Version July 2025
INTRODUCTION —
Endometriosis is a disease characterized by ectopic endometrial glands and stroma (ie, outside the endometrial cavity and uterine musculature) that commonly causes pelvic pain and/or infertility. As endometriosis is a chronic, inflammatory condition for which there is no cure, treatment involves long-term management of symptoms. A multimodal approach is typically required, including medication, and adjuvant and nonpharmacologic therapies.
This topic will discuss endometriosis treatment as it applies to adolescent patients. Discussions of epidemiology, clinical features, and diagnosis specific to adolescent patients are presented in related content.
●(See "Endometriosis in adolescents: Epidemiology, clinical features, and diagnosis".)
●(See "Endometriosis: Long-term treatment with gonadotropin-releasing hormone agonists".)
In this topic, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
ISSUES SPECIFIC TO ADOLESCENT PATIENTS
Importance of shared decision-making — As most adolescents present to health care visits with a family member or guardian, shared decision-making is critical and should include all involved parties. In general, the clinician first meets with the patient and others together and then offers to meet with the patient alone. Private and confidential time allows the adolescent to present their specific concerns and discuss matters such as sexual history that may not be known to the family. This is important for establishing trust as well as hearing the patient's point of view; adolescents may perceive family members as minimizing or dismissing their pain symptoms [1]. Private time with the adolescent should be offered with every follow-up visit to ensure the adolescent can disclose all symptoms and concerns. (See "Confidentiality in adolescent health care".)
Points for discussion — As part of the shared decision-making process, we discuss the issues below. A narrative review of patients with endometriosis reported that not incorporating shared decision-making likely contributes to reduced patient trust, lower treatment adherence, and lessened quality of life [2].
●Communication – Clear and empathetic communication validates the patient's symptoms and experience. Patients may feel dismissed, with their pain having been normalized or deemed psychological. Discussion and explanation of the disease process, symptoms, and treatment options facilitate patient engagement and goal setting.
●Desire for definitive diagnosis before initiating treatment – Some individuals and/or their families may prefer to avoid hormonal treatment or other interventions for pelvic pain unless a definitive diagnosis is established. Furthermore, since endometriosis is considered a chronic condition in which long-term hormone suppression is recommended (except when a patient is actively trying to achieve pregnancy, which can be decades later), not all individuals are comfortable committing to years of therapy based on a clinical diagnosis alone. (See 'Decision for surgery' below.)
●Medical and/or surgical risk factors – Patients are evaluated for risk factors that might be contraindications to medical therapy and/or surgery. Complicating factors include prior abdominal surgery, presence of congenital gynecologic anomalies, and underlying medical conditions. Specific to hormonal contraception, both the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use maintain evidence-based recommendations for use of contraceptive methods in the context of a range of medical conditions and personal characteristics [3,4]. The benefits and side effects of estrogen-containing contraceptives are discussed in detail separately. (See "Combined estrogen-progestin contraception: Side effects and health concerns".)
●Hormonal treatment if continued pain – It is important to advise patients and their families that even if endometriosis is not identified at time of laparoscopy, hormonal treatment is often still recommended for patients with dysmenorrhea or cyclic exacerbation of pelvic pain.
•(See "Primary dysmenorrhea in adolescents".)
•(See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
●Treatment expectations – We discuss that long-term treatment that extends through the reproductive years is necessary for most patients, and that it may take time to find a suitable treatment regimen. Further, we explain that discontinuation of therapy can result in the recurrence of pain and/or endometriosis lesions. As treatment selection will evolve based on the patient's goals, and treatment efficacy and tolerability, we encourage a flexible and adaptable approach.
Quality of life — Endometriosis negatively impacts physical and mental health-related quality of life among adolescents and young adults [5,6]. Adolescents may note difficulty in completing daily activities, attending school, and engaging in social activities with family and friends. A longitudinal study found almost half of affected adolescents reported skipping exercise during menstruation due to pain, meaning an inability to participate in physical education classes and extracurricular sports [5]. In addition, endometriosis diagnosed at a younger age has been associated with increased incidence of somatic disorders [7], including chronic pain conditions and mood disorders. (See 'Co-occurring mood disorders' below.)
