{"paper_id":"af26ad75-0781-40d8-bf7b-d0664b370aff","body_text":"Citation:\nRandhawa, AE and T ufte-Hewett, AD and Weckesser, AM and Jones, GL and Hewett, FG (2021)\nSecondary School Girls’ Experiences of Menstruation and Awareness of Endometriosis: A Cross-\nSectional Study . Journal of Pediatric and Adolescent Gynecology , 34 (5). pp. 643-648. ISSN\n1083-3188 DOI: https://doi.org/10.1016/j.jpag.2021.01.021\nLink to Leeds Beckett Repository record:\nhttps://eprints.leedsbeckett.ac.uk/id/eprint/7686/\nDocument Version:\nArticle (Accepted Version)\nCreative Commons: Attribution-Noncommercial-No Derivative Works 4.0\nThe aim of the Leeds Beckett Repository is to provide open access to our research, as required by\nfunder policies and permitted by publishers and copyright law.\nThe Leeds Beckett repository holds a wide range of publications, each of which has been\nchecked for copyright and the relevant embargo period has been applied by the Research Services\nteam.\nWe operate on a standard take-down policy . If you are the author or publisher of an output\nand you would like it removed from the repository , please contact us and we will investigate on a\ncase-by-case basis.\nEach thesis in the repository has been cleared where necessary by the author for third party\ncopyright. If you would like a thesis to be removed from the repository or believe there is an issue\nwith copyright, please contact us on openaccess@leedsbeckett.ac.uk and we will investigate on a\ncase-by-case basis.\n\n1 \n \nTitle Page \n \nTitle: Secondary School Girls’ Experiences of Menstruation and Awareness of \nEndometriosis: A cross-sectional study \nAuthors: \nA. E. Randhawa, MSc, Centre for Social Care, Health and Related Research, Birmingham \nCity University, 4 Cardigan Street, Birmingham B4 7BD, UK \nA. D. Tufte-Hewett (Corresponding Author*), PhD, Department of Psychology, Birmingham \nCity University, 4 Cardigan Street, Birmingham B4 7BD, UK \nA. M. Weckesser, PhD, Centre for Social Care, Health and Related Research, Birmingham \nCity University, 4 Cardigan Street, Birmingham B4 7BD, UK \nG. L. Jones, DPhil, Department of Psychology, School of Social Sciences, Leeds Beckett \nUniversity, Leeds LS1 9HE \nF. G. Hewett, MSc, MBChB, Manor Practice, James Preston Health Centre, 61 Holland \nRoad, Sutton Coldfield, West Midlands, B72 1RL \nSite of Study: West Midlands, England \nFunding: Birmingham City University’s Faculty of Health, Education & Life Sciences \nDisclaimers: None \n*Corresponding Author: Dr Angela Hewett, Phone: 0121 202 4205, Fax: N/A, Email: \nangela.hewett@bcu.ac.uk, Birmingham City University, 4 Cardigan Street, Birmingham, B4 \n7BD \n \n \n \n \n \n \n \n \nWord count of abstract and main text (excluding title page, acknowledgements, references \nand tables): 250 (Abstract), 3165 (main text) \n \n \n\n2 \n \nTitle: Secondary School Girls’ Experiences of Menstruation and Awareness of \nEndometriosis: A cross-sectional study \n \nStructured Abstract \nStudy Objective:  To characterise typical (ie, normal) menstrual characteristics in a large \nsample of secondary school girls, as well as knowledge of typical menstruation, \nendometriosis awareness and educational needs. To establish whether self-reported atypical \nperiod symptoms indicate menstrual characteristics suggesting the need for further clinical \nreview for a specialist opinion.  \nDesign: Cross-sectional survey.  \nSetting: Secondary schools in West Midlands, England.   \nParticipants: 442 girls, 15-19 years. \nInterventions and Main Outcome Measures: The questionnaire determined demographic \ncharacteristics, age at menarche, menstrual cycle patterns and experiences, awareness of \nendometriosis, and preferences for learning about it.  \nResults: Period pain was common (94%), with pain reported as moderate/severe (86%).  \nGirls reported missing school due to their periods (23%), mainly due to pain.  Most believed \ntheir period was typical (63%); however, 27% were unsure, and 30% did not know if it was \nregular. Self-report of atypical periods was associated with symptoms suggesting need for \nclinical review and with consulting a doctor (χ²(2) = 36.272, p < 0.001). Only 8% could \ndescribe endometriosis, though 86% wanted to learn more about it. \nConclusion: Most secondary school girls report dysmenorrhea. Although most reporting \natypical periods had seen a doctor, over a quarter did not know whether their period was \ntypical or regular.  