{"paper_id":"f124aafc-1cce-4ba8-a2c7-5f19f363e92c","body_text":"Women's Reproductive Health\nISSN: 2329-3691 (Print) 2329-3713 (Online) Journal homepage: www.tandfonline.com/journals/uwrh20\nBuilding Bridges: Enhancing Diagnosis and Care\nfor Endometriosis Across the Primary-Secondary\nCare Continuum\nBabu Karavadra, Rebecca Mawson, Sharon Dixon, Ulrik Bak Kirk & Andrew\nW. Horne\nTo cite this article: Babu Karavadra, Rebecca Mawson, Sharon Dixon, Ulrik Bak Kirk & Andrew\nW. Horne (09 Sep 2025): Building Bridges: Enhancing Diagnosis and Care for Endometriosis\nAcross the Primary-Secondary Care Continuum, Women's Reproductive Health, DOI:\n10.1080/23293691.2025.2540344\nTo link to this article:  https://doi.org/10.1080/23293691.2025.2540344\n© 2025 The Author(s). Published with\nlicense by Taylor & Francis Group, LLC.\nPublished online: 09 Sep 2025.\nSubmit your article to this journal \nArticle views: 1240\nView related articles \nView Crossmark data\nCiting articles: 1 View citing articles \nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=uwrh20\n\nWomen's RepRoductive HealtH\nBuilding Bridges: Enhancing Diagnosis and Care for Endometriosis \nAcross the Primary-Secondary Care Continuum\nBabu Karavadra a , Rebecca Mawson b , Sharon Dixon c , Ulrik Bak Kirk d  and  \nAndrew W. Horne e \nadepartment of p rimary c are and m ental Health, university of liverpool, liverpool, uK; bschool of m edicine and p opulation \nHealth, university of sheffield, sheffield, uK; cnuffield d epartment of p rimary c are Health s ciences, university of o xford, \no xford, uK; dResearch unit for General p ractice and d epartment of p ublic Health, a arhus university, a arhus, d enmark; ecen\ntre for Reproductive Health, i nstitute for Regeneration and Repair, university of e dinburgh, e dinburgh, uK\nABSTRACT\nEndometriosis affects approximately 10% of women of reproductive age worldwide. \nJourneys to diagnosis can be complex, with an average of 9 years between development \nof symptoms and diagnosis, which has not improved despite guidance and policy \nfocus. Learning how to reduce this time was identified as a James Lind Alliance Top Ten \nresearch priority. There are well-documented challenges throughout care journeys for \npeople with known or possible endometriosis. Endometriosis can be associated with \nsymptomatic impacts throughout the life course and across body systems, and support \nnecessitates holistic attention to these. This opinion piece explores community-based \nsupport opportunities, advocating for a collaborative, cohesive approach among \nprofessionals. Endometriosis is a chronic condition, with treatment often extending \nacross primary and secondary care for several years. Inequalities in care for endometriosis \nare evident, whether that be due to geographic variation in provision of specialist \ncenters or racial disparities in diagnosis rates. Deprived communities also face lower \nreferral rates and subsequent lower specialist diagnosis. The persistent focus of research \non secondary care drives these inequalities as those unreferred and undiagnosed \nwomen are left unaccounted for within the endometriosis sphere. The role of primary \ncare as advocates and enablers of these women is pivotal in reducing inequity of care. \nSmoother journeys for people living with endometriosis are urgently needed and we \nneed to build bridges between our services to enable this to happen.\nIntroduction\nEndometriosis affects approximately 10% of women of reproductive age worldwide (Giudice, 2010). \nJourneys to diagnosis can be complex, with an average of 9 years between development of symptoms \nand diagnosis, which has not improved despite guidance and policy focus. Learning how to reduce \nthis time was identified as a James Lind Alliance Top Ten research priority (Horne et  al., 2017). \nThere has rightly been a focus on the complexities associated with diagnostic processes and journeys \nin endometriosis. The focus on diagnosis is seen as pivotal to enabling evidence-based care but risks \npositioning diagnosis as an endpoint of a care journey, and not a point along it (Simoens et  al., \n2012; Staal et  al., 2016). People with known, confirmed, possible or suspected endometriosis may \nexperience symptoms and care needs which precede, follow or span the time of diagnosis. There are \nwell-documented challenges to and through care journeys for people with known or possible \nendometriosis.