{"paper_id":"6987dd77-8813-4d38-b727-e51a56007d89","body_text":"D\nysmenorrhea is a common gynecologic condi -\ntion that impairs women’s quality of life (QOL),  \ninterferes with their academic and professional perfor -\nmance,  and reduces overall well-being [1].  At a societal \nlevel,  it contributes to reduced productivity and eco -\nnomic losses due to school or work absenteeism [2 , 3].  \nAlthough early medical consultation and treatment are \neffective,  only approximately 10% of Japanese women \nwith dysmenorrhea seek medical care,  despite an esti -\nmated prevalence of 8-10 million [4].\nEndometriosis,  is an estrogen-dependent condition \naffecting women of reproductive age (aged 15-49 years).  \nIt is characterized by endometrial-like tissue outside the \nuterus,  which can cause chronic inflammation,  fibrosis/\nadhesion,  and pelvic pain.  Typical symptoms include \nsevere menstrual pain requiring analgesics,  dyschezia \nduring menstruation,  deep pelvic pain,  and dyspareu-\nnia [5 , 6].  Menstrual abnormalities — such as shortened \ncycles (< 28 days),  prolonged bleeding (> 7 days),  and \n\"DUB\u0001.FE\u000f \u00010LBZBNB\r \u0001\u0013\u0011\u0013\u0017\n7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014\r \u0001QQ\u000f \u0001\u0012\u0016\u001aô\u0012\u0017\u0019\n$PQZSJHIU⡥\u0001 \u0013\u0011\u0013\u0017\u0001CZ\u00010LBZBNB\u00016OJWFSTJUZ\u0001.FEJDBM\u00014DIPPM\u000f\nhttp ://escholarship.lib.okayama-u.ac.jp/amo/Original Article\nSelf-Reported Adolescent Menstrual Symptoms and Delayed Gynecologic \nConsultation among Japanese Women with Endometriosis\nTomoko Ikeda＊,  and Mikiya Nakatsuka\nFaculty of Health Sciences,  Okayama University,  Okayama 700-8558,  Japan\nEndometriosis symptoms often first appear during adolescence,  yet delays in seeking gynecologic consultation \nremain a persistent challenge worldwide.  Despite growing international evidence,  the specific patterns of \nsymptom recognition and consultation delay among Japanese women — particularly in relation to self-monitoring \nbehaviors and cultural barriers — remain poorly understood.  This study aimed to provide foundational data to \nguide menstrual education and preconception care strategies by conducting a cross-sectional online survey with \nretrospective recall among women with endometriosis to assess menstrual characteristics and symptom  \npatterns from adolescence to initial care seeking.  The survey was conducted in Japan in January 2024 and \nenrolled 166 women with endometriosis and 200 controls.  Participants reported current and adolescent men -\nstrual characteristics,  symptom recognition,  analgesic and low-dose estrogen–progestin use,  school/work \nimpact,  and age at first gynecologic consultation for menstrual problems.  Women with endometriosis reported \nheavier bleeding,  stronger pain,  and greater school/work absence than controls,  both currently and retrospec-\ntively.  The median age at first recognition of heavy bleeding or school/work absence was 16 years,  whereas \nconsultation occurred at approximately 21-23 years,  indicating a consultation delay of 5-6 years.  Notably,  while \nself-monitoring of symptoms was more frequent among women with endometriosis,  it only modestly shortened \nconsultation delays.  This study provides evidence from Japan that consultation delay persists despite active \nself-monitoring of symptoms,  highlighting the influence of educational and cultural barriers on health-seeking \nbehavior.  These findings underscore the importance of integrating menstrual education with clinical guidance \nto promote timely gynecologic consultation.\nKey words:  endometriosis,  adolescence,  menstrual disorders,  consultation delay,  health-seeking behavior\nReceived December 22, 2025 ; accepted February 16, 2026.\n＊Corresponding author. Phone : +81-86-235-6866; Fax  : +81-86-235-6866\nE-mail : t-ikeda@okayama-u.ac.jp (T. Ikeda)\nConflict of Interest Disclosures: No potential conflict of interest relevant  \nto this article was reported.\n\nanemia — may also occur [7].  According to the \nAmerican College of Obstetricians and Gynecologists,  \nearly diagnosis and treatment in adolescents can pre -\nvent disease progression and reduce infertility risk.  \nTherefore,  the early use of low-dose estrogen–progestin \n(LEP) therapy is recommended [8].  Over 40% of ado -\nlescents with severe dysmenorrhea or chronic pelvic \npain are diagnosed with endometriosis [9-11],  high -\nlighting the importance of early recognition and timely \ngynecologic consultation.\nSymptoms often first appear during adolescence,  \napproximately 2-3 years after menarche,  when ovula -\ntory cycles are established.  DiVasta et al.  [12] reported \nthat women diagnosed with endometriosis typically \nexperienced severe menstrual pain from the age of 16 \nyears.  However,  the time of onset,  specific symptom \npatterns,  and age-related changes remain insufficiently \nstudied,  particularly in relation to healthcare-seeking \nbehaviors.  