Title: Cross-sectional study for derivation of a cut-off value for identification of a early versus
delayed diagnosis of endometriosis based on analytical and descriptive research methods
Version: 3 Date: 02 Aug 2022
Reviewer's report:
1. The authors use statistical modeling to determine a cutoff value for a “timely” diagnosis. They
use this to determine that the early onset of symptoms is the most important risk factor for a long
delay. Young age at first physician consultation was also associated with a long delay. There
were no other significant findings.
2. The use of a cutoff to determine factors that cause delay seems reasonable. But it is not clear
why a 5-year delay is “timely.” There is no excess morbidity in the data. Clarify why a 5-year
delay is “timely.”
3. Your title implies that it is reasonable to treat non-responsive pelvic pain medically for 5 years
without a diagnosis. Is that what you mean?  If not, the title needs to be corrected to demonstrate
that this identifies only two factors associated with a long delay but not the length of time for
a "timely" diagnosis as promised in the title.
4. What is your cutoff for non-responsive pelvic pain that is treated medically?
5. How does the delay in your groups compare with Staal, et al., your references 36 & 39?
6. When should patents be treated surgically?
7. Line 43 What does “definitively diagnosed” mean? i.e., surgical visualization, histology,
imaging, etc.?
8. Line 43 Does “definitively diagnosed” include treatment?
9. Line 49-50. Is an “urgent need to develop adequate concepts to improve the endometriosis
education and care among” adolescents similar to a need to care for dysmenorrhea in adolescents.
10. Line 77-79 Is “long delay in diagnosis” also associated with asymptomatic endometriosis.
Fuentes et al. (2014) have a 14% prevalence in groups known to be asymptomatic contrasted
with 2.3% in retrospective control groups with no symptoms or surgical approach clarified. Is
delay also associated with asymptomatic endometriosis and no need for surgery in more women
than those who have surgery for pain? [Fuentes A, et al, Prevalence of endometriosis in 287
women undergoing surgical sterilization in Santiago Chile). (Article in Spanish) Rev Med Chil.
2014 Jan;142(1):16-9. PMID: 17976623, PMCID: PMC2289387]
11. Line 81 Discuss your data on the “health-related quality of life” as analyzed in Table 6 with
no difference in pain intensity or ASRM score. Were other factors analyzed?
12. Line 203 -220: What were the indications for surgery in the German arm of the EndoCost
study?
13. Line 203 -220: Does the data change when based on the indication?
14. Line 230, Table 2. Please clarify “First physician consultation” in Table 2. Is it the same as
the “Age first physician consultation“ in Table 6?
15. Line 288-299: If “None of the demographic or disease-related variables studied,” including
ASRM stage, was associated with “the length of the diagnosis delay,” why is the 5-year cutoff
important?
16. Line 288-299: What adverse events were associated with “the length of the diagnosis delay”
in this study?
17. Line 288-299: Contrast the adverse events associated with “the length of the diagnosis delay”
in this study with those in your reference 23 (Surrey et al. 2020).
18. Line 328-330 Is 5 years your “defined target corridor for diagnosis” by physicians and
endometriosis patients”? Please contrast that with 6- to 12-month trials of NSAIDs and hormonal
suppression.
19. Line 328-330 If 5 years is your “defined target corridor for diagnosis” by physicians and
endometriosis patients,” please expand on the one year in your reference 23 (Surrey et al. 2020).
20. Line 440-443 What is the citation for dienogest controlling symptoms “but it sometimes
does not significantly slow down the activity of the disease itself”? How often does this occur?
21. Line 495: Clarify the “unfavorable course of the disease” that occurs if the delay is greater
than 5 years.