General practitioners and endometriosis: Level of knowledge and the impact of training

Participation of general practitioners and therapeutic patient education in the care of infertile couples

BACKGROUND

Fertility treatment pathways are complex and lengthy. The current prevalence of infertility makes it a public health issue. The involvement of general practitioners and the training of fertility instructors to provide therapeutic education have been suggested as ways of involving patients in the process and improving the therapeutic trajectory of these patients, who often have co-morbidities.

OBJECTIVE

To describe the activity of trained fertility instructors; to assess the interest of doctors in the fertility chart provided by women; and to describe the outcomes of their fertility care pathway.

METHODS

66 French fertility instructors were interviewed in June 2024. The 15 general practitioners who had received additional training were also interviewed. The records of all couples who received fertility counselling and treatment between 1 January 2022 and 31 December 2023, the study cut-off date, were analysed.

RESULTS

Doctors declared that the women had gained a clear understanding of their menstrual cycle, which was useful for diagnosis and treatment follow-up. The chart was particularly useful for diagnosing the causes of infertility and identifying when in the cycle to take medication. Only 4 of the 551 women were lost to follow-up. Of the remaining 547 women, 204 (37%) became pregnant. Of these, 75% had a live birth or an ongoing pregnancy at study cut-off.

CONCLUSIONS

The involvement of fertility instructors and general practitioners improved the couple's ability to interact with doctors and to adhere to infertility treatment. The fertility chart provided by the women proved to be useful in the diagnosis and treatment process.

The impact of early diagnosis of endometriosis on quality of life

BACKGROUND

Endometriosis is one of the most common chronic diseases in women, with a prevalence of up to 10%. The disease particularly affects women of reproductive age. Endometriosis has a significant impact on the patient's quality of life (QoL). In the current study, we aimed to evaluate the role of early diagnosis of endometriosis on patients' QoL.

METHODS

In this longitudinal prospective study, 205 women with endometriosis who were referred to the gynecology department of Amir al-Mominin Hospital (Zabol-Iran) in 2021 were evaluated. Patients were divided into two groups based on the time of diagnosis, including early diagnosis and late diagnosis. An Endometriosis Health Profile (EHP) questionnaire was used to collect information about QoL before and 18 months after treatment. Data were analyzed using SPSSv.26 software and significance level was considered less than 0.05.

RESULTS

In both groups with early and late diagnosis, the QoL scores improved without significant difference (p = 0.303). There was a significant difference between lower stages (1 and 2) and higher stages (3 and 4) in terms of treatment effects on patients' QoL, and higher stages of endometriosis affected patients' QoL before and after treatment more than lower stages (P values < 0.05).

CONCLUSION

Early or late diagnosis of endometriosis doesn't affect patients' QoL and patients benefit from treatment regardless of the time of diagnosis.

Prevalence and sociodemographic distribution of endometriosis symptoms and indicators in Denmark

INTRODUCTION

Endometriosis is characterized by a range of non-specific symptoms which may contribute to the significant delay in diagnosis. Knowledge about the distribution of endometriosis symptoms across different geographical regions as well as other sociodemographic factors could add knowledge and guide initiatives to reduce this underdiagnosis. This study aims to explore how the prevalence of endometriosis symptoms and indicators are linked to the different sociodemographic factors.

STUDY DESIGN

The study used data from the CYKLUS-survey; a women's health survey sent to 63,199 Danish women aged 16 to 51 in 2023. Self-reported information on endometriosis symptoms and indicators was linked to Danish register data on sociodemographic factors. Age-standardized prevalence of six endometriosis symptoms and indicators were estimated for each of the nine different regions of residence and for the whole country. In addition, logistic regression analysis was used to estimate the association between sociodemographic factors and the six endometriosis symptoms and indicators.

RESULTS

11,407 women were included in the study. Age-standardized prevalence of symptoms showed little variation across Danish regions. However, younger age, lower socioeconomic status, and non-Danish origin were found to be associated with higher prevalences, and higher education was found to be associated with lower prevalences.

CONCLUSION

No major regional differences in endometriosis symptoms and indicators were found. However, associations were found between several sociodemographic factors and endometriosis symptoms and indicators, suggesting disparities in the burden of symptoms. These findings call for further investigation into factors causing these disparities in Denmark.

Assessing healthcare needs in endometriosis: a scoping review

OBJECTIVE

Women with endometriosis still have to seek the legitimacy of their disease from the medical community and often feel unheard. This scoping review aims to map the scientific literature to describe barriers and facilitators in the endometriosis management from both patients' and healthcare professionals' (HCPs') perspectives.

