{"paper_id":"68288448-c503-4670-b98a-000d8bbb3040","body_text":"BJGP OPEN\nGeneral practitioners’ perspectives on patients presenting \nwith endometriosis symptoms – an interview study\nPetersen, Sólja; Bak Kirk, Ulrik; Pencheri, Maria; Dixon, Sharon; Mawson, \nRebecca; Nørgaard, Birgitte; Marcussen, Michael \nDOI: https://doi.org/10.3399/BJGPO.2025.0086\nTo access the most recent version of this article, please click the DOI URL in the line above. \nReceived 26 April 2025\nRevised 02 July 2025\nAccepted 01 September 2025\n© 2025 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons \nAttribution 4.0 License (http://creativecommons.org/licenses/by/4.0/). Published by BJGP Open. For editorial \nprocess and policies, see: https://bjgpopen.org/authors/bjgp-open-editorial-process-and-policies \nWhen citing this article please include the DOI provided above.\nAuthor Accepted Manuscript\nThis is an ‘author accepted manuscript’: a manuscript that has been accepted for publication in BJGP Open, but \nwhich has not yet undergone subediting, typesetting, or correction. Errors discovered and corrected during this \nprocess may materially alter the content of this manuscript, and the latest published version (the Version of Record) \nshould be used in preference to any preceding versions\n\n                               \n                             \n                     \n1\nTitle\nGeneral practitioners’ perspectives on patients presenting with endometriosis symptoms – an \ninterview study \nRunning title\nExploring Endometriosis: Insights from General Practitioners in the Faroe Islands.\nAuthors\nSólja Petersen1, Ulrik Bak Kirk2,3, Maria Pencheri2, Sharon Dixon4, Rebecca Mawson5, \nBirgitte Nørgaard1, Michael Marcussen1\nAffiliations\n1. Department of Public Health, University of Southern Denmark, Odense, Denmark\n2. Department of Public Health, Aarhus University, 8000 Aarhus, Denmark \n3. Research Unit for General Practice, 8000 Aarhus, Denmark\n4. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.\n5. The University of Sheffield, Division of Population Health, Sheffield, United Kingdom\nTitle/qualifications\nSólja Thomina Petersen: MSc, Research Assistant, ORCID: 0009-0004-8341-2568\nUlrik Bak Kirk: MA, Ph.D. fellow, ORCID: 0000-0003-1683-2189\nMaria Pencheri: MPH, Research Assistant, ORCID: 0009-0001-5538-3390\nSharon Dixon: MBBS, MSc, MRCGP, doctoral research fellow, ORCID: 0000-0002-7469-\n6093\nRebecca L. Mawson: MD, MBChB, MRCGP, ORCID: 0000-0001-6377-6197\nBirgitte Nørgaard: Ph.D., Professor, ORCID: 0000-0002-2284-2335\nMichael Haurum Marcussen: PhD, associated professor, ORCID: 0000-0001-8376-912X\n\n                               \n                             \n                     \n2\nCorresponding author\nRebecca L. Mawson, r.l.mawson@sheffield.ac.uk.\nConflicts of interest\nRebecca Mawson is an NIHR Academic Clinical Lecturer. Sharon Dixon is supported by an \nNIHR Doctoral Research Fellowship (NIHR301787). The views expressed in this publication \nare those of the authors and do not necessarily reflect those of the NIHR or the Department of \nHealth and Social Care. \nSharon Dixon also serves as an unpaid voluntary member of the Endometriosis UK Medical \nAdvisory Panel. The other authors declare no conflicts of interest.\nAuthor contributions\nAll authors contributed substantially to this paper. All co-authors have reviewed and \napproved the final version of the manuscript.\n\n                               \n                             \n                     \n3\nAbstract\nBackground: Endometriosis affects about one in ten women, yet diagnosis often takes eight \nto twelve years after onset of symptoms. In the Faroe Islands, GPs play a key role in \nrecognizing symptoms, managing care and coordinating referrals to specialists. Therefore, \nGPs’ perspectives on how challenges arise or how they could be improved are crucial to \ndeveloping effective interventions for change.\nAim: To investigate how GPs in the Faroe Islands experience encounters with patients \npresenting with endometriosis symptoms.\nDesign and setting: Qualitative interview study with six GPs from various practice across \nthe Faroe Islands. \nMethod: This study conducted semi-structured individual interviews and analysed \nparticipants’ responses using systematic text condensation inspired by Malterud’s thematic \nanalysis to explore GPs’ perspectives on their interactions with patients presenting with \nendometriosis symptoms.\nResults: Within the constraints of the Faroese healthcare system, many GPs reported \ndifficulties collaborating with gynaecologists on treatment protocols. Limited referral \npathways often led to challenges, particularly when referrals were declined or when patients \nwere returned to general practice without clear diagnosis or management plan. GPs expressed \nfrustration with the limited treatment options available in primary care and a sense of being \nprofessionally constrained. They emphasized the need for specialist involvement and \nhighlighted the importance of building long-term relationships with patients offering holistic \ncare, managing expectations early, and maintaining continuity of care. \nConclusion: This study highlights the difficulties when GPs managing and referring patients \nwith suspected endometriosis. Enhancing collaboration with specialists and improving \nreferral protocols are crucial for optimising patients’ care and outcomes.