Potential impact on future fertility — While the impact of adolescent endometriosis on future fertility is a common concern among patients and family members, this topic is of ongoing debate given the lack of meaningful prospective studies. In a retrospective cohort study of 55 adolescents under 19 years of age who were laparoscopically diagnosed with endometriosis, 18 patients expressed a wish to conceive during a mean follow-up period of 10.4 years; 13 of the 18 (72.2 percent) had a successful pregnancy outcome, and 9 (69.2 percent) of the pregnancies were observed in patients with stages I to II endometriosis [8]. Another study of 52 adolescents with a mean follow-up of 8.6 years reported that fecundability rates were strongly correlated with the initial stage of the disease, which may be considered reassuring given that the majority of adolescents have early stage disease [9]. These data suggest the impact of adolescent endometriosis on subsequent fertility may be limited given that the majority of cases are early stage, but this merits further investigation.
A detailed discussion of endometriosis-related infertility and its treatment is available separately. (See "Endometriosis: Treatment of infertility in females".)
Co-occurring mood disorders — Adolescents with endometriosis experience a higher prevalence of anxiety and depression that require medication and/or therapy compared with peers without the disease, which underscores the importance of screening for these conditions at routine visits [5]. Further, patients who experience co-occurring chronic pain and psychological conditions, such as depression and anxiety, experience more severe pain and worse quality of life compared with patients with chronic pain alone [10]. The relationship between chronic pain and mood disorders is multifactorial and likely involves common genetic, inflammatory, and neurobiological vulnerabilities [11]. While there is an association between chronic pain and mood disorders, we reassure patients that their pain is real and not a manifestation or consequence of depression or anxiety [12]. In our practice, a social worker frequently meets with patients affected by endometriosis to provide resources, including mental health resources.
PREFERENCE FOR CLINICAL DIAGNOSIS
●Initial clinical diagnosis – For most adolescent patients with symptoms suggestive of endometriosis, including dysmenorrhea and/or pelvic pain, we suggest starting medical therapy based on a suspected clinical diagnosis rather than requiring a surgical diagnosis to start medical therapy. While both approaches are reasonable for most patients (adolescent and adult), most medical treatments for a presumed clinical diagnosis of endometriosis are low risk, have similar efficacy with surgery, and treat conditions with similar symptoms (such as primary dysmenorrhea and adenomyosis) (table 1) [13,14]. Symptom-based presumptive clinical diagnosis reduces the time to treatment and is in line with published guidelines [13-18]. (See "Endometriosis in adolescents: Epidemiology, clinical features, and diagnosis", section on 'Role of presumptive clinical diagnosis'.)
●Decision to proceed with surgery – We generally reserve surgery for patients whose symptoms are not adequately controlled with medication (generally after six-month trial), who decline or have contraindications to a trial of medical therapy, or who have clear indications for surgery (eg, a large ovarian endometrioma or obstructive bowel or urinary tract disease, which are uncommon in adolescent patients). Selection is based on patient preferences around the risks and benefits of each [14]. (See 'Decision for surgery' below.)
●Option to change treatment approach – Regardless of initial approach, the patient may switch to the alternate option. Patients who do not adequately respond to medical management may transition to surgery, and patients who undergo surgery are recommended postoperative medical management, particularly if endometriosis is confirmed. In addition, patients planning surgery may elect a course of medication to control symptoms while they are waiting for treatment. Thus, we emphasize selecting the approach that best improves quality of life and encourage flexibility in treatment planning.
INITIAL TRIAL OF NSAID PLUS HORMONAL TREATMENT —
For adolescent patients, first-line medication treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs) plus hormonal therapy. [14-19].
Rationale — We suggest first-line hormonal medical therapy (combined estrogen-progestin contraceptives or progestin-only medication) plus NSAIDs rather than other medical treatment options (eg, gonadotropin-releasing hormone [GnRH] agonists or antagonists). Hormonal treatment plus NSAID improves symptoms, is low risk, is generally well tolerated, and provides contraception for those who desire it [14,15,19]. GnRH analogs (agonists and antagonists) are generally not advised as first-line therapy for adolescent patients younger than 18 years because they may reduce bone mineral density. (See 'GnRH agonist or antagonist' below.)
