{"paper_id":"6ede4dba-238c-4490-9f6c-52384ed8fdad","body_text":"REVIEW\nAbdominal Radiology (2025) 50:4844–4853\nhttps://doi.org/10.1007/s00261-025-04870-7\nExtended author information available on the last page of the article\nAbstract\nEndometriosis is a gynecologic disorder characterized by endometrial-like tissue in ectopic locations, outside of the uterine \ncavity. In the adolescent population, the diagnosis of endometriosis is often overlooked as a cause of pelvic pain because \nof limited awareness by both patients and providers and a tendency to undervalue the complaints of pain by both families \nand caregivers. Although historically diagnosed by laparoscopy, there has been a shift in recent years towards imaging \ndiagnosis. Transvaginal ultrasound is considered the first-line imaging technique for endometriosis in the adult population; \nhowever, this minimally invasive procedure is commonly avoided in adolescents, with MRI often used instead. Here, we \ndiscuss the clinical presentation and imaging considerations and treatment options involved in adolescents with suspected \nendometriosis.\nGraphical abstract \nKeywords Endometriosis · Adolescent endometriosis · MRI endometriosis · US endometriosis · Deep endometriosis\nReceived: 24 December 2024 / Revised: 28 February 2025 / Accepted: 2 March 2025 / Published online: 21 March 2025\n© The Author(s) 2025\nAdolescent endometriosis: clinical insights and imaging \nconsiderations\nBrooke S. Lampl1 · Cara R. King2 · Marjan Attaran2 · Myra K. Feldman1\n1 3\n\nAbdominal Radiology (2025) 50:4844–4853\nIntroduction\nEndometriosis is a gynecologic disorder in which endo -\nmetrial-like tissue is found outside the uterine lining, often \nassociated with inflammation [1]. The clinical presentation \nis variable, with pelvic pain comprising the most frequent \nsymptom across all age groups. In the adolescent popula -\ntion, endometriosis is often overlooked as a cause of pel -\nvic pain because of limited awareness by caregivers as well \nas a confusing clinical picture, where patients may pres -\nent with cyclical and acyclical pain. This combination of \nfactors may lead to a delay in diagnosis, which can have \nconsiderable clinical implications, such as persistent pain, \ncentral sensitization, and potential infertility. Adolescents, \ngenerally considered between the ages of 10 and 19 years, \nare a unique patient cohort in that they have started puberty \nbut are not yet adults. The adolescent population may feel \nuncomfortable discussing symptoms or may consider their \nsymptoms normal. Additionally, adolescents are more likely \nthan previously thought to develop deep endometriosis, a \nsevere form of endometriosis involving tissues below the \nperitoneum.\nAlthough the diagnosis of endometriosis in adults is often \nconfirmed by laparoscopy, there has been increased empha-\nsis on diagnosis and surgical planning via imaging in recent \nyears [2]. In the adult population, transvaginal ultrasound \nis considered the first-line imaging technique for clinically \nsuspected endometriosis, with magnetic resonance imaging \n(MRI) reserved as a second-line imaging study to confirm \nthe diagnosis and for treatment planning [ 3]. In contrast, \nin the adolescent population, transabdominal ultrasound \nis the first-line imaging technique for pelvic pain. Many \nadolescents who are not sexually active may feel uncom -\nfortable undergoing transvaginal ultrasound, although it \nis not contraindicated in the nonsexually active patient. A \ntransabdominal ultrasound can be helpful for the identifica-\ntion of ovarian endometriomas but has a limited role in the \nevaluation of deep pelvic endometriosis. Therefore, in these \npatients, MRI is playing an increasingly important role in \ndiagnosis [4, 5]. This paper discusses the nuances associ -\nated with the clinical and imaging diagnosis of suspected \nendometriosis in adolescents.\nPresentation\nEndometriosis is a chronic condition in which ectopic endo-\nmetrial glands and stroma are found outside of the uterus. \nIt is the most common cause of secondary dysmenorrhea \nin adolescents. In a review by Janssen et al. [ 6], 70% of \nadolescents undergoing laparoscopy for dysmenorrhea \nunresponsive to nonsteroidal anti-inflammatory drugs \nand suppressive hormone therapy were diagnosed with \nendometriosis.\nEndometriosis can present with a broad spectrum of \nsymptoms. Classically, the adult patient experiences severe \ndysmenorrhea associated with luteal phase symptoms of \npelvic pain. However, patients can have symptoms ranging \nfrom chronic daily pain to dyspareunia, cyclic bowel and \nbladder symptoms, and infertility. In adolescents, noncyclic \npain or pain between periods is a common complaint. In \none retrospective study, more than 90% of adolescents with \nendometriosis complained of acyclic pain, and 62% com -\nplained of both acyclic and cyclic pain [7]. Other symptoms \nmay include irregular heavy periods, dyspareunia, and nau-\nsea. Adolescents and young adults less than 24 years of age \nare far more likely to report higher pain scores than older \npatients [8].