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Endometriosis in adolescents: Diagnosis and treatment

Marc R Laufer, MD
Section Editors
Robert L Barbieri, MD
Diane Blake, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Endometriosis refers to the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature. These ectopic endometrial implants are usually located in the pelvis, but can occur nearly anywhere in the body. The disease can be associated with many distressing and debilitating symptoms, or it may be asymptomatic. Despite numerous studies, considerable controversy remains regarding the incidence, pathogenesis, natural history, and optimal treatment of this disorder.

This topic will discuss endometriosis specifically in adolescents. The disease in adults is reviewed separately:

(See "Endometriosis: Pathogenesis, clinical features, and diagnosis".)

(See "Endometriosis: Treatment of pelvic pain".)

(See "Endometriosis: Management of ovarian endometriomas".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 03, 2017.
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  1. Vercellini P, Fedele L, Arcaini L, et al. Laparoscopy in the diagnosis of chronic pelvic pain in adolescent women. J Reprod Med 1989; 34:827.
  2. Kontoravdis A, Hassan E, Hassiakos D, et al. Laparoscopic evaluation and management of chronic pelvic pain during adolescence. Clin Exp Obstet Gynecol 1999; 26:76.
  3. Goldstein DP, De Cholnoky C, Emans SJ. Adolescent endometriosis. J Adolesc Health Care 1980; 1:37.
  4. Laufer MR. Gynecologic Pain: Dysmenorrhea, Acute and Chronic Pelvic Pain, Endometriosis, and Premenstrual Syndrome. In: Pediatric & Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR (Eds), Wolters Kluwer Lippincott Williams & Wilkins, Philadelphia 2012. p.238.
  5. Reese KA, Reddy S, Rock JA. Endometriosis in an adolescent population: the Emory experience. J Pediatr Adolesc Gynecol 1996; 9:125.
  6. Laufer MR, Goitein L, Bush M, et al. Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol 1997; 10:199.
  7. Ballweg ML. Big picture of endometriosis helps provide guidance on approach to teens: comparative historical data show endo starting younger, is more severe. J Pediatr Adolesc Gynecol 2003; 16:S21.
  8. Laufer MR. Premenarcheal endometriosis without an associated obstructive anomaly: Presentation, diagnosis, and treatment. Fertil Steril 2000; 74:S15.
  9. Goldstein DP, deCholnoky C, Leventhal JM, Emans SJ. New insights into the old problem of chronic pelvic pain. J Pediatr Surg 1979; 14:675.
  10. Yamamoto K, Mitsuhashi Y, Takaike T, et al. Tubal endometriosis diagnosed within one month after menarche: a case report. Tohoku J Exp Med 1997; 181:385.
  11. Simpson JL, Elias S, Malinak LR, Buttram VC Jr. Heritable aspects of endometriosis. I. Genetic studies. Am J Obstet Gynecol 1980; 137:327.
  12. Sampson JA. Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol 1927; 14:422.
  13. Schifrin BS, Erez S, Moore JG. Teen-age endometriosis. Am J Obstet Gynecol 1973; 116:973.
  14. Sanfilippo JS, Wakim NG, Schikler KN, Yussman MA. Endometriosis in association with uterine anomaly. Am J Obstet Gynecol 1986; 154:39.
  15. Halban, J. Hysteroadenosis metastica. Wien Klin Wochenschr 1924; 37:1205.
  16. Meyer, R. Uber entzundliche neterope epithelwucherungen im weiblichen Genetalg ebiet und uber eine bis in die Wurzel des Mesocolon ausgedehnte benigne Wucherung des Dar mepithel. Virch Arch Pathol Anat 1909; 195:487.
  17. Marsh EE, Laufer MR. Endometriosis in premenarcheal girls who do not have an associated obstructive anomaly. Fertil Steril 2005; 83:758.
  18. Batt RE, Mitwally MF. Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogy. J Pediatr Adolesc Gynecol 2003; 16:337.