The decision for surgery is addressed below. (See 'Decision for surgery' below.)
Treatment selection — Treatment selection is driven by patient preferences regarding route and frequency of use, need for contraception and contraceptive efficacy, adverse effects, and product cost and availability.
Nonsteroidal anti-inflammatory drugs (NSAIDs) — A trial of NSAIDs is reasonable based on the low risk of treatment, low cost, and demonstrated efficacy for treating dysmenorrhea, although evidence specific to treating endometriosis-associated pain is inconclusive [20]. While NSAIDs are typically dosed in combination with hormonal treatment, some patients may elect treatment with NSAIDs only. However, while NSAIDs treat pain, they do not treat the underlying disease process. Patients who are unable to take NSAIDs may opt for a trial of acetaminophen for pain management.
●Drug and dose – Commonly used drugs include ibuprofen, naproxen, or mefenamic acid, among others (table 2). Drug selection is based on availability, symptom response, and adverse effects. For patients weighing <60 kg, weight-based dosing is advised (eg, naproxen 5 to 6 mg per kg orally twice daily) [21]. Patients should be educated on the adequate dose and timing [15,22].
In our practice, we typically begin treatment with ibuprofen or naproxen, as these are readily available and may have already been trialed but without adequate dose and timing. Naproxen may be a more desirable option given it is longer acting and less frequently dosed than other NSAIDs; this may help adolescents in school as medications administered in school often need parental permission and a nursing office visit.
●Timing and treatment duration – The medication should be started one to two days before the expected onset of severe pain, if possible, and, for patients with dysmenorrhea, be continued for the duration of menses [23]. A three-month trial of NSAIDs is a reasonable approach when the pain evaluation suggests a nonacute gynecologic source, and dysmenorrhea is the primary symptom [15,19].
Discussions of NSAID selection, dosing, and treatment efficacy are presented in related content.
●(See "Primary dysmenorrhea in adolescents", section on 'Choice of NSAID'.)
●(See "Endometriosis: Medical treatment of pelvic pain", section on 'Nonsteroidal anti-inflammatory drugs'.)
Hormonal treatment options and dosing schedules — Options for hormonal medication include combined estrogen-progestin contraceptives (oral pill, transdermal patch, and vaginal ring) and progestin-only medications (oral pill, injection, implant, and intrauterine device) [14,15]. Information to guide selecting a hormonal contraceptive is available separately. (See "Contraception: Counseling and selection".)
●Biologic rationale – The biologic rationale is that use of hormonal therapy results in a hypoestrogenic state that leads to decidualization and subsequent atrophy of ectopic and eutopic endometrial tissue, thereby decreasing menstrual bleeding and, in turn, reducing bleeding-related pain. There are no data suggesting one hormonal contraceptive formulation is better than another for the treatment of dysmenorrhea or nonmenstrual pelvic pain. These agents are particularly useful in adolescents who also desire contraception or menstrual management, which NSAIDs do not provide.
●Hormonal treatment options – Selection of a hormonal treatment is highly dependent on patient preferences regarding administration, dosing, contraceptive efficacy (figure 1), potential adverse effects, medical comorbidities and contraindications, and availability. Issues related to selecting a hormonal contraceptive are discussed separately. (See "Contraception: Counseling and selection".)
•Combined estrogen-progestin contraceptives – All combined estrogen-progestin contraceptives effectively reduce endometriosis-related pain; available products include oral pills, transdermal patches, and vaginal rings (table 3). The route of administration and dosing schedule varies by product. For patients who desire oral pills, some clinicians and patients favor combination hormonal contraceptives with 30 mcg or greater of ethinyl estradiol, especially if used continuously, given the potentially higher risk of breakthrough bleeding with less ethinyl estradiol [24]. Additionally, there is some evidence that ethinyl estradiol doses less than 30 mcg may not be as supportive for peak bone mass accrual in adolescents [25-27]. However, a lower dose of ethinyl estradiol may be selected if a patient has had side effects from higher ethinyl-estradiol-containing medications, or the patient expresses concerns and desires for lower-dose pills.