\nA holistic, life-course approach is vital, as endometriosis affects various aspects of life, from phys -\nical and mental health to social well-being and daily function (Maindal et  al., 2025). Warzecha et  al. \n(2020) found that endometriosis can cause significant psychological distress, including depression and \n© 2025 t he a uthor(s). p ublished with license by taylor & Francis Group, llc.\nCONTACT Babu Karavadra  b.karavadra@nhs.net  d epartment of p rimary c are and m ental Health, university of liverpool, liverpool, uK.\nhttps://doi.org/10.1080/23293691.2025.2540344\nt his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution license ( http://creativecommons.org/licenses/by/4.0/ ), which \npermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. t he terms on which this article has been \npublished allow the posting of the a ccepted m anuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nReceived 30 a pril 2025\nRevised 10 July 2025\na ccepted 23 July 2025\nKEYWORDS\nprimary care; inequalities; \nendometriosis; general \npractice\n\n2 B. KARAVADRA ET AL.\nanxiety (Warzecha et  al., 2020). Similarly, Culley et  al. highlighted its social and psychological impacts \n(Culley et  al., 2013). This is a strength of primary care, from which specialists could benefit.\nThe 2024 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report re-frames \nendometriosis as a chronic condition, which can be associated with symptomatic impacts throughout \nthe life course and across body systems (Aleboyeh et  al., 2024). The NCEPOD report was produced \nusing case report review combined with organization, clinician and patient surveys (in England). Holistic \nsupport necessitates personalized attention to all of these. This represents an opportunity for partner -\nship; primary care has expertise and experience in holding support for people living with complex and \nlong-term conditions, during and in between episodes of specialist care input. The NCEPOD report \nhighlights the impact of the need for repeated re-referrals into specialist care for advice or treatment, \nonce a diagnosis has been ascertained, each of which are associated with potential delays to care.\nWe believe that patients with endometriosis deserve a collaborative, cohesive approach among \nprofessionals, from primary care through to specialist care. Bridges between primary and specialist \ncare silos will enable the smoother passage of patients and will also offer potential benefits for cli -\nnicians (Dixon et  al., 2024). Recognizing and valuing the skills and expertise held across settings will \nfoster collaborative multi-disciplinary care and enable bi-directional learning. This includes, for example, \nprimary care research and expertise in supporting people with unexplained symptoms and pain, in \nexploring the impacts of access to care on diagnosis and researching and mitigating health inequities.\nInequalities in care for endometriosis are evident, whether that be due to geographic variation in \nprovision of specialist centers or racial disparities in diagnosis rates. There is an inverse care law at \nplay in endometriosis (Hart, 1971): deprived communities face lower referral rates and subsequent \nlower specialist diagnosis, within a context of greater multimorbidity and lesser access to primary \ncare. The 2024 Office of National Statistics (ONS) report “Characteristics of women with an endo -\nmetriosis diagnosis in England March 2011-December 2021” demonstrates vividly the impact of socio \ndemographic characteristics on the likelihood of receiving a diagnosis, with lower diagnosis rates in \nthe most deprived areas, and variance by documented ethnicity (Office for National Statistics, 2024). \nThe persistent focus of research within secondary care, or only with those who have successfully \nnavigated access to a diagnosis, exacerbates these inequalities because un-referred and undiagnosed \nwomen are left unaccounted for within the endometriosis evidence sphere. The role of primary care \nas advocates and enablers of these women is pivotal in reducing inequity of care.\nIn the UK, a two-tier system exists, where some areas only have access to generalist gynecology \nwhile specialist centers provide care for a minority (De Silva et  al., 2024). This influences both access \nto diagnosis and access to specialist care. Furthermore, there is an additional two-tiered system, which \nis rapidly growing in a context of NHS waiting lists (longest for gynecology), creating a barrier \nbetween those who can pay for care (and a diagnosis) and those who cannot. This was evident in \nthe NCEPOD report in which 28% of people identified with confirmed or known endometriosis had \naccessed private care (Aleboyeh et  al., 2024). The ONS report also noted lower rates of NHS hospital \ndiagnoses of endometriosis in the least deprived areas, thought to reflect this greater use of private \nhealthcare.