{"paper_id":"3b649e03-527f-42f7-9971-5c8a921f17cc","body_text":"Muhaidat et al. BMC Women’s Health          (2021) 21:381  \nhttps://doi.org/10.1186/s12905-021-01530-y\nRESEARCH\nPrevalence of endometriosis in women \nundergoing laparoscopic surgery \nfor various gynaecological indications \nat a Jordanian referral centre: gaining insight \ninto the epidemiology of an important women’s \nhealth problem\nNadia Muhaidat1* , Shawqi Saleh1, Kamil Fram1, Mohammed Nabhan1, Nadia Almahallawi2, \nSaif Aldeen Alryalat3, Mutasem Elfalah3 and Mohammed Elfalah4 \nAbstract \nBackground: Endometriosis is a considerable health challenge for women of reproductive age. Information about \nits prevalence in the Jordanian population is sparse. The objective of this research was to evaluate the presence of \nendometriosis in gynaecological patients undergoing laparoscopic surgery for various indications and to correlate \nthe finding of endometriosis with variables, including patient demographics, obstetric history, type, and indication of \nlaparoscopic procedure.\nMethods: A retrospective cohort study involving 460 women who underwent different laparoscopic procedures for \na variety of indications was conducted in the Department of Obstetrics and Gynaecology in Jordan University Hospi-\ntal, a tertiary referral hospital in Jordan, between January 2015 and September 2020.\nResults: The prevalence of endometriosis in this patient group was higher than that of the general population \n(13.7% vs. 2.5%), and the mean age at diagnosis (31.9 years) was younger than the general population’s age of peak \nincidence (35–45 years). It was significantly higher in women with lower numbers of pregnancies (p = 0.01) and a \nlower number of Caesarean sections (p = 0.05) and in those where the indication for surgery was related to decreased \nfertility or pelvic pain (p = 0.02). Women with high parity or where the surgery’s indication suggested normal fertility, \nsuch as family planning, were less likely to have endometriosis.\nConclusion: To our knowledge, this is the first Jordanian study to assess the prevalence of endometriosis in women \nundergoing gynaecological laparoscopy. This study suggests that the epidemiology of endometriosis in this region \nfollows similar trends to what has been previously documented in international literature, while emphasizing the \nneed for further research into this important women’s health issue in this part of the world.\n© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-\nmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.\nOpen Access\n*Correspondence:  Nadiadat@hotmail.com\n1 Department of Obstetrics and Gynaecology, Faculty of Medicine, The \nUniversity of Jordan, Queen Rania Street, Amman 11942, Jordan\nFull list of author information is available at the end of the article\n\nPage 2 of 8Muhaidat et al. BMC Women’s Health          (2021) 21:381 \nBackground\nEndometriosis is a benign gynaecological disease char -\nacterized by the presence of endometrial tissue in the \nform of stroma and glands outside the uterus and is \nassociated with a spectrum of clinical presentations, \nranging from asymptomatic women to patients suffer -\ning debilitating pelvic pain and/or fertility issues [1 , 2].\nThe actual prevalence in the population is difficult \nto ascertain because the diagnosis is often delayed or \noverlooked [2 ], but it is estimated that the condition \naffects up to 10% of women of reproductive age [3 ]. A \ncross-sectional population survey in the United States \nestimated the prevalence of diagnosed endometriosis \nto be 6.1% [4 ]; however, a study conducted in Italy sug -\ngests that only 6 out of 10 cases of endometriosis in the \ngeneral population are diagnosed [5 ].\nEndometriosis in Jordan, a middle-income country \nin the Middle East, is considered a significant pub -\nlic health issue affecting the quality of life of women \nof reproductive age [6 ]. The prevalence according to a \ncommunity-based survey of women aged 15–55  years \nby Al-Jefout et al. was found to be 2.5% [6 ]. In another \nstudy, the prevalence of endometriosis in symptomatic \nyoung Jordanian women undergoing laparoscopy for \nrefractory chronic pelvic pain was found to be as high \nas 71.4% [7 ]. Therefore, there is considerable variation \nin the prevalence according to the type of population \nsample under investigation.