\nDiagnostic delay\nDiagnostic delay is common in adolescents and is driven \nby factors involving patients and clinicians. Of note, ado -\nlescents wait three times longer than adults to seek medi -\ncal care [ 9]. Many factors lead to adolescents normalizing \nthe degree of pain they are experiencing. Young adolescents \noften experience embarrassment and will not commonly \nshare information about their periods with family or friends. \nThey do not realize that the degree of pain they are expe -\nriencing is abnormal and are led to believe that menstrual \ncramps are an expected part of the menstrual cycle through \nsocietal norms. When clinicians obtain a medical history \nfrom an adolescent, it is important to determine the extent \nto which this pain is interfering with school and extracur -\nricular activities, as absenteeism is noted to be much higher \nin adolescents with endometriosis [ 8]. Their quality of life \nis dramatically impacted, leading to poor socialization and \nconcern for isolation at a particularly vulnerable time of \ntheir lives. Adolescents with endometriosis are more likely \nto report mental health issues such as anxiety and depres -\nsion, the use of pain medications, and the avoidance of exer-\ncise [10].\nClinicians are less likely to consider a diagnosis of endo-\nmetriosis in adolescents than in adults. The difference in \nclinical presentation and lack of specific findings on pelvic \nexamination and ultrasound often mislead the clinician. \nThe pelvic examination in adolescents with endometriosis \nis often relatively benign compared to the pelvic examina -\ntion in adults with endometriosis, which is more likely to \nreveal a pelvic mass or nodularity. Additionally, the com -\nmon site of disease, the posterior cul-de-sac and uterosacral \nligaments, can be challenging to evaluate on physical exam, \nparticularly in patients who have not been sexually active. \nThus, clinicians are less likely to order pelvic ultrasound \n1 3\n4845\n\nAbdominal Radiology (2025) 50:4844–4853\nexaminations for adolescents and are more reluctant to rec -\nommend diagnostic laparoscopy, which could be perceived \nas a relatively aggressive diagnostic measure in such young \nindividuals. However, laparoscopy is paramount for diag -\nnosis in this population, as most endometriosis lesions in \nthese patients are superficial and not likely to be noted via \nimaging studies. In addition, endometriosis lesions in ado -\nlescents often do not have the classic powder-burn, black or \nbrown endometrial tissue, on direct visualization by lapa -\nroscopy and therefore can easily be missed by Gynecologic \nsurgeons. These atypical lesions, often presenting as clear, \nwhite, or small hemorrhagic lesions, produce high levels of \nprostaglandins and substantial pain [8, 11].\nDiagnostic imaging considerations\nThe need for imaging should be determined by both his -\ntory and physical examination, as imaging is not routinely \nneeded in a patient with mild dysmenorrhea. Evaluation \nof the adolescent with symptoms of endometriosis should \nbegin with a detailed history regarding the type and loca -\ntion of pain, cyclic association, a positive family history of \nendometriosis, a history of obstructive genital malforma -\ntions, early menarche, short menstrual cycles, and the use \nof contraceptives to treat severe dysmenorrhea, as well as \ninciting factors [11, 12].\nStandard imaging evaluation for the adolescent patient \nwith concern for endometriosis should begin with a trans -\nabdominal pelvic ultrasound examination, which is consid -\nered first-line imaging, particularly in young patients who \nare not sexually active. Although transabdominal ultrasound \nis limited in its evaluation of endometriosis, it may exclude \nother causes of pain such as adnexal masses or congenital \nanomalies [8]. Additionally, transabdominal ultrasound may \nidentify some forms of endometriosis, including endome -\ntriomas; however, these are a less common manifestation of \nendometriosis in the adolescent population.