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

Abstract

<h3>Background</h3> 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. <h3>Methods</h3> 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. <h3>Results</h3> 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<0.0001), respectively. ED visitation was highly correlated with presence of adnexal mass on imaging (Pearson's r=0.62, p<1.2e-9), but not independently associated with shorter diagnostic delay. <h3>Conclusions</h3> 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.