While much of the data specific to hormonal treatment of endometriosis are based on combined oral pills, the transdermal patch and vaginal ring are acceptable alternatives. Some adolescents may prefer the ring for its longer-interval dosing schedules, although this option may be uncomfortable for others, including teens who have not used tampons. All of these methods are safe and effective if given cyclically, and the oral pill and vaginal ring may be used in an extended or continuous fashion [28-30]. While the transdermal patch can be used in an extended-cycle pattern, some clinicians prefer cyclic dosing because of theoretical increased thrombosis risk with extended patch use. Discussion of data regarding treatment efficacy is presented in related content. (See "Endometriosis: Medical treatment of pelvic pain", section on 'Estrogen-progestin contraceptives'.)
Detailed discussions of combined estrogen-progestin contraceptives, dosing, and counseling points are available separately:
-(See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use".)
-(See "Contraception: Transdermal contraceptive patches".)
-(See "Contraception: Hormonal contraceptive vaginal rings".)
•Progestin-only medications
-Commonly used contraceptives – Progestin-only medications include oral pills (commonly drospirenone or norethindrone acetate), medroxyprogesterone acetate injection (intramuscular or subcutaneous), and the etonogestrel implant. Small studies suggest 52 mg levonorgestrel intrauterine devices may also reduce symptoms [31]. Discussions of progestin-only treatment options and supporting data are available in related content. (See "Endometriosis: Medical treatment of pelvic pain", section on 'Progestins'.)
-Norethindrone acetate – Norethindrone acetate is a progestin-only medication that has been found to be a well-tolerated and effective option to manage pain and bleeding in adolescents with all stages of laparoscopically confirmed endometriosis [32]. Norethindrone acetate can be prescribed at doses 2.5 mg or greater and suppresses ovulation and bleeding. Norethindrone acetate is not a formally approved contraceptive and is dispensed in a pill bottle; the packaging and indications for use of norethindrone acetate may make this a desirable option for adolescents and/or caregivers who prefer noncontraceptive management. Additional discussion is available in related content. (See "Dysmenorrhea in adult females: Treatment", section on 'Progestin-only methods'.)
-Medications to avoid – By contrast, norethindrone 0.35 mg is not approved as a treatment for endometriosis-related pain; it is insufficient for suppressing ovulation and does not lead to a hypoestrogenic state [33]. In addition, the over-the-counter progestin-only pill (commercial name Opill), which contains norgestrel 0.075 mg, has not been studied for treating endometriosis-related pain. While not approved and without studies that support their use, these medications may be considered in certain circumstances, such as for patients who have had significant adverse effects from other medications.
●Cyclic versus extended dosing – Extended or continuous use of hormonal contraceptives is safe, well tolerated, and appears to be more efficacious than cyclic dosing (with monthly menses) with regards to treating dysmenorrhea [34]. Consistent with multiple international guidelines, we encourage continuous dosing schedule, especially for patients whose pain did not adequately improve with cyclic dosing. We educate patients that continuous use of hormonal contraceptives may result in more episodes of unscheduled bleeding, and tightened timing and adherence to the medication may help minimize bleeding episodes. Patients with bothersome unscheduled bleeding may require a scheduled hormone-free interval (eg, every three months) or consider a change in dose or formulation.
•(See "Hormonal contraception for menstrual suppression".)
•(See "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception".)
Track and reassess symptoms — We ask patients to keep a symptom diary and then reassess their symptoms after three to four months of treatment. Examples of pain trackers are available in publications [35] and online (Center for Young Women's Health of Boston Children's Hospital). Patients may use endometriosis-specific or menstrual-tracking applications on their mobile devices to track symptoms. Digital tools (eg, commercial name EndoWheel) may assist patients in capturing the multiple dimensions of symptom burden.
●Symptom improvement – Patients whose symptoms improve adequately continue the initial medical therapy. We assess for symptom improvement by asking patients about their overall status and improvement with initial medical therapy. Signs of improvement may include having a lower burden of symptoms in a symptom diary, improved school and/or work attendance, and/or increased participation in extracurricular and social activities. Patients are reevaluated in three-to-six month intervals, with longer intervals used for patients with greater duration of stable symptoms.
