{"paper_id":"316f62e9-2ff0-47ba-8332-07ddebc46bce","body_text":"eprints@whiterose.ac.uk\nhttps://eprints.whiterose.ac.uk\nUniversities of Leeds, Sheffield and York\nDeposited via The University of York.\nWhite Rose Research Online URL for this paper:\nhttps://eprints.whiterose.ac.uk/id/eprint/218778/\nVersion: Published Version\nArticle:\nFryer, Jodie, Mason-Jones, Amanda Jayne and Woodward, Amie (2024) Understanding \ndiagnostic delay for endometriosis: a scoping review using the social ecological \nframework. Health care for women international. ISSN: 1096-4665 \nhttps://doi.org/10.1080/07399332.2024.2413056\nReuse \nThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs \n(CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long \nas you credit the authors, but you can’t change the article in any way or use it commercially. More \ninformation and the full terms of the licence here: https://creativecommons.org/licenses/ \nTakedown \nIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by \nemailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. \n\nHealth Care for Women International\nISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/uhcw20\nUnderstanding diagnostic delay for endometriosis:\nA scoping review using the social-ecological\nframework\nJodie Fryer, Amanda J. Mason-Jones & Amie Woodward\nTo cite this article: Jodie Fryer, Amanda J. Mason-Jones & Amie Woodward (17 Oct 2024):\nUnderstanding diagnostic delay for endometriosis: A scoping review using the social-ecological\nframework, Health Care for Women International, DOI: 10.1080/07399332.2024.2413056\nTo link to this article:  https://doi.org/10.1080/07399332.2024.2413056\n© 2024 The Author(s). Published with\nlicense by Taylor & Francis Group, LLC\nView supplementary material \nPublished online: 17 Oct 2024.\nSubmit your article to this journal \nArticle views: 49\nView related articles \nView Crossmark data\nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=uhcw20\n\nHealtH Care for Women InternatIonal\nUnderstanding diagnostic delay for endometriosis: A \nscoping review using the social-ecological framework\nJodie Fryer a , Amanda J. Mason-Jones b  and Amie Woodward c \nanorth Yorkshire Council, Harrogate, UK; bDepartment of Health Sciences, University of York, York, UK; \ncInstitute for Health and Care Improvement, York St. John University, York, UK\nABSTRACT\nDiagnostic delay for endometriosis is a well-established phe -\nnomenon. Despite this, little is known about where in the \nhealth care system these delays occur or why they occur. Our \nreview is the first attempt to synthesize and analyze this inter -\nnational evidence. A systematic scoping review with a pre-spec -\nified protocol incorporated the literature on diagnostic delay \nfor endometriosis using the social-ecological theoretical frame -\nwork. Four databases (PubMed, MEDLINE, EMBASE, PsychINFO) \nwere searched from inception to September 2023. The search \nyielded 403 studies, 23 of which met the inclusion criteria. \nMost were from high-income country researchers. The average \ndiagnostic delay reported across studies was 6.8 years (range \n1.5–11.4 years) but this masked the very wide differences \nreported between countries. Considering the impact on indi -\nviduals and the health system, addressing diagnostic delay for \nendometriosis must remain a priority for researchers, health \ncare providers and policy makers.\nEndometriosis is currently difficult to diagnose. This results in delays in \ndiagnosis which negatively impacts those suffering and increases the sever -\nity of pain and extent of the disease with increased costs to healthcare \nsystems. Despite this, little is known about where in the healthcare system \nthese delays occur or why they occur. Our review is the first attempt to \nsynthesize and analyze this evidence using the global literature.\nBackground\nEndometriosis is an estrogen dependent gynecological condition char -\nacterized by the presence of active endometrial tissue lying outside of \nthe uterus, typically in the pelvic region (Olšarová & Mishra, \n2020). It \nhttps://doi.org/10.1080/07399332.2024.2413056\n© 2024 the author(s). Published with license by taylor & francis Group, llC\nCONTACT amanda J. mason-Jones  amanda.mason-jones@york.ac.uk   Department of Health Sciences, \nUniversity of York, room 233, Seebohm rowntree Building, Heslington, York, Yo10 5DD, UK.\n Supplemental data for this article can be accessed online at https://doi.org/10.1080/07399332.2024.2413056.\nthis is an open access article distributed under the terms of the Creative Commons attribution-nonCommercial-noDerivatives \nlicense (\nhttp://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction \nin any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. the \nterms on which this article has been published allow the posting of the accepted manuscript in a repository by the author(s) \nor with their consent.\nARTICLE HISTORY\nReceived 25 January \n2024\nAccepted 2 October 2024\n\n2 J. FRYER ET AL.\nis a chronic, progressive inflammatory disease which affects more than \n170 million women worldwide (Della Corte et  al., \n2020). Endometriosis \nmainly affects women of reproductive age (15–49 years), with up to 1 \nin 10 believed to have the condition, although it is estimated that as \nmany as 60% of endometriosis cases remain undiagnosed (Agarwal et  al., \n2019; Della Corte et  al., 2020). Prevalence estimates of endometriosis \nare generally poor and highly varied, ranging from 4 to 50% although \nthe most consistent estimates suggest a prevalence ranging from 6 to \n10% (Zhang et  al., \n2021). Despite the progressive nature of endometri -\nosis, a correct diagnosis takes an average of 10 years and at least 7 visits \nto a health practitioner (Bach et  al., \n2016; Eisenberg et  al., 2022). This \nlengthy delay is reflected in the disease burden in which gynecological \ndiseases are reported as the leading cause of Disability Adjusted Life \nY ears (DALYs) and Y ears Lived with Disability (YLD) among the 15–49-\nyear age group (GBD Compare). This is despite clear clinical diagnostic \nindicators including chronic pelvic pain (CPP), dysmenorrhea (painful, \nheavy menstruation), dyspareunia (painful intercourse), that