Self-Reported Adolescent Menstrual Symptoms and Delayed Gynecologic Consultation among Japanese Women with Endometriosis

Study design and participants. This cross-sec - tional online questionnaire survey included women aged 20-45 years residing in Japan and incorporated retrospective recall of adolescent menstrual symptoms. The endometriosis group comprised women who self-reported gynecologist-diagnosed endometriosis (clinical or laparoscopic diagnosis). The control group comprised women who reported no history of endome- triosis or other gynecologic conditions. Sample size considerations. The sample size was determined pragmatically based on recruitment feasi - bility and available resources; therefore, no formal a priori power calculation was performed. Data collection. Data were collected in January 2024 using an anonymous online questionnaire admin- istered by Cross Marketing Inc., a commercial research agency in Japan. The structured survey assessed socio- demographic characteristics (age, marital status, employment, pregnancy, and delivery history), men - strual characteristics (cycle length, duration, and flow volume), symptom severity, analgesic use, treatment history (LEP and analgesics), impact on daily life, and gynecologic consultation history. For adolescent men- strual experiences, participants retrospectively recalled their symptoms during their teenage years, including cycle characteristics, pain, daily life impact, and self-monitoring of symptoms. Outcomes. Primary outcomes were as follows: (i) menstrual characteristics and symptoms during ado- lescence and adulthood; (ii) analgesic and LEP use; (iii) age at first recognition of endometriosis-related symptoms; (iv) age at first gynecologic consultation and delay between symptom recognition and consulta- tion; and (v) awareness and self-monitoring of men - strual symptoms during adolescence. Statistical analysis. Categorical variables are pre- sented as counts and percentages, and continuous vari- ables as mean ± standard deviation or median [range], depending on distribution. Between-group compari - sons (endometriosis vs. control) were performed using χ2 tests for categorical variables and t-tests for continu- ous variables. Within-group comparisons (current vs. adolescence) were performed using paired t-tests or McNemar’s test, as appropriate. Two-sided p< 0.05 was considered statistically significant. Analyses were con- ducted using IBM SPSS Statistics version 29.0.1.0 (IBM Corp., Armonk, NY , USA). Ethical considerations. This study was approved by the appropriate ethics committee (approval number: T20-04). Participation was voluntary, and informed  *LFEB
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 consent was obtained electronically at the beginning of the online questionnaire. Responses were anonymized to protect participant confidentiality. External validity. Because the data were collected through an online survey in Japan, the findings should be interpreted with caution when generalizing to popu- lations in other cultural or healthcare contexts.

Participant characteristics. Among the 166 women in the endometriosis group, 51 had laparo - scopically confirmed and 115 had clinically diagnosed endometriosis. No significant differences were observed between the endometriosis and control groups regarding age, marital status, employment, pregnancy history, or parity, suggesting that subsequent group comparisons were not substantially confounded by the baseline characteristics (Table 1). Current menstrual status. 1. Endometriosis vs. control group. Cycle length and menstrual duration did not differ significantly between groups. However, heavy men - strual bleeding was more frequent in the endometriosis group than in controls. Although the mean pain sever- ity score did not differ significantly, analgesic use in every menstrual cycle and school/work absence were significantly more common in the endometriosis group than in the control group (Table 2). 2. Endometriosis group: treated vs. untreated. Cycle length, menstrual duration, and pain severity did not differ according to treatment status. However, heavy menstrual bleeding and school/work absence were significantly less frequent in treated than in untreated women, suggesting that therapy mitigated bleeding and day-to-day disruption (Table 2). 