\n\n                               \n                             \n                     \n4\nKeywords\nEndometriosis, qualitative research, referral and consultation, general practice, primary care\n\n                               \n                             \n                     \n5\nHow this fits in \nThis study examines the referral barriers GPs face in managing endometriosis in the Faroe \nIslands. It highlights the importance of early patient expectation management and strong GP–\npatient relationships. The findings advocate for stronger collaboration with gynaecologist to \nenhance quality and continuity of care. \n\n                               \n                             \n                     \n6\nIntroduction\nEndometriosis is a condition that affects approximately one in ten women [1], equating to \naround 190 million women worldwide [2]. Endometriosis is defined as a chronic condition in \nwhich tissue resembling the endometrium is found outside the uterus [3]. However, it \npresents with diverse and complex symptoms, including chronic pelvic pain, painful \nintercourse, heavy bleeding, menstrual pain, and infertility [4,5]. Its symptoms can vary \nwidely and fluctuate in severity between individuals and over time. Its symptoms are non-\nspecific and may overlap with other common conditions, such as irritable bowel syndrome, \nbladder symptoms, fatigue, and chronic pelvic pain [6-9]. While endometriosis is highly \nprevalent, studies have revealed an average diagnostic delay of 8–12 years between symptom \nonset and confirmed diagnosis [10,11].\nIn Denmark, general practitioners (GPs) are the primary contact in the publicly funded \nhealthcare system, ensuring free and equal access for all residents [12,13]. Similarly, in the \nFaroe Islands, Faroese GPs serves as gatekeepers to secondary healthcare. Residents access \ngynaecological care through referral from their GPs to National Hospital in Tórshavn, the \nlargest medical facility in the Faroe Islands [14].\nThe existing literature demonstrates that GPs encounter significant challenges in both \ndiagnosing and managing endometriosis, primarily due to time constraints and limited \nopportunities for thorough examinations [6,15]. Additional factors contributing to diagnostic \ndelays for endometriosis include uncertainty about normal versus abnormal menstrual pain, \npatients feeling dismissed by healthcare professionals, and patients delaying seeking medical \nhelp. These factors collectively hinder timely diagnosis [16-18].\n\n                               \n                             \n                     \n7\nFrom evaluating symptoms to establishing a diagnosis and then onward care, GPs play a \ncrucial role in managing endometriosis, as they are expected to have a strong familiarity with \ntheir patients and a comprehensive understanding of each patient’s illness and treatment \noptions. Therefore, GPs serve as the professionals primarily responsible for patient care, \nacting as gatekeepers and coordinators for specialised hospital services and municipal \nresources [12,19]. \nTo our knowledge, GPs’ perceptions of managing patients with suspected endometriosis have \nbeen inadequately explored. This study aims to enhance understanding of the context in \nwhich such care is delivered. Women with endometriosis often report challenging healthcare \nexperiences, including diagnostic delays and feelings of dismissal [20,21]. Addressing these \nissues is central to the objectives of this research. By investigating GPs’ perspectives on care \ndelivery, we seek to identify opportunities to improve management and support for this \npatient population. \nMethods\nThis study is reported following the Consolidated Criteria for Reporting Qualitative Studies \n(COREQ), a 32-item checklist for interviews and focus groups [22]. \nStudy Design\nThis study used a qualitative design with semi-structured individual interviews to explore \nGPs’ perceptions of their encounters with patients presenting with endometriosis symptoms. \nIt thematically analysed participants’ responses using Malterud’s systematic text \ncondensation method [23].\n\n                               \n                             \n                     \n8\nParticipants and Recruitment\nAll GPs were recruited using snowball sampling, which involved email outreach to a \nrepresentative of the exclusive healthcare insurance provider in the Faroe Islands and direct \ncontact with the chairman of the Faroe Medical Association. These key gatekeepers were \ncrucial in accessing GPs throughout the Faroe Islands by distributing the information letter to \ntheir 36 members. The final sample included six GPs working in different settings, with \nvarying practice sizes and multiple geographical areas. To ensure confidentiality and \nanonymity, further details are not disclosed. There was no formal patient or public \ninvolvement in the conduct of this study. However, patients were involved in developing the \ninterview guide.\nStudy context: Endometriosis in Faroe Islands General Practice\nAs of 2025, 36 GPs serve a population of approximately 55,000 residents, of which 11,000 \nare Faroese women of childbearing age [24,25].