are known \nfor 82.9% of women (Becker et  al., \n2021; Olšarová & Mishra, 2020). \nApart from the YLD the economic impact includes increased costs to \nthe individual, to healthcare providers, and to the wider economic \ninfrastructure (Surrey et  al., \n2020). The current ‘gold standard’ for diag -\nnosis is a laparoscopy, although surgeons may be hesitant to perform \nthis due to the invasive nature of the procedure (Becker et  al., \n2021; \nNICE, 2017). There is also evidence that symptoms may be dismissed \nas ‘normal’ by health care practitioners (Bullo, 2020; Olšarová & Mishra, \n2020). The researchers’ aim for this review was to explore the delay \nfaced by those attempting to obtain a diagnosis of endometriosis. The \nsocio-ecological model has been used to exemplify multifaceted issues \narising as a result of delayed endometriosis diagnosis and provides the \nopportunity to develop effective interventions at the micro, meso and \nmacro levels.\nMethods\nThe study protocol was registered on the Open Science Framework OSF: \n10.31219/osf.io/yzuvb\nPatient and public involvement\nWomen who have experienced diagnostic delay for endometriosis were \ninvolved in designing the research. The research question was informed \nby their priorities, experiences and preferences. Dissemination of this \nresearch will be facilitated through charities focused on endometriosis.\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 3\nData sources and search strategy\nThe development of our search strategy was guided by the SPIDER frame -\nwork to ensure key concepts were captured in the searches (Booth et  al., \n2016). Four databases were searched from inception to September 2023. \nThey included PubMed, MEDLINE, EMBASE and PsycINFO. No date \nlimits were set on the searches. Search terms included key terms derived \nfrom search strings relating to ‘endometriosis’ and ‘diagnostic delay’ and \nwere adapted for each database; For example, the search strategy for \nMEDLINE was: ‘Endometriosis.mp. or (exp Pelvic Pain/or exp Chronic \nPain/)) and exp Delayed Diagnosis/’ .\nEligibility criteria\nIncluded studies were primary studies in English involving the pelvic  \nregion or reproductive organs only, that mentioned pelvic pain with a \nsuspicion of endometriosis, and diagnostic delay (in the context of \nendometriosis).\nScreening and data extraction\nAll studies were screened by one reviewer (JF) with a 10% sample checked \nby a second reviewer (SM) and any disagreements resolved by a third \nreviewer (AW/AMJ).\nWe extracted data on a predeveloped and piloted data extraction form \nand included study characteristics, methods and design, and demographic \ncharacteristics of the population. Additionally, we recorded the most fre -\nquently reported symptoms, length of and reason for delay.\nData analysis\nWe grouped studies by themes identified from the individual included \nstudies (Braun & Clarke, \n2006) and contextualized them to form a public \npolicy perspective using the socio-ecological model (Lee et  al., 2017). No \nformal quality appraisal was undertaken in line with methodological guid -\nance for scoping reviews (Grant & Booth, 2009).\nResults\nOur searches yielded 403 studies following deduplication. Title and abstract \nscreening and full-text screening resulted in 23 studies encompassing the \nviews and experiences of over 9167 participants (\nFigure 1 ).\n\n4 J. FRYER ET AL.\nStudy characteristics\nTable 1  provides an overview of the included studies and highlights the \ndiversity of methods used by researchers. Six studies were qualitative and \n17 were quantitative. Over a third of the studies (9/23) were published \nfrom 2020 onwards. Sixteen studies were conducted by researchers based \nin high-income countries including the UK (Ballard et  al., \n2006; Ghai \net  al., 2020), US (As-Sanie et  al., 2019; DiBenedetti et  al., 2018; DiVasta \net  al., 2018; Dmowski et  al., 1997; Soliman et  al., 2017), the Netherlands \n(Staal et  al., 2016; van der Zanden et  al., 2021), Norway (Fernandes et  al., \n2020; Husby et  al., 2003), Canada (Singh et  al., 2020), Australia (Armour \net  al., 2020), New Zealand (Tewhaiti-Smith et  al., 2022), and Italy (Lukic \net  al., 2016; Pino et  al., 2023). Three were conducted by researchers in \nmiddle income countries; Brazil (Andres et  al., 2014; Santos et  al., 2012) \nand Iran (Riazi et  al., 2014) and four were conducted by researchers in \nmultiple countries (Hudelist et  al., 2012; Lamvu et  al., 2020; Nnoaham \nFigure 1.  PrISma flow diagram.\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 5\nTable 1.  table of included studies.\nfirst author, year, country Study design Participants and methods main finding(s)\nQuantitative\nandres et  al., \n2014, Brazil retrospective \nstudy\n21 Patients (aged 13–20) with histologically \nconfirmed endometriosis after undergoing \nsurgery.\nneed for increased awareness of adolescent onset of endometriosis. Current imaging \ntechniques are inadequate. Gynecologists fail to recognize symptoms.\narmour et  al., \n2020, \naustralia\nCross-sectional \nstudy\n409 Participants (aged 18–45), 340 with \nendometriosis, 69 without. recruited via \nsurvey link.\neSHre guidelines reduced diagnostic delay from 9.9 years before 2005 to 1.5 years as \nof 2013 onwards. Year medical attention is sought, number of doctors seen and \ndelayed health seeking all increase diagnostic delay.\nDiVasta et  al., \n2018, United \nStates\nCross-sectional \nlongitudinal \ncohort study\n670 Participants (aged 12–49), 402 with \nself-reported endometriosis, 268 controls. \nrecruited from 2 tertiary centers.\nneed to understand changing symptom patterns and symptom base more – \nparticularly how this may differ between an adult and adolescent population. \nacyclic pain appears to increase with age – potentially due to increased severity of \nendometriosis at surgery.\nDmowski et  al., \n1997, United \nStates\nretrospective \nstudy\n693 Patients (aged 15–40), 377 with CPP \nsymptoms, 336 infertility +/− pain. \nevaluated at the Institute for the Study \nand treatment of endometriosis.