Improving endometriosis care: the primary care approach

Poster presented at the 4th Congress of SEUD (Society of Endometriosis and Uterine Disorders), Florence (Italy) April 2018IntroductionThe diagnosis of endometriosis is still a challenge since most patients suffer symptoms for almost a decade until a definitive diagnosis is made. We designed a specific protocol with the aim of improving the management of endometriosis in our public health care system by facilitating access to an endometriosis specialist directly in the primary care setting and optimizing hospital care.Patients and methodsThe Catalan public health system has a specific area for sexual and reproductive healthcare in each primary care center, where patients have access to a gynecologic consultation (by a midwife or gynecologist) without referral from their GP/family physician. We established a specialized Endometriosis Unit which includes endometriosis specialists from a tertiary teaching hospital and its corresponding primary care center in Barcelona. Based on their medical history, symptoms or findings after a routine or specific primary care consultation, patients were referred to an endometriosis specialist within the same primary care center, following our specific protocol, for an initial evaluation including a transvaginal ultrasound examination (TVUS) to search for endometriosis. The diagnosis was made based on TVUS findings and following the currently available criteria from the MUSA and IDEA groups. Optimal management of patients was assured by a selected case discussion at a weekly scientific and multidisciplinary Endometriosis Committee at our Unit. Referral to the hospital was made only if surgical management was required because of associated infertility or failure of medical treatment.All patients referred to the aforementioned Primary Care Endometriosis Consultation (PCEC) from March 2016 to November 2016 were included for analysis.ResultsA total of 90 patients were evaluated at the PCEC during the study period. In the descriptive analysis, medians (range) for the main variables were as follows: age 34y (19-45), BMI 23.3kg/m2 (15.8-47), age at menarche 12y (8-16), parity 0 (0-3). Endometriosis was found in 72% (65/90) of women. Thirty percent of patients (27/90) had a previous diagnosis of endometriosis before referral, and amongst those without a diagnosis (n=63), endometriosis was found in 70% of them. In these patients, TVUS showed adenomyosis in 64%, ovarian endometriosis in 23%, and deep endometriosis in 36%. Whereas in the hole sample (n=90) these findings were present in 54%, 46%, and 40% respectively. As for symptoms, severe dysmenorrhea was present in 59% (53/90), heavy menstrual bleeding in 19% (17/90), and dyspareunia in 17% (15/90). As much as 46% (41/90) of patients had their daily activities affected by their symptoms. We compared time-to-event with a Kaplan-Meier plot (duration of symptoms) in patients with and without endometriosis, and found that patients with the disease suffer from symptoms much longer than those without the diagnosis (p=0.015). Only one patient (1/90) was referred to the hospital for ART. ConclusionThis novel strategy could help improve the diagnosis, management, and prognosis of endometriosis, as well as patients’ quality of life. It could also reduce the number of referrals to the hospital. The implementation of this system may well be cost-effective since optimal management can decrease costs associated with ill-timed diagnosis, infertility or surgery.