Symptoms reported in cohort studies

A cross-sectional study within the Women's Health Study: From Adolescence to Adulthood compared 295 adolescents (diagnosed at 18 or younger) with 107 adults (diagnosed after 18), all with surgically confirmed endometriosis, recruited from two tertiary care centers and surrounding communities ^[3]. Most (90%) had moderate to severe menstrual pain ^[3]. More adolescents than adults reported pain starting at menarche (50% versus 33%) and nausea with pain (69% versus 53%) ^[3]. Noncyclic pelvic pain was common in both groups, and pain interfered with work or school, activities, exercise and sleep to a similar degree ^[3]. The authors concluded that symptoms did not differ much by age at diagnosis and advised clinicians to include endometriosis in the differential diagnosis for adolescent and young adult women with noncyclic pelvic pain and nausea ^[3]. Because everyone had surgery and was treated at tertiary centers, the study cannot show what symptoms look like in adolescents who have not had surgery ^[3].

A US series of 25 females aged 21 or younger reported dysmenorrhea (64%), menorrhagia (44%), abnormal or irregular uterine bleeding (60%), gastrointestinal symptoms (56%) and genitourinary symptoms (52%) ^[6]. A series of this size can describe but cannot compare ^[6].

Early menstrual history before diagnosis

A French cross-sectional study of 229 women operated on for endometriosis asked about adolescent history ^[22]. Women with histologically confirmed deep infiltrating endometriosis (98 of 229) more often had a family history of endometriosis (odds ratio 3.2), more school absenteeism during menstruation (odds ratio 1.7), and more oral contraceptive use for severe primary dysmenorrhea (odds ratio 4.5) ^[22]. An Australian case-control study of 268 women with moderate to severe endometriosis and 244 controls found that menarche after age 14 was inversely associated with endometriosis (odds ratio 0.3) and a history of dysmenorrhea was associated with it (odds ratio 2.6) ^[23]. Both designs look backward from a diagnosis, so they cannot say how many teenagers who miss school or take contraceptives for painful periods will later be diagnosed with endometriosis ^[22][23].

Appearance of lesions at surgery

ACOG states that endometriosis may look different in an adolescent than in an adult, with lesions typically clear or red and difficult to identify for gynecologists unfamiliar with the age group ^[9]. A 2020 update by Shim and Laufer likewise states that the appearance may differ, resulting in delayed recognition ^[24]. In a New Zealand cohort, atypical red vascular lesions were the main type in 60% (12 of 20) of adolescents and 20% (29 of 143) of non-adolescents ^[11]. The numbers are small and from a single hospital, so they describe that cohort only ^[11].

Dysmenorrhea is common, and most of it is not endometriosis

A systematic review and meta-analysis of 38 studies including 21,573 young women found a pooled prevalence of dysmenorrhea of 71.1%, with 20.1% reporting absence from school or university because of it and 40.9% reporting reduced concentration or classroom performance ^[25]. The studies came from both high-income and lower-income countries ^[25]. These data are about period pain overall and not about endometriosis. They show why painful periods in adolescence are common enough that distinguishing a secondary cause is difficult. ACOG says that most adolescents with dysmenorrhea have primary dysmenorrhea and that endometriosis should be considered when dysmenorrhea persists and is clinically significant despite treatment with hormonal agents and nonsteroidal antiinflammatory drugs (NSAIDs) ^[9]. ESHRE's 2022 guideline lists chronic or acyclical pelvic pain, particularly combined with nausea, dysmenorrhea, dyschezia, dysuria, dyspareunia and cyclical pelvic pain, as symptoms suggestive of endometriosis in adolescents, and rates this a strong recommendation based on very low-certainty evidence ^[8].

