{"paper_id":"40d04c55-dc51-4355-bca4-3d8964a1ad09","body_text":"167Vol. 47, No. 4, December2025\n Research article\n  Research article\nSri Lanka Journal of Obstetrics and Gynaecology   2025; 47: 167-173\nDOI:  https://doi.org/10.4038/sljog.v47i4.8233\nCorrespondence: SG , e-mail: sgyamtsho@jdwnrh.gov.bt \nhttps://orcid.org/000-0002-6746-1421\na,b Department of Obstetrics and Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhuatn.\nReceived 07th October 2025\nAccepted 31st December 2025\nPrevalence of endometriosis among women undergoing\nlaparoscopic surgery for gynaecological indications at Jigme\nDorji Wangchuck National Referral Hospital, Thimphu, Bhutan\nSonam Gyamtshoa, Nidup Gyeltshenb\nThis is an open-access article distributed under the terms of t he Creative Commons Attribution 4.0 International License, whic h\npermits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\nKeywords: endometriosis, prevalence, laparoscopy, pelvic pain, infertilit y\nAbstract\nIntroduction: Endometriosis is a chronic, inflammatory disease which is characterized by the presence of endometrial like\ntissue outside the uterus. Endometriosis affects approximately 190 million women worldwide. The study was carried out to\ndetermine the prevalence of endometriosis among women undergoing laparoscopic surgeries at Department of Obstetrics\nand Gynaecology in Jigme Dorji Wangchuck National Referral Hospital (JDWNRH).\nMethod: This hospital based observational study was carried out among women, who had undergone laparoscopic\nsurgeries for gynecological indications in Department of Obstetrics and Gynaecology in JDWNRH from December 2023 to\nNovember 2024, involving 83 women who had undergone laparoscopic surgeries.\nResults: The overall prevalence of endometriosis among these women undergoing laparoscopic surgeries  was 18.07%.\n33.33% of women with chronic pelvic pain, 28% with infertility and 25% with ovarian cyst had endometriosis. Comparing the\ndifferent indications for laparoscopic surgeries for the endometriosis, did not show significant differences (p=0.519).\nConclusion: This study highlights the higher prevalence of endometriosis among the women undergoing laparoscopic\nsurgery particularly in women with chronic pelvic pain, and infertility. This high prevalence may be due to symptomatic women\nundergoing laparoscopy.\n\n168 Sri Lanka Journal of Obstetrics and Gynaecology\nResearch article\nIntroduction\nEndometriosis is a chronic, inflammatory disease\nwhich is characterized by the presence of endometrial\nlike tissue outside the uterus 1. Endometriosis affects\nwomen of reproductive age groups and has various\nclinical manifestations ranging from mild symptoms\nto severe dysmenorrhea, dyspareunia, chronic pelvic\npain, anxiety, or infertility\n2.\nEndometriosis affects approximately 190 million\nwomen worldwide which is roughly 10% of the\nwomen of reproductive age group globally\n1,3. The actual\nprevalence in the population is difficult because there\nis often delay in the diagnosis\n3. However the prevalence\nof endometriosis varies in different regions of the globe.\nIn Canada, the prevalence is 7%4, where as in Australia,\nthe cumulative prevalence of clinically confirmed or\nsuspected endometriosis in the population was 11.4%\n5.\nA Jordanian multi-center retrospective study  done for\nwomen undergoing laparoscopic surgery for various\ngynaecological indications found overall prevalence of\n10.3%\n6.\nThe gold standard for diagnosing endometriosis is by\nlaparoscopic visualization of lesions followed by\nhistopathological confirmation\n2. According to the type\nof lesions seen during the time of laparoscopy, it can\nbe superficial peritoneal, ovarian, and deep endo-\nmetriosis\n1. Recent guidelines recommended a non-\nsurgical (clinical) diagnosis based on symptoms,\nphysical examinations and imaging\n7. Endometriosis had\nremains under diagnosed due to the sign and symptoms\noverlapping with other gynecological conditions2 and\nalso limited awareness, knowledge of health care\nproviders, unknown prevalence of endometriosis in\nBhutanese set up, which could have delayed the diag-\nnosis and delivery of effective therapy. This study aims\nto find out the prevalence of endometriosis in Bhutanese\nwomen undergoing laparoscopy for different gynae-\ncological conditions.