The burden of endometriosis on patients and the health care system

Vered H Eisenberg, MD, MHA, senior obstetrician-gynecologist at Sheba Medical Center in the Sackler Faculty of Medicine at Tel Aviv University in Israel and colleagues conducted the retrospective, case-controlled study.¹ Researchers reviewed case records from a computerized database of a nationwide Israeli healthcare plan containing 2.1 million members. This is approximately 25% of the country’s population and reflects its demographics. Researchers cited another study where data sources are fully described.²

From this database, researchers examined 6,146 women between the ages of 15-55 years (mean age ± SD: 40.4 ± 8.0) as of December 31st, 2015 that had been enrolled in the health care plan for a full year and had been diagnosed by a PCP or other specialist with endometriosis between 1998-2015. “While the results of imaging and surgical evaluation were not used for validating the diagnosis, more than 90% had a previous record of a pelvic/gynecological US examination,” the authors said. Endometriosis patients were compared with 24,572 controls who had not been diagnosed with the condition. They were matched 1:4 based on age in 5-year groupings, and on where participants resided.

Eisenberg and colleagues reported that women with endometriosis (WWE) were more likely to be of higher socioeconomic status (SES) and have lower body mass index (BMI) than controls. They also said those with endometriosis were more likely to live in the Central region of Israel and less likely to live in areas with mainly Arab or orthodox Haredi populations.

Researchers reported that after adjusting for BMI and SES, study participants with endometriosis were significantly more likely to experience infertility, with 36.9% of women being affected. The highest lifetime infertility rates in women with endometriosis were in those aged 40-44, according to the authors.

In addition to infertility, WWE were more likely to have chronic comorbidities, including chronic kidney disease, diabetes, cancer, hypertension, and cardiovascular disease.¹ Researchers also noted a higher incidence of irritable bowel disease and appendicitis, “conditions with potentially overlapping abdominal pain symptoms, where the distinction between comorbidity and misdiagnosis is often challenging.”¹

WWE were much more likely to have seen a PCP or gynecologist within the past year than controls Eisenberg and colleagues said; nearly 20% had at least 5 gynecological visits, which researchers said was 1.5 times as many as the control group. The endometriosis group also had higher rates of hospitalizations and ED visits, with double the chance of controls being hospitalized once, and triple the chance of being hospitalized at least twice.¹

They were also more likely to have imaging procedures such as MRI and ultrasound, and to also have more lab tests for complete blood count, luteinizing hormone, and follicle-stimulating hormone tests. “Overall, 42.2% of women with endometriosis had a pelvic/genital US, of which only 3.1% underwent a dedicated endometriosis US.,” researchers said.

The endometriosis group was also more likely to undergo CA-125 and CA-15.3 testing for ovarian and breast cancer respectively. The additional healthcare needed by endometriosis patients adds up: “Overall, endometriosis was associated with an excess in total per-person direct medical costs across all age groups and with an age-adjusted OR of 1.75 (95% CI 1.69–1.85),” researchers reported.

WWE were more likely to use oral contraceptives (23.6% versus 15.6% in the control group) for the past twelve months and had an even higher rate of lifetime use at 71% versus 53.2% in controls.1 “Women aged 25–29 had the highest rates of oral contraceptive use in 2015: 86.4% and 73.4% among endometriosis patients and controls, respectively,” Eisenberg and colleagues said. They reported a similar, low rate of IUD insertion for both groups. Gonadotropin use was triple in the endometriosis group compared to controls. Pain medication use, such as narcotics like tramadol, was also higher in the endometriosis group, as was antidepressant use (11.8 versus 8.6% in controls).

Researchers noted that young women between 15–19 years old with endometriosis had a much higher rate of oral contraceptive use (76.9% vs. 9.6%), PCP visits (57.7% vs. 14.4%), and gynecological visits (57.7% vs. 14.4%). Women aged 20-24 also had an increase in PCP visits (92.8% vs. 83.1%), gynecological visits (76.6% vs. 54.8%), and oral contraceptives (83.8% vs. 56.7%). Researchers said pain medication and contraceptive use in this younger age group also had higher use than in the age-matched control group.

“Women with a diagnosis of endometriosis have a significantly higher burden of infertility and chronic comorbidities, increased healthcare resource utilization, and excess costs, particularly younger patients whose healthcare needs may differ widely from those of otherwise healthy women,” Eisenberg and colleagues concluded.

Reference

1. Eisenberg VH, Decter DH, Chodick G, Shalev V, Weil C. Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization. J Clin Med. 2022;11(4):1133. Published 2022 Feb 21. doi:10.3390/jcm11041133
2. Eisenberg VH, Weil C, Chodick G, Shalev V. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG. 2018;125(1):55-62. doi:10.1111/1471-0528.14711