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Human Reproduction, Vol.27, No.5 pp.

1292– 1299, 2012
Advanced Access publication on March 14, 2012 doi:10.1093/humrep/des073


The burden of endometriosis: costs
and quality of life of women
with endometriosis and treated
in referral centres

Downloaded from at Arizona Health Sciences Library on December 5, 2012
Steven Simoens 1, Gerard Dunselman 2, Carmen Dirksen 3,
Lone Hummelshoj 4, Attila Bokor5, Iris Brandes 6, Valentin Brodszky 7,
Michel Canis 8, Giorgio Lorenzo Colombo9, Thomas DeLeire 10,
Tommaso Falcone 11, Barbara Graham 12, Gu¨lden Halis 13,
Andrew Horne 14, Omar Kanj 8, Jens Jørgen Kjer 15, Jens Kristensen15,
Dan Lebovic10, Michael Mueller 16, Paola Vigano 17,
Marcel Wullschleger 16, and Thomas D’Hooghe 18,*
Katholieke Universiteit Leuven, Leuven, Belgium 2Department of Obstetrics & Gynaecology, Research Institute GROW, Maastricht
University Medical Centre, Maastricht, The Netherlands 3Maastricht University Medical Centre, Maastricht, The Netherlands 4World
Endometriosis Research Foundation, London, UK 5Semmelweis University, Budapest, Hungary 6Medizinische Hochschule Hannover,
Hannover, Germany 7Corvinus University, Budapest, Hungary 8University Hospital Centre, Clermont-Ferrand, France 9University of Pavia,
Pavia, Italy 10University of Wisconsin, Madison, WI, USA 11Cleveland Clinic, Cleveland, OH, USA 12NHS National Services Scotland,
Edinburgh, Scotland 13Praxis fu¨r Fertilita¨t-KEZ-Berlin, Berlin, Germany 14University of Edinburgh, Edinburgh, Scotland 15University of
Copenhagen, Copenhagen, Denmark 16University of Bern, Bern, Switzerland 17University of Milan, Milan, Italy 18Department of Obstetrics
and Gynecology, Leuven University Fertility Center, University Hospitals Leuven, UZ Gasthuisberg, 3000 Leuven, Belgium

*Correspondence address. Tel: +32-16-343624; Fax: +32-16-344368; E-mail:

Submitted on April 18, 2011; resubmitted on January 18, 2012; accepted on February 8, 2012

background: This study aimed to calculate costs and health-related quality of life of women with endometriosis-associated symptoms
treated in referral centres.
methods: A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary
care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact
related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss,
total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis.
results: Data analysis of 909 women demonstrated that the average annual total cost per woman was E9579 (95% confidence interval
E8559– E10 599). Costs of productivity loss of E6298 per woman were double the health care costs of E3113 per woman. Health care
costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-asso-
ciated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of
direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility
and a higher number of years since diagnosis.
conclusions: Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than
drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endomet-
riosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohn’s disease, rheumatoid arthritis). It arises
predominantly from productivity loss, and is predicted by decreased quality of life.
Key words: endometriosis / cost-of-illness / quality of life / international / multi-centre