Although self-monitoring of symptoms such \nas heavy menstrual bleeding,  severe menstrual pain,  or \nnon-menstrual pelvic pain may lead to early consulta -\ntion,  evidence on whether symptom awareness leads to \ntimely medical care is limited.\nThis study aimed to provide foundational data to \nguide menstrual education and preconception care \nstrategies.  Specifically,  we conducted a cross-sectional \nonline survey with retrospective recall among women \nwith endometriosis to assess menstrual characteristics \nand symptom patterns from adolescence to diagnosis.  \nWe investigated the age at symptom recognition,  anal-\ngesic use,  daily life impact,  and awareness of symp -\ntoms,  as well as their association with delays in gyneco-\nlogic consultation.  Our objectives align with recent \ninternational and national guidelines.  The 2022 guide-\nlines of the European Society of Human Reproduction \nand Embryology emphasize early diagnosis and inter -\nvention in adolescents with suspected endometriosis \n[13],  whereas the 2023 guidelines of the Japan Society \nof Obstetrics and Gynecology highlight timely treat -\nment with NSAIDs and LEP therapy to improve QOL \nand reproductive outcomes [14].  These perspectives \nsuggest the broader relevance of our findings to both \nglobal and Japanese clinical practice.\nMethods\nStudy design and participants. This cross-sec -\ntional online questionnaire survey included women \naged 20-45 years residing in Japan and incorporated \nretrospective recall of adolescent menstrual symptoms.  \nThe endometriosis group comprised women who \nself-reported gynecologist-diagnosed endometriosis \n(clinical or laparoscopic diagnosis).  The control group \ncomprised women who reported no history of endome-\ntriosis or other gynecologic conditions.\nSample size considerations. The sample size was \ndetermined pragmatically based on recruitment feasi -\nbility and available resources; therefore,  no formal a \npriori power calculation was performed.\nData collection. Data were collected in January \n2024 using an anonymous online questionnaire admin-\nistered by Cross Marketing Inc.,  a commercial research \nagency in Japan.  The structured survey assessed socio-\ndemographic characteristics (age,  marital status,  \nemployment,  pregnancy,  and delivery history),  men -\nstrual characteristics (cycle length,  duration,  and flow \nvolume),  symptom severity,  analgesic use,  treatment \nhistory (LEP and analgesics),  impact on daily life,  and \ngynecologic consultation history.  For adolescent men-\nstrual experiences,  participants retrospectively recalled \ntheir symptoms during their teenage years,  including \ncycle characteristics,  pain,  daily life impact,  and \nself-monitoring of symptoms.\nOutcomes. Primary outcomes were as follows:  \n(i) menstrual characteristics and symptoms during ado-\nlescence and adulthood; (ii) analgesic and LEP use;  \n(iii) age at first recognition of endometriosis-related \nsymptoms; (iv) age at first gynecologic consultation \nand delay between symptom recognition and consulta-\ntion; and (v) awareness and self-monitoring of men -\nstrual symptoms during adolescence.\nStatistical analysis. Categorical variables are pre-\nsented as counts and percentages,  and continuous vari-\nables as mean ± standard deviation or median [range],  \ndepending on distribution.  Between-group compari -\nsons (endometriosis vs.  control) were performed using \nχ2 tests for categorical variables and t-tests for continu-\nous variables.  Within-group comparisons (current vs.  \nadolescence) were performed using paired t-tests or \nMcNemar’s test,  as appropriate.  Two-sided p< 0.05 was \nconsidered statistically significant.  Analyses were con-\nducted using IBM SPSS Statistics version 29.0.1.0 (IBM \nCorp.,  Armonk,  NY ,  USA).\nEthical considerations. This study was approved \nby the appropriate ethics committee (approval number:  \nT20-04).  Participation was voluntary,  and informed \n\u0012\u0017\u0011\n*LFEB\u0001FU\u0001BM\u000f \"DUB\u0001.FE\u000f \u00010LBZBNBɹ7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014\n\nconsent was obtained electronically at the beginning of \nthe online questionnaire.  Responses were anonymized \nto protect participant confidentiality.\nExternal validity. Because the data were collected \nthrough an online survey in Japan,  the findings should \nbe interpreted with caution when generalizing to popu-\nlations in other cultural or healthcare contexts.\nResults\nParticipant characteristics. Among the 166 \nwomen in the endometriosis group,  51 had laparo -\nscopically confirmed and 115 had clinically diagnosed \nendometriosis.  No significant differences were \nobserved between the endometriosis and control groups \nregarding age,  marital status,  employment,  pregnancy \nhistory,  or parity,  suggesting that subsequent group \ncomparisons were not substantially confounded by the \nbaseline characteristics (Table 1).\nCurrent menstrual status.\n1. Endometriosis vs. control group.\nCycle length and menstrual duration did not differ \nsignificantly between groups.  However,  heavy men -\nstrual bleeding was more frequent in the endometriosis \ngroup than in controls.  