METHODS AND MEASURES

We searched the literature published between 2012 and 2023 in the Web of Science, PsychInfo, PubMed, CINAHL, Embase, and Cochrane Library databases. A total of 52 eligible studies were identified.

RESULTS

We observed several barriers in the endometriosis management: the perception of patients as challenging and psychosomatic; lack of awareness and medical knowledge; persistent taboos and biases; challenging communication about pain, pregnancy, and infertility; lack of empathy from HCPs; and barriers in diagnostic tools and healthcare accessibility. Key facilitators were HCPs and community awareness; taking patients' symptoms seriously; compassionate communication about fertility and pain; shared decision-making, encouraging patients to seek evidence-based information; and multidisciplinary support.

CONCLUSION

We were able to identify concrete barriers and facilitators to successful endometriosis management. Future research is now required to identify optimal ways to implement this evidence, and research the extent to which it applies to more diverse populations in non-Western setting, and to explore the impact of HCP demographic characteristics.

Informational support for women with endometriosis: a scoping review

BACKGROUND

Ten per cent of women of reproductive age suffer from endometriosis, a painful and incurable disease that leaves women with severe implications for their health and overall well-being. Due to the absence of a cure and the limited effectiveness of available treatments, acquiring accurate information is paramount for women to successfully navigate both their daily lives and the complexities of the healthcare system. This scoping review aimed to map the current literature on women with endometriosis information needs, their information seeking behaviour, and the format and scope of current information resources available.

METHODS

The scoping review was conducted using the JBI methodology for scoping reviews and reported according to the PRISMA-ScR statement. The final search was conducted in August 2024, through the databases Medline, Cinahl, Embase, Scopus, and WebofScience. Studies on information resources on endometriosis and information seeking behaviour as well as information needs of women with endometriosis were eligible for inclusion.

RESULTS

The majority of the 25 included studies focused on information resources, specifically webpages and social media sites. While few studies analysed information seeking behaviour and information needs, the evidence shows women's high interest in a broad spectrum of information topics. Across all studies, the internet was the most important access point for information.

CONCLUSION

Addressing the absence of systematic analyses on the information seeking behaviour and needs of women with endometriosis is crucial for future research. This step is essential for the development of customised information resources that cater specifically to the diverse needs of women affected by endometriosis.

Understanding AI's Role in Endometriosis Patient Education and Evaluating Its Information and Accuracy: Systematic Review

BACKGROUND

Endometriosis is a chronic gynecological condition that affects a significant portion of women of reproductive age, leading to debilitating symptoms such as chronic pelvic pain and infertility. Despite advancements in diagnosis and management, patient education remains a critical challenge. With the rapid growth of digital platforms, artificial intelligence (AI) has emerged as a potential tool to enhance patient education and access to information.

OBJECTIVE

This systematic review aims to explore the role of AI in facilitating education and improving information accessibility for individuals with endometriosis.

METHODS

This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to ensure rigorous and transparent reporting. We conducted a comprehensive search of PubMed; Embase; the Regional Online Information System for Scientific Journals of Latin America, the Caribbean, Spain and Portugal (LATINDEX); Latin American and Caribbean Literature in Health Sciences (LILACS); Institute of Electrical and Electronics Engineers (IEEE) Xplore, and the Cochrane Central Register of Controlled Trials using the terms "endometriosis" and "artificial intelligence." Studies were selected based on their focus on AI applications in patient education or information dissemination regarding endometriosis. We included studies that evaluated AI-driven tools for assessing patient knowledge and addressed frequently asked questions related to endometriosis. Data extraction and quality assessment were conducted independently by 2 authors, with discrepancies resolved through consensus.

RESULTS

Out of 400 initial search results, 11 studies met the inclusion criteria and were fully reviewed. We ultimately included 3 studies, 1 of which was an abstract. The studies examined the use of AI models, such as ChatGPT (OpenAI), machine learning, and natural language processing, in providing educational resources and answering common questions about endometriosis. The findings indicated that AI tools, particularly large language models, offer accurate responses to frequently asked questions with varying degrees of sufficiency across different categories. AI's integration with social media platforms also highlights its potential to identify patients' needs and enhance information dissemination.

CONCLUSIONS

AI holds promise in advancing patient education and information access for endometriosis, providing accurate and comprehensive answers to common queries, and facilitating a better understanding of the condition. However, challenges remain in ensuring ethical use, equitable access, and maintaining accuracy across diverse patient populations. Future research should focus on developing standardized approaches for evaluating AI's impact on patient education and exploring its integration into clinical practice to enhance support for individuals with endometriosis.

