{"paper_id":"1df02e04-0f14-4b5f-af09-41a9a1f6544e","body_text":"Journal of Racial and Ethnic Health Disparities\nhttps://doi.org/10.1007/s40615-025-02763-5\n \r Monica W. Rosen\nmwoll@med.umich.edu\nLauren Capra\nlaurencapra1@gmail.com\nKathleen E. O’Brien\nobrien.kathleen.e@gmail.com\nSusan J. Woolford\nswoolfor@med.umich.edu\nNiko A. Kaciroti\nnicola@med.umich.edu\nHarlan McCaffery\nhmccaff@med.umich.edu\nCheyney C. Dobson\ndobsonc@med.umich.edu\nErin Isaacson\neiaacso@med.umich.edu\n1 University of Michigan Medical School, 1301 Catherine St, \nAnn Arbor, MI 48109, USA\n2 Department of Obstetrics and Gynecology, University of \nMichigan, 1500 E. Medical Center Dr, Ann Arbor, MI  \n48109, USA\n3 Department of Pediatrics, University of Michigan, 1500 E. \nMedical Center Dr, Ann Arbor, MI 48109, USA\n4 University of Michigan Child Health Evaluation and \nResearch Center, 2800 Plymouth Rd, Ann Arbor, MI  \n48109, USA\n5 University of Michigan School of Public Health, 1415 \nWashington Heights, Ann Arbor, MI 48109, USA\nAbstract\nObjective Endometriosis often presents in adolescence as chronic pelvic pain (CPP) or dysmenorrhea. Research in adults \ndemonstrates non-White race is associated with delayed surgical diagnosis of endometriosis; however, inequity in adoles -\ncents has never been studied. We investigated inequities in laparoscopy rates among adolescents according to race, ethnicity, \nand socioeconomic status (SES).\nMethods We performed a retrospective cohort study of outpatient and operating room visits at a single academic medical \ncenter in the midwestern United States. Subjects were aged 10–21 who were seen by a gynecologic subspecialist between \n2013 and 2023 for dysmenorrhea or CPP. Subjects with a previous diagnosis of endometriosis by prior laparoscopy or found \nto have an adnexal mass or cyst at the time of laparoscopy were excluded. Subjects were classified as non-surgical, undergo-\ning scheduled laparoscopy, or undergoing emergent laparoscopy. Analyses used race, ethnicity, and SES data abstracted from \nthe electronic health record.\nResults Of 4,480 eligible subjects, 4,426 were expectantly managed, 47 underwent scheduled laparoscopy, and seven under-\nwent emergent laparoscopy. Compared to White subjects, Black subjects were significantly less likely to receive any lapa -\nroscopy (OR 0.20, 95% CI 0.03–0.69, p = .010) or non-emergent surgery (OR 0.01, 95% CI 0.00-0.20, p < .001), and Asian \nsubjects were less likely to undergo any laparoscopy (OR < 0.01, 95% CI 0.00-0.39, p = .009). Hispanic subjects were mar-\nginally less likely to undergo scheduled laparoscopy (OR 0.19, 95% CI 0.01–1.16, p = .082) than non-Hispanic subjects.\nConclusion This study identified inequities in rates of laparoscopy among adolescents, with surgery performed at lower rates \nfor Black, Asian, and Hispanic subjects.\nKeywords Adolescents · Chronic pelvic pain · Endometriosis · Diagnostic laparoscopy · Socioeconomic status · Racial \nand ethnic inequities\nReceived: 10 September 2025 / Revised: 10 November 2025 / Accepted: 16 November 2025\n© The Author(s) 2025\nRacial and Ethnic Inequities in Rates of Diagnostic Laparoscopy \nfor Evaluation of Endometriosis in Adolescents with Pelvic Pain: a \nRetrospective Cohort Study\nLauren Capra1 · Kathleen E. O’Brien2 · Susan J. Woolford3,4 · Niko A. Kaciroti4,5 · Harlan McCaffery3 ·  \nCheyney C. Dobson4 · Erin Isaacson2 · Monica W. Rosen2\n1 3\n\n\nJournal of Racial and Ethnic Health Disparities\nIntroduction\nEndometriosis is a chronic gynecologic disorder charac -\nterized by the presence of endometrial tissue implanted \noutside of the uterine cavity that may cause an array of \nsymptoms including chronic pelvic pain (CPP), dysmen -\norrhea, and subfertility. Studies have estimated the preva -\nlence of endometriosis at up to 15% of women of early \nreproductive age, with many patients endorsing symptom \nonset prior to age 15 [ 1]. While diagnostic laparoscopy \nand histologic examination is considered the gold standard \nfor diagnosis of endometriosis, current clinical guidelines \nrecommend conservative management with hormonal \nmenstrual suppression before moving toward surgical \ninvestigation [ 2].