\nThe two main manifestations of endometriosis can \nbe categorized into endometriosis-related pain, such as \ndysmenorrhea, chronic pelvic pain, dyspareunia, dys -\nchezia, and infertility. Symptoms can be significantly \ndisruptive and affect the woman’s quality of life. How -\never, 20–25% of women are affected but completely \nasymptomatic [8 – 10]. The age of peak incidence was \nfound to be approximately 40 years [11, 12].\nThere are challenges involved in the process of diag -\nnosing endometriosis. First, the symptoms with which \nthe patient presents may overlap with other conditions, \nsuch as adenomyosis, interstitial cystitis and irritable \nbowel syndrome. Second, the patient may consider \nher pain to be a normal manifestation of the menstrual \ncycle, which leads to a delay in seeking medical advice \n[1].\nThe gold standard for the diagnosis of endometrio -\nsis is direct visualization during laparoscopy [13– 15]. \nAccording to the appearance of lesions found during \nsurgery, endometriosis can be classified into subtle, \ntypical, cystic, or deep [16]. While this condition is \ncommonly diagnosed during laparoscopy in patients \nwith symptoms of endometriosis [8 , 17], it is also \nfound incidentally in patients undergoing laparoscopic \nsurgery for indications other than clinical suspicion \nof endometriosis. For example, one meta-analysis of \nasymptomatic patients with clomiphene-resistant pol -\nycystic ovary syndrome with endometriosis found a \nprevalence of surgically confirmed endometriosis of \n7.7% [18]. Another study of women asymptomatic for \nendometriosis undergoing laparoscopy for other indi -\ncations by Rawson found a prevalence of endometrio -\nsis of as much as 43.5% and demonstrated that subtle \nendometriotic changes were commonly found during \nlaparoscopy in women who denied typical symptoms of \nthe condition and reported normal fertility [19].\nSeveral other factors have been found to be associated \nwith the presence of endometriosis. A meta-analysis by \nYong and Weiyuan suggested that a higher body mass \nindex may be associated with a lower risk of endome -\ntriosis [20]. This finding agrees with Ferrero et  al. who \ndemonstrated that women with endometriosis have \nlower body mass indices and are less frequently obese \nthan women who do not suffer from endometriosis [21]. \nFurthermore, Matalliotakis et al. found that women with \nendometriosis had a lower body weight and fewer prior \npregnancies, elective abortions and ectopic pregnancies \nthan women seeking care for infertility who did not have \nendometriosis [22]. An inverse relationship between gra -\nvidity and endometriosis was also found within a sub -\ngroup of subjects who had diagnostic laparoscopy [23].\nThis study aims to elaborate more on the prevalence \nof endometriosis in Jordanian women undergoing lapa -\nroscopy for different indications.\nMethods\nStudy type and objective\nThis is a retrospective cohort study involving a sample \nof 460 women who underwent different laparoscopic \nprocedures for a variety of indications in the Depart -\nment of Obstetrics and Gynaecology in Jordan Uni -\nversity Hospital, a tertiary referral hospital in Jordan, \nbetween January 2015 and September 2020.\nThe objective of this research was to determine the \nprevalence of endometriosis diagnosed during lapa -\nroscopy and to correlate the finding of endometriosis \nwith several variables, including age, body mass index \n(BMI), obstetric history, type of laparoscopic proce -\ndure, and indication for surgery.\nKeywords: Endometriosis, Laparoscopy, Jordan, Prevalence, Women’s health, Infertility, Pelvic pain\n\nPage 3 of 8\nMuhaidat et al. BMC Women’s Health          (2021) 21:381 \n \nInclusion and exclusion criteria\nThe inclusion criteria for the study were as follows: \n(1) female patient of reproductive age (16–50  years of \nage) and (2) undergoing gynaecological laparoscopy \nbetween January 2015 and September 2020. Patients \nwere excluded from the study if they were under \n16 years or over 50 years of age or if they were already \ndiagnosed or treated for endometriosis prior to the \nindex surgery.\nData collection\nPatients undergoing gynaecological laparoscopy were \nidentified from the clinical and theatre records. A total \nof 460 patients qualified for inclusion. Data collection \nwas performed by retrospectively reviewing the elec -\ntronic medical records of the patients. The diagnosis of \nendometriosis was made by one of six consultants with \nlongstanding experience in laparoscopic surgery and the \ndiagnosis of endometriosis. Positive cases were identified \nbased on documentation of the presence of endometri -\notic lesions (subtle, typical, cystic, or deep) in the elec -\ntronic operative notes of the laparoscopic surgery. Where \nhistological examination of tissue samples was avail -\nable, this was correlated with clinical findings, with 100% \nagreement between clinical and histological diagnoses.