Understanding the diagnostic process of endometriosis in primary care: An interview study with general practitioners in Denmark using clinical vignettes

Endometriosis is a chronic, systemic condition affecting ∼5–10% of individuals assigned female at birth, though the true prevalence remains unknown. It is characterised by endometrium-like tissue growing outside the uterus, where it causes inflammation, adherence formation, and scar tissue, which can lead to a range of symptoms, including none (asymptomatic), cyclical or chronic pelvic pain, heavy menstrual bleeding, dysuria, dyschezia, dyspareunia, fatigue, and subfertility [ 1 , 2 ]. Endometriosis is associated with significant impacts on people’s quality of life, physical and mental health, and work capacity [ 3–5 ]. A well-documented diagnostic delay of 7–9 years exists for endometriosis; a figure that has shown little improvement over the last decade [ 6 ]. In England, it has been shown that women with endometriosis consult their GP an average of six times before receiving a diagnosis [ 7 ]. A Danish study found that in the period up to 10 years before diagnosis, women with endometriosis used the healthcare system 19% more than those without the condition [ 8 ]. A Danish population cohort study reported a prevalence of 1.63% women in Denmark with a hospital-based diagnosis of endometriosis. This is significantly lower than estimates of prevalence, raising the possibility of under-ascertainment of cases [ 9 ]. There are concerns that this prolonged delay and underdiagnosis might contribute to disease progression, worsening of symptoms, and increased risk of chronic pain and infertility [ 10 ]. GPs play a pivotal role in the early recognition and management of endometriosis; however, this relies heavily on their awareness of the condition’s symptoms and sufficient knowledge about its presentation [ 11 ]. In Denmark, all citizens have free access to a GP, who serves as the primary point of contact with healthcare services. GPs act as gatekeepers, managing 90% of medical contacts and providing referrals to specialists, including gynaecologists and hospital services, when needed. Endometriosis care is typically provided in secondary care settings, including hospital-based gynaecology departments and a small number of specialised endometriosis centres, which patients can only access through GP referral [ 12 ]. Research identifies multiple factors contributing to the diagnostic delay in endometriosis. Both patients and doctors might normalise or dismiss severe menstrual or pelvic pain, compounded by a general lack of awareness and adequate knowledge about the condition, unclear clinical guidelines, and limited collaboration with gynaecologists [ 13–15 ]. Studies with GPs in England and the Faroe Islands suggest that framing delays solely as a lack of awareness may oversimplify the reality of clinical practice, including uncertainty about best practice when trials of treatment are effective in alleviating symptoms, and the structural challenges around referrals [ 16 , 17 ]. Factors contributing to diagnostic delays in Denmark remain unexplored. Building on a previous study by Dixon et al. [ 16 ], this study aimed to provide a comprehensive understanding of the challenges, reasoning pathways, and decision-making processes Danish GPs face when managing patients presenting with symptoms suggestive of endometriosis.

This study employed a qualitative research approach to gain in-depth insights into the diagnostic process of endometriosis in general practice in Denmark. The study is reported in accordance with the Standards for Reporting Qualitative Research (SRQR) [ 18 ]. The design included two main components, drawing inspiration from Dixon et al. [ 16 ], who used a comparable methodology to explore GPs’ perspectives in England: (1) two-phased co-production of fictional clinical vignettes, and (2) semi-structured interviews with GPs. In the preparatory phase, utilising their clinical and academic experience, MP and KEH reviewed real-life endometriosis cases to establish the foundation for creating fictional yet prototypical clinical vignettes. Our intention was to explore GP reflections across a range of possible presentations, including: A ‘textbook’ or typical presentation highlighting common gynaecological symptoms of endometriosis, such as dysmenorrhoea. A vignette focused on gastrointestinal symptoms, particularly noting the misidentification of endometriosis as IBS, which is a known factor in delayed diagnoses [ 19 ]. An adolescent vignette that, as earlier work suggests, represents an area of uncertainty for GPs [ 16 ]. A ‘textbook’ or typical presentation highlighting common gynaecological symptoms of endometriosis, such as dysmenorrhoea. A vignette focused on gastrointestinal symptoms, particularly noting the misidentification of endometriosis as IBS, which is a known factor in delayed diagnoses [ 19 ]. An adolescent vignette that, as earlier work suggests, represents an area of uncertainty for GPs [ 16 ]. A multidisciplinary workshop was organised to refine the fictional vignettes developed in Phase 1. Participants included the following individuals, with their initials referring to the authors of this study: Facilitator (MP). General practitioner (AP). Two endometriosis researchers (KEH, HM). Two clinical endometriosis experts (AF, MSH). Two patients with lived experiences of endometriosis. Facilitator (MP). General practitioner (AP). Two endometriosis researchers (KEH, HM). Two clinical endometriosis experts (AF, MSH). Two patients with lived experiences of endometriosis. The participant group was carefully selected to represent key stakeholders in the diagnostic process, ensuring the vignettes were realistic and clinically relevant. A structured and inclusive agenda ensured all voices were heard, fostering collaboration and consensus. After minor revisions, the workshop resulted in three expert-validated fictional vignettes. See Supplementary Material 1 for a detailed overview of the three clinical cases. GPs from three regions in Denmark were recruited using a two-pronged approach to ensure variation: Personal outreach: MP visited GP practices in Central Denmark, distributing recruitment letters. Collaborative outreach: Three GPs from the Research Unit for General Practice in Aarhus facilitated recruitment by sending invitation letters to their clinical networks. Personal outreach: MP visited GP practices in Central Denmark, distributing recruitment letters. Collaborative outreach: Three GPs from the Research Unit for General Practice in Aarhus facilitated recruitment by sending invitation letters to their clinical networks. This strategy ensured diversity in the sample, including urban and rural settings, single-handed practice and group practices, and practices with varying access levels to secondary and tertiary care. Recruitment stopped when this diversity was achieved. Halfway through recruitment, it became apparent that a larger proportion of female GPs expressed interest in participating. To promote gender balance, we explicitly encouraged the participation of male GPs. Despite these efforts, the final sample remained predominantly female. Participant characteristics are presented in Table 1 . The study included 27 practicing GPs (7 males and 20 females) with an average age of 50 (41–66 years) and clinical experience ranging from newly qualified to 27 years of practice. In Denmark, GPs are specialists in family medicine following a 5-year postgraduate training programme, which includes mandatory hospital rotations in obstetrics and gynaecology. GPs routinely perform pelvic examinations when clinically indicated and are responsible for cervical cancer screening (Pap smears) in primary care. There are no universally applied primary care-specific diagnostic criteria for endometriosis and GPs often refer patients through established gynecological referral pathways; rather, diagnosis is typically initiated based on patient symptom patterns and confirmed in secondary care. Baseline characteristics of participating GPs. *NA: not available. Data were collected through online semi-structured interviews conducted via Zoom by MP between March and September 2023. Interview length ranged from ∼30 to 45 min. GPs were presented with all three fictional clinical vignettes in sequence during the interviews, in the same order from 1 to 3. The clinical vignettes were designed to stimulate reflection on diagnostic reasoning and clinical interpretation, rather than to elicit formal diagnostic pathways. They served as conversation tools in the interview guide, prompting discussion around five key questions for each vignette. Are there other questions you would ask the fictional patient? What would you do next in an assessment or examination? Thoughts and considerations regarding preliminary/working diagnosis. Intended treatment plan. Suggestions for the patient. Are there other questions you would ask the fictional patient? What would you do next in an assessment or examination? Thoughts and considerations regarding preliminary/working diagnosis. Intended treatment plan. Suggestions for the patient. Each vignette included additional extensions, which all GPs were asked to consider during the interview (see Supplementary Material 1 for the full interview guide, including all vignettes). We adopted this approach because our aim was to explore the challenges, reasoning pathways, and decision-making processes that GPs encounter when managing these patients. GPs were informed that the interview would focus on managing gynaecological issues in general practice but were not informed about our endometriosis focus beforehand. Interviews were recorded, transcribed, and analysed by MP and LJN. The recordings were destroyed immediately after transcription, and the transcriptions were anonymised and stored securely in accordance with GDPR standards. MP translated the interviews into English for presentation in the manuscript. To ensure the accuracy of the translations, they were discussed with a native speaker and partially refined using a translation program (DeepL version 2.00) and ChatGPT version 4. Data analysis was performed using NVivo (version 14). MP and LJN followed Braun and Clarke’s six-phase thematic analysis approach using a hybrid inductive-deductive coding strategy [ 20 , 21 ]. The results were discussed and refined with UBK, KEH, SD, and LH. The multidisciplinary research team consisted of public health researchers (MP, LJN), GP researchers (AP, SD), endometriosis researchers (KEH, UBK, HM), a social scientist (LH), and gynaecologists specialised in endometriosis (AF, MSH) to provide a comprehensive and diverse perspective on the diagnostic process. MP and LJN were most closely involved in the analysis and were supervised by senior researchers with extensive experience in qualitative research (SD, LH, KEH, UBK).