\nAlthough this approach to pelvic pain may be appropriate \nin adults with regular access to medical care, the same treat-\nment strategy is not practical for adolescents, where severe \nsymptoms may limit participation in school and social \nactivities during a crucial time in development [ 1]. Recent \nstudies suggest that adolescents may experience a diagnos -\ntic delay of approximately two years [3].\nHistorically, endometriosis was thought to occur in \nBlack women at lower rates than in White women. Previ -\nous literature on endometriosis has been heavily biased \ntoward White and Asian patients due to the enduring \nbelief that the condition is more common in these popu -\nlations [ 4]. However, endometriosis is one of the most \ncommon indications for Black women in the United \nStates to undergo gynecologic surgery, with emerging \nresults suggesting a similar prevalence of endometriosis \nbetween Black and White patients [ 4, 5]. In addition to \nmisconceptions regarding prevalence, the difficulty of \ndiagnosing endometriosis is complicated by non-specific \nclinical presentation, with pelvic pain as the most com -\nmon presenting complaint. Significant racial and ethnic \ndisparities remain across different areas of pain care, with \npatients belonging to a racial minority receiving lesser-\nquality pain care than their non-Hispanic White counter -\nparts [ 4, 6].\nThere is little existing literature examining demo -\ngraphics of adolescents with suspected endometrio -\nsis and how these patients are diagnosed and treated. \nAlthough the exact prevalence of endometriosis in ado -\nlescents is unknown, it is likely underestimated in light \nof diagnostic difficulty and reliance on potentially inac -\ncurate patient accounts of symptom onset [ 7]. In addi -\ntion to prolonging patient discomfort, there is concern \nthat diagnostic delay may contribute to disease progres -\nsion, which can lead to infertility and chronic pain. Thus, \ntime from symptom onset to diagnosis and treatment is \ncrucial. Given the documented disparities in care based \non sociodemographic factors in the adult population, \nwe aimed to investigate inequities in rates of diagnostic \nlaparoscopy among adolescents presenting with dysmen -\norrhea or CPP according to race, ethnicity, and socioeco -\nnomic status (SES). We hypothesized that we would find \ndisparities in the care of adolescents like those found in \nadult women.\nMethods\nSubjects\nWe performed an electronic health record (EHR) review \nto identify a cohort of adolescents aged 10–21 years, \nassigned female at birth, and seen for complaints of dys -\nmenorrhea or CPP by Pediatric and Adolescent Gyne -\ncology or Minimally Invasive Gynecologic Surgery at a \nsingle academic medical center in the midwestern United \nStates in the 11 years between 2013 and 2023. All sub -\njects with dysmenorrhea and CPP were identified using \nDataDirect, a web-based, self-serve, precision health \nsoftware tool enabling access to clinical data such as \ndiagnoses, encounters, procedures, medications (ordered \nand administered), and labs (ordered and results) on more \nthan 5 million unique patients from across our institu -\ntion’s enterprise. Primary dysmenorrhea, defined as \nmenstrual pain in the absence of pelvic pathology, was \nidentified using ICD-10 code N94.4. CPP, defined as pel -\nvic pain lasting for greater than six months, was identi -\nfied using ICD-10 code 94.9.