Referee report. For: Diagnosis of pelvic endometriosis: A systematic review and accuracy meta-analysis of non-invasive tests available in primary care [version 1; peer review: 1 approved with reservations, 1 not approved]

This systematic review and accuracy meta-analysis synthesized primary test-accuracy studies (125 studies; 250,574 participants) evaluating how symptoms, clinical history, and first-line non-invasive tests perform for predicting pelvic endometriosis, using surgical or non-surgical reference standards; searches ran through September 2022 across major databases and pooled effects with bivariate random-effects models. Across studies of mixed quality, dysmenorrhoea, pelvic pain, dyschezia, dyspareunia, family history, nulligravidity, BMI, trans-vaginal ultrasound findings (including endometrioma and invasive endometriosis), and CA-125 were quantified via summary diagnostic odds ratios, with greater bias risk in studies using non-surgical (database/self-report) reference standards. A limitation explicitly noted by the reviewer includes mixed study quality and reliance on reference standards that varied by study design. This paper is centrally about endometriosis — it systematically evaluates the diagnostic accuracy of non-invasive tests and symptoms for pelvic endometriosis in primary care.

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