The majority do not have knowledge of endometriosis, contrasting with \nadolescents’ familiarity with other common chronic conditions such as diabetes and epilepsy. \nWe suggest Menstrual Health Education (MHE) to improve knowledge of typical \nmenstruation and pain treatment, aiding earlier identification of problematic period symptoms \nthat might indicate underlying pathology. \n \n \n \n \nKey Words: Adolescent, menstruation, dysmenorrhea, endometriosis, delayed diagnosis, \neducation \n \n \n\n3 \n \nIntroduction \nMenstrual pain  (dysmenorrhea) is the main gynaecological complaint of adolescents .1 The \nmajority of adolescents with menstrual pain have primary dysmenorrhea, painful menstruation \nin the absence of pathology, but a significant minority have  secondary dysmenorrhea, painful \nmenses due to pelvic pathology.2 Endometriosis, the chronic condition defined by the presence \nof endometrial gland and stroma outside the uterine lining, is the leading cause of secondary \ndysmenorrhea as well as chronic pelvic pain (CPP) in this age group. 2, 3 Approximately two-\nthirds of adolescent girls with CPP or secondary dysmenorrhea who undergo laparoscopy have \nevidence of endometriosis.4,5    \nThe true prevalence of adolescent endometriosis  is unclear due to delayed recognition and \nintervention.3,6 Two to 10% of women of reproductive age have endometriosis,7 and a majority \nof those diagnosed as adults report first experiencing symptoms in adolescence.8, 9 Delays from \nsymptom onset to diagnosis can result in persistent chronic pain, significant adverse impacts \non quality of life,10,11 potential progression of the disease ,12 and possible infertility. 13  \nAdolescents unaware of typical menstrual characteristics may not recognise , or seek out help \nfor, abnormal symptoms.14,15 This study aims to characterise typical menstrual characteristics \nin a large sample of secondary school girls, and to explore  this age groups’ knowledge of \ntypical menstruation, endometriosis  awareness and educational needs. An additional further \naim is to establish whether those who experience menstrual characteristics that might indicate \nthe need for clinical review and specialist opinion, report their period to be atypical. \nMaterials and Methods \nParticipants and setting \nA descriptive cross-sectional survey study was carried out with secondary school girls aged \n15 to 19 years old. AR recruited participants from secondary schools in the West Midlands, \nEngland. Schools included an independent girl’s school (A), an independent mixed-sex \n\n4 \n \nboarding school (B), and a government run mixed-sex academy school (C), representing a \ndiverse range of recruitment sites. Non-random convenience sampling was used. \nQuestionnaire and Procedure \nA self-administered pen and paper survey was designed specifically for this research. The \nsurvey consisted of questions newly developed to meet the aims of the study and also \nincluded existing questions used by other researchers conducting similar studies.16-19,26 AR \nand AH developed survey questions in consultation with GR and AW. The final \nquestionnaire consisted of four sections: 1) demographic characteristics (e.g. age, ethnicity, \nand school type); 2) age at menarche, cycle patterns, and menstrual experiences; 3) \npreferences for communicating about menstruation with others; and 4) awareness of \nendometriosis, and preferences for learning about it in future.  \nThe opening question to section four was ‘Do you know what endometriosis is?’ \nRespondents who answered ‘yes’ were then asked to describe endometriosis in their own \nwords. This allowed for the assessment of respondents’ levels of awareness and \nunderstanding, in line with previous endometriosis research.18 After being asked if they know \nwhat endometriosis is, as done in previous similar surveys with adolescents,18 a short lay \n(non-medical) description of endometriosis, was provided to participants on a separate page.  \nThe description was based on a definition of the condition employed in an information leaflet \nproduced for teenagers by Endometriosis UK in 2014.a Participants were then asked if they \nwould like to learn more about endometriosis, as well as how they would like to learn about \nit, who they were comfortable talking about it with and whether they thought boys should \nlearn about it too. \n \na Leaflet, “Is This Normal? About Endometriosis: What Every Girl Needs to Know” available at: \nhttps://www.endometriosis-uk.org/sites/default/files/files/campaign%20materials/print-is-this-normal-\nleaflet-endometriosis-Feb2014-final.pdf  \n\n5 \n \nThe survey was piloted with 10 girls from the target population (aged 15-19) to assess the \nclarity of wording, acceptability of formatting, and ease of implementation. Following pilot \ntesting, data collection was completed between November 2017 and March 2018. At least a \nweek prior to survey completion, all female students meeting the target criteria were given \nverbal information about the research by the first author or a teacher at their school. They \nwere also given a study information sheet, and a parent/guardian information sheet if under \n16 years. Schools were given the choice between opt-in and opt-out parental consent as they \nwere best positioned to know which would be most acceptable to students and \nparents/guardians. One school (A) requested that all students were given the parent/guardian \ninformation sheet and used opt-in parental consent, whilst two schools (B & C) used opt-out \nparental consent for under 16s. Participants had the opportunity to ask questions before \nproviding consent and completing the survey. Survey completion took approximately 5-10 \nminutes. \nEthics and Data Analysis \nThe university ethics committee at Birmingham City University granted ethical approval for \nthis study. After survey completion, all participants received a leaflet signposting relevant \nand locally accessible health and support organisations should they want further information, \nor have concerns about, their menstrual health. All questionnaires were reviewed and checked \nfor completion and accuracy by the principal investigator before inputting the data into an \nelectronic database using a pre-constructed codebook. Responses to the free-text question \nasking participants to define endometriosis were transferred into QSR’s NVivo 11, to be \ncoded using content analysis, in line with previous endometriosis research.\n18 AR read and re-\nread the answers to enable familiarisation, and then they were grouped to obtain categories. \nFinal categories were reached upon agreement by two researchers (AR & AH). Each category \nwas given a number to allow for further statistical analysis.   \n\n6 \n \nData was analysed using SPSS Version 24. Tests for normality were performed on the \ncontinuous variables (i.e. current age, age of menarche), which were found to be non-\nnormally distributed. Therefore, subsequent analysis of data used either the Mann-Whitney U \ntest or the Kruskal-Wallis test for continuous data, and Chi-squared tests for the categorical \ndata. For the latter, if expected cell counts were less than 5 for >20% of the cells,  a Fisher’s \nexact test was used for 2x2 tables, and a likelihood ratio chi-squared test for larger tables.20   \nA p value of <0.05 was considered to show a statistically significant result. \nResults \nSample Demographic Characteristics and Menstrual Experiences \nA total of 442 secondary school  girls, aged 15 to 19 years , participated in the survey , with a \nmedian age of 17 years. The overall response rate to the survey was 53%. \nAt the time of survey completion, 99.5% of participants had started their periods (440/442). \nThe me dian age of menarche was 12.5 years  and ranged from 9 to 16.42 years. Most \nparticipants reported menstrual bleeding between 4 and 7 days (88.9%) , and the me dian \nduration was 5 days. Only 48.6%, of the sample reported the length of their menstrual cycle , \nand for those reporting between 21-45 days, the median length was 28 days. Irregular periods \nwere reported by 31.3% of responders, and 29.6% indicated that they did not know the length \nof their cycle. Those who provided the  length of their cycle, and did not tick ‘don’t know’ or \n‘irregular periods’ were assumed to have regular periods (39.1%). The full response rates by \nschool, demographic and menstrual bleeding pattern information collected for the sample are  \nshown in Table I. \nTable I. Sociodemographic factors and menstrual bleeding patterns. \nTable II shows