\nMethod\nStudy design\nThis hospital based observational study was carried\nout among women, who had undergone laparoscopic\nsurgeries for gynecological indications in Department\nof Obstetrics and Gynaecology in Jigme Dorji\nWangchuck National Referral Hospital over a period\nof one year from December 2023 to November 2024.\nStudy setting\nThis study was conducted in the Department of\nObstetrics and Gynaecology at Jigme Dorji Wangchuck\nNational Referral Hospital (JDWNRH), which is apex\ntertiary hospital with high volume of patients referred\nfor management of gynaecological disorders in Bhutan\nand advanced laparoscopic surgeries facility available.\nStudy participants\nThis study included women between 18 to 49 years,\nwho were admitted for laparoscopic surgeries. Women\nunder the age of 18 years and over 50 years or already\nin menopause were excluded from the study.\nSampling technique and data collections\nCensus sampling was done to collect all the data of\nthe women, undergoing laparoscopic surgeries during\nthis study period. Data were collected from patient’s\nadmission case sheet from the maternity ward, and\nOperation notes from the Operation Theater using a\nData collection Proforma form after obtaining informed\nconsent. These group of women who underwent\nlaparoscopic surgeries in the Department of Obstetrics\nand gynaecology for various indications were assessed\nfor the presence of endometriosis and staging was done\nusing the r ASMR classification scoring by the\noperating gynaecologists using the and r ASRM (revised\nAmerican society for reproductive medicine) form\n8.\nA written permission on the usage of r ASRM form\nfor the data collection was granted by Elsevier\nPublisher on 22\nnd October 2023 via email.\nData processing and analysis\nThe collected data were double checked and entered\ninto Epidata version 3.3 (Epi Data Association,\nOdense, Denmark) and exported to STATA version 13\n(Stata Corp, Stata Statistical Software) for analysis.\nDescriptive statistics such as frequency, percentage,\nstandard deviation, and mean of the variables were\ncalculated. Pearson Chi-square or Fisher’s exact test\nwas used, test the association between two attributes\nas well as for testing of difference in proportions.\nSignificance level was set at P value <0.05.\nEthical clearance and ethics issues\nThe ethical clearance was obtained from Institutional\nReview Board (IRB) of Khesar Gyelpo University of\nMedical Sciences of Bhutan (Ref. No. IRB/Approval/\nPN/2023-019/1100, 14-Dec-2023) and administrative\napproval from JDWNRH was obtained prior to\n\n169Vol. 47, No. 4, December2025\n Research article\ncommencement of the study. Informed written consent\nwas obtained from the participating eligible patients.\nThey were given full autonomy to decide whether to\nparticipate in the study or not with the right to reject\ntaking part in the study after explaining to them\ncomprehensively in the Informed Consent Form and\nreading out the Information Sheet.\nResults\nEighty three women had undergone gynecological\nlaparoscopic surgeries from December 2023 to\nNovember 2024 over a period of one year were included\nin this study. Fifteen women were found to have\nendometriosis out of 83 women who underwent\nlaparoscopic surgeries for various indications, making\nthe overall prevalence of endometriosis of 18.07%.\nThe mean age of the women was 34.90±8.2 years\n(Table 1). The majority of the women (87.95%)\nwho had undergone laparoscopic surgery were\nmarried, 67.47% were multiparous and 54.22% were\nhousewives (Table 1).