3. Control group: analgesic users vs. non-users. Cycle length and menstrual duration did not differ between women who used analgesics and those who did not. However, heavy menstrual bleeding, pain severity, school/work absence due to symptoms, and activity restriction were significantly higher among analgesic users than among non-users, suggesting that analgesic use in controls largely reflects underlying symptom bur- den rather than symptom resolution (Table 2). Adolescent menstrual status (retrospective): con - trol vs. endometriosis group. Recall responses of “do not remember” were more frequent in the control group than in the endometriosis group. Compared with con- trols, women with endometriosis more frequently reported a cycle length ≤ 24 days, menstrual duration ≥ 8 days, heavy menstrual bleeding, greater pain sever- ity, analgesic use in every menstrual cycle, and more frequent school/work absence (Table 2). Change from adolescence to the present state. 1. Endometriosis group (adolescence vs. current). Cycle length ≤ 24 days was more frequently reported at present than during adolescence, whereas menstrual duration ≥ 8 days was slightly more frequent during adolescence than at present. Heavy menstrual bleeding was markedly more common during adolescence than at present. Pain severity was significantly higher during adolescence. The frequency of analgesic use did not differ between the time points. Regarding daily-life impact, both school/work absence and activity restric- tion were more frequent during adolescence (Table 2). 2. Control group (adolescence vs. current). Cycle length did not differ between the adolescent and present states. Menstrual duration ≥ 8 days was significantly more common at present than during ado- lescence, whereas reports of light bleeding were less +VOF
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&OEPNFUSJPTJT  5BCMF 　 Participant characteristics Control (n = 200) Endmetriosis (n = 166) P-value Age (year) 27.6± 4.5 27 ［20-35］ 27.5± 4.4 27 ［20-35］ 0.669 Marital status 　　Single 127 (63.5%) 102 (61.4%) 0.795 　　Married 68 (34.0%) 58 (34.9%) 　　Divorced 5 (2.5%) 6 (3.6%) Employment status 　　Full-time employee 37 (18.5%) 46 (27.7%) 0.189 　　part-time worker 64 (32.0%) 45 (27.1%) 　　Self-employed 9 (4.5%) 5 (3.6%) 　　Student 33 (18.6%) 32 (19.3%) 　　Unemployed 57 (28.5%) 38 (22.9%) History of pregnancy 51 (25.5%) 47 (28.3%) 0.545 History of childbirth 37 (18.5%) 40 (24.1%) 0.130 Values are presented as mean ± SD, median [range], or n (%). Nominal variables were compared using the χ2 test, and continuous variables using the t-test. The endometriosis group included women who had been diagnosed with endometriosis or clinical endometriosis by a gynecologist. Within this group, “confirmed endometriosis” referred to diagnoses verified by laparoscopy, while “suspected endometriosis” referred to clinical diagnoses without laparoscopic confirmation. SD, standard deviation.  *LFEB
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 5BCMF 　 Comparison of menstrual characteristics between women with and without endometriosis (current and retrospective experi - ences) Current menstrual experiences Endometriosis group (n = 166) Control group (n = 200) Overalla) Untreated b) Receiving treatment with LEP or analgesicsc) P-value (between groups) Overalld) (n = 166) (n = 88) (n = 78) (n = 200) Menstrual cycle length 　 38 days 28 (16.9%) 12 (13.6%) 16 (20.5%) 32 (16.0%) 　Do not remember 0 0 0 0 Duration of menstruation 　4-7 days 143 (86.1%) 72 (81.8%) 71 (91.0%) ns 174 (87.0%) 　≥ 8 days 23 (13.9%) 16 (18.2%) 7 (9.0%) 26 (13.0%) 　Do not remember 0 0 0 0 Menstrual flow volume 　Light 32 (19.3%) 8 (9.1%) 24 (30.8%) < 0.001 28 (14.0%) 　Moderate 88 (53.0%) 46 (52.3%) 42 (53.8%) 137 (68.5%) 　Heavy 46 (27.7%) 34 (38.6%) 12 (15.4%) 35 (17.5%) Self-rated severity of menstrual pain (0-10 scale) 5.0± 3.0 5［0-10］ 5.3± 3.0 6［0-10］ 4.7± 2.9 5［0-10］ ns 4.7± 2.5 5［0-10］ Frequency of analgesic use during menstruation 　Never use 39 (23.5%) 50 (56.8%) 31 (39.7%) ns 78 (39.0%) 　Sometimes 46 (27.7%) 23 (26.1%) 23 (29.5%) 68 (34.0%) 　Always 81 (48.8%) 15 (17.0%) 24 (30.8%) 54(27.0%) Impact of menstruation on daily