{"paper_id":"d8cc8178-01a5-49a4-a95f-b73b66bf056c","body_text":"Open Journal of Obstetrics and Gynecology, 2023, 13, 907-917 \nhttps://www.scirp.org/journal/ojog \nISSN Online: 2160-8806 \nISSN Print: 2160-8792 \n \nDOI: 10.4236/ojog.2023.135078  May 31, 2023 907 Open Journal of Obstetrics and Gynecology \n \n \n \n \nDiagnosis Delay and Assessment of the Quality \nof Life of Patients with Endometriosis Using the \nEndometriosis Health Profile 5 Questionnaire \nin a Sub-Saharan Population \nMonzango Sibo1,2*, Mboloko Esimo1, Mputu Lobota1, Itewa Monka1,2, Kitenge Kia Kayembe1, \nTambola Grace1,2, Samba Kevine1,2, Maesheka Patrick1,2, Ntanga Kabuya1,2, Amba Naomie2, \nMaxime Fastrez3, Buka Ikoko4, Ndjukendi Ally4, Sangana Georges5, Barhayiga Berthe6,  \nMbanzulu Pita1, Longo Mbenza7, Clément Ferrier8, Emile Darai8 \n1Department of Gynecology and Obstetrics, University Clinics of Kinshasa, Faculty of Medicine, Kisangani,  \nDemocratic Republic of the Congo \n2Department of Gynecology, Service of Laparoscopic Surgery, Onyx Medical Center, Kisangani, Democratic Republic of the Congo \n3Department of Gynecology and Obstetrics, Erasme Endometriosis Clinic, Free University of Brussels, Brussels,  \nKingdom of Belgium \n4Department of Psychiatry, Neuro-Psychopathological Center of Kinshasa, Faculty of Medicine, Kinshasa,  \nDemocratic Republic of the Congo \n5Department of Surgery, Department of Laparoscopic Visceral Surgery, HJ Hospital, Kinshasa, Democratic Republic of the Congo \n6Department of Anesthesia and Resuscitation, University Clinics of Kinshasa, Faculty of Medicine, Kinshasa,  \nDemocratic Republic of the Congo \n7Department of Internal Medicine, University Clinics of Kinshasa, Faculty of Medicine, Kinshasa, Democratic Republic of the Congo \n8Department of Gynecology and Obstetrics, Tenon Hospital, Sorbonne University, Paris, France \n \n \n \nAbstract \nContext: Endometriosis is a pathology that directly affects the daily lives of \nwomen with frequent impairment of their quality of life. In our environment, \nmedical, socio-cultural, financial factors and factors related to the organiz a-\ntion of the health care system greatly delay its diagnosis. The objectives of the \npresent study were to determine the diagnosis delay and to assess the quality \nof life before surgery of women with endometriosis using the specific Endo-\nmetriosis Health Profile 5 (EHP-5) questionnaire. Methods: We carried out a \ndescriptive, observational, retrospective study in 8 medical centers in the City \nof Kinshasa, from January 2019 to October 2022. A total of  80 women with \nendometriosis confirmed by laparoscopy (16 diagnostic and 64  operative la-\nparoscopies) and histopathology were interviewed. We used the revised \nAmerican Society for Reproductive Medicine (rASMR) classification, the  En-\nHow to cite this paper: Sibo, M., Esimo, \nM., Lobota, M., Monka, I., Kayembe, K.K., \nGrace, T., Kevine, S., Patrick, M., Kabuya, \nN., Naomie, A., Fastrez, M., Ikoko, B., Ally, \nN., Georges, S., Berthe, B., Pita, M., Mbe n-\nza, L., Ferrier, C . and Darai, E. (2023) Di-\nagnosis Delay and Assessment of the Qua l-\nity of Life of Patients with Endometriosis \nUsing the Endometriosis Health Profile 5 \nQuestionnaire in a Sub-Saharan Popul a-\ntion. Open Journal of Obstetrics and G y-\nnecology, 13, 907-917. \nhttps://doi.org/10.4236/ojog.2023.135078 \n \nReceived:  April 24, 2023 \nAccepted: May 28, 2023 \nPublished: May 31, 2023 \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 908 Open Journal of Obstetrics and Gynecology \n \ndometriosis Fertility Index (EFI) score was calculated for infertile women and \nthe EHP-5 questionnaire to assess quality of life. Our data was entered and \nanalyzed using Statistical A nalysis Software 16.1 (STATA 16.1). Results: Di-\nagnosis delay of endometriosis was on average 12 ± 4.3 years. The overall \nmean EHP-5 score of all patients showed a severe det erioration in quality of \nlife (604 ± 235). A neg ative relationship was observed between the age of the \npatient, the diagnostic delay, and the alteration of the quality of life in p a-\ntients over 36 years old and those with about 11 years of diagnostic delay \npresenting the slight