\nCharacteristics N (%)\nAge\nMean age ±SD 34.90 ±8.2SD\nMarital status\nMarried 73 (87.95)\nUnmarried 8 (9.64)\nDivorced 2 (2.40)\nEducation level\nNon formal education 24 (28.92)\nPrimary 10 (12.05)\nLower secondary 4 (4.82)\nHigher secondary 32 (38.55)\nTertiary 13 (15.66)\nOccupation\nHousewife 45 (54.22)\nCivil servant or corporate 16 (19.28)\nFarmer 3 (3.61)\nBusiness 14 (16.87)\nStudent 5 (6.02)\nParity\nNulliparous 27 (32.53)\nMultiparous 56 (67.47)\nHistory of Miscarriage\nYes 7 (8.43)\nNo 76 (91.57)\nHistory of Caesarean section\nYes 13 (15.66)\nNo 70 (84.34)\nTable 1. Socio-demographic characteristics of women undergoing laparoscopic surgeries for\ngynaecological indications at JDWNRH during the period from December 2023 to 2024, N=83\n\n170 Sri Lanka Journal of Obstetrics and Gynaecology\nResearch article\nTable 2 and 3 contains the type of indications and\nlaparoscopic surgeries that were performed on the\nwomen who were involved in this study. Majority of\nthe indications was done for suspected ectopic\npregnancies (20.48%) followed by ovarian cyst\n(19.28%) and family planning (18.07%).\nAs depicted in Table 3, diagnostic laparoscopy± dye\ntest (28.92%) was the most common surgeries done,\nwhich was followed by salpingectomy (20.48%) and\ntubal sterilization (18.07%).\nAs depicted in Table 4 and 5, fifteen women were\nfound to have endometriosis out of 83 women who\nunderwent laparoscopy surgeries for various indi-\ncations, making the overall prevalence of endometriosis\nof 18.07%.\nUpon comparing the different indications for laparo-\nscopic surgeries for the presence of endometriosis,\ndid not find significant differences (p=0.519).\nLaparoscopy indications N (%)\nPrimary or secondary infertility 11 (13.25)\nOvarian cysts 16 (19.28)\nEctopic pregnancy 17 (20.48)\nChronic pelvic pain 6 (7.23)\nFibroids 7 (8.43)\nTubal sterilization 15 (18.07)\nOthers \n¥ 11 (13.25)\n¥ Includes abnormal uterine bleeding, cervical intraepithelial\nlesions, suspected abdominal tuberculosis and pelvic infections.\nTable 2. Gynaecological indications in women\nfor undergoing laparoscopic surgeries at\nJDWNRH during the period from December\n2023 to 2024, N=83\nIndication for No endometriosis Endometriosis      p-valve\nLaparoscopy number (%) (%)\nPrimary or secondary 8 (72.73) 3 (27.27) P =0.519\ninfertility\nOvarian cystμ 12 (75) 4 (25)\nEctopic pregnancy 14 (82.35) 3 (17.65)\nChronic pelvic pain 4 (66.67) 2 (33.33)\nFibroid \n† 7 (100) 0 (0).\nTubal sterilization 13 (86.67) 2 ( 13.33)\nOthers¥ 10 (90.90) 1 (9.09)\nType of laparoscopy surgery N (%)\nDiagnostic laparoscopy 24 (28.92)\n± Dye test\nSalpingectomy or salpingostomy 17 (20.48)\nTubal sterilization 15 (18.07)\nOvarian cystectomy 13 (15.66)\nTotal Laparoscopy 13 (15.66)\nhysterectomy (TLH)\nOophorectomy or 1 (1.20)\nsalpingo-ophorectomy\nTable 3. The types of laparoscopic surgeries\nperformed among the women at JDWNRH\nduring the period from December 2023\nto 2024, (N=83)\nTable 4. Numbers and percentages of patients with versus without evidence of\nendometriosis according to the indication for laparoscopy (N=83)\nμ Ovarian cyst and ectopic pregnancy were merged together as adnexal mass.\n† Fibroid and others were merged together under others.\n¥ includes abnormal uterine bleeding, CIN lesions, suspected abdominal tuberculosis and pelvic infections.\n\n171Vol. 47, No. 4, December2025\n Research article\nTable 4 show the details of various indications and the\npresence of endometriosis. Endometriosis was found\nin 33.33% of women undergoing laparoscopy for\nchronic pelvic pain followed by those who underwent\ndiagnostic laparoscopy for infertility (28% ) and ovarian\ncyst (25%) (Table 4). No endometriosis was detected\nin those women who underwent laparoscopy for\ntreatment of Fibroid uterus (Table 4).\nEndometriosis stage n (%)\nStage 1 7 (46.66)\nStage 2 1 (6.66)\nStage 3 3 (20)\nStage 4 4 (26.66)\nType of lesions\nμ\nRed or flame like lesions 6 (40)\nClear or vesicles 5 (33.33)\nWhite or opaque 3 (20)\nEndometrioma 3 (20)\nTable 5. Stage and type of endometriosis\nlesions among the women who had undergone\nlaparoscopic surgeries for gynaecological\nindications at JDWNRH during the period\nfrom December 2023 to 2024, (N=15)\nμ Some of the women have more than one type of lesions\nFigure 1. Laparoscopic panoramic view showing\nfemale pelvis with the vesicle lesions of endo-\nmetriosis (blue arrow) and endometrioma and\nobliteration of Pouch of Douglas (yellow arrow).