life 　No disruption in daily life 48 (28.9%) 19 (21.6%) 29 (37.2%) ns 84 (42.0%) 　Manageable with analgesics 75 (45.2%) 43 (48.9%) 32 (41.0%) 83 (41.5%) 　Partially disrupted despite analgesics 26 (15.7%) 15 (17.0%) 11 (14.1%) 23 (11.5%) 　Significant disruption in daily life 17 (10.2%) 11 (12.5%) 6 (7.7%) 10 (5.0%) Impact of menstruation on academic or occupational performance 　No impact 73 (44.0%) 32 (36.4%) 41 (52.5%) 0.042 121 (60.5%) 　Restricted activity without absence 52 (31.3%) 28 (31.8%) 24 (30.8%) 50 (25.0%) 　Occasional pain-related school/work absence 41 (24.7%) 28 (31.8%) 13 (16.6%) 29 (14.5%) a) Currently diagnosed with endometriosis (n = 166): Women who self -reported a diagnosis of endometriosis by a medical professional. b) Currently untreated endometriosis (n= 88): Subgroup of women with endometriosis who were not receiving hormonal therapy (e.g., LEP) or analgesics at the time of the survey. c) Currently treated endometriosis (n = 78): Subgroup of women with endometriosis who were receiving hormonal therapy (e.g., LEP) and /or analgesics at the time of the survey. d) Control group (n = 200): Women who self -reported no diagnosis of endometriosis. e) Control group, not using analgesics (n= 78): Subgroup of the control group who reported no use of analgesics during menstruation. f) Control group, using analgesics (n= 122): Subgroup of the control group who reported the use of analgesics during menstruation. g) Retrospective menstrual experiences during adolescence, endometriosis group (n = 166): Women currently diagnosed with endometriosis who retrospec - tively reported menstrual characteristics and symptoms during adolescence (< 20 years of age). h) Retrospective menstrual experiences during adolescence, control group (n= 200): Women in the control group who retrospectively reported menstrual char - acteristics and symptoms during adolescence (< 20 years of age). +VOF
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&OEPNFUSJPTJT  (continued from previous page) Current menstrual experiences Retorospective menstrual expreience during adolescence Control group (n = 200) Current status: Endometriosis vs. Control i) Endometriosis group (n = 166) Control group (n = 200) Teenage years (retrospective): Endometriosis vs. Control ii) Group comparison based on current age iii) No medication usee) Using analgesicsf) P-value (between groups) Overallg) Overallh) Endometriosis group Control group (n = 78) (n = 122) (n = 166) (n = 200) P-value P-value 10 (12.8%) 14 (11.5%) ns ns 21 (12.7%) 13 (6.5%) 52 (66.7%) 92 (75.4%) 101 (60.8%) 119 (59.5%) 0.047 < 0.001 ns 16 (20.5%) 16 (13.1%) 21 (12.7%) 22 (11.0%) 0 0 23 (13.9%) 46 (23.0%) 70 (89.7%) 104 (85.2%) ns ns 128 (77.1%) 153 (76.5%) 8 (10.3%) 18 (14.8%) 26 (15.7%) 17 (8.5%) 0.013 0.001 < 0.001 0 0 12 (7.2%) 30 (15.0%) 17 (21.8%) 11 (9.0%) < 0.001 11 (6.6%) 10 (5.0%) 57 (73.1%) 80 (65.6%) a) vs d): 0.009 b) vs e): < 0.001 c) vs f): < 0.001 75 (45.2%) 151 (75.5%) < 0.001 < 0.001 0.009 4 (5.1%) 31 (25.4%) 80 (48.2%) 39 (19.5%) 3.3± 2.3 3［0-10］ 5.6± 2.2 6［0-10］ < 0.001 b) vs e): 0.002 c) vs f): 0.002 6.2± 3.1 7［0-10］ 4.6± 2.6 5［0-10］ < 0.001 < 0.001 ns a) vs d): < 0.001 36 (21.7%) 91 (45.5%) < 0.001 ns 44 (26.5%) 64 (32.0%) 86 (51.8%) 45 (22.5%) 62 (79.5%) 22 (18.0%) < 0.001 39 (23.5%) 87 (43.5%) 9 (11.5%) 74 (60.7%) a) vs d): 0.027 b) vs e): < 0.001 c) vs f): 0.015 60 (36.1%) 77 (38.5%) < 0.001 0.044 5 (6.4%) 18 (14.8%) 37 (22.3%) 27 (13.5%) ns 2 (2.6%) 8 (6.6%) 30 (18.1%) 9 (4.5%) 64 (82.1%) 55 (45.1%) < 0.001 60 (36.1%) 123 (61.5%) ns 9 (11.5%) 42 (34.4%) a) vs d): 0.004 b) vs e): < 0.001 60 (36.1%) 52 (26.0%) < 0.001 5 (6.4%) 25 (20.5%) 46 (27.7%) 25 (12.5%) Comparisons were conducted as follows: (i) current menstrual experiences between the endometriosis and control groups; (ii) retrospective menstrual experi - ences during adolescence between the endometriosis and control groups; and (iii) within -group comparisons between current and retrospective adolescent menstrual experiences. P-values correspond to the comparison indicated by each superscript. Values are expressed as mean ± SD, median [range], or n (%). Comparisons were made between the endometriosis and control groups, as well as between treatment and non-treatment subgroups within