For patients with some, but suboptimal, symptom improvement, we confirm correct and consistent use of all medications and adequate NSAID dosing. Patients who initially chose NSAID-only therapy may want to add hormonal treatment at this time. Patients are again reassessed in three to four months. Those whose symptoms are adequately controlled continue the combined medical therapy. Those who do adequately respond proceed to the bullet below.
●Inadequate symptom response – While there are data supporting the use of NSAIDs and hormonal medication for the treatment of dysmenorrhea [36,37], the preferred next steps for clinical evaluation and management of patients with persistent endometriosis-related pain are less clear, in part because of limited supporting data.
Patients with continued symptoms despite an adequate trial of hormonal and NSAID therapy have the option of adjusting their drug combination or proceeding with surgery for diagnosis and treatment. Adjusting their drug combination may entail switching from cyclic use of a hormonal contraceptive (taking placebos to induce withdrawal bleeds) to continuous use of a hormonal contraceptive (skipping placebos to suppress menstruation). Adjusting their drug combination may also include a trial of an alternative hormonal formulation, particularly if there were unwanted side effects, although there are no data suggesting that once amenorrhea is achieved with tolerable side-effects, a different estrogen-progestin or progestin-only contraceptive will improve their pain symptoms. However, patients who desire a trial of a different combination of medications may reasonably do so.
Duration of medical therapy — Endometriosis is a chronic estradiol-mediated disease. Thus, we advise patients to continue hormonal suppressive therapy until they actively desire pregnancy (or enter menopause) [15]. Patients whose symptoms recur undergo repeat evaluation to exclude other causes. (See 'Exclude other causes of pain' below.)
RECURRENT OR ONGOING PAIN —
Endometriosis is a chronic and inflammatory disease and can recur despite medical and surgical therapy. We take the following approach for patients with recurrent pain:
Exclude other causes of pain — Patients with pain or symptom flares in the setting of a chronic disease are evaluated to exclude other potential causes of pain exacerbation (eg, urinary tract infection or an ovarian cyst complicating chronic pelvic pain) (table 4).
Pelvic pain is often multifactorial, and co-occurring pain conditions such as irritable bowel syndrome (IBS), interstitial cystitis, vulvar pain of unknown cause (formerly vulvodynia), and myofascial pain (eg, high tone pelvic floor myofascial pain) are more common in patients with endometriosis [7]. At initial presentation of pelvic pain and at times of pain recurrence, patients should always undergo a comprehensive evaluation to co-occurring pain conditions. Pain can persist despite medical and surgical therapy for endometriosis and does not necessarily indicate recurrent endometriosis lesions. (See "Endometriosis in adolescents: Epidemiology, clinical features, and diagnosis".)
Treat co-occurring pain syndromes — Coexisting pain conditions are common in adolescents with endometriosis [38] and should be thoroughly investigated and treated before considering repeat surgery for endometriosis.
●(See "Chronic pelvic pain in nonpregnant adult females: Causes".)
●(See "Chronic pelvic pain in adult females: Evaluation".)
Trial of alternate medical therapy — Although there are few studies that directly compare two or more hormonal drugs, a change in treatment modality may be considered if adolescents have persistent pain associated with endometriosis while taking continuous hormonal therapy. Additionally, change may be necessary if bothersome unscheduled bleeding occurs while using hormonal suppressive therapy. Individual experiences may vary and a patient may need to try several different treatments within and across classes to identify a hormone treatment that adequately controls symptoms with minimal side-effects. Opioid medication is not advised for pain related to endometriosis [15].
Different NSAID and/or hormonal medication — Patients with continued pain symptoms, particularly those who have not achieved amenorrhea, may try switching to a different class of medication (eg, combination estrogen-progestin therapy to progestin-only), use continuous or extended suppression, or increasing the dose or potency of the existing treatment (eg, increasing norethindrone acetate from 5 mg daily to 7.5 mg daily), although there are no clinical trials that examine comparative efficacy. (See 'Hormonal treatment options and dosing schedules' above.)