\nIn this article, we consider opportunities for enhanced collaboration within the United Kingdom \n(UK) National Health Service (NHS) along the care journey, to diagnosis and beyond. People living \nwith endometriosis (both possible and recognised) need and deserve smoother care journeys. Delivery \nof endometriosis care requires communication and coordination between all those involved along the \nwhole care pathway. Improving care journeys could be enabled by recognizing and breaking down \nthe current silos in care and by building bridges between them.\nWe argue that achieving this is a collective responsibility, shared by all who deliver any aspect of \nendometriosis care or research, and which requires services and systems to work collaboratively and \ncohesively, underpinned by mutual respect and understanding.\nSection 1: Opportunities for Bridge Building along Diagnostic Journeys\nThe complex journeys to receiving a diagnosis are well-documented. Improving time to diagnosis of \nendometriosis is a stated aim of the Women’s Health Strategy for England (Department of Health & \n\nWoMEn' S REpRoDUc TIVE HEALTH 3\nSocial Care, 2022). However, knowing how to operationalize improvements effectively requires an \nunderstanding of how diagnostic journeys unfold, and the identification of opportunities for inter -\nvention throughout them. This includes recognizing the complex reality of care journeys and healthcare \nsystems, and consideration of potential inequities that can arise along them. We need to be \ninter-disciplinary and inter-sectional. We have much to learn from the women who have endometriosis \nsymptoms but are not diagnosed or do not successfully navigate healthcare systems, as they represent \na critical unmet need. Doing this will require cross-sector cohesion and collaboration. General prac -\ntitioners (GP) hold care for those who are and are not diagnosed with endometriosis (Burton et  al., \n2017; Dixon et  al., 2021). Their insights and advocacy can contribute significantly in this space, \nalthough it is women’s voices we most need to gather and hear. Counting the people who we do not \nsee in our clinics (and who are therefore not included in research) is harder than counting those we \nsee – but is crucial. Research that only includes those with a diagnosis is critically valuable but may \nnot help us answer questions about inequity and underrepresentation. Primary care is often concep -\ntualized as a bottleneck in diagnostic journeys, with lack of awareness, the suggested underlying \nmechanism, which can be fixed with education. However, evidence suggests that while this is welcome \nand essential, it needs to recognize the reality of GPs work and considerations (Dixon et  al., 2024).\nThe lack of a noninvasive diagnostic test for endometriosis means that attaining a diagnosis neces -\nsitates a process of clinical assessment in primary care. This process is often followed by a guideline \nsanctioned trial of treatment and initial ultrasound scan followed by review of the outcome of these. \nIf these are not effective, tolerated or acceptable, then referral to secondary care is advised for a \nrepeated clinical assessment, and referral for further investigations followed by review as the minimum \npathway steps, all of which have the potential to contribute an accumulation of time to what is \nconceptualized as the diagnostic journey. This also leaves open a critical uncertainty about ongoing \ncare when the initial trial of treatment is (or is understood to be) effective in ameliorating symptoms. \nRecognizing the potential nuance here, it is worthy of reflection that the management sanctioned as \nsymptomatic trials of treatment in guidance are the same options used as first-line choices when \nendometriosis is diagnosed, which risks a paradox (Dixon et  al., 2021, 2024).\nFor those who attain a diagnosis of endometriosis, there are well-documented benefits, which must \nnot be underestimated. These include access to evidence-based treatments, both medical and surgical. \nSeveral studies have found that hormonal treatment in particular is associated with a greater improve -\nment in health-related quality of life outcomes, although we note that this is often effective for those \nwith symptoms aligned to endometriosis or without a diagnosis (Souza et  al., 2011; Tripoli et  al., \n2011). However, the shared decision making process is informed by knowledge of the diagnosis and \nattendant focussed evidence.