  19. Gleicher N, el-Roeiy A, Confino E, Friberg J. Is endometriosis an autoimmune disease? Obstet Gynecol 1987; 70:115.
  20. Dmowski WP, Braun D, Gebel H. Endometriosis: genetic and immunologic aspects. Prog Clin Biol Res 1990; 323:99.
  21. Nothnick WB. Treating endometriosis as an autoimmune disease. Fertil Steril 2001; 76:223.
  22. Doyle JO, Missmer SA, Laufer MR. The effect of combined surgical-medical intervention on the progression of endometriosis in an adolescent and young adult population. J Pediatr Adolesc Gynecol 2009; 22:257.
  23. Walling MK, Reiter RC, O'Hara MW, et al. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994; 84:193.
  24. American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 310, April 2005. Endometriosis in adolescents. Obstet Gynecol 2005; 105:921.
  25. Wright KN, Laufer MR. Endometriomas in adolescents. Fertil Steril 2010; 94:1529.e7.
  26. Cramer DW, Hornstein MD, Ng WG, Barbieri RL. Endometriosis associated with the N314D mutation of galactose-1-phosphate uridyl transferase (GALT). Mol Hum Reprod 1996; 2:149.
  27. Hornstein MD, Thomas PP, Sober AJ, et al. Association between endometriosis, dysplastic naevi and history of melanoma in women of reproductive age. Hum Reprod 1997; 12:143.
  28. Woodworth SH, Singh M, Yussman MA, et al. A prospective study on the association between red hair color and endometriosis in infertile patients. Fertil Steril 1995; 64:651.
  29. Pittaway DE, Fayez JA. The use of CA-125 in the diagnosis and management of endometriosis. Fertil Steril 1986; 46:790.
  30. Stratton P, Winkel C, Premkumar A, et al. Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathologic examination for the detection of endometriosis. Fertil Steril 2003; 79:1078.
  31. Tanaka YO, Itai Y, Anno I, et al. MR staging of pelvic endometriosis: role of fat-suppression T1-weighted images. Radiat Med 1996; 14:111.
  32. Ha HK, Lim YT, Kim HS, et al. Diagnosis of pelvic endometriosis: fat-suppressed T1-weighted vs conventional MR images. AJR Am J Roentgenol 1994; 163:127.
  33. Kistner, RW. Treatment of endometriosis by inducing pseudo-pregnancy with ovarian hormones. Fertil Steril 1959; 10:539.
  34. Vercellini P, Frontino G, De Giorgi O, et al. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril 2003; 80:560.
  35. Miller L, Notter KM. Menstrual reduction with extended use of combination oral contraceptive pills: randomized controlled trial. Obstet Gynecol 2001; 98:771.
  36. Gambone JC, Mittman BS, Munro MG, et al. Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process. Fertil Steril 2002; 78:961.
  37. Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol 1999; 93:51.
  38. Vercellini P, Trespidi L, Colombo A, et al. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril 1993; 60:75.
  39. Propst AM, Laufer MR. Endometriosis in adolescents. Incidence, diagnosis and treatment. J Reprod Med 1999; 44:751.
  40. Matkovic V, Jelic T, Wardlaw GM, et al. Timing of peak bone mass in Caucasian females and its implication for the prevention of osteoporosis. Inference from a cross-sectional model. J Clin Invest 1994; 93:799.
  41. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997; 67:817.
  42. Davis GD, Thillet E, Lindemann J. Clinical characteristics of adolescent endometriosis. J Adolesc Health 1993; 14:362.
  43. Demco L. Mapping the source and character of pain due to endometriosis by patient-assisted laparoscopy. J Am Assoc Gynecol Laparosc 1998; 5:241.
  44. Laufer MR. Identification of clear vesicular lesions of atypical endometriosis: a new technique. Fertil Steril 1997; 68:739.
  45. Redwine DB, Yocom LB. A serial section study of visually normal pelvic peritoneum in patients with endometriosis. Fertil Steril 1990; 54:648.
  46. Nisolle M, Paindaveine B, Bourdon A, et al. Histologic study of peritoneal endometriosis in infertile women. Fertil Steril 1990; 53:984.
