Adolescent Endometriosis Care Before Surgery

Adolescents With Pathology-Confirmed Endometriosis Experience Variable Preoperative Care Across Centers

Key Points

Highlights:

• Adolescents with pathology-confirmed endometriosis commonly present with progressive dysmenorrhea, heavy menstrual bleeding, and school or activity absenteeism.
• Preoperative management and referral pathways vary considerably across pediatric centers before diagnostic laparoscopy.

Importance:

• Endometriosis in adolescents is frequently underrecognized and diagnosed late, despite significant symptom burden and functional impairment.
• Understanding patterns of presentation, healthcare utilization, and preoperative management may help streamline referral pathways and improve earlier recognition of the disease.

What's Done Here?

• This is a multicenter retrospective cohort study of adolescents and young adults (<22 years) with pathology-confirmed endometriosis who underwent diagnostic laparoscopy.
• The study included 305 patients from eight tertiary pediatric hospitals participating in the Midwest Pediatric and Adolescent Gynecology Consortium.
• Demographic characteristics, presenting symptoms, comorbidities, prior healthcare utilization, and preoperative medical management strategies were extracted from medical records and analyzed descriptively.

Key Results:

• The median age at presentation to pediatric and adolescent gynecology was 15.6 years.
• The most common presenting symptoms were progressive dysmenorrhea (76.7%), heavy menstrual bleeding (50.8%), and school or activity absenteeism due to menstrual pain (55.1%).
• Patients often sought care from multiple providers prior to specialist evaluation, most commonly primary care or adolescent medicine physicians.
• Most patients (92.8%) had tried hormonal suppression prior to laparoscopy, most commonly combined oral contraceptives.
• Non-steroidal anti-inflammatory drugs were used by 80.7% of patients, while opioid use remained relatively uncommon (5.9%).
• Patterns of referral and medical management varied substantially across participating institutions.

 Strengths and Limitations:

• Strengths are the large multicenter cohort, the inclusion of pathology-confirmed endometriosis, and the ability to examine real-world patterns of adolescent presentation and preoperative management across multiple pediatric institutions.
• Limitations are the retrospective design, variability in documentation across institutions, and inclusion only of patients who ultimately underwent surgery, which may limit generalizability to adolescents managed non-operatively.

From the Editor-in-Chief – EndoNews

"Endometriosis in adolescents continues to present a diagnostic and management challenge, in part because symptoms may overlap with common menstrual complaints and because clinical examination findings are often limited. The present multicenter study provides valuable insight into the real-world clinical pathways that precede surgical diagnosis in this population.

One notable aspect of this work is the use of pathology-confirmed cases across multiple pediatric institutions, which strengthens the reliability of the observations and reduces the diagnostic uncertainty that often complicates epidemiologic analyses of adolescent endometriosis. By focusing on patients who ultimately underwent laparoscopy, the study offers a clearer view of the clinical patterns that characterize adolescents with confirmed disease.

The findings also highlight the complexity of healthcare utilization in this population. Adolescents frequently interact with several different medical specialties before reaching pediatric and adolescent gynecology services. This pattern underscores the multidisciplinary nature of the condition and suggests that early recognition of symptom clusters—particularly progressive dysmenorrhea accompanied by functional impairment—may play a critical role in improving diagnostic pathways.

Equally important is the variability observed in preoperative management strategies across centers. While hormonal suppression and nonsteroidal anti-inflammatory medications remain cornerstones of symptom management, differences in prescribing patterns and referral pathways suggest that consensus regarding optimal early management strategies remains limited. Such variability is not unexpected in a condition where both diagnostic confirmation and therapeutic decision-making often depend on individual clinical judgment.

Taken together, these findings emphasize that adolescent endometriosis should be viewed not only as a gynecologic condition but also as a healthcare systems challenge, involving recognition, referral pathways, and coordination among providers. Future research aimed at standardizing early evaluation strategies and identifying patients most likely to benefit from surgical diagnosis may help reduce delays and improve outcomes for adolescents with this disease."

Lay Summary

Adolescents with endometriosis frequently experience significant menstrual pain and functional impairment before diagnosis, according to a new multicenter study published in the Journal of Pediatric and Adolescent Gynecology. The study, led by Dr. Geri Hewitt and colleagues, analyzed clinical characteristics and preoperative management patterns among young patients with pathology-confirmed endometriosis. 

To better understand how adolescents with endometriosis present and how they are treated before surgical diagnosis, the researchers conducted a retrospective analysis of 305 patients under the age of 22 who underwent diagnostic laparoscopy at eight tertiary pediatric hospitals in the Midwestern United States. All cases included histopathologic confirmation of endometriosis, allowing the investigators to characterize presentation patterns and care pathways with greater diagnostic certainty.

The median age at presentation to pediatric and adolescent gynecology specialists was 15.6 years. Progressive dysmenorrhea was the most common symptom, reported by 76.7% of patients, followed by heavy menstrual bleeding (50.8%) and missed school or activities due to pain (55.1%). Many patients also reported gastrointestinal symptoms, headaches, and other systemic complaints.

Before reaching specialized gynecologic care, adolescents frequently sought evaluation from multiple healthcare providers, most commonly primary care or adolescent medicine physicians, and in some cases gastroenterologists, adult gynecologists, or physical therapists.

Most patients had already received medical treatment for symptom control prior to diagnostic laparoscopy. Hormonal menstrual suppression was widely used, particularly combined oral contraceptives, while nonsteroidal anti-inflammatory drugs were the most common analgesics. Opioid use remained relatively uncommon.

Despite similarities in symptom presentation, the study found substantial variability in referral patterns and preoperative treatment approaches across participating institutions, suggesting differences in clinical practice and thresholds for surgical evaluation.

The authors note that improving recognition of key symptoms—such as progressive dysmenorrhea and school absenteeism—may help facilitate earlier referral and evaluation of adolescents with suspected endometriosis.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41557926/