\nDiagnostic delays were found to be longer in women who were symptomatic earlier \nin life. longer delays led to more advanced disease at laparoscopy. these findings \nwere only significant in the pain group. Diagnostic delay steadily decreased \nbetween 1979 and 1995. Delays were longer in the pelvic pain group than the \ninfertility group.\nGhai et  al., \n2020, United \nKingdom\nretrospective \ncross-sectional \nstudy\n101 Women with surgically confirmed \nendometriosis recruited via written postal \nquestionnaire.\nWomen often have their pain normalized and do not feel their pain is taken seriously. \nmisdiagnosis, menstrual cramps during adolescence, earlier symptom onset and \ndelays between presenting with symptoms and onward referral all increased \ndiagnostic delays. Shorter delays were found when women changed to a more \nunderstanding gynecologist.\nHudelist et  al., \n2012, austria \nand Germany\nCross-sectional \nstudy\n171 Patients (aged >18) with histologically \nconfirmed endometriosis recruited from \ntertiary referral centers for diagnosis and \ntreatment of endometriosis.\nIncreasing number of misdiagnoses, patient impression of not been taken seriously, \nnormalization of symptoms, women with cramps during adolescence, and whose \nmothers viewed menstruation as a negative event all experienced increased \ndiagnostic delays. medication use, extent of disease and main symptomatic \ncomplaint were all non-significant factors.\nHusby et  al., \n2003, norway Cross-sectional \nstudy\n261 Patients with pain and endometriosis, \n223 members of the norwegian \nendometriosis association, 38 \nnonmembers.\nthere were no statistically significant differences in the mean diagnostic delay between \n1978-2001. Delays did not differ between those with pain only and pain and \ninfertility, additionally, there was no difference in diagnostic delay between \nmembers and nonmembers. most of the delays were from seeing a GP to diagnosis.\nlamvu et  al., \n2020, United \nStates, australia, Canada, \nIreland, new Zealand, \nSouth africa, and the \nUnited Kingdom\nCross-sectional \nstudy\n451 respondents (aged 19–60) with or \nwithout endometriosis. recruited through \n‘my endometriosis team’ .\nrespondents described discussing their symptoms more than 20 times and were \ncommonly misdiagnosed with both mental and physical conditions. about half of \nrespondents waited over 6 years for a diagnosis while almost a quarter waited 11 \nor more years. longer delay was associated with more pelvic symptoms. many \nwomen felt doctors did not listen and that their recommendations were \ninconsistent with what they wanted.\n(Continued)\n\n6 J. FRYER ET AL.\nfirst author, year, country Study design Participants and methods main finding(s)\nlukic, \n2016, Italy Cohort study 67 Patients with deep dyspareunia \ndiagnosed with pelvic endometriosis \nattending an endometriosis unit.\nWomen often suffer from pathology for a long time before presenting to health \nservices. Both signs and symptoms of endometriosis need to be better recognized \nor women need to be clearer in describing signs and symptoms to allow diagnosis. \nroughly two-thirds of women don’t consult their GP for sexual dysfunction.\nnnoaham et  al., \n2011 \n(Belgium, Brazil, China, \nIreland, Italy, nigeria, \nUnited Kingdom, United \nStates and Spain)\nmulticentre \ncross-sectional \nstudy with \nprospective \nrecruitment\n1,418 Premenopausal women (aged 18–45) \nwithout previous surgical diagnosis of \nendometriosis. 745 with endometriosis, \n587 symptomatic, 86 sterilized. recruited \nin hospital before surgery.\nDelays were increased when state funded care was sought when compared to \nself-funded care or through insurance. Patients with longer delays had more pelvic \nsymptoms and a higher Body mass Index (BmI), even when adjusting for potential \nconfounders. most of the delay was due to length of time between referral from \nprimary care to a gynecologist. Women with endometriosis had a longer delay \nthan symptomatic controls without endometriosis at surgery. Diagnostic delays \nranged from 3.3 years to 10.7 years.\nPino et  al., \n2023, Italy Cross-sectional \nstudy\n689 Women with endometriosis. the mean diagnostic delay was 11.4 years and the mean time from symptom onset to \ndiagnosis (14.8 years) was significantly longer for adolescents than for older \nwomen.\nSantos et  al., \n2012, Brazil retrospective \nstudy\n262 Women (aged 17–49) with surgically \nconfirmed endometriosis. recruited \nthrough an outpatient clinic for \nendometriosis and CPP .\nDiagnostic delay differed between different age categories; however, the difference \nwas found to be non-significant. Women with dysmenorrhea and deep dyspareunia \nhad a longer delay, which those with dyspareunia (not deep) and acyclic pain had \na shorter delay. Women experiencing infertility experienced a longer delay than \ntheir fertile counterparts. Site and severity of disease were not significant factors.\nSingh et  al., \n2020, Canada Cross-sectional \nsurvey\n2004 Women (aged 18–49) were recruited \nvia email using 3 independent survey \nsampling panels.\nDelays in health seeking were longer than physician-related delays. on average \nwomen saw 3 different physicians before receiving a diagnosis. the odds of \nreceiving a diagnosis of endometriosis were highest when women experienced \ninfertility, cyclic pelvic pain or cramping, and pelvic pressure.\nSoliman et  al., \n2017, United \nStates\nCross-sectional \nstudy\n683 respondents (aged 18–29) recruited \nfrom 3 market research panels.\nYounger age at symptom onset and white ethnicity were associated with a longer \ndiagnostic delay. Patients with constipation, bloating or diarrhea were diagnosed \nsooner than those with pain during sex. Delays were also shorter among women \nhaving a diagnostic procedure, women seen by a gynecologist and women \ndiagnosed via non-surgical methods.\nStaal et  al., \n2016, \nnetherlands\nretrospective \ncross-sectional \nstudy\n47 Patients (aged 14–29) diagnosed with \nendometriosis by surgery or mrI.\nDiagnostic delay was shorter for patients who consulted their GP due to subfertility \nrather than pain. a longer delay from presenting to a GP to referral was \nexperienced by patients who were a young age when they developed symptoms, \nmisdiagnosed or their symptoms were normalized – the same delays were not \nexperienced between referral to a gynecologist and diagnosis.