GnRH agonist or antagonist — We generally avoid empiric use of gonadotropin-releasing hormone (GnRH) agonists or antagonists for adolescent patients 18 years and younger. However, adolescent patients with confirmed endometriosis and refractory pain may elect a trial of GnRH agonist or antagonist with add-back therapy.
●GnRH agonist with add-back – GnRH agonist with add-back therapy (table 5) is reasonable for adolescent patients with confirmed endometriosis and recurrent or refractory endometriosis-related symptoms [14,15]. Although supporting data are limited, we generally treat for six to nine months and then immediately restart of estrogen-progestin or progestin-only hormonal therapy. Add-back therapy with combined progestin and low-dose estrogen is generally preferred to progestin alone in adolescents based on the preservation of bone mineral density (figure 2) and patient quality of life [39-41]. Most bone mass in females has accumulated by age 18 [42]. Adverse effects of GnRH agonist plus add-back therapy may include memory loss, insomnia, and hot flashes [43].
Additional discussion of GnRH agonists after surgical diagnosis and treatment is presented in related content.
•(See "Endometriosis: Long-term treatment with gonadotropin-releasing hormone agonists".)
●GnRH antagonist with add-back – For patients 18 years and older with refractory or recurrent pain, GnRH antagonists (elagolix or relugolix in combination with estradiol and norethindrone) are reasonable options. Relugolix combination therapy minimizes the impact on bone loss. Until further studies establish efficacy and safety in patients younger than 18 years, we do not advise using these medications for this age group.
Supporting data, dosing, and adverse effects are discussed in related content. (See "Endometriosis: Medical treatment of pelvic pain", section on 'GnRH antagonists'.)
●Repeat trial of GnRH treatment – Patients whose symptoms recur while off GnRH treatment (agonist or antagonist) may elect to a repeat trial of the GnRH treatment with add-back therapy. A treatment change should be based on shared decision-making and an understanding that there are no comparative studies that definitively demonstrate superiority in certain treatments over others. Long-term use of GnRH agonists and add-back hormonal therapy is presented in detail separately. (See "Endometriosis: Long-term treatment with gonadotropin-releasing hormone agonists".)
●Adjunct treatment of neuropathic pain – Patients with persistent pain may benefit from a trial of neuromodulator drugs, including anticonvulsants (eg, gabapentin, pregabalin), tricyclic antidepressants (TCAs; eg, amitriptyline), and serotonin-norepinephrine reuptake inhibitors (SNRIs; eg, duloxetine, venlafaxine) (table 6) [44]. Patients who may benefit from neuromodular drugs include those who may display signs or symptoms of central sensitization. Their abdominal examination may reveal allodynia (pain from nonpainful stimuli) and/or hyperalgesia (increased sensitivity from painful stimuli). However, use of these medications for endometriosis-related pain, particularly for younger patients, has not been studied and benefit is unclear [45-47]. Additional discussion of neuropathic pain treatment is presented in related content. (See "Chronic pelvic pain in adult females: Treatment", section on 'Interventions for central sensitization or neuropathic pain'.)
Decision for surgery
●Initial surgery – For most adolescent patients, we suggest surgery as a second-line treatment because effective and lower-risk medical therapies are available [14]. In this approach, we reserve initial surgery for individuals whose symptoms do not adequately improve on medical therapy [15]. However, some individuals and/or their families may prefer initial surgical diagnosis and treatment rather than empiric medical therapy. These patients may reasonably proceed with surgery first and then medical therapy as indicated. Detailed discussions of surgical diagnosis and treatment are presented in related content.
●Preference to avoid repeat surgery – Given that endometriosis is a chronic inflammatory disease, we avoid repeat laparoscopy if possible. However, repeat surgery may be considered in select patients who previously experienced long-term pain relief with surgery, who have evidence of residual or recurrent disease, and whose pain persists despite adequate trials of suppressive medical therapy and other sources of pain have been evaluated and treated.
Multidisciplinary approach to chronic pain treatment — A multidisciplinary approach for managing pelvic pain, including pain treatment services and complementary and alternative therapies, should be offered to all adolescent patients with endometriosis. (See "Chronic pelvic pain in adult females: Treatment", section on 'Nonpharmacologic therapies'.).