\nWe included all identified adolescents who had emer -\ngent or scheduled diagnostic laparoscopy, as well as non-\nsurgical subjects managed expectantly. Those who had \na diagnostic laparoscopy were identified by ICD-9 code \n54.21. We then performed a thorough chart review on all \nadolescents who had a laparoscopy and excluded those \nwho already had a diagnosis of endometriosis by prior \nlaparoscopy, as well as those found to have an adnexal \nmass or cyst at the current laparoscopy. Data were \nentered into a secure Research Electronic Data Capture \n(REDCap) database by three study team members. The \nresults were then cross-verified by an additional study \nteam member. Missing data was indicated as such in the \nresults.\nMeasures\nThe primary outcomes in the study were non-emergent \nlaparoscopy and emergent plus non-emergent laparoscopy. \nThe primary exposures were race and ethnicity, which \n1 3\n\nJournal of Racial and Ethnic Health Disparities\nwere self-reported by the subject and documented in the \nEHR. Potential confounders included age, BMI, insur -\nance type, and socioeconomic status as measured by the \narea deprivation index (ADI). The ADI is a measure of \nneighborhood deprivation developed by the University of \nWisconsin Center for Health Disparities Research [ 8]. We \nmapped ADI state decile rankings to each subject by cen -\nsus block group using their address recorded in the EHR. \nWe did not test for modifier effects due to the low num -\nber of subjects with laparoscopy. Data were entered into a \nsecure REDCap database.\nStatistical Analysis\nData were analyzed using R v. 4.3.1 and package rstanarm \nv. 2.26.1. Bayesian multiple logistic regression modeling \nwas used to estimate the odds of scheduled laparoscopies. \nWeakly informative priors of Normal(0,2.5/Sx), where Sx \nis the SD of covariates x, were used for the coefficients \nusing the software’s default autoscaling procedure. Odds \nratios were estimated with White race and non-Hispanic \nethnicity as the reference categories. SES was measured \nby the ADI state ranking by block group. Markov Chain \nMonte Carlo convergence was assessed using Gelman’s \npotential scale reduction factor, which was < 1.005 for all \nparameters.\nThis study was deemed exempt by the University of \nMichigan Institutional Review board because it used de-\nidentified retrospective data.\nResults\nThe final cohort included 4,480 patients meeting inclu -\nsion criteria; of these, 4,426 were expectantly managed, \n47 underwent scheduled diagnostic laparoscopy, and seven \nunderwent emergent laparoscopy (Fig. 1). In the non-sur -\ngical group, the majority of subjects were White (77.0%), \nfollowed by Black (13.3%), Asian (4.6%), and Other or \nUnknown race (4.6%). Within the group that underwent \nsurgical intervention, an even higher percentage were White \n(90.2%), followed by Black and American Indian/Alaska \nNative (3.9% each). No Asian subjects were surgically \nmanaged. Regarding ethnicity, the non-surgical group was \npredominantly non-Hispanic (93.7%), as was the surgical \ngroup (96.2% for those who underwent any surgery and \n97.9% for those who underwent scheduled laparoscopic \nsurgery). The median age was 16.6 years in the non-surgical \ngroup, 19.4 years in subjects receiving any laparoscopy, \nand 19.3 years for those undergoing scheduled laparoscopy. \nThe majority of subjects in this study had private insurance \nregardless of treatment strategy, and rates of surgery did not \nFig. 1 Subject flow diagram\n \n1 3\n\nJournal of Racial and Ethnic Health Disparities\nlaparoscopic surgery (OR 0.19, 95% CI 0.01–1.16, p =.082) \nthan non-Hispanic subjects. Older subjects were more likely \nto have any laparoscopy (OR 1.33, 95% CI 1.19–1.50, \np <.001). There was no significant difference in the rate of \nsurgical intervention according to ADI (OR 1.03, 95% CI \n0.93–1.14, p =.602). The odds ratios of receiving laparos -\ncopy by race/ethnicity, socioeconomic status, and age can \nbe found in Table 2.