\nResearcher Characteristics and Reflexivity\nThe interviewer (STP) is a female researcher with personal and professional experience in \nendometriosis. The research team included diverse expertise in health sciences, including \nGPs. While their preconceptions influenced the research process, open-ended questions \nensured consistency and allowed participants to express their views, emphasizing the \nimportance of diversity in qualitative research [26]. \nInterview Guide\nA semi-structured interview guide was prepared, inspired by Malterud’s approach [23], \naiming to maintain a consistent focus on the subject matter [27]. The first author (STP) \n\n                               \n                             \n                     \n9\ndeveloped and refined this guide in collaboration with the last author (MM). The guide was \npilot tested by both the first and last authors (STP and MM) in two interviews, which led to \nminor revisions, including rephrasing questions for clarity and modifying their sequence to \nenhance flow. These pilot interviews are not included in the final sample of interviews. The \nmain open-ended questions asked during the interviews are presented in figure 1.\nFigure 1. The main open-ended questions asked during the interviews.\n• What has been your experience of supporting or evaluating patients \nreporting/describing symptoms of endometriosis?\n• What has been your experience in managing these patients?\n• Could you expand on this with any examples from your work? \nData Collection\nThe first author (STP), who is Faroese and fluent in both Faroese and Danish, conducted six \nindividual interviews: five in person at the GPs’ practices and one online using Zoom. Five \ninterviews were conducted in Faroese and one in Danish. All interviews conducted in Faroese \nwere subsequently translated into Danish by the first author (STP). The interviews took place \nbetween March and April 2024, lasted 35–40 minutes, and were audio-recorded and \ntranscribed verbatim by the first author (STP). None of the participants were previously \nknown to the interviewer.\nAnalysis\nThe data were thematically analysed in four steps, as described by Malterud [28]. This \napproach, rooted in Giorgi’s phenomenology, allowed participants to share their lived \nexperiences, which is central to the study’s aims. The four steps were as follows: (1) Possible \nthemes: We created a general overview, identifying preliminary themes relevant to the \nresearch question; (2) De-contextualisation: We identified and organised data elements that \n\n                               \n                             \n                     \n10\nelucidated the research question by systematically reviewing the transcripts line by line to \nextract meaningful units; (3) Condensation: We reduced the empirical data to a \ndecontextualised selection of meaningful units, which was then sorted into thematic code \ngroups across participants; (4) Synthesis: We discussed the initial analysis again and further \nrefined and developed the themes. Finally, we reconceptualised the data by developing \ndescriptions, concepts, and narratives that elucidated the research question [28].\nTwo authors (STP and MM) independently analysed the data using NVivo 14 software to \nidentify patterns and subthemes, then discussed their findings with two co-authors (GPs and \nqualitative researchers) to reach a consensus [29]. Any discrepancies in interpretation were \nresolved through discussion within the research team until agreement was achieved.\nAn example of the thematic analysis process is presented in Table 1.\nTable 1. The four steps of the thematic analysis- exemplified.\nStep 1. Possible \nthemes: Overall \nimpression\nStep 2. De-contextualisation: \nFrom themes to codes\nStep 3. Condensation: \nFrom codes to meaning\nStep 4. Synthesis: From condensation \nto description and concepts\nManaging \nexpectations\n‘I believe it can be frustrating \nwhen expectations don’t align. \nFor instance, a patient might \nread about endometriosis and \nanticipate being seen by a \ngynaecologist...’\nHaving that \nconversation early in \nthe process is essential\nThe GPs emphasised the critical \nimportance of managing patient \nexpectations for those exhibiting \nendometriosis symptoms. Four of the \nfive interviewed GPs highlighted the \nneed to manage patient expectations \nearly in the process.\nGatekeeper \nfunction\n‘This creates a situation where \ngynaecologists may prefer that \nwe [the GPs] refrain from \nreferring patients with \nendometriosis unless there are \nconsiderations for surgery or \nfertility, as if the patient must \nbe planning to have a child...’\n‘You often feel helpless in \npractice because when you \nrefer a patient to the \ngynaecologist and they are \ntold that everything looks \nnormal and that “there’s \nnothing wrong with you”, it \nExperiencing a sense of \nhelplessness while \nbearing the \nresponsibility alone.\nIt can be challenging to \nnavigate a system \nBy validating and acknowledging the \npatient’s concerns, GPs find that it \nencourages greater receptiveness to \nfurther treatments. Many patients have \nendured a long journey without \neffective relief for their symptoms. The \nGPs noted that those with \nendometriosis and chronic pain often \nstruggle to be taken seriously, which \ncan lead them to develop additional \npsychosocial disorders if their long-\nstanding pain is not addressed.\n\n                               \n                             \n                     \n11\ncan be disheartening. After \nall, the specialists are the \nexperts’\nwhere referrals are \nlimited to one place.