The tangled web of reasons for the delay in diagnosis of endometriosis in women with chronic pelvic pain: will the suffering end?

Patient experiences of endometriosis diagnosis: A mixed methods approach

OBJECTIVE

To examine patient-described experiences of endometriosis diagnosis.

DESIGN

Mixed-methods study.

SETTING

Online patient-led endometriosis support groups.

POPULATION OR SAMPLE

People with endometriosis aged over 18.

METHODS

A survey with qualitative and quantitative questions was distributed through online patient-led endometriosis support groups. Descriptive statistics were used to analyse quantitative data, and thematic analysis was used for qualitative responses. Quantitative and qualitative data were triangulated to examine patient experiences of endometriosis diagnosis across age groups.

MAIN OUTCOME MEASURES

Experiences of endometriosis diagnosis among people with endometriosis.

RESULTS

A total of 2017 people with endometriosis from 63 countries responded to the questionnaire. Patients experienced an average delay of 3.7 years between symptom onset and first presentation of symptoms to a physician (the care-seeking delay) and an average delay of 5.8 years between first presentation of symptoms to a physician and diagnosis of endometriosis (the healthcare-related delay). Patients experienced an average total diagnostic delay of 9.6 years. Participants aged over 35 at the time of the study reported significantly longer times to receive an endometriosis diagnosis (mean 10.7, 95% confidence interval [CI] 10.2-11.2) compared with participants age 18-24 (6.8, 95% CI 6.1-7.5 years). The qualitative analysis identified the following themes: physicians normalised endometriosis symptoms, patients felt their symptoms were ignored by physicians because they were considered unreliable, and participant character attributes (e.g. age, appearance, weight or physical ability) led to clinician dismissal.

CONCLUSIONS

People with endometriosis of all age groups reported pervasive negative healthcare experiences during their adolescence. Patients experience delays in seeking care and in receiving a diagnosis once presenting for care.

Peculiar Aspects of Endometriosis in Adolescents

Although documented rates of endometriosis in adolescent patients undergoing laparoscopy for chronic pelvic pain range from about 25% to 45%, adolescent endometriosis has received limited attention in terms of research activity and follow-up studies. In this manuscript, distinctive characteristics of adolescent and young endometriosis have been considered in order to define pathogenetic and scientific concepts that might be useful in clarifying some aspects of the adult disease as well. Some highlights relative to the cellular origin of the disease can be derived from reported cases before menarche, from the appearance of endometriotic lesions in teenagers (mostly stage I-II endometriosis), and from the relative infrequency of ovarian endometriotic cysts in this population. Adolescents and young patients might be also particularly useful for studying the natural course of the disease. To this end, clinical manifestations and recurrence patterns of the disease in adolescent patients need to be elucidated. Differences in clinical aspects of the disease between the adult and young populations are presented. Risk of recurrence and potential risk factors involved in the reappearance of the disease in teenagers are completely unknown. (Journal of Endometriosis 2010; 2: 19–25)

Endometrial BCL6 Overexpression in Eutopic Endometrium of Women With Endometriosis

The objective of this study was to examine B-cell CLL/lymphoma 6 (BCL6) expression in human eutopic endometrium across the menstrual cycle in women with and without endometriosis and to establish a cutoff for future studies. This design was a series of case-control studies in tertiary University teaching hospitals. We examined BCL6 expression by messenger RNA and immunohistochemically in prospectively collected samples in both the proliferative (P) and the secretory phases. BCL6 is minimally increased in the mid-secretory phase of the menstrual cycle compared to the P phase in normal patients. BCL6 protein expression was significantly higher in the secretory phase of patients with endometriosis (n = 29) versus fertile controls without endometriosis at laparoscopy (n = 20; P < .0001). Normal fertile controls (n = 28) recruited for endometrial biopsy also had low levels of secretory phase BCL6 expression compared to women with unexplained infertility (UI; n = 119). A receiving-operator characteristic analysis of these data revealed an area under the curve of 94% (95% confidence interval 85%-100%; P < .0001) with an HSCORE cutoff of 1.4 to differentiate cases with and without endometriosis. Using this cutoff value, BCL6 was positive in 88% of cases with UI. Laparoscopic examination of a subset of 65 patients confirmed abnormalities in 98% of cases; 61 (93.8%) were found to have endometriosis, 3 (4.6%) with hydrosalpinx, and 1 (1.5%) with a normal pelvis. These data suggest that BCL6 is a promising candidate as a single diagnostic biomarker for detection of endometriosis in women with otherwise UI and may be associated with endometrial dysfunction, including progesterone resistance.