Although the mean pain sever-\nity score did not differ significantly,  analgesic use in \nevery menstrual cycle and school/work absence were \nsignificantly more common in the endometriosis group \nthan in the control group (Table 2).\n2. Endometriosis group: treated vs. untreated.\nCycle length,  menstrual duration,  and pain severity \ndid not differ according to treatment status.  However,  \nheavy menstrual bleeding and school/work absence \nwere significantly less frequent in treated than in \nuntreated women,  suggesting that therapy mitigated \nbleeding and day-to-day disruption (Table 2).\n3. Control group: analgesic users vs. non-users.\nCycle length and menstrual duration did not differ \nbetween women who used analgesics and those who did \nnot.  However,  heavy menstrual bleeding,  pain severity,  \nschool/work absence due to symptoms,  and activity \nrestriction were significantly higher among analgesic \nusers than among non-users,  suggesting that analgesic \nuse in controls largely reflects underlying symptom bur-\nden rather than symptom resolution (Table 2).\nAdolescent menstrual status (retrospective): con -\ntrol vs. endometriosis group. Recall responses of “do \nnot remember” were more frequent in the control group \nthan in the endometriosis group.  Compared with con-\ntrols,  women with endometriosis more frequently \nreported a cycle length ≤ 24 days,  menstrual duration \n≥ 8 days,  heavy menstrual bleeding,  greater pain sever-\nity,  analgesic use in every menstrual cycle,  and more \nfrequent school/work absence (Table 2).\nChange from adolescence to the present state.\n1. Endometriosis group (adolescence vs. current).\nCycle length ≤ 24 days was more frequently reported \nat present than during adolescence,  whereas menstrual \nduration ≥ 8 days was slightly more frequent during \nadolescence than at present.  Heavy menstrual bleeding \nwas markedly more common during adolescence than \nat present.  Pain severity was significantly higher during \nadolescence.  The frequency of analgesic use did not \ndiffer between the time points.  Regarding daily-life \nimpact,  both school/work absence and activity restric-\ntion were more frequent during adolescence (Table 2).\n2. Control group (adolescence vs. current).\nCycle length did not differ between the adolescent \nand present states.  Menstrual duration ≥ 8 days was \nsignificantly more common at present than during ado-\nlescence,  whereas reports of light bleeding were less \n+VOF\u0001\u0013\u0011\u0013\u0017 \"EPMFTDFOU\u0001%FMBZ\u0001JO\u0001&OEPNFUSJPTJT\n\u0012\u0017\u0012\n5BCMF \u0012　 Participant characteristics\nControl\n(n = 200)\nEndmetriosis\n(n = 166) P-value\nAge (year) 27.6± 4.5\n27 ［20-35］\n27.5± 4.4\n27 ［20-35］ 0.669\nMarital status\n　　Single 127 (63.5%) 102 (61.4%) 0.795\n　　Married 68 (34.0%) 58 (34.9%)\n　　Divorced 5 (2.5%) 6 (3.6%)\nEmployment status\n　　Full-time employee 37 (18.5%) 46 (27.7%) 0.189\n　　part-time worker 64 (32.0%) 45 (27.1%)\n　　Self-employed 9 (4.5%) 5 (3.6%)\n　　Student 33 (18.6%) 32 (19.3%)\n　　Unemployed 57 (28.5%) 38 (22.9%)\nHistory of pregnancy 51 (25.5%) 47 (28.3%) 0.545\nHistory of childbirth 37 (18.5%) 40 (24.1%) 0.130\nValues are presented as mean ± SD,  median [range],  or n (%).  \nNominal variables were compared using the χ2 test,  and continuous \nvariables using the t-test.\nThe endometriosis group included women who had been diagnosed \nwith endometriosis or clinical endometriosis by a gynecologist.  \nWithin this group,  “confirmed endometriosis” referred to diagnoses \nverified by laparoscopy,  while “suspected endometriosis” referred \nto clinical diagnoses without laparoscopic confirmation.\nSD,  standard deviation.\n\n\u0012\u0017\u0013\n*LFEB\u0001FU\u0001BM\u000f \"DUB\u0001.FE\u000f \u00010LBZBNBɹ7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014\n5BCMF \u0013　 Comparison of menstrual characteristics between women with and without endometriosis (current and retrospective experi -\nences)\nCurrent menstrual experiences\nEndometriosis group (n = 166) Control group \n(n = 200)\nOveralla) Untreated b)\nReceiving treatment \nwith\nLEP or analgesicsc)\nP-value\n(between \ngroups)\nOveralld)\n(n = 166) (n = 88) (n = 78) (n = 200)\nMenstrual cycle length\n　< 25 days 31 (18.7%) 18 (20.5%) 13 (16.7%) ns 24 (12.0%)\n　25-38 days 107 (64.5%) 58 (65.9%) 49 (62.8%) 144 (72.0%)\n　> 38 days 28 (16.9%) 12 (13.6%) 16 (20.5%) 32 (16.0%)\n　Do not remember 0 0 0 0\nDuration of menstruation\n　4-7 days 143 (86.1%) 72 (81.8%) 71 (91.0%) ns 174 (87.0%)\n　≥ 8 days 23 (13.9%) 16 (18.2%) 7 (9.0%) 26 (13.0%)\n　Do not remember 0 0 0 0\nMenstrual flow volume\n　Light 32 (19.3%) 8 (9.1%) 24 (30.8%) < 0.001 28 (14.0%)\n　Moderate 88 (53.0%) 46 (52.3%) 42 (53.8%) 137 (68.5%)\n　Heavy 46 (27.7%) 34 (38.6%) 12 (15.4%) 35 (17.5%)\nSelf-rated severity of menstrual pain (0-10 scale) 5.0± 3.0\n5［0-10］\n5.3± 3.0\n6［0-10］\n4.7± 2.9\n5［0-10］ ns 4.7± 2.5\n5［0-10］\nFrequency of analgesic use during menstruation\n　Never use 39 (23.5%) 50 (56.8%) 31 (39.7%) ns 78 (39.0%)\n　Sometimes 46 (27.7%) 23 (26.1%) 23 (29.5%) 68 (34.0%)\n　Always 81 (48.8%) 15 (17.0%) 24 (30.8%) 54(27.0%)\nImpact of menstruation on daily life\n　No disruption in daily life 48 (28.9%) 19 (21.6%) 29 (37.2%) ns 84 (42.0%)\n　Manageable with analgesics 75 (45.2%) 43 (48.9%) 32 (41.0%) 83 (41.5%)\n　Partially disrupted despite analgesics 26 (15.7%) 15 (17.0%) 11 (14.1%) 23 (11.5%)\n　Significant disruption in daily life 17 (10.2%) 11 (12.5%) 6 (7.7%) 10 (5.0%)\nImpact of menstruation on academic or occupational performance\n　No impact 73 (44.0%) 32 (36.4%) 41 (52.5%) 0.042 121 (60.5%)\n　Restricted activity without absence 52 (31.3%) 28 (31.8%) 24 (30.8%) 50 (25.0%)\n　Occasional pain-related school/work absence 41 (24.7%) 28 (31.8%) 13 (16.6%) 29 (14.5%)\na) Currently diagnosed with endometriosis (n = 166): Women who self -reported a diagnosis of endometriosis by a medical professional.