Educational Intervention and Referral for Early Detection of Endometriosis among Technical Secondary Schools Students

Despite rising awareness that endometriosis could begin throughout adolescence, most endometriosis research fails to involve and incorporate this age category (Gallagher et al., 2018). Moreover, little is recognized about endometriosis in adolescents, which is problematic given that earlier recognition and detection could lead to better outcomes and change the course of this debilitating condition from a disease, chronic pain, and quality-of-life standpoint (Sieberg et al., 2020). The true disease prevalence in the general adolescent population remains unknown. Adolescents are typically diagnosed purely based on symptoms of pain, which likely contributes to the high frequency of endometriosis among symptomatic adolescent patients (Shah and Missmer, 2011). Endometriosis exists when endometrium-like tissue (the lining of the womb) develops outside the uterus. It creates a chronic inflammatory reaction, which ends in the genesis of scar tissues (adhesions and fibrosis) in the pelvis and different parts of the body (Foti et al., 2018). The prevalence of endometriosis in adolescents seems to be comparable to that in adults, as 35–70% of the patients presenting with chronic pelvic pain seemed to have pelvic endometriosis on laparoscopy, despite some authors considering it as an underestimated problem in premenarche or postmenarche girls (Ragab et al., 2015). In Egypt, the prevalence rates are unknown, because a definitive diagnosis is established only at laparoscopy (Soliman et al., 2017; Bourdel et al., 2019). There are four different stages of endometriosis: stages 1 and 2 represent primary stages, whereas third and fourth stages are advanced stages; this is according to the classification of the American Society for Reproductive Medicine. The stage of the disease is determined by its location, amount, depth, and size of the endometriotic foci. The endometriosis manner of development is not absolutely recognized, and numerous theories exist to clarify it. The most accepted one suggests that immune dysfunction and unusual differentiation of endometriotic tissue may be involved in the development of the disease. Alternative potential descriptive hypotheses include genetic, epigenetic, and environmental factors (Laganà et al., 2017). Adolescent endometriosis may not manifest with ‘classical’ symptoms like dysmenorrhea, dyschezia, endometriomas, dyspareunia, and/or infertility. Common symptoms in adolescents with endometriosis involve general pelvic pain, abdominal discomfort, and low energy. Moreover, heavy menstrual bleeding, headaches, dizziness, and low back pain are more popular. Abdominal symptoms may include bloating, constipation, diarrhea, nausea, pain with defecation, and pain that improves after intestinal movements. Severe dysmenorrhea that is correlated or linked with missed entertainment and activities should raise the suspicion of endometriosis (Sachedin and Todd, 2020). Pain is typically the predominant feature for adolescents and probably interferes with activities of daily living and/or school attendance. Suffering and complaints of noncyclical pain are more repeated and popular among this age group compared with adult women with endometriosis (Sarıdoğan, 2017). Health care providers do not simply diagnose endometriosis because of its broad and variable symptoms, and many persons complaining or suffering from it have inadequate and limited knowledge of the condition. This can take a long time between the beginning of symptoms and diagnosis (Agarwal et al., 2019). Early diagnosis and long-term management of endometriosis are very important in adolescent girls taking into account their potential for future pregnancy and need for preventing disease sequelae and complications. However, symptoms and clinical findings of adolescent endometriosis may vary from those of typical adult endometriosis, causing difficulty in diagnosis. In adolescents, dysmenorrhea may present as acyclic or unresponsive to routinely and commonly used medication (Nakamura, 2021). Several adolescent girls who have endometriosis experience and suffer from debilitating endometriosis-associated pain, which increases school absenteeism (Nnoaham et al., 2011; Culley et al., 2013). In these situations, addressing endometriosis can lower school absenteeism, increase an individual’s capability to contribute and participate in the labor force or daily activities, and also empower adolescent girls by enhancing and supporting their right to the highest level of reproductive health and overall well-being. Non-steroidal anti-inflammatory drugs (NSAIDs) are the initial line of treatment. Menstrual suppression with combined birth control (COCs) and progestin-only choices can safely be offered to adolescents. If these methods are ineffective, gonadotropin-releasing hormone agonists with add-back treatment can be considered. Abdominal ultrasonography is indicated when the initial line of treatment cannot improve symptoms. Endometriosis should be considered and evaluated in adolescents who experience and suffer from ongoing pain in spite of medical therapy. If laparoscopy is carried out and endometriosis is visualized and confirmed, it ought to be treated with either ablation or excision (Sachedin and Todd, 2020). Adolescent girls might wait up to three times more than adult women to seek medical