Quality of life

In a cross-sectional analysis of 567 participants younger than 25 (360 with endometriosis and 207 controls) from the Boston-area cohort, those with endometriosis had lower Short Form-36 scores: the physical component summary mean was 43.4 compared with 53.8 in controls, and the mental component summary mean was 43.3 compared with 46.3 ^[26]. Among cases, earlier menarche, more severe pelvic pain and a longer diagnostic delay were associated with poorer quality of life ^[26]. A cross-sectional design cannot show whether delay causes poorer quality of life or whether people with more severe disease both wait longer and feel worse ^[26]. A narrative review of life-course effects, based on a quasi-systematic literature review and expert opinion, notes that symptoms often begin at a time of life when many trajectory-defining decisions are made ^[27].

Diagnostic delay in adolescents and young adults

What the delay studies measure

Most delay studies measure the interval between a person's first reported symptom and a surgical or clinical diagnosis, usually reported by adults looking back, so recall and selection matter. A 2025 systematic review of 17 observational studies found reported times to diagnosis between 0.3 and 12 years, varying with the definition, country and population, and concluded that delay is primarily driven by physicians; the authors rated the evidence as ranging from poor to good quality ^[28].

Studies in adults that link teenage onset to longer delay

A Brazilian cohort study interviewed 200 women with surgically confirmed endometriosis at an outpatient clinic ^[4]. The median time from first symptoms to diagnosis was 7.0 years overall, 12.1 years in women aged 19 or younger at onset, and 3.3 years in women aged 30 or older ^[4]. A UK cross-sectional questionnaire study of 101 women at a specialist center found a median delay of 8 years and a negative correlation between age at symptom onset and delay (Spearman coefficient minus 0.63), and menstrual cramps in adolescence, normalization of pain and the attitudes of health professionals were associated with delayed diagnosis ^[29].

An Endometriosis Association survey of 4,334 women who reported a surgical diagnosis found that two thirds reported symptoms beginning during adolescence, and that these women waited longer to seek medical care than those whose symptoms began in adulthood ^[30]. Sometime before diagnosis, 63% were told that nothing was wrong with them, and those who first saw a gynecologist had a shorter time to diagnosis than those who first saw a generalist ^[30]. The survey relied on self-report from respondents to a patient organization, so it may not represent all patients ^[30].

In an Austrian and German questionnaire study of 171 women with histologically confirmed endometriosis, the median interval from symptom onset to diagnosis was 10.4 years and 74% had received at least one false diagnosis ^[5]. Misdiagnosis, a mother who considered menstruation a negative event, and patients' own normalization of dysmenorrhea were associated with a longer delay, and the authors note possible selection bias because only surgically treated patients were included ^[5]. A multicenter study across ten countries of 1,418 women aged 18 to 45 undergoing laparoscopy found a delay of 6.7 years, principally in primary care ^[7]. These were adults, so the study does not isolate the adolescent experience.

Studies of adolescents themselves

Adolescent cohorts generally report shorter intervals, which may partly reflect that the person has had fewer years since symptom onset. In the Boston cohort, time from symptoms to diagnosis averaged 2 years for adolescents and 5 years for adults (P less than .001), and participants had seen on average three doctors before diagnosis regardless of age ^[3]. In the US series of 25 young women, the mean time from onset to correct diagnosis was 22.8 months (range 1 to 132 months) and the median number of physicians seen was 3 ^[6]. A 2013 narrative article argued that laparoscopic diagnosis is almost always postponed by several years, that destructive lesions can develop meanwhile, and that delay is likely one reason for disease progression, without presenting new measurements ^[31]. A 2020 review states that normalization of dysmenorrhea contributes to delay ^[32].

How endometriosis is assessed in adolescents

History and examination

ESHRE's 2022 guideline has a section on adolescents ^[8]. It recommends that clinicians take a careful history for possible risk factors, such as a positive family history, obstructive genital malformations, early menarche or a short menstrual cycle (strong recommendation, very low-certainty evidence), and says clinicians may consider endometriosis in young women with cyclical school absenteeism or oral contraceptive use for dysmenorrhea (weak recommendation, very low-certainty evidence) ^[8]. For examination, adult recommendations can be applied in the absence of adolescent evidence, and the acceptability of vaginal or rectal examination should be discussed with the adolescent and her caregiver (good practice point) ^[8].