\nb) Currently untreated endometriosis (n= 88): Subgroup of women with endometriosis who were not receiving hormonal therapy (e.g.,  LEP) or analgesics at the \ntime of the survey.\nc) Currently treated endometriosis (n = 78): Subgroup of women with endometriosis who were receiving hormonal therapy (e.g.,  LEP) and /or analgesics at the \ntime of the survey.\nd) Control group (n = 200): Women who self -reported no diagnosis of endometriosis.\ne) Control group,  not using analgesics (n= 78): Subgroup of the control group who reported no use of analgesics during menstruation.\nf) Control group,  using analgesics (n= 122): Subgroup of the control group who reported the use of analgesics during menstruation.\ng) Retrospective menstrual experiences during adolescence,  endometriosis group (n = 166): Women currently diagnosed with endometriosis who retrospec -\ntively reported menstrual characteristics and symptoms during adolescence (< 20 years of age).\nh) Retrospective menstrual experiences during adolescence,  control group (n= 200): Women in the control group who retrospectively reported menstrual char -\nacteristics and symptoms during adolescence (< 20 years of age).\n\n+VOF\u0001\u0013\u0011\u0013\u0017 \"EPMFTDFOU\u0001%FMBZ\u0001JO\u0001&OEPNFUSJPTJT\n\u0012\u0017\u0014\n(continued from previous page)\nCurrent menstrual experiences Retorospective menstrual expreience \nduring adolescence\nControl group (n = 200)\nCurrent status:\nEndometriosis vs. \nControl i)\nEndometriosis \ngroup (n = 166)\nControl group \n(n = 200) Teenage years \n(retrospective):\nEndometriosis vs. \nControl ii)\nGroup comparison based \non current age iii)\nNo medication \nusee)\nUsing \nanalgesicsf)\nP-value\n(between \ngroups)\nOverallg) Overallh) Endometriosis \ngroup\nControl \ngroup\n(n = 78) (n = 122) (n = 166) (n = 200) P-value P-value\n10 (12.8%) 14 (11.5%) ns ns 21 (12.7%) 13 (6.5%)\n52 (66.7%) 92 (75.4%) 101 (60.8%) 119 (59.5%) 0.047 < 0.001 ns\n16 (20.5%) 16 (13.1%) 21 (12.7%) 22 (11.0%)\n0 0 23 (13.9%) 46 (23.0%)\n70 (89.7%) 104 (85.2%) ns ns 128 (77.1%) 153 (76.5%)\n8 (10.3%) 18 (14.8%) 26 (15.7%) 17 (8.5%) 0.013 0.001 < 0.001\n0 0 12 (7.2%) 30 (15.0%)\n17 (21.8%) 11 (9.0%) < 0.001 11 (6.6%) 10 (5.0%)\n57 (73.1%) 80 (65.6%)\na) vs d): 0.009 \nb) vs e): < 0.001\nc) vs f): < 0.001\n75 (45.2%) 151 (75.5%) < 0.001 < 0.001 0.009\n4 (5.1%) 31 (25.4%) 80 (48.2%) 39 (19.5%)\n3.3± 2.3\n3［0-10］\n5.6± 2.2\n6［0-10］ < 0.001 b) vs e): 0.002\nc) vs f): 0.002\n6.2± 3.1\n7［0-10］\n4.6± 2.6\n5［0-10］ < 0.001 < 0.001 ns\na) vs d): < 0.001 36 (21.7%) 91 (45.5%) < 0.001 ns\n44 (26.5%) 64 (32.0%)\n86 (51.8%) 45 (22.5%)\n62 (79.5%) 22 (18.0%) < 0.001 39 (23.5%) 87 (43.5%)\n9 (11.5%) 74 (60.7%) a) vs d): 0.027\nb) vs e): < 0.001\nc) vs f): 0.015\n60 (36.1%) 77 (38.5%) < 0.001 0.044\n5 (6.4%) 18 (14.8%) 37 (22.3%) 27 (13.5%) ns\n2 (2.6%) 8 (6.6%) 30 (18.1%) 9 (4.5%)\n64 (82.1%) 55 (45.1%) < 0.001 60 (36.1%) 123 (61.5%) ns\n9 (11.5%) 42 (34.4%) a) vs d): 0.004\nb) vs e): < 0.001 60 (36.1%) 52 (26.0%) < 0.001\n5 (6.4%) 25 (20.5%) 46 (27.7%) 25 (12.5%)\nComparisons were conducted as follows: (i) current menstrual experiences between the endometriosis and control groups; (ii) retrospective menstrual experi -\nences during adolescence between the endometriosis and control groups; and (iii) within -group comparisons between current and retrospective adolescent \nmenstrual experiences.  P-values correspond to the comparison indicated by each superscript.\nValues are expressed as mean ± SD,  median [range],  or n (%).  Comparisons were made between the endometriosis and control groups,  as well as between \ntreatment and non-treatment subgroups within each group.  Heavy menstrual bleeding was defined as self-reported “heavy” menstrual flow compared with “nor-\nmal” or “light. ” Pain-related absence from school or work was defined as self-reported absence from school or work due to menstrual pain.  Pain severity was \nassessed using a self -reported 0-10 numerical rating scale.  Regular analgesic use was defined as analgesic use during every menstrual cycle.  Group differ -\nences were evaluated using the χ2 test for categorical variables and the t-test for continuous variables.\nLEP,  low-dose estrogen progestin; SD,  standard deviation.\nns, not statistically significant.\n\ncommon in adolescence than at present.  Pain severity,  \nanalgesic use,  and daily-life impact did not differ sig -\nnificantly between time points (Table 2).