{"paper_id":"072aaf2d-e570-42be-9007-97d0d6903bef","body_text":"International Journal of Pharmaceutical and Phytopharmacological Research (eIJPPR) | October 2020| Volume 10 | Issue 5 | Page 36-42 \nMaha Fouad Messawa, Endometriosis in Saudi Arabia; Prevalence, Presentation, Complications, and Updated Management: Simple systematic \nreview \nISSN (Online) 2249-6084 (Print) 2250-1029        \n                                                                                www.eijppr.com \n \n \n \n \nEndometriosis in Saudi Arabia; Prevalence, \nPresentation, Complications, and Updated \nManagement: Simple systematic review \n \nMaha Fouad Messawa1*, Salma Yousef Omar2, Reem Ahmed Babagi3 \n1 Consultant of Obstetrics and Gynae Oncology, Heraa General Hospital (HGH), Makkah, KSA. \n2 Consultant of Obstetrics and Gynecology, Maternity & Children Hospital (MCH), Makkah, KSA. \n3 Consultant Obstetrics and Gynecology, King Abdullah Medical Complex (KAMC), Jeddah, KSA. \nABSTRACT \nBackground: Endometriosis is a benign disease of the female genital system characterized by a chronic growth of \nendometrial-like tissue, consisting of glands and/or stroma, found outside the uterine cavity in sites other than the uterine \ncavity like the pelvic cavity, ovaries, pouch of Douglas, and uterosacral ligaments. The commonest symptom that \nwomen present to health services is pelvic pain, which usually begins before menses and continues along the duration of \nmenstrual flow. Objectives: This study aims to review the recent updates in prevalence, presentation, complications, \nand updated management of endometriosis in Saudi Arabia.  Methods: PubMed database and EBSCO Information \nServices were used for articles Screening. All Saudi papers concerning the prevalence, presentation, complications, and \nupdated management of endometriosis and other articles have been used in making the article. We excluded additional \npapers that are not relevant to this topic. The data were collected as per the particular manner in which the group \nmembers would study it. Conclusion: Endometriosis significantly affects the quality of life and health of the patient and \nmay lead to infertility. Effective surgical treatment should be used with a clinical diagnosis of endometriosis. \nFurthermore, knowledge of the different atypical presentations and imaging methods used to diagnose endometriosis is \nthe responsibility of the clinician, and the importance of awareness cannot be ignored.  \n \nKey Words: endometriosis, management of endometriosis, prevalence of endometriosis in Saudi Arabia \n eIJPPR 2020; 10(5):36-42 \nHOW TO CITE THIS ARTICLE: Maha Fouad Messawa, Salma Yousef Omar, Reem Ahmed Babagi (2020). “Endometriosis in Saudi Arabia; \nPrevalence, Presentation, Complications, and Update d Management: Simple systematic review ”, International Journal of Pharmaceutical and \nPhytopharmacological Research, 10(5), pp.36-42. \n \n \n \nINTRODUCTION \nEndometriosis is a benign disease of the female genital \nsystem characterized by a chronic growth of endometrial-\nlike tissue, consisting of stroma and/or glands, found \noutside the uterine cavity in sites other than the uterine \ncavity like the pelvic cavity, ovaries, pouch of Douglas, \nand uterosacral ligaments [1]. Childbearing age is the most \npredominantly affected age by endometriosis with the \nmean age of 25 –29 years at diagnosis [2]. It is mostly \ndiagnosed in women with infertility more than pelvic pain. \nAbout 50% of women younger than 20 years with chronic \npelvic pain or dyspareunia have endometriosis [3]. The \noverall prevalence for both symptomatic and \nasymptomatic females in reproductive age is found to be \n10–15%, 70% of women with chronic pelvic pain, and \n38% (range 20-40%) among infertile women [4]. The \ncommonest symptom that women present to health \nservices is pelvic pain, which usually begins before \nmenses and continues along with the duration of menstrual \nflow. Dysmenorrhea and deep