each group. Heavy menstrual bleeding was defined as self-reported “heavy” menstrual flow compared with “nor- mal” 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 assessed using a self -reported 0-10 numerical rating scale. Regular analgesic use was defined as analgesic use during every menstrual cycle. Group differ - ences were evaluated using the χ2 test for categorical variables and the t-test for continuous variables. LEP, low-dose estrogen progestin; SD, standard deviation. ns, not statistically significant. common in adolescence than at present. Pain severity, analgesic use, and daily-life impact did not differ sig - nificantly between time points (Table 2). Symptom recognition, consultation timing, and self-monitoring 1. Symptom onset and gynecologic consultation in the endometriosis group. The median age at first recognition of symptoms was 16, 16, and 20 years for heavy bleeding, school/work absence, and chronic pelvic or back pain unrelated to menstruation, respectively. The median age at first gynecologic consultation was 23 years overall, with 21, 22, and 22 years among those reporting heavy bleeding, school/work absence, and chronic pelvic or back pain, respectively. Recognition of heavy bleeding and school/ work absence occurred significantly earlier than recog- nition of chronic pelvic or back pain (both p< 0.01). The median intervals from symptom recognition to consultation were 36, 78, and 30 months for heavy bleeding, school/work absence, and chronic pelvic or back pain, respectively. No significant differences in consultation age or delay were observed between par - ticipants with vs. without each symptom (Table 3). 2. Awareness and monitoring of symptoms during adolescence. A significantly higher proportion of women in the  *LFEB
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 5BCMF 　 Age at symptom onset and time to initial gynecological visit among women with endometriosis Symptom type Age at first awareness of menstrual symptoms P-value Age at first gynecological visit P-value Time from symptom awareness to gynecological visit (months) P-value All 16.8± 4.1 16［11-29］ 22.9± 4.4 23［13-32］ 73.2± 60.0 60［0-216］ Heavy menstrual bleedingb) 　Present (n = 80) 17.2± 3.5 16［12-28］ 0.003 22.1± 4.5 21［13-31］ 0.725 57.6± 52.8 36［0-192］ 0.181 　Absent (n = 86) 20.7± 4.7 20［12-29］ 23.8± 4.4 24［15-32］ 42.0± 40.8 48［0-120］ Severe menstrual pain (leading to pain school/work absence)c) 　Present (n = 46) 15.6± 2.1 16［12-19］ <0.001 21.4± 3.8 22［15-29］ 0.271 69.6± 57.6 78［0-156］ 0.581 　Absent (n = 120) 20.6± 5.4 20［11-32］ 23.4± 4.7 23［13-32］ 40.8± 56.4 36［0-204］ Chronic lower back or pelvic pain unrelated to menstruationd) 　Present (n = 32) 20.1± 6.1 18［12-34］ 0.878 23.1± 5.0 22［15-32］ 0.251 42.0± 46.8 30［0-132］ 0.663 　Absent (n = 134) 20.1± 5.6 20［11-32］ 22.8± 4.4 23［13-31］ 28.8± 66.0 24［0-204］ All of the above symptoms presente) 　Present (n = 12) 15.5± 1.7 15［14-18］ 0.013 22.0± 2.4 22［20-25］ 0.526 78.0± 40.8 84［24-120］ 0.228 　Absent (n = 166) 19.0± 4.5 19［12-29］ 22.9± 4.6 23［13-32］ 46.8± 48.0 36［0-192］ Data reflect retrospective reports of symptoms during adolescence from participants currently diagnosed with endometriosis. a) Heavy menstrual bleeding =response “heavy” (vs “normal/light”). b) Severe menstrual pain =school/work absence due to menstrual pain. c) Chronic lower back or pelvic pain unrelated to menstruation =lower back or pelvic pain outside menses, including dyspareunia and /or dyschezia. d) All symptoms present indicates co-occurrence of these three conditions. endometriosis group reported consciously monitoring their menstrual flow during adolescence. Similarly, conscious monitoring of pain, fatigue, or headache was more frequent in the endometriosis group (Table 4). 3. Monitoring behaviors and consultation timing in the endometriosis group. In the endometriosis group, age at first consultation did not differ significantly by self-monitoring behavior. However, the interval from symptom recognition to consultation was significantly shorter among women who consciously monitored their menstrual cycle and among those who monitored appetite and bowel move- ments. These findings suggest that self-monitoring behaviors were associated with earlier consultation (Table 5).