A screening questionnaire for adolescents has been proposed. Geysenbergh and colleagues selected six questions reported to predict endometriosis in adult questionnaires (age of menarche, cycle duration, dysmenorrhea, pain descriptors, dyschezia and urinary symptoms), but the abstract of their report does not describe testing the tool in adolescents ^[33].

Imaging

ESHRE recommends transvaginal ultrasound for adolescents in whom it is appropriate, because it is effective in diagnosing ovarian endometriosis, and says that if it is not appropriate, MRI or transabdominal, transperineal or transrectal scanning may be considered (strong recommendation, low-certainty evidence) ^[8]. A 2024 review of deep infiltrating endometriosis in adolescence likewise states that ultrasound should be considered the first-line imaging technique despite the possibility of missed early-stage disease, and that MRI may be preferred when ultrasound is not accepted ^[34].

A 2026 scoping review of imaging in people aged 14 to 25 identified 35 evidence sources, nine of them primary studies ^[35]. It reported that the primary evidence was limited, heterogeneous and mostly specialist-based, that findings were most consistent for ovarian endometrioma and posterior deep endometriosis, that superficial disease was poorly captured, and that normal imaging remained common in symptomatic cohorts ^[35]. Its authors state that negative imaging should not be interpreted as excluding endometriosis, particularly superficial disease, when symptoms persist ^[35]. The two cohort studies described earlier illustrate the point: 13.3% of 270 and 39.3% of 345 referred adolescents had imaging features of endometriosis, so many symptomatic adolescents had none ^[20][21].

Blood tests

ESHRE states that serum biomarkers such as CA-125 are not recommended for diagnosing or ruling out endometriosis in adolescents (strong recommendation, low-certainty evidence) ^[8].

Laparoscopy and histology

ESHRE states that in adolescents with suspected endometriosis in whom imaging is negative and treatment with NSAIDs or hormonal contraceptives has not been successful, diagnostic laparoscopy may be considered (weak recommendation, low-certainty evidence) ^[8]. If laparoscopy is done, clinicians should consider taking biopsies, although negative histology does not entirely rule out the disease ^[8]. ACOG's 2018 opinion says that if dysmenorrhea has not improved within 3 to 6 months of starting therapy, the clinician should investigate for secondary causes and for treatment adherence ^[9].

The distinctions between reported symptoms, clinical assessment, imaging, surgical findings and pathology carry particular weight here. A person can have a history suggestive of endometriosis with normal imaging, and a surgeon can see lesions that look different from those in adults ^[9][35]. Each is a different kind of evidence, and the guidelines treat them as separate steps ^[8].

What guidelines say about adolescents

Two professional documents address adolescents directly. ACOG Committee Opinion No. 760 (2018) states that when the history suggests primary dysmenorrhea, empiric treatment should be initiated, and that therapy for endometriosis must be individualized to patient choice, the need for contraception, contraindications to hormone use and adverse effects ^[9].

The ESHRE guideline (2022) gives 109 recommendations overall, including a chapter on adolescents ^[8]. For severe dysmenorrhea or endometriosis-associated pain it recommends hormonal contraceptives or progestogens as first-line hormone therapy, while noting that some progestogens may decrease bone mineral density (strong recommendation, very low-certainty evidence), and it suggests that clinicians consider NSAIDs (good practice point) ^[8]. In adolescents with laparoscopically confirmed endometriosis in whom those therapies failed, clinicians may consider GnRH agonists for up to 1 year with add-back therapy, after discussion of side effects and long-term risks in a secondary or tertiary care setting (weak recommendation, low-certainty evidence) ^[8]. On surgery, it says clinicians may consider removal of lesions, but that recurrence rates may be considerable, especially without hormone treatment afterward (weak recommendation, very low-certainty evidence), and that postoperative hormone therapy should be considered (strong recommendation, very low-certainty evidence) ^[8]. It also recommends that adolescents be told about the possible effect of ovarian endometriosis and surgery on ovarian reserve and about fertility preservation options, while stating that the true benefit and indications in adolescents remain unknown ^[8].