\nTable 1. Continued.\n(Continued)\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 7\nfirst author, year, country Study design Participants and methods main finding(s)\ntewhaiti-Smith et  al., \n2022, \nnew Zealand\nCross-sectional \nstudy\n800 respondents (aged 18–74), 620 with \nendometriosis, 180 with CPP . recruited \nusing social media, flyers, and through \ntargeted dissemination.\nDiagnostic delay was longer in patients with endometriosis than those experiencing \nCPP . on average women saw 4.8 doctors before they were diagnosed with \nendometriosis. Year of first doctors visit was negatively correlated with the number \nof doctors consulted suggesting health-seeking delays are reducing over time. \noverall diagnostic delay was reduced by 6.5 years by the introduction of guidelines.\nVan niekerk et  al., \n2022, \naustralia, oceania, United \nKingdom and north \namerica\nCross-sectional \nstudy\n318 Women (23 of whom with symptoms of \nperimenopause, 35 in medical \nmenopause and 7 in surgical \nmenopause). recruited via online \nadvertising on social media.\nlonger diagnostic delays, number of endometriosis-related symptoms, depression, anxiety, \npain after sexual intercourse and during urination were all negative predictors of \nself-compassion. Women with longer diagnostic delays were found to have higher \nlevels of endometriosis-related distress are likely to report lower levels of self-\ncompassion and would benefit from early engagement in psychological interventions.\nQualitative\nas-Sanie et  al., \n2019, United \nStates\nQualitative study \n– interactive \ndiscussion\nInterdisciplinary group of expert researchers, \nclinicians, and patients put together the \nSociety for Women’s Health research.\nIdentified themes impacting diagnostic delay through guided interactive discussion. \nthese included diagnostics, barriers to diagnosis, the future of diagnostics, \ntreatment, barriers to treatment and the future of treatment – with several \nsubthemes including stigma and understanding.\nBallard et  al., \n2006, United \nKingdom\nQualitative, \ninterview-\nbased study\n32 Women (aged 16–47) attending a pelvic \npain clinic. 28 diagnosed with \nendometriosis.\nDelays occur at every stage of the diagnostic pathway. Delays occur at both the \npatient-level and medical-level, with normalization being a common factor. others \ninclude stigma, nonspecific testing, and improper use of treatments.\nDiBenedetti et  al., \n2018, \nUnited States\nQualitative \ncross-sectional \nstudy with an \ninterview \nelement\n16 Women (aged 24-48), 11 with \nendometriosis and 5 healthy controls. \nrecruited via 2 qualitative research \nfacilities.\na painful periods screening tool was developed to aid in the recognition of \npathological symptoms of endometriosis. the tool was found have face validity \nand content validity, clearly and concisely able to assess core symptoms and \ndistinguish between normal and pathological symptoms.\nfernandes et  al., \n2020, \nnorway\nQualitative \ninterview-\nbased study\n13 Doctors – 8 gynecologists and 5 General \nPractitioners (GP’s) identified via google \nsearch.\nPatients attending clinic often feel embarrassed and disbelieved regarding symptoms. \nDoctors do not like to take responsibility for diagnosis due to not being \nspecialized in women’s health issues. Diagnosis is often delayed due to multiple \nmisdiagnoses.\nriazi et  al., \n2014, Iran Qualitative \ninterview-\nbased study\n12 endometriosis patients (aged 22–37) and \n6 gynecologists\nDyspareunia was noted as one of the most important symptoms of the disease. \nWomen’s recognition of this symptom is often delayed due to delayed marriage (and \nso delayed intercourse). Beliefs around dysmenorrhea being normal and common \nduring virginity also delay diagnosis. from a medical viewpoint, unreliability of \ndiagnostic markers, misdiagnosis and mismanagement all increase diagnostic delay.\nVan der Zanden et  al., 2022, \nnetherlands\nQualitative focus \ngroup-based \nstudy\n23 Women (aged 29–45) placed in 6 focus \ngroups. recruited by social media, \nthrough a patient interest group and \nthrough a center of expertise in \nendometriosis\nHealth-seeking behavior is often influenced by peers, normalization leads to delays. \nnondiscriminatory tests, being referred to the wrong specialist and given pain \nmedication without proper indication for use were all attributed to diagnostic \ndelays. referral was faster in women with menstruation specific complaints. not all \ndoctors have equal knowledge and some women received incomplete examination.\nTable 1. Continued.\n\n8 J. FRYER ET AL.\net  al., 2011; Van Niekerk et  al., 2022). The age range of participants was \nbetween 12 and 74 years old with an average age of 28.7 years.\nAge of onset of endometriosis\nThe mean age at onset of endometriosis symptoms was 14.1 years old \nfor adolescents (range 13–15.3 years), and 20.4 years old for adults \n(range 20–23.2 years). One study including both adults and adolescents \nfound the mean age at onset of endometriosis symptoms was 18.4 years \n(range 9–45 years). The average age at diagnosis was 16 for adolescents \nand 28.8 for adults (range 22–32). The average age of the first visit \nto primary care was 14 for adolescents and 25.8 years for adults  (range \n20–32.6).