Our analysis identified the complexity of reasoning pathways and decision-making processes for GPs in Denmark. We present our analysis through seven themes that are cross-cutting across the three vignettes, although it will draw out areas of similarity or difference within each theme. Quoted GPs are identified by a study ID followed by sex (F/M) and age (41–66 years) ( Table 2 ). Overview of themes identified in the study. All three vignettes illustrate the thorough assessment and diagnostic strategies GPs employ when managing patients with non-specific symptoms such as chronic pelvic pain, fatigue, difficulty concentrating, dyspareunia, and painful bowel movements: “We need to approach this systematically and experiment step by step” GP25, F44; Vignette 2 “When I am thinking about fatigue and difficulty concentrating, I will consider a wide range of possibilities, as a GP” GP18, F47; Vignette 1 Unsurprisingly perhaps, the classic textbook symptoms of endometriosis, such as menstrual pain or chronic pelvic pain, appear to be more readily recognised as indicative of this possibility. The majority of GPs we spoke to came quickly to suggest endometriosis in Vignette 1, whereas this was a less predominant consideration for the adolescent (Vignette 3) and least of all for the gastrointestinal symptoms (Vignette 2): “She might just be experiencing normal menstrual pain, which usually goes away on its own. It’s also possible she could have endometriosis” GP7, F41; Vignette 3 While the majority of GPs identified endometriosis as their final working diagnosis, they still conducted comprehensive assessments to rule out other potential causes or associations, including diabetes, anaemia, thyroid disorders, sexually transmitted infections, stress, past experiences of sexual assault, and overall mental well-being. “We need to approach this systematically and experiment step by step” GP25, F44; Vignette 2 “When I am thinking about fatigue and difficulty concentrating, I will consider a wide range of possibilities, as a GP” GP18, F47; Vignette 1 “She might just be experiencing normal menstrual pain, which usually goes away on its own. It’s also possible she could have endometriosis” GP7, F41; Vignette 3 Where symptoms followed a cyclical pattern, GPs in both Vignettes 1 (textbook) and 2 (gastrointestinal) were seemingly prompted to consider the possibility of endometriosis. “Do these [the symptoms] have any relation to her period?” GP20, F50; Vignette 2 Notably, nearly half of the GPs did not inquire about cyclicity themselves in the Vignette 2 (gastrointestinal), but when this cyclical pattern was made explicit in the vignette extensions, almost all suspected endometriosis. In contrast, for Vignette 3 (early onset), GPs did not inquire about the cyclical pattern, likely because this vignette clearly indicated that the patient presented with menstrual pain, an inherently cyclical symptom, rendering additional questions on this aspect unnecessary. The GPs highlighted that, as the first point of contact in the healthcare system, they encounter a wide range of patient concerns, making it essential to consider all possibilities and avoid missing a range of potential causes including cancer. In Vignette 2 (gastrointestinal), symptoms such as bowel issues and blood in the stool triggered a diagnostic hierarchy, where ruling out malignancies took precedence over considering non-malignant conditions like endometriosis. This approach was particularly emphasised due to the strong resemblance of symptoms to potential warning signs: “If you have blood from the rectum, I have to be sure it is not serious” GP20, F50; Vignette 2 This perspective also suggests that, in contrast to more serious concerns like malignancies, endometriosis may be perceived as less urgent or severe by some GPs. For example, the concern of ruling out malignancy was also evident, to some extent, in Vignette 1 (textbook): “If you have blood from the rectum, I have to be sure it is not serious” GP20, F50; Vignette 2 “It’s something we come across [in general practice], and it can be nothing or everything. It can be cancer that caused her to grow something crazy inside her ovary suddenly” GP18, F41; Vignette 1 Most GPs highlighted the importance of understanding their patients’ priorities and integrating individual preferences and concerns into medical decision-making. This emphasis on patient-centred care and shared decision-making was evident across all three vignettes. For example, one GP reflected on supporting the patient in Vignette 1 (textbook) based around exploring her personal reproductive concerns and priorities: “What about her pregnancy wish? Where is she at that? Depending on her situation, hormone therapy could be an option, and we can discuss how much hormone therapy she prefers and what steps to take next, such as scans or confirming the endometriosis diagnosis” GP3, M66, Vignette 1 Comparably, in Vignette 3 (early onset), one GP emphasised the importance of considering the patient’s future options while respecting her autonomy: “What about her pregnancy wish? Where is she at that? Depending on her situation, hormone