\nAmong the women , who were diagnosed  with\nendometriosis during the laparoscopy, majority\n(46.66%) had stage 1, and 26.66% had stage 4\nendometriosis (Table 5) as per Revised American\nsociety for Reproductive medicine classification of\nendometriosis. 40% of the women had red or flame\nlike lesions, 33.33% had clear or vesicles, in some\ncases there were existence of more than one type of\nlesions as shown in Figure 1.\nDiscussion\nIn our study we found that the overall prevalence of\nendometriosis was 18.07% among the women who\nhad undergone laparoscopic surgeries. We observed\nthat endometriosis was more prevalent in women with\nchronic pelvic pain (33.33%), followed by infertility\n(27.27%), and less common in women undergoing\ntubal sterilization.\nThe prevalence of this study corroborated with a\nsystemic review by Yousef Moradi et al concluded that\nthe prevalence was 18%\n9. On the contrary, the\nprevalence was 7% in Canada, 11.4% in Australia and\nprevalence of 10.3% in a multicenter retrospective\nstudy done in Jordan4,5,6. The higher prevalence in our\nstudy compared to other studies could be due to\nsymptomatic women undergoing laparoscopic surgery\nwith conditions potentially related to chances of\nendometriosis like ovarian cyst (19.28%), infertility\n(13.25%) and chronic pelvic pain (8.43%).\nThe mean age of our participants was 34.90 years\n(SD±8.2). This is almost corresponding to the mean\nage of  36.1±7.2 years in Brazil (10), 34.54± 6.72 years\nin Northeast, India\n11, 31.2 years in a study done in\nNigeria12 and 29±4.3 years to a study done by Mishra,\net al13. This age profile aligns with the reproductive\nage range, where many gynecological issues including\nendometriosis, are most prevalent.\nAmong those diagnosed with endometriosis in our\nstudy, 33.33% with chronic pelvic pain(CPP) had\nendometriosis, which  correlate with study done in\nJordan, where 29.7% with  chronic pelvic pain had\nendometriosis\n6, but a study done by Taylor, et al had\nobserved endometriosis in more than 50-80% of the\nCPP cases\n3, and 44% in another study by Harder,\net al14 . The lower prevalence compared to other studies\ncould be due to small sample size in our study. The\nmechanisms underlying the association between\nendometriosis and chronic pelvic pain are multifaceted.\n\n\n172 Sri Lanka Journal of Obstetrics and Gynaecology\nResearch article\nOne proposed pathway is the inflammatory response\nelicited by ectopic endometrial tissue. The presence\nof this tissue leads to local inflammation, which can\nsensitize nociceptive pathways and contribute to the\nperception of pain among women who had endo-\nmetriosis, Prostaglandin E2 has been identified as a\nkey player in the pathophysiology of endometriosis-\nrelated pain, as it can enhance pain sensitivity and\npromote the development of chronic pain syndromes\n15.\nIn this study, 27.7 % women with endometriosis had\nprimary or secondary infertility and findings were\nsimilar to many studies6,2. Endometriosis affect fertility\nby altering the peritoneal environment or by distorting\nthe pelvic anatomy. Infertility is also affected by\nendometriosis by causing chronic inflammation\nwhich impairs ovarian, tubal or endometrial function,\nleading to disorder of folliculogenesis, fertilization or\nimplantation\n2,3,14.\nIn this study, 25% of the ovarian cystectomy were\nendometrioma. This finding was  higher compared to\na study done by Mohammad Al-Jafari, et al, where\nonly 11.9% of the cysts were endometrioma\n6. This\nhigh prevalence in our study could be due to more\nsuspected ovarian cysts for endometrioma were\noffered laparoscopic surgery.\nThe distribution of endometriosis stages showed that\nstage I (46.66%) was most common, followed by\nstage IV (26.66%). This distribution was consistent\nwith findings by Kalpana S, et al, and Vineet V Mishra\net al, who also reported that early stage endometriosis\nis more frequently diagnosed likely due to advance-\nments in imaging and better diagnostic set up\n11,13.