alteration. Patients with a high social level had very s e-\nvere quality impairment. Women on hormonal treatment, those with a hist o-\nry of pregnancy, childbirth, miscarriage and abortion had a slight and signi f-\nicant deterioration in quality of life (p  < 0.05). Conclusion: Despite some li-\nmitations, our preliminary study highlights that in sub -Saharan Africa, the \ndiagnosis of endometriosis is delayed and asso ciated with a severe alteration \nin quality of life. Moreover, diagnosis of endo metriosis seems to be restricted \nto wom en with high social level s. Therefore, further efforts are required to \ndevelop a health policy to decrease delay for d iagnosis with potential benefits \non symptoms, quality of life, fertility while limiting stigma and psych ological \neffects of this debilitating pathology. \n \nKeywords \nDiagnosis Delay, EHP-5, Endometriosis, Quality of Life, Sub-Saharan \n \n1. Introduction \nEndometriosis is a chronic gynecological disease characterized by the presence \nof endometrial-like tissue outside the uterus [1]. Although diagnosis of endome-\ntriosis is mainly suggested in women with dysmenorrhea, dyspareunia, chr onic \npelvic pain and infertility, recent European Society of Human Reproduction and \nEmbryology (ESHRE) recommendations emphasize the need to evoke the dia g-\nnosis for less specific symptoms beyond the genital sphere, in particular back \npain, digestive disorders or even chronic asthenia, posing the concern on the \nfeasibility of various investigations to assess the diagnosis , especially in develop-\ning countries [2] [3] [4] [5]. \nEndometriosis is thought to affect 190 million women worldwide [1] with an in-\ncidence of 2% to 10% of women of childbearing age [1] [2]. This incidence reaches \n12% to 45% in infertile women [6] [7]. However, it should be emphasized that these \nepidemiological data emanate from developed countries benefiting easily from ad-\nvanced imaging modalities (transvaginal ultrasound and MRI) [8]-[12]. Conversely, \nin sub-Saharan countries, diagnostic tools for endometriosis are more limited thus \nexplaining the insufficient epidemiological data, especially on diagnostic delay, im-\npact on quality of life and fertility management [4] [9]-[13]. \nA recent study suggests the contribution of specific questionnaire s to as sess \nthe diagnosis of endometriosis, ESHRE guidelines underline their limited value  \nCopyright © 2023 by author(s) and  \nScientific Research Publishing Inc. \nThis work is licensed under the Creative \nCommons Attribution International  \nLicense (CC BY 4.0). \nhttp://creativecommons.org/licenses/by/4.0/  \n  \nOpen Access\n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 909 Open Journal of Obstetrics and Gynecology \n \n[4]. Moreover, due to limited availability of imaging techniques in developing \ncountries, the diagn osis of endometriosis is still made during surgery for pain \nand/or infertility in women with advanced stages and severe alteration of quality \nof life (QOL). In this specific setting, previous studies have reported the contr i-\nbution of non-specific (SF-36) and specific endometriosis questionnaires (EHP-30 \nand EHP-5) to assess QoL [14]-[18]. \nTherefore, the objectives of the current preliminary study were to determine, \nin a sub -Saharan population, the time to diagnosis and the evaluation of the \nquality of life using the EHP -5 questionnaire in women with endometriosis \nproven by surgery and histology. \n2. Material and Methods \n2.1. Selection of Participant \nWe carried out a descriptive, observational, and retrospective study in 8 medical \ncenters in the City of Kinshasa (CPUA, OMC, CUK, Edith Medical, HJ Hospital, \nClinique Diamant, Cl inique Médecin de Nuit and Clinique Dr . Lipombi); from \nJanuary 2019 to October 2022 including 80 women with endometriosis co n-\nfirmed by laparoscopy and histology were interviewed. \nAll the women completed symptom questionnaires on gynecological (dysm e-\nnorrhea, non-menstrual pelvic pain and dyspareunia), digestive (diarrhea and/or \nconstipation, pain on bowel movement, intestinal cramping, pain on defecation, \ntenesmus and cyclic rectal bleeding) and non- specific