therapy could be an option, and we can discuss how much hormone therapy she prefers and what steps to take next, such as scans or confirming the endometriosis diagnosis” GP3, M66, Vignette 1 “It depends on her wishes. Even though she’s not sexually active, she’s at an age where it could be the case in a few years. In this case, being on contraception might be fine, but it is up to her to decide. It depends on what she wants” GP12, M41; Vignette 3 Most of the GPs demonstrated strong awareness of patients’ psychological, emotional, and social well-being across all vignettes, guided by the bio-psycho-social model [ 22 ]. They emphasised that emotional distress could exacerbate physical symptoms, such as menstrual pain, while recognising that physical pain can negatively impact emotional well-being: “You can get stressed or feel down if you are in a lot of pelvic pain. Pelvic pain can also be worsened if you are stressed, upset, or in a bad mood, so it can create a bit of a spiral, all connected” GP25, F44; Vignette 2 However, some GPs seemed to adopt a mind-body dualistic approach, separating mental health concerns from physical health issues. For example, one GP explained that she wanted to understand what was most pressing for the patient. “You can get stressed or feel down if you are in a lot of pelvic pain. Pelvic pain can also be worsened if you are stressed, upset, or in a bad mood, so it can create a bit of a spiral, all connected” GP25, F44; Vignette 2 “I will ask the patient what is most important to her – her lack of mental well-being or her gynaecological problems” GP6, F; Vignette 1 This dualism was also evident in how GPs considered potential underlying causes. For instance, when the patient in Vignette 3 (early onset) presented with strong menstrual pain, one GP would inquire: “ Does she do well in high school, or is she unsure about where she belongs?” GP3, M66; Vignette 3 Although this may reflect an effort to understand psychosocial stressors, it risks overlooking the patient’s physical concern. “ Does she do well in high school, or is she unsure about where she belongs?” GP3, M66; Vignette 3 In Vignettes 1 (textbook) and 3 (early onset), awareness of the potential stigma surrounding gynaecological symptoms influenced some GPs’ assessments of the pain’s underlying cause. For instance, one GP suggested that feelings of exclusion might exacerbate menstrual pain: “Whether it is because she already feels excluded [from the group] and then the menstrual pain is seen as the cause in her mind, or if it is the other way around” GP19, F63 ; Vignette 3 Another GP suggested that the pelvic pain experienced by the patient in Vignette 1 (textbook) could be attributed to general life challenges commonly faced at the age of 25: “Life can hurt and manifest as pain in the lower abdomen for many reasons when you are 25” GP23, F46; Vignette 1 This may reflect an underlying stigma where pain related to the lower abdomen in women is psychologised rather than acknowledged as a potential medical condition. However, most GPs maintained that the pain was primarily of biological origin: “Whether it is because she already feels excluded [from the group] and then the menstrual pain is seen as the cause in her mind, or if it is the other way around” GP19, F63 ; Vignette 3 “Life can hurt and manifest as pain in the lower abdomen for many reasons when you are 25” GP23, F46; Vignette 1 “It sounds like it could be endometriosis (…) causing her pain and stomach cramps” GP15, F49; Vignette 1 In Vignette 1 (textbook), many GPs recognised that endometriosis cannot be definitively diagnosed outside a specialist setting. They noted that in their experience of caring for patients longitudinally, gynaecologists also often overlook the condition. Consequently, they stressed the importance of referring patients to an endometriosis specialist or dedicated endometriosis clinics: “I have previously referred a patient to a gynaecologist who does not find anything. That’s why if I have a specific suspicion, I refer them directly to a specialized gynaecologist with expertise in endometriosis because I know a lot of general gynaecologists often overlook it” GP21, F56; Vignette 1 This theme was less relevant in Vignette 2 (gastrointestinal), as GPs were more inclined to refer patients to gastroenterologists due to the established diagnostic hierarchy. Comparably, in Vignette 3 (early onset), referral to a gynaecologist was less prominent, as most GPs preferred to trial hormone therapy before considering specialist involvement. This may reflect a reluctance to refer based on the patient’s young age. “I have previously referred a patient to a gynaecologist who does not find anything. That’s why if I have a specific suspicion, I refer them directly to a specialized gynaecologist with expertise in endometriosis because I know a lot of general gynaecologists often overlook it” GP21, F56; Vignette 1

