{"paper_id":"1b288875-68c4-4f1d-89cf-f10d2c7c1619","body_text":"DOI: https://doi.org/10.53350/pjmhs221611024 \nORIGINAL ARTICLE \n \n1024   P J M H S  Vol. 16, No.01, JAN  2022 \nAssessment of Presentation and Prevalence of Endometriosis in the \nPopulation of Kotri Pakistan: A Cross Sectional Study \n \nNAZISH NAQVI 1, RAHILA IMTIAZ 2, RIZWANA PERVEEN 3, SARWAT KHALID 4, MADIHA RAFIQUE 5, HINA AKMAL \nMEMON6  \n1Consultant Gynaecologist, SESSI Hospital SITE Kotri, Pakistan. \n2Assistant professor Gynaecology, Karachi Medical and Dental College Abbasi Shaheed Hospital Karachi, Pakistan. \n3Consultant Gynaecology, Liaquatabad hospital Karachi, Pakistan. \n4Assistant Professor Gynaecology, Karachi Medical and Dental College Abbasi Shaheed Hospital, Pakistan. \n5Senior Woman Medical Officer Gynaecology, Peoples University of Medical and Health Sciences for women Nawabshah, Pakistan. \n6Woman Medical officer Gynaecology, District health quarters hospital Jamshoro @kotri /Bilawal Medical College hospital Kotri, Pakistan. \nCorresponding author: Nazish Naqvi, Email: nazish_syed@hotmail.com  \n \nABSTRACT \nAim: The present study aims at the determination of presentation and prevalence of endometriosis in the  Kotri \nPakistan. \nStudy design: A cross sectional study \nPlace and duration: This study was conducted at SESSI Hospital SITE Kotri, Pakistan from June 2019 to July \n2020. \nMethodology: A total of 800 patients were admitted to the gynecology ward.  A total of 160 patients were \nsuspected to have endometriosis as their signs and symptoms w ere indicative of the disease . The age r ange of \nthe patients was from 17  to 48 years. All the patients underwent laparotomy or laparoscopy for diagnosis and \ntreatment. Individual proforma was filled for all the patients according to the severity of the disease. The stage of \nthe disease for each patient was identified as per American Fertility Society endometriosis staging.  \nResults: The symptoms of endometriosis were prevalent in 160 (20%) of the 800 patients who had been admitted \nto the ward. A total of 40 (25%) were diagnosed with endometriosis on laparoscopy/laparotomy.  \nConclusion: The overall prevalence of endometriosis seen during the study period was 5%. Endometriosis is a \ncommon women's health issue in the population of Pakistan. Nonetheless, it is underestimated. Its prevalence is \nhigh in patients between the ages of 21 years to 30 y ears. The most common presentation of endometriosis is \ninfertility. A diagnostic laparoscopy must be performed in patients who present with symptoms suggestive of \nendometriosis. Timely diagnosis and treatment can help in reproduction.  \nKeywords: Endometriosis, infertility, laparoscopy, laparotomy \n \nINTRODUCTION \nEndometriosis is a painful disease in which tissue of the \nendometrium tends to grow outside the uterus. It most \ncommonly involves the ovaries. Other common sites are \nfallopian tubes and tissues of the pelvic lining. On rare \noccasions, it also seems to involve extra-pelvic organs. The \ntissue of endometriosis has a functional similarity with the \nendometrial tissue. Hence, its thickness increases with \neach menstrual cycle and similarly, it breaks down and \nthen bleeds  [1]. However, unlike original endometrial \ntissue, endometriosis cannot escape the cavity in which is it \nsituated. The debris keeps collecting and can form a cyst. \nA cyst of endometriosis formed in the ovaries is called an \nendometrioma. The othe r normal tissues of the body \nsurrounding an endometrioma can form scars and \nadhesions [1].  \n The symptoms of endometriosis are majorly \nassociated with menstrual periods. Endometriosis has the \npotential of causing severe pain, especially during \nmenstruation. However, the severity of the pain is not an \nindication of the extent of the disease. Endometriosis \npatients often complain of dyspareunia. During a menstrual \ncycle, feeling pain with bowel movements and urination is \nalso common in most patients. Patients  experience \nexcessive bleeding during menstruation and bleeding \nbetween two cycles  [2]. The worst and most common \noutcome of the disease is infertility. Other symptoms of \nendometriosis include diarrhea, bloating, constipation, \nfatigue, and nausea. These sy mptoms are aggravated \nduring menstruation. Endometriosis can be mistaken for \npelvic inflammatory disease, ovarian cyst, and irritable \nbowel syndrome due to overlapping symptoms.  \n There are many explanations for the causes of \nendometriosis. One theory sugg ests that during \nmenstruation, the shed off part of the endometrium moves \nto fallopian tubes through a retrograde movement and \nreaches in the pelvic cavity rather than moving out of the \nbody. The endometrial tissue adheres to the pelvic cavity \nand starts t hickening and bleeding there with eac h \nmenstrual cycle. The 'induction theory' suggests that the \nnormal tissue of the peritoneal cavity starts functioning like \nendometrial tissue under the influence of hormones. The \nhormones can also transform the embryonic cells into \nendometrial cells during puberty giving rise to \nendometriosis. In some instances, the endometrial tissue \nadheres to a surgical incision followed by a C -section or a \nhysterectomy. Another theory suggests that the lymphatic \nsystem or blo od vessels can transport the endometrial \ntissue from the uterus to other parts of the body [3].  \n There are several risk factors that increase the \nchances of occurrence of endometriosis. Some of them are \nnull parity, puberty at a younger age, late menopaus e, \nmenstrual cycle shorter than 27 days, heavy menstruation  \nfor over seven days, high level of estrogen in the body, low \nBMI, family history of endometriosis, and any other disorder \nrelated to the reproductive system. Infertility is the most \n\nN. Naqvi, R. Imtiaz, R. Perveen et al \n \nP J M H S  Vol. 16, No.01, JAN  2022   1025 \ngruesome compl ication of endometriosis. Endometriosis \nmay obstruct the fallopian tubes and hence disrupt the \nprocess of ovulation. Despite that, patients with mild or \nmoderate endometriosis can conceive. Endometriosis \nincreases the risk of ovarian cancer. The patients c an \nrarely develop endometriosis -associated adenocarcinoma \nlater in life [4]. \n The diagnosis of endometriosis is built based on \nclinical symptoms, pelvic examination, and some \ninvestigations such as ultrasound, magnetic resonance \nimaging (MRI), and diagnost ic laparoscopy  [5]. \nLaparoscopy helps in the identification of the size, location, \nand extent of endometrial implants. Depending on the size \nof the implant, treatment can also be done during \nlaparoscopy. Other modes of treatment are analgesics, \nhormonal therapy, removal of the implant through surgery, \nand even hysterectomy in severe cases  [6]. The present \nstudy was conducted to determine the presentation and \nprevalence of endometriosis in the  population of Kotri \npresented at SESSI Hospital SITE Kotri, Pakistan. \n \nMETHODOLOGY \nThis cross-sectional study was conducted in the \nGynecology and Obstetrics department of  SESSI Hospital \nSITE Kotri, Pakistan  from June 2019 to July 2020. During \nthis whole duration, 800 patients were admitted to the \ngynecology ward. Out of  those, 160 (20%) had signs and \nsymptoms strongly suggestive o f endometriosis and were \nselected for the study. The ages of the pat ients ranged \nfrom 17 to 48 years. Inclusion criteria for the study were the \npresence of symptoms such as secondary dysmenorrhe a, \ninfertility, deep dyspareunia, no response to ibuprofen, and \nabnormal uterine bleeding. Furthermore, patients were \nexamined and those patients who had lesions in the \nvaginal wall on examination, cervical lesions, fixed adnexal \nmass, nodular uterosacral ligament, and induration in cul -\nde-sac were included in the study. Exclusion criteria \nincluded no history of the treatment of endometriosis and \npatients who did not sign the consent. Written informed \nconsent was taken from all the p atients beforehand. They  \nexplained the procedure of laparoscopy and laparotomy. All \nthe participants were educated an d counseled about the \ndisease and its outcomes. \n A detailed history regarding symptoms was taken \nfrom all the patients.  