6. Time elapsed from initial presentation to diagnostic laparoscopy: factors affecting diagnostic delay in adolescents with biopsy-confirmed endometriosis

Abstract

Background Endometriosis is common among adolescents with chronic pelvic pain but remains underdiagnosed, in part due to a desire to avoid major surgery for young patients. We sought to identify factors affecting time from presentation to laparoscopy (diagnostic delay) in adolescents with biopsy-proven endometriosis. Methods This is a retrospective review of medical records of women aged 14-25 who underwent diagnostic laparoscopy with biopsy-proven endometriosis at a tertiary hospital system between January 2011 and September 2020. Time from initial presentation to laparoscopy was calculated. Multiple regression analysis was used to test the effect of 3 variables on diagnostic delay: specialty of initial OB/GYN provider (community generalist or subspecialist), clinical setting of initial encounter (routine outpatient visit or ED-/hospital-associated visit), and presence of an adnexal mass on initial imaging. Statistical analysis was performed in Prism v.8. This study was approved by the institutional review board. Results Of 254 adolescents who underwent laparoscopy, 91 (35.8%) had biopsy-proven endometriosis. Of these, 80 had a documented initial encounter prior to laparoscopy and thus included in final analysis. In our sample, median delay to laparoscopy was 5.2 (IQR 2.1-31.8) months. This included 33 (41%) patients who presented to a subspecialist (including via referral from outside providers with no prior records available). For patients presenting to community generalists, median delay was 24.6 (3.5-42.8) months. For women who presented after ED or hospital visit (20%), median delay was 0.6 (0.1-3.7) months, compared to 11.1 (3.3-35.4) in the outpatient setting. If an adnexal mass was found on initial imaging (35%), median delay was 1.6 (0.3-3.7) months, compared to 19.4 (4.7-39.5) without imaging findings. In multiple regression analysis, initial presentation to a subspecialist and presence of an adnexal mass were associated with a shorter time to laparoscopy, with an estimated decrease of 5.2±1.8 months (p=0.005) and 18.6±3.4 months (p Conclusions Patients in the community setting experienced a median time from presentation to definitive diagnosis of over 2 years. Patients with an adnexal mass on initial imaging (35%) experienced a significantly shorter time to laparoscopy (-18.6 months). While presentation to a subspecialist was also associated with a shorter diagnostic delay, the impact of subspecialty referral on access to diagnostic laparoscopy and potential practice differences between generalists and subspecialists requires further study.