A 2020 review describes a similar sequence ^[32]. A 2017 review states that there is no consensus on whether surgery should be avoided as much as possible to prevent multiple operations, or considered early before more severe lesions develop, and that further research is needed to determine which approach offers a better long-term outcome ^[19]. That is a plain statement of uncertainty from the research literature. Even the "strong" ESHRE recommendations for adolescents are often built on low or very low certainty evidence ^[8].

What studies show about treatment outcomes

First-line medicines for painful periods

Most of the randomized evidence in adolescents concerns dysmenorrhea, not confirmed endometriosis. A placebo-controlled trial of 76 healthy adolescents aged 19 or younger with moderate or severe dysmenorrhea compared a low-dose oral contraceptive with placebo for 3 months ^[36]. The pain score was lower with the contraceptive (3.1 versus 5.8, P = .004), and these participants used fewer pain medications ^[36]. The trial did not test for endometriosis and lasted three cycles ^[36].

A Cochrane review of 80 randomized trials (5,820 women) of NSAIDs for primary dysmenorrhea found them more effective than placebo for pain relief (odds ratio 4.37) but associated with more adverse effects, with evidence rated low quality for most comparisons ^[37]. A Cochrane review of combined oral contraceptives for primary dysmenorrhea included 10 trials and concluded that evidence for pain improvement was limited ^[38]. These reviews concern primary dysmenorrhea in women of various ages and cannot be applied directly to endometriosis pain ^[37][38].

Progestogen and bone health in adolescents

The VISanne study was a 52-week open-label, single-arm study in 6 European countries of dienogest 2 mg daily in adolescents aged 12 to under 18 with clinically suspected or laparoscopically confirmed endometriosis ^[15]. Of 111 patients analyzed, 97 (87.4%) completed it ^[15]. Mean lumbar spine bone mineral density fell by 1.2% from baseline at the end of treatment, with partial recovery 6 months later in the subgroup with decreased density, while the pain score fell from 64.3 mm to 9.0 mm on a visual analog scale by week 48 ^[15]. The authors noted that bone accretion is critical in adolescence and that treatment should be tailored to expected pain relief and individual osteoporosis risk factors ^[15]. With no control group, the study cannot separate the drug's effect from natural changes in pain over time ^[15].

GnRH agonists with add-back therapy

A randomized, double-blind trial from Boston assigned 51 adolescents and young women on a GnRH agonist to add-back with norethindrone acetate plus conjugated equine estrogens or norethindrone acetate plus placebo for 12 months; 34 completed it ^[16]. Bone mineral content and density increased in the combined group but not in the other, and physical functioning improved more with the combination, with no significant adverse events reported ^[16]. The trial compared two add-back regimens, not add-back against none ^[16].

A questionnaire sent in 2016 to the same group gives a longer view ^[17]. Of 41 participants who could be located, 25 responded; almost all (24 of 25) reported side effects during treatment, 80% (16 of 21) reported side effects lasting longer than 6 months after stopping, and almost half (9 of 20) reported side effects they considered irreversible, including memory loss, insomnia and hot flashes, yet two thirds (16 of 25) would recommend the treatment ^[17]. Only part of the group answered, and responders may differ from non-responders ^[17]. A chart review of the same 51 participants found that 45% continued GnRH agonist with add-back beyond the 12-month trial, for an average of 31.7 additional months ^[39].

Surgery and combined treatment

Results after surgery come from case series and cohort studies. In a New Zealand cohort of 20 adolescents followed for a mean of 2.6 years after laparoscopic excision, pain scores for dysmenorrhea and pelvic pain fell significantly and quality of life improved ^[11]. In a US series of 25 adolescents followed for one year after surgery, 64% reported resolved pain, 16% improved pain, 12% continued pain and 8% recurrent pain ^[6]. Both studies were small, had no comparison group, and relied on patients' own reports ^[6][11].