\nWomen who are identified as having deep disease, might be offered treatment in a specialized \ncenter that offers advanced endometriosis surgery and access to specialist pain services, although it \nhas been argued that consideration should be given to expanding holistic support to all with impactful \nsymptoms, whether their endometriosis is categorized as deep or superficial, noting the heterogeneity \nof the association between categorization and symptomatic impact (De Silva et  al., 2024).\nA diagnosis of endometriosis can be experienced as something which legitimizes women’s symptoms \nand allows them to seek the respective support for their condition, whether this be professionally \nvia medical practitioners or through their employer for work-based adjustments (Ballard et  al., 2006). \nIn addition, a diagnosis allows women to have a common language in which they can express the \nimpact of their symptoms to other people and therefore find ways of coping with them (Ballard \net  al., 2006). Primary research has consistently shown that work-related productivity and employment \nis also negatively impacted for those women with endometriosis (Hansen et  al., 2013; Moradi et  al., \n2014; Nnoaham et  al., 2011); again, a diagnosis enables women to negotiate any workplace adaptations \nwith their employer as necessary. However, while diagnosis is constructed as necessary or helpful in \nnegotiating adjustments and support in the workplace, there is scope to reflect on this societal norm, \nincluding the potential for unintended impacts, such as the hierarchy of support predicated upon \ndiagnosis, but perhaps not on symptoms. This acts as a relentless driver toward the perceived necessity \nof diagnosis, which has impacts for those with symptoms without a confirmed or unifying diagnosis, \nincluding after investigations.\n\n4 B. KARAVADRA ET AL.\nWe note that these studies recruited women from specialist centers, and as GPs we see women \nwhose care remains with us, whether they receive a diagnosis of endometriosis or not. Consideration \nand care need to be given to the support and legitimacy of all of these women. We can be mindful \nin our rhetoric to ensure that we do not inadvertently delegitimise chronic pelvic pain syndrome.\nThe barriers to a timely diagnosis are complex. In a healthcare system, which can be experienced \nas complex to navigate and appear fragmented, collaborative working between primary and secondary \ncare specialists can be challenging but is essential. Patient, healthcare professional related and health -\ncare structure-related factors all contribute to a delay in diagnosis, akin to those seen in cancer \ndiagnosis (Dixon et  al., 2021; Olesen et  al., 2009). These are structural or systemic barriers, and they \nrequire a structural response, which considers inequities within the inequity of care, and recognizes \nand responds to intersectionality. Interventions are often predicated upon single interactions, but \nthinking of care journeys as a process may offer value (Black et  al., 2023).\nSection 2: Inequities in Diagnosis, with Impacts on Access to Care\nThere are stark inequalities in diagnosis and management of endometriosis with evidence of inter -\nsectional accumulation, which creates overlapping discrimination and disadvantage. The lack of easily \naccessible noninvasive diagnosis compounds this by the need for access to secondary care services. \nThe inverse care law seemingly applies, both for access to primary care and to secondary care \n(Hart, 1971).\nClear racial disparities are present, with Black, Asian, and Minority Ethnic (BAME) women facing \nlonger delays and misdiagnoses. Evidence suggests Black women are 50% less likely to be diagnosed \nwith endometriosis than White women (Bougie et  al., 2019). In the United States, Black women \naccount for around 5% of diagnosis, with 72% being White women (Christ et  al., 2021). Y et, there \nis no evidence that White women are more likely to have endometriosis (Bougie et  al., 2022). There \nare likely to be multiple mechanisms for this inequality, but the long shadow of racist myths about \nbiological pain thresholds for Black women is a likely contributory factor. Normalization of pain and \nhow pain is perceived cause unacceptable healthcare delays in surgery and diagnosis. Research par -\nticipation also has potential to worsen disparities, with the lack of diversity in studies leading to \nguidelines developed for predominantly White heterosexual women through the lens of secondary \ncare (Khan et  al., 2024).