{"paper_id":"da9cb2ba-e85d-4ff8-9244-1f302f6739b1","body_text":"Global Insights in Medicine and Nursing\nhttps://www.pangupress.com/journal/gimn\n19\nDoi: 10.65140/gimn202601.18\nArticle\nAcademic Editor: Henry Ma\nReceived:31 March 2026\nAccepted:29 April 2026\nPublished:24 June 2026\nCopyright: This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License (CC BY 4.0), which\npermits unrestricted use, distribution, and\nreproduction in any medium, provided the original\nauthor(s) and source are credited.\nCurrent Status of Clinical Diagnosis\nand Management of Adolescent\nEndometriosis\nShengnan Wei1 and Pu Li2,*\n1. School of Medicine, Tianjin University, Tianjin 300000, China\n2. Department of Gynecology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin,\n300000, China\n* Correspondence: Pu Li, w8823_@tju.edu.cn\nAbstract\nEndometriosis is a disorder characterized by the presence of functional\nendometrial tissue, including glands and stroma, outside the uterine cavity.\nWhen it occurs in adolescents, defined by the World Health Organization as\nindividuals aged 10 to 19 years, it is referred to as adolescent endometriosis\nor early-onset endometriosis. It is one of the major pathological causes of\ndysmenorrhea and chronic pelvic pain in this population. Adolescent\nendometriosis is often insidious in onset and heterogeneous in clinical\npresentation, and may be accompanied by gastrointestinal and urinary tract\nsymptoms, pain syndromes, as well as anxiety and depression. To date,\nthere are no established noninvasive approaches for early diagnosis or\neffective strategies for disease prevention. As a result, adolescent\nendometriosis is frequently overlooked, leading to substantial diagnostic\ndelay and seriously affecting physical and mental health as well as future\nfertility.\nKeywords: Adolescent; Endometriosis; Diagnosis; Management\n1. Introduction\nEndometriosis (EMs) is a chronic gynecologic disorder characterized by the presence of functional\nendometrial tissue, including glands and stroma, outside the uterus, where it can proliferate, invade surrounding\ntissues, and undergo repeated bleeding, thereby leading to pain, inflammation, mass formation, and infertility [ 1].\nIt is one of the major causes of dysmenorrhea, chronic pelvic pain, and infertility. Its exact etiology and\npathogenesis remain incompletely understood. The biological properties of the eutopic endometrium, retrograde\nmenstruation, hormonal imbalance, immune and inflammatory factors, genetic susceptibility, and environmental\nexposures may all be involved in the development and progression of EMs [ 1]. The World Health Organization\nand the American College of Obstetricians and Gynecologists define adolescence as 10 to 19 years and 12 to 21\nyears, respectively, and EMs occurring during this period is generally referred to as adolescent endometriosis. A\nmulticenter study showed that among individuals whose symptoms began between 9 and 19 years of age, the\nmedian delay to diagnosis was as long as 14.8 years, substantially longer than that observed in those with\nsymptom onset in adulthood (20 to 30 years, 6.9 years; 31 to 45 years, 2.9 years) [2]. This diagnostic delay has\nbeen attributed to several factors, including nonspecific and relatively mild symptoms, the perception of\nmenstruation as a negative event by both patients and their mothers, normalization of dysmenorrhea, limited\nawareness of the disease among some healthcare professionals, insufficient access to specialist care, and the\nlimitations of currently available diagnostic tools. Together, these factors can profoundly impair quality of life,\nmental health, and long-term reproductive outcomes in adolescents with EMs [3]. Therefore, early recognition\n\n20\nDoi: 10.65140/gimn202601.18\nand timely management of adolescent endometriosis deserve greater clinical attention. This review summarizes\nthe current status of clinical diagnosis and management of adolescent endometriosis, with the aim of providing\nnew perspectives for its early detection and treatment in adolescent females.