Racial and Ethnic Inequities in Rates of Diagnostic Laparoscopy for Evaluation of Endometriosis in Adolescents with Pelvic Pain: a Retrospective Cohort Study

Objective Endometriosis often presents in adolescence as chronic pelvic pain (CPP) or dysmenorrhea. Research in adults demonstrates non-White race is associated with delayed surgical diagnosis of endometriosis; however, inequity in adoles - cents has never been studied. We investigated inequities in laparoscopy rates among adolescents according to race, ethnicity, and socioeconomic status (SES).

We performed a retrospective cohort study of outpatient and operating room visits at a single academic medical center in the midwestern United States. Subjects were aged 10–21 who were seen by a gynecologic subspecialist between 2013 and 2023 for dysmenorrhea or CPP. Subjects with a previous diagnosis of endometriosis by prior laparoscopy or found to have an adnexal mass or cyst at the time of laparoscopy were excluded. Subjects were classified as non-surgical, undergo- ing scheduled laparoscopy, or undergoing emergent laparoscopy. Analyses used race, ethnicity, and SES data abstracted from the electronic health record.

Of 4,480 eligible subjects, 4,426 were expectantly managed, 47 underwent scheduled laparoscopy, and seven under- went emergent laparoscopy. Compared to White subjects, Black subjects were significantly less likely to receive any lapa - roscopy (OR 0.20, 95% CI 0.03–0.69, p = .010) or non-emergent surgery (OR 0.01, 95% CI 0.00-0.20, p < .001), and Asian subjects were less likely to undergo any laparoscopy (OR < 0.01, 95% CI 0.00-0.39, p = .009). Hispanic subjects were mar- ginally less likely to undergo scheduled laparoscopy (OR 0.19, 95% CI 0.01–1.16, p = .082) than non-Hispanic subjects.

This study identified inequities in rates of laparoscopy among adolescents, with surgery performed at lower rates for Black, Asian, and Hispanic subjects.

Adolescents · Chronic pelvic pain · Endometriosis · Diagnostic laparoscopy · Socioeconomic status · Racial and ethnic inequities Received: 10 September 2025 / Revised: 10 November 2025 / Accepted: 16 November 2025 © The Author(s) 2025 Racial and Ethnic Inequities in Rates of Diagnostic Laparoscopy for Evaluation of Endometriosis in Adolescents with Pelvic Pain: a Retrospective Cohort Study Lauren Capra1 · Kathleen E. O’Brien2 · Susan J. Woolford3,4 · Niko A. Kaciroti4,5 · Harlan McCaffery3 · Cheyney C. Dobson4 · Erin Isaacson2 · Monica W. Rosen2 1 3 Journal of Racial and Ethnic Health Disparities

Endometriosis is a chronic gynecologic disorder charac - terized by the presence of endometrial tissue implanted outside of the uterine cavity that may cause an array of symptoms including chronic pelvic pain (CPP), dysmen - orrhea, and subfertility. Studies have estimated the preva - lence of endometriosis at up to 15% of women of early reproductive age, with many patients endorsing symptom onset prior to age 15 [ 1]. While diagnostic laparoscopy and histologic examination is considered the gold standard for diagnosis of endometriosis, current clinical guidelines recommend conservative management with hormonal menstrual suppression before moving toward surgical investigation [ 2]. Although this approach to pelvic pain may be appropriate in adults with regular access to medical care, the same treat- ment strategy is not practical for adolescents, where severe symptoms may limit participation in school and social activities during a crucial time in development [ 1]. Recent studies suggest that adolescents may experience a diagnos - tic delay of approximately two years [3]. Historically, endometriosis was thought to occur in Black women at lower rates than in White women. Previ - ous literature on endometriosis has been heavily biased toward White and Asian patients due to the enduring belief that the condition is more common in these popu - lations [ 4]. However, endometriosis is one of the most common indications for Black women in the United States to undergo gynecologic surgery, with emerging

suggesting a similar prevalence of endometriosis between Black and White patients [ 4, 5]. In addition to misconceptions regarding prevalence, the difficulty of diagnosing endometriosis is complicated by non-specific clinical presentation, with pelvic pain as the most com - mon presenting complaint. Significant racial and ethnic disparities remain across different areas of pain care, with patients belonging to a racial minority receiving lesser- quality pain care than their non-Hispanic White counter - parts [ 4, 6]. There is little existing literature examining demo - graphics of adolescents with suspected endometrio - sis and how these patients are diagnosed and treated. Although the exact prevalence of endometriosis in ado - lescents is unknown, it is likely underestimated in light of diagnostic difficulty and reliance on potentially inac - curate patient accounts of symptom onset [ 7]. In addi - tion to prolonging patient discomfort, there is concern that diagnostic delay may contribute to disease progres - sion, which can lead to infertility and chronic pain. Thus, time from symptom onset to diagnosis and treatment is crucial. Given the documented disparities in care based on sociodemographic factors in the adult population, we aimed to investigate inequities in rates of diagnostic laparoscopy among adolescents presenting with dysmen - orrhea or CPP according to race, ethnicity, and socioeco - nomic status (SES). We hypothesized that we would find disparities in the care of adolescents like those found in adult women.