  47. Fedele L, Parazzini F, Bianchi S, et al. Stage and localization of pelvic endometriosis and pain. Fertil Steril 1990; 53:155.
  48. Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994; 62:696.
  49. Abbott J, Hawe J, Hunter D, et al. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004; 82:878.
  50. Cook AS, Rock JA. The role of laparoscopy in the treatment of endometriosis. Fertil Steril 1991; 55:663.
  51. Wright J, Lotfallah H, Jones K, Lovell D. A randomized trial of excision versus ablation for mild endometriosis. Fertil Steril 2005; 83:1830.
  52. Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628.
  53. Sutton CJ, Pooley AS, Ewen SP, Haines P. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertil Steril 1997; 68:1070.
  54. Unger CA, Laufer MR. Progression of endometriosis in non-medically managed adolescents: a case series. J Pediatr Adolesc Gynecol 2011; 24:e21.
  55. Yeung P Jr, Sinervo K, Winer W, Albee RB Jr. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil Steril 2011; 95:1909.
  56. Laufer MR, Einarsson JE. Surgical management of early stage adolescent endometriosis. Presented at the World Congress of Endometriosis, Canada, 2017.
  57. Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis. Fertil Steril 2008; 90:S260.
  58. Lubianca JN, Gordon CM, Laufer MR. "Add-back" therapy for endometriosis in adolescents. J Reprod Med 1998; 43:164.
  59. Chu MC, Zhang X, Gentzschein E, et al. Formation of ethinyl estradiol in women during treatment with norethindrone acetate. J Clin Endocrinol Metab 2007; 92:2205.
  60. Luciano AA, Turksoy RN, Carleo J. Evaluation of oral medroxyprogesterone acetate in the treatment of endometriosis. Obstet Gynecol 1988; 72:323.
  61. Moghissi KS, Boyce CR. Management of endometriosis with oral medroxyprogesterone acetate. Obstet Gynecol 1976; 47:265.
  62. Vercellini P, De Giorgi O, Oldani S, et al. Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis. Am J Obstet Gynecol 1996; 175:396.
  63. Vercellini P, Cortesi I, Crosignani PG. Progestins for symptomatic endometriosis: a critical analysis of the evidence. Fertil Steril 1997; 68:393.
  64. Kaser DJ, Missmer SA, Berry KF, Laufer MR. Use of norethindrone acetate alone for postoperative suppression of endometriosis symptoms. J Pediatr Adolesc Gynecol 2012; 25:105.
  65. Brady PC, Missmer SA, Laufer MR. Hepatic Adenomas in Adolescents and Young Women with Endometriosis Treated with Norethindrone Acetate. J Pediatr Adolesc Gynecol 2017; 30:422.
  66. Walch K, Unfried G, Huber J, et al. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis--a pilot study. Contraception 2009; 79:29.
  67. Ponpuckdee J, Taneepanichskul S. The effects of implanon in the symptomatic treatment of endometriosis. J Med Assoc Thai 2005; 88 Suppl 2:S7.
  68. Al-Jefout M, Palmer J, Fraser IS. Simultaneous use of a levonorgestrel intrauterine system and an etonogestrel subdermal implant for debilitating adolescent endometriosis. Aust N Z J Obstet Gynaecol 2007; 47:247.
  69. Yisa SB, Okenwa AA, Husemeyer RP. Treatment of pelvic endometriosis with etonogestrel subdermal implant (Implanon). J Fam Plann Reprod Health Care 2005; 31:67.
  70. Barbieri RL. Treatment of endometriosis with the GnRH agonists. In: Gonadotropin Releasing Hormone Analogs: Applications in Gynecology, Barbieri RL, Friedman AJ (Eds), Elsevier Science, New York 1991. p.63.
  71. Hornstein MD, Surrey ES, Weisberg GW, Casino LA. Leuprolide acetate depot and hormonal add-back in endometriosis: a 12-month study. Lupron Add-Back Study Group. Obstet Gynecol 1998; 91:16.
  72. Barbieri RL. Hormone treatment of endometriosis: the estrogen threshold hypothesis. Am J Obstet Gynecol 1992; 166:740.