\nWhere you live also factors into inequalities with geographic disparities in access to primary and \nsecondary care. A population-based Spanish study showed those in rural areas have lower rates of \ndiagnosis of endometriosis, even when removing deprivation as a cofounding factor (Medina-Perucha \net  al., 2022). Similarly, a Danish study revealed significant regional differences in the incidence of \nhospital-diagnosed endometriosis (Illum et  al., 2022), even though another study found no major \nregional differences in endometriosis symptoms and indicators (Josiasen et  al., 2025). The availability \nof specialist endometriosis centers may impact on management, particularly in those with severe \nendometriosis who are often managed by general gynecologists when there is no tertiary referral \ncenter (NHS England, n.d.).\nHistorically, endometriosis was seen as a condition of White professional women (Bougie et  al., \n2022). This exemplifies how diagnosis can be affected by affluence, with those least deprived being \nmore likely to get referred and diagnosed (Medina-Perucha et  al., 2022). Those who can afford to \nsee specialists will be the ones who get the diagnosis. Even within the UK NHS setting where health -\ncare is universally accessible, disparities occur due to long waiting lists and poor access to specialist \ncenters leading to increase in private healthcare access (Aleboyeh et  al., 2024; Office of National \nStatistics, 2024). In the United States, those in the public health system were 3.5 times less likely to \nhave a laparoscopy and 2.7 times more likely to be prescribed opioids than those in the private sector \n(Fourquet et  al., 2019).\nThese disparities layer upon each other when we consider the impact of intersectionality, and how \nsome will be impacted by multiple disadvantages. When we consider women from Black, Asian and \nethnic minorities who live in deprived communities, the barriers can be insurmountable. This leads \nto a vicious cycle of detriment with the socioeconomic impact of endometriosis and the impact of \n\nWoMEn' S REpRoDUc TIVE HEALTH 5\nsymptoms on education, relationships, and social mobility. These communities get managed predom -\ninantly in the primary care setting, therefore, capturing the respective individuals for diagnosis early \nis key to preventing the growing gap in outcomes.\nSection 3: The Role of Primary Care in Addressing Inequities in Diagnosis of \nEndometriosis\nPrimary care functions as a gatekeeper to healthcare within many single-payer national health systems \nincluding UK, Netherlands, Spain, Italy, Australia, and New Zealand (Innocenti et  al., 2025). By \nmanaging referrals and triaging the health needs of the population, primary care provides a highly \ncost-effective model. Unfortunately, endometriosis presents a challenge as there is no universally \naccessible way to differentiate endometriosis from other conditions which may cause similar presen -\ntations (de Kok et  al., 2024).\nPrimary care has a central role in providing early identification and advocacy for women with \nsuspected endometriosis, but we lack the tools to be able to do this. In the UK setting, the gyne -\ncology waiting lists have doubled with around 600,000 women waiting to be seen (NHS England, \n2025). Raising awareness of endometriosis in primary care is only part of what will reduce delays; \neasy to use diagnostic techniques that do not require invasive testing via secondary care, and timely \naccess and liaison with secondary care specialists, both for initial referrals and the ongoing care \njourney is important.\nFor those living in areas of high deprivation, primary care can act as a bridge to reduce inequal -\nities and improve access to secondary care services. General practice has a legacy of research into \nhealth inequities and of considering how to act cohesively and structurally to consider, identify, and \nmitigate against these. Initiatives such as the Deep End movement (Watt, 2011), and the focus on \nhealth inequalities in general practice conferences are exemplars of areas where there is scope for \nbidirectional learning.\nThis is also of potential importance to endometriosis researchers. Tackling the well-documented \ninequities in endometriosis requires better representation in inclusion in trials and research. This \nrisks a paradox; recruiting participants with known endometriosis effectively acts in opposition to \nstudying those who have not been enabled to navigate care systems. Utilizing data routinely collected \nin primary care is a possible strategy to enhance representation, but this is subject to the same dif -\nficulty if we include those who have attained a diagnosis. Primary care data is not collected for \nresearch purposes, and research using these datasets are a good example of an area whereby collab -\norating on sensemaking about GP records and the dataset being used could enhance research.