One of the strengths of this study lies in its methodological approach. We co-developed realistic vignette scenarios in collaboration with multidisciplinary stakeholders and patients to facilitate interviews. The three vignette scenarios varied in severity, age, and symptom profiles, enabling a comprehensive exploration of GPs diagnostic and management approaches. This design captured a diverse range of clinical experiences and decision-making processes, strengthening the robustness of our findings. In this study, GPs were unaware that the focus was on endometriosis, allowing for authentic reflections on their diagnostic considerations, closely mirroring real-life primary care scenarios. Recruitment efforts were designed to ensure a representative sample, including in-person clinic visits and direct distribution of recruitment letters, which helped engage GPs without prior research affiliations. Additionally, the analysis was conducted by two researchers with input from the wider team, enhancing rigour, ensuring cross-validation, and maintaining thorough quality control. However, this study has some limitations. Most participants were from Central Denmark, which may limit the applicability of findings to other regions. Additionally, female GPs were overrepresented, potentially reflecting their interest in the subject area, which their sphere of work may in turn influence because of evidence that female patients tend to prefer female GPs. In Vignette 2 (gastrointestinal), some GPs acknowledged that the study’s gynaecological context influenced their diagnostic reasoning, suggesting they might not have considered this perspective in routine practice. Furthermore, a few participants reported refreshing their knowledge of gynaecology before the interview. This may have increased their likelihood of focusing more on gynaecological causes than in a real-life clinical setting.

Although the clinical vignettes were not designed to reconstruct formal diagnostic pathways, they illuminated recurring patterns in clinical reasoning. Even among experienced specialists in general practice, endometriosis emerged as a condition marked by uncertainty, shaped by non-specific symptom presentations, diagnostic hierarchies, and dependence on secondary care confirmation. Together, these insights suggest that diagnostic delay is not solely an issue of individual awareness, but of system organisation, highlighting the importance of strengthened cross-sector collaboration and clearer referral structures. Our study found that due to the non-specific nature of endometriosis symptoms, GPs must consider a broad range of potential diagnoses, even when prioritising the most concerning symptoms. This process is time-intensive and requires a thorough evaluation to rule out malignancies. Consistent with previous research, it often involves multiple consultations, physical assessments, and treatment trials [ 16 , 17 ]. The gastrointestinal presentation in Vignette 2 illustrates the diagnostic challenges GPs face, as most did not initially consider endometriosis as their initial working diagnosis. This underscores the crucial role of assessing cyclical symptoms when evaluating women with gastrointestinal complaints. Previous research suggests that diagnostic delays in endometriosis often occur because symptoms are misattributed to gastrointestinal conditions, such as irritable bowel syndrome [ 23 ]. The overlapping symptoms, including abdominal pain, bloating, and changes in bowel habits, likely contribute to the diagnostic uncertainty and delay [ 19 ]. This study contributes potential explanations for this by contextualising it in the reflections on process and competing considerations that GPs are managing in real world practice when patients present with undifferentiated symptoms. Some GPs’ reflections to Vignette 1 (textbook) and Vignette 3 (early onset) suggest an element of possible mind-body dualism. This risks overlooking the interplay between biological, psychological, and social factors in endometriosis management with possible implications for the interpretation of symptom patterns that could be indicative of endometriosis. One possible explanation may be clinical uncertainty surrounding endometriosis and the presence of both physical and psychological symptoms in patients. This complexity may contribute to moments of dualistic reasoning in clinical interpretation, focusing on treating one symptom at a time as a more manageable approach. Research suggests that endometriosis can severely impact psychosocial well-being, contributing to stress, anxiety, and depression [ 3 , 24 ]. Our study found that stigma surrounding gynaecological symptoms might influence assessments of pain. While holistic care requires personalised impacts of psychosocial factors on pain, and vice versa, there is a risk that this might complicate assessments of possible underlying causes, inadvertently blinkering clinicians to possible endometriosis. Patient-reported experiences highlight that their concerns are often perceived as dismissed by doctors, reflecting a lack of awareness about the diverse and heterogeneous symptoms of endometriosis [ 6 , 7 , 13 ]. Research further suggests that the frustration and disbelief many women with endometriosis experience in their healthcare encounters can contribute to increased anxiety and depression [ 25 ]. GPs described