\nEthical Considerations\nThis study complied with ethical principles for medical research described in the Declaration \nof Helsinki [30,31]. Before initiation, this study was approved by the institutional review \nboard at the University of Southern Denmark (ID:12.166). All data were managed in \ncompliance with the European General Data Protection Regulations [32]. Before inclusion, \nGPs were thoroughly informed about the study’s objectives through verbal and written \ncommunication and provided written informed consent. They were also informed that their \nparticipation was voluntary, that they could withdraw their consent at any time without \nconsequence, and that their statements would be treated confidentially and anonymised. \nAccording to Danish legislation, no further approval was required [33].\nResults\nFour key themes emerged from the analysis: Managing Expectations, Gatekeeper Function, \nPatient Rights, and Individual Treatment. The findings are organised around these themes \nand further illustrated with relevant quotes from participants to provide context and depth.\nManaging Expectations\nAll GPs reported that patients often hold high and sometimes unrealistic expectations \nregarding both treatment options and the possibility of urgent referrals to specialised care. All \nGPs emphasised the importance of managing these hopes early through expectation \nreconciliation. This process was seen as essential for maintaining trustful GP-patient \nrelationships, as patients often anticipated solutions that exceeded the GP’s capacity to \ndeliver. Several GPs described their role in addressing patient expectations based on prior \n\n                               \n                             \n                     \n12\nexperiences with referrals or care-seeking behaviour. They observed that patients frequently \nheld unrealistic beliefs about gynaecologists’ ability to provide immediate solutions for their \nsymptoms and pain, underscoring the critical role of clear communication and expectation \nmanagement in consultations with these patients:\n‘…The patients believe the gynaecologist can resolve their issues and make their pain \ndisappear, even when that isn’t possible.’ – (GP3)\nAll GPs stressed that managing patient expectations early improves both treatment outcomes \nand the GP-patient relationship:\n‘It’s much easier for me to address things early on in the process. Once they have some \ninitial information, they can come back to me with questions. This makes it simpler to \nestablish a strong GP-patient relationship. I want them to feel confident in sharing their \nthoughts with me, and I make sure they trust that I take their concerns seriously and know \nwhat I’m doing. Building that trust starts right from the beginning.’ – (GP6)\nAll GPs voiced frustration over the challenges of managing patient expectations, particularly \nwhen patients often arrive with information about endometriosis and anticipate immediate \nreferrals to a gynaecologist. However, they explained that certain procedural steps must first \nbe completed within general practice before a referral can be made. This misunderstanding \ncan lead to patient dissatisfaction, as they may feel delayed in accessing secondary care \ndespite the GP’s efforts to provide supportive guidance. To address this, all GPs emphasised \nthe importance of managing expectations early, noting that the referral pathway is complex \nand involves several steps before a referral to a specialist can be made. By proactively \n\n                               \n                             \n                     \n13\naddressing these expectations, all GPs felt better equipped to provide effective care and \nmanage patient concerns. Several GPs noted that this proactive communication helped \npatients understand what to expect when contacting their GP, thereby reducing their \nfrustration and fostering greater collaboration and trust in the GP-patient relationship.\nGatekeeper Function\nAll GPs frequently encountered patients who strongly requested referrals to a gynaecologist; \nhowever, gynaecologists had previously advised all GPs to limit such referrals for \nendometriosis due to extensive waiting lists, asking them to prioritise other patient groups. \nThis situation puts all GPs under pressure from both patients and gynaecologists, creating \ndifficult dilemmas for them because managing endometriosis often extends beyond their \nexpertise. These cases underscore the challenges all GPs face in balancing patient needs with \nsystemic constraints:\n‘The gynaecologist cannot take any action until the initial steps are addressed here in \ngeneral practice. However, patients often don’t understand this and insist on seeing a \ngynaecologist right away. I’m trying to manage resources effectively, which makes this a \nsignificant challenge.’ – (GP1)\nThe gynaecologists advised all GPs to follow standardised treatment protocols, including the \nuse of pain relief medications (analgesics) and hormone therapy, before considering referrals. \nIn order to maintain patient trust, all GPs prioritised building strong GP-patient relationships \nthrough education, ensuring that all treatment options available in general practice are \nthoroughly discussed. All GPs emphasised the importance of adopting a holistic approach, \nrecognising that some patients might also experience psychosocial challenges. Furthermore, \n\n                               \n                             \n                     \n14\nall GPs acknowledged the difficulty in managing symptoms that were not always explainable \nor validated by diagnostic tests.