symptoms (lower back \npain and asthenia), epidemiological characteristics as well as prior medical trea t-\nment and surgery. \nAll the women completed the EHP -5 composed of 11 questions. First five \nquestions address pain, control and helplessness, emotional well -being, social \nsupport, and self-image. The remaining six questions evaluate the impact on work, \nrelationships with children, sexual relationships, and feelings about the medical \nprofession, treatment, and infertility. Patients are asked to answer questions and \nrate their quality of life based on the past four weeks. \nEach question is rated on a scale of 5 (never = 1; rarely = 2; sometimes = 3; often \n= 4; always 5). The score was calculated by summing the responses to the eleven \nquestions: never = 0 points; rarely = 25 points; sometimes = 50 points; often = 75 \npoints; always = 100 points. The scores can therefore range from 0 to 1100. The \nquality of life is perfect (score = 0), slight deterioration (0 < score ≤ 275), moderate \ndeterioration (275 < score ≤ 550), severe deterioration (550 < score ≤ 825) and very \nsevere alteration (825 < score ≤ 1100). The validated short version of EHP-5 ques-\ntionnaire was used. The validated French version of the Endometriosis Health Pro-\nfile-5 or EHP-5 corresponds to a short adaptation of the EHP-30. [17] \nAll patients were operated on by laparoscopy, including 16 diagnostic lap a-\nroscopies and 64 operative laparoscopies. Briefly, the laparoscopy was performed \nin the modified dorsolithotomy  position under endotracheal general anesthesia. \nProphylactic antibiotic therapy was given at the beginning of the operation except \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 910 Open Journal of Obstetrics and Gynecology \n \nfor diagnostic laparoscopy. After pneumoperitoneum induction, an umbilical 10 \nmm trocar was inserted for endoscope and two or three suprapubic 5 mm trocars. \nAfter exploration of the abdomino-pelvic cavity and adhesiolysis and resection of \nendometriotic lesions when required, the extent of the disease was evaluated using \nthe rASMR classification to stage the disease and the EFI score to evaluate the \nchance of spontaneous pregnancy after surgery. Histological criteria for endome-\ntriosis diagnosis included the presence of ectopic endometrial and stromal tissues. \nWe considered at a high socio-economic level any patient who fully supported \nthese treatment costs and at a low socio- economic level any patient who was \nunable to support herself and whose support was provided by social assistance \n2.2. Ethics Approval \nThe study was approved by the Ethics Committee of the School of Public Health \nof the University of Kinshasa according to the Declaration of Helsinki under \nnumber ESP/CE/187/2022. All patients signed informed consent. \n2.3. Statistical Analysis \nContinuous variables were c ompared with Student ’s t -test and categorical va-\nriables were compared with the χ2 test or Fisher ’s exact test, as appropriate. P \nvalues < 0.05 were considered statistically significant. STATA software (version \n16.1) was used for data analysis. \n3. Results \n3.1. Epidemiological and Socio-Economic Characteristics of the \nPopulation \nThe mean patients’ age was 33 ± 6.9 years (ranges: 20 to 47 years), and the mean \nBMI was 21.2 ± 4.04 Kg/m2. More than three-quarters of the population had uni-\nversity levels, 78% had a university level, 85% of the patients had a high economic \nlevel. One-quarter of the population had sport activity with an average of 5.8 hours \nper week. Forty -one percent of our patients consumed an average of 196 cubic \ncentimeters of alcohol per day (mostly ethanol) and smoking was observed in 16% \nof the population. History of depression, pregnancy, abdominal surgery and family \nhistory of first-degree dysmenorrhea accounted for 13%, 68%, 59% and 24% r e-\nspectively. In our series, 50% consulted for a desire to conceive. \n3.2. Symptoms and Pre-Operative Examinations of the Population \nThe average diagnostic delay was 11.8 ± 4.8 years. The main frequent symptoms \nsuggestive of endometriosis were dysmenorrhea (81%), chronic pelvic pain \n(70%), deep dyspareunia (64%)  and infertility (50%). Although half of the p a-\ntients had infertility, 68% of the population had a history of pregnancy. More o-\nver, about half of the patients had a history of abortion. It is interesting to note \nthat one-third of the patients had normal clinical examinations. Only two-thirds \nof the patients underwent a transvaginal sonography wh ile MRI was performed \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 911 Open Journal of Obstetrics and Gynecology \n \nin 71% of the patients allowing the diagnosis of endometriosis in 91% of them. \nThe clinical and paraclinical characteristics are listed in Table 1 . \n3.3. Surgical Characteristics, rASMR Stages and EFI Score of  \nthe Population \nAll the patients underwent a laparoscopy including 80% operative and 20% d i-\nagnostic laparoscopy. The diagnosis of endometriosis was confirmed histologically  \n \nTable 1 . Clinical and paraclinical characteristics. \nVariables  Population (n  = 80) \nDuration of complaint (year ± sd)  11.8 (±4.3)  \nAge at first menstruation (year ± sd)  10.8 (±1.6)  \nClinical manifestations  \n• Dysmenorrhea \n• Deep dyspareunia \n• Dyschesia \n• Dysuria \n• Pelvic pain \n• Metrorrhagia \n• Infertility \n \n81% \n64% \n38% \n23% \n70% \n49% \n50% \nPresence of endometriosis  \nOn clinical examination  \n• Normal \n• Adnexal mass \n• Deep pelvic endometriosis \n• Adnexal mass and Deep pelvic endometriosis \nOn Transvaginal ultrasonography  \n• Normal \n• Endometrioma \n• Deep pelvic endometriosis \n• Adnexal mass and Deep pelvic endometriosis \n \n \n36% \n34% \n11% \n19% \n \n21% \n38% \n18% \n23% \nEndometriosis on MRI  \n• Not done \n• Normal \n• Superficial peritoneal endometriosis \n• Endometrioma \n• Deep pelvic endometriosis \n• Endometrioma and deep pelvic endometriosis \n \n29% \n4% \n11% \n28% \n16% \n12% \nOngoing treatment  \n• Hormonal contraception \n• Hormonal IUD \n \n14% \n10% \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 912 Open Journal of Obstetrics and Gynecology \n \nin all the patients. \nMost of the population had a stage III- IV rASRM stages. EFI score was ev a-\nluated for the 40 patients wishing to conceive. The majority of our patients had \nan EFI score between 4 and 6. These results can be found in Table 2 . \n3.4. Quality of Life (QoL) of the Population Using EHP-5 \nUsing the EHP-5 questionnaire, the mean QoL score was 604 ± 235. The distr i-\nbution of the patients according to QoL quartile is given in Table 3 . Relations be-\ntween epidemiologic, economic and symptoms and EHP-5 score are summarized  \n \nTable 2 . Description of surgical parameters. \nVariables  Population (n  = 80) \nType of surgery  \n- Diagnostic laparoscopy \n- Therapeutic laparoscopy \n• Electro-coagulation of peritoneal lesion \n• Salpingectomy \n• Unilateral ovarian cystectomy \n• Bilateral ovarian cystectomy \n• Torus resection \n• Uterosacral ligament resection \n• Ureterolysis \n• Colpectomy \n• Bowel resection \n \n20% \n14% \n \n9% \n12% \n26% \n19% \n21% \n5% \n16% \n11% \nrASRM stage  \n• I and II \n• III and IV \n \n38% \n62% \nEFI score (n  = 40) \n• (0 - 3) \n• (4 - 6) \n• (7 - 8) \n• (9 - 10) \n \n20.0% \n47.5% \n22.5% \n10.0% \n \nTable 3 . Distribution of the QoL of the population according to EHP-5. \nEHP-5, mean score (±sd)  604 (±235)  \nQuality of Life/EHP -5 Score  \n- Perfect (score = 0) \n- Slight alteration (0 < score ≤ 275) \n- Moderate alteration (275 < score ≤ 550) \n- Severe impairment (550 < score ≤ 825) \n- Very severe alteration (825 < score ≤ 1100) \n \n0 \n11% (n = 9) \n34% (n = 27) \n37% (n = 30) \n18% (n = 14) \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 913 Open Journal of Obstetrics and Gynecology \n \nin Table 4 . A negative relationship was observed between the age of the patient, \nthe diagnostic delay and the deterioration of the quality of life in patients over 36 \nyears old and those with about 11 years of diagnostic delay presenting the slight \nalteration. Patients with a high social level had very severe QoL impairment. \nWomen on hormonal treatment, those with  a history of pregnancy, childbirth, \nmiscarriage and abortion had a slight deterioration in quality of life. \n4. Discussion \nThe present