Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative.

OBJECTIVE: To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative. STUDY DESIGN: LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience. RESULTS: Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88). CONCLUSIONS: LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Overlap Between Irritable Bowel Syndrome Diagnosis and Endometriosis in Adolescents.

BACKGROUND & AIMS: Gastroenterologic symptoms often are reported by adults with endometriosis, leading to unnecessary diagnostic tests or complicated treatment. We investigated associations between endometriosis and irritable bowel syndrome (IBS) in adolescents and whether concurrent pain disorders affect these. METHODS: We collected data from within The Women's Health Study: Adolescence to Adulthood, which is a US longitudinal study of premenopausal females with and without endometriosis. Our study cohort included participants younger than 21 years enrolled from 2012 to 2018. Participants completed an extensive health questionnaire. Those with IBS based on a self-reported diagnosis or meeting Rome IV diagnostic criteria were considered cases and those without IBS were controls. Subjects without concurrent gastrointestinal disorders or missing pain data (n = 323) were included in the analyses. We calculated adjusted odds ratios using unconditional logistic regression. RESULTS: More adolescents with endometriosis (54 of 224; 24%) had comorbid IBS compared with adolescents without endometriosis (7 of 99; 7.1%). The odds of IBS was 5.26-fold higher among participants with endometriosis than without (95% CI, 2.13-13.0). In girls with severe acyclic pelvic pain, the odds of IBS was 35.7-fold higher in girls without endometriosis (95% CI, 4.67-272.6) and 12-fold higher in girls with endometriosis (95% CI, 4.2-36.3), compared with no/mild pain. For participants with endometriosis, each 1-point increase in acyclic pain severity increased the odds of IBS by 31% (adjusted odds ratio, 1.31; 95% CI, 1.18-1.47). CONCLUSIONS: In an analysis of data from a longitudinal study of girls and women with and without endometriosis, we found significant associations between endometriosis and IBS, and a linear relationship between acyclic pelvic pain severity and the odds of IBS. Increased provider awareness and screening for IBS and endometriosis will improve patient outcomes and increase our understanding of these complex disorders.

A Clinical and Pathologic Exploration of Suspected Peritoneal Endometriotic Lesions.

Endometriosis is generally histopathologically defined as the presence of at least 2 of the following: endometrial stroma, Müllerian epithelium, and/or hemosiderin-laden macrophages (HLM). Despite clinically evident endometriotic lesions, biopsies are frequently nondiagnostic. In this study, we conducted a large-scale review of biopsies of lesions clinically thought to represent endometriosis and correlate the histologic findings with clinical appearance to expand sensitivity of the pathologic definition of endometriosis, particularly in patients on hormonal therapy. In all, 112 biopsies from 78 patients (mean age=25, range 18-39 yr) were reviewed for histopathologic features suggestive of or diagnostic for endometriosis including the presence of endometrial stroma, Müllerian epithelium, dystrophic calcifications, HLM, chronic inflammation, adhesions, and vascular proliferation. Endometriosis was confirmed by pathologic criteria in 37 of 78 patients (47%). Biopsies from patients on hormonal therapy (n=62, 80%) were significantly less likely to meet pathologic criteria for endometriosis (P=0.01). Nondiagnostic biopsies (70/112; 63%) frequently displayed HLM (20%), chronic inflammation (29%), dystrophic calcifications (26%), vascular proliferation (20%), or adhesions (20%) and were significantly more likely to have a vascular clinical appearance (P=0.01). Diagnostic biopsies (42/112; 38%) were more likely to have a blue/black clinical appearance (P=0.03), demonstrate HLM (P=0.004), and display pseudodecidualization (P=0.05). Patients with a high clinical suspicion of endometriosis have a range of histologic findings, with less than half meeting the current histopathologic criteria for diagnosing endometriosis. Given the heterogeneous histopathologic appearance, revision of the histologic criteria may be warranted with further exploration, particularly for lesions with predominantly vascular features.

Long-acting reversible contraception side effect management.

PURPOSE OF REVIEW: Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects. RECENT FINDINGS: Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up. SUMMARY: Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Spectrum of symptoms in women diagnosed with endometriosis during adolescence vs adulthood.