\nAfter a transabdominal ultrasound examination has been \nperformed, one may consider performing a transvaginal \nultrasound (TVUS). Although this technique is superior to \ntransabdominal ultrasound in its evaluation of the female \npelvis and specifically in identifying endometriosis, it is a \nsensitive procedure that may be considered in the adoles -\ncent after considerable thought and care. Transvaginal ultra-\nsound is less commonly used in adolescent patients who are \nnot sexually active and may cause anxiety and discomfort \neven in those who are sexually active; however, as a gold-\nstandard technique, it can still be offered to women of repro-\nductive age after a discussion of risks and benefits. In some \ncircumstances, transrectal or transperineal ultrasound may \nbe considered in nonsexually active patients [ 13]. Table 1 \noutlines standard transabdominal and transvaginal ultra -\nsound protocols for the evaluation of endometriosis.\nGiven the limited value of transabdominal ultrasound in \nthe evaluation of deep endometriosis and the potential con -\ncerns associated with transvaginal ultrasound, MRI is a help-\nful tool in the evaluation of adolescents with dysmenorrhea. \nWith appropriate preparation, most adolescents are able to \ntolerate MRI and do not require anesthesia. Furthermore, \nadolescent patients with endometriosis are more likely to \ndevelop deep endometriosis than previously thought, which \nis better evaluated with MRI than Ultrasound. MRI is non -\ninvasive and provides excellent soft tissue detail without \nradiation [14]. MRI of the pelvis may be performed without \nor with intravenous (IV) contrast in adolescents; adoles -\ncent patients can generally tolerate the placement of an IV \ncatheter. Vaginal contrast (aqueous gel) has been shown to \nimprove the detection of endometriosis, particularly that of \ndeep endometriosis, but the use of this contrast may be con-\nsidered uncomfortable or invasive by adolescent patients \n[5]. Patients are asked to self-insert the gel before imaging, \nbut if they refuse or are unable to insert the contrast, MRI \nmay still be performed [ 5]. Fasting for at least 4 h prior to \nimaging and/or intestinal peristalsis agents may be helpful \nto decrease bowel motion artifact [15]. Table 2 summarizes \nthe full MRI protocol commonly used to evaluate endome -\ntriosis. An abbreviated protocol, utilizing volumetric T2-W \n3D SPACE and T1-W Vibe Dixon axial pre-contrast fat \nsaturated images, has also been suggested in the evaluation \nof endometriosis as the disease often occurs in a predictable \npattern. The abbreviated protocol may be useful in younger \npatients or those with anxiety and can help decrease overall \nthroughput time [15].\nUltimately, if imaging is negative and patients are refrac-\ntory to clinical treatment, the reference standard for the \ndiagnosis of endometriosis in adolescent patients remains \nlaparoscopy, with diagnosis and treatment occurring at the \nsame time. Imaging, however, assists in earlier diagnosis \nand treatment of adolescent patients, who traditionally expe-\nrience delays in diagnosis as well as aids in preoperative \nTable 1 Transabdominal and transvaginal ultrasound protocols for the \nevaluation of endometriosis\nPelvic structure Planes Comment\nUterus Longitudinal and Transverse\nEndometrium Longitudinal With \nCine\nOvaries and adnexa Longitudinal and Transverse With or \nwithout \nDoppler\nBladder Longitudinal and Transverse\nCul de sac and poste-\nrior compartment*\nLongitudinal and Transverse Cine slid-\ning sign\n*Transvaginal protocol only\n1 3\n4846\n\nAbdominal Radiology (2025) 50:4844–4853\nof patients aged 18 to 20 years. Rectosigmoid lesions were \nnot seen in any patients younger than 15 years, and no blad-\nder or ureter lesions were identified in their cohort. Ovarian \nendometriomas were observed in 20.7% of the patients in \nthis study [17].\nSuperficial endometriosis is defined as endometrio -\nsis along the surface of the peritoneum or organs without \nsubperitoneal extension. These lesions are reliably identi -\nfied by laparoscopy but not routinely identified on imaging \nstudies. There is evidence that superficial endometriosis \ncan be identified on transvaginal ultrasound examinations \nas hypoechogenic nodules measuring less than 5 mm in \ncharacteristic locations such as along the uterosacral liga -\nments, but detection of such nodules is operator dependent, \nand identification of superficial endometriosis by trans -\nabdominal ultrasound has not been described. With MRI, \nsuperficial disease can be identified as hyperintense foci in \ncharacteristic locations on T1-weighted (T1W) images [18].