retrospective study was to evaluate epidemiologic, socio -economic, \nand quality of life of patients with endometriosis in the context of a sub-Saharan \ncountry underlining the limits of the health care system. \nAlthough our population corresponds mainly to women with high economic \nand educational attainments, it is interesti ng to note that the delay in diagnosis \nis well over eleven years although most of the patients exhibited symptoms su g-\ngestive of endometriosis such as dysmenorrhea, chronic pelvic pain, deep dy s-\npareunia and infertility. Indeed, our delay in diagnosis of 11 years contrasts with \nthose reported in USA (4.4 years) and between 7 and 9 years in France [14]-[18]. \n \nTable 4 . Relation between epidemiologic, economic and symptoms and EHP-5 score. \nVariables  \nAlteration quality of life  \np-value  \nMild Moderate  Severe  Very Severe  \nAge 36 (6.8) 36 (5.6) 31 (7.0) 31 (6.3) <0.05* \nComplaint duration 10.6 (2.0) 13.3 (5.2) 12.1 (3.8) 9.1 (3.0) <0.05* \nMarried status 78% 70% 50% 50% 0.24 \nUniversity level 89% 78% 77% 71% 0.81 \nHigh social level 89% 70% 90% 100% 0.05* \nSports practice 22% 26% 27% 21% 0.98 \nDysmenorrhea 67% 85% 83% 79% 0.64 \nDyspareunia 56% 52% 73% 71% 0.33 \nDyschesia 22% 33% 43% 43% 0.64 \nDysuria 22% 11% 30% 29% 0.35 \nPelvic pain 67% 70% 67% 79% 0.87 \nMetrorrhagia 33% 52% 53% 43% 0.70 \nInfertility 56% 44% 50% 57% 0.87 \nHormonal treatment 67% 56% 10% 7% <0.05* \nPregnancy history 100% 93% 53% 29% <0.05* \nHistory of childbirth 100% 93% 53% 29% <0.05* \nHistory of miscarriage 22% 37% 7% 7% <0.05* \nAbortion history 56% 56% 47% 29% 0.40 \n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 914 Open Journal of Obstetrics and Gynecology \n \nThis apparent discrepancy can be explained by the fact that no  abnormality at \nclinical examination was observed in one -third of the patients in our study. \nMoreover, even after transvaginal sonography, the diagnosis of endometriosis \nwas considered in only two -thirds of the patient. All these data suggest that \npractitioners are insufficiently aware of the disease thus efforts must be made to \nimprove not only medical awareness but also socio -cultural and financial factors \nin the health care system in our environment contributing to delayed diagnosis, \nAlso, the availability of a new test based on the expression of miRNAs in the sa-\nliva of endometriosis patients could be a good option to overcome the diagnosis \ndelay of endometriosis but raises the issue of its cost especially in developing \ncountries. \nThe normalization of pain by patients and by professionals during menstru a-\ntion and/or during sexual intercourse, the various taboos such as sexuality, men-\nstruation and the female body, the discrediting of women’s words; the causes ex-\nplained by religion as the suffering and punishment of original sin; sexist prej u-\ndices explaining the fact that women are less well cared for and under -diagnosed \ncompared to men. We believe that raising awareness on the enhancement of \nwomen’s rights and gender equality should be encouraged to awaken  women in \nour community. This would contribute to reducing the diagnostic delay in our \nenvironment. \nQoL is a crucial concern for patients with endometriosis and practitioners and \ninterventions should be tailored accordingly depending on each patient ’s needs. \nIn our s eries, the average EHP -5 score showed a severe deterioration in quality \nof life. To our knowledge, the current study is the first to evaluate QoL in p a-\ntients with a validated questionnaire in a sub-Saharan population. We opt to use \nthe EHP-5 questionnaire, a validated short version of the EHP -30 questionnaire \nexhibiting the same picture of health items but with less restrictive to complete  \n[18]. Moreover, the simplicity and relevance of the EHP -5 questionnaire has \nbeen proven to assess the QoL of patients with endometriosis representing an \nadequate tool to assess the impact of medic al and surgical management  [2] [19] \n[20]. In addition, we demonstrated the relation between the degree of QoL alt e-\nration with some characteristics such as an inverse correlation with the age of \nthe patients. Indeed, patients over 