For many young people, school nurses are often among the first adults outside their home to witness their severe menstrual pain up close. Long before clinical evaluation occurs, nurses across the country see countless students for recurring abdominal pain as well as other common endometriosis symptoms that disrupt learning and cause immense psychological and physical distress. Endometriosis affects up to 18% of students assigned female at birth, and diagnostic delays average a devastating seven to ten years. Despite these numbers, many medical professionals often dismiss symptoms that should raise concern as “routine”, which delays needed care and reinforces the idea that suffering is simply part of growing up female.
For conditions like endometriosis, where symptoms often begin in adolescence, this normalization can have lasting consequences. Severe period pain, one of the most common symptoms of endometriosis, is the leading cause of school absences among adolescent girls. Research suggests that at least 12% of girls lose days of school each month due to menstrual pain, with the majority of these students missing one to two days monthly. For these students, recurring absences quickly compound into missed lectures, incomplete assignments, withdrawal from extracurricular activities, and the social isolation that comes from constantly having to explain why they cannot participate.
The cumulative effect of this extends beyond individual test scores or attendance records and can shape educational trajectories and college readiness. Adolescence is a critical stage for developing self-advocacy skills, body literacy, and the confidence to navigate health systems, all capacities many young women will need throughout their reproductive years and beyond. When severe menstrual pain is repeatedly dismissed or normalized, it doesn’t just delay diagnosis; it teaches young girls that their pain assessments are unreliable, that they should minimize their experiences to avoid being seen as dramatic or attention-seeking.
This internalized dismissal can persist long after a diagnosis is finally made. Research on chronic pain has shown that years of having symptoms trivialized can lead to increased anxiety, depression, and difficulty articulating symptoms to providers, even when being taken seriously. Contrastingly, when pain is validated early, it signals to patients that they are credible witnesses to their own bodies and that persistent symptoms deserve equally persistent attention.
This makes school an important site for early recognition—and early detection of the disease is, moreover, critical for the effective treatment and management for endometriosis. Unlike clinicians who may see patients briefly and sporadically, school nurses observe students over time and can see the patterns that unfold across weeks or months, such as how recurring visits to the health office might be tied to menstrual cycles, unexplained absences, and other symptoms that affect class participation. But without specific training, even experienced nurses may lack the tools to distinguish between what may be typical menstrual discomfort and symptoms that warrant closer medical attention, as well as recurring complaints that may be treated symptom by symptom rather than as part of a larger pattern.
This is the critical gap that the Endometriosis Foundation of America’s (EndoFound) ENPOWR program aims to address as it expands its signature endometriosis education program to school nurses across the United States. ENPOWR provides free, classroom-ready menstrual health and endometriosis resources to schools and community organizations nationwide. “Everything we do is free to schools and to parents,” says Carolyn Mayer, ENPOWR’s Program Director. “Our goal is to get education and awareness out there as widely as possible to fill gaps in health education, specifically endometriosis education, that exist throughout the country.”
EndoFound’s education program, which has been serving students across the country since its founding in 2013, expanded to school nurses out of critical need, as student education alone is not enough if the adults these students are most likely to turn to are not equally prepared. “If we tell a student during our presentations to talk to someone, and the closest point of contact is a school nurse who is not knowledgeable about endometriosis, then we run into another problem,” Mayer says. In those moments, nurses can either validate a student’s concerns and help them seek further care or unintentionally reinforce the idea that what they’re experiencing is normal. By developing targeted professional development for school nurses, ENPOWR equips them to recognize red flags, document symptom patterns over time, and support conversations with family and healthcare providers.
ENPOWR’s school nurse trainings are designed to fit within a nurse’s scope of practice, focusing on recognition of symptoms, documentation, and response rather than straight-on diagnosis. Sessions cover how endometriosis can present in adolescence, emphasizing that symptoms can often extend beyond pelvic pain. Gastrointestinal and urinary complaints, for example, are frequently treated as unrelated issues, even when experienced cyclically. Nurses learn to recognize that endometriosis can manifest as chronic fatigue, pain that radiates to the legs or lower back, nausea, or headaches. Even when symptoms align with menstrual cycles, they are rarely connected to reproductive health by students or their families. The training provides specific documentation frameworks in the form of straightforward tools for tracking when symptoms occur, their severity, and functional impact. Rather than simply noting “stomach ache” in a health log, nurses are encouraged to ask questions such as, does this symptom occur monthly? Does it prevent the student from attending classes? Have over-the-counter medications provided any relief? Such documentation can provide evidence to support conversations with parents who may not be aware of their child’s symptoms or with doctors who may otherwise hear only about isolated incidents rather than a holistic view of a chronic condition unfolding over time. By translating what nurses see day to day in schools to clearer clinical narratives, ENPOWR aims to reduce the likelihood that students’ pain will be dismissed as routine.