\nDiscussion\nCurrent research on chronic pelvic pain suggestive of endo-\nmetriosis in the adult population demonstrates a disparity in \nhow patients are diagnosed and treated based on their race. \ndiffer according to insurance type. ADI did not significantly \ncontribute to differences in rates of surgical intervention. \nCharacteristics of the cohort and comparisons between sur-\ngical and non-surgical subjects can be found in Table 1.\nDespite comprising 13.2% of our included subjects, \nonly 3.9% of the surgically managed subjects were Black, \nand both laparoscopies were performed for emergent indi -\ncations. Black subjects were significantly less likely to \nreceive any laparoscopic surgery (OR 0.20, 95% CI 0.03–\n0.69, p =.01) or non-emergent surgery (OR 0.01, 95% CI \n0.00–0.20.00.20, p <.001) than White subjects. Subjects of \nAsian descent were less likely to undergo any laparoscopic \nsurgery (OR < 0.01, 95% CI 0.00–0.39.00.39, p =.009, mar-\nginal probability < 0.01%) than White subjects. Hispanic \nsubjects were marginally less likely to undergo scheduled \nTable 1 Characteristics of the cohort and comparison of characteristics between non-surgical subjects and surgical subjects\nCharacteristic Total Cohort (N = 4,480a) Non-Surgical (N = 4,426a) Surgical (N = 5 4a) p-valueb\nAge, yearsc 16.6 (14.4–18.9) 16.6 (14.4–18.9) 19.4 (17.3–20.9) < 0.001\nRace N = 4,398 N = 4,347 N = 5 1 0.007\nWhite 3,394 (77.2) 3,348 (77.0) 46 (90.2)\nBlack 579 (13.2) 577 (13.3) 2 (3.9)\nAsian 201 (4.6) 201 (4.6) 0 (0.0)\nAmerican Indian/Alaska Native 19 (0.1) 17 (0.4) 2 (3.9)\nHawaiian/Pacific Islander 4 (0.1) 4 (0.1) 0 (0.0)\nOther/Unknown 201 (4.6) 200 (4.6) 1 (2.0)\nEthnicity N = 4,385 N = 4,333 N = 5 2 0.771\nNon-Hispanic 4,110 (93.7) 4,060 (93.7) 50 (96.2)\nHispanic 275 (6.3) 273 (6.3) 2 (3.8)\nInsurance Coverage N = 4,142 N = 4,142 N = 4 7 0.377\nOther 13 (0.3) 13 (0.3) 0 (0.0)\nPrivate 2,771 (66.1) 2,736 (66.1) 35 (74.5)\nPublic 1,405 (33.5) 1,393 (33.6) 12 (25.5)\nArea Deprivation Index a 3.0 (1.0–6.0) 3.0 (1.0–6.0) 3.0 (2.0–6.0) 0.341\nData presented as n (%) unless otherwise noted aTotal counts of patients in each group differ from total counts for each covariate due tomissing \ndatabNon-surgical vs. surgical cMedian (IQR)\nTable 2 Odds ratios of receiving laparoscopy by race/ethnicity, socioeconomic status, and age\nCharacteristic Any Laparoscopya (N = 5 4 ) Non-Emergent Laparoscopy (N = 4 7 )\nOR (95% CI) p-value OR (95% CI) p-value\nRace\nWhite Reference Reference\nBlack 0.20 (0.03–0.69) 0.010 0.01 (0.00–0.20.00.20) < 0.001\nAsian 0.00 (0.00–0.39.00.39) 0.009 0.00 (0.00–0.49.00.49) 0.010\nAmerican Indian/Alaska Native 8.69 (1.01–40.7) 0.050 11.13 (1.56–46.49) 0.018\nHawaiian/Pacific Islander < 0.01 (0.00–1.12.00.12) 0.053 < 0.01 (0.00–0.92.00.92) 0.045\nOther/Unknown 0.36 (0.01–2.11) 0.314 0.50 (0.03–2.52) 0.49\nEthnicity\nNon-Hispanic Reference Reference\nHispanic or Latinx 0.48 (0.07–2.04) 0.351 0.19 (0.01–1.16) 0.082\nArea Deprivation Index 1.03 (0.93–1.14) 0.602 1.04 (0.93–1.16) 0.46\nAge 1.33 (1.19–1.50) < 0.001 1.31 (1.17–1.48) < 0.001\naMarginal probabilities by race: White = 0.97%, Black = 0.19%, Asian < 0.01%, American Indian/Alaska Native = 7.8%, Hawaiian/Pacific \nIslander < 0.01%, Other/Unknown = 0.35%.