The Minister is very welcome. I thank her for taking time out of her busy schedule to be with us today. It is always greatly appreciated in the Seanad.

I thank the Minister for coming in. I really appreciate her spending the time on this issue. I know it is an issue she cares about. I am raising it today because I have received significant feedback from many women suffering from endometriosis about the continued challenges they face.

I know we have the endometriosis framework and that the endometriosis surgery abroad interim scheme is temporary. However, I fear that, given the state of endometriosis care in Ireland, it is likely to be in place for several years. Patient advocates have expressed specific concerns about the operation of the scheme. I heard from one woman who was refused surgery in Cork due to fear of poor surgery outcome as the clinicians could not sufficiently answer her questions about follow-up care. She was then considered ineligible for the surgery abroad scheme. Women report being scared to go abroad and cannot afford the upfront payments. The administrative burden of filling out the forms is a barrier for many women. I spoke to a woman named Helen who spent €8,700 on surgery in Germany and is still waiting for her reimbursement. Referral for treatment abroad remains a serious concern. Under the scheme, only consultants can refer but, as the Minister is well aware, gynaecologists have huge waiting lists and diagnostic laparoscopies cannot always be fulfilled due to the long lists.

There is uncertainty for clinicians about what is required under the scheme. For example, are scans required for referrals? Do clinicians need confirmation of stage 3 or stage 4 endometriosis before referring? I recognise there may be concerns about GPs referring due to a lack of expertise, but can GP referrals be considered in the short-term with targeted training to upskill them?

This would greatly reduce waiting times for women suffering from debilitating pain who must often wait years to see consultants. I was deeply disheartened to find out that obstetrics and gynaecology are optional training for GP's despite the fact that women make up 50% of the population. This training should, of course, be mandatory. Women are being forced to go private and pay thousands of euro to travel overseas simply to get a diagnosis. It can take many months to get a scan while they are living with unbearable pain. That is after years of waiting to see a consultant in the first place. It has been reported to me that the locations of the hospitals for the surgery abroad interim scheme seem to have been randomly selected. There is no detail on whether the hospitals selected for the scheme are fit for treating stage 4 endometriosis, for example. Patient advocates have been asking for the inclusion of countries like Greece, which is known for its high-quality endometriosis treatment. Why has Greece been omitted from the list? Patients are frustrated by the lack of understanding around endometriosis. It is still being treated like a gynaecological issue when we know it is a whole-body disease affecting the bladder, bowel and pelvis. Paracetamol and ibuprofen are still being suggested for use as pain management. I recently heard from one woman who went to the emergency room with a burst cyst and who was given paracetamol by means of a drip.

I also have serious concerns about fertility options for endometriosis patients. Under HSE guidelines, only cancer patients qualify for egg freezing. While endometriosis patients can get IVF, they have to immediately get pregnant, and this is despite the fact that endometriosis is the most common reason for infertility. I have met patients as young as 15 who are being recommended chemical menopause and women in their late teens and early 20s who have had hysterectomies. Unless they are ready to have a baby immediately, they cannot have their eggs frozen. This is devastating for them. They have to choose between living with excruciating pain and being a mother.

For the women who get surgery abroad and finally get some relief from the agony, there is the impossible cost of medicine to keep them pain free. Ryeqo is prescribed to women who have had endometriosis treatment to reduce the growth of internal lesions. It is expensive. It costs about €140 per month and is not available on the drugs repayment scheme. There is a similar drug that is used in the treatment of prostate cancer; it is available. It is really hard for women to trust the system when similar drugs for a particular condition are refundable but those relating to endometriosis involve a significant cost. The optics of the disparity in this regard are incredibly jarring.

Will the Minister commit to expanding referral options to include GP's under the treatment abroad interim scheme? Will endometriosis patients be allowed to freeze their eggs through the HSE? Will the Minister include Greece in the approved list of countries under the scheme? Will she make obstetrics and gynaecology training mandatory for all GPs? Will she consider the inclusion of Ryeqo to the drugs payment scheme?

The Senator raised quite a number of issues. I suspect that she and I have spoken to many women who have many of the same issues.

We must recognise that endometriosis is a whole-system condition, but it does in many cases start from a gynaecological position as well. We have to acknowledge both of those things. We are very much trying to move the dial in terms of how it is understood and described. That is why the framework has been advanced beyond where it started out to really try to recognise, as the Senator said, that this is a whole-system condition for many women, although not all, and that it impacts maybe one in six women. It is a very common condition indeed.

I launched the national framework for the management of endometriosis on 18 October. It is the first time that we have had such a framework. It gives a presumptive diagnosis background for GPs rather than their having to articulate and advance an argument. It gives a presumptive diagnosis basis, which is an enormous step forward for people on a pathway to get proper specialist care in the regional centres.

Let me speak about the endometriosis surgery abroad interim scheme, ESAIS, scheme in particular, because there are a couple of important pieces in respect of that. We created the scheme specifically because we did not want women to have to pay upfront in the way they have done for either the treatment abroad scheme or the cross-border directive where they can be reimbursed. I recognise that, first, the treatment they were looking for was not necessarily available in Ireland and, second, it was too expensive to try to pay for that upfront. It is really important to understand that. The only way we could legally set up a scheme is that it is absolutely essential that it is a temporary scheme to meet a need we cannot meet today while we are on a pathway to meeting that need clinically. Otherwise, the scheme would not survive. It has to be understood that it has to be temporary and time limited. As a result, it is limited to two years.