\n2. Prevalence and Risk Factors for Adolescent Endometriosis\n2.1. Prevalence\nReported prevalence rates of adolescent endometriosis vary considerably across studies, ranging from 19%\nto 73% [4]. Previous studies have shown that the disease most commonly develops after menarche, with an\nestimated prevalence of 4% to 17% among postmenarchal girls. Some patients may even develop related\nsymptoms before menarche. Among adolescent females with chronic pelvic pain, the prevalence of\nendometriosis has been reported to range from 25% to 38% [5]. In those who undergo further laparoscopic\nevaluation for chronic pelvic pain or refractory dysmenorrhea, the detection rate increases substantially,\nreaching approximately 62% to 75% [6]. A systematic review further found that, among symptomatic\nadolescents undergoing laparoscopy, the detection rate of endometriosis ranged from 25% to 100% across\nstudies, with a mean of 64%. Among cases staged according to the revised American Society for Reproductive\nMedicine classification, most lesions were classified as stage I or II, although some patients had already\nprogressed to stage III or IV disease [7]. In an analysis of 50 adolescents with obstructive reproductive tract\nanomalies, Kapczuk et al. found that approximately half had concomitant endometriosis at the time of\nlaparoscopy. Further stratified analysis showed marked differences in prevalence according to the site of\nobstruction, with the highest risk observed in patients with cervical aplasia [8].\n2.2. Risk Factors\nThe etiology of adolescent endometriosis has not yet been fully elucidated, but available evidence suggests\nthat its risk profile may reflect exposures occurring across the life course. Early-life intrauterine and perinatal\nexposures, such as low birth weight, preterm birth, in utero exposure to maternal smoking or diethylstilbestrol,\nand infant feeding patterns, may contribute to later susceptibility to endometriosis [9]. After the onset of puberty,\nwith the establishment of menstruation, factors such as increased retrograde menstruation and outflow tract\nobstruction may further promote the development of ectopic lesions [8]. From adolescence to adulthood, early\nmenarche before 12 years of age, short menstrual cycles, heavy menstrual bleeding, low body mass index,\nfamily history, and obstructive Müllerian anomalies have all been associated with an increased risk of\nendometriosis. In addition, some studies have suggested that migraine and asthma may also be associated with\nadolescent endometriosis [ 10]. Overall, adolescent endometriosis is likely to result from the combined effects of\nearly-life susceptibility and puberty-specific exposures.\n3. Clinical Features and Key Diagnostic Considerations in Adolescent Endometriosis\n3.1. Clinical Presentation\nThe clinical manifestations of adolescent endometriosis are nonspecific, with pain representing the\npredominant symptom. Among adolescents with pelvic pain, dysmenorrhea alone accounts for 9.4% of\npresentations, noncyclic pelvic pain alone for 28. 1%, and the coexistence of both for 62.5% [ 11 ]. In addition to\npelvic pain, adolescents with endometriosis frequently present with gastrointestinal and urogenital symptoms.\nStudies have shown that 56% and 52% of laparoscopically confirmed cases report at least one gastrointestinal or\nurogenital symptom, respectively. Gastrointestinal symptoms mainly include nausea, abdominal bloating,\ntenesmus, diarrhea, and constipation, whereas urogenital symptoms commonly include bladder pain, dysuria,\nurinary frequency, urinary urgency, nocturia, and hematuria [ 12, 13]. Adolescent endometriosis is also associated\nwith a substantial burden of comorbidity. Smorgick et al. reported that among adolescents and young women\nwith endometriosis, 56% had concomitant pain syndromes, 48% had mood disorders, and 26% had asthma [ 14].\nMiller et al. further found that migraine was significantly more common in adolescents with endometriosis than\nin those without the disease (69.3% vs 30.7%), and that migraine severity was linearly associated with an\nincreased risk of endometriosis [ 15]. Collectively, these findings indicate that adolescent endometriosis is not\nmerely a pelvic pain disorder, but rather a heterogeneous condition centered on pain and frequently\n\n21\nDoi: 10.65140/gimn202601.18\naccompanied by gastrointestinal symptoms, urogenital manifestations, and chronic pain related comorbidities.\nIts complex and nonspecific clinical phenotype is a major contributor to difficulties in early recognition and to\nsubstantial diagnostic delay.\n3.2. Imaging Findings\nImaging plays an important role in the evaluation of adolescent endometriosis, but its diagnostic\nperformance remains clearly limited, particularly for early-stage or superficial lesions. Therefore, negative\nimaging findings do not exclude the disease. In an ultrasonographic study of 270 symptomatic and\nasymptomatic adolescents, Martire et al. found that only 13.3% had at least one ultrasound feature suggestive of\nendometriosis, including ovarian endometrioma in 11. 