Survey of General Practitioner Perspectives on Endometriosis Diagnosis, Referrals, Management and Guidelines in New Zealand

INTRODUCTION

There is a growing body of literature concerning endometriosis patients' perspectives on the healthcare system and endometriosis care in New Zealand. However, there is little research available on the perspectives of general practitioners (GPs) internationally, and none currently in New Zealand. The purpose of this study is to address New Zealand GPs' understanding of and approach to endometriosis diagnosis, referrals, management and guidelines.

METHODS AND MATERIALS

An online, anonymous survey was shared with 869 GP clinics and completed by 185 New Zealand-based GPs regarding their awareness and application of the inaugural 2020 'Diagnosis and Management of Endometriosis in New Zealand' guidelines, their perception of their endometriosis knowledge, the diagnostic value they assign to symptoms, the treatments they recommend and the reasons they refer patients to specialist gynaecologists. Differences between groups were conducted using Chi-squared tests, and text answers were assessed thematically using inductive, semantic coding.

RESULTS

All 185 GPs had gynaecology consults, and 73% had gynaecology consults every week. Despite 65% being aware of the 2020 guidelines, only 35% overall had read them. Only 52% of GPs considered themselves to know enough about endometriosis for their routine practice. The most common treatment to be considered first line was intrauterine contraceptive devices (IUDs; 96%), whereas the most common alternative treatment recommended was exercise (69%). The most common reason for referral to specialist care was the failure of all attempted treatments (84%).

CONCLUSIONS

Many of the study's results align with current New Zealand and international endometriosis guidelines, particularly the prioritisation of progestin-only therapies, the reduced emphasis on surgical treatment as the first line and the low rates of alternative treatment recommendations. This study also highlights the need to improve awareness of inappropriate GP recommendations, including long-term treatment with prescription-only pain relief such as codeine and pregnancy for symptomatic relief.

PATIENT OR PUBLIC CONTRIBUTION

Two of the authors involved in the design and conduct of the study, data interpretation and manuscript preparation have sought care for endometriosis.

TRIAL REGISTRATION

NA.

Towards reducing diagnostic delay in endometriosis in primary care: a qualitative study

BACKGROUND

Due to a heterogeneity of symptoms, a lack of an adequate diagnostic test, and a lack of awareness, diagnostic delay in endometriosis in primary care on average amounts to 35 months.

AIM

To determine which interventions are most feasible to reduce time to diagnosis in primary care, focusing on GPs' preferences, the intervention's content, design, and implementation.

DESIGN & SETTING

We conducted a qualitative study by performing focus groups with GPs and GP trainees between July and October 2021.

METHOD

Data collection was continued until saturation was obtained. Focus groups were transcribed and openly encoded. Themes were formulated by three independent researchers.

RESULTS

Divided over five focus groups 22 GPs and 13 GP trainees participated. Three themes were formulated: increasing awareness, combined intervention, and reaching unaware GPs. Suggestions for a combined intervention strategy were adaptation of guidelines, a diagnostic support tool, and compulsory education. To reach unaware GPs, participants felt that education should be offered in regional networks and education for GP trainees should be mandatory. A guideline on menstrual symptoms should be considered and the term endometriosis should be added to the differential diagnosis paragraphs of existing guidelines. A diagnostic support tool should be linked to a guideline and consist of a flowchart with steps starting with the first presentation of symptoms leading to the diagnosis of endometriosis.

CONCLUSION

According to GPs, a combined intervention strategy consisting of an adapted guideline, a diagnostic support tool, and education might be successful interventions in reducing diagnostic delay in endometriosis.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Perception and Comfort with Endometriosis Management Among OB/GYN Residents

Purpose

The diagnosis of endometriosis often takes several years, delaying appropriate care while patients suffer from pelvic pain, dysmenorrhea, and dyspareunia. Understanding whether residents in obstetrics and gynecology (OB/GYN) are being adequately exposed to and trained in the diagnosis and management of the disease is important for improving care.

Methods

We conducted an online cross-sectional survey of OB/GYN residents to investigate their comfort level and familiarity with endometriosis diagnosis and management. Residency program directors and coordinators of 20 OB/GYN residency programs in California, USA were emailed to disseminate the 31-question, anonymous survey in January to February 2023. Responses were collected using Redcap and analysis was conducted using STATA.