dyspareunia are also the \nmain pain complaints with 80% and 30% prevalence [5]. \nThe disease has several etiological factors including \nenvironmental and genetic factors. The certain mechanism \nfor the development of endometriosis is not clear. Various \npathogenesis mechanisms have been suggested for the \nformation of endometriosis. This involves retrograde \nmenstruation leading to the implantation of gizzard \n  \n  Corresponding author:  Maha Fouad Messawa \n  Address: Heraa General Hospital (HGH), Makkah, KSA. \nE-mail:  Mmessawa @ hotmail.com \nRelevant conflicts of interest/financial disclosures: The authors declare that the research was conducted in the absence of any commercial \nor financial relationships that could be construed as a potential conflict of interest. \nReceived: 19 April 2020; Revised: 14 September 2020; Accepted: 20 September 2020 \n\nInternational Journal of Pharmaceutical and Phytopharmacological Research (eIJPPR) | October 2020| Volume 10 | Issue 5 | Page 36-42 \nMaha Fouad Messawa, Endometriosis in Saudi Arabia; Prevalence, Presentation, Complications, and Updated Management: Simple systematic \nreview  \n \n37 \nendometrial tissue, development of endometrial tissue \nfrom coelomic mesothelial cells undergo metaplasia an d \nhematogenous or lymphatic distribution of endometrial \ncells [6]. \nThe onset of pain is usually reported during adolescence, \nso, early referral, identification, and management may \nease the pain, inhibit disease progress, and preserve \nfertility [7]. Physical examination must be done during \nearly menses when the implants are expected to be the \nlargest and tender. The doctor should also palpate for \ndefined, retroverted uterus, nodules along the uterosacral \nligaments pelvic masses, or uterine and adnexal tenderness \n[8]. A rectovaginal checkup is necessary to identify cul-\nde-sac, septal, or uterosacral nodules, [9]. Occasionally, \ncomputed tomography, pelvic magnetic resonance \nimaging, and ultrasonography are used to locate actual \nlesions, although these techniques are not useful to \ndetermine the endometriosis severity [10]. Blood tests \ncould show a change in analytes, proteins, microRNAs, \nand other markers’ levels matching to a disease state, \nwhich could be the base for identifying novel biomarkers \n[11]. \nManagement of endometriosis may be medical or surgical, \nbased on the severity of the symptoms and the patient's \ndesire to keep or restore fertility. Symptomatic \nendometriosis is usually treated by medical or surgical \ntreatment both equally effective [12]. Drugs available for \nmedicinal therapies include oral contraception, progestin, \nandrogens, and gonadotrophin-releasing hormone (GnRH) \nanalogs. Medical treatment choice is done based on side \neffect profile, cost, and personal preference [13]. \nEndometriosis surgery can be carried out laparoscopically \nor as an open operation. Surgical removal of \nendometriosis results in significant pain relief and \nimprovement in the quality of life after just six months \ncompared to diagnostic laparoscopy, but about 20% of \npatients show no progress following surgery [14]. \nThe recurrence of pain after six months of therapy could \nbe 50% of cases during the 12-24 months after completion \nof treatment. Recurrence can be partially attributed to \nlarge lesions that respond poorly to medical care [15].  \nInfertility management in females with endometriosis \nneeds further care. Surgery and advanced reproductive \ntechniques (ARTs) cross over due to the various stages of \nthe disorder and the age of the recipient. Minimal and \nminor diseases also benefit from specialist surgery. \nAdvanced intermediate and extreme phases typically \nrequire in vitro fertilization (IVF) [16]. \nThis study aimed to review the recent updates in \nprevalence, presentation, complications, and updated \nmanagement of endometriosis in Saudi Arabia. \nMETHODS AND MATERIALS: \nPubMed and EBSCO Information Services were