\nSymptom recognition, consultation timing, and \nself-monitoring\n1. Symptom onset and gynecologic consultation in \nthe endometriosis group.\nThe median age at first recognition of symptoms was \n16,  16,  and 20 years for heavy bleeding,  school/work \nabsence,  and chronic pelvic or back pain unrelated to \nmenstruation,  respectively.  The median age at first \ngynecologic consultation was 23 years overall,  with 21,  \n22,  and 22 years among those reporting heavy bleeding,  \nschool/work absence,  and chronic pelvic or back pain,  \nrespectively.  Recognition of heavy bleeding and school/\nwork absence occurred significantly earlier than recog-\nnition of chronic pelvic or back pain (both p< 0.01).\nThe median intervals from symptom recognition to \nconsultation were 36,  78,  and 30 months for heavy \nbleeding,  school/work absence,  and chronic pelvic or \nback pain,  respectively.  No significant differences in \nconsultation age or delay were observed between par -\nticipants with vs.  without each symptom (Table 3).\n2. Awareness and monitoring of symptoms during \nadolescence.\nA significantly higher proportion of women in the \n\u0012\u0017\u0015\n*LFEB\u0001FU\u0001BM\u000f \"DUB\u0001.FE\u000f \u00010LBZBNBɹ7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014\n5BCMF \u0014　 Age at symptom onset and time to initial gynecological visit among women with endometriosis\nSymptom type\nAge at first\nawareness of\nmenstrual\nsymptoms\nP-value\nAge at first\ngynecological\nvisit\nP-value\nTime from symptom\nawareness to\ngynecological visit\n(months)\nP-value\nAll 16.8± 4.1\n16［11-29］\n22.9± 4.4\n23［13-32］\n73.2± 60.0\n60［0-216］\nHeavy menstrual bleedingb)\n　Present (n = 80) 17.2± 3.5\n16［12-28］ 0.003 22.1± 4.5\n21［13-31］ 0.725 57.6± 52.8\n36［0-192］ 0.181\n　Absent (n = 86) 20.7± 4.7\n20［12-29］\n23.8± 4.4\n24［15-32］\n42.0± 40.8\n48［0-120］\nSevere menstrual pain (leading to \npain school/work absence)c)\n　Present (n = 46) 15.6± 2.1\n16［12-19］ <0.001 21.4± 3.8\n22［15-29］ 0.271 69.6± 57.6\n78［0-156］ 0.581\n　Absent (n = 120) 20.6± 5.4\n20［11-32］\n23.4± 4.7\n23［13-32］\n40.8± 56.4\n36［0-204］\nChronic lower back or pelvic pain \nunrelated to menstruationd)\n　Present (n = 32) 20.1± 6.1\n18［12-34］ 0.878 23.1± 5.0\n22［15-32］ 0.251 42.0± 46.8\n30［0-132］ 0.663\n　Absent (n = 134) 20.1± 5.6\n20［11-32］\n22.8± 4.4\n23［13-31］\n28.8± 66.0\n24［0-204］\nAll of the above symptoms presente)\n　Present (n = 12) 15.5± 1.7\n15［14-18］ 0.013 22.0± 2.4\n22［20-25］ 0.526 78.0± 40.8\n84［24-120］ 0.228\n　Absent (n = 166) 19.0± 4.5\n19［12-29］\n22.9± 4.6\n23［13-32］\n46.8± 48.0\n36［0-192］\nData reflect retrospective reports of symptoms during adolescence from participants currently diagnosed with endometriosis.\na) Heavy menstrual bleeding =response “heavy” (vs “normal/light”).\nb) Severe menstrual pain =school/work absence due to menstrual pain.\nc) Chronic lower back or pelvic pain unrelated to menstruation =lower back or pelvic pain outside menses,  including dyspareunia and /or \ndyschezia.\nd) All symptoms present indicates co-occurrence of these three conditions.\n\nendometriosis group reported consciously monitoring \ntheir menstrual flow during adolescence.  Similarly,  \nconscious monitoring of pain,  fatigue,  or headache was \nmore frequent in the endometriosis group (Table 4).\n3. Monitoring behaviors and consultation timing \nin the endometriosis group.\nIn the endometriosis group,  age at first consultation \ndid not differ significantly by self-monitoring behavior.  \nHowever,  the interval from symptom recognition to \nconsultation was significantly shorter among women \nwho consciously monitored their menstrual cycle and \namong those who monitored appetite and bowel move-\nments.  These findings suggest that self-monitoring \nbehaviors were associated with earlier consultation \n(Table 5).\nDiscussion\nPrincipal findings. This study retrospectively \nexamined menstrual symptoms,  treatment patterns,  \nand consultation behaviors among Japanese women \nwith endometriosis compared with controls.  Women \nwith endometriosis experienced heavier bleeding,  more \nsevere pain,  and greater disruption to daily life from \nadolescence.  Although symptoms were typically recog-\nnized around the age of 16 years,  the first gynecologic \nconsultation occurred at 21-23 years,  indicating a con-\nsultation delay of approximately 5-6 years.  Importantly,  \nself-monitoring of symptoms alone did not consistently \nlead to earlier consultation.\nHowever,  the association between self-monitoring \nand consultation behavior was not uniform when the \ntype of self-monitored symptoms was considered.  A \nmore detailed examination of symptoms observed \nduring adolescence suggested that observation limited \nto menstrual symptoms,  such as bleeding and pain,  \ndiffered in its association with consultation behavior \nfrom monitoring of broader physical symptoms,  \nincluding appetite and bowel habits.  Notably,  women \nwho consciously observed changes in appetite or bowel \nhabits experienced a significantly shorter interval \nbetween symptom recognition and the first gynecologic \nconsultation.