Endometriosis in adolescent: a review of current diagnostic and therapeutic guidelines and expert consensus

Endometriosis is a widespread, chronic, inflammatory gynecological condition characterized by the presence of endometrial like tissue outside of the uterine cavity. Endometriosis affects 6–10% of women of reproductive age [1, 2]. In adolescents, available data are considerably more limited; however, it is estimated that endometriosis occurs in approximately 47% of girls with chronic pelvic pain (CPP) and in up to 70% of those experiencing primary dysmenorrhea resistance to nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal treatments [3, 4]. The pathogenesis of endometriosis has not been completely understood; however, retrograde menstruation (Sampson’s theory) is considered the most likely mechanism, supplemented by hypotheses involving coelomic metaplasia, immune dysfunction, as well as genetic and environmental factors. Hormonal influences can also have a significant role, particularly estrogen dependency and progesterone resistance which promote the persistence of ectopic endometrial lesions and the development of a localized inflammatory response [2, 5]. In adult women, the most characteristic symptoms include: chronic pelvic pain, dysmenorrhea, dyspareunia and infertility. Among women of reproductive age presenting with chronic pelvic pain or infertility, the prevalence of endometriosis is estimated at approximately 35–45% [2, 6, 7]. In adolescents, the dominant manifestations are more severe menstrual pain compared to adult women, often associated with heavy (44%) or irregular (60%) menstrual bleeding. Gastrointestinal symptoms — such as nausea, dyschezia, constipation and diarrhea, as well as urinary tract symptoms, chronic fatigue, signs of depression, migraines and severe headaches are also frequently reported. These manifestation are often misassigned to perimenstrual/ /period symptoms [8, 9]. Before the age of 20, endometriosis tends to be less advanced, typically presenting as superficial peritoneal lesions, although deep endometriosis or ovarian endometriomas can also occur [3]. Consequently, the diagnostic process is often prolonged, and the delay in establishing a diagnosis may reach 4–11 years [10]. Adolescent endometriosis is often underdiagnosed, so recognizing the varied spectrum of symptoms is crucial to enable timely onset of appropriate treatment and contribute to improved quality of life. During adolescence, disease progression may occur, potentially affecting future fertility and overall health. The aim of this review is to compare current guidelines and recommendations regarding the diagnosis and management of endometriosis in adolescents. DIAGNOSTIC PROCESS IN IDENTIFYING ENDOMETRIOSIS IN ADOLESCENTS The diagnostic process of endometriosis differs between adolescents and adult women. These differences result from the distinct clinical presentation — often nonspecific in younger patients — as well as limitations in the use of certain diagnostic equipments and reduced access to specialized gynecologic care for this age group. In adolescents, a detailed medical history is crucial, obtained from both the patient and the legal guardian. This should include the: character and intensity of pelvic pain, duration of symptoms, response to previously initiated pharmacotherapy, and the presence of symptoms from other systems. Physical examination often reveals no significant abnormalities, and gynecological examination may be limited due to anatomical, psychological and cultural factors [4, 11]. In clinical practice, the primary diagnostic process remains transabdominal ultrasound or transrectal ultrasound (TRUS) in sexually inactive adolescents. Transvaginal ultrasonography (TVUS), while diagnostically valuable, may pose psychological discomfort or cultural limits for adolescents and is therefore recommended after thorough counselling or in patients who are already sexually active. In selected situations — particularly in cases of inconclusive ultrasound findings or suspected advanced disease — magnetic resonance imaging (MRI) is advised [12–15]. International guidelines underline that in adolescents, a clinical diagnosis of endometriosis may be figure out based on symptoms and response to hormonal therapy, without histopathological confirmation. Diagnostic laparoscopy remains part of standard diagnostic procedures, current recommendations advise its use primarily in cases of failure of empiric treatment or when differentiation from other diseases is required [12–15]. Available systematic reviews by Yeung et al. [16] indicate that in the majority of adolescent patients, endometriotic lesions are superficial (presenting as red lensions, “dew drop” lesions or membranous endometriosis) corresponding to stage I of disease severity according to the American Society for Reproductive Medicine (ASRM) classification. Superficial endometriotic lesions in adolescents only sporadically exhibit surrounding zones of fibrosis or sclerosis, which are considerably more common in adult women [17]. Other literature data suggest that in patients under 20 years of age, stage II is the most frequently observed stage of disease according to the ASRM classification [16, 17]. It should be emphasized that the stage of disease assessed using the ASRM