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Pediatric surgeons are called upon to evaluate abdominal and pelvic pain in girls of all ages. Dysmenorrhea and adnexal pathology are important to consider in the evaluation and subsequent management of such patients. An understanding of not only the pathology and surgical management but also the long-term implications is absolutely crucial for pediatric surgeons and pediatricians alike. Careful diagnosis and an emerging commitment to ovarian preservation define treatment for pediatric dysmenorrhea and adnexal pathology. In this review, we discuss primary and secondary dysmenorrhea as well as adnexal pathology that may present in pediatric patients.