period pain rates for the sample as well as medication usage and school \nabsences. Their pain responses were categorised as ‘mild pain’ (answers 1 to 3), ‘moderate \n\n7 \n \npain’ (4-7), and ‘severe pain’ (8-10), using the similar cut-off scores as in previous research.16   \nThe effectiveness of their pain medication was rated from 0 to 10, and these responses were \ncategorised into ‘ no/low effectiveness’ (0 to 3), ‘moderate effectiveness’ (4-7), and ‘high \neffectiveness’ (8-10), using the same cut-off scores as in previous research.16    \nSchool absence due to  periods was reported by 100 ( 22.7%) responders with the majority \nmissing 1 day, and 2 days given as the maximum response. The reason most often stated was \nthat their period was ‘too painful’ (91.0%). Almost a third of the sample had visited a doctor \nabout periods (29.5%).  \nTable II. Menstrual pain, medication use and school absence \nPerceived typicality of periods \nParticipants indicated whether they thought their periods were typical (ie, normal) for someone \ntheir age, with 274 (63.1%) responding ‘yes’, 44 (10.1%) responding ‘no’, and 116 (26.7%) \nresponding ‘unsure’. Further analysis was conducted using this data to examine if those who \nperceive their period to be  atypical also report symptoms comparable with N ational Institute \nfor Health and Care Excellence (N ICE) criteria31 for referral for further clinical review and \nspecialist investigation. NICE guidelines are standard clinical guidelines developed for the UK \nNational Health Service and are developed by independent committ ees comprised of \nprofessionals, members of the pub lic, and relevant stakeholders.  Finally, knowledge of \nendometriosis was compared across the groups according to whether the girls thought their \nperiod was typical for someone their age.  \nGrouping by Self-reported Typicality of Period \nThe girls who believed that their periods were not typical for someone their age were more \nlikely to report  irregular periods (χ²(2) = 46.42, p < 0.001), take medication for period pain \n(χ²(2) = 8.75, p < 0.05), take oral contraceptive pills (OCPs)  (χ²(2) = 9.58, p < 0.01), have \n\n8 \n \nknowledge of endometriosis (χ²(2) = 8.75, p < 0.05), and have seen a doctor about their periods \n(χ²(2) = 36.272, p < 0.001). Pain severity ratings were significantly different between the \ngroups, with those who thought their periods were typical having lower pain scores than those \nwho thought their periods were not typical and those that were unsure (H(2)=11.62, p = 0.003). \nThose who thought that their periods were not typical also reported that their pain medication \nwas less effective than th ose who reported that their periods were typical (H (2)=10.465, p = \n0.005). Although school absence was not significantly related to perceived typicality (i.e., \n‘normalness’) of periods, it was related to pain severity, with those in the highest pain group \n(8-10 on the pain scale) missing more school (χ²(2) = 49.78, p < 0.001). \nAwareness of Endometriosis \nAlthough forty-four participants (10.1%) answered ‘yes’ to the question ‘Do you know what \nendometriosis is?’, forty-six participants provided a description of endometriosis, which were \ncoded and categorised into description types . Only 8.2% went on to accurately describe the \ncondition. Descriptions were based on symptoms, the bi ological mechanisms involved in \nendometriosis, or a combination of both. Pain as a symptom was mentioned most frequently, \nrepresenting 50% (23/46) of descriptions. Descriptions including biological mechanisms were \nbased on the lining of the womb appearing elsewhere (15/46) and blood being unable to leave \nthe body (5/46). Some descriptions were vague, or did not capture any element of the definition \nof endometriosis. Five responders’ descriptions were simply of a period, and four  could be \ncategorised as ‘something to do with a period’, which was likely evident given the nature of \nthe survey. Participants who stated that they knew what endometriosis was also indicated how \nthey knew; almost half (21/43) knew about endometriosis from the internet or media. \nThe majority of participants (85.9%) indicated that they would like to learn more about \nendometriosis. Over half (51.3%) indicated school as their preferred source of learning, via \nlessons or the school nurse. However, only 26.5% indicated they were comfortable discussing \n\n9 \n \nendometriosis with a schoolteacher. The majority of participants (82.8%) thought boys \nshould learn about endometriosis as well.   \nDiscussion \n \nThis study characterises typical menstrual characteristics for secondary school girls; it \nexplores this age groups’ knowledge of typical menstruation and awareness and educational \nneeds regarding endometriosis. It further establishes if self-reported atypical period \nsymptoms indicate menstrual characteristics suggesting the need for further specialist clinical \nreview.   \nThis study demonstrates the critical need for improved adolescent menstrual health education \n(MHE). One in four girls (27%) were unsure if their periods were typical, 1 in 10 (10%) \nconsidered their periods non-typical and nearly 1 in 3 (30%) did not know if their periods \nwere regular. Female pupils report available MHE provision to be overly abstract (focused on \nthe biological aspects of menstruation) and that it does not address their concerns about \nwhether their periods are ‘normal.’21-24 Those unaware of typical menstrual characteristics \nmay not recognise, or seek out help for, abnormal symptoms.14,15     \nPain remains a significant factor in girls’ period experiences, with a majority (86%) reporting \ntheir period pain to be moderate or severe, reflecting similarly high levels of adolescent \ndysmenorrhea from past research\n1,17,25-30. Nearly 1 in 3 girls report visiting a doctor about \ntheir periods, a rate reflecting the wide-spread experiences of pain and uncertainties around \ntypical menstruation. Period pain is the primary reason for missing school (91%) and those \nwith severe pain are more likely to miss school (45%). While most girls (66%) have taken \nmedication or OCPs to manage pain, a significant number have not. Girls want to learn more \nabout menstrual cramps and how to manage pain.24 A key component, therefore, of MHE is \n\n10 \n \nthe inclusion of discussions of pain treatment options, including medication options such as \nnon-steroidal anti-inflammatory drugs and OCPs. \nThis study demonstrated that those reporting non-typical periods were significantly more \nlikely to report irregular periods, severe period pain, taking medication for period pain, \nfinding medication inadequate for pain, taking OCPs, seeing a doctor about their periods, and \nknowing what endometriosis is. Contact with medical services might have resulted in OCP \nprescriptions, as well as discussions with health care professionals about possible \nendometriosis. As per recent clinical updates\n3 and UK and European guidelines,7,31 those \nreporting higher pain levels and ineffective pain relief from medication exhibit atypical \nperiods indicative of the need for possible clinical review for a specialist opinion.   \nFindings also demonstrate the acute need for improved endometriosis awareness amongst \nadolescents. Only 8% of secondary school girls knew what endometriosis was, approximately \nhalf the rate in Italy (19%)19 and a third of that in Australia (24%).17   Adolescents in the \ngeneral population report comparatively high familiarity with other health conditions.32 The \nmajority are familiar with asthma (88%), arthritis (84%), diabetes (81%), HIV/AIDS (78%), \nand breast cancer (72%); approximately one-third are familiar with Parkinson’s disease \n(39%) and epilepsy (31%).32 Girls are considerably less aware of endometriosis than other \nchronic conditions with similar adult prevalence rates, specifically diabetes and epilepsy.    \nImproving individuals’ awareness of endometriosis may help improve time to diagnosis. The \naverage delay from symptom onset to diagnosis is eight years in the United Kingdom.33 In the \nUnited States, where referrals are not needed to access gynaecological specialist care, the \naverage delay is four and a half years.34 While improving adolescents’ knowledge of \nmenstruation and endometriosis may reduce diagnostic times, stigma around speaking about \nperiods must also be addressed, as research shows girls and adult women may be reluctant to \n\n11 \n \nspeak about their menstrual health even with health professionals.35 Further, there is evidence \nhealth care professionals may dismiss or ‘normalise’ the endometriosis symptoms of those \nwho