\n‘There are two main aspects to consider. The first is the professional side, where we focus on \ndiagnosis. The second aspect involves the psychosocial factors, which often play a significant \nrole. This includes how the patient manages their education, relationships, and other life \ncircumstances. Sometimes, these psychosocial factors can be just as impactful and occupy as \nmuch attention as the illness itself.’ – (GP3)\nConsequently, all GPs stressed the need to approach these interactions with empathy, \naffirmation, and appreciation, fostering a supportive and understanding environment for this \npatient group:\n‘Often, it is beneficial for her to feel heard and to have a safe space to come to without \nexperiencing additional distress. It is crucial to convey that I genuinely believe her.’ – (GP2)\nAll GPs emphasized validating patient’s experience, even when pain’s cause is unclear, \nrecognizing that symptoms affect physical, social, and mental well-being, and require holistic \ndiscussions.\nAll GPs described challenges when patients’ referrals to the gynaecological department for \nendometriosis investigations are denied, complicating their ability to explore alternative \ntreatment options within primary care. Additionally, when gynaecological assessments reveal \nno abnormalities, patients are often returned to general practice without further \n\n                               \n                             \n                     \n15\nrecommendations despite their persistent symptoms. This lack of guidance added to the \ncomplexity of managing these cases:\n‘Our greatest challenge is the feeling of being unable to provide the specialised treatment \nthat our patients need. This situation is particularly difficult for GPs, as the responsibility \nultimately returns to us.’ – (GP4)\nWhen patients’ referrals are denied because their pain is deemed insufficient for further \nendometriosis investigations or when they are sent back to general practice due to \ninconclusive findings, all GPs described a sense of powerlessness and frustration when left to \nshoulder the full responsibility for managing these patients’ care, against their preference, \nhaving tried to seek specialist support:\n‘Our greatest challenge is the feeling of being unable to manage on your own. You seek help \nfrom a specialist, only to find out that your request is denied.’ – (GP1)\nThe GPs expressed frustration over the challenges posed by the limited availability of referral \noptions:\n‘It is a challenge that I often do not have a specific place to refer them to, and even when I do \nmake a referral, you often find nothing. ... As a result, the situation remains unresolved and \nlacks follow-up.’ – (GP1)\nAll GPs perceived the lack of referral options as a barrier, leading to helplessness. They \nrelied on specialists without receiving clear guidance and faced uncertainty due to the \nabsence of protocols for managing endometriosis in general practice. \n\n                               \n                             \n                     \n16\n‘It is reassuring to have followed established protocols and to transfer responsibility to a \nspecialist, but without clear instructions, it becomes more challenging to assert that I have \nfulfilled my role and that the next steps are now in your hands. We find ourselves lacking the \nauthority to dictate the process and can only make referrals.’ – (GP4)\nAll GPs recognised the limited capacity of the gynaecology department, where patients with \nmore acute conditions were prioritised over those with endometriosis symptoms. Despite \nunderstanding these constraints, they felt a strong responsibility to advocate for their patients:\n‘However, I also understand that they [gynaecologists] need to prioritise, which is why we \nmust ensure that we write thorough referrals so that the patients can be appropriately \nprioritised.’ – (GP3)\nAll GPs acknowledged gynaecologist’s resource constraints but stressed the need to address \npatients with persistent symptoms, even with normal test results for endometriosis. They felt \ngynaecologists overlooked the challenges in general practice, which hindered effective \nmanagement of endometriosis.\nPatient Rights\nAll GPs valued a diagnosis and recognised its value and meaning for patients. However, they \nalso recognised that the same treatment could be offered whether or not the patient was \ndiagnosed with endometriosis. They disagreed on the value of investigations, with some \nbelieving the underlying cause of pain was irrelevant to treatment, regardless of an \nendometriosis diagnosis:\n\n                               \n                             \n                     \n17\n‘I have spoken with the gynaecologists, who have stated that they are not doing anything \ndifferently from what we [GPs] are doing. It does not alter the treatment or the prognosis. \nTherefore, I do not always refer them further. Sometimes, I initiate treatment with oral \ncontraceptives, an intrauterine device, or another approach before referring them.’ – (GP1)\nAll GPs observed that if the prescribed medication alleviated a patient’s pain, they often \ninferred a likely diagnosis of endometriosis and proceeded to manage their treatment \naccordingly:\n‘However, when I suggest that taking birth control pills continuously might provide relief, it \nleads me to strongly suspect that the individual has endometriosis.’ – (GP1)\nConversely, some GPs emphasised the need to prioritise awareness of endometriosis and its \npotential long-term impact on patients’ quality of life:\n‘Fortunately, there has been increased awareness surrounding endometriosis, particularly \namong young people. When patients themselves advocate for their symptoms, it becomes \neasier to identify those who come in with abdominal pain, as this could be indicative of \nvarious conditions. Therefore, this heightened awareness can facilitate earlier detection, \npotentially preventing the condition from worsening.’ – (GP4)\nHowever, all GPs experienced a notable deficiency in information regarding managing \nendometriosis within primary care. The existing guidelines were either inadequate or entirely \nlacking, necessitating that GPs independently seek out subjective resources to inform their \npractice:\n\n                               \n                             \n                     \n18\n‘I was sitting last week looking up some recommendations about endometriosis. I found that \nthere is a significant absence of clinical guidelines in the Faroe Islands, which complicates \nthe management of this condition…’ – (GP4)\nSome GPs highlighted that an abnormal gynaecological examination did not necessarily rule \nout endometriosis. In such cases, they continued to manage care for patients suspected of \nhaving endometriosis, which proved particularly challenging when they disagreed with \ngynaecologists’ evaluations:\n‘If the gynaecologists reject the diagnosis but you still believe it is endometriosis, then I \nwould continue to consider it as such.’ – (GP3)\nAll GPs voiced concerns about the potential consequences for patients’ access to necessary \ntreatment if they relied solely on gynaecologists’ conclusions, particularly when no \nabnormalities were detected during examinations.\nIndividual Treatment\nSeveral GPs reported having to adjust their treatment approaches to align with the limited \nresources available in general practice:\n‘…if medications i.e., Brufen [ibuprofen] and others hadn’t been effective, I would have \nexplored other options, such as referring the patient to a psychologist, and looked into \nalternative ways to support them in managing their condition and improving their quality of \nlife.’ – (GP2)\n\n                               \n                             \n                     \n19\nCollaboration with psychologists and physiotherapists is key to developing comprehensive \ntreatment plans. All GPs stressed a holistic approach, recognizing endometriosis’ impact on \nmental health and social well-being, and included referrals to these professionals as an \nintegral part of care.\nAll GPs emphasized the importance of addressing patients’ psychological symptoms \nalongside physical ones, recognizing that chronic pain often led to depression and other \nmental health issues. They also noted the impact of endometriosis-related pain on \nemployment and highlighted the need for referrals to municipal services, such as job \nplacement assistance, when patients’ work capacity was reduced.\nThe GPs recognised their responsibility for patient care but emphasised the need to consider \nthe patients’ resources and capacity for treatment. With limited resources, GPs adjusted their \ncommunication and strategies, exploring alternative treatment options:\n‘There are times when I feel that if I can’t alleviate her pain and discomfort, she may \nperceive that I’m not doing everything possible for her. I imagine that when someone is \nstruggling so much, they might be left with the impression that no one is truly helping them.’ \n– (GP2)\nAll GPs emphasized the need for a supportive approach when patients faced severe pain with \nno effective treatments. Reassuring patients and allocating extra consultation time helped \nmanage expectations, plan treatments, and build trust in the GP-patient relationship. One GP \nhighlighted that proper preparation was essential for meaningful care:\n\n                               \n                             \n                     \n20\n‘I have to remember to prepare them properly to inform them properly, right from the start. \nSo that you don’t send them out into something, like where I don’t actually remember to take \ncare of all the things that I want to, and that’s what happens if we’re too busy.’ – (GP3)\nAll GPs acknowledged that these patients required additional time and resources to manage \ntheir treatment effectively. Despite the constraints of general practice, the GPs expressed a \nstrong commitment to providing the best possible care within available resources.\nDiscussion\nSummary\nThis study highlighted the challenges GPs face within the Faroe Islands geographically \nconstrained system when managing endometriosis patients, particularly in collaborating with \ngynaecologists when referrals were declined or unclear.