\nThese findings suggest that consultation behavior \nmay be influenced not merely by whether symptoms \nwere self-monitored,  but by which types of symptoms \nwere observed.  While observation focused solely on \nmenstrual symptoms may allow symptoms to be inter -\npreted as constitutional or transient,  awareness of sys -\ntemic changes extending beyond the menstrual cycle \nand affecting daily life may strengthen the perception of \nabnormality and prompt medical consultation.\n+VOF\u0001\u0013\u0011\u0013\u0017 \"EPMFTDFOU\u0001%FMBZ\u0001JO\u0001&OEPNFUSJPTJT\n\u0012\u0017\u0016\n5BCMF \u0015　 Awareness and self-observation of menstrual characteristics during adolescence in women with and without endometriosis\nConsciously\nobserved by\noneselfc)\nDid not consciously\nobserved)\nCannot say\neither waye) Do not rememberb) P-value\nObservation of menstrual start dates and \ncycle regularity\n　Control group (n = 200) 88 (44.0%) 62 (31.0%) 23 (11.5%) 27 (13.5%)\n　Endometriosis group (n = 166) 60 (40.5%) 60 (36.1%) 26 (15.7%) 20 (12.0%) 0.330\nObservation of menstrual blood volume\n　Control group (n = 200) 46 (23.0%) 97 (48.5%) 27 (13.5%) 30 (15.0%)\n　Endometriosis group (n = 166) 62 (37.3%) 60 (36.1%) 26 (15.7%) 18 (10.8%) 0.011\nObservation of menstrual pain\n　Control group (n = 200) 42 (21.0%) 109 (54.5%) 23 (11.5%) 26 (13.0%)\n　Endometriosis group (n = 166) 60 (36.1%) 67 (40.4%) 21 (12.7%) 18 (10.8%) 0.009\nObservation of physical condition changes \nassociated with menstruation\n　Control group (n = 200) 115 (57.5%) 33 (16.5%) 24 (12.0%) 28 (14.0%)\n　Endometriosis group (n = 166) 81 (48.8%) 46 (27.7%) 20 (12.0%) 19 (11.4%) 0.071\nThis table summarizes participantsʼ awareness and perceptions of menstrual symptoms during adolescence.\na) Consciously observed by oneself =the participant recognized the symptom based on her own perception.\nb) Did not consciously observe =the symptom was present but not consciously recognized by the participant.\nc) Cannot say either way== uncertainty in recall.\nd) Do not remember =unable to recall details (e.g.,  timing or characteristics).\n\nComparison with previous studies. Our findings \nalign with earlier reports describing characteristic \nsymptoms of endometriosis and their negative impact \non QOL [15 , 6].  International studies similarly indicate \nthat adolescents experiencing dysmenorrhea and school \nabsenteeism often delay seeking gynecologic care [2].  \nHowever,  few studies have quantitatively demonstrated \nthe gap between symptom awareness and consultation \nbehavior.  This study provides new evidence from Japan,  \nshowing that consultation delays persist even among \nwomen who consciously monitored their symptoms,  \nsuggesting that structural and cultural barriers may out-\nweigh awareness in shaping consultation behavior.\nNovelty and cultural context. The novelty of this \nstudy lies in its systematic documentation of consulta -\ntion delay among Japanese women with endometriosis \nand its focus on symptom self-monitoring during ado -\nlescence.  Previous studies have reported that,  in Japan,  \nmenstrual pain and menstrual-related discomfort are \noften normalized as “constitutional” or “part of the \ndevelopmental process,” and that many women do not \nseek medical care even when menstrual symptoms \ninterfere with daily life [4].  Within this cultural context,  \nmenstrual symptoms may be more readily justified as \nissues to be managed individually,  potentially delaying \ntheir recognition as medical concerns.\nOur findings are consistent with prior research \ndescribing characteristics of menstrual perceptions and \nhealthcare-seeking behaviors in Japan.  The observed \ndelay of several years between symptom recognition in \nadolescence and the first gynecologic consultation sug-\ngests that social and cultural factors may influence con-\nsultation behavior.  These interpretations are based on \nthe present findings and indicate that consultation delay \ncannot be fully explained by individual symptom \nawareness or self-monitoring alone.\nIn the Japanese healthcare context,  adolescents tend \nto access gynecologic care later than in Western coun -\ntries,  making the consultation delay observed in this \nstudy particularly relevant for clinical and educational \npractice in Japan.\nImplications for education and preconception care.\nOur results emphasize the need for comprehensive \nmenstrual education not only to improve literacy but \nalso to reduce structural and cultural barriers.  In Japan,  \nmenstrual education has traditionally focused on bio -\nlogical mechanisms rather than the functional impact of \nsymptoms on daily life or fertility.  The Japan Association \nof Obstetricians and Gynecologists (2021) has empha -\nsized the importance of preconception education,  \nincluding awareness of dysmenorrhea and endometrio-\nsis [16].  