\nThe lack of funding for primary care, specifically for reproductive health conditions, risks depri -\noritising women’s health, however within this context, there is scope for active consideration of justice \nand equity (Kirk et  al., 2024). We need to create and use opportunities to recognize practices in high \ndeprivation areas and increase funding. The impact could be significant for those women who have \nthe greatest barriers to access, which could benefit both clinical care and research.\nAt times, the disconnect between primary care and secondary care professionals can fragment the \ndiagnostic journey. Although secondary care colleagues have their own service delivery challenges, it \nis key that specialists in secondary care further recognize the importance of primary care within the \nscope of endometriosis and endometriosis care. This includes our knowledge of our patients and our \ncommunities, and our role as enduring advocates throughout whole journeys, between sporadic and \nintermittent contacts with specialist care. Building bridges between primary and secondary care is \ncrucial to improve communication and relationships to ease the journey to diagnosis.\nSection 4: After Diagnosis: Collaborative Approaches for Holistic Ongoing Care\nOnce diagnosed, the management of endometriosis necessitates a multidisciplinary approach that \nintegrates primary and secondary care to provide comprehensive support to patients. Endometriosis \nis a complex condition that affects not only reproductive health but also physical and mental well-being, \nnecessitating the involvement of various healthcare professionals, including gynecologists, primary \n\n6 B. KARAVADRA ET AL.\ncare physicians, colorectal surgeons, urologists, pain specialists, radiologists, specialist nurses, psy -\nchologists, and physiotherapists (Omtvedt et  al., 2022). Without coordination, patients face fragmented \ncare, delayed diagnoses, and suboptimal treatment outcomes.\nA systematic review by Dancet et  al. emphasized that integrated care models, which include pain \nmanagement, psychological support, and physiotherapy, are critical for improving patient-centered \noutcomes in endometriosis care (Dancet et  al., 2014). O’Farrell et  al. emphasized the importance of \nmeasuring integrated care at the interface between primary and secondary care, indicating that effec -\ntive collaboration may lead to better health outcomes for patients (O’Farrell et  al., 2022).\nBreaking down silos between primary and secondary care is essential for enhancing the manage -\nment of endometriosis. Poor coordination often results in delayed diagnosis and treatment, worsening \nsymptoms and reducing quality of life (Dunlea et  al., 2023). Shared care pathways and interdisci -\nplinary meetings can align healthcare providers, enabling seamless, patient care (Warzecha et  al., \n2020). Furthermore, people are bounced between services, with frequent discharges from specialist \ncare back to primary care; further exacerbating the inequalities in access to healthcare for patients. \nThe NCEPOD report highlighted the impact of delays in referral and re-referrals, on experiences \nof care (Aleboyeh et  al., 2024). This fragmentation adds to the burden for people with endometriosis \nand for the GPs supporting them. Access to specialist input is difficult and this extends beyond \ndiagnosis.\nA holistic, life-course approach is vital, as endometriosis affects various aspects of life, from phys -\nical and mental health to social well-being and daily function (Maindal et  al., 2025). Warzecha et  al. \n(2020) found that endometriosis can cause significant psychological distress, including depression and \nanxiety (Warzecha et  al., 2020). Similarly, Culley et  al. highlight its social and psychological impacts \n(Culley et  al., 2013). This is a strength of primary care, from which specialists could benefit.\nBy adopting a coordinated approach that addresses the full spectrum of symptoms, healthcare \nproviders can ensure women receive personalized, comprehensive care. This fosters early inter -\nvention, improves symptom management, and enhances overall well-being of those affected by \nendometriosis.