Principal findings. This study retrospectively examined menstrual symptoms, treatment patterns, and consultation behaviors among Japanese women with endometriosis compared with controls. Women with endometriosis experienced heavier bleeding, more severe pain, and greater disruption to daily life from adolescence. Although symptoms were typically recog- nized around the age of 16 years, the first gynecologic consultation occurred at 21-23 years, indicating a con- sultation delay of approximately 5-6 years. Importantly, self-monitoring of symptoms alone did not consistently lead to earlier consultation. However, the association between self-monitoring and consultation behavior was not uniform when the type of self-monitored symptoms was considered. A more detailed examination of symptoms observed during adolescence suggested that observation limited to menstrual symptoms, such as bleeding and pain, differed in its association with consultation behavior from monitoring of broader physical symptoms, including appetite and bowel habits. Notably, women who consciously observed changes in appetite or bowel habits experienced a significantly shorter interval between symptom recognition and the first gynecologic consultation. These findings suggest that consultation behavior may be influenced not merely by whether symptoms were self-monitored, but by which types of symptoms were observed. While observation focused solely on menstrual symptoms may allow symptoms to be inter - preted as constitutional or transient, awareness of sys - temic changes extending beyond the menstrual cycle and affecting daily life may strengthen the perception of abnormality and prompt medical consultation. +VOF
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&OEPNFUSJPTJT  5BCMF 　 Awareness and self-observation of menstrual characteristics during adolescence in women with and without endometriosis Consciously observed by oneselfc) Did not consciously observed) Cannot say either waye) Do not rememberb) P-value Observation of menstrual start dates and cycle regularity 　Control group (n = 200) 88 (44.0%) 62 (31.0%) 23 (11.5%) 27 (13.5%) 　Endometriosis group (n = 166) 60 (40.5%) 60 (36.1%) 26 (15.7%) 20 (12.0%) 0.330 Observation of menstrual blood volume 　Control group (n = 200) 46 (23.0%) 97 (48.5%) 27 (13.5%) 30 (15.0%) 　Endometriosis group (n = 166) 62 (37.3%) 60 (36.1%) 26 (15.7%) 18 (10.8%) 0.011 Observation of menstrual pain 　Control group (n = 200) 42 (21.0%) 109 (54.5%) 23 (11.5%) 26 (13.0%) 　Endometriosis group (n = 166) 60 (36.1%) 67 (40.4%) 21 (12.7%) 18 (10.8%) 0.009 Observation of physical condition changes associated with menstruation 　Control group (n = 200) 115 (57.5%) 33 (16.5%) 24 (12.0%) 28 (14.0%) 　Endometriosis group (n = 166) 81 (48.8%) 46 (27.7%) 20 (12.0%) 19 (11.4%) 0.071 This table summarizes participantsʼ awareness and perceptions of menstrual symptoms during adolescence. a) Consciously observed by oneself =the participant recognized the symptom based on her own perception. b) Did not consciously observe =the symptom was present but not consciously recognized by the participant. c) Cannot say either way== uncertainty in recall. d) Do not remember =unable to recall details (e.g., timing or characteristics). Comparison with previous studies. Our findings align with earlier reports describing characteristic symptoms of endometriosis and their negative impact on QOL [15 , 6]. International studies similarly indicate that adolescents experiencing dysmenorrhea and school absenteeism often delay seeking gynecologic care [2]. However, few studies have quantitatively demonstrated the gap between symptom awareness and consultation behavior. This study provides new evidence from Japan, showing that consultation delays persist even among women who consciously monitored their symptoms, suggesting that structural and cultural barriers may out- weigh awareness in shaping consultation behavior. Novelty and cultural context. The novelty of this study lies in its systematic documentation of consulta - tion delay among Japanese women with endometriosis and its focus on symptom self-monitoring during ado - lescence. Previous studies have reported that, in Japan, menstrual pain and