BACKGROUND: Endometriosis symptoms often start at a young age, and the time between symptom onset and endometriosis diagnosis can be several years. It is not clear whether the symptoms that are experienced by adolescents differ from adults. Better understanding may shorten the often lengthy delay in diagnosis. OBJECTIVE: The purpose of the study was to further elucidate the symptom presentation of adolescents as compared with adults to determine whether differences existed, based on age at surgical diagnosis that could impact time to diagnosis. STUDY DESIGN: This investigation was a cross-sectional study at enrollment within a longitudinal cohort of adolescents and women with endometriosis. The population-based cohort was recruited from 2 tertiary care centers and the surrounding communities. Participants included adolescents (diagnosed at ≤18 years old; n=295) and adults (diagnosed at >18 years old; n=107) with surgically confirmed endometriosis who were enrolled into The Women's Health Study: From Adolescence to Adulthood. Participants completed an expanded version of the World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project standard clinical questionnaire that included items regarding menstrual history, associated symptoms, and pain. Chi-square or Fisher's exact tests were applied to categoric data; Wilcoxon rank sum tests were applied to continuous data. RESULTS: Most participants (90%) experienced moderate-severe menstrual pain. On average, 3 doctors were seen before diagnosis, regardless of age at presentation (range, 0-25 years). Time from symptoms to diagnosis averaged 2 years for adolescents and 5 years for adults (P<.001). More adolescents (50%) than adults (33%) reported pain starting at menarche (P=.002) and nausea accompanying pain (69% vs 53%; P=.01). Noncyclic, general pelvic pain was prevalent. One-half of the participants reported relief of their general pelvic pain after a bowel movement. Pain interfered with work/school, daily activities, exercise, and sleep to a moderate-extreme degree; difficulties were similar by age at diagnosis. CONCLUSIONS: Pelvic pain was severe and noncyclic and negatively impacted quality of life. At our tertiary care centers, symptoms of endometriosis did not differ between women surgically diagnosed during adolescence compared with those diagnosed as adults. Adolescents had more nausea and symptom onset at menarche. Multi-year delays in diagnosis were common. Clinicians should be aware of these alternate symptom patterns and include endometriosis in their differential diagnosis for both adolescent and young adult women who experience noncyclic pelvic pain and nausea.

Bone marrow fat content in 70 adolescent girls with anorexia nervosa: Magnetic resonance imaging and magnetic resonance spectroscopy assessment.

BACKGROUND: Adolescents and women with anorexia nervosa have increased bone marrow fat and decreased bone formation, at least in part due to hormonal changes leading to preferential stem cell differentiation to adipocytes over osteoblasts. OBJECTIVE: The purpose of this study was to evaluate marrow fat content and correlate with age and disease severity using knee MRI with T1 relaxometry (T1-R) and MR spectroscopy (MRS) in 70 adolescents with anorexia nervosa. MATERIALS AND METHODS: We enrolled 70 girls with anorexia nervosa who underwent 3-T knee MRI with coronal T1-W images, T1-R and single-voxel proton MRS at 30 and 60 ms TE. Metaphyses were scored visually on the T1-W images for red marrow. Visual T1 score, T1 relaxometry values, MRS lipid indices and fat fractions were analyzed by regression on age, body mass index (BMI) and bone mineral density (BMD) as disease severity markers. MRS measures included unsaturated fat index, T2 water, unsaturated and saturated fat fractions. RESULTS: All red marrow measures declined significantly with age. T1-R values were associated negatively with BMI and BMD for girls ≤16 years (P=0.03 and P=0.002, respectively) and positively for those≥17 years (P=0.05 and P=0.003, respectively). MRS identified a strong inverse association between T2 water and saturated fat fraction from 60 ms TE data (r=-0.85, P<0.0001). There was no association between unsaturated fat index and BMI or BMD. CONCLUSIONS: The association between T1 and BMI and BMD among older girls suggests more marrow fat in those with severe anorexia nervosa. In contrast, the physiological association between marrow fat content and age remained dominant in younger patients. The strong association between T2 water and saturated fat may relate to the restricted mobility of water with increasing marrow fat.

Adolescent Gynecomastia.

Gynecomastia, defined as the presence of glandular breast tissue in men, is a common, typically benign physical exam finding during adolescence. Although the exact pathogenesis of gynecomastia is unknown, it is likely due to a hormonal imbalance between estrogens and androgens. Most cases are idiopathic and do not require further evaluation if the history and physical examination are reassuring. Although the majority of cases will resolve spontaneously, surgical correction may be an option for adolescents with persistent and problematic gynecomastia. Gynecomastia can have significant negative impact on one's self-esteem, and it is crucial that primary care providers screen adolescents with gynecomastia for mental health concerns. Future studies are necessary to elucidate the true incidence and prevalence of gynecomastia in adolescent males, and to further investigate the short-term and long-term physical and emotional effects of gynecomastia.

MR Imaging in a case of severe anorexia nervosa: the 'flip-flop' effect.

