{"paper_id":"130c6250-6557-4559-bfac-ea5992fc17d4","body_text":"Submit Manuscript | http://medcraveonline.com\nwith many patients left undiagnosed with an estimated average delay \nof up to 10.4years. 5,8–10 Two thirds of women with endometriosis \nare initially misdiagnosed and almost half are examined by five \nphysicians or more before a correct diagnosis is made. 11 Diagnostic \ndelay is significantly longer in women presenting with pelvic pain \nin comparison to those presenting with infertility. 5,12,13 In addition, \ndelay before surgical diagnosis of deep infiltrating endometriosis is \nsignificantly longer for patients with advanced stage IV disease than \nfor those with stage I, II or III disease.14 The endometriosis-associated \ncosts to society are aggravated by delayed diagnosis and empirical \ntreatments, as are the costs to the individual when disease symptoms \ninterfere with daily function.5,15,16 \nDiagnostic delay in endometriosis is normally considered as \nthe time interval between the appearance of symptoms and the \nperformance of diagnostic surgery. Recently, Nnoaham et al. 5 \ndescribed a delay of 6.7 years in affected women, which was mainly \ndue to delays in referral from the primary care physician to the \ngynecologist, with women reporting an average of seven visits before \nspecialist referral. Ballard et al.17 investigated possible reasons for the \ndiagnostic delay in endometriosis using a qualitative questionnaire \ngiven to women attending a pelvic pain clinic.17 The authors found that \ndelays in the diagnosis of endometriosis occur at both an individual \npatient level and at a medical healthcare system level. At an individual \nlevel; women bore symptoms due to inaccurate perception of normal \nversus abnormal pain, embarrassment, endurance and individual \ncoping strategies; while general practitioners and family doctors tend \nto normalize symptoms, symptoms are intermittently suppressed \nthrough hormones and nondiscriminatory investigations such as \na normal transvaginal scan are relied upon. They highlighted the \nimportance of an early diagnosis for women who suffer at physical, \nemotional, and social levels when they remain undiagnosed. Other \npossible reasons for this delay may be related to a lack of awareness \nor knowledge, or simply lack of confidence in surgery results. Early \ndiagnosis of endometriosis refers, by definition, to early surgery, since \nsurgery is the gold standard for diagnosis. But early surgery is not \nadvocated for all patients. In certain cases, empirical treatment is \nstrongly recommended. \nLaparoscopic surgery under general anesthesia is most commonly \nrequired to reach a definitive diagnosis of endometriosis, but this is \nexpensive and potentially associated with complications.18\nNumerous reasons have been advocated in an attempt to explain \nthe diagnostic delay of endometriosis. Traditionally these could be \ndivided into three groups:\ni. Disease related factors, such as overlapping of endometriosis \nsymptoms with other morbidities (i.e., urinary tract infection, in-\nterstitial cystitis, pelvic inflammatory disease and others), and the \nlack of good nonsurgical methods of diagnosing the disease or at \nleast predicting its presence.\nii. Patient related factors, including symptom endurance due to \ninaccurate perception of normal versus abnormal pain, embarras-\nsment, and individual coping strategies.\niii. Physician related factors, such as lack of awareness or knowled -\nge, or simply lack of confidence in surgery results.\nAlthough these traditional explanations for the delay in diagnosis \nmay account for a large portion of the delays, I would like to point out \nsome additional factors that may be even more substantial. These have \nto do with health care medical policy. There is a considerable void \nin clinical guidelines to direct clinicians regarding the appropriate \ninvestigation and appropriate modality, timing and provision of \nadequate treatment. These could be explained by several factors \nincluding:\ni. A diversity in symptoms (cysts, pain, infertility or a combination \nof these) and in clinical settings (adolescence, chronic pain patien-\nts, patients desiring fertility, etc.), has led to lack of guidelines.\nii. Many of the existing recommendations advocate delaying surgery \nresulting in a delay in diagnosis.\niii. Due to a shortage in adequately powered randomized controlled \ntrials that aim to answer some of the important clinical questions, \ngood evidence-based recommendations cannot be made.\niv. Some of the existing clinical recommendations are too general at \nbest and contradicting and confusing at times (i.e. Does surgery \nfor ovarian endometrioma improve fertility performance or impair \novarian reserve and which type of patient should it be recommen -\nded for?).\nIn conclusion, many physicians in community practice are \nstill largely unaware of the role of specialized care in the optimal \nMOJ Womens Health. 