come to seek care.36 \nThis research showed that girls want to know more about endometriosis (86%), and school \nlessons are the preferred mode of learning about the condition (41%). Girls are less \ncomfortable speaking with their teachers (27%) than with school nurses (37%), doctors \n(44%), friends (56%) or parents (64%) about endometriosis. Previous research shows most \nteen girls (63%) are uncomfortable talking about periods with teachers,37 thus, as found \nelsewhere,38 students may prefer outside experts (youth workers, sexual health professionals, \netc.) deliver MHE content. Girls worry about being shamed at school about their periods, \nparticularly by boys.23,39 The majority of girls feel boys should learn about endometriosis \n(83%), and inclusion of boys in general MHE could reduce period-related bullying.24,37 \nIn addition, MHE needs to allow girls to not just learn about biological factors associated \nwith menstrual cycles and menstrual bleeding, but also provide safe spaces for girls to discuss \nwhat having a period is really like for them.  Research shows that girls want to discuss the \npsychological and social aspects of having a period – not just the biological aspects.21,23,24,40  \nGunson et al., (2016)41 found that overly positive and naturalistic descriptions of \nmenstruation could lead girls to feel that their experiences did not live up to expectations.  \nMost adolescent girls feel comfortable talking about menstruation with female friends,37 and \nthis allows them to provide support for each other around the aspects of menstruation that \ngirls view negatively.42 MHE should also take into account a wide age-range since although \nthe average age of menarche was 12.5 in this study, some girls started as early as 9.  MHE \nwould therefore ideally start early and continue in an ongoing fashion, instead of as a one-off.   \n\n12 \n \nStrengths and Limitations \nThe survey was modelled on those from similar previous studies16-19 and designed to address \nthis study’s aims. A limitation was an absence of validated questionnaires to draw upon.  \nDespite the pilot study indicating that the questionnaire was fit for purpose, some main \nsurvey respondents confused the length of their period with the length of their menstrual \ncycle (resulting in 37 respondents reporting menstrual cycles of between 2 and 7 days). The \n23 respondents linking endometriosis to pain in their descriptions of the condition may have \ndeduced this connection from survey questions focused on their period pain experiences. \nHowever, as only 5% of the total number surveyed responded to the endometriosis definition \nquestion with an answer including pain, it does not appear to have overly influenced the \nresults on endometriosis awareness. It is also worth noting that a higher percentage of girls \nmay have reported wanting to learn about endometriosis because the condition was \nintroduced to them in this survey, therefore increasing its salience. The survey did not include \nquestions regarding secondary school girls’ experiences of heavy menstrual bleeding, a \ncommon adolescent gynaecological concern and possible symptom of underlying pathology43 \nthat warrants investigation in future research.  The frequency of OCP use was somewhat low \nin this sample (13.7%). Previous research44 suggests that the percentage of girls receiving a \nprescription for OCPs in the UK is 19%. The low frequency of OCP use may also be due to \ndelays in access reported for adolescents in the UK.45 It is possible that cycle length, \nperceived cycle regularity and pain levels could have been influenced by OCP use; however, \nas described above, the percentage of the sample using OCPs was low. The survey did not \ninclude questions regarding use of other menstrual management or contraceptive medications \n(e.g. intrauterine devices, contraceptive injections, etc.).  \nTo our knowledge, this is the first England-based study on the typical experience of \nmenstruation for adolescents (of any age) as well as their knowledge of typical menstruation \n\n13 \n \nand endometriosis. Only two recent similar studies on menstrual characteristics in adolescents \nand young women have been conducted in Australia17 and Italy.19 This study had a large and \nethnically diverse sample, nearly half (49.1%) of participants identified as Asian, 35.8% as \nWhite, 10.7% as Black and 4.4% as Mixed Race. Such diversity is important given menstrual \nexperiences of ethnic minority populations have been under-represented in the literature \npreviously.