We report an MR imaging phenomenon that can lead to misinterpretation. The unique appearance of the soft tissues and bone marrow in a 19-year-old severely malnourished woman with anorexia nervosa raised concerns about technical failure or systemic pathology. Due to extreme fat depletion, the T1-weighted images appeared to be fat-suppressed and the fat-suppressed fluid-sensitive images appeared to be non-fat-suppressed ("flip-flopped"). Failure to recognize the influence of a patient's overall nutritional status on MR images may cause confusion and misdiagnosis.

Vertebral fracture assessment in adolescents and young women with anorexia nervosa: a case series.

Rates of vertebral fracture (VF) in young women with anorexia nervosa (AN) are not well understood. We sought to determine the rates of asymptomatic VF in patients suffering from AN, hypothesizing that VF rates would be higher in subjects with low bone mineral density (BMD) Z-scores. We recruited young women with AN (n = 80) for participation in a longitudinal trial. Dual-energy X-ray absorptiometry images of the lateral thoracic and lumbar spines were obtained for VF assessment at 0, 6, 12, and 18 mo. Thirteen subjects (16%) had a low spinal BMD at baseline (BMD Z-score ≤-2 standard deviation). Using the Genant semiquantitative technique, 2 of 80 subjects at baseline (2.5%) had evidence of a single Genant grade 1 deformity. One subject had a Genant grade 2 deformity. Over the 18-mo trial, 10 incident VFs occurred in 9 subjects (12.5%). Using quantitative techniques, only 2 subjects had a more than 15% loss in vertebral height. Neither anthropometric data nor markers of disease severity were associated with fracture. In conclusion, ill young women with AN were at low risk for asymptomatic VF in our cohort. VFs were not predicted by duration of illness, severity of malnutrition, or traditional measures of areal BMD at the lumbar spine.

Adolescent and young adult long-acting reversible contraception post-insertion visit attendance before and after COVID-19.

OBJECTIVES: Widespread use of telemedicine for contraceptive care, including long-acting reversible contraception (LARC), was adopted in the United States in response to the COVID-19 pandemic. Given the rapid implementation of these services, little is known about the use of telemedicine for adolescent and young adult (AYA) contraceptive care. This study examined the routine use of telemedicine for LARC post-insertion care by comparing visit attendance between AYAs receiving LARC before and after the COVID-19 pandemic onset. METHODS: This analysis included LARC insertions 3/1/19-11/30/19 (pre-pandemic onset cohort) and 4/1/20-12/31/20 (post-pandemic onset cohort) from three Adolescent Medicine subspecialty clinics in the United States. De-identified data were collected via review of the electronic health record. Descriptive statistics, χ2 tests, and t-tests described and compared groups. Adjusted logistic regression models examined factors associated with attending a post-insertion visit and attending this visit via telemedicine. RESULTS: This analysis included 525 LARC insertions (279 pre- and 246 post-pandemic onset). The proportion of AYAs attending a post-insertion visit increased after the COVID-19 pandemic onset (pre 30 % vs. post 46 %; p≤0.001). Adjusted models revealed that the post-pandemic onset cohort was nearly twice as likely to attend a post-insertion visit as the pre-pandemic onset cohort (OR=1.90; 95 % CI=1.68-2.15). Of those attending this visit in the post-pandemic onset cohort (n=112), 42 % utilized telemedicine. CONCLUSIONS: AYAs were more likely to attend post-insertion visits after the COVID-19 pandemic onset than before. Telemedicine may have influenced this change in visit attendance.

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Post-insertion Visits: Outcomes over 1 Year.

STUDY OBJECTIVE: Telemedicine for long-acting reversible contraception (LARC) care is understudied given the rapid implementation of these services in response to the COVID-19 pandemic. We compared outcomes over 1 year of adolescents and young adults (AYAs) attending a LARC post-insertion visit via telemedicine vs in person. DESIGN: Longitudinal cohort study. SETTING: Four academic adolescent medicine clinics in the United States. PARTICIPANTS: AYAs (ages 13-26 years) who received LARC between 4/1/20 and 3/1/21 and attended a post-insertion visit within 12 weeks. INTERVENTIONS: none. MAIN OUTCOME MEASURES: Outcomes over 1 year were compared between AYAs who completed this visit via telemedicine vs in person. We analyzed the data using descriptive statistics, bivariate analyses, and regression models. RESULTS: Of 194 AYAs (ages 13.9-25.7 years) attending a post-insertion visit, 40.2% utilized telemedicine. Menstrual management (odds ratio (OR) = 1.02; confidence interval (CI): 0.40-2.60), acne management (P = .28), number of visits attended (relative risk (RR) = 1.08; CI: 0.99-1.19), and LARC removal (P = .95) were similar between groups. AYAs attending via telemedicine were less likely than those attending in person to have STI testing (P = .001). Intrauterine device expulsion or malposition and arm symptoms with implant in situ were rare outcomes in both groups. CONCLUSION: Roughly 40% of AYAs attended a post-insertion visit via telemedicine during the first year of the COVID-19 pandemic and had similar 1-year outcomes as those attending in person. The decreased likelihood of STI testing for those using telemedicine highlights the need to provide alternative options, when indicated, such as asynchronous or home testing. Our results support the use of telemedicine for AYA LARC post-insertion care and identify potential gaps in telemedicine care which can help improve clinic protocols.

Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications.

OBJECTIVE: This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults. STUDY DESIGN: We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded. RESULTS: A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication. CONCLUSION: IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use. IMPLICATIONS: Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.

Quantitative somatosensory testing of the abdomen: establishing initial reference values across developmental age and biological sex.

ABSTRACT: Abdominal pain is a common symptom of several debilitating conditions (eg, inflammatory bowel disease, irritable bowel syndrome, and endometriosis) and affects individuals throughout their lifespan. Quantitative sensory testing (QST) reference values exist for many body sites but not the abdomen. Using a QST battery adapted from the German Research Network on Neuropathic Pain, we collected QST data on the upper and lower abdomen in 181 pain-free participants, ages 12 to 50 years, to establish reference values by age and biological sex. The normative values are presented as medians for each QST measure by sex (male, n = 63; female, n = 118) and across 3 age categories (adolescents: 12-19 years, n = 48; young adults: 20-30 years, n = 87; and adults: 31-50 years, n = 46). Evaluating the sensory functioning of the abdomen and characterizing ranges of QST measures is an essential first step in understanding and monitoring the clinical course of sensory abnormalities in patients with underlying diseases affecting the abdomen and pelvis. The impact of age and development on sensory functioning is necessary, given age-related changes in pain perception and modulation.

Laparoscopically confirmed endometriosis and anti-Müllerian hormone levels: Findings from the Nurses' Health Study II.

OBJECTIVE: Anti-Müllerian hormone is a reliable measure of ovarian reserve associated with menopause timing and fertility. Previous studies have observed that individuals with endometriosis have lower anti-Müllerian hormone levels than those without. However, sample sizes have been small and information is limited regarding the long-term influence of endometriosis on anti-Müllerian hormone levels among the general population, which may have important implications for menopause timing and chronic disease risk. METHODS: Among 1961 premenopausal women in the Nurses' Health Study II who provided a blood sample and had not been pregnant in the last 6 months, we used generalized linear models to determine the association between laparoscopically-confirmed endometriosis and log-transformed plasma anti-Müllerian hormone level, adjusted for age (continuous and squared) and other potential confounding variables. RESULTS: Participants were on average 40 years old (interquartile range 37-42 years) at blood draw. Women with endometriosis diagnosed prior to blood draw (n = 119) had a lower mean anti-Müllerian hormone level (1.6 ng/mL [SD = 2.3]) than women without known endometriosis (n = 1842) (2.8 ng/mL [SD = 3.0]). In multivariable adjusted models, women with endometriosis had 29.6 % lower anti-Müllerian hormone levels (95 % CI: -45.4, -9.2 %) than women without. This association was greater among women with a body mass index of 25 kg/m2 or more (percent difference: -44.0 % (-63.7, -13.8)), compared to those with a body mass index of under 25 kg/m2 (percent difference: -19.8 % (-41.7, 10.4)), but did not vary by parity or infertility history. CONCLUSIONS: Lower anti-Müllerian hormone levels in women with endometriosis may be one mechanism through which endometriosis influences risk of infertility, younger age at menopause, and cardiovascular disease.

Subgroups of pelvic pain are differentially associated with endometriosis and inflammatory comorbidities: a latent class analysis.