\nAll GPs stressed the importance of setting patient expectations early, building strong \nrelationships, and adopting a holistic care approach, as patients often have evolving \nsymptoms and needs. The study also revealed a resource gap in general practice, limiting \nGPs’ ability to fully address patient needs. Bridging this gap requires additional time for \npersonalized treatment plans and collaboration with other professionals, such as \npsychologists and physiotherapists. A multidisciplinary approach is essential to support \npatients’ employment and provide comprehensive care for managing endometriosis \nsymptoms.\nStrengths and Limitations\nA key strength of our study is the diverse experiences of GPs, providing valuable insights \ninto managing endometriosis and addressing relevant themes. To ensure dependability, all \n\n                               \n                             \n                     \n21\ninterviews were conducted by the first author (STP) using a semi-structured interview guide, \nwith detailed documentation throughout. The study’s reliability was further enhanced by \nclose collaboration within the research team during data analysis and discussions. The \ninterviewer (STP) was mindful of the potential influence of her personal and professional \nengagement with endometriosis. This risk was minimized using Malterud’s systematic text \ncondensation during the analysis. This approach emphasizes reflexivity and bracketing to \nreduce subjective influence and strengthen the study’s trustworthiness [34]. The inclusion of \nmultiple participant quotations in the Results section further enhances transparency and \nsupports the credibility of the findings. Additionally, an independent review by co-authors \nreinforced the rigor and reliability of the analysis [35]. Also, the involvement of co-authors \nwith general practice expertise added credibility, as much of the existing literature lacks input \nfrom professionals in the field. Our study’s credibility was also bolstered by obtaining \nperspectives from multiple GPs [36]. Moreover, our study focused on the primary healthcare \nsector, which has received relatively little attention in the existing literature, where the focus \nhas predominantly been on the secondary healthcare sector [37].\nOur study had some limitations. Firstly, due to the small GP population in the Faroe Islands, \nanonymizing participants restricted our ability to share details about personal experiences and \ngeographical differences. Secondly, recruitment was challenged, with only six GPs \nparticipating. While a larger sample could yield different results, these six represented nearly \none-fifth of the total GP population, which is considered acceptable. Due to confidentiality \nconcerns and participant preferences, detailed location data could not be disclosed, despite \ntwo attempts to obtain consent. All participating GPs explicitly declined to share this \ninformation, citing concerns that even limited details might compromise their anonymity. \nNonetheless, it is important to note that participants represented a range of practice types and \n\n                               \n                             \n                     \n22\ngeographic regions.\nDespite this, their diverse perspectives strengthen the relevance of our findings to similar \nhealthcare settings.\nComparison with existing literature\nA key finding of our study was the GPs’ recognition of the complex and multifaceted \nsymptoms experienced by patients with endometriosis and the significant support these \npatients require. While the GPs acknowledged their primary responsibility for managing \ntreatment, they identified a lack of the necessary skills and resources to provide effective care \nwithin general practice settings. These findings are consistent with those of Frayne et al. [6], \nwho highlighted the challenges GPs face in delivering consistent care due to the lack of \nspecific diagnostic tools and clinical guidelines. Despite these limitations, all GPs stated a \nstrong commitment to supporting their patients, even when the challenges exceeded their \nprofessional capacity.\nAll GPs expressed feeling powerless when standard treatments failed to relieve patient’s \nsymptoms, often leading to increased risk of depression, anxiety, and stress. Casalechi et al. \nlinked chronic pelvic pain in endometriosis to a higher prevalence of psychological \nconditions [38]. Despite recognizing the need for a holistic approach, GPs cited limited \nconsultation time as a major barrier, aligning with the Dixon et al. findings on time \nconstraints and obstacles [39]. Similarly, Grundstrom et al. emphasized addressing both the \nmental and physical aspects of patients’ pain [40]. The GPs often scheduled additional \nconsultations and follow-up appointments to mitigate the challenge of time constraints. This \napproach is consistent with the findings of Frayne et al., who noted that the complexity of \n\n                               \n                             \n                     \n23\nendometriosis symptoms frequently required longer or more frequent visits to meet patients’ \nneeds adequately [6].