\n1 3\n\nJournal of Racial and Ethnic Health Disparities\nclassified as urgent or emergent. In our study, 2/7 adoles -\ncents receiving emergent surgery identified as Black, 1/7 as \nHispanic, and 1/7 as another non-White race. This finding \nis limited due to our small sample size of subjects undergo-\ning emergent surgery, but points to a similar troubling trend \nof minority patients potentially being denied surgery on an \nelective basis and ultimately requiring emergent interven -\ntion [14]. Coupled with trends from studies in the pediatric \npopulation, the observed variations in surgical care access \ndiscussed in this study could indicate underlying disparities \nin healthcare accessibility that warrant additional investiga-\ntion. One strategy to address and reduce these racial and \nethnic disparities is to implement training programs focused \non unconscious bias, cultural competence, and language \nservices.\nThe findings of this study are limited to a single aca -\ndemic center for subspecialty gynecologic care in the \nmidwestern United States. Due to differing patient demo -\ngraphics and cultural differences, these results may not \nbe fully generalizable to all adolescent populations. \nAdditionally, the results are further limited by only hav -\ning a small number of subjects in certain subgroups. \nSimilarly, our study demonstrated a low overall rate of \nsurgical intervention, which may differ from the manage -\nment strategies at other healthcare institutions.\nThis study does not capture possible additional ineq -\nuities that occur in initial management of CPP, dys -\nmenorrhea, or suspected endometriosis in adolescents, \nincluding nonsurgical treatments and referral to specialty \ncare. As subjects in our sample were seen by a Pediat -\nric and Adolescent Gynecology or Minimally Invasive \nGynecologic Surgery subspecialist, they were most com -\nmonly referred after seeing a general provider—often \na pediatrician, family medicine practitioner, or general \ngynecologist. Prior research suggests that race and eth -\nnicity impact pediatric care beyond the surgical space, \nwhich may have influenced evaluation, initial treatment \nmodalities, and referrals to subspecialty care that adoles -\ncents received before being seen by our providers. For \nexample, a recent study of ED care in the United States \nfrom 2005 to 2016 found that Black, Hispanic, and Asian \nchildren were less likely to receive blood tests, X-rays, \nand CT scans compared to their white counterparts, and \nthat Black and Hispanic children were also less likely to \nreceive general procedures in the ED [ 15].\nAnother limitation of this retrospective study is the \ninability to explore the attitudes and desires of adolescent \nsubjects and their families regarding surgical manage -\nment of their pain. It is possible that the subjects included \nin this study may have had increased symptom severity \nor simply have been more apt to request aggressive mea -\nsures for workup and treatment by nature of proceeding \nStudies of adults have found that White patients are more \nlikely to receive non-hysterectomy endometriosis surgery, \nmore likely to undergo minimally invasive versus open pro-\ncedures, and experience fewer surgical complications than \npatients of all other races and ethnicities [ 9, 10]. Addition-\nally, research in the adult population has demonstrated that \npatients of non-White race averaged a longer delay between \nsymptom onset and diagnosis of endometriosis, were more \nlikely to have presented to the emergency department (ED) \nfor pelvic pain, and were more likely to have an additional \nsurgical indication prior to laparoscopy compared to their \nWhite counterparts [11].