classification in adolescent patients does not demonstrate a clear correlation with the severity of pain symptoms. A review of the literature indicates that endometriosis in adolescents may occur at any stage of disease advancement [18], although stages I and II according to the ASRM classification clearly predominate. These observations challenge the traditional concept of linear disease progression, according to which early-stage endometriosis in young patients would predictably lead to the development of more advanced forms of the disease (stages III–IV) in adulthood [16–18]. | Table 1. Diagnostic approach to suspected endometriosis in adolescents versus adult women | ||| | Diagnostic step | Adolescents | Adult women | | | Medical history | Detailed history focusing on: - pain phenotype (dysmenorrhea, chronic pelvic pain), - age at symptom onset, - impact on daily functioning, - response to prior therapies (NSAIDs, hormonal treatment), - associated symptoms (gastrointestinal; urinary, mental illness), - family history of endometriosis | Comprehensive history including: - pelvic pain, - menstrual cycle characteristics, - infertility/subfertility, - associated symptoms (gastrointestinal; urinary, mental illness, dyspareunia) - previous gynecological procedures/ surgeries, - obstetric history, - previous medical treatments | | | Physical examination | Examination may be limited. Abdominal and transabdominal pelvic examination may reveal tenderness or a palpable mass. When appropriate and acceptable, a rectal examination may be considered *Patient comfort, consent, and cooperation are crucial | Full gynecological examination including speculum assessment (as indicated), bimanual pelvic examination, and rectovaginal palpation when deep infiltrating endometriosis is suspected. Findings may include uterosacral ligament nodularity, reduced uterine mobility, adnexal mass, or pelvic tenderness | | | Imaginig examination | Ultrasound | Transabdominal pelvic ultrasound is usually the first-line modality; transrectal ultrasound may be considered in selected cases. Sensitivity is limited for superficial/early stage disease; ultrasound is most useful for detecting ovarian endometriomas and features of advanced disease | TVUS is the first-line modality, with high diagnostic performance — particularly when performed using an endometriosis-specific (expert) protocol. Enables assessment of ovarian endometriomas and DIE | | MRI | Considered when ultrasound is inconclusive or when mapping of suspected disease is required | Indicated when DIE is suspected, for preoperative planning, or when ultrasound results are unclear. Provides detailed anatomical information | | | Surgical treatment | Considered when symptoms persist despite appropriate empirical medical therapy or when the diagnosis remains uncertain. A minimally invasive, fertility-sparing approach is recommended. Routine „peritoneal shaving” is not recommended. The procedure should be performed cautiously, primarily to confirm diagnosis, assess disease extent, and preserve future fertility, while prioritizing symptom control over extensive excision | Not recommended as a first-line diagnostic procedure. Considered when imaging is inconclusive, symptoms persist despite adequate medical management, or when surgical treatment is indicated | | | Empirical treatment | Typically initiated prior to invasive diagnostics (NSAIDs and hormonal therapy such as combined oral contraceptives or progestins). Clinical improvement supports a presumptive diagnosis | Empirical medical treatment is considered in symptomatic women with suspected endometriosis. Hormonal therapy (combined hormonal contraceptives or progestins) and NSAIDs are commonly used. Treatment response should guide further management; persistent symptoms may warrant advanced imaging and/or surgical evaluation, including consideration of more advanced operative interventions | | | DIE — deep infiltrating endometriosis; MRI — magnetic resonance imaging; NSAIDs — nonsteroidal anti-inflammatory drugs; TVUS — transvaginal ultrasound | THERAPEUTIC PROCEDURE AND TREATMENT ALGORITHM According to international guidelines and expert consensus statements, therapeutic management of endometriosis in adolescents should begin with patient education and lifestyle modification, including the use of nonsteroidal anti-inflammatory drugs, followed by the initiation of hormonal therapy if symptoms persist. American College of Obstetricians and Gynecologists (ACOG), European Society of Human Reproduction and Embryology (ESHRE), North American Society for Pediatric and Adolescent Gynecology (NASPAG) and Polish Society of Gynecologists and Obstetricians (PTGiP) recommend continuous combined hormonal contraception or progestin-only therapy as first-line treatment [12–15], including the levonorgestrel-releasing intrauterine system [14]. European Society of Human Reproduction and Embryology (ESHRE) also identifies dienogest as an effective first-line therapy stage for the reduction of endometriosis related symptoms, while noting its potential adverse effects on bone mineral density [14]. In the absence of clinical improvement after first-line therapy, treatment with gonadotropin-releasing hormone analogues may be considered. American College of Obstetricians and Gynecologists (ACOG) and ESHRE recommend