Subjects We performed an electronic health record (EHR) review to identify a cohort of adolescents aged 10–21 years, assigned female at birth, and seen for complaints of dys - menorrhea or CPP by Pediatric and Adolescent Gyne - cology or Minimally Invasive Gynecologic Surgery at a single academic medical center in the midwestern United States in the 11 years between 2013 and 2023. All sub - jects with dysmenorrhea and CPP were identified using DataDirect, a web-based, self-serve, precision health software tool enabling access to clinical data such as diagnoses, encounters, procedures, medications (ordered and administered), and labs (ordered and results) on more than 5 million unique patients from across our institu - tion’s enterprise. Primary dysmenorrhea, defined as menstrual pain in the absence of pelvic pathology, was identified using ICD-10 code N94.4. CPP, defined as pel - vic pain lasting for greater than six months, was identi - fied using ICD-10 code 94.9. We included all identified adolescents who had emer - gent or scheduled diagnostic laparoscopy, as well as non- surgical subjects managed expectantly. Those who had a diagnostic laparoscopy were identified by ICD-9 code 54.21. We then performed a thorough chart review on all adolescents who had a laparoscopy and excluded those who already had a diagnosis of endometriosis by prior laparoscopy, as well as those found to have an adnexal mass or cyst at the current laparoscopy. Data were entered into a secure Research Electronic Data Capture (REDCap) database by three study team members. The

were then cross-verified by an additional study team member. Missing data was indicated as such in the results. Measures The primary outcomes in the study were non-emergent laparoscopy and emergent plus non-emergent laparoscopy. The primary exposures were race and ethnicity, which 1 3 Journal of Racial and Ethnic Health Disparities were self-reported by the subject and documented in the EHR. Potential confounders included age, BMI, insur - ance type, and socioeconomic status as measured by the area deprivation index (ADI). The ADI is a measure of neighborhood deprivation developed by the University of Wisconsin Center for Health Disparities Research [ 8]. We mapped ADI state decile rankings to each subject by cen - sus block group using their address recorded in the EHR. We did not test for modifier effects due to the low num - ber of subjects with laparoscopy. Data were entered into a secure REDCap database. Statistical Analysis Data were analyzed using R v. 4.3.1 and package rstanarm v. 2.26.1. Bayesian multiple logistic regression modeling was used to estimate the odds of scheduled laparoscopies. Weakly informative priors of Normal(0,2.5/Sx), where Sx is the SD of covariates x, were used for the coefficients using the software’s default autoscaling procedure. Odds ratios were estimated with White race and non-Hispanic ethnicity as the reference categories. SES was measured by the ADI state ranking by block group. Markov Chain Monte Carlo convergence was assessed using Gelman’s potential scale reduction factor, which was < 1.005 for all parameters. This study was deemed exempt by the University of Michigan Institutional Review board because it used de- identified retrospective data.

The final cohort included 4,480 patients meeting inclu - sion criteria; of these, 4,426 were expectantly managed, 47 underwent scheduled diagnostic laparoscopy, and seven underwent emergent laparoscopy (Fig. 1). In the non-sur - gical group, the majority of subjects were White (77.0%), followed by Black (13.3%), Asian (4.6%), and Other or Unknown race (4.6%). Within the group that underwent surgical intervention, an even higher percentage were White (90.2%), followed by Black and American Indian/Alaska Native (3.9% each). No Asian subjects were surgically managed. Regarding ethnicity, the non-surgical group was predominantly non-Hispanic (93.7%), as was the surgical group (96.2% for those who underwent any surgery and 97.9% for those who underwent scheduled laparoscopic surgery). The median age was 16.6 years in the non-surgical group, 19.4 years in subjects receiving any laparoscopy, and 19.3 years for those undergoing scheduled laparoscopy. The majority of subjects in this study had private insurance regardless of treatment strategy, and rates of surgery did not Fig. 1 Subject flow diagram 1 3 Journal of Racial and Ethnic Health Disparities laparoscopic surgery (OR 0.19, 95% CI 0.01–1.16, p =.082) than non-Hispanic subjects. Older subjects were more likely to have any laparoscopy (OR 1.33, 95% CI 1.19–1.50, p <.001). There was no significant difference in the rate of surgical intervention according to ADI (OR 1.03, 95% CI 0.93–1.14, p =.602). The odds ratios of receiving laparos - copy by race/ethnicity, socioeconomic status, and age can be found in Table 2.