attention for their symptoms and then experience further delays between requesting help and obtaining a diagnosis (Randhawa and Land, 2017). Maternity nurses play a crucial role in counseling and educating adolescent girls for early detection and management of endometriosis through education. Nurses help them to understand the disease and its connected risk factors to avoid long-term complications, encouraging adolescent girls to make positive and healthy life-style changes. Moreover, the nurses provide psychological support and make community referrals to local support groups for helping students to enhance their coping skills (Norton and Holloway, 2016). Effective referral systems from the community to the health care facility are vitally important to save many lives and guarantee quality and a continuum of care (Give et al., 2019) and play a very important role in management of diseases in any health care system (Jindal, 2011; Anil et al., 2017). Moreover, there is a need for more research studies to improve girls’ awareness for early detection and management of endometriosis to ensure its effective prevention, early diagnosis, and improved management (Johnson et al., 2017; Zondervan et al., 2020). Significance of the study The prevalence of endometriosis in Egypt is annoying owing to scarce information and data, as well as deficiency of a documentation or filling system for endometriosis cases, and laparoscopy being the only reliable diagnostic examination (Gad et al., 2017). Endometriosis affects ∼10–15% of women in the reproductive age (Wei et al., 2020). Despite the exact or accurate prevalence of endometriosis in adolescents being indefinite, most women diagnosed with this disease report that their symptoms started throughout the time of adolescence. The true prevalence among adolescents is partly difficulty and complex owing to their delays in obtaining a diagnosis. This usually takes numerous years, and so several adolescents would be classed as an ‘adult’ by the time of diagnosis and confirmation (Randhawa and Land, 2017). Typically, there is a delay of 8 or more years from symptom onset to diagnosis and an average of seven visits or 3 years visiting a primary care doctor before referral to a gynecologist. Adolescent girls who undergo or experience severe dysmenorrhea are at a greater risk of interrupted education and academic performance; disrupted cognitive development; poor emotional, psychosocial, and physical outcomes; and missed career opportunities (Bush et al., 2017). Nurses can play a role in the health education of adolescent girls with endometriosis by assisting them in coping with their condition as well as their families in adapting to this condition and providing a source of support during follow-up. Nurses also have a crucial role in providing health education about lifestyle modifications that can affect endometriosis-related symptoms (de Almeida Asencio et al., 2019). Aim The aim was to evaluate the effect of educational intervention and referral for early detection of endometriosis among technical secondary school students. Hypotheses The use of educational intervention will improve adolescent girls’ knowledge and self-reported practice regarding early detection and management of symptoms suggesting endometriosis. There is a significant association between adolescent girls’ knowledge and self-reported practice regarding early detection and management of symptoms suggesting endometriosis, which would be improved at posttest. Patients and methods Research design: a quasi-experimental research design (pretest and posttest) was used to achieve the aim of the study. It is an empirical interventional study used to estimate the causal effect of an intervention on target population without random assignment. Setting: the present study was carried out at technical secondary schools for girls. In Minia City, there are four technical secondary schools for girl’s students: two industrial, one commercial, and one a hotel). These schools represented all Minia City geographical areas. Sample type: adolescent girls were selected using the cluster sampling technique. Inclusion criteria were girls who had menstruation more than 1 year ago, with an age range between 15 and 18 years. Exclusion criteria were secondary school girls diagnosed with endometriosis and those who not willing to participate. Sample size: the total number of adolescent girl students in all technical secondary schools in Minia City was 3000 for the academic year 2020–2021: two industrial, one commercial, and one a hotel technical secondary school (1400, 900, and 700, respectively). The researchers took about 10% from the total number of students, which represented 300 girl students, as follows: 140, 90, and 70, respectively, from the two industrial, one commercial, and one a hotel technical secondary schools, respectively. Tools Four tools were used in the present study for data collection: The first (pretest) tool, personal data assessment tool: it is an interviewing questionnaire established by the authors. It includes two parts. Part I: sociodemographic data such as name, age, residence, marital status, educational level of their mothers, mother’s occupation, economic status, and telephone number. Part II: menstrual history such as age at menarche, duration of menstrual blood flow, length and regularity of menstrual cycle, amount of menstruation, and presence of dysmenorrhea. The second