Page 157 - Diagnostic delay of endometriosis

Endometriosis is problematic in the primary care setting for various reasons. Patients initially present to their general practitioner not with endometriosis, but with a combination of symptoms that could be the result of a variety of conditions. The extent of disease does not necessarily correlate with the severity of symptoms, and women may be diagnosed opportunistically when presenting with other problems, for example infertility. They may have extensive disease, but only mild or even absent symptoms and vice versa. This scenario does not correspond to common expectations of disease and presenting symptoms. Since for many women the occurrence of their symptoms coincides with menstruation, general practitioners may have a tendency to trivialize symptoms and consider them as ‘normal’ discomforts. This normalisation can result in symptom control rather than a search for a diagnosis. On average, women with endometriosis report seven visits to their general practitioner before being referred to a specialist, and nearly three-quarters of women experience misdiagnosis.13, 14 It is for these reasons, amongst others, that unsatisfactory experiences within the primary care setting are common. 5, 15, 16 Qualitative studies in women with endometriosis revealed that many of them felt that their symptoms were not taken seriously despite frequent encounters with a general practitioner, and perceived a long-term struggle to receive an appropriate referral.
As a general practitioner, I would notice that some women do not return to my office, but I may not be aware of the underlying reason why some patients give up going to their doctor and choose to endure the pain until something triggers them to return.3, 5 One of my key objectives is to acknowledge all of my patients in their concerns and take them seriously. As I am the gate keeper for medical specialist care, it is important for me to consider which patients will require a referral for medical specialist care, and which can be managed in primary care. A close collaboration with gynaecologists will provide me with an easily accessible opportunity to discuss individual patients with a specialist to optimize the appropriate level of care. An adequate evaluation of a woman presenting with pelvic or menstrual complaints consists of a recording of the full spectrum of symptoms combined with a carefully conducted but complete gynaecologic evaluation, which is challenging given the limited consultation time. It appears that a majority of general practitioners does not feel confident in identifying signs consistent with endometriosis in speculum and bimanual examination, and many of them omit a gynaecological examination even if they suspect endometriosis.5, 17 The development of a widely available and accurate non-invasive diagnostic test for endometriosis may seem like the
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