We have an enormous body of work to do in order to try to upskill and advance imaging and surgical options here. I am pleased to say that work in this regard is progressing. For example, there have been a number of different study abroad opportunities. We are creating fellowships for surgeons to do much more detailed work. The Royal College of Physicians of Ireland around the corner is having a dedicated day on endometriosis in March. This is a big step forward for the clinical community, which had not previously recognised endometriosis at that level before.

The Royal College of Surgeons in Ireland is also leaning in. There has been a very big change in the clinical community's understanding of endometriosis and their commitment to upskilling, imaging and surgery options.

Again, the criteria for this scheme must be tightly set. It is not that we are selecting countries or clinics at random. We are looking for specific accredited lists. The British Society for Gynaecological Endoscopy and the European Endometriosis League both provide specific clinical criteria. The clinic in Greece that the Senator mentioned is not on that list, which is why it is not part of this scheme, but we have asked clinicians to visit the clinic to see whether it meets the standards and the reason is as follows. As before, consultants were reluctant to recommend that women get their treatment abroad because they could not stand over and verify it. We are now saying to them that we have done that for them based on these internationally accredited lists and therefore, this clinic is fine and they do not have the option any more. We are telling them they should be comfortable referring to a clinic because it is against a measurable list. Greece and Romania were not on the list but we have tried to take extra steps to see if they can meet the standards. Some will and some will not but unless we keep within the criteria of the scheme, the scheme itself cannot survive. That is why this is so important. We are trying to do something very different. We have never created a scheme like this. We are creating it to try to meet a need. In many cases, there are women availing of this already and we are trying to do our best to make sure that women are supported in every way but we do operate within certain constraints. I appreciate that I have not answered all of the questions but I have run out of time and will answer if I have another opportunity.

It would be great if the Minister could answer some of my other questions, particularly that important piece about fertility.

I am delighted to hear that there is a time limit for introducing this scheme. Best efforts are being made but with the reality of training and building up expertise, will we get there in two years? I suppose that is why the feedback from patients has been to ask for the scheme to work as well as possible for patients while it exists. I recognise that it is a bridge until the end goals of the framework can be put in place.

About 20 hospitals in the UK are on the scheme but I have spoken to clinicians who say that these are not particularly renowned hospitals. I appreciate that these hospitals might fall, under a certain amount of criteria from British medical guidance, but clinicians here are not sure if they will take Irish patients or if these are hospitals of renown. There is confusion among clinicians about how to refer and when to refer and on the quality of the hospitals. I recognise that there have been study abroad opportunities to build up that expertise. I think that is incredibly positive and thank the Minister.

As this is an internationally accredited list, we would simply use the list because we can stand over it both legally and from a clinical perspective. Those clinicians mentioned by the Senator should speak to the clinical director, Dr. Cliona Murphy, about this matter.

We also have tried to expand the surgical options here. I demanded a programme of an additional 100 surgeries be done in quarter 4 of 2025 using every tool that we could among our maternity hospitals. I am pleased to say that we got 142 extra surgeries within our own system. That shows we really are trying to make progress in this regard.

The Senator is right to highlight obstetric training for GPs and it is very important. As for fertility, that is a different scheme and I am expanding it as best I can. I am certainly very alive to the concerns of endometriosis patients.

As for the drug mentioned by the Senator, as she will be aware, we have a drug assessment process operated through the HSE and I leave value-for-money analysis and health technology assessments, HTAs, to it. We must also ensure that the applications are made. This matter is more complex than simply me deciding.

We are trying in every possible way that we can to change the dial in terms of how endometriosis is understood. Bernard Gloster and I wrote to every GP in the country to highlight both how common endometriosis is and the presumptive diagnosis pathway. We are trying to upskill and train. We have hired an additional colorectal surgeon to work in a multisystem way alongside obstetric surgeons to make sure that we have the personnel to perform more complex surgeries here.

As I said, the Royal College of Physicians of Ireland, which includes the Institute of Obstetricians and Gynaecologists, will host a day dedicated to endometriosis. The Royal College of Surgeons in Ireland is also leaning into it. We are developing treatment and long-term fellowships abroad in order that we have a much better standard of surgery here.

Yes, a two-year scheme is challenging. Are we going to meet that clinical need within that period? It is a race to do so but we are trying to pull every lever we can to deliver a much better service for endometriosis patents. I also recognise what the Senator said about pain and pain management. Again, there is a huge spectrum. The clinical guidance includes paracetamol. While I know women who take paracetamol for pain relief and that is fine for them, paracetamol is absolutely not enough for very many endometriosis sufferers who have felt patronised in the extreme by being told that taking paracetamol is the solution for them.

It might be the solution for one woman but it is not the solution for every woman and we have not reached a solution in relation to pain management for the more complex and severe cases of endometriosis.

I thank the Senator and the Minister for her time. I appreciate the Minister coming to the House.

As a vote has been called in the Dáil, we will need to suspend so that a Minister can attend the Seanad.