For Lisell Zuniga, a Health Services Administrator in Illinois and President-Elect of the Illinois Association of School Nurses (IASN), the need for this kind of training was immediately clear. In her role overseeing school health services, she regularly encounters students who present with ongoing abdominal pain, severe menstrual symptoms, and frequent absences that occur around the same time every month. “Too often, these concerns are normalized or minimized, both in schools and in healthcare settings, which can delay appropriate care,” Zuniga says.
For example, consider this all-too-common scenario at a school in the United States: a fifteen-year-old girl visits the health office consistently the first day or two of her period for an entire semester, each time complaining of severe cramps. A school nurse might offer over-the-counter pain medication (if approved by a doctor or parent, or depending on the state), encourage rest, and send her back to class—standard protocol for menstrual discomfort. The visits are logged month after month, but not necessarily connected as part of a pattern. The student learns that this is simply what she should expect; that managing periods means taking pain medication that does not work and pushing through.
After an ENPOWR training, however, the same scenario will likely unfold differently. The school nurse will still provide immediate care, but will now know to ask follow-up questions, such as how long this has been happening, and whether the pain interferes with the ability to focus in class or carry on daily activities. The nurse will now document not just the concurrent symptoms, but also take note of any patterns in occurrence. This awareness hastens care, but perhaps most importantly, the student learns that her experience is worth a closer look.
After bringing ENPOWR to her district and later to a professional development conference for school nurses across Illinois, Zuniga saw a shift in how nurses approached these cases. “One of the most significant shifts was reframing menstrual pain from something that is simply managed at school to something that warrants closer attention when it is persistent, severe, or disruptive to learning,” she says. The training, she adds, validated what nurses were already seeing in their health offices while also expanding their confidence and clinical perspective.
“This type of professional development is essential not only for school nurses but for nurses across all specialties,” Zuniga continues. “Menstrual health concerns and conditions like endometriosis present in many healthcare settings, and without adequate education, symptoms can be overlooked or minimized regardless of practice area. For school nurses in particular, this training is critical because they serve as advocates, connectors, and trusted partners for students and families. Nurses are often the first to notice when a health issue is impacting a student’s ability to learn, and they play a key role in supporting parents so they can effectively advocate for their child.”
By equipping nurses with education, tools, and confidence, ENPOWR’s training, Zuniga believes, helps break down barriers between schools and healthcare systems; promotes informed conversations with parents and providers, supports early intervention, and reduces the risk of delayed or missed diagnoses.
Zuniga’s experience reflects a broader demand ENPOWR is seeing as it expands its school nurse trainings across the country. In addition to district-level professional development sessions, the program has begun presenting at state and regional conferences, reaching hundreds of school nurses at once. Recent trainings in New York have generated significant interest, with expansion planned for Connecticut and New Jersey in the coming months. Just this January, Mayer, along with endometriosis and infertility specialist Dr. Serin Seckin, delivered a professional development session to hundreds of school nurses in partnership with the New York State Education Department and the New York State Center for School Health. The webinar championed a powerful paradigm shift: severe menstrual pain is not “normal,” and students deserve validation, support, and timely intervention. Participants discovered how to recognize critical menstrual health “red flags” and learned about the profound academic, emotional, and physical toll endometriosis takes on young people navigating their educational journey. Armed with actionable, school-appropriate support strategies and access to comprehensive free resources, these nurses left prepared to make an immediate impact in their schools.
Mayer says this professional development-based model allows ENPOWR to reach nurses more efficiently and intervene earlier and more consistently. In addition, such recorded training sessions are meant to be watched both live and on demand, and often serve as an enduring virtual training resource for the respective partner, amplifying early detection and compassionate care far beyond one session and creating a ripple effect that will protect generations of students to come.
These trainings also demonstrate how much influence everyday decisions in school health offices carry and the weight of judgments made there. Nurses are already responding to students’ pain every day; the difference now lies in whether they are equipped and supported to recognize when symptoms point beyond routine discomfort. For school districts, administrators, or individual school nurses interested in bringing this training to their communities, ENPOWR’s programs are available free of charge, and schools can request training directly through ENPOWR’s website, where they’ll also find classroom-ready educational resources for students and families. The program also depends on schools and districts taking the initiative to request training, a step that can fundamentally change how menstrual pain is recognized and addressed in schools and communities.
“We know the need is there,” Mayer says, “We’re hearing from nurses who are seeing patterns in their health offices and want better tools to respond.”
The time is now to turn the tide in how we address this disease as early as possible. If you want to help equip school nurses and health educators—the critical first line of defense for students suffering from this often-invisible condition—with the knowledge and tools to intervene earlier, advocate more effectively, and fundamentally alter the trajectory of care for adolescents in pain, please reach out at enpowr@endofound.org.