Long-term follow-up, progression and recurrence

Does endometriosis progress?

Evidence on progression in adolescents is limited and conflicting. A review states that spontaneous resolution is possible, that recent reports suggest adolescent endometriosis can be progressive in at least a significant proportion, and that deep endometriosis is claimed to have its roots in adolescence; these are statements of possibility, not measured rates ^[19].

A case series of three adolescents aged 13 to 16 with stage I disease who did not continue suppressive therapy reported a higher stage at a second laparoscopy in each ^[40]. A retrospective review of 90 patients aged 12 to 24 compared stage at a second laparoscopy after surgery and continuous medical therapy: no change in 70%, improvement in 20% and worsening by one stage in 10% ^[41]. Only patients whose pain worsened and who chose a second operation were included, and there was no untreated comparison group, so the study cannot show that treatment slowed progression, although the authors suggested so ^[41]. These small studies describe a plausible concern, not a measured natural history ^[40][41]. In the MRI study described earlier, odds of endometriosis rose with age, but a cross-sectional study cannot follow individuals across ages, and the pattern could reflect referral and selection ^[21].

Recurrence after surgery

A retrospective cohort at an Italian tertiary center followed 57 women aged 21 or younger (mean age 19.0 years) after first-line conservative surgery ^[13]. Over 5 years, 32 (56%, 95% confidence interval 43% to 68%) had a recurrence; 11 had a second laparoscopy that confirmed disease, and in the other 21 recurrence rested on symptoms or clinical or sonographic findings ^[13]. No association was found with symptoms, stage, type of surgery or postoperative medical treatment ^[13]. The authors state that recurrence appears higher than in older women, and the abstract does not describe a concurrent older comparison group ^[13].

A multicenter Korean study of 105 patients younger than 20 who had laparoscopic enucleation of endometriomas found recurrence in 16.2% over a mean follow-up of 47.3 months, with cumulative rates of 6.4% at 24 months, 19.9% at 60 months and 30.9% at 96 months ^[14]. A single-center Korean cohort compared 34 adolescents with 142 women aged 25 to 35 who had endometrioma surgery followed by a GnRH agonist for 3 to 6 months and then cyclic oral contraceptives; cumulative recurrence at 60 months was comparable (5.3% and 8.5%) ^[42]. Recurrence in the Korean studies meant endometrioma on ultrasound, whereas the Italian series also counted symptoms, so the percentages cannot be compared directly ^[13][14][42]. Overall, recurrence is reported after surgery in young people, and rates rise as follow-up lengthens ^[13][14].

What long-term follow-up data exist beyond recurrence

Few studies follow adolescents with endometriosis into later adulthood. The longest follow-up periods among those summarized here are up to 6 years in the New Zealand cohort ^[11], 5 years in the Italian series ^[13], up to 161 months in a Korean cohort ^[14], and a 2016 questionnaire to people who had joined a trial between 2008 and 2012 ^[17]. In the abstracts reviewed for this article, none reports lifetime outcomes for people diagnosed in adolescence, such as cumulative pregnancy or live birth rates or pain trajectories over decades. This is a gap in the research and says nothing about what any individual should expect.

What this does not tell you

This article summarizes published research. It does not say whether any person, teenage or adult, has endometriosis, adenomyosis or any other condition, and it does not recommend a test, a treatment or a time to seek care.

Prevalence figures describe adolescents who were referred, scanned or operated on, and they cannot be turned into a probability for an individual ^{[1][2][20][21]}. The symptom lists in guidelines come from studies of people who already had a diagnosis, and many adolescents with the same symptoms have primary dysmenorrhea or another cause ^[8][9][25]. Normal imaging does not rule endometriosis out, and abnormal imaging is not a diagnosis by itself ^[35].