\nEthical approval\nEthical approval was granted by the Institutional Review \nBoard of Jordan University Hospital prior to commenc -\ning data collection. Reference number 1012021/3168.\nStatistical analysis\nWe used SPSS version 26.0 (Chicago, USA) in our analy -\nsis. Mean (± standard deviation) was used to describe \ncontinuous variables (e.g., age and BMI). Count (fre -\nquency) was used to describe other nominal variables.\nWe performed a chi-square test followed by Z-test \nfor proportions to analyse the difference in frequency \nfor procedure, indication, parity, miscarriages, ectopic \npregnancies, and Caesarean sections between patients \nwith and without endometriosis. We used an independ -\nent sample t-test to analyse the mean difference between \nmeasurements (e.g., age and BMI) and the presence of \nendometriosis. We adopted a p value of 0.05 as a signifi -\ncance threshold.\nWe performed a logistic regression analysis to find fac -\ntors associated with endometriosis on multivariate level. \nWe included variables with p value < 0.1 on univariate \nanalysis. We reported model classification accuracy and \nNagelkerke R Square. We reported odds ratio and their \n95% confidence interval (CI) for variables with p value of \n0.05.\nResults\nStudy sample demographics\nA total of 460 patients who underwent gynaecologi -\ncal laparoscopic surgery between 2015 and 2020 were \nincluded in this study, with a mean age of 33.09 (± 7.45) \nyears (SD). Characteristics of the included sample, \nincluding age; BMI; parity; and number of miscarriages, \nectopic pregnancies, and Caesarean sections, are illus -\ntrated in Table 1.\nOverall prevalence of endometriosis\nThe overall prevalence of endometriosis in all patients \nwas 13.7% (Table  2). Diagnostic laparoscopy was the \nmost common procedure performed on 251 (54.6%) \npatients. Infertility was the most common indication in \n177 (38.5%) patients. Diagnosis was made by the surgeon, \nidentifying features of endometriosis. According to the \ndescription of lesions provided in the patients’ records, \nthe type of endometriosis was determined (subtle, typi -\ncal, cystic or deep) by the surgeon during the procedure. \nHistopathological examination of suspected endome -\ntriotic tissue samples was available for 13 patients (21% \nof those with clinical evidence of endometriosis), and \nwhere available, there was 100% agreement with clinical \nTable 1 Main demographic characteristics of patients included \nin the study sample\nCharacteristics Minimum Maximum Mean SD\nAge 16 50 33.09 7.454\nBMI 17 46 26.84 4.658\nParity 0 8 1.60 1.933\nMiscarriages 0 16 0.59 1.620\nEctopic pregnancies 0 2 0.08 0.296\nCaesarean sections 0 5 0.51 1.034\nTable 2 Numbers and percentages of patients with and without \nevidence of endometriosis during laparoscopy\n*Represented as a percentage of total cases with endometriosis\nEvidence of endometriosis \nand its subtypes\nNumber Percentage (%)\nNo 397 86.3\nYes 63 13.7\nSubtle 16 25.4*\nTypical 26 41.3*\nCystic 17 27.0*\nDeep 4 6.3*\n\nPage 4 of 8Muhaidat et al. BMC Women’s Health          (2021) 21:381 \nfindings. These were patients who had prior to surgery \nconsented to the excision of the cystic lesion or oopho -\nrectomy and where an intraoperative diagnosis of ovar -\nian endometrioma was made based on gross appearance. \nThis was then confirmed by histopathology for all cases. \nHistopathological examination was performed by one of \ntwo pathologists with special interest and expertise in \ngynaecological diseases.\nEighteen (28.6%) patients had some form of surgical \ntreatment (endometrioma resection, ablation of endo -\nmetriotic lesions, or adhesiolysis at the time of primary \noperation), as there was previous suspicion of the pres -\nence of pathology; hence, patients consented for further \nsurgical management. For a further 10 (15.9%) patients, \nthey were recommended to undergo further surgery \nto treat endometriosis as a second step procedure after \nobtaining proper consent and preparing the patient. In \nthe remaining patients, the finding of endometriosis was \nnot associated with symptoms related to the disease; it \nwas therefore deemed incidental, not requiring surgical \ntreatment at that stage.\nTables 3 and 4 contain the types of laparoscopic sur -\ngeries that were performed on the patient sample of this \nstudy and their indications.