Practices and Attitudes Concerning Endometriosis Among Nurses Specializing in Gynecology

Endometriosis is a chronic disease affecting approximately 10% of fertile women. These women often have negative health care experiences. This study adds new knowledge about endometriosis care in a hospital setting and nurses' attitudes toward the disease. To explore how the personal attitudes of gynecological nurses, their specialized knowledge, and their clinical experiences influenced the way they conceptualized and cared for women with endometriosis, participant observations and semistructured interviews were conducted. Categorization of patients into certain kinds, with more or less legitimate needs, provided an important framework for practice. Specialized knowledge qualified the nurses' views of their patients and seemed to be conducive to sustained patient involvement. However, the organization of care based solely on medical specialization restricted a holistic approach. An important goal is, therefore, to investigate patients' perspectives of health and illness and to create participatory relationships with patients, regardless of their diagnosis.

World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: II. Clinical and covariate phenotype data collection in endometriosis research

OBJECTIVE

To harmonize the collection of nonsurgical clinical and epidemiologic data relevant to endometriosis research, allowing large-scale collaboration.

DESIGN

An international collaboration involving 34 clinical/academic centers and three industry collaborators from 16 countries on five continents.

SETTING

In 2013, two workshops followed by global consultation, bringing together 54 leaders in endometriosis research.

PATIENTS

None.

INTERVENTION(S)

Development of a self-administered endometriosis patient questionnaire (EPQ), based on [1] systematic comparison of questionnaires from eight centers that collect data from endometriosis cases (and controls/comparison women) on a medium to large scale (publication on >100 cases); [2] literature evidence; and [3] several global consultation rounds.

MAIN OUTCOME MEASURE(S)

Standard recommended and minimum required questionnaires to capture detailed clinical and covariate data.

RESULT(S)

The standard recommended (EPHect EPQ-S) and minimum required (EPHect EPQ-M) questionnaires contain questions on pelvic pain, subfertility and menstrual/reproductive history, hormone/medication use, medical history, and personal information.

CONCLUSION(S)

The EPQ captures the basic set of patient characteristics and exposures considered by the WERF EPHect Working Group to be most critical for the advancement of endometriosis research, but is also relevant to other female conditions with similar risk factors and/or symptomatology. The instruments will be reviewed based on feedback from investigators, and-after a first review after 1 year-triannually through systematic follow-up surveys. Updated versions will be made available through http://endometriosisfoundation.org/ephect.

Lag time between onset of symptoms and diagnosis of endometriosis

OBJECTIVE

To assess lag time between onset of symptoms and diagnosis of endometriosis in patients followed up at the Outpatients Clinic of Endometriosis and Chronic Pelvic Pain, at the Hospital do Servidor Público Estadual de São Paulo "Francisco Morato de Oliveira", from January 2003 to November 2009.

METHODS

In a retrospective analytical study, a total of 310 women with endometriosis confirmed by surgery and pathological examination were evaluated in the period from January 6, 2003 to November 29, 2009. Data were gathered through revision of the follow-up visit forms at the specialized outpatients clinic and medical records. The software Epi-Info 3.3.2 was used for statistical analysis.

RESULTS

The mean lag time between onset of symptoms and confirming diagnosis of endometriosis was 46.16 months (3.84 years), ranging from 6 to 324 months. Patients aged under 20 years had a mean time until diagnosis of 2.8 years (33.6 months, range of 6 to 144 months). In patients aged 20-29 years, it was 3.51 years (42.18 months, range 6-192 months). In those aged 30-40 years, the mean time was 4.14 years (49.69 months, range 6-324 months). And in women age over 40 years, it was 3.15 years (37.86 months, range 6-216 months).

CONCLUSION

The lag time between onset of symptoms and diagnosis of endometriosis was shorter, as compared to other national and international evaluations.

Acupuncture for pain in endometriosis

BACKGROUND

Endometriosis is a prevalent gynaecological condition, significantly affecting women's lives. Clinical presentations may vary from absence of symptoms to complaints of chronic pelvic pain, most notably dysmenorrhoea. The management of pain in endometriosis is currently inadequate. Acupuncture has been studied in gynaecological disorders but its effectiveness for pain in endometriosis is uncertain.

OBJECTIVES

To determine the effectiveness and safety of acupuncture for pain in endometriosis. 