menstrual-related discomfort are often normalized as “constitutional” or “part of the developmental process,” and that many women do not seek medical care even when menstrual symptoms interfere with daily life [4]. Within this cultural context, menstrual symptoms may be more readily justified as issues to be managed individually, potentially delaying their recognition as medical concerns. Our findings are consistent with prior research describing characteristics of menstrual perceptions and healthcare-seeking behaviors in Japan. The observed delay of several years between symptom recognition in adolescence and the first gynecologic consultation sug- gests that social and cultural factors may influence con- sultation behavior. These interpretations are based on the present findings and indicate that consultation delay cannot be fully explained by individual symptom awareness or self-monitoring alone. In the Japanese healthcare context, adolescents tend to access gynecologic care later than in Western coun - tries, making the consultation delay observed in this study particularly relevant for clinical and educational practice in Japan. Implications for education and preconception care. Our results emphasize the need for comprehensive menstrual education not only to improve literacy but also to reduce structural and cultural barriers. In Japan, menstrual education has traditionally focused on bio - logical mechanisms rather than the functional impact of symptoms on daily life or fertility. The Japan Association of Obstetricians and Gynecologists (2021) has empha - sized the importance of preconception education, including awareness of dysmenorrhea and endometrio- sis [16]. Educational interventions should address mis-  *LFEB
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 5BCMF 　 Observation of menstrual symptoms and timing of gynecological consultation (endometriosis group only) Observation of menstrual cycle Observation of menstrual blood volume Total sample (n = 166) Aware (n = 60) Unaware/ unsure/forgot (n = 106) P-value Aware (n = 62) Unaware/ unsure/forgot (n = 104) P-value First gynecological visit (age) 22.9± 4.4 23［13-32］ 24.4± 4.7 24［16-32］ 22.3± 4.2 23［13-30］ 0.109 22.3± 4.8 23［13-31］ 23.3± 4.1 23［16-32］ 0.199 Time from symptom awareness to first gynecologi - cal consultation 　Heavy menstrual bleeding (n = 80) (n = 80) (n = 19) (n = 61) (n = 35) (n = 45) 56.4± 52.8 36［0-192］ 57.6± 57.6 36［12-180］ 55.2± 52.8 36［0-192］ 0.450 61.2± 61.2 36［0-180］ 51.6± 48.0 12［12-192］ 0.333 Severe menstrual pain (n = 46) (n = 9) (n = 37) (n = 14) (n = 32) (leading to pain -related school /work absence) (n = 46) 68.4± 56.4 78［0-156］ 63.6± 60.0 72［0-120］ 69.6± 56.4 84［0-156］ 0.436 45.6± 72.0 24［0-132］ 79.2± 49.2 84［0-156］ 0.141 Chronic lower back or pelvic pain unrelated to menstruation (n = 32) (n = 7) (n = 25) (n = 10) (n = 22) 43.2± 48.0 36［0-132］ 9.6± 55.2 10［0-108］ 38.4± 64.8 32［0-204］ 0.038 56.4± 50.4 36［24-132］ 37.2± 49.2 36［0-108］ 0.262 This table compares participants according to their awareness of menstrual condition during adolescence. “Aware” = consciously observed menstrual flow or related symptoms. “Unaware/unsure/forgot” = did not observe, were unsure, or did not remember. Continuous variables are shown as mean ± SD and median [range]. Group differences were tested using t -tests. “Age at first gynecological visit ” and “Time from symptom recognition to first visit ” were com - pared between awareness categories. conceptions such as “pain will resolve with age,” nor - malizing medical consultation as a routine response and sharing peer examples of treatment leading to improved QOL. Integrating this perspective into school curricula, engaging families and communities, and mobilizing midwives and nurses as educators could strengthen support systems and facilitate earlier consultation. Strengths and limitations. The strengths of this study include its systematic examination of associations between retrospectively recalled adolescent menstrual symptoms, treatment patterns, and gynecologic con - sultation behaviors among Japanese women, using a comparison between women with endometriosis and controls. By focusing on the temporal gap between symptom recognition during