\nUpon comparing the frequency of endometriosis \namong different groups, we found a statistically sig -\nnificant difference in the prevalence of endometriosis \nin patients undergoing laparoscopy according to indi -\ncation (p  = 0.020), as detailed in Table  5. On post hoc \nZ-test for proportions, the difference was most signifi -\ncant for family planning, where all 37 (100%) patients \nundergoing laparoscopies for family planning indica -\ntion were negative, and for chronic pelvic pain, where \n5 (31.3%) endoscopies were positive. The condition was \nmost commonly found when the indication for lapa -\nroscopy was chronic pelvic pain (31.3%), followed by \ninfertility (16.9%), recurrent pregnancy loss (16.7%), \novarian cyst (16%), diagnosis after suspected perfora -\ntion (9.7%), and ectopic pregnancy (4.3%). No cases of \nendometriosis were identified in those undergoing lap -\naroscopies for family planning purposes, such as tubal \nligation.\nPrevalence of endometriosis according to type \nof laparoscopic procedure\nUpon comparing different procedures with the pres -\nence of endometriosis, we did not find a significant dif -\nference (p  = 0.059). Table  6 details the frequencies. In \nall, 50% of those undergoing laparoscopically assisted \nvaginal hysterectomy had endometriosis; however, as \nonly two patients were included in this group, it may \nnot be very representative. Endometriosis was found in \n15.9% of patients who underwent diagnostic laparos -\ncopy, followed by those who underwent laparoscopic \novarian cystectomy (14.9%). Less frequently, the find -\ning of endometriosis was associated with laparoscopic \nsalpingectomy or salpingostomy (8.3%), and no cases of \nendometriosis were identified among patients who had \nlaparoscopic oophorectomy or tubal ligation.\nTable 3 Types of laparoscopic surgeries performed on 460 \npatients\nProcedure Number Percentage (%)\nDiagnostic laparoscopy 251 54.6\nLaparoscopic ovarian cystectomy 121 26.3\nLaparoscopic salpingectomy/salpingos-\ntomy\n48 10.4\nTubal ligation, bilateral or unilateral 37 8.0\nLaparoscopic oophorectomy 1 0.2\nLaparoscopically assisted vaginal hyster-\nectomy\n2 0.4\nTable 4 Indications for laparoscopic surgeries performed on 460 \npatients\nPrevalence of endometriosis according to indication for laparoscopy\nIndication for laparoscopy Number Percentage (%)\nSuspected uterine perforation 31 6.7\nInfertility, primary or secondary 177 38.5\nOvarian cyst accident 125 27.2\nEctopic pregnancy 47 10.2\nFamily planning 37 8.0\nChronic pelvic pain 16 3.5\nRecurrent pregnancy loss 6 1.3\nOther 21 4.6\nTable 5 Numbers and percentages of patients with versus \nwithout evidence of endometriosis according to the indication \nfor laparoscopy\nIndication for \nlaparoscopy\nNo \nendometriosis \nnumber (%)\nEndometriosis \nnumber (%)\np value\nSuspected uterine perfora-\ntion\n28 (90.3) 3 (9.7) 0.020\nInfertility, primary or \nsecondary\n147 (83.1) 30 (16.9)\nOvarian cyst accident 105 (84%) 20 (16%)\nEctopic pregnancy 45 (95.7) 2 (4.3)\nFamily planning 37 (100.0) 0 (0.0)\nChronic pelvic pain 11 (68.8) 5 (31.3)\nRecurrent pregnancy loss 5 (83.3) 1 (16.7)\nOther 19 (90.5) 2 (9.5)\n\nPage 5 of 8\nMuhaidat et al. BMC Women’s Health          (2021) 21:381 \n \nPrevalence of endometriosis according to age, BMI, \nparity, number of miscarriages, ectopic pregnancies \nand caesarean sections\nAs shown in Table 7, the mean age of patients with endo-\nmetriosis was 31.97 (SD 6.55) years, while it was 33.27 \n(SD 7.58) years for those without endometriosis. This dif-\nference was not statistically significant (p = 0.155).\nIn this study population, no significant association was \nfound between the patient’s body mass index (BMI) and \nthe presence of endometriosis (p = 0.13). The mean BMI \nfor patients with a positive finding of endometriosis was \n26.4 (SD 4.3) kg/m 2, whereas it was 27.0 (SD 4.7) kg/m 2 \nfor those without endometriosis (Table 7).\nOut of the 460 participants, previous obstetric history \ndata were available for 436 patients. Endometriosis was \nsignificantly higher in patients with a lower number of \nparities (p = 0.008) and Caesarean sections (p = 0.035) \n(Table 8). Regarding parity, endometriosis was found in \npatients with parities up to 4, with no cases of endome -\ntriosis found in grand multipara. The prevalence in nul -\nliparous women was 19%. It was 19.7% in women with a \nparity of one, 5.3% in women with a parity of two, 19.0% \nin women with a parity of 3, and 2.4% in women with a \nparity of 4.