tool, assessment tool for early detection of endometriosis: it is an interviewing questionnaire established by the authors. It includes three parts. Part I, indicators/risk factors suggest endometriosis: it includes family history of endometriosis, early start of the menstrual cycle, irregular menstruation, absenteeism from school at time of menses, oral contraception usage for dysmenorrhea, dysmenorrhea resistant to NSAIDs, and noncyclical pelvic pain that is not obviously related to the menstrual cycle. Part II, symptoms suggestive of endometriosis: it includes having dysmenorrhea, dyspareunia for married girls, dyschezia, dysuria, pelvic/abdominal or lower back pain, pain during sitting, pain down the legs, menorrhagia, fatigue, diarrhea, constipation, bloating, or nausea, especially during menstrual periods. Part III, pain assessment: it includes age at first menstrual pain, level of pain, duration of pain, time of pain, drugs given to relieve pain, and who described drugs. Pain level was evaluated by using a horizontal visual analog scale (VAS) 0–10. A score of 0 was defined as no pain and 10 was defined as the most severe intolerable pain. The girls were asked to rate the level of pain by making a mark on a scale. The scores received from the scale were classified into mild dysmenorrhea if it was between 1 and 3 points, moderate between 4 and 7 points, and severe between 8 and 10 points (McCaffery et al., 1989). The third tool, knowledge assessment tool about endometriosis (pre/post): it is an interviewing questionnaire established by the authors to assess adolescent girls’ knowledge regarding endometriosis. It includes 15 questions (are you hear about endometriosis, definition, causes, risk factors, sites, clinical feature, stages, diagnosis, complication, prognosis, effect on reproduction, etc.) and their source of information about endometriosis. Scoring system: knowledge questions were given scores 2 and 1 for correct and incorrect answers, respectively. Total knowledge score was classified as poor (75%). The fourth tool, practices for management of endometriosis (pre/post): it is an interviewing questionnaire established by the authors to assess adolescent girls’ self-reported management practices toward endometriosis. It includes five questions (referred for physician consultation/diagnosis, first recommended treatment for endometriosis, cases that doctor recommend surgery, pharmaceutical and nonpharmaceutical methods to relieve pain from endometriosis, and foods that may positively or negatively affect endometriosis). Scoring system: self-reported management practices answers were given scores of 2 and 1 for correct and incorrect answers, respectively. Overall self-reported management practices scores were categorized as unsatisfactory (<60%) and satisfactory (≥60%). Validity: to establish validity, the tool was reviewed by a panel of five experts from Community Health and Obstetrics and Gynecological Department. The recommended modifications were done accordingly, and then the tool was designed in its final format. The validity was 97.6%. Reliability: it was assessed using the Cronbach's alpha coefficient, it was 0.814 for 1st tool, (0.856 and 0.874) for 2nd tool (part I, II), 0.931 for 3rd tool and 0.922 for 4th tool. Pilot study A pilot study was conducted on 10% of adolescent girl students (30) after developing the tool, to check clarity, validity, and time required for completion. Needed modifications were done according to the results of the pilot study, and the results of the students who participated in the pilot study were included in the study. Ethical consideration Administrative approval to implement the current study was obtained from all school managers after clarifying the aim of research to ensure their help, support, and to permit the intervention implementation during less-workload activities. Participants were told that their contribution was voluntary and had the right to discontinue at any time, their data would be kept private, and the data collected would be used only for the purpose of the present study. Procedure The researchers visited the school two days a week from 9 a.m. to 12 p.m. (according to students’ schedule) until the predetermined sample size was achieved. The current study was carried out through three phases: assessment (pretest), implementation, and follow-up and evaluation (posttest). The study was conducted from the beginning of October 2021 to the end of December 2021. Assessment (pretest) At the beginning, the researchers conducted the first meeting with adolescent girls and briefly explained the essence and the intent of the study. The girls were told about that their contribution are optional and has the right to discontinue at any time. Oral approval was obtained from all girls. After achieving the adolescent girls’ consent to participate in the present research, the authors provided an overview and illustration of the evaluation tools. Pretest was done by using an interviewing questionnaire to evaluate sociodemographic characteristics, menstrual history, indicators/symptoms suggesting endometriosis, pain characteristics, and evaluation of their knowledge and management practices regarding endometriosis. It took about 25–30 min to complete the question sheet. Implementation (carrying out education intervention) In the implementation phase, the researchers conducted educational sessions about endometriosis and its managements (definition of endometriosis, causes, risk factors, clinical picture, sites, stages, diagnosis, complications, treatment, and management). The educational sessions were provided to a group of girls based on their schedule, and each session took about 30–45 min. Health educational sessions were given to the girls as a lecture using audiovisual aids (PowerPoints and brochures) and group discussions were initiated to improve adolescent girls’ knowledge about early detection and early management of endometriosis if detected in any case. At the end of the lecture, feedback from the girls was obtained to ensure the ultimate benefits were received. The researchers collaborate with gynecologists in outpatient clinic of Minia Maternal and Child University Hospital to receive the referred cases for consultation and confirm the diagnosis. About 32 suspected cases were referred for early detection of endometriosis. The criteria for referral were severe dysmenorrhea, have more than five symptoms suggesting endometriosis, and have more than five risk factors as mentioned in the tool 2. Brochures covering information about endometriosis was given to adolescent girls at the end of the educational intervention sessions to achieve its objectives. It consists of significant information about endometriosis (concept, causes, risk factors, clinical feature, sites, stages, diagnosis, complication, treatment and management, and effect on reproduction). Moreover, the investigators contacted adolescent girls through mobile for follow-up and support. Follow-up and evaluation (posttest) Follow-up and evaluation phase was conducted after 3 months of educational program implementation (follow-up posttest) to ensure the effectiveness of educational intervention and follow-up of the referred suspected cases (32 girls) for gynecologist for early detection of endometriosis, and eight cases were confirmed by medical consultation. The influence of the educational intervention on improving knowledge for early detection and early management was achieved through a pretest and posttest comparisons; the posttest intervention was carried out after 3 months. Statistical analysis The collected data were organized, categorized, and analyzed using the statistical package for the social sciences (SPSS), Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and mean and SDs for quantitative variables. The statistical tests used were paired t test, χ2 test, and r test. Statistical significance was considered as significant when P value less than or equal to 0.05 and highly significant when P value less than or equal to 0.001, and no statistically significant difference was considered when P value was more than 0.05.

[Table 1] shows the distribution of participants according to their sociodemographic data. It showed that 74.3% of studied students were between the ages of 15 and 16 years, with a mean age of 16.01±0.98 years, 78.7% of them were single, 53.0% were from urban area, and 82.7% of them had enough monthly income. Concerning to their mothers’ education, 34.7% of their mothers had secondary education. [Table 2] demonstrates the distribution of participants according to their menstrual history. It was revealed that 47.3% of the studied students had menarche at the age range from 13 to 14 years, with a mean age of 12.97±0.18 years, 48.0% of them had irregular menstruation, and 70.3% of them reported dysmenorrhea. [Table 3] represents pain characteristics among studied students with dysmenorrhea. It reveals that 67.8% of studied students had their first menstrual pain in the age range from 12 to 14 years, with a mean age of 13.85±0.31 years and 69.3% reported nothing was taken to alleviate this pain. Regarding the level of pain, less than half of them (48.4%) experienced moderate menstrual pain, whereas severe dysmenorrhea was reported among 15.1% of them ([Figure 1]) [Table 4] illustrates the distribution of studied students having dysmenorrhea according to indicators/risk factors suggesting endometriosis. It showed that 13.7% of them had a family history of endometriosis, and 65.9% reported dysmenorrhea resistant to NSAIDs. Moreover, 22.7% of them experienced abdominal pain that was not associated with menstrual cycle. [Table 5] represents the distribution of studied students with dysmenorrhea according to symptoms suggesting endometriosis. It was revealed that the most frequent symptoms were irregular menstruation, which was found among 83.9% of them, followed by pelvic/abdominal or lower back pain (81.0%) and pain while sitting and pain down the legs (45.9%). The majority of them (89.6%) experienced fatigue, diarrhea, constipation, bloating, or nausea, during menstruation. Menorrhagia was found among 26.5% of them. [Table 6] represents distribution of studied students with dysmenorrhea according to number of risk factors and symptoms suggesting endometriosis, it revealed that out of 211 students, only 15.2% of students were referred for physician consultation and diagnosis as they had more than or equal to 5 symptoms and had more than or equal 5 risk factors of endometriosis. [Table 7] illustrates the percentage distribution of referred students with severe dysmenorrhea. It shows that 93.75% of them underwent ultrasonography, 6.3% underwent laparoscopy, whereas 9.4% of them underwent MIR. Moreover, of 32 girls who were referred for consultation/diagnosis of endometriosis, 24 (75%) girls were diagnosed with