the use of GnRH agonists in adolescents with laparoscopically confirmed endometriosis and failure of previous therapy, with the maximum treatment duration not exceeding 12 months [13, 14]. All societies emphasize the necessity of concomitant add-back therapy to reduce hypoestrogenic symptoms and preserve bone mineral density. North American Society for Pediatric and Adolescent Gynecology (NASPAG) highlights that adolescence is a critical period for achieving peak bone mass; therefore, empirical use of GnRH agonists or antagonists in adolescents without a definitive diagnosis of endometriosis and failure of hormonal therapy is disouraged [12]. When empirical treatment fails to achieve adequate symptom control and the disease significantly impairs daily functioning, diagnostic and therapeutic laparoscopy may be considered [12–15]. However, current guidelines emphasize the importance of minimizing surgical interventions in young women, particularly overly aggressive excision of endometriotic lesions, due to the risk of recurrence and postoperative complications, including the formation of postoperative adhesions. In adolescents with ovarian endometriosis, a cautious surgical approach is recommended, taking into account the potential risk of diminished ovarian reserve [12–15]. LAPAROSCOPY IN THE DIAGNOSTIC EVALUATION OF ENDOMETRIOSIS IN ADOLESCENTS For many years, laparoscopy has been considered the “gold standard” for the diagnosis of endometriosis, allowing both direct visualization of endometriotic lesions and collection of tissue for histopathological examination. In the adolescent population, however, its role remains a matter of discussion, primarily due to the — albeit limited — invasiveness of the procedure and the growing importance of diagnostic and therapeutic strategies based on empirical treatment. Data derived from meta-analyses and observational studies indicate that among adolescents referred for laparoscopy because of chronic pelvic pain or severe dysmenorrhea, the intraoperative detection rate of endometriosis is approximately 60–70% [19] These findings were confirmed by Janssen et al. [20] and Sachedin et al. [21], who demonstrated that the prevalence of laparoscopically confirmed endometriosis ranged from 62% to 75% in studied populations of adolescents presenting with pain symptoms. In the majority of patients, the disease was diagnosed at an early stage — stage I or II according to the American Society for Reproductive Medicine (ASRM) classification — with a predominance of superficial peritoneal lesions. This lesion pattern may explain the limited sensitivity of imaging modalities in this group of patients and simultaneously indicates that, in a subset of adolescents, laparoscopy remains the only method enabling unequivocal visualization of endometriotic lesions and establishment of a definitive diagnosis [19–21]. It should also be emphasized that although the clinical presentation of endometriosis in adolescents often allows for recognition of the disease, it does not reliably reflect the extent or stage of disease progression. Brosens et al. [22] proposed the concept of endometriosis as a “progressive” condition; however, available studies conducted in adolescent populations suggest that despite most laparoscopically confirmed cases corresponding to early ASRM stages, the disease may occur across all stages of severity in this age group . This underscores the fact that accurate assessment of lesion characteristics and disease extent based solely on clinical symptoms remains substantially limited and continues to pose a significant therapeutic challenge [4, 23]. More recent data concerning the safety of laparoscopic procedures in adolescent patients indicate a relatively low rate of intraoperative and postoperative complications, as well as a low frequency of reoperations in this age group. In an analysis of 284 cases, 86.27% of patients experienced no complications within 30 days following surgery. The most commonly reported adverse event was postoperative pain (approximately 5%), whereas surgical site infections were rare (approximately 1%). No patients required reoperation. These findings suggest that diagnostic laparoscopy performed in specialized centers is associated with a favorable safety profile and may represent a justified diagnostic option in adolescents with severe pain refractory to conservative treatment [24]. At the same time, current recommendations emphasize that laparoscopy should not be considered a first-line diagnostic or therapeutic modality in adolescents with suspected endometriosis. In most surgically treated girls, superficial peritoneal lesions are identified, the long-term clinical significance of which, as well as their impact on future fertility, remains the subject of ongoing research. The ACOG recommend reserving laparoscopy for patients in whom several months of conservative management — including nonsteroidal anti-inflammatory drugs and hormonal therapy — has proven ineffective. Similar positions are reflected in contemporary European guidelines, including those issued by the ESHRE and the PTGiP, which allow for a clinical diagnosis of endometriosis in adolescents based on a typical symptom profile and a favorable response to hormonal treatment, without the need for routine laparoscopic confirmation [12–15]. Recent observational studies further indicate that although laparoscopy enables accurate assessment of disease stage and allows for simultaneous surgical treatment in the form of lesion ablation, the procedure itself does not eliminate the risk of subsequent surgical interventions in the future. Currently available data do not provide clear evidence supporting the superiority of lesion excision over ablative techniques in adolescents with superficial, low stage advance endometriosis [14, 25]. Shim et al. [25] emphasize that peritoneal shaving, particularly in cases without macroscopically visible disease, is not supported by current scientific evidence and may increase the risk of postoperative complications, most notably adhesion formation. These concerns are further corroborated by observations reported by Laufer et al. [26], who described worsening pelvic pain following extensive peritonectomy performed for superficial endometriosis, which was attributed to the development of postoperative adhesions. The table summarizes key diagnostic and therapeutic elements derived from current clinical guidelines and expert consensus statements issued by major scientific societies, with a focus on adolescent patients. NASPAG guaidance present a textbook-based expert consensus and was included due to the limited availability of high-quality evidence in adolescent populations. | Table 2. Diagnosis and management of endometriosis in adolescents: a review of clinical guidelines and expert consensus statements (ACOG, ESHRE, PTGiP, NASPAG) | ||||| | Medical history | Physical examination/ /gynecologic examination/ /laboratory tests | Imaging studies | Surgical treatment | Medical treatment | | | ACOGa (2018) [13] | Medical history is a key component of the diagnostic process. Detailed medical history, with particular attention to the cyclicity and characteristics of pain, its impact on quality of life, and school absenteeism. Other potential causes of dysmenorrhea should be carefully excluded | Pelvic examination should be considered to evaluate potential causes of secondary dysmenorrhea. Findings on pelvic examination may point to alternative or coexisting etiologies such as: endometriosis, obstructed reproductive tract anomalies, enlarged or irregular uterus, cervical friability or discharge suggesting pelvic inflammatory disease, adnexal masses (e.g. ovarian cysts), or pelvic floor dysfunction. Although serum Ca-125 levels may be increased in patients with endometriosis, the blood test are not recommended to monitor treatment or screen for endometriosis | Ultrasounds should be considered in all adolescents with suspected secondary dysmenorrhea, regardless of pelvic exam findings, as the preferred first-line imaging modality to identify obstructive genital tract anomalies, myomas, and adnexal masses including ovarian endometriomas. While ultrasound is useful for detecting ovarian endometriosis, it has limited value for non-ovarian endometriotic lesions. MRI may be required for more detailed characterization of müllerian anomalies or adnexal pathology, but it is not effective to be useful for identifying endometriotic peritoneal lesions or determining the extent of disease | Recommended for patients with chronic pelvic pain or dysmenorrhea or both unresponsive to pharmacologic therapy. To improve visualization, pelvic filling with saline and immersion of the laparoscope are recommended (magnification technique). Allows confirmation of the disease; tissue sampling for histopathological examination should be obtained from all visible lesions, and lesions should be removed (ablation or excision).Surgical procedures should be performed by an experienced surgeon. „Peritoneal stripping” is not recommended due to the risk of complications and lack of evidence of its effectiveness. Insertion of an LNG-IUS should be considered during the surgery. Radical procedures such as oophorectomy or hysterectomy are contraindicated | First line therapy Supressive hormonal therapy in adolescents with surgically confirmed or suspected endometriosis: — Continuous combined hormonal contraception (CHC); — Progestin-only therapy; — Levonorgestrelreleasing intrauterine system (LNG-IUS 52 mg). Second line therapy Patients with pain refractory to surgery and first line hormonal suppression: — GnRH agonist therapy for at least 6 months with add-back therapy. *Limited long-term data on bone mineral density effects in adolescents. *Add-back therapy is essential to prevent bone loss and hypoestrogenic symptoms. *DEXA scanning is not required before therapy or during treatment ≤ 12 months. *Counsel patients regarding adequate dietary calcium and vitamin D. *After discontinuation patients should transition to continuous hormonal therapy | | ESHREb (2022) [14] | A key diagnostic element is careful assessment of pain characteristics, including: - chronic or non-cyclic pelvic pain associated with nausea, dysmenorrhea, dyschezia, or dyspareunia, -as well as cyclic pelvic pain. *In adolescents, pain presentation is more heterogeneous than in adult women; therefore, a particularly thorough and detailed medical history is strongly recommended | Lack of adolescent-specific data. Per vaginam/per rectum examination has low sensitivity; may identify deeply infiltrating lesions. Normal findings do not exclude