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group (MSDG) Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, CNKI and TCMDS (from inception to 2010) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised single or double-blind controlled trials enrolling women of reproductive age with a laparoscopically confirmed diagnosis of endometriosis and comparing acupuncture (body, scalp or auricular) to either placebo or sham, no treatment, conventional therapies or Chinese herbal medicine.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed risk of bias and extracted data; we contacted study authors for additional information. Meta-analyses were not performed as only one study was included. The primary outcome measure was decrease in pain from endometriosis. Secondary outcome measures included improvement in quality of life scores, pregnancy rate, adverse effects and rate of endometriosis recurrence.

MAIN RESULTS

Twenty-four studies were identified that involved acupuncture for endometriosis; however only one trial, enrolling 67 participants, met all the inclusion criteria. The single included trial defined pain scores and cure rates according to the Guideline for Clinical Research on New Chinese Medicine. Dysmenorrhoea scores were lower in the acupuncture group (mean difference -4.81 points, 95% confidence interval -6.25 to -3.37, P < 0.00001) using the 15-point Guideline for Clinical Research on New Chinese Medicine for Treatment of Pelvic Endometriosis scale. The total effective rate ('cured', 'significantly effective' or 'effective') for auricular acupuncture and Chinese herbal medicine was 91.9% and 60%, respectively (risk ratio 3.04, 95% confidence interval 1.65 to 5.62, P = 0.0004). The improvement rate did not differ significantly between auricular acupuncture and Chinese herbal medicine for cases of mild to moderate dysmenorrhoea, whereas auricular acupuncture did significantly reduce pain in cases of severe dysmenorrhoea. Data were not available for secondary outcomes measures.

AUTHORS' CONCLUSIONS

The evidence to support the effectiveness of acupuncture for pain in endometriosis is limited, based on the results of only a single study that was included in this review. This review highlights the necessity for developing future studies that are well-designed, double-blinded, randomised controlled trials that assess various types of acupuncture in comparison to conventional therapies.

Prevalence of newly diagnosed endometriosis in women attending the general practitioner

OBJECTIVE

To investigate the prevalence of newly diagnosed endometriosis in premenopausal women who requested a consultation with their general practitioner because of non-gynecological problems.

METHOD

Participants in the study were invited to complete a questionnaire investigating the presence of pain symptoms and infertility. On the basis of the characteristics of these symptoms, some patients underwent gynecological examination and transvaginal ultrasound. Radiological examinations were performed when bowel or bladder endometriosis were suspected.

RESULTS

A total of 1291 women without a previous diagnosis of endometriosis were included in the study. On the basis of the symptoms, 108 women were referred to a gynecologist. After gynecological examination and transvaginal ultrasound, endometriosis was suspected in 51 women (47.2%). The diagnosis of endometriosis was confirmed by radiological investigations and/or surgery in 46 patients; the diagnosis of endometriosis was presumed in 2 other women but it was not confirmed by radiological investigations and/or surgery. The prevalence of endometriosis diagnosed by magnetic resonance imaging and/or surgery was 3.6% (46/1291).

CONCLUSION

The prevalence of newly diagnosed symptomatic endometriosis in this study was at least 3.6%. A simple evaluation of symptoms (pain and infertility) that can be performed by a general practitioner facilitates the diagnosis of endometriosis.

Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis

OBJECTIVE

To determine whether first physician seen and symptoms beginning in adolescence have an impact on the diagnostic experience of endometriosis.

DESIGN

Cross-sectional study of self-reported survey data.

SETTING

Academic research.

PATIENT(S)

Four thousand three hundred thirty-four Endometriosis Association Survey respondents reporting surgical diagnosis of endometriosis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Specialty of first physician seen, timing of onset of symptoms, time to seeking medical care and to diagnosis, number of physicians seen, and satisfaction with care.

RESULT(S)

Almost all respondents reported pelvic pain. Fifty percent first saw a gynecologist and 45% saw a generalist for symptoms related to endometriosis. Two thirds reported symptoms beginning during adolescence; they waited longer to seek medical care than adults did. Those seeing a generalist first took longest to get diagnosed; those seeing a gynecologist first saw fewer physicians. Sometime before diagnosis, 63% were told nothing was wrong with them.

CONCLUSION(S)

Women and girls who reported seeing a gynecologist first for symptoms related to endometriosis were more likely to have a shorter time to diagnosis, to see fewer physicians, and to report a better experience overall with their physicians. The majority reported symptoms beginning during adolescence, also reporting a longer time and worse experience while obtaining a diagnosis.