\nOvarian endometriomas are ovarian cystic lesions that \ncontain blood products of variable age. When present, these \nendometriomas can be identified by characteristic imaging \nfeatures on ultrasound examinations and MRI as described \nby the American College of Radiology (ACR) Ovarian \nReporting and Diagnosis System (O-RADS). On ultrasound \nexaminations, lesions can be unilocular or may contain a \nfew internal septa. Endometrioma cyst fluid has character -\nistic homogeneous, low-level echoes, sometimes referred to \nas ground-glass echoes. The inner walls of the cyst should \nbe smooth, and punctate echogenic foci may be observed \nwithin the wall. There should be no vascular flow on Dop -\npler imaging within an endometrioma (Figs. 1a-c and 2a and \nb) [19]. On MRI, endometriotic cyst contents are homoge -\nneously hyperintense on T1W images. Endometriotic cyst \nfluid is hypointense or intermediate on T2-weighted (T2W) \nimages, often referred to as “T2 shading,” which can appear \nas homogeneous or graduated. On T2W images, endome -\ntriomas may have hypointense nodules or linear mural foci \nthat do not enhance. Endometriomas show variable diffu -\nsion signal. Septa may be present but should not enhance \n(Figs. 1e and 2c and d) [20].\nDeep endometriosis is typically multifocal but tends to \noccur in characteristic locations in the pelvis. The utero -\nsacral ligaments, which are paired uterine suspensory liga -\nments that extend from the torus uterinus (posterior cervix) \nposteriorly to the sacrum, are the most common location of \ndeep endometriosis during adolescence (Fig. 2e).\nDeep endometriosis lesions are not reliably seen on \ntransabdominal ultrasound studies, but the diagnosis of \ndeep endometriosis by transvaginal ultrasound has been \nwell described [21, 22] and typically focuses on identifica -\ntion of direct or indirect imaging findings of endometriosis. \nDirect imaging findings are sonographic observations that \nmanagement which may require a multidisciplinary team in \nmore severe cases.\nImaging findings\nIt is known that endometriosis phenotypes evolve through -\nout a patient’s lifetime. Although adolescents may present \nwith superficial endometriosis, deep endometriosis, or ovar-\nian endometriomas, the proportion of superficial disease is \ngreater in adolescent patients, with the proportion of deep \nendometriosis and endometriomas increasing after age 24 \n[16]. An MRI study of endometriosis in patients aged up \nto 20 years found that the prevalence of endometriosis on \nMRI increased linearly with age [ 17]. In this study, retro -\ncervical lesions (uterosacral ligaments and posterior vagina) \nwere seen in 4.7% of patients aged younger than 15 years, \nin 30% of patients aged 15 to 18 years, and in up to 65% \nTable 2 MRI protocol for the evaluation of endometriosis\nSequence Plane slice \nthick-\nness \n(mm)\ncomment\nT2WI TSE Axial 3–5 Small FOV for \nfemale pelvis\nCoronal \nand/or \nsagittal\n4 Large FOV\nT1WI in-phase and \nout-of-phase\nGRE or Dixon\nAxial 2–3 Large FOV\nT1WI with fat suppression \nnon-contrast\nAxial 4 Small FOV for \nfemale pelvis\nSagittal 3–4 Large FOV\nT1WI with IV contrast Axial 3 Small FOV , Sub-\ntraction images\nSagittal 3–4 Large FOV , Sub-\ntraction images\nDiffusion-weighted Imaging Axial 4–5 b values = 0, 50, \n1000 s/mm2\nT1WI pre-three-dimen-\nsional fast spoiled GRE \nwith fat suppression\nCoronal\nSagittal\n1 Optional of \nupper abdomen\nT2WI FRFSE with fat \nsaturation\nCoronal\nSagittal\n5 Optional of \nupper abdomen\nT2WI fast-spin echo-planar \nfast spin echo\nCoronal Large FOV to \ninclude kidneys\nT2WI fast spin echo with \nfat saturation\nAxial Large FOV\nAdapted from VanBuren W, Feldman M, Shenoy-Bhangle AS, \nSakala MD, Young S, Chamie LP, Giudice L, Hindman NM, Tong A, \nRabban JT, Yano M, Kilcoyne A, Dave HD, Poder L, Kho RM, Bur -\nnett TL, Khan Z, King C, Shen L, Colak C, Burk KS, Andrieu PIC, \nFranco IVP, Glanc P, Kielar AZ, Taffel MT, Kania LM, Bonde A, \nPectasides M, Arif-Tiwari H, Laifer-Narin S, Nicola R, Jha P (2024) \nRadiology State of the art Review: Endometriosis Imaging Interpre -\ntation and Reporting. Radiology 312:e233482.  h t t p s :   /  / d o  i . o  r  g  /  1 0  . 1 1   4 8 \n/  r a d  i o l . 2 3 3 4 8 2\n1 3\n4847\n\nAbdominal Radiology (2025) 50:4844–4853\nhyperintense foci on T1W or T2W images; such foci are \nthought to correspond to areas of glandular endometrium-\nlike tissue [ 23]. The retrocervical area (including the torus \nuterinus, uterosacral ligaments, and posterior vaginal wall) \nis the most common site of deep endometriosis in adoles -\ncents. While no consensus exists, the uterosacral ligaments \nare probably normal when less than 3 mm in thickness and \nindeterminate when 3–5 mm in thickness. The ENDO -\nV ALIRM group described diagnostic criteria for proximal \nuterosacral ligament disease (within 2 cm of the torus ute -\nrinus), including regular or irregular uterosacral ligament \nthickening (> 5 mm), nodules along the ligament that are \nvisible in 2 planes, irregular retraction of the ligaments, and \nhemorrhagic foci along the uterosacral ligaments regardless \nof the presence of thickening (Fig. 3) [24]. Rectosigmoid \ndeep endometriosis has also been reported at low rates in \nadolescents [17] This type of deep endometriosis is often \ncontiguous with retrocervical disease and can characteristi -\ncally cause a thickening of the rectosigmoid wall that has a \nfan shape or “mushroom cap” appearance.