chosen as \nthe search databases for the publications used within the \nstudy, as they are high-quality sources. PubMed is one of \nthe largest digital libraries on the internet developed by the \nNational Center for Biotechnology Information (NCBI), \nwhich is a part of the United States National Library of \nMedicine. Topics concerning the prevalence, presentation, \ncomplications, and updated management of endometriosis \nand other articles have been used in making the article. \nRestriction to the last 20 years, Saudi Arabia country and \nEnglish language due to unavailable resources for \ntranslation were used. The articles were screened by titles, \nand reviewing the abstracts yielded 10 articles, which \nwere enrolled.  \nInclusion criteria:   \nArticles were selected based on the relevance to the \nproject, which should include one of the following topics; \n‘endometriosis, management of endometriosis, prevalence \nof endometriosis in Saudi Arabia’.  \nExclusion criteria:  \nAll other publications, which did not have either of these \nsubjects as their main end, or repetitive research, and \nanalyses of reviews were omitted. \nStatistical Analysis: \nNo software has been utilized to analyze the data. The data \nwere extracted based on a specific form that contains \n(Author’s name, publication year, country, study type, and \nresults). These data were reviewed by the group members \nto determine the initial findings and the modalities of \nperforming the surgical procedure. A double revision of \neach member’s outcomes was applied to ensure the \nvalidity and minimize the mistakes. \nRESULTS: \nThe search of the aforementioned databases returned 52 \nstudies that were included for title screening. 21 of them \nwere included for abstract screening, which led to the \nexclusion of 8 articles. The remaining 13 publications’ \nfull-texts were reviewed. The full-text revision lead to the \nexclusion of 3 studies, and 10 studies were enrolled for \nfinal data extraction (Table 1) \nThe included studies had different study designs and \npopulation types. \nRagab et al. (2015) conducted a study to determine the \nprevalence of endometriosis among adolescent school \ngirls with severe dysmenorrhea. 654 adolescents \nparticipated; the mean age of girls was 15.2±3.53 years, \nage of menarche in years was 13±1.2 SD, 48.9% (n=320) \nhad varying degrees of menstrual pain. Severe \ndysmenorrhea was reported in 68.8% (n=220/320) of \nthem, 56 (25.5%) had ultrasound findings indicated \n\nInternational Journal of Pharmaceutical and Phytopharmacological Research (eIJPPR) | October 2020| Volume 10 | Issue 5 | Page 36-42 \nMaha Fouad Messawa, Endometriosis in Saudi Arabia; Prevalence, Presentation, Complications, and Updated Management: Simple systematic \nreview  \n \n38 \nendometriosis. Endometriosis was proposed in 77.3% of \nthem. \nMostafa, et al. (2012) reported that all patients had \nabdominal pain but only 3 had a palpable mass. \nHistopathological confirmation was done in each case. In \nconclusion, the study reported that endometriosis is not as \nrare as thought, and should be included in the differential \ndiagnosis of abdominal wall masses in reproductive-age \nfemales. \nIsbister et al. (2002) reported a case referred to an \ninfertility clinic. She was admitted for laparoscopy. The \nperineal lump had recurred and became more severe, and \nafter analysis, it was discovered to have a diffuse mass of \n5 × 5 cm at the back of its episiotomy scar. She was \nadmitted for laparoscopy and perineal mass excision and, \non that date, endometriosis was detected in the Douglas \npouch. \nAlsinan et al. (2019) case study indicated that hormone \ntherapy treatment resulted in a successful outcome \ncompared to the surgical resection method mentioned in \nseveral papers. \nSameer et al. (2017) reported the prevalence of \nendometriosis 14.3%. The prevalence of endometriosis is \ndistributed over all age groups, suggesting that it should \nstill be