& The Author 2012. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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hospitalization. Questionnaires were piloted and reviewed for face and content validity by To close the gaps identified in the review papers. 2007). hospitalizations (i. Medical or to sign an informed consent form in order to participate in the study. 1990). Productivity loss was valued using national The definition of a representative centre was based on the recognition of estimates of gross weekly earnings. but could have been made earlier. a history of endometriosis who came to the hospital for a clinical Endometriosis is associated with dysmenorrhoea. et al. monitoring tests. the Design EuroQol-5D instrument was filled in by women at the beginning of the Prospective questionnaires were designed to enable the collection of infor. In- nomic evaluations assessing the cost-effectiveness of approaches to direct costs of productivity loss due to endometriosis and its treatment earlier diagnosis and treatment of at Arizona Health Sciences Library on December 5. As is the usual practice in cost-of-illness analyses. costs of support with household activities). Questionnaires were translated riosis Research Foundation (WERF) EndoCost study aims to calculate into the local language of each participating country. (1996)]. study.. were also included. Each participating country’s health this centre as a referral centre for women with endometriosis-associated economist was responsible for collecting the price data using a .The burden of endometriosis 1293 symptoms within and outside a country.. (1987). the members of the WERF EndoCost Consortium and by six women at University Hospitals Leuven. surgical treatments aim to manage symptoms. Data valuation Prices reflected charges based on official list prices in all countries. which induces a chronic. also elicited data about the volume of resource use relating to physician tization of future research in endometriosis. are of increasing concern. For each country. Cost studies of cation. 1993). who had at least one contact with based on original articles by Houston et al. 2006a. The diagnosis of endometriosis was not neces- sarily made in this time period. data dimensions together represent the health state. hotel service). Meuleman et al. medication.. the WERF EndoCost Consortium.g. based on hospital records using the r-AFS score (1985). was established in use were applied. The mation on costs and quality of life related to endometriosis-associated EuroQol-5D is a generic instrument that contains five dimensions of symptoms during October and November 2009. public policy makers and health care payers This means that costs included direct health care costs (e. The cost estimates pro. consultations. In addition. physician visits. ism’) as well as reduced productivity at work (‘presenteeism’) within the past week. Prices included the contribution of the third-party payer 2007 comprising 12 representative tertiary care centres from 10 countries. Each dimension can be rated at three endometriosis-associated symptoms and as they fall outside any religious levels: ‘no problems’.b. 1994. surgery and infor- endometriosis allow the identification of the drivers of diagnosis mal care provided by family/friends) as well as direct non-health care costs costs and treatment costs.. but the main methods are summarized here.. 2005). problem unrelated to the disease. one or more Introduction gynaecologists and one health economist with a major interest in endo- Endometriosis is defined as the presence of endometrial-like tissue metriosis participated in the network. cost data can be fed into eco. yet is often under-diagnosed (Kennedy et al. transportation costs. The can rise to 30–50% in women with infertility and/or pain (Gruppo ita- study excluded women with suspected endometriosis and women with liano per lo studio dell’endometriosi. Wheeler the treating centre due to endometriosis-associated symptoms during (1989). Ethical approval was obtained from Downloaded from http://humrep. These 2 months were health-related quality of life: mobility. pain/dis- chosen as they were considered to be a representative period to study comfort and anxiety/depression. 2005). the ethical committee of each participating centre. To register the evolution of health-related quality of life over time. 2009). outside the uterus. at 4 weeks and at 8 weeks (EuroQol Group. Questionnaires vided by this cost-of-illness analysis may be used to justify the priori. monitoring tests. except Setting for the Netherlands and the UK where unit costs based on actual resource A research network. 2008). chronic pelvic pain. pain at ovulation.. Questionnaires elicited demographic characteristics and year of endo- This approach is combined with an assessment of endometriosis. and the woman’s co-payment. This prevalence the calendar year of 2008. Three recent review papers have emphasized the Data measurement lack of research on costs of endometriosis and identified several Cost questions were developed specifically for the purpose of the WERF avenues for future research. The five holiday period. Women were required tility. Estimates of the prevalence of endometriosis Participants among the general population of women of reproductive age vary The study population included women with a laparoscopic and/or histo- between 2 and 10% [reviewed by Eskenazi and Warner (1997). (e. Vessey et al. Belgium. fatigue and infer. metriosis diagnosis. support with household ac- tivities and informal care. surgical procedures. abnormal bleeding. 2011). self-care. Perspective In a society where spiralling health care costs and limited resources The WERF EndoCost Study measured costs from the societal perspective.oxfordjournals. (1993) and Kjerulff et al. the costs of women with endometriosis treated in referral centres..g. ‘some problems’ and ‘major problems’. costs of medi- need to pay attention to the costs of endometriosis. other therapies. were collected over 2 months and results were then extrapolated to an annual time-frame (Simoens et al.e. The methods of the WERF EndoCost study are reported in detail else. This generic instrument considered the time lost from work (‘absentee- where (Simoens et al. Endometriosis was staged at the time of diagnosis related quality of life in participating patients.. the World Endomet. which our study seeks to address (Gao EndoCost study by the participating health economists and gynaecologists. daily activities. inflammatory reaction (Kennedy et al. Hummelshoj et al. logical diagnosis of endometriosis. Productivity loss was measured using the Work Materials and Methods Productivity and Activity Impairment Questionnaire (Reilly et al. The endometriosis-associated costs to society are considerable yet poorly identified. 2012 dyspareunia.. 2006. and to remove or reduce physical disease. D’Hooghe et al.