\ncorrespond with ectopic endometrial-like tissue in charac -\nteristic locations for endometriosis such as the uterosacral \nligaments, uterine serosa, rectosigmoid region, bladder, \nand vagina. These lesions are typically hypoechoic nodules \nor areas of hypoechoic thickening with smooth or irregu -\nlar/spiculated borders. Hyperechoic or cystic foci may be \nobserved within the lesions. Indirect findings are sono -\ngraphic observations that are a result of deep endometrio -\nsis implants but do not correspond with the lesions directly. \nIndirect observations may include fixed uterine retrover -\nsion, abnormal position of the ovaries, and tethering of \nbowel loops to the uterus [2]. Sliding maneuvers performed \nalong the posterior uterine wall and rectum, along the ante -\nrior uterine wall and bladder and at the level of both ovaries \ncan also provide indirect evidence of endometriosis when \nabnormal sliding between structures is observed [2].\nDeep endometriosis in adolescents is typically diagnosed \non MRI. Imaging findings of deep endometriosis on MRI \nhave been well described. On T2W images, deep endometri-\nosis lesions are hypointense compared to muscle. The lesions \nmay be nodular or may manifest as thickening along struc -\ntures, and the surface of the lesions can be smooth or irregu-\nlar/stellate. The lesions may or may not be accompanied by \nFig. 1 18 year-old woman with left-sided pelvic pain. a The ovaries \nwere not identified by transabdominal ultrasound technique. b, c The \npatient was amenable to transvaginal ultrasound which showed a uni -\nlocular left ovarian cystic lesion with homogeneous low-level inter -\nnal echoes and no internal vascular flow with color Doppler. d The \nlesion shows characteristic T2 shading on T2W MR image (solid white \narrow) with a peripheral dark spot (dashed white arrow). e The lesion \nshows characteristic homogeneous hyperintense signal on T1W image \nwith fat suppression. Patient underwent laparoscopy 2 months later \nwith cystectomy of the endometrioma. Superficial endometriosis was \nnoted in the posterior cul-de-sac\n \n1 3\n4848\n\nAbdominal Radiology (2025) 50:4844–4853\nTreatment\nTreatment strategies for endometriosis include both medical \nand surgical modalities and often require a multi-modal and \nmultidisciplinary approach.\nHormonal management\nHormonal suppression with combined hormonal contra -\nceptives or progestins remains the cornerstone of medical \ntherapy for the management of endometriosis and should \ntypically be used as initial therapy for primary dysmenor -\nrhea. Medical management should be considered suppres -\nsive and not curative as it will not resolve endometriomas \nor deep disease but suppresses ovulation and creates a local \nhypoestrogenic state, which may prevent the development \nor growth of endometriomas. Of note, although the use of \noral contraceptives may improve symptoms, it does not \nprevent the progression of deep disease or the possibility \nof future infertility [12]. The treatment choice is dependent \non various factors, including lifestyle, comorbidities, tol -\nerability (i.e., ability to swallow pills), and willingness to \ntrial medications. Combined oral contraceptives are often \nfirst-line therapy as they are typically well tolerated and \nEndometriosis and congenital female \nreproductive tract anomalies\nEndometriosis is known to occur in conjunction with con -\ngenital female reproductive tract anomalies and has been \nfound in association with all forms of Mullerian anomalies \n[25]. A recent meta-analysis demonstrated that the rate of \nendometriosis was significantly higher (47%) among those \nwith obstructive Mullerian anomalies than among those with \nMullerian anomalies that were not associated with obstruc -\ntion (19%) [ 26]. This study also demonstrated slightly \nhigher rates of endometriosis among those with nonobstruc-\ntive Mullerian anomalies (23%) than among those without \nanomalies (21%). The diagnostic appearance and imaging \ncriteria for ovarian endometriomas and deep endometrio -\nsis do not differ in the setting of congenital reproductive \ntract anomalies (Fig. 4). If a pelvic mass or genitourinary \nmalformation is identified, the suspicion for an obstructive \nMullerian anomaly and associated endometriosis should \nbe heightened. It is unknown if there are differences in the \nlocation of deep endometriosis among individuals with such \nanomalies.