endometriosis. [Figure 2] illustrates the distribution of studied students according to their previous knowledge about endometriosis and their needs for educational intervention. It reveals that the majority of them (89%, n=267) had not heard about endometriosis previously (have no previous knowledge), and 93% of them (n=279) needed educational intervention to increase knowledge about this disease. Regarding the studied students’ sources of information about endometriosis, 39.8% of them got their information from a health care provider (physician or nurse), followed by family and/or relatives (28.4%), mass media (TV, radio, or internet) (18.3%), then friends (9.3%), and only 4.2% from school/medical symposium ([Figure 3]). [Table 8] represents the mean distribution of studied students according to their correct answers about endometriosis in pretest and posttest. It shows that there was a significant increase in the mean scores of all items of participants’ knowledge about endometriosis after the educational intervention, with highly statistically significant differences in each parameter of their knowledge (P=0.0001 in each one), for example, the mean scores of participants’ knowledge about meaning, causes, risk factors, clinical manifestations, and complication of endometriosis increased from 1.13±0.33, 1.10±0.29, 2.18±0.38, 2.12±0.32, and 1.08±0.25, respectively in pretest to 1.89±0.31, 1.72±0.45, 3.86±0.34, 3.72±0.41, and 1.87±0.34, respectively, in posttest. [Table 9] demonstrates that 72.8% of studied students had poor knowledge about endometriosis in pretest, which reduced to 20.3% in posttest. Mean score of their knowledge was 11.25±3.24 in pretest, which increased to 20.03±2.33 in posttest, with highly statistically significant differences in their knowledge level. [Table 10] illustrates the percentage distribution of referred students with severe dysmenorrhea according to their management practices of symptoms suggestive of endometriosis. It is noticed that 25.0% of them used hormonal contraceptive drugs for managing symptoms after confirming endometriosis diagnosis. There were statistically significant differences in girls’ practices of nonpharmaceutical methods of pain relief in before and after intervention concerning application of heating pad, taking warm baths, exercise regularly, relaxation, eating foods that positively affect endometriosis symptoms, and avoiding foods that negatively affect endometriosis symptoms, where P=0.0001, 0.050, 0.010, 0.009, 0.0001, and 0.0001, respectively. Additionally, the mean score of studied students (with severe dysmenorrhea) regarding symptom management practices of endometriosis was 5.37±1.142 in pretest, which increased to 9.81±1.21 in posttest, with highly statistically significant improvements in their practice levels. [Figure 4] illustrates comparison of pain level associating dysmenorrhea among studied students at pre and after educational intervention, it was observed that all studied girls (100%) with dysmenorrhea had severe menstrual pain at before intervention, which decreased to 25.0% after intervention, with highly statistically significant differences (P=0.0001). [Table 11] illustrates that there was a highly statistically significant relation between studied students’ total knowledge about endometriosis and their demographic data related to their age, residence, socioeconomic level, and their mother’s education and occupation in both pretest and posttest, with highly statistically significant differences. [Table 12] reveals that there was a weak positive correlation between knowledge about endometriosis of studied students with severe dysmenorrhea and their symptom management practices in pretest, where r value was 0.134, with statistically significant differences, where P value was 0.020. Furthermore, there were moderate positive correlations between knowledge about endometriosis of studied students with severe dysmenorrhea and their symptom management practices after implementation of the educational intervention, where r value was 0.372, with statistically significant differences, where P value was 0.002

Endometriosis is complex and difficult to diagnose in adolescents who are not aware of the condition and are more uncertain or hesitant to undergo gynecologic examinations. The characteristics of adolescent endometriosis are different and unlike those of adults, which should be kept in mind in their diagnosis and management (Nakamura, 2021). Although the precise prevalence of endometriosis in adolescents is not recognized, approximately two-thirds of adolescent girls experiencing chronic pelvic pain or dysmenorrhea and unresponsive to hormonal therapies or contraception and NSAIDs will be diagnosed with endometriosis during diagnostic laparoscopy (American College of Obstetricians and Gynecologists ACOG, 2018). Nurses employed in primary health care settings are often among the prime person who face or encounter adolescents with symptom complaints, so they play a very significant role in initiating diagnostic referral and providing education and support (Randhawa and Land, 2017). The current study aimed to evaluate the effect of educational intervention and referral for early detection of endometriosis among technical secondary school students. Findings of the current study showed that near three-quarters of studied participants were between the ages of 15 and 16 years, with a mean age of 16.01±0.98 years. This agreed