Delay figures are mostly reported by adults looking back, and they vary by country, health system and definition ^[7][28]. Treatment results come largely from small, uncontrolled series and describe what happened to selected patients, not what a treatment will do for another person ^{[6][11][13][14][15]}. Studies also differ in how they define adolescence, endometriosis and recurrence ^{[3][13][14][21][35]}. Evidence on progression is limited and in part conflicting ^[19][41], and data on lifelong outcomes for people diagnosed in adolescence, including fertility, are sparse.

The guidelines cited here are written for clinicians and rest largely on low-certainty evidence and expert consensus ^[8][10]. They are not instructions for parents or teenagers, and this article does not provide any.

References

1. Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D'Hooghe TM. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update. 2013;19(5):570-82. doi:10.1093/humupd/dmt016. PMID 23727940.
2. Hirsch M, Dhillon-Smith R, Cutner AS, Yap M, Creighton SM. The Prevalence of Endometriosis in Adolescents with Pelvic Pain: A Systematic Review. J Pediatr Adolesc Gynecol. 2020;33(6):623-630. doi:10.1016/j.jpag.2020.07.011. PMID 32736134.
3. DiVasta AD, Vitonis AF, Laufer MR, Missmer SA. Spectrum of symptoms in women diagnosed with endometriosis during adolescence vs adulthood. Am J Obstet Gynecol. 2018;218(3):324.e1-324.e11. doi:10.1016/j.ajog.2017.12.007. PMID 29247637.
4. Arruda MS, Petta CA, Abrão MS, Benetti-Pinto CL. Time elapsed from onset of symptoms to diagnosis of endometriosis in a cohort study of Brazilian women. Hum Reprod. 2003;18(4):756-9. doi:10.1093/humrep/deg136. PMID 12660267.
5. Hudelist G, Fritzer N, Thomas A, Niehues C, Oppelt P, Haas D, et al. Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences. Hum Reprod. 2012;27(12):3412-6. doi:10.1093/humrep/des316. PMID 22990516.
6. Dun EC, Kho KA, Morozov VV, Kearney S, Zurawin JL, Nezhat CH. Endometriosis in adolescents. JSLS. 2015;19(2). doi:10.4293/JSLS.2015.00019. PMID 26005317.
7. Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011;96(2):366-373.e8. doi:10.1016/j.fertnstert.2011.05.090. PMID 21718982.
8. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022(2):hoac009. doi:10.1093/hropen/hoac009. PMID 35350465.
9. American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol. 2018;132(6):e249-e258. doi:10.1097/AOG.0000000000002978. PMID 30461694.
10. ACOG Committee on Clinical Practice Guidelines-Gynecology. Diagnosis of Endometriosis. Obstet Gynecol. 2026;147(3):432-448. doi:10.1097/AOG.0000000000006181. PMID 41712950.
11. Roman JD. Adolescent endometriosis in the Waikato region of New Zealand--a comparative cohort study with a mean follow-up time of 2.6 years. Aust N Z J Obstet Gynaecol. 2010;50(2):179-83. doi:10.1111/j.1479-828X.2010.01141.x. PMID 20522077.
12. Smorgick N, As-Sanie S, Marsh CA, Smith YR, Quint EH. Advanced stage endometriosis in adolescents and young women. J Pediatr Adolesc Gynecol. 2014;27(6):320-3. doi:10.1016/j.jpag.2013.12.010. PMID 25256880.
13. Tandoi I, Somigliana E, Riparini J, Ronzoni S, Vigano' P, Candiani M. High rate of endometriosis recurrence in young women. J Pediatr Adolesc Gynecol. 2011;24(6):376-9. doi:10.1016/j.jpag.2011.06.012. PMID 21906976.