\nDiagnostic delay\nThe definition of diagnostic delay was consistent across studies and \nwas defined as the time between symptom onset and diagnosis. The \naverage diagnostic delay was 6.8 years with an average of 1.5 years in \nAustralia (Armour et  al., \n2020 ) and just over 11 years in the US and \n(DiBenedetti et  al., 2018 ; Pino et  al., 2023 ). However, there was a \nwide range between the shortest and longest delay reported b y research -\ners. The shortest delay reported for adults was 1 year, and the longest \ndelay was 27 years (Ballard et  al., \n2006). The shortest delay experienced \nby adolescents was 0.5 years in Brazil and Italy (Andres et  al., 2014 ; \nPino et  al., 2023 ), and the longest delay was 35 years in Italy (Pino \net  al., 2023 ). Some researchers reported specific points at which delay s \noccurred. These were from symptom onset to primary care/general \npractitioner (GP) consultation (As-Sanie et  al., \n2019 ; Ballard et  al., \n2006 ; DiBenedetti et  al., 2018 ; DiVasta et  al., 2018 ; Hudelist et  al., \n2012 ; Husby et  al., 2003 ; Singh et  al., 2020 ; Soliman et  al., 2017 ; Staal \net  al., 2016 ; Tewhaiti-Smith et  al., 2022 ; van der Zanden et  al., 2021 ); \nReferral for gynecology consultation (Ballard et  al., 2006 ; Ghai et  al., \n2020 ; Hudelist et  al., 2012 ; Staal et  al., 2016 ; van der Zanden et  al., \n2021 ); Gynecology referral to final diagnosis (Ballard et  al., 2006 ; Ghai \net  al., 2020 ; Hudelist et  al., 2012 ; Staal et  al., 2016 ; van der Zanden \net  al., 2021 ). Mean delays through this pathway reported across the \nstudies were 2.0, 2.5, and 2.8 years, respectively. Time from primary \ncare presentation to diagnosis was reported by some researchers with -\nout mention of transition to secondary care (DiVasta et  al., \n2018 ; Ghai \net  al., 2020 ; Husby et  al., 2003 ; Singh et  al., 2020 ; Soliman et  al., \n2017 ). The average diagnostic delay between primary care presentation \nand diagnosis was 2.9 years ( Figure 2 ).\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 9\nReasons for diagnostic delay\nNearly all included studies conducted by researchers focused on  the patients’ \nperspective, two focused on the health care provider (HCP) perspective, \nand one included both perspectives. There were 6 main themes identified \nby researchers with a range of factors contributing to diagnostic delay. We \nshow a summary of these in \nTable 2 and Supplementary Figure 2S .\nResearchers revealed that access to care differed depending on the \nspecific health system in place. Financial barriers to access were men -\ntioned for those requiring private healthcare, whilst physical access to \ncare was more frequently noted for those seeking public healthcare s er-\nvices. Researchers in only one study compared waiting times between \nthose seeking public healthcare and insurance or self-funded healthcare \n(Nnoaham et  al., \n2011). They found that waiting times for endometriosis \ncare were significantly longer for those seeking public rather than private \nhealthcare (8.3 years vs. 5.5 years). Both HCPs and patien ts shared similar \nviews on the reasons for diagnostic delay although they expressed the \ndelays differently. Where HCPs thought frequently presenting patients \nwere somatizing, patients stated they presented frequently because they \nfelt unheard by HCPs. This was reflected by the number of doctors seen, \nwhich averaged 2.0 for adolescents (DiVasta et  al., \n2018) and 4.1 for \nadults (range 2.5–7) (DiVasta et  al., 2018; Hudelist et  al., 2012; Nnoaham \net  al., 2011; Singh et  al., 2020; Tewhaiti-Smith et  al., 2022) and the \nnumber of times symptoms were discussed before diagnosis. Over a \nquarter of women reported discussing symptoms more than 20 t imes \n(Lamvu et  al., \n2020) with healthcare practitioners. None of the research -\ners’ studies evaluated the number of consultations with all HCPs prior \nto referral or the effect of diagnostic delay on the patient based on the \ntype or gender of HCP consulted.\nFigure 2.  Schematic representation of the global average of diagnostic delay for endometriosis.\n\n10 J. FRYER ET AL.\nThe themes identified by researchers highlighted increasing diagnostic \ndelay of endometriosis at each time point along the diagnostic pathway \nfrom symptom onset to diagnosis. This resulted in delay which led to \nincreases in both the severity of pain and the extent of disease (Dmowski \net  al., \n1997; Soliman et  al., 2017) ( Figure 3 ). Both patients and HCPs \nappeared to demonstrate an overall lack of understanding and education \nabout endometriosis. This meant that even patients who overcame barriers \nto healthcare (such as financial barriers or feelings of embarrassment) \nwere often unable to find the words to describe their symptoms appro -\npriately. As a result, HCPs were often reported to be dismissive leading \nTable 2.  the main themes and contributing factors relating to diagnostic delay.\nmain theme Contributing factors\n1 access to healthcare Physical access to care, financial barriers, stigma, embarrassment, not being \naware of endometriosis, religious beliefs and normalization of symptoms.\n2 Knowledge limitations Poor recognition of symptoms (patients and HCPs), HCP thinking \nendometriosis is a ‘rare’ disease, inability to define between normal and \npathological symptoms (patients and HCPs), lack of awareness and lack \nof training and evidence available to HCPs.\n3 misdiagnosis Differential presentation of symptoms between women, atypical symptoms, \ncomorbidities, communication challenges between different HCPs, lack \nof specificity in testing, lack of definitive diagnostic testing, and use of \nnon-definitive tests.\n4 Stigmatization Stigma, normalization, dismissal, patient unable to properly verbalize pain \nand/or symptoms causing communication challenges between patient \nand HCPs.\n5 method of diagnosis Hesitation to refer for more invasive definitive tests, age, HCP \nuncomfortable with requirement to perform physical exam (particularly \non adolescents), perceived need for surgical over clinical diagnosis in \nsome health systems.\n6 lack of guidelines no screening tools available, inconsistency in available patient reported \noutcome measures (Proms) and guidelines, poor interdisciplinary \nhandling of patients, and need for involvement of multiple HCPs.\nFigure 3.  Pathways to diagnostic delay for endometriosis.\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 11\nto misdiagnosis. Furthermore, the lack of clinical guidelines appeared to \ncompound the lack of knowledge by health care providers. Invasive diag -\nnostic testing was not favored by either HCPs or patients.