the presence of pelvic pain symptoms. no sample size calculation was conducted.367–0. A total of 3216 women received letters and with anxiety/depression at the beginning of the study. Some of these variables over the 2-month course of the study.080.. were combined with estimates of the time period for which a particular demographic data in Table I). EuroQol-5D 1450 provided informed consent in time to be mailed the questionnaires utility scores varied little over the 2-month course of the study on 24 September 2009. 16% of women reported measure costs rather than test a specific hypothesis about costs at Arizona Health Sciences Library on December 5. Two to supplement answers for missing values. monitoring tests (19%). Similar results were obtained when a logistic euro ¼ 1. with derived from national documents and local sources in each country (refer. a higher age. the estimated annual (2009) health care costs for diabetes mellitus . If resource use was not applicable or not quality-adjusted life years of 1. The to E9579 per woman (95% CI: E8559–E10 599) (see Table II).. Costs per woman were described as mean (+standard deviation). quality-adjusted life year is an outcome measure that accounts for the Total costs were dominated by indirect costs of productivity loss quantity and quality of life. Quality-adjusted life years were calculated costs) and non-health care costs (E168. The Downloaded from http://humrep. ences are available from the corresponding author on request). gression analysis was restricted to patients with positive costs. 56% centre identified eligible women and invited them on 31 August 2009 to reported problems with pain/discomfort and 36% reported problems participate in the study. Data may be clustered per country and. Utility values were assigned to the EuroQol-5D health states using na- tional health utility indices (Dolan et al. 5% of direct costs).809 quality-adjusted life years (standard deviation: 0. As is usual practice in cost-of-illness analyses. Women with the costs of endometriosis. 2008). Each centre had the opportunity to contact women quality of life as a person with the best possible health state.. the final model being restricted to variables significant at the 5% level. Direct costs were between diseases. and that allows for comparison of outcomes (mean: E6298 per woman. Italy and Switzerland. Only 24% of women generated a each participating centre. after adjusting Costs per woman were computed by multiplying resource use by unit for country. minimum: 20. a higher number of years since minimum/maximum and as 95% confidence intervals (CIs). This represents a re- Analysis duction in quality of life of 19% when compared with a person with the Data collection and input into the central database were carried out in best possible health state. Shaw et al. Cohen’s kappa coefficient was applied to explore the possible evolution of EuroQol-5D scores ciated with lower direct health care costs. Medication accounted for 10% of health care Sample size costs. nomic Co-operation and Development. Given that this analysis indicated that country had an effect on care costs of E3113 per woman suffering from endometriosis- costs (although this was not statistically significant). than endometriosis. Each referral with self-care. therefore. costs were converted into compared with patients with positive costs and when a multivariate re- euro using purchasing power parity exchange rates (Organisation for Eco. An analysis checked whether women had negative quality-adjusted life years.. 1995. 2007. In the absence of a Of 3216 women invited to participate in the study. 95% of direct of the area under the curve. 66% of total costs). and missing data were dealt with using the mean stage of endometriosis. indicating that they had the same known. Furthermore. 1995).oxfordjournals. it was Table III shows that quality of life was the most important predictor assumed that data of complete cases were representative for women of total costs and of health care costs. cost data were log- transformed. We demonstrate that the annual health effect.. maximum: 1) over the course of 1year. 29% reported problems with usual activities. 2006. Costs were expressed in euro (1 also predicted total costs. Discussion A regression analysis assessed the effect of demographic. Estimates of costs and health-related quality of life during October and November 2009 were multiplied by six to generate annual estimates. Quality-adjusted life years were calculated by means made up of health care costs (E3113 per woman. The price year was 2009. 3% reported problems therefore. presence of infertility and a higher number of years since diagnosis lysis was carried out by the co-ordinating health economist (S. standardized form in collaboration with the gynaecologist. 1450 provided national index for Denmark. Average total annual costs amounted health state lasts to compute quality-adjusted life years. implying that they con- women with missing data were comparable to women with a complete sidered their current state of health to be worse than death.1294 Simoens et al.193.484. utility informed consent and had questionnaires posted to them. Overall quality assurance of data entry and data ana. endometriosis-associated symptoms generated an average of 0. France. a multi. health care costs). data set in terms of woman characteristics. Conversely. a multivariate regression associated symptoms and treated in referral centres are similar to analysis was run including dummy variables representing specific countries.0. 0. an inability to work due to reasons other costs. Total costs first seeking medical help and a higher body mass index were asso- were broken down into major cost drivers.. 2007). Price data were A backward method to select independent variables was applied. Greiner et al.40 US$ on 25 October 2010). hospitalization (18%) and physician visits (16%). Of these values were derived from a representative sample of the UK population using the time trade-off technique (Dolan et al. 2009).). the imputation technique. a more severe who had missing data. Utility values women. 2012 for women who reported a utility value at least at the beginning of the most important items of health care costs were surgery (29% of study and at 8 weeks. As this was the case. P .S. a conservative approach was adopted by setting the associated cost equal to zero. 2005. this study was designed to Regarding health-related quality of life. clinical and The WERF EndoCost study has shown that the costs of women with socio-economic characteristics as well as quality of life on total costs and endometriosis treated in referral centres are substantial. economic burden that is at least comparable to the burden associated level regression analysis was conducted including country as a random with other chronic diseases. Hungary.. Cleemput et al. (some or major) problems with mobility. resulting in an on direct health care costs. which tended to include only a few hundred women (Simoens et al. This sample size is larger than previous studies on (kappa coefficient: 0. Lamers Results et al. Due to non-normality.001). were associated with higher direct health care costs. 909 returned the questionnaires (response rate of 28%. For those countries that did regression analysis was conducted on patients without costs when not have the euro as their national currency.