Current research on chronic pelvic pain suggestive of endo- metriosis in the adult population demonstrates a disparity in how patients are diagnosed and treated based on their race. differ according to insurance type. ADI did not significantly contribute to differences in rates of surgical intervention. Characteristics of the cohort and comparisons between sur- gical and non-surgical subjects can be found in Table 1. Despite comprising 13.2% of our included subjects, only 3.9% of the surgically managed subjects were Black, and both laparoscopies were performed for emergent indi - cations. Black subjects were significantly less likely to receive any laparoscopic surgery (OR 0.20, 95% CI 0.03– 0.69, p =.01) or non-emergent surgery (OR 0.01, 95% CI 0.00–0.20.00.20, p <.001) than White subjects. Subjects of Asian descent were less likely to undergo any laparoscopic surgery (OR < 0.01, 95% CI 0.00–0.39.00.39, p =.009, mar- ginal probability < 0.01%) than White subjects. Hispanic subjects were marginally less likely to undergo scheduled Table 1 Characteristics of the cohort and comparison of characteristics between non-surgical subjects and surgical subjects Characteristic Total Cohort (N = 4,480a) Non-Surgical (N = 4,426a) Surgical (N = 5 4a) p-valueb Age, yearsc 16.6 (14.4–18.9) 16.6 (14.4–18.9) 19.4 (17.3–20.9) < 0.001 Race N = 4,398 N = 4,347 N = 5 1 0.007 White 3,394 (77.2) 3,348 (77.0) 46 (90.2) Black 579 (13.2) 577 (13.3) 2 (3.9) Asian 201 (4.6) 201 (4.6) 0 (0.0) American Indian/Alaska Native 19 (0.1) 17 (0.4) 2 (3.9) Hawaiian/Pacific Islander 4 (0.1) 4 (0.1) 0 (0.0) Other/Unknown 201 (4.6) 200 (4.6) 1 (2.0) Ethnicity N = 4,385 N = 4,333 N = 5 2 0.771 Non-Hispanic 4,110 (93.7) 4,060 (93.7) 50 (96.2) Hispanic 275 (6.3) 273 (6.3) 2 (3.8) Insurance Coverage N = 4,142 N = 4,142 N = 4 7 0.377 Other 13 (0.3) 13 (0.3) 0 (0.0) Private 2,771 (66.1) 2,736 (66.1) 35 (74.5) Public 1,405 (33.5) 1,393 (33.6) 12 (25.5) Area Deprivation Index a 3.0 (1.0–6.0) 3.0 (1.0–6.0) 3.0 (2.0–6.0) 0.341 Data presented as n (%) unless otherwise noted aTotal counts of patients in each group differ from total counts for each covariate due tomissing databNon-surgical vs. surgical cMedian (IQR) Table 2 Odds ratios of receiving laparoscopy by race/ethnicity, socioeconomic status, and age Characteristic Any Laparoscopya (N = 5 4 ) Non-Emergent Laparoscopy (N = 4 7 ) OR (95% CI) p-value OR (95% CI) p-value Race White Reference Reference Black 0.20 (0.03–0.69) 0.010 0.01 (0.00–0.20.00.20) < 0.001 Asian 0.00 (0.00–0.39.00.39) 0.009 0.00 (0.00–0.49.00.49) 0.010 American Indian/Alaska Native 8.69 (1.01–40.7) 0.050 11.13 (1.56–46.49) 0.018 Hawaiian/Pacific Islander < 0.01 (0.00–1.12.00.12) 0.053 < 0.01 (0.00–0.92.00.92) 0.045 Other/Unknown 0.36 (0.01–2.11) 0.314 0.50 (0.03–2.52) 0.49 Ethnicity Non-Hispanic Reference Reference Hispanic or Latinx 0.48 (0.07–2.04) 0.351 0.19 (0.01–1.16) 0.082 Area Deprivation Index 1.03 (0.93–1.14) 0.602 1.04 (0.93–1.16) 0.46 Age 1.33 (1.19–1.50) < 0.001 1.31 (1.17–1.48) < 0.001 aMarginal probabilities by race: White = 0.97%, Black = 0.19%, Asian < 0.01%, American Indian/Alaska Native = 7.8%, Hawaiian/Pacific Islander < 0.01%, Other/Unknown = 0.35%. 1 3 Journal of Racial and Ethnic Health Disparities classified as urgent or emergent. In our study, 2/7 adoles - cents receiving emergent surgery identified as Black, 1/7 as Hispanic, and 1/7 as another non-White race. This finding is limited due to our small sample size of subjects undergo- ing emergent surgery, but points to a similar troubling trend of minority patients potentially being denied surgery on an elective basis and ultimately requiring emergent interven - tion [14]. Coupled with trends from studies in the pediatric population, the observed variations in surgical care access discussed in this study could indicate underlying disparities in healthcare accessibility that warrant additional investiga- tion. One strategy to address and reduce these racial and ethnic disparities is to implement training programs focused on unconscious bias, cultural competence, and language services. The findings of this study are limited to a single aca - demic center for subspecialty gynecologic care in the midwestern United States. Due to differing patient demo - graphics and cultural differences, these results may not be fully generalizable to all adolescent populations. Additionally, the results are further limited by only hav - ing a small number of subjects in certain subgroups. Similarly, our study demonstrated a low overall rate of surgical intervention, which may differ from the manage - ment strategies at other healthcare institutions. This study does not capture possible additional ineq - uities that occur in initial management of CPP, dys - menorrhea, or suspected endometriosis in adolescents, including nonsurgical treatments and referral to specialty care. As subjects in