\nThis study identified inequities in rates of diagnostic \nlaparoscopy for CPP among adolescent patients by race and \nethnicity, with surgery performed at lower rates for Black, \nAsian, and Hispanic subjects compared to non-Hispanic \nWhite subjects. Historically, endometriosis has been con -\nsidered a disease of White women, and medical education \nhas perpetuated stereotypes surrounding Black patients and \ntheir experience of pain [12]. Evidence does not substantiate \ngenetic or biological differences between races or ethnici -\nties as a significant contributor to health disparities among \nminorities. To date, literature does not indicate a reduced \nneed for surgical interventions in racial and ethnic minor -\nity children. Additionally, prevalent misconceptions about \nbiological differences across racial and ethnic groups could \ninfluence the medical advice provided to racial and ethnic \nminority patients. For example, providers might be biased \nin their perception that certain minority patients can endure \nmore pain or feel less pain. There might also be implicit bias \nin surgical referral. Lastly, there might be insurance or cul -\ntural barriers influencing who is able to seek care, leading to \ninequity in who receives surgical intervention.\nFindings of this study suggest that there are racial and \nethnic disparities underlying the decision to proceed with \ndiagnostic laparoscopy in adolescent patients with symp -\ntoms suggestive of endometriosis. Our study results align \nwith a large study published in 2020 of 155,064 pediatric \npatients from 2005 to 2018 that demonstrated that regard -\nless of other potentially contributing disparity domains, \nBlack and Hispanic children had lower rates of all surgeries \ncompared to their White, non-Hispanic counterparts (aOR \n0.6, 95% CI 0.5–0.8 for Black children and aOR 0.7, 95% \nCI 0.5–0.9 for Hispanic children) [ 13]. While this study \nfocused on children 0–18, our findings purport that this \ntrend extends into later adolescence as well.\nThese findings are similar to a recent cross-sectional anal-\nysis of 219,098 children in the United States from 1999 to \n2018, which demonstrated that Black, Asian, and Hispanic \npatients had lower rates of all types of surgery compared to \ntheir White counterparts [14]. This study further found that \nHispanic children were more likely to have surgery that was \n1 3\n\nJournal of Racial and Ethnic Health Disparities\nCompeting interests The authors have no relevant financial or non-\nfinancial interests to disclose.\nOpen Access   This article is licensed under a Creative Commons \nAttribution 4.0 International License, which permits use, sharing, \nadaptation, distribution and reproduction in any medium or format, \nas long as you give appropriate credit to the original author(s) and the \nsource, provide a link to the Creative Commons licence, and indicate \nif changes were made. The images or other third party material in this \narticle are included in the article’s Creative Commons licence, unless \nindicated otherwise in a credit line to the material. If material is not \nincluded in the article’s Creative Commons licence and your intended \nuse is not permitted by statutory regulation or exceeds the permitted \nuse, you will need to obtain permission directly from the copyright \nholder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  v e c  o m m o  n s .  o \nr g  / l i c e n s e s / b y / 4 . 0 /.\nReferences\n1. Shim JY , Laufer MR. Adolescent endometriosis: an update. J \nPediatr Adolesc Gynecol. 2020;33(2):112–9.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  \n0 1 6  / j .  