...........oxfordjournals........ .... 2009)..... number of women (%) 904 Single and living with partner 200 (22) Married 513 (57) Single and not living with partner 123 (14) Divorced/separated 67 (7) Downloaded from http://humrep. endometriosis..... hence.............. In addition. Characteristic Mean (standard Minimum– Maximum Number of women for which data deviation) are available .. because women with more difficult cases of endomet............... the possibility that the study has underestimated the eco- Koster et al.. (E2858)..... Yu et al.4 (6........7) 41– 230 889 Current marital status.....6– 194...........1 (27.... It is a challenge to extrapolate the costs reported in this study to riosis may be more likely to be treated in referral centres and are likely national estimates of endometriosis-related costs for two reasons. number of women (%) 891 Employee 680 (76) Self-employed 77 (9) Housewife/carer 65 (7) In education 44 (5) Voluntary work 27 (3) Unable to work due to endometriosis 29 (3) Unable to work due to other reasons 50 (6) Number of years since diagnosis 6... Crohn’s disease (E3100–E7447) and rheumatoid arthritis to have a higher consultation rate and..... 2006........The burden of endometriosis 1295 Table I Characteristics of women....3) 0– 45 887 r-AFS stage..... other hand.....1 (6............... Age (years) 36. 2005).....7 901 Weight (kg) 72...7) 15– 67 905 Height (cm) 166. also similar to quality of life before and during the initial surgical diagnosis and treat- other chronic diseases such as ankylosing spondylitis (productivity ment of endometriosis prior to any referral to the centres included in loss ¼ 66% of total costs) and rheumatoid arthritis (productivity the study...... the study may have overestimated the economic burden of (Kennedy et at Arizona Health Sciences Library on December 5.... we show that the in.. 2008).. On the (E4284) in selected European countries (Leardini et al..... number of women (%) 706 Minimal-mild (stages I –II) 200 (28) Moderate-severe (stages III– IV) 506 (72) a Percentages do not add up to 100% because women may have multiple occupations.. 2002.. nomic burden associated with endometriosis cannot be excluded direct costs of productivity loss are twice as large as the direct health since the study did not measure any burden related to cost or care costs of endometriosis-associated symptoms..... number of women (%) 819 Asian/Oriental 17 (2) Black African 1 (0) African American 5 (1) Black Caribbean 2 (0) Hispanic or Latino 3 (0) North/West European 516 (63) East European 84 (10) South European 86 (10) North American white 75 (9) Other white 21 (3) Mixed race 9 (1) a Occupation..or riosis and due to the well-documented long diagnostic delays between underestimates the economic burden of endometriosis....... surgery accounts for most of the direct health care costs of endomet- The design of the EndoCost study conceivably either over..1) 135... 2012 Widowed 1 (0) Ethnic origin................. higher costs...... On the one initial symptoms and laparoscopic diagnosis of endometriosis hand..... This burden is likely to be significant due to the fact that loss ¼ 57% of total costs) (Franke et al....7 (7..