preserved as a differential diagnosis in our day- to-\nday practice, particularly in the reproductive age group \nextremes, preventing an unnecessary delay in diagnosis \nand adequate timely treatment. \nRouzi et al. (2013) conducted a study to evaluate the \nprevalence of endometriosis in women who had \ngynecologic laparoscopy at a university hospital in the \nKSA and found that 190 gynecologic laparoscopies were \ndone. The laparoscopy indications included ectopic \npregnancy, infertility, chronic pelvic pain, infertility and \nchronic pelvic pain, pelvic mass, removal of a missing \nintrauterine contraceptive device. Endometriosis was \ndiagnosed in (11.1%). In women with endometriosis, the \ncomplaints included pelvic pain, infertility, pelvic pain \nand infertility, and pelvic mass; One patient (4.8%) had an \nunknown complaint. \nAl-Talib et al. (2013) studied on a 31-year-old woman \nwith appendicular implantation in the lining of the back of \nthe uterus. And that the appendix fused with the front wall \nof the abdomen. When performing surgery for chronic \npelvic pain, surgeons should expect that endometriosis \nmay contribute to pain in patients with endometriosis. \nKhairy (2005) reported a woman with vague abdominal \npain and ultimately was found to have endometriosis of \nthe appendix at King Khalid University Hospital Riyadh, \nKSA. The histological result showed endometriosis of the \nappendicular apex. \nAladin et al. (2019) evaluated the prevalence of infertility \namong women attending the outpatient and inpatient \ndepartment in Maternity and Children. The reported \ncauses of infertility included endometriosis in 18 (3.2%). \nKhadawardi, et al. (2020) found that while lots of women \nwith endometriosis become pregnant and give birth to \nhealthy babies, endometriosis is highly associated with \ninfertility. More investigations are required to investigate \nthe pathobiology of this condition. \n \nTable 1: Author, publication year, study design, country, outcome, and reference number of the included studies \nAuthor’s \nName \nPublication \nYear Region Study Type Outcomes Ref. \nRagab et al. \n2015 Saudi Arabia cross-sectional \nprospective \nThe study reported that endometriosis prevalence in \nadolescents 12.3% associated with severe dysmenorrhea \nwas despite some declined laparoscopy. Severe \ndysmenorrhea has been identified in 68.8% of the cases. \n25.5% had ultrasound results indicative of endometriosis.⠀ \n[17] \nMostafa, et al. \n5-year period (2007-\n2012) \nNajran Armed \nForces Hospital, \nNajran, Saudi \nArabia and Sohag \nUniversity Hospital, \nSohag, Egypt. \nDescriptive \nanalysis \nThis study found that all patients had abdominal pain but \nonly three patients had a palpable mass. Histopathological \nconfirmation was done in each case. No recurrence or \ncomplications were observed on follow-up (6-24 months; \nmean 13.2 months). In conclusion, study reported that \nendometriosis is not as rare as thought, and should be \nincluded in the differential diagnosis of abdominal wall \nmasses in reproductive-age females. \n[18] \n\nInternational Journal of Pharmaceutical and Phytopharmacological Research (eIJPPR) | October 2020| Volume 10 | Issue 5 | Page 36-42 \nMaha Fouad Messawa, Endometriosis in Saudi Arabia; Prevalence, Presentation, Complications, and Updated Managem ent: Simple systematic \nreview  \n \n39 \nIsbister, et al. \n2002 Saudi Arabia Case report \nCase reported two‐month history of painful defecation, \nwhich eventually became continuous and kept her awake at \nnight. The case was admitted for laparoscopy. She then \npresented again complaining that for the entire period she \nhad been infertile. She had gone at an infertility clinic. The \nperineal lump had recurred and became more severe, and \nafter analysis, she was discovered to have a diffuse mass of \n5 × 5 cm at the back of its episiotomy scar. She was \nadmitted for laparoscopy and perineal mass excision and, on \nthat date, endometriosis