Adjuvant therapies that may be helpful include exercise, cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), acupuncture [48], and pelvic floor physical therapy [49]. Physical therapy may need to be tailored to the adolescent as teens uncomfortable with vaginal insertion may need therapy techniques performed on pelvic floor musculature externally.
RESOURCES FOR PATIENTS AND CLINICIANS —
Online resources for patients and clinicians include:
●World Health Organization (WHO) – Endometriosis fact sheet
●Boston Children's Hospital Center for Young Women’s Health
●Society for Women's Health Research – Endometriosis Toolkit Guide for Teens
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endometriosis".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●The Basics (see "Patient education: Endometriosis (The Basics)")
●Beyond the Basics topics (see "Patient education: Endometriosis (Beyond the Basics)")
In addition, information and patient education specific to adolescent endometriosis is available through the Center for Young Women's Health at Boston Children's Hospital, including:
●Endometriosis: General information
●Endometriosis: Frequently asked questions (FAQs)
●Endometriosis: Coping with pain
●Endometriosis: Continuous hormonal pills (OCPs)
●Endometriosis: Hormonal treatment overview
SUMMARY AND RECOMMENDATIONS
●Issues specific to adolescent patients – As with all patient care, shared decision-making is critical and should include all involved parties, including the patient, responsible family member, or guardian. Clear (ie, age-appropriate) and empathetic communication validates the patient's symptoms and experiences. We discuss goals of treatment, emphasis on quality of life, potential impact on future fertility, and frequently co-occurring conditions. (See 'Issues specific to adolescent patients' above.)
●Preference for initial hormonal suppression based on clinical diagnosis – For patients with endometriosis-related symptoms, we suggest initial hormonal therapy rather than surgical treatment (Grade 2C). Medical therapy often improves pain symptoms, is low-risk, and avoids surgical risks and complications. However, some patients may reasonably proceed directly with surgery for definitive diagnosis and treatment. (See 'Rationale' above.)
•Initial treatment – For patients who elect a trial of medical therapy, we suggest a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal treatment rather than either alone (Grade 2C). The rationale is to maximize potential symptom improvement rather than beginning with a single agent and then adding another if needed. However, a step-wise approach to treatment is also reasonable. We begin with a three-month trial and then reassess the patient's symptoms. In this setting, hormonal treatment typically consists of estrogen-progestin contraceptive or progestin-only medication. (See 'Initial trial of NSAID plus hormonal treatment' above.)
•Track and reassess symptoms – We ask patients to keep a symptom diary and then reassess their symptoms after three to four months of treatment. At the follow-up visit, patients with continued symptoms have the option of trying an alternate medical regimens for an additional three months or proceeding with surgery. (See 'Track and reassess symptoms' above.)
●Management of recurrent pain – Endometriosis is a chronic and inflammatory disease; pain and endometriosis-related symptoms can recur despite medical and surgical therapy. (See 'Recurrent or ongoing pain' above.)
•Initial approach – Patients with pain or symptom flares in the setting of a chronic disease are evaluated to exclude other potential causes of pain exacerbation. Patients are evaluated for co-occurring pain syndromes. Patients taking continuous hormonal therapy may elect a change in treatment modality.
-(See 'Exclude other causes of pain' above.)
-(See 'Treat co-occurring pain syndromes' above.)
•Decision to proceed with surgery – A definitive diagnosis of endometriosis is often considered for adolescents whose symptoms persist despite three to six months of hormonal therapy and NSAIDs. Many patients with treatment-resistant symptoms are found to have endometriosis at the time of surgery. When surgery is selected, laparoscopy is the gold standard for diagnosis of endometriosis and surgical removal of endometriosis is recommended. There is no role for diagnostic laparoscopy without surgical removal of endometriosis. (See 'Decision for surgery' above.)
•Avoid repeat surgery – We avoid repeat laparoscopy because endometriosis is a chronic disease. However, repeat surgery may be reasonable in select patients with recurrent pain symptoms if other causes of their symptoms have been excluded. (See 'Decision for surgery' above.)