j p a g . 2 0 1 9 . 1 1 . 0 1 1.\n2. Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, \nD’Hooghe TM. Prevalence of endometriosis diagnosed by lapa -\nroscopy in adolescents with dysmenorrhea or chronic pelvic pain: \na systematic review. Hum Reprod Update. 2013;19(5):570–82.  h \nt t p  s : /  / d o i  . o  r g /  1 0 . 1  0 9 3  / h u  m u p d / d m t 0 1 6.\n3. Li H, Cho Y , Taylor H, Vash-Margita A. Time elapsed from initial \npresentation to diagnostic laparoscopy: factors affecting diagnos-\ntic delay in adolescents with biopsy-confirmed endometriosis. J \nPediatr Adolesc Gynecol. 2021;34(2):41–242.\n4. Bougie O, Nwosu I, Warshafsky C. Revisiting the impact of race/\nethnicity in endometriosis. Reprod Fertil. 2022;3(2):R34–41.  h t t p  \ns : /  / d o i  . o  r g /  1 0 . 1  5 3 0  / R A  F - 2 1 - 0 1 0 6.\n5. Kyama CM, Mwenda JM, Machoki J, Mihalyi A, Simsa P, Chai \nDC, et al. Endometriosis in African women. Womens Health. \n2007;3(5):629–35.  h t t p  s : /  / d o i  . o  r g /  1 0 . 2  2 1 7  / 1 7  4 5 5 0 5 7 . 3 . 5 . 6 2 9.\n6. Anderson KO, Green CR, Payne R. Racial and ethnic dispari -\nties in pain: causes and consequences of unequal care. J Pain. \n2009;10(12):1187–204.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  j p a i n . 2 0 0 9 . 1 0 . \n0 0 2.\n7. Khashchenko EP, Uvarova EV , Fatkhudinov TK, Chuprynin VD, \nAsaturova A V , Kulabukhova EA, et al. Endometriosis in adoles-\ncents: diagnostics, clinical and laparoscopic features. J Clin Med. \n2023;12(4):1678.  h t t p  s : /  / d o i  . o  r g /  1 0 . 3  3 9 0  / j c  m 1 2 0 4 1 6 7 8.\n8. University of Wisconsin School of Medicine and Public Health \nCenter for Health Disparities Research. Neighborhood Atlas.  h t t p  \ns : /  / w w w  . n  e i g  h b o r  h o o  d a t  l a s  . m e  d i c i  n e  . w i s c . e d u / Accessed  O c t o b e \nr 6, 2024.\n9. Sutaria T, Flowers LC, Shockley ME, Blemur D, Barnes WA, \nLachiewicz MP. Association between race and utilization of hys-\nterectomy and non-hysterectomy surgeries for endometriosis. J \nMinim Invasive Gynecol. 2022;29(11):S96.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 \n1 6  / j .  j m i g . 2 0 2 2 . 0 9 . 3 1 1.\n10. Westwood S, Fannin M, Ali F, Thigpen J, Tatro R, Hernandez A, \net al. Disparities in women with endometriosis regarding access \nto care, diagnosis, treatment, and management in the united \nstates: A scoping review. Cureus. 2023;15(5):e38765.  h t t p  s : /  / d o \ni  . o  r g /  1 0 . 7  7 5 9  / c u  r e u s . 3 8 7 6 5.\n11. Li HJ, Song Y , Cho YK. Racial disparities in access to diag -\nnostic laparoscopy for endometriosis: diagnostic delay, ED vis -\nits, and pre-operative indications. J Minim Invasive Gynecol. \n2021;28(11):S134.  h t t p  s : /  / d o i  . o  r g /  1 0 . 1  0 1 6  / j .  j m i g . 2 0 2 1 . 0 9 . 2 4 1.\nwith a specialist referral. Additionally, it is possible that \nsubjects may not have been compliant with medications \noffered to treat their pain, which might have made them \nmore likely to seek out a laparoscopy.\nStudies have shown that approximately two-thirds of \nadolescents with CPP or dysmenorrhea are eventually found \nto have evidence of endometriosis on laparoscopic examina-\ntion [2, 16], and case reports describe significant symptom \nburden even in premenarchal patients [17]. When combined \nwith the relative paucity of adolescent-specific resources for \ntreating and supporting patients with CPP, this can lead to \nsignificant diagnostic delay and prolonged patient suffering \n[18]. Further research should examine the impact of patient \nrace and ethnicity on receiving subspecialist referral and \nworkup at the primary care level. This will allow for a more \nnuanced picture of diagnostic delay, important for assess -\ning and quantifying the magnitude of effect that CPP has on \nadolescents. Additionally, bias reduction training may help \nlessen this inequity and promote a fairer standard of practice \namong adolescent gynecologists.