our sample were seen by a Pediat - ric and Adolescent Gynecology or Minimally Invasive Gynecologic Surgery subspecialist, they were most com - monly referred after seeing a general provider—often a pediatrician, family medicine practitioner, or general gynecologist. Prior research suggests that race and eth - nicity impact pediatric care beyond the surgical space, which may have influenced evaluation, initial treatment modalities, and referrals to subspecialty care that adoles - cents received before being seen by our providers. For example, a recent study of ED care in the United States from 2005 to 2016 found that Black, Hispanic, and Asian children were less likely to receive blood tests, X-rays, and CT scans compared to their white counterparts, and that Black and Hispanic children were also less likely to receive general procedures in the ED [ 15]. Another limitation of this retrospective study is the inability to explore the attitudes and desires of adolescent subjects and their families regarding surgical manage - ment of their pain. It is possible that the subjects included in this study may have had increased symptom severity or simply have been more apt to request aggressive mea - sures for workup and treatment by nature of proceeding Studies of adults have found that White patients are more likely to receive non-hysterectomy endometriosis surgery, more likely to undergo minimally invasive versus open pro- cedures, and experience fewer surgical complications than patients of all other races and ethnicities [ 9, 10]. Addition- ally, research in the adult population has demonstrated that patients of non-White race averaged a longer delay between symptom onset and diagnosis of endometriosis, were more likely to have presented to the emergency department (ED) for pelvic pain, and were more likely to have an additional surgical indication prior to laparoscopy compared to their White counterparts [11]. This study identified inequities in rates of diagnostic laparoscopy for CPP among adolescent patients by race and ethnicity, with surgery performed at lower rates for Black, Asian, and Hispanic subjects compared to non-Hispanic White subjects. Historically, endometriosis has been con - sidered a disease of White women, and medical education has perpetuated stereotypes surrounding Black patients and their experience of pain [12]. Evidence does not substantiate genetic or biological differences between races or ethnici - ties as a significant contributor to health disparities among minorities. To date, literature does not indicate a reduced need for surgical interventions in racial and ethnic minor - ity children. Additionally, prevalent misconceptions about biological differences across racial and ethnic groups could influence the medical advice provided to racial and ethnic minority patients. For example, providers might be biased in their perception that certain minority patients can endure more pain or feel less pain. There might also be implicit bias in surgical referral. Lastly, there might be insurance or cul - tural barriers influencing who is able to seek care, leading to inequity in who receives surgical intervention. Findings of this study suggest that there are racial and ethnic disparities underlying the decision to proceed with diagnostic laparoscopy in adolescent patients with symp - toms suggestive of endometriosis. Our study results align with a large study published in 2020 of 155,064 pediatric patients from 2005 to 2018 that demonstrated that regard - less of other potentially contributing disparity domains, Black and Hispanic children had lower rates of all surgeries compared to their White, non-Hispanic counterparts (aOR 0.6, 95% CI 0.5–0.8 for Black children and aOR 0.7, 95% CI 0.5–0.9 for Hispanic children) [ 13]. While this study focused on children 0–18, our findings purport that this trend extends into later adolescence as well. These findings are similar to a recent cross-sectional anal- ysis of 219,098 children in the United States from 1999 to 2018, which demonstrated that Black, Asian, and Hispanic patients had lower rates of all types of surgery compared to their White counterparts [14]. This study further found that Hispanic children were more likely to have surgery that was 1 3 Journal of Racial and Ethnic Health Disparities Competing interests The authors have no relevant financial or non- financial interests to disclose. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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This study identifies inequities in the rates of comple - tion of laparoscopic surgery for adolescent subjects of a racial or ethnic minority with CPP and/or dysmenor - rhea. Further research is needed to identify the contribut - ing factors leading to these differences and to guide more equitable care.

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