Educational interventions should address mis-\n\u0012\u0017\u0017\n*LFEB\u0001FU\u0001BM\u000f \"DUB\u0001.FE\u000f \u00010LBZBNBɹ7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014\n5BCMF \u0016　 Observation of menstrual symptoms and timing of gynecological consultation (endometriosis group only)\nObservation of menstrual cycle Observation of menstrual blood volume\nTotal sample\n(n = 166)\nAware\n(n = 60)\nUnaware/\nunsure/forgot\n(n = 106)\nP-value Aware\n(n = 62)\nUnaware/\nunsure/forgot\n(n = 104)\nP-value\nFirst gynecological visit (age) 22.9± 4.4\n23［13-32］\n24.4± 4.7\n24［16-32］\n22.3± 4.2\n23［13-30］ 0.109 22.3± 4.8\n23［13-31］\n23.3± 4.1\n23［16-32］ 0.199\nTime from symptom awareness to first gynecologi -\ncal consultation\n　Heavy menstrual bleeding (n = 80) (n = 80) (n = 19) (n = 61) (n = 35) (n = 45)\n56.4± 52.8\n36［0-192］\n57.6± 57.6\n36［12-180］\n55.2± 52.8\n36［0-192］ 0.450 61.2± 61.2\n36［0-180］\n51.6± 48.0\n12［12-192］ 0.333\nSevere menstrual pain (n = 46) (n = 9) (n = 37) (n = 14) (n = 32)\n(leading to pain -related school /work absence) \n(n = 46)\n68.4± 56.4\n78［0-156］\n63.6± 60.0\n72［0-120］\n69.6± 56.4\n84［0-156］ 0.436 45.6± 72.0\n24［0-132］\n79.2± 49.2\n84［0-156］ 0.141\nChronic lower back or pelvic pain unrelated to \nmenstruation (n = 32) (n = 7) (n = 25) (n = 10) (n = 22)\n43.2± 48.0\n36［0-132］\n9.6± 55.2\n10［0-108］\n38.4± 64.8\n32［0-204］ 0.038 56.4± 50.4\n36［24-132］\n37.2± 49.2\n36［0-108］ 0.262\nThis table compares participants according to their awareness of menstrual condition during adolescence.  “Aware” = consciously observed menstrual flow or \nrelated symptoms.  “Unaware/unsure/forgot” = did not observe,  were unsure,  or did not remember.  Continuous variables are shown as mean ± SD and \nmedian [range].  Group differences were tested using t -tests.  “Age at first gynecological visit ” and “Time from symptom recognition to first visit ” were com -\npared between awareness categories.  \n\nconceptions such as “pain will resolve with age,” nor -\nmalizing medical consultation as a routine response and \nsharing peer examples of treatment leading to improved \nQOL.  Integrating this perspective into school curricula,  \nengaging families and communities,  and mobilizing \nmidwives and nurses as educators could strengthen \nsupport systems and facilitate earlier consultation.\nStrengths and limitations. The strengths of this \nstudy include its systematic examination of associations \nbetween retrospectively recalled adolescent menstrual \nsymptoms,  treatment patterns,  and gynecologic con -\nsultation behaviors among Japanese women,  using a \ncomparison between women with endometriosis and \ncontrols.  By focusing on the temporal gap between \nsymptom recognition during adolescence and subse -\nquent healthcare-seeking behavior in young adulthood,  \nthis study provides important insight into care-seeking \ndelays that may contribute to delayed diagnosis of endo-\nmetriosis.\nSeveral limitations should also be acknowledged.  \nFirst,  the analysis included women with surgically con-\nfirmed endometriosis as well as those diagnosed clini -\ncally.  To assess the potential impact of diagnostic mis-\nclassification,  we conducted a supplementary analysis \ncomparing women with laparoscopically confirmed \ndiagnoses and those with clinical diagnoses.  Although \na difference was observed in marital status,  no signifi -\ncant differences were found between diagnostic groups \nin adolescent menstrual characteristics,  age at first \ngynecologic consultation,  or the interval between \nsymptom recognition and consultation.  These findings \nsuggest that inclusion of clinically diagnosed cases is \nunlikely to have substantially distorted the main con -\nclusions of this study.\nSecond,  assessment of adolescent menstrual charac-\nteristics and symptoms relied on participants’ retro -\nspective recall and may therefore be subject to recall \nbias.  A higher proportion of control participants \nreported difficulty recalling adolescent symptoms com-\npared with women with endometriosis,  suggesting \npotential differences in recall accuracy between groups.  \nWomen diagnosed with endometriosis may recall ado-\nlescent symptoms more vividly due to their diagnostic \nexperiences,  which could have augmented group differ-\nences in symptom severity or frequency in comparisons \nof adolescent symptoms (Table 2 and Table 4).  In con-\ntrast,  the primary outcomes of this study — age at first \ngynecologic consultation and the interval between \nsymptom recognition and consultation — are relatively \nsimple time-based measures and may be less susceptible \nto recall bias than detailed recollection of symptom \nseverity.  Accordingly,  while the findings regarding \n+VOF\u0001\u0013\u0011\u0013\u0017 \"EPMFTDFOU\u0001%FMBZ\u0001JO\u0001&OEPNFUSJPTJT\n\u0012\u0017\u0018\n(continued from previous page)\nObservation of fatigue/headache Observation of appetite/bowel movements\nAware\n(n = 60)\nUnaware/\nunsure/forgot\n(n = 106)\nP-value Aware\n(n = 81)\nUnaware/\nunsure/forgot\n(n = 85)\nP-value\n22.7± 4.9\n23［13-31］\n23.0± 4.1\n23［16-32］ 0.385 23.0± 4.3\n23［16-32］\n22.8± 4.6\n23［13-31］ 0.862\n(n = 37) (n = 43) (n = 21) (n = 59)\n55.2± 58.8\n36［0-180］\n56.4± 49.2\n30［12-192］ 0.457 33.6± 20.4\n24［12-72］\n63.6± 58.8\n42［0-192］ 0.028\n(n = 14) (n = 32) (n = 17) (n = 29)\n50.4± 57.6\n72［0-108］\n76.8± 57.6\n84［0-156］ 0.198 63.6± 60.0\n72［0-132］\n72.0± 57.6\n78［0-156］ 0.398\n(n = 12) (n = 20) (n = 15) (n = 17)\n50.4± 46.8\n4［24-132］\n38.4± 51.6\n48［0-108］ 0.350 31.2± 50.4\n42［0-84］\n52.8± 48.0\n36［0-132］ 0.229\nAdditional analyses stratified participants who retrospectively reported specific adolescent symptoms: heavy menstrual bleeding (n = 80),  absence from school \nor work due to menstrual pain (n = 46),  and chronic lower back or pelvic pain unrelated to menstruation (n= 32).