\nConclusion\nThis study identifies inequities in the rates of comple -\ntion of laparoscopic surgery for adolescent subjects of \na racial or ethnic minority with CPP and/or dysmenor -\nrhea. Further research is needed to identify the contribut -\ning factors leading to these differences and to guide more \nequitable care.\nAcknowledgements This research was presented at the North Ameri -\ncan Society for Pediatric and Adolescent Gynecology in Orlando, \nFlorida at the Annual Clinical and Research Meeting, April 5, 2024.\nAuthor Contributions All authors contributed to the study conception \nand design. Material preparation, data collection, and analysis were \nperformed by LC, KO, SW, NK, HM, CD, EI, and MW. The first draft \nof the manuscript was written by LC and all authors commented on \nprevious versions of the manuscript. All authors read and approved the \nfinal manuscript.\nFunding The authors declare that no funds, grants, or other support \nwere received during the preparation of this manuscript.\nDeclarations\nEthics Approval This study was deemed exempt by the University of \nMichigan Institutional Review board because it used de-identified ret-\nrospective data.\nConsent to Participate Not applicable, as this study used retrospective \nde-identified data.\nConsent to Publish Not applicable.\n1 3\n\nJournal of Racial and Ethnic Health Disparities\nTech Maloinwazyjne. 2020;15(3):424–36.  h t t p  s : /  / d o i  . o  r g /  1 0 . 5  1 1 \n4  / w i  i t m . 2 0 2 0 . 9 7 8 1 7.\n17. Sachedina A, Todd N. Dysmenorrhea, endometriosis and chronic \npelvic pain in adolescents. J Clin Res Pediatr Endocrinol. \n2020;12(Suppl 1):7–17.  h t t p  s : /  / d o i  . o  r g /  1 0 . 4  2 7 4  / j c  r p e  . g a  l e n o  s .  2 0 \n1 9 . 2 0 1 9 . S 0 2 1 7.\n18. Dixon S, Ranger TA, Burchardt J, Patone M, Snelling AJ, Vin -\ncent K, et al. Exploring the interface between adolescent dysmen-\norrhoea and endometriosis: a protocol for a cohort and nested \ncase-control study within the QResearch database. BMJ Open. \n2023;13(2):e069984.  h t t p s :   /  / d o  i . o  r  g  /  1 0  . 1 1   3 6 /  b m j o  p e n - 2  0 2 2 - 0 6 9 \n9 8 4.\nPublisher’s Note Springer Nature remains neutral with regard to juris-\ndictional claims in published maps and institutional affiliations.\n12. Hoberman J. Black & blue: the origins and consequences of med-\nical racism. Oakland, CA: University of California Press; 2012.\n13. Rabbitts JA, Groenewald CB. Epidemiology of pediatric surgery \nin the united States. Paediatr Anaesth. 2020;30(10):1083–90.  h t t p  \ns : /  / d o i  . o  r g /  1 0 . 1  1 1 1  / p a  n . 1 3 9 9 3.\n14. Sanford EL, Nair R, Alder A, Sessler DI, Flores G, Szmuk P. \nRacial/ethnic differences in receipt of surgery among children in \nthe united States. J Pediatr Surg. 2022;57(12):852–9.  h t t p  s : /  / d o i  . o  \nr g /  1 0 . 1  0 1 6  / j .  j p e  d s u  r g . 2  0 2  2 . 0 3 . 0 3 5.\n15. Zhang X, Carabello M, Hill T, He K, Friese CR, Mahajan P. \nRacial and ethnic disparities in emergency department care and \nhealth outcomes among children in the united States. Front Pedi-\natr. 2019;7:525.  h t t p  s : /  / d o i  . o  r g /  1 0 . 3  3 8 9  / f p  e d . 2 0 1 9 . 0 0 5 2 5.\n16. Raznikiewicz A, Korlacki W, Grabowski A. The role of laparos -\ncopy in paediatric and adolescent gynaecology. Wideochir Inne \n1 3","source_license":"CC-BY-4.0","license_restricted":false}