\nThe prevalence of endometriosis was highest in women \nwith no previous Caesarean sections (17.4%), with those \nwho had from one to five Caesarean sections having a \nprevalence less than the overall study population.\nThe prevalence of endometriosis was highest in those \nwho had not suffered any miscarriages (16.6%), followed \nby those who had one (11.7%), three (8.3%), or two (3.6%) \nTable 6 Numbers and percentages of patients with versus without evidence of endometriosis according to the type of laparoscopic \nprocedure\nProcedure No endometriosis number (%) Endometriosis number (%) p value\nDiagnostic laparoscopy 211 (84.1) 40 (15.9) 0.059\nLaparoscopic ovarian cystectomy 103 (85.1) 18 (14.9)\nLaparoscopic salpingectomy/salpingostomy 44 (91.7) 4 (8.3)\nTubal ligation, bilateral or unilateral 37 (100.0) 0 (0.0)\nLaparoscopic oophorectomy 1 (100.0) 0 (0.0)\nLaparoscopically assisted vaginal hysterectomy 1 (50.0) 1 (50.0)\nTable 7 Numbers and means of patients with versus without \nevidence of endometriosis according to the type of laparoscopic \nprocedure\nProcedure No endometriosis \nMean ± SD\nEndometriosis \nMean ± SD\np value\nBMI 27.0 ± 4.7 26.0 ± 4.3 0.130\nAge 33.27 ± 7.58 31.97 ± 6.55 0.155\nTable 8 Numbers and percentages of patients with versus \nwithout evidence of endometriosis according to parity and \nnumber of miscarriages, ectopic pregnancies, and Caesarean \nsections\nNumber No \nendometriosis \nnumber (%)\nEndometriosis \nnumber (%)\np value\nParity 0 153 (81.0) 36 (19.0) 0.008\n1 57 (80.3) 14 (19.7)\n2 54 (94.7) 3 (5.3)\n3 34 (81.0) 8 (19.0)\n4 39 (97.5) 1 (2.5)\n5 17 (100.0) 0 (0.0)\n6 7 (100.0) 0 (0.0)\n7 6 (100.0) 0 (0.0)\n8 7 (100.0) 0 (0.0)\nMiscarriages 0 267 (83.4) 53 (16.6) 0.499\n1 53 (88.3) 7 (11.7)\n2 27 (96.4) 1 (3.6)\n3 11 (91.7) 1 (8.3)\n4 9 (100.0) 0 (0.0)\n5 1 (100.0) 0 (0.0)\n6 3 (100.0) 0 (0.0)\n15 1 (100.0) 0 (0.0)\n16 2 (100.0) 0 (0.0)\nEctopic preg-\nnancies\n0 343 (84.9) 61 (15.1) 0.051\n1 29 (100.0) 0 (0.0)\n2 2 (66.7) 1 (33.3)\nCaesarean \nsections\n0 266 (82.6) 56 (17.4) 0.035\n1 47 (90.4) 5 (9.6)\n2 34 (100.0) 0 (0.0)\n3 15 (93.8) 1 (6.3)\n4 6 (100.0) 0 (0.0)\n5 6 (100.0) 0 (0.0)\n\nPage 6 of 8Muhaidat et al. BMC Women’s Health          (2021) 21:381 \nmiscarriages. None of the patients suffering four or more \nmiscarriages were found to have endometriosis. In rela -\ntion to ectopic pregnancy, the prevalence was 15.1% for \nthose with no previous ectopic pregnancy and 33.3% for \nthose with two previous ectopic pregnancies, whereas \nnone of the patients with a history of one ectopic preg -\nnancy were found to have the condition. The association \nbetween endometriosis and the number of ectopic preg -\nnancies and miscarriages was not found to be statistically \nsignificant.\nWe performed a logistic regression analysis to find fac -\ntors associated with endometriosis on multivariate level. \nWe included variables with p value < 0.1 on univariate \nanalysis. The model has a classification accuracy of 86.4% \nwith Nagelkerke R Square of 0.094. Parity and cesarean \nsection were significantly associated with endometrio -\nsis (p values of 0.036 and 0.046, respectively). Their odds \nratios were 0.8 (95% CI 0.65–0.9) and 0.54 (95% CI 0.3–\n0.9), respectively.\nDiscussion\nThe need to investigate the epidemiology of endometrio -\nsis was recognized a long time ago [24]. The true preva -\nlence of endometriosis within any given population is \ndifficult to determine due to a number of factors. The \nestimated prevalence varies according to geographical \narea, patient group under investigation, presence versus \nabsence of symptoms, and method of diagnosis. Further -\nmore, a significant number of cases may never be diag -\nnosed, as medical advice is not sought by the patient due \nto lack of symptoms or normalization of existing symp -\ntoms [1–7]. As diagnosis is typically only confirmed after \nlaparoscopy, data involving asymptomatic patients are \nlikely deficient [25].\nFurthermore, epidemiological studies of endometriosis \nface a number of methodological challenges, such as dis -\nease definition, selection bias, and challenges associated \nwith performing cohort or case control studies [16, 26].\nThis study found evidence of endometriosis in 13% of \nthe 480 women undergoing gynaecological laparoscopic \nsurgery between 2015 and 2020. This is considered higher \nthan the prevalence in the general population (2.5%) [6]. \nFor some of these patients, laparoscopy was indicated by \nconditions that are potentially related to endometriosis, \nsuch as infertility (37.1%) and chronic pelvic pain (3.3%), \nwhereas for others, the indication did not bear an obvi -\nous connection to this condition, such as family planning \n(7.7%).