0 % , adenomyosis in 5.2 % , and deep infiltrating\nendometriosis in 3.7%. Among patients with dysmenorrhea and dyspareunia, the rate of positive ultrasound\nfindings increased to 21% and 33%, respectively. In those with bowel symptoms or dyspareunia, ultrasound\nfeatures suggestive of deep infiltrating disease were detected in 33 % and 25 % , respectively [ 16 ]. These findings\nsuggest that ultrasonography has greater diagnostic value in patients with specific symptom clusters, especially\nthose at higher risk of deep lesions. Chinese expert consensus further emphasizes that ultrasound assessment\nshould be performed in a systematic manner. For patients with suspected endometriosis, transvaginal\nultrasonography should be used as the primary modality when feasible, with transrectal ultrasonography\nconsidered when necessary. In addition to identifying ovarian endometriomas, attention should be directed\ntoward ovarian mobility, pelvic adhesions, the sliding sign in the pouch of Douglas, and deep infiltrating\nnodules in the anterior and posterior pelvic compartments [ 17, 18]. In cases with inconclusive ultrasound\nfindings or suspicion of deep infiltrating lesions involving the bladder, rectosigmoid colon, bowel, or ureters,\nmagnetic resonance imaging may be used to further assess lesion location and extent, although its sensitivity for\nsuperficial peritoneal lesions remains limited [ 19]. In addition, a retrospective analysis by Iosca et al. of 64\nsurgically confirmed cases showed that multidetector spiral computed tomography with colon water enema had\nrelatively high diagnostic accuracy for intestinal and ureteral adolescent endometriosis [20]. However, because\nof radiation exposure, it is not suitable for routine use in adolescents.\n3.3. Emerging Biomarkers\nAt present, no single serum biomarker is available for the clinical diagnosis of adolescent endometriosis\n[21]. Compared with the adult literature, evidence on novel biomarkers in adolescents remains limited, although\nmicroRNAs have emerged as a particularly promising area of investigation. Vash-Margita et al. reported a\ndistinct serum microRNA expression profile in adolescents and young women with endometriosis, including\nthree upregulated microRNAs such as miR-501-5 p and 11 downregulated microRNAs such as miR-2116-5p\n[22]. These findings suggest potential utility as noninvasive biomarkers for early adolescent endometriosis.\nHowever, the evidence remains insufficient, and such markers cannot yet be applied in routine clinical\ndiagnosis.\n3.4. Laparoscopy\nLaparoscopy remains an important option when symptoms persist, empirical therapy fails to provide\nadequate relief, and the clinical suspicion of endometriosis remains high. In adolescents, laparoscopic findings\nare often less typical than those seen in adults. Lesions may appear as small white spots, reddish hyperemic\nareas, clear or polypoid changes, or vesicle-like lesions, rather than the blue-black implants and fibrotic changes\nmore commonly described in adult disease [23]. Because these appearances can be subtle, failure to recognize\nthem may lead to missed lesions or an underestimation of disease extent during surgery.\n3.5. Early Diagnostic Considerations\nThe diagnosis of adolescent endometriosis should be based on an integrated assessment of medical history,\nspecialist examination, imaging findings, and response to treatment [ 18]. In adolescents with progressively\nworsening dysmenorrhea, noncyclic pelvic pain, or concomitant gastrointestinal and urogenital symptoms,\nparticularly when nonsteroidal anti-inflammatory drugs or empirical hormonal therapy provide insufficient relief,\nclinicians should maintain a high index of suspicion for endometriosis. History taking should focus on pain\ncharacteristics, the temporal relationship between symptoms and menstruation, symptom onset, and previous\n\n22\nDoi: 10.65140/gimn202601.18\ntreatment response. Attention should also be paid to clues suggestive of obstructive reproductive tract anomalies,\nsuch as primary amenorrhea, cyclic pelvic masses, or impaired menstrual outflow. Ultrasonography is the\nfirst-line imaging modality, and magnetic resonance imaging may be used when necessary to further define\nlesion extent and deep infiltration. However, negative imaging does not rule out the disease. In patients in whom\nobstructive reproductive tract anomalies and other structural disorders have been excluded but clinical suspicion\nfor endometriosis remains high, empirical treatment may be initiated first. If symptoms persist despite treatment\nand imaging remains nondiagnostic, laparoscopy should be further considered. Overall, the diagnosis of\nadolescent endometriosis relies on early recognition based on clinical suspicion, dynamic reassessment during\ntreatment, and stratified use of different diagnostic modalities.