with Ragab et al. (2015) and Suvitie et al. (2016), who found that the mean age of the participants was 16.8±1.0 and 15.2±3.53 years, respectively, but it was contradictory to Yousef et al. (2019), who reported that more than three-quarters of the girls were between the age of 12 and less than 14 years, with a mean±SD of 13.19±0.65 years. Moreover, it was in contrast with Mohamed and Hassan (2020), who found that the mean age of the studied participants was 30.45±6.29 years. This is related to the differences in age groups that were included in the study. The current study presented that more than half of the participants were from urban area and near half of them from the rural area. This is in agreement with Mahmoud et al. (2021), who reported that 56.7 and 43.3% of participants were from urban and rural areas, respectively, and also agreed with Kamal Helmy et al. (2021), who reported that 60 and 40% of participants were from urban and rural areas, respectively. The findings of the study illustrated that approximately one-third of participants’ mothers had secondary education and most of them did not work. This finding was in line with Yousef et al. (2019), who found that 32.4% of participant mothers’ education was secondary school and the majority of them (83.7%) were not working. Regarding age at menarche, the current findings implied that near half of the participants had their menarche between 13 and 14 years, with mean±SD of 12.97±0.18 years, which was consistent with Zannoni et al. (2014), Ragab et al. (2015), Suvitie et al. (2016), Kagia (2017), Yousef et al. (2019), Martire et al. (2020), Shim et al. (2020), Karout et al. (2021), and Randhawa et al. (2021), who found that the mean±SD at first period was 13.3±1.1, 12.35±1.34, 12.0±1.2, 13±1.2, 12.5, 11.9±1.1, 12.6±1.2, 12.88±0.89, and 12.3 years, respectively. Concerning duration of menstrual blood flow, the present study showed that the menstrual blood flow of nearly two-thirds of the participants ranged between 4 and 6 days, with mean±SD of 4.85±0.99 days. This comes in agreement with Ragab et al. (2015), Kagia (2017), and Randhawa et al. (2021), who reported that the mean±SD duration of the menstrual blood flow was 4.3±1.3, 4±2.8, and 5.48 days, respectively. The present study illustrated that nearly half of the participants had irregular menstruation. It is in adherence with Kagia (2017), who found that 44.7% of the studied students had irregular menstruation. Menstrual pain remains a significant factor in girls. Approximately three-quarters of the studied participants reported dysmenorrhea, which was in line with Zannoni et al. (2014), Suvitie et al. (2016), Kagia (2017), Alsaleem (2018), and Yousef et al. (2019), who mentioned that 70.6, 72.2, 67.6, 79.3, and 68% of the studied students experienced dysmenorrhea, respectively. In spite of that, different studies have stated a higher prevalence of dysmenorrhea (85.1, 89.6, 80.9, 95, and 88% in the studies by Kabbara et al., 2014; Subasinghe et al., 2016; Abu Helwa et al., 2018; Patel and Barot, 2020; Karout et al., 2021, respectively). Another study reported a lower prevalence (Ragab et al., 2015), which reported that half of the sample had dysmenorrhea. This variation in the prevalence between research studies might be explained by many rationales such as the absence or lack of a universally endorsed approach to define or state dysmenorrhea, difference in the study populations, the age group selected of females themselves, pain perception, cultural, lifestyle, genetics, degree of social and personal stress, and the difference in the strategies for gathering information. Moreover, more than two-thirds of the participants had their first menstrual pain at 12–14 years, with mean±SD of 13.85±0.31 years. This was compatible with Yousef et al. (2019), who revealed that approximately two-thirds of the girls experienced first dysmenorrhea at the same age range (12–14 years, with mean±SD of 13.22±0.87). Moreover, it comes in line with Shim et al. (2020), who revealed that the mean±SD of first menstrual pain was 14.9±1.9 years. A number of research studies have shown a considerable relationship between menstrual pain and earlier menarche; the following recognition might be linked with the fact that girls who experience earlier menarche have longer exposure to uterine prostaglandins resulting in elevated prevalence of dysmenorrhea (Kural et al., 2015). There is a need for more forceful educational sessions to help spread the message that painful menstruation is not normal and can indicate a dangerous or serious condition. Regarding the level of pain that assessed using VAS, it was noticed that approximately two-thirds of the participants reported severe and moderate dysmenorrhea. This shows that dysmenorrhea is still an important universal health problem among adolescents. This finding comes in agreement with several research studies (Kural et al., 2015; Yousef et al., 2019; Hu et al., 2020), which reported 65, 70.2, and 65.3%, respectively. However, some studies have reported a higher percentage of girls who described their menstrual pain as severe and moderate (82 and 90.6% by Abu Helwa et al., 2018; Karout et al., 2021, respectively). The diversity within the vigorous and intensity of painful menses among previous studies may be owing to the distinction in pain perception between participants in various countries and various scales used to assess. Concerning methods to