\nThe mean age of women who were found to have endo-\nmetriosis was 31.97 (SD 6.55) years. This is younger than \nthe age of peak prevalence of endometriosis reported \nin previous studies by Eisenberg et  al. and Abbas et  al. \nwho stated a peak prevalence in the late thirties and \nearly forties [2, 27]. No statistically significant difference \nwas found in the average age or BMI of patients diag -\nnosed with endometriosis and those who were not. This \ncontrasts with previous studies that demonstrated that \nwomen with endometriosis tend to have a lower body \nmass index than the general population [21–23].\nThere was a statistically significant correlation \nbetween the indication for laparoscopy and the percent -\nage of patients who were found to have endometriosis \n(p = 0.02). This was highest in those where the indication \nwas chronic pelvic pain (31.2%) and infertility (16.9%). \nPatients who underwent laparoscopy for recurrent preg -\nnancy loss and ovarian cyst accidents were also found to \nhave endometriosis more frequently than the overall 13%. \nOther indication groups had a lower prevalence of endo -\nmetriosis, with those undergoing laparoscopies for fam -\nily planning purposes noticeably having a 0% prevalence \nof endometriosis. This compares to a study by Mahmood \nand Templeton who evaluated the prevalence of endome-\ntriosis in premenopausal Caucasian women undergoing \nlaparoscopy according to indication and found that it was \n21% for those who underwent laparoscopy to investigate \ninfertility, 15% in those with chronic abdominal pain, and \n6% in women undergoing laparoscopic sterilization [28].\nThere was no significant difference in the prevalence \nof endometriosis when correlated with the type of lapa -\nroscopic surgery. Nevertheless, it should be noted that \nno cases of endometriosis were found in the patient \nsubgroups undergoing laparoscopy for tubal ligation or \noophorectomy.\nThe prevalence of endometriosis was significantly \nhigher in patients with lower parities and numbers \nof Caesarean sections. This could be explained by the \nknown association between endometriosis and infertility \n[10, 29].\nNo significant association was found between the \nprevalence of endometriosis and the number of previ -\nous miscarriages or ectopic pregnancies, but a noticeably \nhigh percentage (33.3%) of women who had 2 previous \nectopic pregnancies were found to have endometriosis. \nThis agrees with previous publications that suggest an \nassociation between the occurrence of ectopic pregnancy \nand the presence of endometriosis [30, 31].\nConclusion\nThere is to date a paucity of information regarding the \ntrue prevalence of endometriosis in Jordan. The numbers \nvary greatly according to the type of population exam -\nined in any given study. To our knowledge, this is the first \nJordanian study to assess the prevalence of endometriosis \nin women undergoing gynaecological laparoscopy. These \npatients comprise a heterogeneous group regarding the \nindication that prompted the procedure.\n\nPage 7 of 8\nMuhaidat et al. BMC Women’s Health          (2021) 21:381 \n \nThe overall presence of endometriosis upon laparos -\ncopy in this study (13%) was found to be higher than \nthe global prevalence of this condition; however, the \nstudy sample does not represent the general popula -\ntion, in which the prevalence is estimated to be 2.5%, \nbut rather a group of patients with some gynaecological \ncomplaint that requires laparoscopic diagnosis or treat -\nment. We also found that, when endometriosis preva -\nlence is investigated in a population sample undergoing \nlaparoscopic gynaecological surgery, the mean age of \naffected patients is lower than the general age of peak \nincidence for this condition.\nThere is significant variation in the prevalence of \nendometriosis in these patients according to several \nfactors. The findings of this study suggest that the find -\ning of endometriosis in Jordanian women undergoing \ngynaecological laparoscopy is more commonly encoun -\ntered in women with lower numbers of pregnancies and \nin those where the indication for surgery was related \nto decreased fertility or pelvic pain. Women with high \nparities or where the surgery’s indication suggested \nnormal fertility, such as family planning, were less likely \nto have endometriosis.\nPatient age and BMI did not seem to have a sig -\nnificant association with endometriosis in this study \npopulation.