\n\nconsultation delay should be interpreted with these lim-\nitations in mind,  they may be relatively robust.\nIn conclusion,  this study demonstrated that while \nmenstrual symptoms suggestive of endometriosis often \nemerge during adolescence,  gynecologic consultation \nmay be delayed for several years.  A key novel finding is \nthat self-monitoring of symptoms alone does not con -\nsistently resolve this delay.  These findings underscore \nthe importance of addressing systemic,  educational,  \nand cultural barriers to gynecologic consultation.  \nFuture interventions should extend beyond promoting \nsymptom awareness to actively reducing these barriers,  \nwhich is expected to contribute to earlier diagnosis,  \nimproved quality of life,  and preservation of future fer-\ntility.\nThis work was supported by a Japan Society for the \nPromotion of Science (JSPS) Grant-in-Aid for Scientific \nResearch (C) (grant number 18K10461) for the \n“Exploratory study of exacerbating and protective factors \nfor dysmenorrhea in adolescent girls that may affect \nfuture fertility.” The funding source had no role in the \nstudy design; the collection,  analysis,  and interpreta -\ntion of data; the writing of the report;  or the decision \nto submit the article for publication.\nReferences\n 1.  De Sanctis V,  Soliman AT,  Elsedfy H,  Soliman NA,  Soliman R \nand El Kholy M: Dysmenorrhea in adolescents and young adults:  \na review in different countries.  Acta Biomed (2016) 87: 233-246.\n 2.  Zannoni L,  Giorgi M,  Spagnolo E,  Montanari G,  Villa G and \nSeracchioli R: Dysmenorrhea,  absenteeism from school,  and \nsymptoms suspicious for endometriosis in adolescents.  J Pediatr \nAdolesc Gynecol (2014) 27: 258-265.\n 3.  Gallagher JS,  DiVasta AD,  Vitonis AF,  Sarda V,  Laufer MR and \nMissmer SA: The impact of endometriosis on quality of life in  \nadolescents.  J Adolesc Health (2018) 63: 766-772.\n 4.  Takeya Y: Dysmenorrhea and health behavior in Japanese women:  \ninfluence on medical consultation.  Jpn J Matern Health (2013) 54:  \n375-381 (in Japanese).\n 5.  Fuldeore MJ and Soliman AM: Prevalence and symptomatic bur -\nden of diagnosed endometriosis in the United States: national \nestimates from a cross-sectional survey of 59,411 women.  Gynecol \nObstet Invest (2017) 82: 453-461.\n 6.  Schliep KC,  Mumford SL,  Peterson CM,  Chen Z,  Johnstone EB \nand Sharp HT,  Stanford JB,  Hammoud AO,  Sun L and Buck Louis \nGM: Pain typology and incident endometriosis.  Hum Reprod (2015) \n30: 2427-2438.\n 7.  Cramer DW,  Wilson E,  Stillman RJ,  Berger MJ,  Belisle S and \nSchiff I,  et al.: The relation of endometriosis to menstrual charac -\nteristics,  smoking,  and exercise.  JAMA (1986) 255: 1904-1908.\n 8.  American College of Obstetricians and Gynecologists: ACOG \nCommittee Opinion No.  310: Endometriosis in adolescents.  Obstet \nGynecol (2005) 105: 921-927.\n 9.  Laufer MR,  Goitein L,  Bush M,  Cramer DW and Emans SJ:  \nPrevalence of endometriosis in adolescent girls with chronic pelvic \npain not responding to conventional therapy.  J Pediatr Adolesc \nGynecol (1997) 10: 199-202.\n10.  Propst AM and Laufer MR: Endometriosis in adolescents: inci -\ndence,  diagnosis and treatment.  J Reprod Med (1999) 44: 751-\n758.\n11.  Janssen EB,  Rijkers AC,  Hoppenbrouwers K,  Meuleman C and \nDʼHooghe TM: Prevalence of endometriosis diagnosed by laparos -\ncopy in adolescents with dysmenorrhea or chronic pelvic pain: a \nsystematic review.  Hum Reprod Update (2013) 19: 570-582.\n12.  DiVasta AD,  Vitonis AF,  Laufer MR and Missmer SA: Spectrum \nof symptoms in women diagnosed with endometriosis during ado -\nlescence vs adulthood.  Am J Obstet Gynecol (2018) 218: 324.e1- \n324.e11.\n13.  ESHRE Guideline Group on Endometriosis: Endometriosis: guideline \nof the European Society of Human Reproduction and Embryology.  \nHum Reprod Open (2022) 2022: hoac009.\n14.  Japan Society of Obstetrics and Gynecology: Clinical guideline for \nendometriosis 2023.  Japan Society of Obstetrics and Gynecology,  \nTokyo (2023) (in Japanese).\n15.  Fuldeore MJ,  Soliman AM,  Snabes MC and Gao X: Real -world \ncost burden and treatment patterns in patients with endometriosis.  \nJ Manag Care Spec Pharm (2017) 23: 408-416.\n16.  Japan Association of Obstetricians and Gynecologists: Report on \npreconception care.  Japan Association of Obstetricians and \nGynecologists,  Tokyo (2021) (in Japanese).\n\u0012\u0017\u0019\n*LFEB\u0001FU\u0001BM\u000f \"DUB\u0001.FE\u000f \u00010LBZBNBɹ7PM\u000f \u0001\u0019\u0011\r \u0001/P\u000f \u0001\u0014","source_license":"public-domain-us","license_restricted":false}