alleviate menstrual pain, more than two-thirds of participants did not use any method. This finding was in the same line with Yousef et al. (2019), who reported that 72.2% of adolescent girls used nothing to alleviate menstrual pain. So, it is important to educate and increase adolescent girls’ knowledge about methods used to alleviate menstrual pain to reduce their suffering. In this study, 13.7% of the participants reported a positive family history of endometriosis, which was consistent with previous studies by Campo et al. (2014), Ragab et al. (2015), and Agarwal et al. (2021), who found that 10, 12, and 10.6% had a positive family history of endometriosis. Endometriosis can present with acyclic or cyclic abdominal pain or heavy menses. These symptoms are sometimes severe enough to cause school absenteeism or loss of other activities (Harada, 2013). About a fifth of the participants experienced acyclic abdominal pain, and this result was comparable with Suvitie et al. (2016); Kagia (2017), who found the same results. Regarding absenteeism from school at the time of menses, 7.6% of the participants did not attend school at the time of menses because of pain. Similar findings were demonstrated by Zannoni et al. (2014), who reported that 12% of adolescent girls did not attend school at the time of menses because of pain. The findings of the study revealed that 5.5% of the participants used oral contraception for dysmenorrhea, which was consistent with Kagia (2017), who reported that 6.1% of the girls used contraception pills for painful menstruation. According to the results of the present study, there were varied numbers of symptoms suggesting endometriosis among participants with dysmenorrhea. The most recurrent symptoms occurring were irregular menstruation; fatigue, diarrhea, constipation, bloating, or nausea; pelvic/abdominal or lower back pain; and pain during sitting (83.9, 89.6, 81.0, and 45.9%, respectively). Moreover, more than a third of the participant girls described pain during bowel movement and urination (36.9 and 32.7%, respectively). Similar findings were demonstrated by Kagia (2017) and Yousef et al. (2019). It is critical and necessary for students to be informed about endometriosis symptoms because they are the first step in diagnosing the condition because its symptoms are similar to those of other disorders. Moreover, Egyptian females are capable of tolerating discomfort and do not require assistance or annual follow-up. Furthermore, diagnosing endometriosis is complicated and time consuming. The finding of the study showed that about fifth of the participants had more than or equal to five symptoms that suggest endometriosis and less than a fifth of them had more than or equal to five risk factors for endometriosis. Consequently, the number of students who had more than five symptoms and also more than five risk factors was 15.2%, and they were referred for physician consultation/diagnosis. The current study found that the majority of participants had not heard about endometriosis previously (have no previous knowledge) and also the majority of them needed educational intervention to increase knowledge about this disease. This agreed with Bush et al. (2017) and Kagia (2017), who found that 90 and 93.6% of students had not previously heard about endometriosis, respectively, and also comes in compliance with Ahmed Gouda Ahmed and Elsayed Mahmoud Radwan (2021), who concluded that that the majority of the studied group (91.0%) needed educational nursing intervention about endometriosis. With respect to the participants’ knowledge before educational intervention, the majority of participants had poor knowledge level regarding all items related to endometriosis. This could be owing to many reasons, such as most participants had no information and had not heard before about endometriosis as well as the reduced role of mass media in handling this health problem. The finding of the study showed that there was a significant increase in the mean scores of all items of participants’ knowledge about endometriosis such as definition, causes, risk factors, signs and symptoms, and complication of endometriosis after the educational intervention, with highly statistically significant improvement in each parameter of their knowledge (P=0.000 in each one). This comes in agreement with Abd El-Mouty et al. (2016), who conducted a study to raise awareness among Mansoura University working women about endometriosis and also agreed with Ahmed Gouda Ahmed and Elsayed Mahmoud Radwan (2021), who conducted a study for improving nonmedical students’ awareness toward endometriosis at Zagazig University and stated that there were significant changes in the knowledge level of the studied students about all items of educational session regarding endometriosis after the educational session and follow-up compared with their knowledge before the educational session. This revealed the effectiveness of the applied structured educational nursing intervention. Regarding the total knowledge level of the participants, the present study denoted that nearly three-quarters of participants had poor knowledge score about endometriosis before intervention implementation. Meanwhile, more than half of them had good knowledge score about endometriosis after intervention implementation versus 5.6% in pretest. This indicated that there was a significant improvement in mean scores of total knowledge level