\nConclusion\nImproving experiences for people with known or suspected endometriosis requires consideration of \nthe whole care journey. It requires systems that help our patients navigate smooth and untroubled \npassage as they journey to and from between primary and secondary care. This holds equally true \nfor initial assessment and diagnosis and for onward care throughout the life course.\nWe argue that it is our collective responsibility to develop and nurture bridges between our care \nsettings, because if we do not, it is our patients who risk falling into the void. If we continue to \nfunction as disconnected sites, perhaps akin to gated cities—at either end of the bridge—with complex \ntolls or entry requirements to our zones, then it is our patients who will flounder. If we keep our \nwork apart in discreet silos, in our clinical work, our research, or our systems, then we miss out on \nopportunities to learn from each other and smooth the road. If we allow oppositional or divisive \ndiscourse, then we risk transitioning the bridge between care settings to one which effectively func -\ntions as a drawbridge, which can be pulled up and between sites of care. It is our patients who will \nfall into the moat, and together we must not allow that to happen.\nAcknowledgements\nSharon Dixon is supported by an NIHR Doctoral Research Fellowship.\nRebecca Mawson is an NIHR Academic Clinical Lecturer.\nBabu Karavadra is an NIHR Academic Clinical Fellow.\nThe views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of \nHealth and Social Care.\n\nWoMEn' S REpRoDUc TIVE HEALTH 7\nAuthor Contributions\nCRediT: Babu Karavadra : Conceptualization, Writing – original draft, Writing – review & editing; Rebecca \nMawson: Conceptualization, Writing – original draft, Writing – review & editing; Sharon Dixon: Conceptualization, \nWriting – original draft, Writing – review & editing; Ulrik Bak Kirk : Conceptualization, Writing – original draft, \nWriting – review & editing; Andrew W . Horne: Conceptualization, Writing – original draft, Writing – review & \nediting.\nDisclosure Statement\nAndrew Horne’s institution (University of Edinburgh) has received payment for consultancy and grant funding \nfrom Roche Diagnostics to assist in the early development of a blood diagnostic biomarker for endometriosis, and \nfurther received payment for consultancy fees from Gesynta and Joii. Andrew Horne has received payment for \npresentations from Theramex and Gedeon Richeter.\nUlrik Bak Kirk’s institution (Aarhus University) has received grant funding from the European Union’s Horizon \n2020 research and innovation program to coordinate the project Finding Endometriosis using Machine Learning \n(reference: FEMaLe/101017562).\nRebecca Mawson has received payment for consultancy from Roche Diagnostics to assist in the early develop -\nment of a blood diagnostic biomarker for endometriosis.\nSharon Dixon is an unpaid voluntary member of Endometriosis UK medical advisory panel.\nThe remaining authors have declared no competing interests.\nORCID\nBabu Karavadra  http://orcid.org/0000-0002-1625-9469\nRebecca Mawson  http://orcid.org/0000-0001-6377-6197\nSharon Dixon  http://orcid.org/0000-0002-7469-6093\nUlrik Bak Kirk  http://orcid.org/0000-0003-1683-2189\nAndrew W . Horne  http://orcid.org/0000-0002-9656-493X\nData Availability Statement\nData sharing is not applicable to this article as no new data were created or analyzed in this study.\nReferences\nAleboyeh, P ., Ellis, D., Freeth, H., Galea, S., Gomez, R., Hamilton, D’ , H., Koomson, M., Mahoney, N., Nwosu, \nE., Protopapa, K., Smith, N., & Warsame, A. ( 2024). National Confidential Enquiry into Patient Outcome and \nDeath (NCEPOD) - Improving the Quality of Healthcare Endometriosis: A Long and Painful Road . Available \nfrom: https://www.ncepod.org.uk/2024endometriosis/Endometriosis_A%20Long%20and%20Painful%20Road_\nfull%20report.pdf  [accessed July 2025].\nBallard, K., Lowton, K., & Wright, J. ( 2006). What’s the delay? A qualitative study of women’s experiences of \nreaching a diagnosis of endometriosis. Fertility and Sterility , 86(5), 1296–1301. https://doi.org/10.1016/J.\nFERTNSTERT.2006.04.054\nBlack, G. B., Lyratzopoulos, G., Vincent, C. A., Fulop, N. J., & Nicholson, B. D. ( 2023). 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International Journal of Environmental Research and Public \nHealth, 17(10), 3641. https://doi.org/10.3390/IJERPH17103641\nWatt, G. ( 2011). GPs at the deep end. British Journal of General Practice , 61(590), 549. https://doi.org/10.3399/\nbjgp11x593794","source_license":"CC0","license_restricted":false}