The most common presenting symptom in adolescents with endometriosis is cyclic pain (1). Less commonly acyclic pain, dyspareunia, gastrointestinal symptoms, irregular menses, urinary symptoms, and vaginal discharge are described (1,446–449). Similar presenting symptoms occur in adolescent patients evaluated for pelvic pain with and without endometriosis (449,450). It is hard to predict the presence of endometriosis in adolescents with pelvic pain merely from the presenting symptoms, because similar symptoms occur in patients evaluated laparoscopically for pelvic pain with and without endometriosis (1,449,450). Laparoscopy should be considered for adolescents with chronic pelvic pain who do not respond to medical treatment (NSAIDs, OCs) because endometriosis is very common (up to 70%) under these circumstances (446,449–456). Minimal and mild endometriosis, according to the revised ASRM classification, are the most common stages of the disease in adolescents. Gynecologic surgeons should pay special attention to red, clear, or white lesions, which are more prevalent in adolescents than in adults with endometriosis (1,446–458). Mild disease can be treated by laparoscopic surgical removal of implants at the time of diagnosis, followed by continuous administration of low-dose combination OCs to prevent recurrence. More advanced disease can be treated medically for 6 months, followed by continuous OCs to prevent progression of disease. Surgery is indicated if this hormonal treatment is not effective. GnRH agonists with add-back therapy can only be considered for adolescents older than 17 years of age who have completed pubertal and bone maturation, and then only if symptoms persist during other forms of hormonal suppression (1,459–461).
Menstrual outﬂow obstructions such as m¨ullerian anomalies may cause early development of endometriosis in adolescents. Regression of the disease was observed when surgical correction of the anomaly was accomplished (462–464).
Evidence suggests that absenteeism from school and the incidence and duration of OC use for severe primary dysmenorrhea during adolescence is higher in women who later develop deeply infiltrative endometriosis than in women without deeply infiltrative endometriosis (166).
Physicians treating adolescents with endometriosis should adopt a multidimensional approach, where surgery, hormonal manipulation, pain medication, mental health support, complementary and alternative therapies, and education in self-management strategies are useful components (1).
Management of Postmenopausal Women