disease and should not preclude further imaging diagnostics. Acceptability of per vaginam/per rectum examination should be discussed with the patient and her legal guardian, considering age and cultural context. No reliable biomarkers identified (including CA-125). Serum markers are not recommended for diagnosing or excluding endometriosis in adolescents | TVUS is effective in detecting ovarian endometriosis; in girls with an intact hymen, it should be performed only after thorough discussion and informed consent. — Alternative imaging modalities include transabdominal, transrectal, and transperineal ultrasound, as well as MRI. — No studies have evaluated the diagnostic accuracy of TVUS specifically in the adolescent population; however, its proven effectiveness in adult patients supports cautious use in adolescents, with simultaneous consideration and discussion of alternative imaging methods | Laparoscopy should be considered in cases of negative imaging findings and lack of symptom improvement despite NSAIDs and hormonal treatment. — Pharmacological therapy should not be delayed while awaiting laparoscopy. — Biopsy of suspected lesions is recommended during surgery; however, a negative histopathological result does not exclude the disease. — Surgical management should be performed laparoscopically by an experienced surgeon, with the aim of complete excision of endometriotic lesions | Available data are limited; however, existing studies suggest the following management approach. First line therapy: Combined oral contraceptives (COCs) or progestins, including the levonorgestrel-releasing intrauterine system (LNG-IUS). Nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunctive therapy. Dienogest is effective; however, a potential reduction in BMD should be considered. Second line therapy Gonadotropin-releasing hormone (GnRH) agonists, reserved for patients with laparoscopically confirmed endometriosis and failure of first-line therapy. Maximum treatment duration of 12 months. Mandatory add-back therapy, preferably combined. Use with caution due to the risk of adverse effects and potential impact on BMD | | PTGiPc (2024) [15] | A detailed and comprehensive medical history is recommended, including the character and severity of dysmenorrhea, age at menarche, menstrual cycle regularity, and the presence of extragenital symptoms (gastrointestinal and urinary tract symptoms) | The extent of physical examination should be adjusted to the patient’s age and level of maturity; gynecological examination may be limited or omitted in sexually inactive girls | To extend the diagnostic evaluation of endometriosis in adolescents, the use of imaging modalities is recommended; however, in many cases their sensitivity remains limited. Ultrasonography should be the first-line imaging method In sexually active girls, TVS is the preferred technique, whereas in sexually inactive girls, examination should be performed using a TRS or via a TA approach with a filled urinary bladder. *In all cases, particular caution should be exercised when examining adolescents due to the high level of anxiety associated with both diagnostic procedures. MRI The examination should be performed in collaboration with a radiologist experienced in the assessment of pelvic pathology. However, routine use of magnetic resonance imaging is not required | Recommended only in cases refractory to conservative treatment and in diagnostically unclear situations. The procedure should be performed laparoscopically by an experienced surgeon, with the aim of confirming the diagnosis and achieving the most tissue-sparing excision of lesions possible, while preserving future fertility | First-line therapy: – Dienogest 2 mg/day for 9–12 months; in the event of adverse effects (e.g., hot flashes, mood disturbances), add-back therapy should be considered. – Combined oral contraceptives (COCs) or progestins; low-dose COCs administered in a continuous regimen. It should be noted that some progestins may reduce bone mineral density. Second-line therapy: – GnRH analogues in girls over 16 years of age, for up to 6 months (always with add-back therapy); potential adverse effects should be discussed with the patient. Alternative therapy: LNG-IUD. Adjunctive pain management: – Nonsteroidal anti-inflammatory drugs (NSAIDs). Failure of first- and second-line therapies and pain management: – Surgical excision of endometriotic lesions | | NASPAG*d (2024) [12] | Key diagnostic stage; response to initiated treatment | Abdominal palpation — evaluation of pain symptoms. Gynecologic examination depending on age and sexual activity; in the majority of patients limited to inspection and assessment of the external genitalia only. There are no validated specific blood tests approved for the diagnosis | TAUS first-line imaging modality [with lower sensitivity in detecting endometriomas and deep infiltrating endometriosis (DIE)]. TVUS in sexually active adolescents. MRI has diagnostic value comparable to 3D ultrasound for most deep lesions; there are insufficient data regarding its use in adolescents | After 3 to 6 months of therapy and not respond to management — laparoscopy is the primary step for diagnosis and treatment. Laparoscopy enables confirmation of the disease; during the procedure all visible lesions should be removed (electrocautery; endocoagulation; laser ablation; excision) and disease staging performed. Peritoneal “stripping” should not be performed | First line therapy Patient education and lifestyle modification/initiation of NSAID therapy. Second line therapy Hormonal therapy (combined hormonal contraceptives or progestins). Third line therapy GnRH agonists and GnRH antagonists *FDA-approved in patients 18 years of age and older *Since adolescence is a time of peak bone accrual, it’s not recommended to empirically use GnRH agonists in adolescents without a definitive diagnosis of endometriosis and failure of first-line hormonal management | | a — American College of Obstetricians and Gynecologists; b — European Society of Human Reproduction and Embryology; c — Polish Society of Gynecologists and Obstetricians; d — North American Society for Pediatric and Adolescent Gynecology; MRI — magnetic resonance imaging; NSAIDs — nonsteroidal anti-inflammatory drugs; TVUS — transvaginal ultrasound; DIE — deep infiltrating endometriosis; TAUS — transabdominal ultrasound; TRS — transrectal probe; TVS — transvaginal ultrasound; TA — transabdominal; LNG-IUD — Levonorgestrel-releasing intrauterine device; BMD — bone mineral density |

Available scientific evidence and analyses of current clinical guidelines indicate that endometriosis in adolescents represents a distinct clinical entity requiring an individualized diagnostic and therapeutic process. The atypical nature of symptoms, the limited utility of conventional imaging modalities, as well as the young age of patients — which predisposes them to psychological barriers associated with gynecological consultations significantly hinder early diagnosis of the disease. As a consequence, prolonged diagnostic delays are frequently observed and, as demonstrated in numerous studies, negatively affect quality of life, psychosocial functioning, and long-term outcomes in adolescent patients. All analyzed data and recommendations from scientific societies emphasize the central role of a detailed medical history and the early initiation of empirical treatment (particularly in patients with dysmenorrhea refractory to standard therapy). This approach represents a significant departure from the traditional paradigm in which laparoscopic confirmation was considered a prerequisite for initiating treatment. Current recommendations indicate that a clinical diagnosis based on typical symptoms and response to hormonal therapy, allowing earlier implementation of effective management strategies in adolescent patients. There is still no clear consensus on how laparoscopy should be used in this population. While the procedure allows direct visualization of endometriotic lesions and assessment of disease stage, routine laparoscopy is not advised. This is due both to the invasive nature of the procedure and the lack of conclusive evidence demonstrating the long-term superiority of early surgical intervention over conservative management in cases of low-stage disease who respond to pharmacological treatmen. Moreover, the risk of postoperative complications — particularly adhesion formation and potential reduction in ovarian reserve — remains an important area for further analysis and discussion in young patients. With regard to pharmacological management, the guidelines are consistent in recommending continuous hormonal therapy as first-line treatment. Particular caution is advised when considering using gonadotropin-releasing hormone analogues (especially in the absence of a definitive diagnosis) due to their potential effects on bone mineral density during the critical period of peak bone mass acquisition. Overall, the current approach to endometriosis in adolescents moves away from aggressive invasive diagnostic strategies and instead emphasizes early clinical recognition, timely empirical treatment, and long term interdisciplinary care. Education of patients, their families, and healthcare providers is also essential and may contribute to reducing time to diagnosis and improving treatment outcomes in this particularly vulnerable population.

Endometriosis in adolescents remains an under-researched and challenging condition. The diagnostic approach must reflect the specific needs of this age group, with particular emphasis on a medical history and careful assessment of symptoms. Timely diagnosis is crucial and adherence to current recommendations may postpone disease progression and improve long term quality of life. International guidelines consistently advise against using laparoscopy as a first line diagnostic step in adolescents, although it remains appropriate when symptoms do not respond to pharmacotherapy or when the clinical picture remains unclear. Patients and their families should receive high quality education and comprehensive information regarding available management options. Clearer diagnostic pathways, greater clinician awareness, and closer attention to symptom presentation are essential to reducing diagnostic delays in this age group. Article information and declarations Author contributions KW-S — 90% conceptualizing, data analysis, writing, funding; AD-C — 10% review & editing, supervision. Funding All authors declare no funding. Acknowledgments None. Conflict of interest All authors declare no conflict of interest. Supplementary material None.