2016;2(1):10‒11. 10\n© 2016 Weintraub. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nThe significance of diagnostic delay in endometriosis\nVolume 2 Issue 1 - 2016\nAdi Y Weintraub\nDepartment of Obstetrics and Gynecology, Soroka University \nMedical Center, Israel\nCorrespondence: Adi Y Weintraub, Department of Obstetrics \nand Gynecology, Soroka University Medical Center, Faculty of \nHealth Sciences, Ben-Gurion University of the Negev, Beer \nSheva, Israel, T el 054-771-7053, Email adiyehud@bgu.ac.il\n \nReceived: January 26, 2016 | Published: February 03, 2016\nMOJ W omen’s Health \nEditorial\n Open Access\nEditorial\nEndometriosis is a common gynecological disorder, which affects \n5-15% of women of reproductive age, with a varied prevalence 1 \ndepending on the population in question and the presence of infertility2 \nand an unpredictable rate of progression.3 Endometriosis has a chronic \nnature which often leads to deterioration in quality of life and high \npsychological morbidity.4,5 Epidemiological studies highlight a high \nprevalence of chronic pelvic pain in community care settings, with \nalmost half of these women diagnosed as having endometriosis.6 \nThe gold standard for diagnosis of endometriosis is surgery, which \nis advocated as a second line investigation after failure of therapeutic \nintervention for the management of chronic pelvic pain. 7 Despite \nprogress, the diagnosis of endometriosis remains a clinical challenge \n\nThe significance of diagnostic delay in endometriosis\n11\nCopyright:\n©2016 Weintraub\nCitation: Weintraub AY. The significance of diagnostic delay in endometriosis. MOJ Womens Health. 2016;2(1):10‒11. DOI: 10.15406/mojwh.2016.02.00018\nmanagement of endometriosis. It is important to dedicate efforts and \nresources to research and perform randomized clinical trials that will \naid in establishing significant evidence based guidelines in an attempt \nto minimize the delay in diagnosis of endometriosis.\nAcknowledgements\nNone.\nConflict of interest\nThe author declares no conflict of interest.\nReferences\n1. Bulun SE. Endometriosis. N Engl J Med. 2009;360(3):268–279.\n2. Olive DL, Schwartz LB. Endometriosis. N Engl J Med . \n1993;328(24):1759–1769.\n3. Cramer DW. Epidemiology of endometriosis. In: Wilson EA editor. En-\ndometriosis. New York, USA: Alan R Liss publishers; 1985. 5 p. \n4. Strathy JH, Molgaard CA, Coulam CB, et al. Endometriosis and infer -\ntility: laparoscopic study of endometriosis among fertile and infertile \nwomen. Fertil Steril. 1982;38(6):667–672.\n5. Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gyne-\ncol Clin North Am. 1992;24(2):235–258. \n6. Missmer SA, Cramer DW. The epidemiology of endometriosis. Obstet \nGynecol Clin North Am. 2003;30(1):1–19.\n7. Rogers PA, D Hooghe TM, Fazleabas A, et al. Priorities for endome -\ntriosis research: recommendations from an international consensus \nworkshop. Reprod Sci. 2009;16(4):335–346.\n8. D Hooghe TM, Hill JA. Endometriosis. In: Berek JS editor. Novak’ s Gy-\nnecology. 14th ed. USA: Lippincott Company; 2006.\n9. Sinaii N, Cleary SD, Ballweg ML, et al. High rates of autoimmune and \nendocrine disorders, fibromyalgia, chronic fatigue syndrome and atopic \ndiseases among women with endometriosis: a survey analysis. Hum Re-\nprod. 2002;17(10):2715–2724.\n10. Nnoaham KE, Hummelshoj L, Webster P, et al. Impact of endometriosis \non quality of life and work productivity: a multicenter study across ten \ncountries. Fertil Steril. 2011;96(2):366–373. \n11. Viganò P, Parazzini F, Somigliana E, et al. Endometriosis and aetiologi-\ncal factors. Best Pract Res Clin Obstet Gynaecol. 2004;18(2):177–200.\n12. Royal College of Obstetricians and Gynaecologists. The initial manage-\nment of chronic pelvic pain. Guideline number 41, London, UK: RCOG; \n2005. p. 1–12. \n13. Hadfield R, Mardon H, Barlow D, et al. Delay in the diagnosis of endo -\nmetriosis: a survey of women from the USA and the UK. Hum Reprod. \n1996;11(4):878–880.\n14. Hudelist G, Fritzer N, Thomas A, et al. Diagnostic delay for endome -\ntriosis in Austria and Germany: causes and possible consequences. Hum \nReprod. 2012;27(12):3412–3416.\n15. Husby GK, Haugen RS, Moen MH. Diagnostic delay in women with \npain and endometriosis. Acta Obstet Gynecol Scand . 2003;82(7):649–\n653.\n16. Hummelshoj L, Prentice A, Groothuis P. Update on endometriosis. Wo-\nmens Health (Lond Engl). 2006;2(1):53–56.\n17. Dmowski WP, Lesniewicz R, Rana N, et al. Changing trends in the diag-\nnosis of endometriosis: a comparative study of women with pelvic endo-\nmetriosis presenting with chronic pelvic pain or infertility. Fertil Steril. \n1997;67(2):238–243.\n18. Vercellini P, Somigliana E, Viganò P, et al. Surgery for endometriosis-as-\nsociated infertility: a pragmatic approach. Hum Reprod. 2009;24(2):254–\n269.","source_license":"CC0","license_restricted":false}