was detected in the Douglas pouch. \n[19] \nAlsinan, et al. \n2019 Saudi Arabia Case Report \nThe study described a 25-year-old woman presented with \nobstructive urinary tract symptoms. It was shown that \ncontrary to the surgical resection approach discussed in \nmany studies, hormone therapy led to a satisfactory \noutcome. Effective comprehensive determination of the \nexact cause and treatment plan of this disorder is important \nto ensure optimal evaluation and development of patient \ncare, including a coordinated and multidisciplinary team \nstrategy including both urologists and gynecologists. \n[20] \nSameer, et al. \n2017 \nWomen Specialized \nHospital, King \nFahad Medical City, \nRiyadh, Saudi \nArabia \nHospital based \ncross sectional \nstudy \nThe study found that; prevalence of endometriosis was \n14.3%. Pelvic pain was the major symptom. The prevalence \nof endometriosis is distributed over all age groups, \nsuggesting that it should still be preserved as a differential \ndiagnosis in our day-to-day practice, particularly in the \nreproductive age group extremes, preventing unnecessary \ndelay in diagnosis and adequate timely treatment. \n[21] \nRouzi, et al. \nBetween January \n2008 and \nDecember 2013 \nJeddah, Saudi \nArabia \nHospital based \ncross sectional \nstudy \nEndometriosis was diagnosed in 21 women (11.1%). 190 \ngynecologic laparoscopies cases were recorded. The \nindications for laparoscopy were infertility (40%), chronic \npelvic pain (17.9%), pelvic mass (6.3%), and removal of a \nmissing intrauterine contraceptive device (3.2%). In women \nundergone gynecologic laparoscopy, endometriosis was \nuncommon. \n[22] \nAl-Talib et al. \n2013 Saudi Arabia Case Report \nA 31-year-old woman suffering from frequent pain in the \nright side of the pelvis for two years, which increases with \nurination and defecation. She was examined by an urologist \nand gastroenterologist consultant and the result was normal. \nWhen performing laparoscopy, it was found that there was \nan appendicular implantation in the lining of the back of the \nuterus. And that the appendix fused with the front wall of \nthe abdomen. When performing surgery for chronic pelvic \npain, surgeons should expect that endometriosis may \ncontribute to pain in patients with endometriosis. \n[23] \nKhairy \n2005 \nKing Khalid \nUniversity Hospital \nRiyadh, KSA. \nCase report \nThe case presents a woman with vague abdominal pain and \nultimately was found to have endometriosis of the appendix. \nAt admission, she had normal vital signs and was afebrile. \nAbdominal examination showed deep tenderness in the \nlower abdomen with no rigidity, guarding, tenderness or any \npalpable mass. All radiological, biochemical, and \nhematological investigations, including CT scan and \npelvic/abdominal ultrasound, were unremarkable. The \nhistological results showed endometriosis of the \nappendicular apex \n[24] \n\nInternational Journal of Pharmaceutical and Phytopharmacological Research (eIJPPR) | October 2020| Volume 10 | Issue 5 | Page 36-42 \nMaha Fouad Messawa, Endometriosis in Saudi Arabia; Prevalence, Presentation, Complications, and Updated Managem ent: Simple systematic \nreview  \n \n40 \nAladin et al. \nfrom 1 December \n2018 to 31 March \n2019 \nMaternity and \nChildren Hospital, \nArar, KSA. \nA hospital-\nbased cross-\nsectional \nstudy \nThe prevalence of infertility was evaluated in women \nattending the outpatient and inpatient department. The \nreported causes of infertility included endometriosis in 18 \ncases (3.2%). \n[25] \nKhadaward, \net al. \n2020 \nUmm Al-Qura \nUniversity, Makkah, \nSaudi Arabia. \nDescriptive \nhospital-based \ncross-sectional \nstudy \nWhile many women with endometriosis become pregnant \nand bear healthy children, endometriosis is closely \nassociated with infertility. More investigations are necessary \nto explore the pathobiology of this disease. \n[26] \n \nDISCUSSION: \nThe prevalence of endometriosis is underestimated due to \nthe need for laparoscopy, which is known to be the \npreferred method to verify the diagnosis. At least 10% of \nall women of reproductive age are affected by the disease \n(the mean age at diagnosis is 25 –29 years) [27]. \nRegarding adolescence, a previous study found that \nendometriosis is not uncommon among adolescents, half \nof the women under 20 years of age who have chronic \npelvic pain or dyspareunia have the disease [28]. Since a \nlaparoscopy or surgery is needed for the accurate \ndiagnosis, the prevalence of endometriosis is hard to \ndetermine correctly.  \nIn a previous study, endometriosis was reported as 4.1% \nin asymptomatic cases after laparoscopy for tubal \nligation. However, in the same study, 20% of patients \nundergoing laparoscopic studies for infertility and 24% of \nwomen with pelvic pain had endometriosis [29]. Another \nstudy reported the total prevalence of both symptomatic \nand asymptomatic cases to be 5% –10% with 38% \nprevalence among infertile women [30]. One of our tabled \nstudies at the KSA reported an endometriosis prevalence \nof 14.3% and 30 to 34 years as the peak age of this \ndisease with a maximum of patients with stage 4 \nendometriosis [21]. A retrospective analysis of 892 post-\nlaparoscopic cases with histologically confirmed \nendometriosis diagnosis. The average age was 33.2±6.3 \nyears [31]. Although, in another study, 383 patients of \nchildbearing age were examined for their debilitating \nsymptoms, 192 of whom were diagnosed with \nendometriosis [32].  \nRecurrence is frequently observed in females with \nendometriosis and ranges widely from study to study. \nRecurrence may be partially attributed to the fact that \nlarge lesions respond poorly to medical attention. It is \nextensively agreed that endometrioma is not appropriate \nfor surgical care, while partial therapeutic relief can be \nobtained [33]. The average recurrence rates vary from 6 \nto 67% according to the parameters that are taken into \naccount [34]. Another research showed a 4-year \nrecurrence rate of 23.7%, 30.6%, 17.8%, and 24.6%, for \novary and vaginal, cervical, vaginal, and ovary \nendometriosis cases (P <0.05). Recurrence rates declined \nin all populations (except the ovarian endometriosis) in \nthe age group of ≥34 years and these results were \nsignificant (P <0.05) [35]. There was no proof of gain \nfrom a comprehensive analysis of the current care for \nwomen with infertility having endometriosis, and it is not \nrecommended for those seeking to conceive [36]. A \nsystematic review of the laparoscopic treatment of \nendometriosis in women with subfertility indicated an \nincrease in conception in the 9-12 months following \nsurgery [37]. A second systematic analysis of \nlaparoscopic excision relative to ablation endometrioma \nshowed a five-fold rise in pregnancy rates [38]. \nCases with moderate to serious endometriosis, especially \nthose affected by ovaries to oviducts with an adhesive \ndisease, have reduced fertility rates. It is technically based \non the mechanical obstruction between the ovaries and \nthe oviduct, with the resulting breakdown of the gamete \ntransfer to the tubal ampulla [35]. Brugnon et al. reported \nthat the number of collected oocytes, transfer rate, and the \nrate of cycles with a frozen embryo were lower in cases of \nendometriosis [39].  \nCONCLUSION: \nEndometriosis significantly affects the quality of life and \nhealth of the patient and may lead to infertility. Effective \nsurgical treatment should be used with a clinical diagnosis \nof endometriosis. Furthermore, knowledge of the different \natypical presentations and imaging methods used to \ndiagnose endometriosis is the responsibility of the \nclinician, and the importance of awareness cannot be \nignored.  \n \nREFERENCES \n \n[1] Agarwal N, Subramanian A. Endometriosis - \nmorphology, clinical presentations and molecular \npathology. 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