Demographic data including age, \nweight, edu cation, socio -economic status, parity, \ncontraceptive history, menstrual history, treatment history, \nand previous investigations were also recorded. Patients \nwere examined for the signs of endometriosis.  The data \nwas recorded on individual pr oforma. The cri teria set for \nlaparoscopy were the appearance of mulberry spots, \nstellate scars, powder burns, chocolate cysts in the \novary/ovaries, and dense adhesions. Laparotomy was to \nbe done on the patients who had been diagnosed clinically \nand had a histopathology report.  \n \nStage  Extent of disease Points \nStage-I Minimal  1-5 \nStage-II Mild 6-15 \nStage-III Moderate 16-40 \nStage-IV Severe >40 \n \n The disease was classified as per the staging system \nof the American Fertility Society after and points were given \nafter an assessment of depth and size of the lesions, and \nseverity of endometrial adhesions. There were four stages \nin the patients that were classified as in the following table.  \n \nRESULTS \nA total of 800 patients were admitted to the gynecology \nward from June 2019 to July 2020. \n Total 160 (20%) out of them were suspected to have \nendometriosis. Out of those who had positive history and \nclinical symptoms of endometriosis, 40 (25%) had \nconfirmation of diagnosis on laparotomy or laparoscopy. \nNone of the patients was diagnosed with cervical or vaginal \nwall endometriosis. Hence, the overall prevalence of \nendometriosis seen during the study period was 5%. The \ndistribution of the patients according to the age is  given in \ntable 1.  \n \nTable 1: Participants’ distribution according to age \nAge group \n(Years) \nTotal population Population with \nendometriosis \nNumber Percentage Number Percentage \n17-20  3 1.87 1 2.5 \n21-30  121 75.63 32 80 \n31-40  30 18.75 6 15 \n41-48  6 3.75 1 2.5 \nTotal 160 40 \n \nTable 2: Participants’ distribution according to weight \nWeight \ngroup (Kg) \nTotal population Population with \nendometriosis  \nNumber Percentage Number Percentage \nBelow 50   10 62.5 2 5 \n50-60  119 74.37 30 75 \n61-70  20 12.5 7 17.5 \nAbove 71  11 6.87 1 2.5 \nTotal  160 40 \n \nTable 3: Participants’ distribution according to parity \nParity Number of patients  Percentage \nNulliparous  29 72.5 \n1-3 children 9 22.5 \nMore than 3 children 2 5 \nTotal 40 \n \nTable 4: Patients’ distribution according to the staging of disease \naccording to AFS  \nStage Severity of \ndisease \nNumber of \npatients \nPercentage \nStage I Minimal 1 2.5 \nStage II Mild 15 37.5 \nStage III Moderate 13 32.5 \nStage IV Severe 11 27.5 \nTotal 40 \n \n The majority of the patients (80%) were between the \nages of 21 years to 30 years. Only 1 patient was above the \nage of 40 and 1 below the age of 20 years. 75% of patients \nweighed 50kg to 60 kg. Only one patient weighed 70 kg. \nThe distribution of weight and parity is given in table 2 and \ntable 3. Most of the patients were nulliparous. \nEndometriosis was the probable cause of infertility in those \npatients. Classification of the patients based on the staging \n\nAssessment of Presentation and Prevalence of Endometriosis in the Population of Kotri Pakistan: A Cross Sectional Study \n \n1026   P J M H S  Vol. 16, No.01, JAN  2022 \nsystem of the American Fertility Society is given in t able 4. \nOut of the total of 40 confirmed patients with endometriosis, \nmost of the patients (37.5%) had mild disease and only one \nhad the minimal disease. 11 (27.5%) patients had severe \ndisease. Patients in Stage III and IV involved the uterus, \novaries, fallopian tubes, and peritoneum.  Moreover, there \nwas obliteration in the Pouch of Douglas, deep -seated \nlesions, and multiple adhesions in the gut.  \n \nDISCUSSION \nAccording to the results of the present study, endometriosis \nis 25% prevalent out of all the patie nts that were  admitted \nin the gynecology ward  with suspicion of endometriosis . A \nsimilar study was conduct ed by Meuleman  et al  in which \nthey had included 220 infertile women and performed \ndiagnostic laparoscopy on all the participants. They found \nthat the prevalence of endometriosis in their study was \n47%. They concluded that all of the participants needed \nreproductive surgery since a large number of patients were \ndiagnosed with endometriosis [7].  \n Nazir et al studied the length of the menstrual cycle in \nendometriosis. They included 50 women who were married \nand had been diagnosed with endometriosis by diagnostic \nlaparoscopy. They concluded that there was a strong \ncorrelation between the short length of the menstrual cycle \nand endometriosis [8 ]. Jefout et a l conducted a study to \nfind out the association of endometriosis and pelvic pain in \nthe population under study. The study included 28 females \nwith chronic pelvic pain. 20 of them were diagnosed with \nendometriosis. Hence they concluded that there was a \nstrong association between chronic pelvic pain and \nendometriosis. They also observed the prevalence of cold \nintolerance in patients with endometriosis [9].  \n Reid et al conducted a similar study to the present \none to identify the prevalence of endometriosis in  the \nAustralian population. The sample size was as large as \n2025 women. The percentage prevalence determined was \n3.4%. They concluded that endometriosis is a common \nhealth issue in women and needs special ackno wledgment \n[10]. Bean et al conducted a study t o assess the incidence \nof endometriosis in pregnant women. They included a total \nof 1341 women who had visited the clinic for early \npregnancy ultrasounds. 5% of the pregnant women were \ndiagnosed with endometriosis. Half of them were \ndiagnosed with endometr iosis for the first time. They \nconcluded that ultrasound is a beneficial to ol to diagnose \nendometriosis [11 ]. However, it is not always the case. \nDiagnostic laparoscopy is the most reliable and authentic \nmethod of diagnosis  [12]. According to the study of Okoth \net al, women with endometriosis are at great risk of \ncardiovascular diseases [13].  \n \nCONCLUSION \nThe overall prevalence of endometriosis seen during the \nstudy period was 5%. Endometriosis is a common women's \nhealth issue in the population of Kotri Pakistan. \nNonetheless, it is underestimated. Its prevalence is high in \npatients between the ages of 21 years to 30 years. The \nmost common presentation of endometriosis is infertility. A \ndiagnostic laparoscopy must be performed in patients who \npresent with symptoms suggestive of endometriosis. Timely \ndiagnosis and treatment can help in reproduction.  \nPermission: It was taken from the ethical review \ncommittee of the institute \nFunding source: None \nConflict of interest: None \n \nREFERENCES \n1. Wang Y, Nicholes  K, Shih IM. The origin and pathogenesis \nof endometriosis. Annual Review of Pathology: Mechanisms \nof Disease. 2020; 15:71-95. \n2. Laganà AS, Garzon S, Götte M, Viganò P, Franchi M, \nGhezzi F, Martin DC. The pathogenesis of endometriosis: \nmolecular and cell biol ogy insights. International journal of \nmolecular sciences. 2019 Jan; 20(22):5615. \n3. Hill CJ, Fakhreldin M, Maclean A, Dobson L, Nancarrow L, \nBradfield A, Choi F, Daley D, Tempest N, Hapangama DK. \nEndometriosis and the fallopian tubes: Theories of origin and \nclinical implications. Journal of clinical medicine. 2020 Jun ; \n9(6):1905. \n4. 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BJOG: An International Journal of Obstetrics & \nGynaecology. 2004 Nov; 111(11):1204-12. \n13. Okoth K, Wang J, Zemedikun D, Thomas GN, \nNirantharakumar K, Adderley NJ. Risk of cardiovascular  \noutcomes among women with endometriosis in the United \nKingdom: a retrospective matched cohort study. BJOG: An \nInternational Journal of Obstetrics & Gynaecology. 2021 Mar \n8.","source_license":"CC0","license_restricted":false}