\nFig. 2 Images from a 19-year-old patient with chronic pelvic pain, dys-\npareunia, and a family history of endometriosis. a Transvaginal ultra-\nsound image through the right ovary shows 2 small cystic structures \nwith low-level internal echoes characteristic of endometriomas (white \narrows with closed arrowheads). b Image through the right ovary with \ncolor Doppler shows no vascular flow within the lesions (white arrows \nwith closed arrowheads). Pelvic MRI was performed 9 months later. \nc T2W axial image shows one of the 2 endometriomas with T2 shad -\ning and a dark spot sign (black arrow). d The lesion shows charac -\nteristic homogeneous hyperintense signal on the corresponding axial \nT1W image (dashed arrow). e Coronal T2W image through the torus \nuterinus/uterosacral ligaments shows asymmetric, irregular thickening \nof the right uterosacral ligament (white arrows with open arrowheads). \nOral contraception was initiated after imaging\n \n1 3\n4849\n\nAbdominal Radiology (2025) 50:4844–4853\nFig. 4  Images from a 22-year-old patient with a known Mullerian \nanomaly and pelvic pain. a Oblique coronal T2W image through the \npelvis shows a unicornuate right uterus communicating with the cervix \n(not shown). A left uterine remnant with functional endometrial tissue \n(thin arrow) with no communication to the cervix or vagina can also be \nseen. b Axial T1W image shows a right ovarian endometrioma (thick \narrow). A T1 hyperintense focus in the left ovary corresponds to a cor-\npus luteum (dashed arrow). Treatment with hormone suppression was \ninitiated. Endometriosis was confirmed on appendectomy\n \nFig. 3 Images from a 15-year-old \npatient with chronic pelvic pain, \ndysmenorrhea, and menorrhagia. \nThe patient’s mother had a his-\ntory of endometriosis. a, b Sagit-\ntal T2W images show a hypoin-\ntense nodule along the proximal \nright uterosacral ligament (white \ndashed arrow) and asymmetric, \nirregular thickening along the \nlength of the right uterosacral \nligament (solid white arrow). c \nAxial T2W image shows that \nthe right uterosacral ligament is \nalso thickened in the axial plane \n(solid white arrow). d Sagittal \nimage through the left uterosacral \nligament for comparison shows \nthe ligament to be smooth with \nno nodules (black arrows). No \nother sites of deep endometriosis \nwere identified. The ovaries (not \nshown) were normal in appear-\nance with no endometrioma. \nTreatment with continuous oral \ncontraceptive pills was initiated \nafter imaging\n \n1 3\n4850\n\nAbdominal Radiology (2025) 50:4844–4853\nThe controversy between laparoscopic ablation versus \nexcision of endometriosis lesions exists because of the \npaucity of high-quality data in the adolescent population. \nExcision of lesions is the preferred method for removal \nand allows for pathologic confirmation, confirmation of \ncomplete removal down to the level of normal tissue, and \nremoval over critical structures, including the bowel, blad -\nder, and ureter. If a patient undergoes general anesthesia for \na laparoscopy, it is important to consider the option of con-\ncurrent levonorgestrel-releasing intrauterine device inser -\ntion for post-operative hormone therapy, as intraoperative \ninsertion may negate the need for a painful office procedure \nfor the adolescent patient. Postoperative hormone therapy \nhas been shown to benefit adolescents by decreasing recur -\nrence and slowing disease progression. [30–32].\nAdolescents with endometriosis often experience a \nwide range of symptoms; the frequent overlap with mul -\ntiple sources of pain, combined with a lack of awareness, \ncan contribute to delays in diagnosis. These pain sources \nmay include gynecologic conditions and non-gynecologic \ncauses, such as gastrointestinal disorders or musculoskeletal \nissues. This complexity can make diagnosis and manage -\nment challenging, often necessitating a multi-disciplinary \napproach. The treatment team may include a pain special -\nist, mental health professional, physical therapist, and \nfunctional medicine specialist [ 33]. Complementary or \nalternative treatment options such as acupuncture may assist \nwith chronic pelvic pain. Involving a school counselor or \nsocial worker can be beneficial in identifying resources to \nsupport classroom engagement and participation in extra -\ncurricular activities, as students with endometriosis often \nface increased absenteeism.\nConclusion\nIn the adolescent population, endometriosis has historically \nbeen overlooked and underdiagnosed due to atypical pre -\nsentation and limited awareness among clinicians. When \npatients are identified, imaging is playing an increasingly \nimportant role in diagnosis and surgical planning. While \nadults may first undergo a transvaginal ultrasound, adoles -\ncents have different imaging considerations, with pelvic \nMRI playing an increasingly important role as it is less inva-\nsive and can demonstrate deep endometriosis. Treatment \nof adolescents is also unique and requires careful thought \nand consideration of the multitude of effects it may have on \nquality of life.