ABSTRACT: Chronic pelvic pain is heterogeneous with potentially clinically informative subgroups. We aimed to identify subgroups of pelvic pain based on symptom patterns and investigate their associations with inflammatory and chronic pain-related comorbidities. Latent class analysis (LCA) identified subgroups of participants (n = 1255) from the Adolescence to Adulthood (A2A) cohort. Six participant characteristics were included in the LCA: severity, frequency, and impact on daily activities of both menstruation-associated (cyclic) and non-menstruation-associated (acyclic) pelvic pain. Three-step LCA quantified associations between LC subgroups, demographic and clinical variables, and 18 comorbidities (10 with prevalence ≥10%). Five subgroups were identified: none or minimal (23%), moderate cyclic only (28%), severe cyclic only (20%), moderate or severe acyclic plus moderate cyclic (9%), and severe acyclic plus severe cyclic (21%). Endometriosis prevalence within these 5 LCA-pelvic pain-defined subgroups ranged in size from 4% in "none or minimal pelvic pain" to 24%, 72%, 70%, and 94%, respectively, in the 4 pain subgroups, with statistically significant odds of membership only for the latter 3 subgroups. Migraines were associated with significant odds of membership in all 4 pelvic pain subgroups relative to those with no pelvic pain (adjusted odds ratios = 2.92-7.78), whereas back, joint, or leg pain each had significantly greater odds of membership in the latter 3 subgroups. Asthma or allergies had three times the odds of membership in the most severe pain group. Subgroups with elevated levels of cyclic or acyclic pain are associated with greater frequency of chronic overlapping pain conditions, suggesting an important role for central inflammatory and immunological mechanisms.

Endometriosis for the primary care physician.

PURPOSE OF REVIEW: This review will empower the primary care provider (PCP) to evaluate, manage, and refer as needed adolescents with dysmenorrhea and/or chronic pelvic pain (CPP) who are suspected to have endometriosis. RECENT FINDINGS: Endometriosis is a common cause of CPP in adolescents who do not respond to primary medical treatment. The presentation in adolescents is unique, causing high rates of misdiagnosis or delayed treatment. Endometriosis-related pain has a marked negative impact on social and mental health. Simple treatments that are available in the primary care setting can alleviate pain and improve quality of life for these young women if initiated in a timely fashion. SUMMARY: Adolescents usually turn to their PCP for evaluation of dysmenorrhea and CPP. By maintaining a high index of suspicion, initiating treatment, and referring when needed, the PCP can have a tremendous effect on the patient's present and future quality of life.

The use of gonadotropin releasing hormone analogues in adolescent and young patients with endometriosis.

PURPOSE OF REVIEW: Endometriosis is increasingly being recognized and diagnosed in adolescents. As a result of this earlier diagnosis, treatment with agents like gonadotropin releasing hormone agonist (GnRHa) begins earlier and may last longer. Long-term effects of GnRHa treatment for endometriosis are of concern when treating adolescents. RECENT FINDINGS: GnRHas are used for adolescents with surgically confirmed endometriosis. GnRHa treatment is effective for pain reduction, but is associated with menopausal symptoms and decreases in bone density. Different regimens of hormonal add-back therapy have been studied in adults to attempt to prevent these side-effects. SUMMARY: GnRHa therapy is a highly effective, nonsurgical treatment option for many adolescents with endometriosis, but is accompanied by side-effects of bone loss and menopausal symptoms. Side-effects may be decreased by introducing appropriate add-back therapy. Monitoring of bone density by DXA is recommended for prolonged use of GnRHa in adolescents.

Treatment of Adolescent Endometriosis Before, During, and After Use of Gonadotropin-Releasing Hormone Agonists: A Retrospective Cohort Study.

OBJECTIVE: To explore the use duration of a gonadotropin-releasing hormone agonists (GnRHa) plus add-back in adolescents with laparoscopically confirmed endometriosis and the treatment course before and after GnRHa therapy. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We identified 51 subjects with laparoscopically confirmed endometriosis who had participated in a randomized trial of a GnRHa plus add-back as adolescents between 2008 and 2012. Electronic medical records were reviewed to obtain demographic data, clinical characteristics, and treatment outcomes after trial completion. The study was deemed IRB exempt. RESULTS: The average age of participants during trial enrollment was 17.9 ± 1.7 years. Thirty-three participants had stage I endometriosis (65%). The most common treatments trialed before GnRHa therapy were combined oral contraceptives (n = 47, 92%) and progestin-only pills (n = 23, 45%). The average duration of GnRHa use during the trial was 9.5 ± 3.5 months; 34 subjects (67%) completed the 1-year trial. After trial completion, 23 subjects (45%) continued to use a GnRHa with add-back therapy. The mean duration of additional GnRHa use was 31.7 ± 28.6 months, and the longest identified duration was an additional 96 months. Twenty-four subjects switched to other hormonal treatments after trial participation, most commonly oral progestins (n = 15) or combined oral contraceptives (n = 6). Thirteen participants (25%) returned to a therapy that had been trialed before GnRHa use. CONCLUSION: Almost half the participants in this cohort continued to use a GnRHa with add-back for treatment of endometriosis beyond the 12-month recommended duration. Treatment varied widely after discontinuation of GnRHa, with many participants returning to previously trialed medical therapies.