36 years  old had a slight alteration compared \nto younger patients. Similarly, we observed that patients with history of labor \nhad a lower impact on QoL. This agrees with a previous multicentric intern a-\ntional study evaluating the QoL using SF -36 questionnaire in patients with col o-\nrectal endometriosis showing that patients with previous childbirth or without \ninfertility had a better QoL , especially concerning the Mental Component Su m-\nmary (MCS). On the other hand, we noted that women with a high s o-\ncio-economic level presented a very severe alteration in the quality of life. this \ncould be explained by the fact that these groups of patients have access to care \nbecause they have financial means, but unfortunately , they consulted several \ndoctors who could not find a solution to their solution on the grounds that there \nwas no precise diagnosis whereas these patients had signs suggestive of the di s-\n\nM. Sibo et al. \n \n \nDOI: 10.4236/ojog.2023.135078 915 Open Journal of Obstetrics and Gynecology \n \nease so most of them were thrown into the beliefs that it was a curse. We must \nalso emphasize that beyond the severity of the  symptoms, it is important to con-\nsider all the epidemiological characteristics of the patients. \nThe EFI score was developed as a reproductive tool to predict the likelihood of \nspontaneous conception after surgery for infertile patients with endometriosis  \n[20]-[24]. Our results go hand in hand with those found by Ferrier and collab o-\nrators, we all note that the EFI score 4 to 6 were the most found in our studies \nand this reinforces the orientation of inf ertile patients with endometriosis t o-\nwards medically assisted procreation whose cost is already very high and less a c-\ncessible in our environment not only for financial constraints but also and above \nall a lack of technical support for medically assisted procreation. \nSome limitations of this study are worth highlighting. First, the retrospective \nnature of the study may be a source of bias. Patients’  answers regarding their \nquality of life before the procedure cannot be as precise as would be desirable, as \nit depends entirely on the patients ’ recollection over a variable time scale. Ho w-\never, we believe this is offset by the fact that people with chronic pain, including \nendometriosis, usually live with their condition for long periods of time and \ntherefore tend to have a clear idea of the nature of their symptoms . Second, the \nsmall sample size is also a potential bias. However, our goal was to have a h o-\nmogeneous population with the diagnosis of endometriosis assessed not only on \nsymptoms or imaging criteria but by systematic laparoscopy although Pascoal et \nal. pointed out that they found that the respective sensitivity and specificity of \nlaparoscopy are 90 % - 94% and 40%  - 79% justifying, as in the current study, \nhistological confirmation  [25]. Finally, no attempt was made to evaluate the \nchanges in QoL after operative laparoscopy while previous studies have reported \non the relevance of QoL questionn aire post treatment to evaluate if patients had \nimprovement in their quality of life after treatment  [19]. Despite some limit a-\ntions of the present study, its stren gth is that it will create a national awareness \nof the problems of endometriosis and therefore lead to system wide changes that \nwill improve the care of women with endometriosis in sub-Saharan Africa. \n5. Conclusion \nDespite some limitation s, our preliminary study highlights that in sub -Saharan \nAfrica, the diagnosis of endometriosis is delayed and associated with a severe a l-\nteration in quality of life. Moreover, diagnosis of endometriosis seems to be r e-\nstricted to women with high social level s. Therefore, further efforts are required \nto develop a health policy to decrease delay for diagnosis with potential benefit s \non symptoms, quality of life, fertility while  limiting stigma and psychological ef-\nfects of this debilitating pathology. \nConflicts of Interest \nThe authors declare no conflicts of interest regarding the publication of this p a-\nper. \n\nM. 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