about endometriosis after educational test. This was consistent with Abd El-Mouty et al. (2016), Abd-Elaziz Ibrahim et al. (2021), and Ahmed Gouda Ahmed and Elsayed Mahmoud Radwan (2021). This may be owing to students’ active participation and good communication with the researchers, educational guidelines played a very important role in helping them acquire knowledge about endometriosis, and also the topic was interesting to them. The results of current study showed that the majority of referred adolescent girls with severe dysmenorrhea underwent ultrasonography, 6.3% underwent laparoscopy, whereas 9.4% of them underwent MIR. Moreover, more than a fifth of them used hormonal contraceptive drugs for managing symptoms after confirming endometriosis diagnosis. The results of the present study revealed that a quarter of the referred participants who experienced severe menstrual pain (8–10 on VAS) and those who underwent diagnostic ultrasound, laparoscopy, or MRI had endometriosis. This result added support to the fact that girls with severe menstrual pain are extremely suspicious to have endometriosis. Therefore, severe menstrual pain may be considered early evidence to search for endometriosis among young adolescent girls. This finding was additionally concluded by Janssen et al. (2013), who reported that the prevalence of endometriosis was 62% among girls with severe menstrual pain. Moreover, a Nigerian study conducted by Fawole et al. (2015), stated that young adult women with dysmenorrhea had a higher possibility and risk of being diagnosed with endometriosis than those who did not have dysmenorrhea. In addition, the results of current study showed that there were statistically significant improvements between before and after intervention among referred adolescent girls with severe dysmenorrhea regarding their management practices of symptoms suggesting endometriosis concerning nonpharmaceutical methods of pain relief such as application of heating pad, taking warm baths, exercise regularly, relaxation, eating foods that positively affect endometriosis symptoms, and avoiding foods that negatively affect endometriosis symptoms. The previous findings were consistent with Ghonemy and El Sharkawy (2017), who conducted a study to evaluate the effect of changing lifestyle on endometriosis-related pain and showed that there was a significant difference in women’s dietary habits and exercises at 3 months after education compared with before health education (P<0.05). Additionally, the mean scores of management practices of endometriosis symptom among studied students with severe dysmenorrhea were highly statistically significantly improved in posttest, which reflects the effectiveness of the educational intervention and the effort of the researchers to covey the proper and accurate information about the methods used to alleviate menstrual pain. The results of the current study showed that there were statistically significant improvements in pain level associated with severe dysmenorrhea among girls after educational intervention (postmanagement at 3 months) (P=0.000). It was notice that although 100% of girls had severe dysmenorrhea before management, solely one-quarter (25%) of them had severe dysmenorrhea after educational intervention. This finding came in line with Yousef et al. (2019). This improvement may be owing to the effect of successful educational intervention and lifestyle changes that play an important role in dealing with pain and help the students manage their symptoms. In this study, there were moderate positive correlations between knowledge about endometriosis of studied students with severe dysmenorrhea and their management practices of endometriosis symptoms after implementation of the educational intervention, where r value was 0.372, with statistically significant differences, where P value was 0.002. This implies that the educational nursing intervention was quite efficient in raising students’ understanding of the most common endometriosis complaints by using simple and clear language in the educational session and appropriate teaching methods and audiovisual aids. Moreover, participant students’ ability to acquire knowledge helped them in increased their understanding and recognition of the study topic.[]

The current study concluded that there was a highly statistically significant difference between total knowledge and total management practices of girls (P<0.001) before and after educational intervention. Moreover, eight suspected cases were detected early and confirmed through referral to a gynecologist and received treatment. So, implementation of educational intervention was effective in early detection and early management of endometriosis and also effective in improving knowledge and management practices of girls regarding endometriosis. Recommendations More health educational interventions are needed on a larger scale among adolescent girls especially those who have risk factors and symptoms suggestive of endometriosis. More research studies are needed regarding endometriosis among adolescent girls because there is little research done in this age group for early detection and early management. Mass media such as TV and social media should be included in raising awareness among adolescent girls about early signs and symptoms of endometriosis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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