\nAcknowledgements We would like to acknowledge Ms. Megan \nGriffiths, scientific writer for the Cleveland Clinic Imaging Institute, \nfor her critical review of the manuscript.\naccessible. These should be taken in a continuous fashion in \nan attempt to achieve amenorrhea. Progestin-only options \nmay be preferred when estrogen is contraindicated or there \nis a desire to avoid unfavorable estrogenic effects. Gonad -\notrophin-releasing hormone (GnRH) analogues, including \nagonists and antagonists, may be considered in refractory \ncases. However, GnRH analogs are associated with bone \nloss, and adolescence is the time of peak bone accrual. \nThese medications should not be considered without a \ndefinitive diagnosis of endometriosis and failure of first-line \nmedication options. If utilized, hormonal add-back therapy \nwith norethindrone acetate and conjugated estrogens should \nbe a part of therapy to preserve bone mineral content [ 27]. \nIf pain persists after 3–6 months of medical suppression, a \ndiagnostic laparoscopy should be considered for definitive \ndiagnosis and excision [28].\nSurgical intervention\nSurgery is indicated when medical management fails or is \nnot tolerated or if the patient desires a definitive diagno -\nsis. The goal of laparoscopic surgery in the adolescent is \nto confirm the diagnosis and debulk the disease to decrease \npain while preserving fertility [ 8]. Preoperative imaging is \ncrucial for surgical planning and patient counseling. Surgi -\ncal outcomes are greatly influenced by surgical expertise. \nGynecologic surgeons specializing in endometriosis pro -\nvide optimized outcomes regarding diagnosis, lesion treat -\nment, improved symptom relief, and fertility preservation. \nDiscussion around fertility preservation should be priori -\ntized, especially in patients with bilateral endometriomas, as \novarian reserve can be negatively impacted postoperatively.\nA thorough survey of both the pelvis and upper abdo -\nmen is crucial to ensure all lesions are identified. Multiple \nports are often required to allow appropriate retraction of \nthe uterus and adjacent structures for complete evaluation. \nCareful attention should be placed on areas found to have \npotential disease on imaging. Furthermore, when an endo -\nmetrioma is identified on imaging, there is a > 90% prob -\nability that alternate areas of endometriosis are present; \ntherefore, the surgeon should be prepared to address addi -\ntional areas for excision. Superficial endometriosis lesions \nin the adolescent population often have a unique pheno -\ntypic appearance, including white implants, clear vesicular \nlesions, or small hemorrhagic areas on the peritoneum, as \ncompared to adults, who often have the characteristic red \nbrown lesions or black, blue, gray “powder burn” lesions. \nPeritoneal pockets, also known as Allen-Master windows, \ncan be associated with endometriosis and should be everted \nat the base and excised. Most adolescents are diagnosed \nlaparoscopically with early Stage I or II endometriosis, with \nadvanced Stage III or IV disease being less common [29].\n1 3\n4851\n\nAbdominal Radiology (2025) 50:4844–4853\npelvic pain not responding to conventional therapy. 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Da Silva LLC, Torres US, Torres LR, Fong MS, Okuyama FH, \nCaiado AHM, Chamie LP, Moura APC, Novis MI, Warmbrand \nG, D’Ippolito G (2021) Performance of imaging interpretation, \nintra-and inter-reader agreement for diagnosis of pelvis endome -\ntriosis: comparison between an abbreviated and full MRI proto -\ncol. Abdominal Radiology 46:4025–4035.\n16. Bourdon M, Maignien C, Marcellin L, Maitrot Mantelet L, \nParpex G, Santulli P, Chapron C (2024) Distribution of endome -\ntriosis phenotypes according to patients’ age in adult women with \nsurgical evaluation. Hum Reprod 39:2259–2267.\n17. Millischer AE, Santulli P, Da Costa S, Bordonne C, Cazaubon E, \nMarcellin L, Chapron C (2023) Adolescent endometriosis: preva-\nlence increases with age on magnetic resonance imaging scan. \nFertil Steril 119:626–633.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  f e r  t n s  t e r t  . 2  0 2 \n2 . 1 2 . 0 3 9\n18. Quesada J, Härmä K, Reid S, Rao T, Lo G, Yang N, Karia S, Lee \nE, Borok N (2023) Endometriosis: A multimodal imaging review. \nEur J Radiol 158:110610.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  e j r a d . 2 0 2 2 . 