\nInterventions to address diagnostic delay\nFour studies conducted by researchers included interventions to tackle \ndiagnostic delay at various points in the healthcare pathway. Of these, two \nteams reported reduced time to diagnosis following the introd uction of \nclinical guidelines (Armour et  al., \n2020; Tewhaiti-Smith et  al., 2022). One \nstudy team found diagnostic delays were reduced by the introduction of \nspecialist endometriosis centers in the US but not in the UK (Ghai et  al., \n2020) and the final intervention study reported by researchers found that \nbecoming a member of an endometriosis society had no effect on diagnostic \ndelay (Nnoaham et  al., \n2011). One study team quantified the reduction in \ndelay (8.4 years), whilst others reported a ‘downward trend’ in diagnostic \ndelays (Armour et  al., \n2020; Ghai et  al., 2020; Tewhaiti-Smith et  al., 2022).\nA range of interventions to reduce diagnostic delay for endometriosis \nwere suggested by researchers including education and awareness cam -\npaigns, collaborative multidisciplinary working between HCPs, promoting \nhealth-seeking behavior for patients, the use of screening tools, increased \nresearch into endometriosis, improving access to medical records, clinical \nguidelines written in the native language, the use of reliable diagnostic \nindicators and early intervention. These interventions span the entirety of \nthe socio-ecological framework (\nFigure 4 ). This multi-level approach to \nintervention allows for the introduction of all encompassing, yet targeted \nand effective interventions tailored according to individual factors and \nbehaviors (Lee et  al., \n2017) and the wider health care system. Using this \nframework for diagnostic delay in endometriosis is useful to visualize the \ncomplexity involved whilst providing a range of options for intervention.\nThe breadth of interventions identified by researchers was aided by the \ndiversity of participants included in the studies and was enhanced by the \ninclusion of views from a range of HCPs (As-Sanie et  al., \n2019; Fernandes \net  al., 2020; Riazi et  al., 2014).\nDiscussion\nPrior to our review it was not clear where in the health care system \ndiagnostic delay occurred in the health system or why they occurred. Our \nreview is the first attempt to synthesize and analyze this evidence. On \naverage, the diagnostic delay for endometriosis was 6.6 years across the \nincluded studies conducted by researchers and ranged from 1.5 to 11.3 years. \nAdolescents often face increased obstacles in obtaining a diagnosis. They \n\n12 J. FRYER ET AL.\nhad the longest diagnostic delay reported by researchers. Delays were \nidentified at all stages from symptom onset to receiving a diagnosis. The \nlongest average delay was the time from gynecology referral to diagnosis \n(2.8 years), followed by primary care presentation to diagnosis (2.5 years), \nand finally, from symptom onset to primary care presentation (2.0 years). \nOnly two study teams included a comparator group, while two included \nhealthy controls. None of the researchers’ studies provided information on \nwomen with negative findings at laparoscopy. The discrepancy in effec -\ntiveness of the introduction of specialist endometriosis centers may be \ndue to differences in health care systems including access to care, service \nuse, service cost, referral pathways and diagnostic guidelines.\nWe acknowledge the limitation of the scoping review methodology. The \ninclusion criteria meant that we excluded non-English language research \npapers and those researchers’ studies focused on specific biomarkers. \nAdditionally, all researchers’ studies relied on patient recall identifying the \nstart of their symptoms rather than prospectively tracking pat ients through-\nout their diagnostic journey or using medical records for verification. \nNevertheless, the strength of our study was a clear focus following a \npre-published protocol including a wide range of researchers’ scholarship \nfrom all over the world whilst locating the problem and potential solutions \nwithin the socio-ecological theoretical framework.\nAlthough the range of average delay was wider than previously reported \nof 3.3 − 11.7 years, the average diagnostic delay was consistent with \nFigure 4.  the socio-ecological model of endometriosis.\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 13\nprevious researchers’ findings of 6.7 years (Nnoaham et al., 2011). Therefore, \nan area in critical need of further research is closer tracking of patients \nthroughout their diagnostic journey. This should include the time from \npresentation to diagnosis, including cases where patients have met all \ncriteria to be considered for surgery but do not have endometriosis, their \ndifferential diagnoses and the differences between women with a positive \nand negative laparoscopy. This may be facilitated by reporting endome -\ntriosis as a differential diagnosis earlier along the diagnostic journey and \nby ensuring primary and secondary care are better coordinated so that \nthe diagnostic journey can be efficiently mapped. Additionally, it may be \nuseful to have the details of the HCPs available during this journey and \ntheir role such as primary care practitioner/GP or gynecologist, and \ndemographic details such as their gender, age, and length of service, all \nof which may be associated with time to diagnosis. The definition and \ncalculation of diagnostic delay is also an area that requires further atten -\ntion. Rather than studies describing the time from symptom onset to \ndiagnosis, the current definition of diagnostic delay that was used across \nresearchers’ studies, it may be more beneficial to determine excess delay . \nThis could provide comparative regional, national and international esti -\nmates of diagnostic delay for endometriosis based on average waiting \ntimes for primary care appointments, referral to gynecology and for \ntreatment/surgery. This would enable direct comparisons of care to be \nmade and identify differences in diagnostic delay between public and \nprivate healthcare for endometriosis. The length of delay matters in terms \nof cost and severity for women and the wider health system. Quicker \ndiagnosis results in less pain, reduced severity of disease and lower inci -\ndence of comorbidities.