14. Lee SY, Kim ML, Seong SJ, Bae JW, Cho YJ. Recurrence of Ovarian Endometrioma in Adolescents after Conservative, Laparoscopic Cyst Enucleation. J Pediatr Adolesc Gynecol. 2017;30(2):228-233. doi:10.1016/j.jpag.2015.11.001. PMID 26612115.
15. Ebert AD, Dong L, Merz M, Kirsch B, Francuski M, Böttcher B, et al. Dienogest 2 mg Daily in the Treatment of Adolescents with Clinically Suspected Endometriosis: The VISanne Study to Assess Safety in ADOlescents. J Pediatr Adolesc Gynecol. 2017;30(5):560-567. doi:10.1016/j.jpag.2017.01.014. PMID 28189702.
16. DiVasta AD, Feldman HA, Sadler Gallagher J, Stokes NA, Laufer MR, Hornstein MD, et al. Hormonal Add-Back Therapy for Females Treated With Gonadotropin-Releasing Hormone Agonist for Endometriosis: A Randomized Controlled Trial. Obstet Gynecol. 2015;126(3):617-627. doi:10.1097/AOG.0000000000000964. PMID 26181088.
17. Gallagher JS, Missmer SA, Hornstein MD, Laufer MR, Gordon CM, DiVasta AD. Long-Term Effects of Gonadotropin-Releasing Hormone Agonists and Add-Back in Adolescent Endometriosis. J Pediatr Adolesc Gynecol. 2018;31(4):376-381. doi:10.1016/j.jpag.2018.03.004. PMID 29551430.
18. Shim JY, Laufer MR, King CR, Lee TTM, Einarsson JI, Tyson N. Evaluation and Management of Endometriosis in the Adolescent. Obstet Gynecol. 2024;143(1):44-51. doi:10.1097/AOG.0000000000005448. PMID 37944153.
19. Sarıdoğan E. Adolescent endometriosis. Eur J Obstet Gynecol Reprod Biol. 2017;209:46-49. doi:10.1016/j.ejogrb.2016.05.019. PMID 27342684.
20. Martire FG, Lazzeri L, Conway F, Siciliano T, Pietropolli A, Piccione E, et al. Adolescence and endometriosis: symptoms, ultrasound signs and early diagnosis. Fertil Steril. 2020;114(5):1049-1057. doi:10.1016/j.fertnstert.2020.06.012. PMID 33036795.
21. Millischer AE, Santulli P, Da Costa S, Bordonne C, Cazaubon E, Marcellin L, et al. Adolescent endometriosis: prevalence increases with age on magnetic resonance imaging scan. Fertil Steril. 2023;119(4):626-633. doi:10.1016/j.fertnstert.2022.12.039. PMID 36592649.
22. Chapron C, Lafay-Pillet MC, Monceau E, Borghese B, Ngô C, Souza C, et al. Questioning patients about their adolescent history can identify markers associated with deep infiltrating endometriosis. Fertil Steril. 2011;95(3):877-81. doi:10.1016/j.fertnstert.2010.10.027. PMID 21071024.
23. Treloar SA, Bell TA, Nagle CM, Purdie DM, Green AC. Early menstrual characteristics associated with subsequent diagnosis of endometriosis. Am J Obstet Gynecol. 2010;202(6):534.e1-6. doi:10.1016/j.ajog.2009.10.857. PMID 20022587.
24. Shim JY, Laufer MR. Adolescent Endometriosis: An Update. J Pediatr Adolesc Gynecol. 2020;33(2):112-119. doi:10.1016/j.jpag.2019.11.011. PMID 31812704.
25. Armour M, Parry K, Manohar N, Holmes K, Ferfolja T, Curry C, et al. The Prevalence and Academic Impact of Dysmenorrhea in 21,573 Young Women: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt). 2019;28(8):1161-1171. doi:10.1089/jwh.2018.7615. PMID 31170024.
26. Gallagher JS, DiVasta AD, Vitonis AF, Sarda V, Laufer MR, Missmer SA. The Impact of Endometriosis on Quality of Life in Adolescents. J Adolesc Health. 2018;63(6):766-772. doi:10.1016/j.jadohealth.2018.06.027. PMID 30454733.
27. Missmer SA, Tu FF, Agarwal SK, Chapron C, Soliman AM, Chiuve S, et al. Impact of Endometriosis on Life-Course Potential: A Narrative Review. Int J Gen Med. 2021;14:9-25. doi:10.2147/IJGM.S261139. PMID 33442286.