\n4. Treatment of Adolescent Endometriosis\nAdolescent endometriosis (EMs) lacks a universally standardized, dedicated management strategy. Current\ntreatment principles emphasize individualized, long-term management, with the primary goals of pain control,\nsuppression of disease progression, preservation of fertility, and reduction of recurrence risk. Given that\nadolescents are in a critical phase of skeletal and reproductive system development, therapeutic decision-making\nshould comprehensively consider age, symptom burden, disease extent, as well as drug safety, tolerability, and\nadherence. For patients without clear surgical indications, medical therapy remains the cornerstone of\nmanagement. In contrast, surgical intervention should be considered in cases complicated by obstructive\nreproductive tract anomalies, evident disease progression, or inadequate response to standardized medical\ntreatment [6, 24].\n4.1. Medical treatment\n4. 1.1. Nonsteroidal anti inflammatory drugs\nNonsteroidal anti inflammatory drugs (NSAIDs) are first line agents for symptomatic relief of pain\nassociated with adolescent endometriosis [26]. They exert analgesic effects mainly by inhibiting cyclooxygenase\nactivity and reducing prostaglandin synthesis. Their role is primarily analgesic rather than disease-controlling.\nAlthough NSAIDs can reduce pain, they do not prevent progression of endometriotic lesions and therefore\ncannot be relied upon as the main long-term approach when suppression of disease activity is required. Current\nevidence is also insufficient to determine whether individual NSAIDs differ meaningfully in efficacy or safety\n[27,28 ]. Gastrointestinal intolerance remains a practical concern, and prolonged use warrants vigilance for\ngastrointestinal bleeding as well as hepatic and renal toxicity.\n4. 1.2. Combined oral contraceptives\nCombined oral contraceptives (COCs) are commonly used in the medical management of adolescent\nendometriosis and are particularly relevant when pain is not adequately controlled with NSAIDs alone. In\nadolescents, they are generally regarded as well tolerated and suitable for long-term use, as available evidence\nhas not shown meaningful adverse effects on short-term growth-related measures such as height, weight, or\nbody fat indices [6, 18]. Their clinical benefit is mainly attributed to suppression of the\nhypothalamic-pituitary-ovarian axis, which reduces estrogenic stimulation of ectopic endometrial tissue and\nthereby limits lesion activity and promotes regression [26]. In practice, COCs are used primarily for the control\nof mild to moderate pain symptoms, including dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain, and\ncan contribute to improved quality of life. Continuous administration may offer better symptom control than\ncyclic regimens, although this advantage is often offset by a higher frequency of breakthrough bleeding or\nirregular vaginal bleeding, which may affect adherence in some patients. The choice of regimen should therefore\nbe individualized according to symptom severity and the patient’s ability to tolerate unscheduled bleeding\n[27,28].\n4. 1.3. Progestins\nProgestins relieve pain and suppress lesion activity by inducing decidualization and atrophy of both\neutopic endometrium and ectopic lesions, while also creating a relatively hypoestrogenic state [29]. Dienogest, a\nnewer progestin, has been shown to alleviate endometriosis related pain and reduce the size of ovarian\n\n23\nDoi: 10.65140/gimn202601.18\nendometriomas [30]. It has relatively limited effects on liver function, renal function, and bone mass, and may\ntherefore be used in the treatment of adolescent endometriosis [31]. Nevertheless, adolescence is a critical\nperiod for bone mass accrual, and prolonged progestin use may carry a risk of bone loss [32]. Its use in this\npopulation therefore requires careful balancing of clinical efficacy against skeletal safety.\n4. 1.4. Gonadotropin releasing hormone agonists\nGonadotropin releasing hormone agonists (GnRH agonists) suppress hypothalamic pituitary ovarian axis\nfunction and induce a hypoestrogenic state, thereby relieving symptoms and inhibiting lesion activity. They are\nwidely regarded as among the most effective medications for endometriosis [33]. However, treatment with\nGnRH agonists may cause a range of hypoestrogenic adverse effects, including hot flushes, night sweats, sleep\ndisturbance, decreased libido, and mood changes, while also increasing the risk of bone loss. Their use in\nadolescents should therefore be approached with caution. In clinical practice, GnRH agonists are generally\nconsidered only for patients older than 16 years, and add back therapy should be initiated from the start of\ntreatment [34].\n4. 1.5. Traditional Chinese medicine\nTraditional Chinese medicine may serve as an adjunctive option for pain management in adolescent\nendometriosis. Available studies suggest that formulas such as Guizhi Fuling, Sanjie Zhentong, and Shaofu\nZhuyu may provide analgesic benefit [35-37].