\n14-19,37 \n \nConclusion \nMost secondary school girls experience period pain, many do not know if their periods are \nregular or typical, and an overwhelming majority do not know what the common chronic \ncondition endometriosis is. Findings demonstrates the critical need for better MHE provision \nto improve girls’ knowledge of typical menstruation and period pain experiences, pain \nmanagement options, and common gynaecological health conditions. Such provision is key to \nimproving girls’ menstrual health knowledge, experiences and outcomes.    \n\n14 \n \nAcknowledgements \nThe authors thank all those who took part in the survey and the schools that facilitated this \nparticipation. Gratitude is also expressed teachers from participating schools as well as \nrepresentatives from Endometriosis UK whose opinions we sought on the acceptability of the \nwording of the survey. Thank you also to Dr. Jeffrey Wood who consulted on the statistical \nanalyses for the paper.  \nDisclosure/Conflicts of Interests \nNone. \nReferences \n1. De Sanctis V, Soliman AT, Elsedfy H, et al: Dysmenorrhea in adolescents and young \nadults: a review in different country. Acta Bio Medica Atenei Parmensis 2016; 87:233 \n2. ACOG: Dysmenorrhea and endometriosis in the adolescent. ACOG Committee Opinion \nNo. 760. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018; \n132:e249 \n3. Shim JY, Laufer MR: Adolescent endometriosis: An update. J Pediatr Adolesc Gynecol \n2020; 33(2):112. doi:10.1016/j.jpag.2019.11.011 \n4. Hirsch M, Dhillon-Smity R, Cutner, A, et al: The prevalence of endometriosis in \nadolescents with pelvic pain: A systematic review. J Pediatr Adolesc Gynecol 2020; in \npress \n5. Janssen EB, Rijkers ACM, Hoppenbrouwers K, et al: Prevalence of endometriosis \ndiagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a \nsystematic review. Hum Reprod Update 2013; 19:570 \n6. Sardogan E, Becker CM, Feki A, et al: Recommendations for the surgical treatment of \nendometriosis-part 1: ovarian endometrioma. Gynecol Surg 2017; 14:27 \n7. Dunselman GAJ, Vermeulen N, Becker C, et al: ESHRE guideline: management of \nwomen with endometriosis. Hum Reprod 2014; 29:400 \n8. Manderson L, Warren N, Markovic M: Circuit breaking: pathway of treatment seeking \nfor women with endometriosis in Australia. Qual Health Res 2008; 4:522 \n\n15 \n \n9. Greene R, Stratton P, Cleary SD, et al: Diagnostic experience among 4,334 women \nreporting surgically diagnosed endometriosis. Fertil Steril 2009; 91:32 \n10. DiVasta AD, Vitonis AF, Laufer MR et al: Spectrum of symptoms in women diagnosed \nwith endometriosis during adolescence vs adulthood. Am J Obstet Gynecol 2018; \n218:324.e1 \n11. Rush G, Misajon R: Examining subjective wellbeing and health-related quality of life in \nwomen with endometriosis. Health Care Women Int 2018; 39:303 \n12. Unger CA, Laufer MR: Progression of endometriosis in non-medically managed \nadolescents. J Pediatr Adolesc Gynecol 2011; 24:e21 \n13. Sinaii N, Plumb K, Cotton L, et al: Differences in characteristics among 1,000 women \nwith endometriosis based on extent of disease. Fertil Steril 2008; 89:538 \n14. Bodén E, Wendel C, Adolfsson A: Adolescents with endometriosis: Their experience of \nthe school health care system in Sweden. Br J Sch Nurs 2013; 8:81 \n15. Moradi M, Parker M, Sneddon A, et al: Impact of endometriosis on women's lives: a \nqualitative study. BMC Women's Health 2014; 14:123 \n16. Parker MA: The MDOT Study: Prevalence of Menstrual Disorder of Teenagers; \nExploring Typical Menstruation, Menstrual Pain (dysmenorrhoea), Symptoms, PMS and \nEndometriosis: University of Canberra, 2006 \n17. Parker MA, Sneddon AE, Arbon P: The menstrual disorder of teenagers (MDOT) study: \ndetermining typical menstrual patterns and menstrual disturbance in a large population-\nbased study of Australian teenagers. BJOG 2010; 117:185 \n18. Shadbolt N, Parker M, Othia L: Communicating endometriosis with young women to \ndecrease diagnosis time. Health Promot J Austr 2013, 24:151  \n19. Zannoni L, Giorgi M, Spagnolo E, et al: Dysmenorrhea, absenteeism from school, and \nsymptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol 2014; \n27:258-265. \n20. McHugh ML: The chi-square test of independence. Biochemia medica 2013; 23:143 \n21. Kissling EA: Bleeding out loud: Communication about menstruation. Fem Psychol 1996; \n6:481  \n22. Beausang CC, Razor AG: Young Western women's experiences of menarche and \nmenstruation. Health Care Women Int 2000; 21:517  \n23. Newton VL: Everyday Discourses of Menstruation, London, Palgrave Macmillan, 2016. \n\n16 \n \n24. Plan International UK: Break the barriers: Girls' experiences of menstruation in the UK. \n2018. https://plan-uk.org/act-for-girls/girls-rights-in-the-uk/break-the-barriers-our-\nmenstrual-manifesto, Last accessed 23.02.21. \n25. Klein JR, Litt IF: Epidemiology of adolescent dysmenorrhea. Pediatrics 1981; 68:661 \n26. Andersch B, Milsom I. An epidemiologic study of young women with dysmenorhea. Am \nJ Obstet Gynecol 1982; 144:655 \n27. Fisher M, Trieller K, Napolitano B: Premenstrual symptoms in adolescents. J Adolesc \nHealth Care 1989; 10:369 \n28. Wilson CA, Keye WR: A survey of adolescent dysmenorrhea and premenstrual symptom \nfrequency: a model program for prevention, detection, and treatment. J Adolesc Health \nCare 1989; 10:317 \n29. Teperi J, Rimpela M: Menstrual pain, health and behaviours in girls. Soc Sci Med 1989; \n29:163 \n30. Hillen TI, Grbavac SL, Johnston PJ, et al: Primary dysmenorrhea in young Western \nAustralian women: prevalence, impact, and knowledge of treatment. J Adolesc Health \n1999; 25:40 \n31. National Institute for Health and Care Excellence: Endometriosis: Diagnosis and \nmanagement. London: NICE; 2019.  \nhttps://www.nice.org.uk/guidance/ng73/resources/endometriosis-diagnosis-and-\nmanagement-pdf-1837632548293, Last accessed 23.02.21. \n32. Austin JK, Shafer PO, Deering JB: Epilepsy familiarity, knowledge, and perceptions of \nstigma: report from a survey of adolescents in the general population. Epilepsy Behav \n2002; 3(4):368. doi:10.1016/s1525-5050(02)00042-2 \n33. Ghai V, Jan H, Shakir F, Haines P, Kent A: Diagnostic delay for superficial and deep \nendometriosis in the United Kingdom. J Obstet Gynaecol 2020; 40(1):83. \ndoi:10.1080/01443615.2019.1603217 \n34. Soliman AM, Fuldeore M, Snabes MC: Factors associated with time to endometriosis \ndiagnosis in the United States. J Womens Health (Larchmt) 2017; 26:788. doi: \n10.1089/jwh.2016.6003. \n35. Seear K: The etiquette of endometriosis: Stigmatisation, menstrual concealment, and the \ndiagnostic delay. Soc Sci Med 2009; 69:1220 \n36. Agarwal SK, Chapron C, Giudice LC, et al: Clinical diagnosis of endometriosis: a call to \naction. Am J Obstet Gynecol 2019; 220(4):354.e1. doi:10.1016/j.ajog.2018.12.039 \n\n17 \n \n37. Weckesser A, Randhawa A, Williams G, et al: Let’s Talk.Period. Centring the Voices of \nYoung People. Plan International UK: London 2019. https://plan-uk.org/file/plan-uk-ltp-\nlearning-briefing-1pdf/download?token=F0NCK5lH, Last accessed 23.02.21. \n38. Pound P, Langford R, Campbell R: What do young people think about their school-based \nsex and relationship education? A qualitative synthesis of young people’s views and \nexperiences.  BMJ Open 2016; 6(9). \n39. Burrows A, Johnson S: Girls' experiences of menarche and menstruation. J Reprod Infant \nPsyc 2005; 23:235  \n40. Marván M and Molina-Abolnik M: Mexican adolescents’ experience of menarche and \nattitudes toward menstruation: Role of communication between mothers and daughters. J \nPediatr Adolesc Gynecol 2012; 25(6):358 \n41. Gunson, JS: Nature, menstrual suppression, and the value of material feminism. Health \nSociology Review 2016; 25(3):312  \n42. Jackson TE, Falmagne RJ: Women wearing white: Discourses of menstruation and the \nexperience of menarche. Feminism & Psychology 2013; 23(3):379  \n43. Haamid F, Sass AE, Dietrich JE. Heavy Menstrual Bleeding in Adolescents [published \ncorrection appears in J Pediatr Adolesc Gynecol 2017; 30(6):665]. J Pediatr Adolesc \nGynecol. 2017; 30(3):335. doi:10.1016/j.jpag.2017.01.002 \n44. Rashed AN, Yingfen H, Wilton L, et al: Trends and patterns of hormonal contraceptive \nprescribing for adolescents in primary care in the UK. BMJ Sex Reprod Health 2015; \n41(3):159 \n45. Holness N: A global perspective on adolescent pregnancy. Int J Nurs Pract 2015; \n21(5):677 \n \n \n \n \n \n \n \n \n\n18","source_license":"CC0","license_restricted":false}