Ovarian endometriomas in adolescents often often represent active angiogenic disease requiring early diagnosis and careful management

As of today, there is no proof that the ovarian endometrioma in an adolescent represents a progressive condition, although evidence is accumulating that active management of this phenotype of endometriosis is warranted. Indeed, although symptoms will often start at a young age, even before menarche, a major delay between their onset and final diagnosis seems almost unavoidable, risking serious damage and impairment of future fertility. Published series of adolescent endometriosis show a relatively frequent presence of endometrioma and a possible rapid progress; furthermore, severity does not seem directly correlated to the degree of pain. Following active management, reported risk of recurrence is high, estimated as between more than 20% at 2 years and 40-50% at 5 years. Unfortunately, no biomarkers of recurrence exist and therefore targeted interventions are impossible. Among factors favoring recurrence, neoangiogenesis and adhesion formation may play an important role. The endometrioma produces a detrimental effect on ovarian function through a number of cellular and molecular features of its bed: in the superficial implant hormonal response in the stromal vessels leads to recurrent bleeding, whereas in the deeper tissue the presence of endometrial glands is associated with smooth muscle metaplasia of the surrounding tissue. Fortunately, the availability of non-invasive imaging techniques and of minimally invasive endoscopic techniques enables today careful investigation and successful management. In conclusion, notwithstanding the existing large gaps in our understanding of the pathogenesis of the ovarian endometrioma, present knowledge suggests that in adolescent girls they often represent a progressive condition necessitating early, active management.