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: 16 Aug 2022
Reviewer's report:
Comments to Authors:
In this article, the authors presented the results of a cross-sectional study for the identification
of a cut-off value of a timely versus late diagnosis of endometriosis. Authors used descriptive
statistics and location parameters to calculate this cut-off value, based on German data from the
EndoCost study.
Five years was identified as the cut-off value that significantly differentiated between short
diagnostic delay (shortDD) versus long diagnostic delay (longDD).  Overall, compared to
women with a shortDD, women with a longDD were not only 13.0 years younger at the age of
first symptom onset (19.3 vs. 32.3 years, p<0.001), but also 8.5 years younger (24.2 vs. 32.7
years old) at the time of first consultation with a physician (p<0.001). The younger the age at
symptom onset, the longer the patient and physician delay intervals and, thus, the longer the
total diagnostic delay.
Results highlight the importance of educating adolescent girls and young women about
endometriosis as a first important approach to improving endometriosis care. Authors suggest
that there is an urgent need to develop target group-specific strategies for informing young
women about normal and pathological menstrual symptoms.
The article is up-to date and well written.
However, there are some major critical points requiring revisions.
Title page:
Please, write authors’ affiliations in English.
Background:
Page 4, lines 72-75. Authors wrote “Surrey et al. [23] divided the diagnostic delay interval
into three categories: short (#1 year), intermediate (1-3 years) and long (3-5 years). Their
classification is intuitive but lacks methodological rigor”. Please, specify why there is a lack
in methodology.
Methods:
Page 6. Authors should specify more in detail their literature review search (time, sources,
eligibility criteria for studies, search strategy, selection process, risk of bias, etc…). I suppose it
is a narrative review but authors should specify it.  I suggest the authors to follow the PRISMA
checklist for systematic review.
Results:
Page 7, Literature Review. Authors should report the results of the electronic database research
process (total of identified articles, total of relevant articles after reading abstracts, total of
excluded articles and reasons, total of articled included in the review).
Table 1: Table 1 is included at the end of the main text (following references) and as a separate
file also. Please, include all the Tables and Figures as separate files only (not in the main text).
Table 1: Please, in the “Study” column specify first author’s name of the study. What
does “access” mean? It is not clear. There are some typos (study (32), Women with
histological confirmes (change in confirmed) endometriosis, nationwide; study (33), Women
with selfreported (change in self-reported) endometriosis, nationwide).
Figure 1:  I wonder how it is possible to have a diagnostic delay of 30 years (more in general
a diagnostic delay of more than 20 years).
Page 14, line 258. There is a typo. Please change “dignostic” with “diagnostic”.
Page 14, line 258. Please, change “variables are presented below (Table 5)” with “variables are
presented in Table 5”
Discussion:
Page 22, line 444. Authors state “The hormonal suppression of symptoms lulls physicians
and patients into a false sense of security.” This sentence requires an explanation. Are the
authors saying that medical management (hormonal suppression) for endometriosis is not safe
for women? Please explain.