...........3 15 666......3 231........281 (0. hospitalization costs related to the costs of the diagnosis-related group associated with a hospital stay.114 (0..2 Downloaded from http://humrep...1 Indirect costs 6298.2–1602..3 Support household activities 65...7 0 31 224.....081) 0......455) .425 Hungary 20....001 r-AFS score 0.4 2412..1 0 15 114...159 20.......051 (0...333 (0....217) 0.3 1331...1 0 290 420....138 Denmark 1.. 0....808 Germany 2.001 Value ¼ 12........557 (0..0 5825......386.541) 0.017) ..426) 0.4 2251.....991 (0..2 311.3 0 5310...185 0.468) 0..........0 Medication 320.0 13 336...2 136.............507) 0.202 0..5–732....229) 0...444 (0.641 (0.731) 0...003 21.001 (0..580) ...7 8559...561 (0.0. Item Mean Standard deviation Minimum Maximum 95% CI of the mean .432) 0.....046 — Body mass index 20....4 0 292 286......0 Direct non-health care costs 167.......0 460..001 ..9–201...019 0.164) 0.3 10 801...679) 0........2 0 11 610.... .......5 Hospitalization 546.2 741..2 0 23 843...526 (0........040 20.......625 (0......098 (0............049 (0......4 Informal care 84..001 13.4 350.4 Other treatments 153...8 481......3 Surgery 899...1 13 244..........557) .2 Direct costs 3281.049 20.0 196......226 n ¼ 909 R2 0.5–123.0..........004 Italy 1.029 (0. Constant 12.768) .078 (0.........507) 0.478) 0.5–199...367 (1........1 0 53 644....................5–409.....579 1.444) 0...340 (0.5–782..6 0 39 120..........0.6–600....712) 0.....456 (0...........020) 0..001 Number of years since diagnosis 0....5 0 5983......988.1296 Simoens et al. P .........815 USA 1.399 (0.......002 — Presence of pelvic pain symptoms 0.......484) 0.926 (0..6 42...001 Unable to work for reason other than endometriosis 21.........3 7262.9 0 12 906.. Coefficient (standard error) P-value Coefficient (standard error) P-value .9–4149..637 (0...7 104.005 0......7 3614...124 Netherlands 20...624 UK 20. 2012 Transportation 102...031 0....016) 0................436 (0...001) 0..427) 0.3 1364.484) 0........029 0..1 Total costs 9579..4 2087. Direct health care costs 3113.733 (0...6–6771....656 (0....545) 0.006 Presence of infertility 0..154 F-test on regression model Value ¼ 11....0 0 5983. Table II Annual costs of endometriosis-associated symptoms (in euro) (n 5 909) at Arizona Health Sciences Library on December 5..409 (0....0–3975..894) .568) 0.......016) ...011 0. 0.8 0 298 584..128 (0......645 (0..001 25..716 (0........465) 0.1 0 167 426.168 2 Adjusted R 0...018 — Number of years since first medical help 20....1 For Germany.. P ........239) 0...790 (0.110 (0..0......0..0..001 Age 20. Independent variable Direct health care costs Total costs ....449) 0.014 0....135 (0.0 623..2 81.3 Physician visits 513....5–10 599...1 Monitoring tests 596.002 Annual number of quality-adjusted life years 25.0 426....4 321.003 — Belgium 20.oxfordjournals..0 43...047 (0..328 0..171) 0.6–88..001 20..218 Switzerland 1.0.............683 (0..4–124..... Table III Multivariate regression analysis of log-transformed costs.