\n4. 1.6. Other medications\nIn addition to the agents commonly used in current practice, gonadotropin releasing hormone antagonists,\naromatase inhibitors (AIs), selective progesterone receptor modulators (SPRMs), selective estrogen receptor\nmodulators (SERMs), dopamine receptor 2 agonists, and statins have also been investigated for the treatment of\nendometriosis [38]. Among these, GnRH antagonists and aromatase inhibitors are developing relatively rapidly.\nThe former have already entered clinical use in adults, whereas the latter are mainly reserved for refractory\ncases [21]. By contrast, SPRMs, SERMs, dopamine receptor 2 agonists, statins, and anti nerve growth factor\nantibodies remain largely exploratory. Overall, evidence regarding the efficacy and safety of these newer agents\nin adolescents remains insufficient, and they should not currently be recommended for routine treatment in this\npopulation.\n4.2. Surgical treatment\nIn clinical practice, treatment of adolescent endometriosis is centered primarily on nonsurgical approaches,\nparticularly NSAIDs and hormonal therapy. The timing of initial surgical intervention must be determined with\ngreat caution. Surgery performed too early may increase the risks of loss of normal ovarian tissue, diminished\novarian reserve, and repeat operations, whereas delayed surgery may allow further disease progression,\ndistortion of pelvic anatomy, and impairment of organ function. Both scenarios may ultimately compromise\nfertility in adolescent patients [39]. At present, surgery is generally considered for adolescents with\nendometriosis who fail to respond after 3 to 6 months of standardized medical treatment, or who present with\ninfertility, lesions of uncertain nature with suspected malignancy, acute complications, or obstructive\nreproductive tract anomalies; such procedures should be undertaken by an experienced multidisciplinary team\n[40,41].\nLaparoscopy is the preferred surgical approach because it is minimally invasive and provides excellent\nvisualization. The goals of surgery are to remove lesions, restore normal pelvic anatomy, relieve obstruction,\nand preserve ovarian function and fertility to the greatest extent possible [21]. Compared with adults,\nadolescents are more likely to have early stage disease, and laparoscopic lesions often appear as vesicular, white\npunctate, or red petechial peritoneal lesions rather than the more typical pigmented lesions seen in adults [42].\nAs a result, the risk of intraoperative underrecognition is relatively high. Surgeons should therefore be familiar\nwith the laparoscopic morphology of adolescent endometriotic lesions. When necessary, high definition\nlaparoscopy with close up magnified inspection and underwater inspection after saline instillation may be used\nto improve lesion detection [ 10]. In addition, suspicious peritoneal lesions should preferably be excised with\n\ncold instruments rather than coagulated, so as to avoid thermal destruction of tissue that may compromise\nhistopathologic evaluation [43 ].\nFor patients with ovarian endometriomas [44], meticulous cyst dissection is essential. Electrocautery\nshould be minimized during hemostasis to reduce thermal injury to ovarian tissue, and alternative methods such\nas suturing or hemostatic sealants may be considered. If lesion ablation is required, plasma energy or carbon\ndioxide laser should be preferred. At the end of surgery, anti adhesion agents such as oxidized regenerated\ncellulose or hyaluronic acid carboxymethylcellulose may also be considered to reduce postoperative adhesion\nformation. Following surgery, adolescents with endometriosis still require long term medical management,\ntogether with psychological support and health education, in order to reduce recurrence and delay disease\nprogression.\n5. Conclusion\nAdolescent endometriosis is an estrogen-dependent disease with chronic inflammatory and progressive\nfeatures. Although symptoms often become evident during adolescence, the processes that predispose to disease\nonset and progression may begin much earlier in life and may be linked to intrauterine and perinatal exposures,\nalong with genetic background, immune dysregulation, and menstrual characteristics. Adolescents represent a\ndistinct clinical population, and no single optimal treatment strategy has yet been defined for them. Management\nshould be tailored to the patient’s symptoms and clinical needs, with attention to the early identification of\nsuspected cases and, when appropriate, the timely use of empirical medical therapy. The expected benefits and\npotential adverse effects of different medications also need to be weighed carefully. 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