\nAccurate calculation of diagnostic delay for endometriosis may be the \nfirst step to improving guidelines, diagnostic measures, and diagnosis more \nbroadly. Additionally, it is important to establish and address barriers to \ndiagnosis. More investigation is needed on the effect of diagnostic delay \nto determine the cost-benefit of reducing diagnostic delay (Cromeens \net  al., \n2021). Though there remains much to be done, our findings can \nprovide the basis for further research and innovations in practice to pre -\nvent unnecessary suffering resulting from the diagnostic delays of endo -\nmetriosis. The socio-ecological framework can be used to assess where \nimproved policies may be effective, how widespread the effects might be \nand to provide a benchmark for their perceived benefit (financial and \notherwise). Further research studies would benefit from utilizing medical \nrecords to track the number of consultations, range of HCPs, and time \nelapsed from initial referral to a final diagnosis and treatment. Our review \nprovides a starting point for others to improve our understanding of where \nchanges need to be made.\n\n14 J. FRYER ET AL.\nAcknowledgment\nWe thank our employers for supporting this work. Thanks also to Siphiwe Mhlongo (SM) \nwho helped with screening studies.\nDisclosure statement\nNo potential conflict of interest was reported by the author(s).\nFunding\nJF received support from North Y orkshire Council, AMJ received support from the \nUniversity of Y ork and AW received support from Y ork St John University.\nORCID\nJodie Fryer  http://orcid.org/0009-0003-6482-8675\nAmanda J. Mason-Jones  http://orcid.org/0000-0002-4292-3183\nAmie Woodward  http://orcid.org/0000-0002-9579-4012\nReferences\nAgarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., \nSingh, S. S., & Taylor, H. S. ( 2019). Clinical diagnosis of endometriosis: A call to \naction. American Journal of Obstetrics and Gynecology , 220(4), 354.e351–354.e312. https://\ndoi.org/10.1016/j.ajog.2018.12.039\nAndres, M. e P ., Podgaec, S., Carreiro, K. B., & Baracat, E. C. ( 2014). Endometriosis is \nan important cause of pelvic pain in adolescence. Revista da Associacao Medica Brasileira , \n60(6), 560–564. https://doi.org/10.1590/1806-9282.60.06.015\nArmour, M., Sinclair, J., Ng, C. H. M., Hyman, M. S., Lawson, K., Smith,  C. A., & Abbott, \nJ. ( 2020). Endometriosis and chronic pelvic pain have similar impact on women, but \ntime to diagnosis is decreasing: An Australian survey. Scientific Reports , 10(1), 16253. \nhttps://doi.org/10.1038/s41598-020-73389-2\nAs-Sanie, S., Black, R., Giudice, L. C., Gray Valbrun, T., Gupta, J., Jones, B., Laufer, M. \nR., Milspaw, A. T., Missmer, S. A., Norman, A., Taylor, R. N., Wallace, K., Williams, \nZ., Y ong, P . J., & Nebel, R. A. (\n2019). Assessing research gaps and unmet needs in \nendometriosis. American Journal of Obstetrics and Gynecology , 221(2), 86–94. https://\ndoi.org/10.1016/j.ajog.2019.02.033\nBach, A. M., Risoer, M. B., Forman, A., & Seibaek, L. ( 2016). Practices and attitudes \nconcerning endometriosis among nurses specializing in gynecology. Global Qualitative \nNursing Research , 3, 2333393616651351. https://doi.org/10.1177/2333393616651351\nBallard, K., Lowton, K., & Wright, J. ( 2006). What’s the delay? A qualitative study of \nwomen’s experiences of reaching a diagnosis of endometriosis. Fertility and Sterility , \n86(5), 1296–1301. https://doi.org/10.1016/j.fertnstert.2006.04.054\nBecker, K., Heinemann, K., Imthurn, B., Marions, L., Moehner, S., Gerlinger, C., Serrani, \nM., & Faustmann, T. ( 2021). Real world data on symptomology and diagnostic ap -\nproaches of 27,840 women living with endometriosis. Scientific Reports , 11(1), 20404. \nhttps://doi.org/10.1038/s41598-021-99681-3\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 15\nBooth, A., Noyes, J., Flemming, K., Gerhardus, A., Wahlster, P ., Van Der Wilt, G. J., \nMozygemba, K., Refolo, P ., Sacchini, D., & Tummers, M. ( 2016). Guidance on choosing \nqualitative evidence synthesis methods for use in health technology asse ssments of complex \ninterventions. Integrate-HTA.\nBraun, V ., & Clarke, V . (2006). Using thematic analysis in psychology. Qualitative Research \nin Psychology , 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa\nBullo, S. ( 2020). \"I feel like I’m being stabbed by a thousand tiny men\": The challenges \nof communicating endometriosis pain. Health , 24(5), 476–492. https://doi.\norg/10.1177/1363459318817943\nCromeens, M. G., Carey, E. T., Robinson, W . R., Knafl, K., & Thoyre, S. ( 2021). Timing, \ndelays and pathways to diagnosis of endometriosis: A scoping review protocol. BMJ \nOpen, 11(6), e049390. https://doi.org/10.1136/bmjopen-2021-049390\nDella Corte, L., Di Filippo, C., Gabrielli, O., Reppuccia, S., La Rosa, V . L., Ragusa, R., \nFichera, M., Commodari, E., Bifulco, G., & Giampaolino, P . ( 2020). The burden of \nendometriosis on women’s lifespan: A narrative overview on quality of life and psy -\nchosocial wellbeing. International Journal of Environmental Research and Public  Health , \n17(13), 4683. https://doi.org/10.3390/ijerph17134683\nDiBenedetti, D. B., Soliman, A. M., Ervin, C., Evans, E., Coddington, C. C., Agarwal, S. \nK., Surrey, E. S., & Taylor, H. S. ( 2018). Development of the painful periods screening \ntool for endometriosis. Postgraduate Medicine , 130(8), 694–702. https://doi.org/10.1080\n/00325481.2018.1526623\nDiVasta, A. D., Vitonis, A. F ., Laufer, M. R., & Missmer, S. A. ( 2018). Spectrum of symp -\ntoms in women diagnosed with endometriosis during adolescence vs. adulthood. \nAmerican Journal of Obstetrics and Gynecology , 218(3), 324.e321–324.e311. \nhttps://doi.\norg/10.1016/j.ajog.2017.12.007\nDmowski, W . P ., Lesniewicz, R., Rana, N., Pepping, P ., & Noursalehi, M. ( 1997). Changing \ntrends in the diagnosis of endometriosis: A comparative study of women with pelvic \nendometriosis presenting with chronic pelvic pain or infertility. Fertility and Sterility , \n67(2), 238–243. \nhttps://doi.org/10.1016/S0015-0282(97)81904-8\nEisenberg, V . H., Decter, D. H., Chodick, G., Shalev, V ., & Weil, C. ( 2022). Burden of \nendometriosis: Infertility, comorbidities, and healthcare resource utilization. Journal of \nClinical Medicine , 11(4), 1133. https://doi.org/10.3390/jcm11041133\nFernandes, A., Skotnes, L. L., Major, M., & Falcão, P . F . ( 2020). Clinicians’ perceptions of \nNorwegian women’s experiences of infertility diseases. International Journal of Environmental \nResearch and Public Health , 17(3), 993. https://doi.org/10.3390/ijerph17030993\nGBD Compare. Institute for Health Metrics and Evaluation. Retrieved October 20 from \nhttp://vizhub.healthdata.org/gbd-compare .