Ideally. conversely. marital status. In fact. Using this theoretical model. the questionnaires and moderate-severe (63%) surgically diagnosed endometriosis in emphasized that women should report resource use based on the whole Icelandic population over a 20-year period (Gylfason endometriosis-associated symptoms only. 15 –49 years of age) (World Bank. E1. 1999) out- Acknowledgements lined above. based on a suffered from endometriosis-associated symptoms reported mostly study in Australian twins representative for the general Australian problems on the pain/discomfort. Therefore. Secondly. however. In this theoretical model. there is uncertainty about the prevalence of endometriosis. Vessey et al. which would add higher total costs and in higher direct health care costs. which is worse than the 0. concluding toms). tributing to the data input. possibly because they were more symptom. than those being exceeds the minimally (clinically) important difference (Jaeschke et al.. women in our study who towards a prevalence rate of 7% (Treloar et al. article did not compare costs and quality of life associated with endo- based on reasonable at Arizona Health Sciences Library on December 5. E9.94 quality-adjusted Downloaded from http://humrep. Bernert et al.6 billion Helen Dewart..6 billion in the USA.5 billion in Germany and E49. non-responders may have in future costing studies in endometriosis. based on the best available evidence (Treloar et al. Andreas Ebert. Annalisa Abbiati. In our theoretical model. 2010) × estimated prevalence of endometriosis among women of re- productive age.. we chose a prevalence of 7%. with minimal-mild (28%) and moderate-severe (72%) endometriosis in The true cost of a disease is measured by the additional burden this study was comparable to the proportion of minimal-mild (37%) imposed by that disease on society.. psychological and social functioning.81 quality-adjusted life years over the Indeed. Myriam Welkenhuysen and Cheryl Williams for con- E9. The burden of endometriosis is likely to prevalence rates. Wheeler (1989). Finally. 2010). On costs for all women with endometriosis-associated symptoms. 2011).6 billion in the Netherlands. annual average (in)direct costs per woman × national number of women of reproductive age (i. vary between countries due to. Donel Murphy. only a theoretical model is possible at present. papers (Fourquet et al. Diane DeMonaco Dowd. Although our analysis not participated because they did not want a daily or weekly reminder resulted in a low R 2. The specific relation to answer the questions. because of poor reporting in most countries of literature review (Gao et al. the total annual societal The authors thank Katja Kleine-Budde. a case –control et al. health care systems. it could be possible to set up studies that challenge. this tional cost estimates. 2011). among other things. E1.5 billion in France. constraints.3 billion in Switzerland.. 2011).. we must recognize that with a diagnostic The regression analysis indicated that quality of life represents the delay of 7 years (Nnoaham et al. 2011.7 billion in Belgium.07 as calculated for the EuroQol-5D (Walters and higher rate of repeat consultations due to lack of resolvement of Brazier. and thus losing time costs: a lower number of quality-adjusted life years resulted in to work and using over-the-counter medicine. (1987). the methods of inclusion employed in this study could imply course of 1 year. Aisha De Graaff. Lynn Borzi. depression/anxiety and usual activ- population with respect to age. Jill McNaughton. Luo et al. We ac. E12. Ying et al.b) and with recently published the diagnosis ‘endometriosis’ (as opposed to its associated symp. E1. extrapolation of centre.3 billion in Italy. present the aggregate results of the first international analysis.The burden of endometriosis 1297 Firstly. though the latter may have a 1989) of 0. the explorative character of the regression analysis. in Hungary. there is a large population most important predictor of total costs and of direct health care of women in our society not being treated at all. since the proportion of women gression analyses of costs (Mackin et al. . population of women without endometriosis as is also the case in ments and costs are similar and that extrapolating costs in tertiary most other cost-of-illness analyses. represented in the patient sample because women were enrolled in 1999. E2.. Owing to to these costs if were they being treated adequately. no a priori hypoth- ognize that the response rate was low (28%) and the subsample of esis was formulated regarding the expected direction of the relation women who participated in the study may have been highly motivated between the factors studied and costs.. 1999). differences in the specific costs to national cost estimates was calculated as follows: access to and financing of. between predictors in the model and costs needs further exploration atic than the non-responders.8 million in Denmark. 2012 that women with moderate-severe endometriosis are over. 2005. arguably the best evidence seems to point In terms of health-related quality of life. which is adaptable to various metriosis between countries. This theoret- which has been reported to vary between 2 and 10% [(reviewed by ically calculated extrapolation of centre-specific costs to national cost Eskenazi and Warner (1997). to E0. this patient population appears to be representative of study design could have been used but due to practical and resource the overall population with surgically diagnosed endometriosis. our population had 0. This finding is consistent with a ethnicity. 2009). level of education and ities dimensions of the EuroQol-5D. Nnoaham et al. Whereas we rec.. estimate the cost-effectiveness of primary and secondary prevention In view of the limitations associated with the extrapolation of costs of endometriosis. 2011. As the primary objective of this article was to for women with endometriosis in tertiary care referral centres to na.oxfordjournals. (1993) and Kjerulff et al. the decrement representative tertiary care centres that typically treat more in quality of life when compared with the general population generally complex and referred cases of endometriosis. However. that this does not imply that symptoms. Paolo Vercellini. 2005). symptoms. treat. etc.85 –0. no prevalence figures exist which allow us to extrapolate that endometriosis impairs health-related quality of life especially in costs for women treated in referral centres and compare these with the domains of pain.9 billion in the UK. treated by their general gynaecologists. 2006a. the WERF EndoCost study did not include a control knowledge.. average.. (1996)]. Furthermore. burden of endometriosis-associated symptoms can be extrapolated Lianna Christensen. based on original papers Houston estimates can be easily re-calculated if a differently justified estimated et al. similar R 2 values have been observed in other re- of the impact of their disease.e. care centres to national cost estimates remains problematic and a Considering our results. life years per year observed in the general population (Kind et al.. E9. prevalence rate is applied.

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