\nSome GPs reported that increased media attention positively impacted their clinical practice \nby raising awareness of endometriosis during patient evaluations and improving the referral \nprocess to gynaecological departments. This heightened awareness encouraged patients to \ntake a more active role in their care [41] and a study from Australia highlighted how social \nmedia even empowered patients to become active participants in managing their health [42]. \nHowever, the UK media’s one-sided portrayal of GPs as responsible for diagnostic delays in \nendometriosis oversimplifies a multifaceted issue and unjustly assigns blame to a single \ngroup of clinicians [37,39]. This narrative is echoed in specialist endometriosis literature, \nwhere GPs are often described as a bottleneck in the diagnostic pathway [43,44].\nOur study highlights challenges in GP-gynaecology collaboration, with GPs reporting \nfrequent denial of endometriosis referrals, as gynaecologists argued treatment in both sectoral \nsettings were similar. This mirrors findings from the Netherlands, where GPs also faced \nreferral difficulties [45]. GPs expressed concern over long waiting times for gynaecological \nappointments, delaying diagnosis and treatment [46]. Despite this, referrals were typically \nseen as a last resort, after exhausting other treatment options. This aligns with Ellis et al.’s \nfindings, where GPs in New Zealand explored alternative treatments like exercise, diet, and \nphysiotherapy before referring patients [47].\nAll GPs often received patients back without clear explanations for their pain, as \ngynaecologists prioritized more acute cases over endometriosis. This may lead GPs to view \nfollow-up consultations as less impactful, given denied referrals or long waiting lists. The \nissue is not a lack of knowledge about endometriosis among GPs, as previous studies suggest \n\n                               \n                             \n                     \n24\n[17]. But rather the limited management options and access to specialist care when standard \napproaches and guidelines are insufficient [37].\n Some of our findings are contextually situated to primary care within remote or insular \ncommunities, for example the relative lack of choice of referral options which intersected \nwith the challenge of managing deferred or rejected referrals. However, we note that there are \nalso many points of resonance with findings described in other settings, for example striving \nto offer holistic support and holding care between services, resources and treatments. While \nwe cannot, and do not, suggest our results are generalisable, we consider that our study \nilluminates’ findings which may resonate with other settings, both insular and no [48,49]. \nOverall, our study emphasised that all GPs took on significant responsibility in managing \npatients with endometriosis. They focused on setting realistic expectations early, embraced a \nholistic approach to care, and prioritized building and maintaining strong GP-patient \nrelationships despite facing systemic challenges.\nImplications for Research and/or Practice\nAll GPs reported challenges in collaborating with gynaecology departments, often feeling \nisolated and unable to access specialist support. They emphasized the importance of setting \npatients’ expectations early and building strong GP-patient relationships. Our findings also \nhighlighted the need for personalised treatment plans addressing both the physical and \npsychosocial challenges. Given the impact of chronic pain on mental health and social well-\nbeing, GPs should consider referrals to psychologists. This aligns with existing research on \nmental health and social effects of endometriosis.\nOngoing awareness campaigns are recommended to highlight endometriosis as a major health \nissue. An example of this is the successful co-created social media campaign in Denmark \n\n                               \n                             \n                     \n25\n[41]. Further research is warranted to better elucidate GPs perceptions of their role in the \nmanagement of endometriosis. Expanding the sample size in future studies would improve \nthe generalisability of the findings (47). Additionally, incorporating patients’ perspectives on \nendometriosis care in the Faroe Islands—an area that remains underexplored—would provide \ncritical insights. Understanding these perspectives is essential for a more comprehensive view \nof the diagnostic and treatment challenges associated with the condition [50,51]. \nSince our study focused exclusively on GPs’ experiences, future research should also \ninvestigate the perspectives of gynaecologists in managing patients with endometriosis \nsymptoms. Such research would provide a more comprehensive understanding of the \nchallenges and facilitate stronger collaboration between GPs and gynaecologists, ultimately \nimproving patient care. \nAdditional information\nFunding\nUBK's institution (Aarhus University) has received grant funding from the European Union's \nHorizon 2020 research and innovation program to coordinate the project Finding \nEndometriosis using Machine Learning (FEMaLe/101017562).\nEthical approval \nThe project is registered with the Danish Research Ethics Committee (12.166) and does not \nrequire ethical approval in accordance with Danish legislation.\n\n                               \n                             \n                     \n26\nAcknowledgements \nWith special thanks to the general practitioners who were interviewed.\n\n                               \n                             \n                     \n27\nReferences\n[1] Rogers PA, D'Hooghe TM, Fazleabas A, et al. 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