\nGhai, V ., Jan, H., Shakir, F ., Haines, P ., & Kent, A. ( 2020). Diagnostic delay for superficial \nand deep endometriosis in the United Kingdom. Journal of Obstetrics and Gynaecology , \n40(1), 83–89. https://doi.org/10.1080/01443615.2019.1603217\nGrant, M. J., & Booth, A. ( 2009). A typology of reviews: An analysis of 14 review types \nand associated methodologies. Health Information & Libraries Journal , 26(2), 91–108. \nhttps://doi.org/10.1111/j.1471-1842.2009.00848.x\nHudelist, G., Fritzer, N., Thomas, A., Niehues, C., Oppelt, P ., Haas, D., Tammaa, A., & \nSalzer, H. ( 2012). Diagnostic delay for endometriosis in Austria and Germany: Causes \nand possible consequences. Human Reproduction , 27(12), 3412–3416. https://doi.\norg/10.1093/humrep/des316\nHusby, G. K., Haugen, R. S., & Moen, M. H. ( 2003). Diagnostic delay in women with \npain and endometriosis. Acta Obstetricia et Gynecologica Scandinavica , 82(7), 649–653. \nhttps://doi.org/10.1034/j.1600-0412.2003.00168.x\n\n16 J. FRYER ET AL.\nLamvu, G., Antunez-Flores, O., Orady, M., & Schneider, B. ( 2020). Path to diagnosis and \nwomen’s perspectives on the impact of endometriosis pain. Journal of Endometriosis \nand Pelvic Pain Disorders , 12 (1), 16–25. http://journals.sagepub.com/\ndoi/10.1177/2284026520903214\nLee, B. C., Bendixsen, C., Liebman, A. K., & Gallagher, S. S. ( 2017). Using the socio-eco -\nlogical model to frame agricultural safety and health interventions. Journal of \nAgromedicine, 22(4), 298–303. https://doi.org/10.1080/1059924X.2017.1356780\nLukic, A., Di Properzio, M., De Carlo, S., Nobili, F ., Schimberni, M., Bianchi, P ., Prestigiacomo, \nC., Moscarini, M., & Caserta, D. ( 2016). Quality of sex life in endometriosis patients \nwith deep dyspareunia before and after laparoscopic treatment. Archives of Gynecology \nand Obstetrics , 293(3), 583–590. https://doi.org/10.1007/s00404-015-3832-9\nNICE. ( 2017). Recommendations | Endometriosis: Diagnosis and management. Retrieved \nOctober 20 from https://www.nice.org.uk/guidance/ng73/chapter/Recommendations .\nNnoaham, K. E., Hummelshoj, L., Webster, P ., d’Hooghe, T., de Cicco Nardone, F ., de \nCicco Nardone, C., Jenkinson, C., Kennedy, S. H., & Zondervan, K. T., World \nEndometriosis Research Foundation Global Study of Women’s Health Consortium. \n(\n2011). Impact of endometriosis on quality of life and work produc tivity: A multicenter \nstudy across ten countries. Fertility and Sterility , 96(2), 366–373.e368. https://doi.\norg/10.1016/j.fertnstert.2011.05.090\nOlšarová, K., & Mishra, G. D. ( 2020). Early life factors for endometriosis: A systematic \nreview. Human Reproduction Update , 26(3), 412–422. https://doi.org/10.1093/humupd/\ndmaa002\nPino, I., Belloni, G. M., Barbera, V ., Solima, E., Radice, D., Angioni, S., Arena, S., \nBergamini, V ., Candiani, M., Maiorana, A., Mattei, A., Muzii, L., Pagliardini, L., Porpora, \nM. G., Remorgida, V ., Seracchioli, R., Vercellini, P ., Zullo, F ., Zupi, E., & Vignali, M, \nEndometriosis Treatment Italian Club. (\n2023). “Better late than never but never late is \nbetter” , especially in young women. A multicenter Italian study on diagnostic delay for \nsymptomatic endometriosis. The European Journal of Contraception & Reproductive \nHealth Care , 28(1), 10–16. \nhttps://doi.org/10.1080/13625187.2022.2128644\nRiazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. ( 2014). \nPatients’ and physicians’ descriptions of occurrence and diagnosis of endometriosis: A \nqualitative study from Iran. BMC Women’s Health, 14, 103. \nhttps://doi.org/10.1186/1472-\n6874-14-103\nSantos, T. M., Pereira, A. M., Lopes, R. G., & Depes, D. e B. ( 2012). Lag time between \nonset of symptoms and diagnosis of endometriosis. Einstein, 10(1), 39–43. https://doi.\norg/10.1590/S1679-45082012000100009\nSingh, S., Soliman, A. M., Rahal, Y ., Robert, C., Defoy, I., Nisbet, P ., & Leyland, N. ( 2020). \nPrevalence, symptomatic burden, and diagnosis of endometriosis in Canada: Cross-\nsectional survey of 30,000 women. Journal D’ obstetrique et Gynecologie du Canada  \n[Journal of Obstetrics and Gynaecology Canada], 42(7), 829–838. \nhttps://doi.org/10.1016/j.\njogc.2019.10.038\nSoliman, A. M., Fuldeore, M., & Snabes, M. C. ( 2017). Factors associated with time to \nendometriosis diagnosis in the United States. Journal of Women’s Health, 26(7), 788–797. \nhttps://doi.org/10.1089/jwh.2016.6003\nStaal, A. H., van der Zanden, M., & Nap, A. W . ( 2016). Diagnostic delay of endometri -\nosis in the Netherlands. Gynecologic and Obstetric Investigation , 81(4), 321–324. https://\ndoi.org/10.1159/000441911\nSurrey, E., Soliman, A. M., Trenz, H., Blauer-Peterson, C., & Sluis, A. ( 2020). Impact of \nendometriosis diagnostic delays on healthcare resource utilization and costs. Advances \nin Therapy , 37(3), 1087–1099. https://doi.org/10.1007/s12325-019-01215-x\n\nHEALTH CARE FOR WOMEN INTERNATIONAL 17\nTewhaiti-Smith, J., Semprini, A., Bush, D., Anderson, A., Eathorne, A., Johnson, N., \nGirling, J., East, M., Marriott, J., & Armour, M. ( 2022). An Aotearoa New Zealand \nsurvey of the impact and diagnostic delay for endometriosis and chronic pelvic pain. \nScientific Reports , 12(1), 4425. \nhttps://doi.org/10.1038/s41598-022-08464-x\nvan der Zanden, M., de Kok, L., Nelen, W . L. D. M., Braat, D. D. M., & Nap, A. W . \n(2021). Strengths and weaknesses in the diagnostic process of endometriosis from the \npatients’ perspective: A focus group study. Diagnosis , 8(3), 333–339. https://doi.\norg/10.1515/dx-2021-0043\nVan Niekerk, L., Johnstone, L., & Matthewson, M. ( 2022). Predictors of self-compassion \nin endometriosis: The role of psychological health and endometriosis symptom burden. \nHuman Reproduction , 37(2), 264–273. \nhttps://doi.org/10.1093/humrep/deab257\nZhang, S., Gong, T. T., Wang, H. Y ., Zhao, Y . H., & Wu, Q. J. ( 2021). Global, regional, \nand national endometriosis trends from 1990 to 2017. Annals of the New York Academy \nof Sciences , 1484(1), 90–101. https://doi.org/10.1111/nyas.14468","source_license":"CC0","license_restricted":false}