Results

67 residents answered at least one non-demographic question and were included. A resident response rate was not calculated because we were unable to determine how many programs distributed the survey. 84% of residents felt they could recognise symptoms of endometriosis but over 30% of senior residents were not comfortable with sonographic diagnosis of endometrioma. Approximately one third of residents felt comfortable managing hypoestrogenic symptoms, osteoporotic risks, and add-back progestin for certain hormonal therapies. Academic-hospital based residents had significantly more exposure to attendings prescribing long-acting reversible contraception, GnRH antagonists, and GnRH agonists but there were no significant differences in trainee prescribing practices or comfort. More respondents would feel comfortable medically managing endometriosis (52%) than surgically managing the disease (26%) if they were in practice today, with only 39% of PGY3-4 residents feeling comfortable surgically managing endometriosis.

Conclusion

There is considerable room for improvement in the education of residents in the diagnosis and medical and surgical management of endometriosis.

Utilization of healthcare prior to endometriosis diagnosis: a Danish case-control study

STUDY QUESTION

Do women with endometriosis have higher utilization of primary and secondary healthcare prior to diagnosis compared to women without endometriosis?

SUMMARY ANSWER

Women with a hospital-based diagnosis of endometriosis had an overall higher utilization of both primary and secondary healthcare in all 10 years prior to diagnosis.

WHAT IS KNOWN ALREADY

Endometriosis is associated with a diagnostic delay, but only a few studies have investigated the potential consequences of this delay with regard to the utilization of healthcare. To the best of our knowledge, no study has investigated it in a period corresponding to the estimated diagnostic delay.

STUDY DESIGN, SIZE, DURATION

This national Danish registry-based case-control study included 129 696 women. Cases were women with a first-time hospital-based diagnosis of endometriosis between 1 January 2000 and 31 December 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We identified 21 616 cases using density sampling. Each case was matched on age at the date of diagnosis (index date) to five women without diagnosed endometriosis (n = 108 080). The utilization of healthcare was assessed for the 10 years before the index.

MAIN RESULTS AND THE ROLE OF CHANCE

Cases had significantly higher use of healthcare in all 10 years preceding the index. The mean number of yearly contacts with the GP was 9.99 for cases and 7.85 for controls, with an adjusted incidence rate ratio of 1.28 (1.27; 1.29). For hospital contacts, the association increased slightly in the first 9 years and was most profound in the last year preceding index when the adjusted incidence rate ratio was 2.26 (95% CI 2.28; 2.31).

LIMITATIONS, REASONS FOR CAUTION

We were not able to include women with an endometriosis diagnosis from the general practitioner or private gynaecologist. Therefore, our results are only applicable to hospital-based diagnoses of endometriosis. We do not have information on the specific reasons for contacting the healthcare providers and we can therefore only speculate that the higher utilization of healthcare among cases was related to endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

This study is in agreement with the other known studies on the subject. Future studies should include specific reasons for contacting the healthcare system and thereby identify any specific contact patterns for women with endometriosis. With this knowledge, healthcare professionals could be better at relating certain healthcare seeking behaviour to endometriosis earlier and thereby reduce the time from onset of symptoms to diagnosis.

STUDY FUNDING/COMPETING INTEREST(S)

This study is supported by grants from the project 'Finding Endometriosis using Machine Learning' (FEMaLe/101017562), which has received funding from The European Union's Horizon 2020 research and innovation program and Helsefonden (21-B-0141). K.Z. report grants from Bayer AG, Roche Inc. and Volition, royalties from Oxford-Bayer scientific collaboration in gynaecological therapies, non-financial collaboration with the World Endometriosis Society and World Endometriosis Research Foundation and is a Wellbeing of Women research advisory committee member. All this is outside the submitted work. The other authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Dismissal informs the priorities of endometriosis patients in New Zealand

Introduction

Endometriosis is a common condition with average delays to diagnosis in New Zealand of almost 9 years.

Methods

In total, 50 endometriosis patients participated in anonymous, asynchronous, online group discussions about their priorities, and their experiences with the development of symptoms, seeking a diagnosis, and receiving appropriate treatment.

Results

Higher subsidy of care was the top change endometriosis patients wanted, followed by more research funding. When asked to choose whether research should be focused on improving diagnosis or improving treatment methods, the results were evenly split. Within this cohort, patients highlighted that they did not know the difference between normal menstrual discomfort and pathological endometriotic pain. If, upon seeking help, medical practitioners classified their symptoms as "normal," these dismissals could instill doubt in patients, which made it more difficult for them to continue to seek a diagnosis and effective treatments. Patients who did not express dismissal had a significantly shorter delay from symptom onset to diagnosis of 4.6 ± 3.4 years vs. 9.0 ± 5.2 years.

Conclusion

Doubt is a frequent experience for endometriosis patients in New Zealand, which was reinforced by some medical practitioners who were dismissive of their pain and thus prolonged the patient's delay to diagnosis.