\nEndometriosis is a significant public health concern \nin Jordan, as it is worldwide, but its epidemiology in \nthis region is still poorly understood. We hope that this \nresearch will add to our awareness of the prevalence \nof this disease in the Middle East and prompt further \nresearch in this field.\nThis research was limited by the fact that it was a \nretrospective single-centre study performed on a rela -\ntively small sample of patients. Due to the retrospec -\ntive nature of the research, histological diagnosis was \nnot available for all cases. Biopsy is not routinely per -\nformed in our centre to diagnose cases of endome -\ntriosis, and as this study was retrospective, only data \navailable in the patients’ records could be extracted and \nanalysed. Additional surgical procedures would require \ninformed consent, and in many cases, the finding of \nendometriosis was incidental in a surgical operation \nwith an unrelated indication. However, in those where \nit was available, there was a 100% correlation with clini -\ncal findings. Further large-scale multicentre prospec -\ntive studies are required to deepen our understanding \nof endometriosis in Jordan and the Middle East.\nAbbreviations\nBMI: Body mass index; SPSS: Statistical package for the social sciences; SD: \nStandard deviation.\nAcknowledgements\nThe authors would like to thank Jordan University Hospital for their help in \nfacilitating this research.\nAuthors’ contributions\nNM was responsible for the conceptualization and design of this study. NM, \nSS, KF, MN, NA, SAA, ME and ME contributed equally to the data collection, \nanalysis, interpretation, and drafting of the manuscript. All authors read and \napproved the final manuscript.\nFunding\nNo funding was required for this study.\nAvailability of data and materials\nThe dataset used and/or analysed during the current study is available from \nthe corresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nThis research was granted ethical approval by the Institutional Review Board \n(IRB) of Jordan University Hospital in accordance with the Declaration of \nHelsinki (reference 1012021/3170). Participant confidentiality was protected. \nAs the study was performed by retrospectively retrieving data from hospital \nrecords and as patient information was handled anonymously, informed con-\nsent was not required for participation, as approved by the IRB above.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1 Department of Obstetrics and Gynaecology, Faculty of Medicine, The \nUniversity of Jordan, Queen Rania Street, Amman 11942, Jordan. 2 Depart-\nment of Family Medicine, Faculty of Medicine, The University of Jordan, \nAmman 11942, Jordan. 3 Department of Ophthalmology, Faculty of Medicine, \nThe University of Jordan, Amman 11942, Jordan. 4 Faculty of Medicine, The \nUniversity of Jordan, Amman 11942, Jordan. \nReceived: 2 June 2021   Accepted: 28 October 2021\nReferences\n 1. Al-Jefout M. Laparoscopy for diagnosis and treatment of endometriosis. \nAdv Gynecol Endosc. 2011;23:183.\n 2. Eisenberg VH, et al. Epidemiology of endometriosis: a large population-\nbased database study from a healthcare provider with 2 million mem-\nbers. BJOG. 2017. https:// doi. org/ 10. 1111/ 1471- 0528. 14701.\n 3. Eskenazi B, et al. Epidemiology of endometriosis. Obstet Gynecol Clin N \nAm. 1997;24(2):235–580.\n 4. Fuldeore MJ, Soliman AM. Prevalence and symptomatic burden of \ndiagnosed endometriosis in the United States: national estimates \nfrom a cross-sectional survey of 59,411 women. Gynecol Obst Investig. \n2017;82(5):453–61.\n 5. Morassutto C, Monasta L, Ricci G, Barbone F, Ronfani L. Incidence and \nestimated prevalence of endometriosis and adenomyosis in Northeast \nItaly: a data linkage study. PLoS ONE. 2016;11(4):e0154227.\n 6. Al-Jefout M, Nesheiwat A, Odainat B, Sami R, Alnawaiseh N. Question-\nnaire-based prevalence of endometriosis and its symptoms in Jordanian \nwomen. Biomed Pharmacol J. 2017;10(2):699–706.\n 7. Al-Jefout M, Alnawaiseh N, Yaghi S, Alqaisi A. Prevalence of endome-\ntriosis and its symptoms among young Jordanian women with chronic \npelvic pain refractory to conventional therapy. J Obst Gynaecol Can. \n2018;40(2):165–70.\n\nPage 8 of 8Muhaidat et al. BMC Women’s Health          (2021) 21:381 \n•\n \nfast, convenient online submission\n •\n  \nthorough peer review by experienced researchers in your field\n• \n \nrapid publication on acceptance\n• \n \nsupport for research data, including large and complex data types\n•\n  \ngold Open Access which fosters wider collaboration and increased citations \n \nmaximum visibility for your research: over 100M website views per year •\n  At BMC, research is always in progress.