adolescence and subse - quent healthcare-seeking behavior in young adulthood, this study provides important insight into care-seeking delays that may contribute to delayed diagnosis of endo- metriosis. Several limitations should also be acknowledged. First, the analysis included women with surgically con- firmed endometriosis as well as those diagnosed clini - cally. To assess the potential impact of diagnostic mis- classification, we conducted a supplementary analysis comparing women with laparoscopically confirmed diagnoses and those with clinical diagnoses. Although a difference was observed in marital status, no signifi - cant differences were found between diagnostic groups in adolescent menstrual characteristics, age at first gynecologic consultation, or the interval between symptom recognition and consultation. These findings suggest that inclusion of clinically diagnosed cases is unlikely to have substantially distorted the main con - clusions of this study. Second, assessment of adolescent menstrual charac- teristics and symptoms relied on participants’ retro - spective recall and may therefore be subject to recall bias. A higher proportion of control participants reported difficulty recalling adolescent symptoms com- pared with women with endometriosis, suggesting potential differences in recall accuracy between groups. Women diagnosed with endometriosis may recall ado- lescent symptoms more vividly due to their diagnostic experiences, which could have augmented group differ- ences in symptom severity or frequency in comparisons of adolescent symptoms (Table 2 and Table 4). In con- trast, the primary outcomes of this study — age at first gynecologic consultation and the interval between symptom recognition and consultation — are relatively simple time-based measures and may be less susceptible to recall bias than detailed recollection of symptom severity. Accordingly, while the findings regarding +VOF
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&OEPNFUSJPTJT  (continued from previous page) Observation of fatigue/headache Observation of appetite/bowel movements Aware (n = 60) Unaware/ unsure/forgot (n = 106) P-value Aware (n = 81) Unaware/ unsure/forgot (n = 85) P-value 22.7± 4.9 23［13-31］ 23.0± 4.1 23［16-32］ 0.385 23.0± 4.3 23［16-32］ 22.8± 4.6 23［13-31］ 0.862 (n = 37) (n = 43) (n = 21) (n = 59) 55.2± 58.8 36［0-180］ 56.4± 49.2 30［12-192］ 0.457 33.6± 20.4 24［12-72］ 63.6± 58.8 42［0-192］ 0.028 (n = 14) (n = 32) (n = 17) (n = 29) 50.4± 57.6 72［0-108］ 76.8± 57.6 84［0-156］ 0.198 63.6± 60.0 72［0-132］ 72.0± 57.6 78［0-156］ 0.398 (n = 12) (n = 20) (n = 15) (n = 17) 50.4± 46.8 4［24-132］ 38.4± 51.6 48［0-108］ 0.350 31.2± 50.4 42［0-84］ 52.8± 48.0 36［0-132］ 0.229 Additional analyses stratified participants who retrospectively reported specific adolescent symptoms: heavy menstrual bleeding (n = 80), absence from school or work due to menstrual pain (n = 46), and chronic lower back or pelvic pain unrelated to menstruation (n= 32). consultation delay should be interpreted with these lim- itations in mind, they may be relatively robust. In conclusion, this study demonstrated that while menstrual symptoms suggestive of endometriosis often emerge during adolescence, gynecologic consultation may be delayed for several years. A key novel finding is that self-monitoring of symptoms alone does not con - sistently resolve this delay. These findings underscore the importance of addressing systemic, educational, and cultural barriers to gynecologic consultation. Future interventions should extend beyond promoting symptom awareness to actively reducing these barriers, which is expected to contribute to earlier diagnosis, improved quality of life, and preservation of future fer- tility. This work was supported by a Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research (C) (grant number 18K10461) for the “Exploratory study of exacerbating and protective factors for dysmenorrhea in adolescent girls that may affect future fertility.” The funding source had no role in the study design; the collection, analysis, and interpreta - tion of data; the writing of the report; or the decision to submit the article for publication.

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