[Diagnosis and management of endometriosis by general practitioners in the south of France]

OBJECTIVE

Assessment of the practices and knowledge of general practitioners in the south of France regarding the diagnosis and management of endometriosis.

METHOD

A descriptive cross-sectional study was conducted among general practitioners in the south of France from November 14, 2021 to February 14, 2022. A questionnaire was developed in consultation with and validated by two university endometriosis reference services of the AP-HM and was sent to general practitioners practicing in the south of France. It was distributed via professional emails, care networks and the south of France's medical order. The questionnaire was divided into three parts: the first simply collected demographic and epidemiological data, the second assessed knowledge of the disease, and the last assessed individual practices. The primary endpoint was the percentage of practitioners with>75% correct responses.

RESULTS

133 general practitioners responded to the questionnaire (133/407, 32.1%). 60.2% performed more than one gynecological consultation per week. 61.7% obtained a rate of correct answers>75%. The general practitioners with the best response rates were more aware of the latest HAS guidelines (P=0.027) and performed gynecological consultations more regularly in the office (P=0.025). Intense dysmenorrhea, chronic pelvic pain and deep dyspareunia were considered as evocative by 98.1%, 95.5% and 95.5% of respondents respectively. On the other hand, uro-digestive disorders were not often mentioned. In case of suspicion of endometriosis on questioning, 54.9% of general practitioners performed a clinical gynaecological examination. 76.7% prescribed an imaging test and 32.3% introduced hormonal treatment during the consultation. Referral of patients to specialists was made by the general practitioner as soon as clinical suspicion arose for 36.8%.

CONCLUSION

The results of our study suggest that the knowledge and practices of general practitioners, performing gynecology consultations in the south of France, is perfectible. In the context of the announcement of a regional reorganization of endometriosis-related care, other similar studies should be conducted regularly in order to assess the evolution of general practitioner's practices.

Endometriosis Is Undervalued: A Call to Action

Endometriosis is an inflammatory chronic pain condition caused by uterine tissue growing outside of the uterus that afflicts at least 11% of women (and people assigned female at birth) worldwide. This condition results in a substantial burden to these women, and society at large. Although endometriosis was first identified over 160 years ago, substantial knowledge gaps remain, including confirmation of the disease's etiology. Research funding for endometriosis is limited, with funding from bodies like the National Institutes of Health (NIH) constituting only 0.038% of the 2022 health budget—for a condition that affects 6.5 million women in the US alone and over 190 million worldwide. A major issue is that diagnosis of endometriosis is frequently delayed because surgery is required to histologically confirm the diagnosis. This delay increases symptom intensity, the risk of central and peripheral sensitization and the costs of the disease for the patient and their nation. Current conservative treatments of presumed endometriosis are pain management and birth control. Both of these methods are flawed and can be entirely ineffective for the reduction of patient suffering or improving ability to work, and neither addresses the severe infertility issues or higher risk of certain cancers. Endometriosis research deserves the funding and attention that befits a disease with its substantial prevalence, effects, and economic costs. This funding could improve patient outcomes by introducing less invasive and more timely methods for diagnosis and treatment, including options such as novel biomarkers, nanomedicine, and microbiome alterations.

Internet-based cognitive behavioral therapy for improving health-related quality of life in patients with endometriosis: study protocol for a randomized controlled trial

BACKGROUND

The trial investigates the efficacy of internet-based cognitive behavioral therapy (iCBT) in improving health-related QoL in patients with endometriosis, which is a chronic gynecological condition affecting up to 15% of people with female-assigned reproductive organs. Endometriosis is stress-related and comes with various physical symptoms such as pelvic pain and infertility. It has a substantial impact on health-related quality of life (QoL), and mind-body interventions seem promising in reducing the psychological burden.

METHODS

This is a monocentric randomized-controlled trial recruiting 120 patients with endometriosis. The intervention consists of eight iCBT modules focusing on psychoeducation, cognitive restructuring, pacing, and emotion regulation. Participants will receive written feedback from a trained therapist weekly. The comparator is a waitlist control group. All participants will be followed up 3 months after the intervention, and the intervention group will additionally be followed up 12 months after the intervention. Trial participants will not be blinded to the allocated trial arm. Primary outcome measures are endometriosis-related QoL, pain, and pain-related disability. Secondary outcomes include coping, illness representations, and psychological flexibility. Statistical analyses will be performed following intention-to-treat principles.

DISCUSSION

This randomized-controlled trial is the first trial to test the efficacy of iCBT for improving endometriosis-related QoL. Potential predictor variables and key mechanisms in treatment will be investigated to enable further progression in medical and psychological care for patients with endometriosis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT05098444 Registered on October 28, 2021.