\nHowever a proportion of our cases (Stage III, IV:\n46.22%) diagnosed reflects the diagnostic delayed and\nother barriers to accessing specialist care in low\nresource setting\n11,12.\nStrength and limitations\nThis study was the first of its kind to assess the\nprevalence of endometriosis in the country and was\nconducted at the National referral hospital and cannot\nbe generalized to the whole population. The other\nlimitation is that the diagnosis of the endometriosis was\ncompletely based on the visual diagnosis of the\nendometriosis lesions which was completed dependent\non observer skills of the gynecologists. Histopatho-\nlogical confirmation of endometriotic lesions was not\ntaken into considerations in this study.\nConclusions\nThis study highlights the higher prevalence of endo-\nmetriosis among the women undergoing laparoscopic\nsurgery particularly in women with chronic pelvic pain,\nand infertility. This high prevalence may be due to\nsymptomatic women undergoing laparoscopy. There-\nfore laparoscopy remain one of the gold standard for\ndiagnosis, staging, and surgically managing of endo-\nmetriosis especially in cases with sign and symptoms\nsuspected of endometriosis.\nAcknowledgements\nAuthors would like to thank all the participants and the\nscrub nurses and anesthetists and the resident doctors\nfor all the support for this study.\nReferences\n1. Horne AW, Missmer SA. Pathophysiology,\ndiagnosis, and management of endometriosis. BMJ.\n2022;\n2. Allaire C, Bedaiwy MA, Yong PJ. Diagnosis and\nmanagement of endometriosis. C Can Med Assoc\nJ. 2023; 195(10): E363-71.\n3. Taylor HS, Kotlyar AM, Flores V A. Endometriosis\nis a chronic systemic disease: clinical challenges\nand novel innovations. Lancet [Internet]. 2021;\n397(10276): 839-52.\n4. Singh S, Soliman AM, Rahal Y , Robert C, Defoy I,\nNisbet P, et al. Prevalence, Symptomatic Burden,\nand Diagnosis of Endometriosis in Canada: Cross-\nSectional Survey of 30 000 Women. J Obstet\nGynaecol Canada [Internet]. 2020; 42(7): 829-38.\n5. Rowlands IJ, Abbott JA, Montgomery GW, Hockey\nR, Rogers P, Mishra GD. Prevalence and incidence\nof endometriosis in Australian women: a data\nlinkage cohort study. BJOG An Int J Obstet\nGynaecol. 2021; 128(4): 657-65.\n6. Al-Jafari M, Aldarawsheh MA, Abouzid M, Serag\nI, Nofal MA, Altiti AR, et al. Prevalence of\nendometriosis in women undergoing laparoscopic\nsurgery for various gynecological indications:\na Jordanian multi-center retrospective study.\nBMC Womens Health [Internet]. 2024; 24(1).\n7. ESHRE Endometriosis Guideline Development\nGroup. Endometriosis?: Guideline of ESHRE.\nEshre [Internet]. 2022; Available from: www.\neshre.eu/guidelines\n\n173Vol. 47, No. 4, December2025\n Research article\n8. Nevalainen A. Special contribution. Water Supply.\n2000; 18(1-2): 298-9.\n9. Res M, Ruts C, Hospital CR, Sciences M,\nCommittee IE, Crh-smims S. Prevalence of. 2018;\n(May): 517-20.\n10. Cardoso JV , Machado DE, da Silva MC, Berardo\nPT, Ferrari R, Abrão MS, et al. Epidemiological\nprofile of women with endometriosis: A\nretrospective descriptive study. Rev Bras Saude\nMatern Infant. 2020; 20(4): 1057-67.\n11. Udupa KS, Phukan P, Saikia N, Dutta A. Study on\nepidemiology of endometriosis in North East India.\nInt J Reprod Contraception, Obstet Gynecol. 2023;\n12(6): 1770-4.\n12. Co O, Kk M, Cj M, Oo A, Io A, Ai A. Awareness\nand Prevalence of Endometriosis among Women\nwith Fertility Challenges attending Gynaecology\nClinic in a Tertiary Hospital in Nigeria. Int J\nGynecol Infertil Res Artic [Internet]. 2024; 2(1).\n13. Mishra V V ., Gaddagi RA, Aggarwal R, Choudhary\nS, Sharma U, Patel U. Prevalence; characteristics\nand management of endometriosis amongst infertile\nwomen: A one year retrospective study. J Clin\nDiagnostic Res. 2015; 9(6): QC01-3.\n14. Harder C, Velho RV, Brandes I, Sehouli J, Mechsner\nS. Assessing the true prevalence of endometriosis:\nA narrative review of literature data. Int J Gynecol\nObstet. 2024; 167(3): 883-900.\n15. Wu MH, Lu CW, Chuang PC, Tsai SJ.\nProstaglandin E2: The master of endometriosis?\nExp Biol Med. 2010; 235(6): 668-77.","source_license":"CC0","license_restricted":false}