their endeavours to take a patient-centred approach, balancing medical considerations with patients’ priorities through shared decision-making. Consistent with previous research, this reflects their commitment to high-quality care and underscores the multifaceted role of GPs; not only managing medical treatment but also guiding patients through complex decisions while addressing their personal values and concerns [ 16 , 17 ]. Our study found that many GPs lacked trust in general gynaecologists and were hesitant to refer patients to them, based on previous negative experiences where gynaecologists outside of endometriosis clinics often overlooked the condition. This suggests a systemic barrier contributing to diagnostic delays. A Danish study identified significant regional disparities in the incidence of hospital-diagnosed endometriosis, indicating unequal access to specialised care across the country [ 9 ]. This suggests that distrust in general gynaecologists may further hinder timely diagnosis, particularly in regions with limited access to endometriosis specialists [ 26 ]. The Danish Society of Obstetrics and Gynaecology (DSOG) recently introduced new guidelines for diagnosing endometriosis in Denmark. However, these guidelines do not specifically address general practice nor provide clear recommendations for how GPs should manage endometriosis [ 27 ]. As a result, GPs may lack sufficient support when navigating complex cases. Previous studies suggest that effectively addressing endometriosis requires a systems-based approach, including improved referral pathways and stronger collaboration between GPs, gynaecologists, and endometriosis specialists [ 11 , 15 ].

This study highlights the challenges of diagnosing and managing endometriosis in primary care, including non-specific symptoms, diagnostic hierarchies, and persistent stigma. While many GPs adopted a patient-centred approach, with holistic consideration of the interaction between symptoms and psychosocial context, we reflect on the potential for an unintended consequence of overlooking or misattributing physical symptoms in this work. Systematic inquiries about cyclical symptoms, particularly in gastrointestinal cases, could improve early recognition. A lack of trust in general gynaecologists may further delay specialist referrals, underscoring the need for stronger collaboration and clearer referral pathways. Targeted GP and specialist (across domains) education on endometriosis’ diverse presentations is essential to reduce misdiagnoses. Enhancing interdisciplinary collaboration, adopting a bio-psycho-social model, and increasing awareness can help reduce diagnostic delays and improve patient outcomes in primary care.

This study highlights several key areas for improving endometriosis diagnosis and management in primary care and onward systems. Given the non-specific nature of symptoms, GPs play a critical role in recognising and addressing diagnostic delays. Ensuring that endometriosis is considered in differential diagnoses, particularly for patients presenting with cyclical pain, gastrointestinal symptoms, or unexplained chronic pain, is essential. We recommend that GPs systematically ask about the cyclical nature of symptoms in women presenting with gastrointestinal issues, as this can facilitate earlier identification of endometriosis. One finding was the persistence of stigma surrounding gynaecological symptoms, which, in some vignettes, influenced diagnostic reasoning. While many GPs demonstrated a patient-centred approach, we reflect that we heard some accounts resonant with mind-body dualism, separating psychological and physical symptoms. Greater emphasis on the bio-psycho-social model in primary care could enhance holistic patient management, ensuring that both biological and psychosocial factors are considered in the diagnostic and treatment process. The study also illuminated that the GPs we spoke to expressed limited trust in general gynaecologists, based upon their accumulated experiences, which may contribute to delays in specialist referrals. The reported lack of trust in general gynaecologists may reflect cumulative experiences of diagnostic uncertainty across sectors, suggesting that delays are not solely rooted in primary care but emerge within a broader system of shared accountability. Addressing this systemic issue requires strengthening collaboration between primary care providers and gynaecologists and other specialists. Clearer referral pathways and establishing multidisciplinary care centres specialising in endometriosis could improve patient access to timely and comprehensive care [ 16 , 17 , 28 ]. Finally, targeted GP education on the broad and varied presentations of endometriosis is essential. Many diagnostic delays stem from misattribution of symptoms to gastrointestinal or psychological conditions, reinforcing the need for targeted training. By increasing awareness and refining diagnostic strategies, GPs can play a pivotal role in reducing delays, improving patient outcomes, and ensuring that women with endometriosis receive the care they need without unnecessary barriers [ 11 , 15 ].