1 1 \n0 6 1 0\n19. Strachowski LM, Jha P, Phillips CH, Blanchette Porter MM, Froy-\nman W, Glanc P, Guo Y , Patel MD, Reinhold C, Suh-Burgmann \nEJ, Timmerman D, Andreotti RF (2023) O-RADS US v2022: \nAn update from the American College of Radiology’s Ovarian-\nAdnexal Reporting and Data System US Committee. Radiology \n308:e230685.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  1 4 8  / r a  d i o l . 2 3 0 6 8 5\n20. Reinhold C, Rockall A, Sadowski EA, Siegelman ES, Maturen \nKE, Vargas HA, Forstner R, Glanc P, Andreotti RF, Thomassin-\nNaggara I (2021) Ovarian-Adnexal Reporting Lexicon for MRI: \nA White Paper of the ACR Ovarian-Adnexal Reporting and Data \nSystems MRI Committee. J Am Coll Radiol 18:713–729.  h t t p  s : /  / \nd o i  . o  r g /  1 0 . 1  0 1 6  / j .  j a c r . 2 0 2 0 . 1 2 . 0 2 2\n21. Guerriero S, Condous G, van den Bosch T, Valentin L, Leone \nFP, Van Schoubroeck D, Exacoustos C, Installé AJ, Martins WP, \nAbrao MS, Hudelist G, Bazot M, Alcazar JL, Gonçalves MO, \nPascual MA, Ajossa S, Savelli L, Dunham R, Reid S, Menakaya \nAuthor contributions B.L. wrote the abstract, introduction, diagnostic \nimaging considerations, conclusion, and main text editing. M.F. orga-\nnized the manuscript, wrote imaging findings, found the figures, and \nedited the manuscript. M.A. wrote presentation and diagnostic delay. \nC.K. wrote the section on treatment. All authors reviewed the manu -\nscript. Revisions perfomed by B.L. and M.F. with contribution from \nC.K.\nData availability No datasets were generated or analysed during the \ncurrent study.\nDeclarations\nCompeting interests The authors declare no competing interests.\nOpen Access   This article is licensed under a Creative Commons \nAttribution 4.0 International License, which permits use, sharing, \nadaptation, distribution and reproduction in any medium or format, \nas long as you give appropriate credit to the original author(s) and the \nsource, provide a link to the Creative Commons licence, and indicate \nif changes were made. The images or other third party material in this \narticle are included in the article’s Creative Commons licence, unless \nindicated otherwise in a credit line to the material. If material is not \nincluded in the article’s Creative Commons licence and your intended \nuse is not permitted by statutory regulation or exceeds the permitted \nuse, you will need to obtain permission directly from the copyright \nholder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  v e c  o m m o  n s .  o \nr g  / l i c e n s e s / b y / 4 . 0 /.\nReferences\n1. Jha P, Sakala M, Chamie LP, Feldman M, Hindman N, Huang C, \nKilcoybe A, Laifer-Narin S, Nicola R, Poder L, Shenoy-Bhangle \nA, Tong A, VanBuren W, Taffel MT (2020) Endometriosis MRI \nlexicon: consensus statement from the society of abdominal radi-\nology endometriosis disease-focused panel. Abdom Radiol (NY) \n45:1552–1568.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 0 7  / s 0  0 2 6 1 - 0 1 9 - 0 2 2 9 1 - x\n2. 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VanBuren W, Feldman M, Shenoy-Bhangle AS, Sakala MD, \nYoung S, Chamie LP, Giudice L, Hindman NM, Tong A, Rabban \nJT, Yano M, Kilcoyne A, Dave HD, Poder L, Kho RM, Burnett \nTL, Khan Z, King C, Shen L, Colak C, Burk KS, Andrieu PIC, \nFranco IVP, Glanc P, Kielar AZ, Taffel MT, Kania LM, Bonde \nA, Pectasides M, Arif-Tiwari H, Laifer-Narin S, Nicola R, Jha P \n(2024) Radiology State of the art Review: Endometriosis Imaging \nInterpretation and Reporting. Radiology 312:e233482.  h t t p  s : /  / d o i  \n. o  r g /  1 0 . 1  1 4 8  / r a  d i o l . 2 3 3 4 8 2\n24. Rousset P, Florin M, Bharwani N, Touboul C, Monroc M, Gol -\nfier F, Nougaret S, Thomassin-Naggara I; ENDOV ALIRM Group \n(2023) Deep pelvic infiltrating endometriosis: MRI consensus \nlexicon and compartment-based approach from the ENDO -\nV ALIRM group. Diagn Interv Imaging 104:95–112.  h t t p  s : /  / d o i  . \no  r g /  1 0 . 1  0 1 6  / j .  d i i i . 2 0 2 2 . 0 9 . 0 0 4\n25. Pitot MA, Bookwalter CA, Dudiak KM (2020) Mullerian duct \nanomalies coincident with endometriosis: a review. Abdom \nRadiol (NY) 45:1723–1740.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 0 7  / s 0  0 2 6 1 - 0 2 \n0 - 0 2 4 6 5 - y\n26. Vercellini P, Salmeri N, Somigliana E, Piccini M, Caprara F, \nViganò P, De Matteis S (2024) Mullerian anomalies and endo -\nmetriosis as a potential explanatory models for the retrograde \nmenstruation/implantation and the embryonic remnants/celomic \nAuthors and Affiliations\nBrooke S.  Lampl1 · Cara R.  King2 · Marjan Attaran2 · Myra K.  Feldman1\n \r Brooke S. Lampl\nlamplb@ccf.org\n \r Myra K. Feldman\nfeldmam2@ccf.org\nCara R. King\nkingc9@ccf.org\nMarjan Attaran\nattaram@ccf.org\n1 Imaging Institute, Cleveland Clinic, Cleveland, United States\n2 Ob/Gyn and Women’s Health Institute, Cleveland Clinic, \nCleveland, United States\n1 3\n4853","source_license":"CC0","license_restricted":false}