\nLearn more biomedcentral.com/submissions\nReady to submit y our researc hReady to submit y our researc h  ?  Choose BMC and benefit fr om: ?  Choose BMC and benefit fr om: \n 8. Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, d’Hooghe TM. \nPrevalence of endometriosis diagnosed by laparoscopy in adolescents \nwith dysmenorrhea or chronic pelvic pain: a systematic review. Hum \nReprod Update. 2013;19(5):570–82.\n 9. Nnoaham KE, Hummelshoj L, Webster P , d’Hooghe T, de Cicco Nardone \nF, de Cicco Nardone C, Jenkinson C, Kennedy SH, Zondervan KT, Study \nWE. Impact of endometriosis on quality of life and work productivity: a \nmulticenter study across ten countries. Fertil Steril. 2011;96(2):366–73.\n 10. Bulletti C, Coccia ME, Battistoni S, Borini A. Endometriosis and infertility. J \nAssist Reprod Genet. 2010;27(8):441–7.\n 11. Farquhar CM. Endometriosis. BMJ. 2000;320(7247):1449–52.\n 12. Shafrir AL, Farland LV, Shah DK, Harris HR, Kvaskoff M, Zondervan K, \nMissmer SA. Risk for and consequences of endometriosis: a critical epide-\nmiologic review. Best Pract Res Clin Obstet Gynaecol. 2018;1(51):1–5.\n 13. Kennedy S, Bergqvist A, Chapron C, Dhooghe T, Dunselman G, Greb R, \nHummelshoj L, Prentice A, Saridogan E. ESHRE guideline for the diagnosis \nand treatment of endometriosis. Hum Reprod. 2005;20(10):2698–704.\n 14. Hsu AL, et al. Invasive and noninvasive methods for the diagnosis of \nendometriosis. Clin Obstet Gynecol. 2010;53(2):413–9.\n 15. Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endo-\nmetriosis in adolescent girls with chronic pelvic pain not responding to \nconventional therapy. J Pediatr Adolesc Gynecol. 1997;10(4):199–202.\n 16. Koninckx PR, Ussia A, Keckstein J, Wattiez A, Adamyan L. Epidemiology \nof subtle, typical, cystic, and deep endometriosis: a systematic review. \nGynecol Surg. 2016;13(4):457–67.\n 17. Guo SW, Wang Y. The prevalence of endometriosis in women with \nchronic pelvic pain. Gynecol Obstet Investig. 2006;62(3):121–30.\n 18. Hager M, Wenzl R, Riesenhuber S, Marschalek J, Kuessel L, Mayrhofer \nD, Ristl R, Kurz C, Ott J. The prevalence of incidental endometriosis in \nwomen undergoing laparoscopic ovarian drilling for clomiphene-\nresistant polycystic ovary syndrome: a retrospective cohort study and \nmeta-analysis. J Clin Med. 2019;8(8):1210.\n 19. Rawson JM. Prevalence of endometriosis in asymptomatic women. J \nReprod Med. 1991;36(7):513–5.\n 20. Yong L, Weiyuan Z. Association between body mass index and endome-\ntriosis risk: a meta-analysis. Oncotarget. 2017;8(29):46928.\n 21. Ferrero S, Anserini P , Remorgida V, Ragni N. Body mass index in endome-\ntriosis. Eur J Obstet Gynecol Reprod Biol. 2005;121(1):94–8.\n 22. Matalliotakis IM, Cakmak H, Fragouli YG, Goumenou AG, Mahutte NG, \nArici A. Epidemiological characteristics in women with and without endo-\nmetriosis in the Yale series. Arch Gynecol Obstet. 2008;277(5):389–93.\n 23. Hemmings R, Rivard M, Olive DL, Poliquin-Fleury J, Gagné D, Hugo P , \nGosselin D. Evaluation of risk factors associated with endometriosis. Fertil \nSteril. 2004;81(6):1513–21.\n 24. Kempers RD, Dockerty MB, Hunt AB, Symmonds RE. Significant post-\nmenopausal endometriosis. Surg Gynecol Obstet. 1960;111:348–56.\n 25. Koninckx PR, Anastasia U, Adamyan L, Tahlak M, Keckstein J, Martin DC. \nThe epidemiology of endometriosis is poorly known since the patho-\nphysiology and the diagnosis are unclear. Best Pract Res Clin Obstet \nGynaecol. 2020;71:14–26.\n 26. Cramer DW, Missmer SA. The epidemiology of endometriosis. Ann N Y \nAcad Sci. 2002;955(1):11–22.\n 27. Abbas S, Ihle P , Köster I, Schubert I. Prevalence and incidence of \ndiagnosed endometriosis and risk of endometriosis in patients with \nendometriosis-related symptoms: findings from a statutory health \ninsurance-based cohort in Germany. Eur J Obstet Gynecol Reprod Biol. \n2012;160(1):79–83.\n 28. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. \nHum Reprod. 1991;6(4):544–9.\n 29. De Ziegler D, Borghese B, Chapron C. Endometriosis and infertility: patho-\nphysiology and management. Lancet. 2010;376(9742):730–8.\n 30. Hunter RH. Tubal ectopic pregnancy: a patho-physiological explanation \ninvolving endometriosis. Hum Reprod. 2002;17(7):1688–91.\n 31. Farland LV, Prescott J, Sasamoto N, Tobias DK, Gaskins AJ, Stuart JJ, \nCarusi DA, Chavarro JE, Horne AW, Rich-Edwards JW, Missmer SA. \nEndometriosis and risk of adverse pregnancy outcomes. Obstet Gynecol. \n2019;134(3):527–36.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}