28. De Corte P, Klinghardt M, von Stockum S, Heinemann K. Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics-A Systematic Literature Review. BJOG. 2025;132(2):118-130. doi:10.1111/1471-0528.17973. PMID 39373298.
29. Ghai V, Jan H, Shakir F, Haines P, Kent A. Diagnostic delay for superficial and deep endometriosis in the United Kingdom. J Obstet Gynaecol. 2020;40(1):83-89. doi:10.1080/01443615.2019.1603217. PMID 31328629.
30. Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaii N. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril. 2009;91(1):32-9. doi:10.1016/j.fertnstert.2007.11.020. PMID 18367178.
31. Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod. 2013;28(8):2026-31. doi:10.1093/humrep/det243. PMID 23739215.
32. Sachedina A, Todd N. Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents. J Clin Res Pediatr Endocrinol. 2020;12(Suppl 1):7-17. doi:10.4274/jcrpe.galenos.2019.2019.S0217. PMID 32041388.
33. Geysenbergh B, Dancet EAF, D'Hooghe T. Detecting Endometriosis in Adolescents: Why Not Start from Self-Report Screening Questionnaires for Adult Women?. Gynecol Obstet Invest. 2017;82(4):322-328. doi:10.1159/000452098. PMID 27816976.
34. Martire FG, Giorgi M, D'Abate C, Colombi I, Ginetti A, Cannoni A, et al. Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression. J Clin Med. 2024;13(2). doi:10.3390/jcm13020550. PMID 38256683.
35. Maple S, Hosking RE, Zhang Y, Deslandes A, Hull ML, Avery JC. Diagnosing endometriosis in adolescents using ultrasound and MRI: A scoping review of imaging approach and implementation considerations. Radiography (Lond). 2026;32(7):103579. doi:10.1016/j.radi.2026.103579. PMID 42833036.
36. Davis AR, Westhoff C, O'Connell K, Gallagher N. Oral contraceptives for dysmenorrhea in adolescent girls: a randomized trial. Obstet Gynecol. 2005;106(1):97-104. doi:10.1097/01.AOG.0000165826.03915.65. PMID 15994623.
37. Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015;2015(7):CD001751. doi:10.1002/14651858.CD001751.pub3. PMID 26224322.
38. Wong CL, Farquhar C, Roberts H, Proctor M. Oral contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev. 2009;2009(4):CD002120. doi:10.1002/14651858.CD002120.pub3. PMID 19821293.
39. Shim JY, Laufer MR, DiVasta AD. Treatment of Adolescent Endometriosis Before, During, and After Use of Gonadotropin-Releasing Hormone Agonists: A Retrospective Cohort Study. J Pediatr Adolesc Gynecol. 2023;36(5):472-475. doi:10.1016/j.jpag.2023.05.001. PMID 37178784.
40. Unger CA, Laufer MR. Progression of endometriosis in non-medically managed adolescents: a case series. J Pediatr Adolesc Gynecol. 2011;24(2):e21-3. doi:10.1016/j.jpag.2010.08.002. PMID 21126894.
41. Doyle JO, Missmer SA, Laufer MR. The effect of combined surgical-medical intervention on the progression of endometriosis in an adolescent and young adult population. J Pediatr Adolesc Gynecol. 2009;22(4):257-63. doi:10.1016/j.jpag.2008.11.003. PMID 19646673.
42. Seo JW, Lee DY, Yoon BK, Choi D. The Efficacy of Postoperative Cyclic Oral Contraceptives after Gonadotropin-Releasing Hormone Agonist Therapy to Prevent Endometrioma Recurrence in Adolescents. J Pediatr Adolesc Gynecol. 2017;30(2):223-227. doi:10.1016/j.jpag.2016.10.004. PMID 27744096.