Reframing endometriosis care in low-resource settings: a pragmatic 5R framework for recognition, rule-out, relief, referral and review.

Endometriosis is a chronic inflammatory gynecological condition associated with severe dysmenorrhea, chronic pelvic pain, deep dyspareunia, cyclic bowel or urinary symptoms and infertility. It is also linked to psychological morbidity, reduced quality of life and lost economic productivity. In low-resource settings, diagnostic and therapeutic delays often reflect pathway failure rather than specialist scarcity alone: symptoms are commonly normalized, first-contact recognition remains weak, differential diagnosis is inconsistent, referral pathways are poorly governed and structured follow-up is frequently absent. This article proposes a pragmatic 5R Framework (Recognition, Rule-Out, Relief, Referral and Review) tailored for symptom-led endometriosis care in low-resource settings. The framework draws on international guidelines, clinical review evidence, African and low- and middle-income country (LMIC) evidence on access barriers, global scoping reviews of policy and service-delivery gaps, imaging guidance, and health-systems evidence on task redistribution. Its central proposition is that endometriosis-compatible symptoms should trigger structured first-contact recognition, safety-oriented rule-out, fertility-sensitive first-line relief, need-based referral and planned review before definitive specialist confirmation is available. The framework is not a validated clinical decision rule; rather, it isa testable pathway model for local adaptation, consensus refinement, facility-level audit and prospective implementation research. Its utility lies in translating established evidence-based principles into an accountable care sequence that permits earlier action without compromising diagnostic caution, reproductive goals or referral responsibilities.