  73. Surrey ES, Hornstein MD. Prolonged GnRH agonist and add-back therapy for symptomatic endometriosis: long-term follow-up. Obstet Gynecol 2002; 99:709.
  74. Kiesel L, Schweppe KW, Sillem M, Siebzehnrübl E. Should add-back therapy for endometriosis be deferred for optimal results? Br J Obstet Gynaecol 1996; 103 Suppl 14:15.
  75. DiVasta AD, Feldman HA, Sadler Gallagher J, et al. Hormonal Add-Back Therapy for Females Treated With Gonadotropin-Releasing Hormone Agonist for Endometriosis: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:617.
  76. Divasta AD, Laufer MR, Gordon CM. Bone density in adolescents treated with a GnRH agonist and add-back therapy for endometriosis. J Pediatr Adolesc Gynecol 2007; 20:293.
  77. Kennedy SH, Williams IA, Brodribb J, et al. A comparison of nafarelin acetate and danazol in the treatment of endometriosis. Fertil Steril 1990; 53:998.
  78. Wheeler JM, Knittle JD, Miller JD. Depot leuprolide acetate versus danazol in the treatment of women with symptomatic endometriosis: a multicenter, double-blind randomized clinical trial. II. Assessment of safety. The Lupron Endometriosis Study Group. Am J Obstet Gynecol 1993; 169:26.
  79. Rock JA, Truglia JA, Caplan RJ. Zoladex (goserelin acetate implant) in the treatment of endometriosis: a randomized comparison with danazol. The Zoladex Endometriosis Study Group. Obstet Gynecol 1993; 82:198.
  80. Nafarelin for endometriosis: a large-scale, danazol-controlled trial of efficacy and safety, with 1-year follow-up. The Nafarelin European Endometriosis Trial Group (NEET). Fertil Steril 1992; 57:514.
  81. Crosignani PG, Gastaldi A, Lombardi PL, et al. Leuprorelin acetate depot vs danazol in the treatment of endometriosis: results of an open multicentre trial. Clin Ther 1992; 14 Suppl A:29.
  82. Shaw RW. An open randomized comparative study of the effect of goserelin depot and danazol in the treatment of endometriosis. Zoladex Endometriosis Study Team. Fertil Steril 1992; 58:265.
  83. Shaw RW. Nafarelin in the treatment of pelvic pain caused by endometriosis. Am J Obstet Gynecol 1990; 162:574.
  84. Barbieri RL, Evans S, Kistner RW. Danazol in the treatment of endometriosis: analysis of 100 cases with a 4-year follow-up. Fertil Steril 1982; 37:737.
  85. Buttram VC Jr, Reiter RC, Ward S. Treatment of endometriosis with danazol: report of a 6-year prospective study. Fertil Steril 1985; 43:353.
  86. Burry KA. Nafarelin in the management of endometriosis: quality of life assessment. Am J Obstet Gynecol 1992; 166:735.
  87. Efstathiou JA, Sampson DA, Levine Z, et al. Nonsteroidal antiinflammatory drugs differentially suppress endometriosis in a murine model. Fertil Steril 2005; 83:171.
  88. Ozawa Y, Murakami T, Tamura M, et al. A selective cyclooxygenase-2 inhibitor suppresses the growth of endometriosis xenografts via antiangiogenic activity in severe combined immunodeficiency mice. Fertil Steril 2006; 86:1146.
  89. Olivares C, Bilotas M, Buquet R, et al. Effects of a selective cyclooxygenase-2 inhibitor on endometrial epithelial cells from patients with endometriosis. Hum Reprod 2008; 23:2701.
  90. Laschke MW, Elitzsch A, Scheuer C, et al. Selective cyclo-oxygenase-2 inhibition induces regression of autologous endometrial grafts by down-regulation of vascular endothelial growth factor-mediated angiogenesis and stimulation of caspase-3-dependent apoptosis. Fertil Steril 2007; 87:163.
  91. Kyama CM, Mihalyi A, Simsa P, et al. Non-steroidal targets in the diagnosis and treatment of endometriosis. Curr Med Chem 2008; 15:1006.