{"paper_id":"806df4a3-01bd-4b33-a6a3-fe7e4e4744cf","body_text":"International Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 1 \n \nKnowledge Regarding Endometriosis and \nWellbeing Among Women Diagnosed with \nEndometriosis. \n \nAnnie Nirmala1, Anusuya Prabhu2 \n \n1Assistant Professor Koshys College of Nursing \n2Assistant Professor Manipal College of Nursing \n \nABSTRACT \nBackground: Endometriosis is a major problem  and it affects millions of women worldwide. Its \nprevalence is comparable to that of diabetes and hypertension. 10% of the reproductive age gets affected \nby Endometriosis i.e 176 million women are being affected with Endometriosis. It affects the age group  \nbetween 26 to 35 years.  \n \nObjectives: To assess the knowledge regarding endometriosis and wellbeing among women diagnosed \nwith endometriosis.  \n \nMethods: A descriptive study was conducted from January 2019 to April 2019, among 85 women aged \nbetween 21-49 years who were diagnosed with e ndometriosis and were on treatment in infertility center \nfrom Udupi taluk, Karnataka. Proportionate sampling technique  was used to select the participants. A \npretested knowledge questionnaire was used to collect the data after obtaining informed consent from the \nparticipants. After collecting the information, a leaflet, which contains brief information about \nendometriosis and lifestyle modifications strategies was given to all the participants.   \n \nResults: 50 (58.8%) of women had good knowledge  regarding endometriosis and 81 (95.3%) of women \ndiagnosed with endometriosis had average wellbeing. The study found no statistical significant \nrelationship between scores of knowledge and wellbeing (p>0.05).  \n \nConclusion: The women diagnosed with endometriosis, is psychologically affected and thus counselling \nis very important to lead a normal day to day life. \n \nKEYWORDS: Endometriosis, women, knowledge, wellbeing. \n \nINTRODUCTION: \n      Endometriosis is a gynaecological disorder, as the ectopic endometrial tissue grows outside the uterus. \nEndometriosis affects 8% –10% of women of reproductive age; in 30% of the women, the condition is \nassociated with primary or secondary infertility.  Endometriosis is a condition which is not curable, \nhowever there are certain treatment which improves  the symptoms like Analgesics, hormonal treatment, \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 2 \n \nsurgical removal of endometriosis and complementary therapies like yoga, meditation and deep breathing \nexercises. \n \nSome women experience no symptoms. If symptoms occur they may include: \nPelvic or back pain before or during the menstrual period, very painful menstrual cramps, pain during sex, \nabnormal or heavy menstrual flow, painful bowel movements, diarrhea, constipation or other intestinal \nproblem during menstrual periods, painful urination or feeling the need to urinate often during menstrual \nperiods, difficulty in conceiving. \n \nAccording to extrapolated statistics, out of 1, 065, 070, 6072 people 53,253,530 are  suffering from \nendometriosis in India. The incidence is about 10-15% in all infertile women1 .  \n \nAccording to a study conducted by Dept. Of General surgery, Fr. Muller’s medical college, Mangalore, \nKarnataka, the incidence of endometriosis in Karnataka has been reported to be as high as 44% in \nasymptomatic women undergoing laparoscopy for non -gynecological symptoms,while the incidence of \numbilical endometriosis is estimated to be only 0.5% to 1% of all womenwith extra gonadal \nendometriosis2. \n \nPrevalence of endometriosis may be as high as 25% to 35%among infertile women. Infertility occurs in \nabout 30-40 % of women with endometriosis.A woman with a mother or sister with endometriosis is six \ntimes more likely to develop endometriosis than women without this familial history 3. \n \n \nA case report was done in Bagalkot, Karnataka of a 23 year old female being diagnosed with \nEndometriosis when she had an emergency caesarean section. The patient had no symptoms of \nEndometriosis. Endometriosis symptoms can be either symptomatic or asymptom atic but its rare to see \nthis condition asymptomatic. The patient was counselled to complete her family early so that it does not  \nlead to infertility or further progress of her condition 4.   \n \nA qualitative study was conducted to explore the experiences of women who are being diagnosed with \nEndometriosis. Out of 297 articles, 22 articles were included based on the inclusion criteria and were \nanalyzed. The study result showed that women diagnosed  with Endometriosis had negative experiences \nas it affected their social life, intimate relationship and their mental health wellbeing. The study concluded \nthat the professional healthcare givers should support the women in all dimensions of wellbeing and to \nimprove the quality of life of women diagnosed with Endometriosis 5. \n \nA study was conducted in Harvard medical school to find the relationship between endometriosis and risk \nfor infertility. 58,427 married premenopausal female nurses less than 40 years of age were included in the \nstudy. The result showed that there is a relationship between Endometriosis and risk of infertility 6 . \n \nA meta-analysis study was conducted in Europe to see the association between coffee and caffeine intake \nand risk of Endometriosis. The method of data collection was by meta-analysis of epidemiological studies \npublished up to January 2013. A total of eight studies, six case -control and two cohort studies were \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 3 \n \nidentified. The study concluded that there is no evidence of association between coffee/caffeine \nconsumption and the risk of Endometriosis 7.  \n \nA retrospective study was conducted at graduate school of medicine, Tokyo to assess the efficacy of \nassisted reproductive techniques (ART) and non -ART on women diagnosed with Endometriosis. A total \nof 1864 sample records were taken from the year January 2000 to December 2015. Data were collected \nby evaluating the outcomes of the treatment. Majority of women 49.4% conceived through ART and  \n21.9% conceived by non -ART. The study concluded that non ART  had limited role in patient with \nadvanced Endometriosis, thus ART helps to achieve conception 8. \n \nA review was conducted with an aim to assess the social and psychological impact of Endometriosis on \nwomen’s lives. Out of 3141 articles, 42 articles were retervied based on the inclusion and exclusion criteria \nwhich included 1110 women diagnosed with Endometriosis. The data was collected by using quality of \nlife questionnaire which included their everyday activities, their intimate relationship, planning of having \nchildren, mental health and wellbeing. The study concluded that Endometriosis had a significant social \nand psychological impact on women living with Endometriosis 9. \n \nMATERIALS AND METHODS: \nThis was a e xploratory correlational study design carried out to determine the knowledge regarding \nendometriosis and wellbeing of women diagnosed with endometriosis, for a period of four months from \nJanuary 2019 to April 2019 at infertility centre in Udupi taluk, Karnataka. After obtaining administrative, \ninstitutional ethical committee permission (IEC 679/2018) and informed written consent the women who \nwere diagnosed with endometriosis and are on  treatment were recruited for the study.  \nA total of 85 women who were diagnosed with endometriosis and are taking treatment were taken for the \nstudy using proportionate sampling technique. The sample size was based on pilot study. The age of the \nparticipants ranged from 29 to 49 yea rs. Participants were taken from infertility centres, Udupi District, \nKarnataka. The participants were  selected using the proportionate sampling  technique and informed \nconsent was taken from the participants before collecting the data. \nThe Inclusion criteria for the following study were women diagnosed to have Endometriosis and who:  \n• are willing to participate in the study  \n• can read and write either Kannada or English.  \n• are undergoing treatment at Kasturba Hospital, Manipal or Kamath Nursing     Home, Udupi. \n \nThe sampling technique used in this study was non-probability, purposive sampling technique.  \nThe knowledge questionnaire and the wellbeing tool was developed by the investigator. The knowledge \nquestionnaire (r = 0.80)  consists of 30 items regarding anatomy and physiology of female reproductive \nsystem, Endometriosis definition, risk factor, etiology, symptoms, diagnosis, treatment, prevention, \ncomplication. Each correct answer carries one mark. Higher the knowledge scores reflected higher the \nknowledge among women diagnosed with Endometriosis. The scores varied from 1 – 30. The scores are \nGood knowledge which ranges from 21 -30, average knowledge ranges from 11 -20, poor knowledge \nranges from 0-10.  \n \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 4 \n \nThe tool consists of 32 items  (r = 0.81)  (physical wellbeing 8 items, psychological wellbeing 8 items, \nsocial wellbeing 8 items, spiritual wellbeing 8 items). It is a five point Likert scale. The higher the sc ore \nreflects higher the wellbeing among women diagnosed with Endometriosis. The scoring for each positive \nitem was 1 for never, 2 for seldom, 3 for quite often, 4 for very often, 5 for always. The negative questions \nare negatively scored. The scoring for e ach negative item was 1 for always, 2 for very often, 3 for quite \noften, 4 for seldom, 5 for never. The extent of wellbeing was arbitrary classified as low to high. The scores \nvaried from 32-160. The scores are high wellbeing 118-160, average wellbeing 75-117 and low wellbeing \n32-74.  \n \nRESULTS: \nSample characteristics \nMost of the women 33 (38.8%)  in  age group of 21 -30 were high risk age group and majority 60 \n(70.6%) of the women were housewife, majority of the women 59 (69.4%) did not have children, most 45 \n(52.9%) of the women were not diagnosed with infertility, in the last one year. 51 (60%) of th e women \nwere diagnosed with endometriosis, the women experiencing lower abdominal pain were 43 (50.6%) and \nit was not during menstruation, majority of them 48 (56.5%) had the pain score of 4-7, 35 (41.2%) of the \nwomen did not experience dyspareunia, women had menstruation every month were 79 (92.9%), most of \nthe women 39 (45.9%) changes 4 -5 pads per day during first 2 -3 days of menstruation, majority of the \nwomen 56 (65.9%) underwent gynaecological surgery and the surgery performed was cystectomy 28 \n(33%).  \n \nFrequency and percentage of knowledge regarding endometriosis \nKnowledge differs from person to person   majority 50 (58.8%) women have good knowledge, 35 \n(41.2%) women have average knowledge and there is no poor knowledge regarding endometriosis among \nwomen diagnosed with endometriosis. Maximum knowledge score of women diagnosed with \nendometriosis was 30 and minimum  score was 12 and mean and standard deviation was 21.02 and 4.66. \nWomen diagnosed with endometriosis had more knowledge in anatomy and physiology of female \nreproductive system.  \n \nFrequency and percentage of wellbeing regarding endometriosis \nMajority 81 (95.3%) women have average wellbeing, 4 (4.7%) women have high wellbeing and there \nwas no low wellbeing among women diagnosed with endometriosis. Maximum wellbeing score of women \ndiagnosed with endometriosis 129 and minimum score 91 and mean an d standard deviation was 101.93 \nand 7.95. Women diagnosed with Endometriosis had high wellbeing in psychological domain of \nwellbeing. \n \nSpearman’s rho correlation (r) test on scores of Knowledge and Wellbeing \nIt shows  that there was no significant statistical relationship between scores of knowledge and \nwellbeing since p valve was more than 0.05, hence the null hypothesis with respect to scores of knowledge \nand wellbeing was accepted and research hypothesis is rejected.  The data infers that there was no \nsignificant statistical relationship between scores of knowledge and wellbeing.  \n \nTable 1   Frequency and percentage distribution of socio-demographic data \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 5 \n \n                                                                                                                       N=85                                                                                                                                                                                                                                                                                                          \nDemographic data f % \nAge (in years) \n21-30 \n31-40 \n41-49 \n \n33 \n31 \n21 \n \n38.8 \n36.5 \n24.7 \nWork status  \nEmployed  \nHousewife \n \n25 \n60 \n \n29.4 \n70.6 \nEducation  \nPrimary school  \nHigh school  \nPUC  \nDegree or postgraduate \n \n5 \n15 \n18 \n47 \n \n5.9 \n17.6 \n21.2 \n55.3 \nMarital status \nMarried  \nSingle  \nDivorced \n \n85 \n0 \n0 \n \n100 \n0 \n0 \nBMI  \nUnderweight <18.5  \nNormal 18.5-24.9  \nOverweight 25-29. \n \n1 \n53 \n31 \n \n1.2 \n62.4 \n36.5 \n \nN = Total number no samples, f = frequency, % = percentage   \n \nTable 2   Frequency and percentage distribution of Endometriosis history \n                                                                                                                          N=85                                                                                                                                                                                                                                                                                                          \nDemographic data f % \nAge of menarche (in years) \n12  \n13  \n14  \n15 \n \n6 \n30 \n36 \n13 \n \n7.1 \n35.3 \n42.4 \n15.3 \nHaving children  \nYes  \n No \n \n26 \n59 \n \n30.6 \n69.4 \nDiagnosed with infertility  \nYes  \n No   \n \n40 \n45 \n \n47.1 \n52.9 \nDiagnosed with Endometriosis   \nLess than 1 year  \n1-2 years  \nMore than 2 years \n \n51 \n9 \n25 \n \n60 \n10.6 \n29.4 \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 6 \n \nFamily history of Endometriosis  \n  No   \n  Yes \n \n \n85 \n0 \n \n100 \n0 \nExperiencing lower abdominal pain  \nYes  \nNo   \nIf yes, during menstruation  \nYes  \nNo   \n \n43 \n42 \n \n43 \n42 \n \n50.6 \n49.4 \n \n50.6 \n49.4 \nPain score  \n0 \n1-3  \n4-7  \n8-10 \n \n17 \n31 \n35 \n2 \n \n20 \n36.5 \n41.2 \n2.4 \nDyspareunia  \nYes  \nNo   \n \n27 \n58 \n \n31.8 \n68.2 \nDays of menstrual cycle   \n3-5  \n6-8 \n \n77 \n8 \n \n90.6 \n9.4 \nGet menstruation every month  \nYes   \nNo   \n \n79 \n6 \n \n92.9 \n7.1 \nNumber of pads changed per day  (first 2-3 days) \n2-3  \n4-5  \n6-7 \n \n31 \n39 \n15 \n \n36.5 \n45.9 \n17.6 \nGynaecological surgery  \nYes  \nNo   \n \n56 \n29 \n \n65.9 \n34.1 \nName of the surgery  \nCystectomy  \nMyomectomy  \nLaparoscopy  \nNil \n \n28 \n21 \n10 \n26 \n \n33 \n24.8 \n11.8 \n       30.6 \nExperiencing pain other than menstrual pain  \nYes  \n No   \n \n8 \n77 \n \n9.4 \n90.6 \nDiagnosed to have Diabetes mellitus  \nYes  \nNo \n \n0 \n85 \n \n0 \n100 \nDiagnosed to have Hypertension     \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 7 \n \nYes   \nNo \n0 \n85 \n0 \n100 \nN = Total number no samples, f = frequency, % = percentage   \n \n \n \nTable 3 Domain wise analysis for knowledge scores \n \n    \n Area  \nTotal \nscore \nMaximum \nobtained \nscore \nMinimum \nobtained \nscore \nMean SD \nAnatomy and \nphysiology \n11 11 4 10.02 1.47 \nDefinition  3 3 0 1.95 0.75 \nEtiology and \nsymptoms \n5 5 0 2.55 1.32 \nDiagnosis  5 5 1 3.49 1.38 \nTreatment and \nmanagement  \n5 5 0 2.54 1.30 \nComplication  1 1 0 0.51 0.50 \nTotal score of \nknowledge \n30 30 12 21.02 .66 \n   SD = Standard Deviation \n \nTable 4 Domain wise analysis of wellbeing scores of women diagnosed with Endometriosis \n \n \nArea  \nTotal \nscore \nMaximum \nobtained \nscore \nMinimum \nobtained \nscore \nMean SD \nPhysical wellbeing 35 35 22 27.03 3.79 \nPsychological \nwellbeing \n28 28 18 23.81 2.31 \nSocial wellbeing 39 39 19 25.90 4.34 \nSpiritual wellbeing 32 32 20 25.12 3.14 \nTotal scores of \nwellbeing \n129 129 91 101.93 7.95 \n  SD = Standard Deviation  \n \nTable 5 Spearman’s rho correlation (r) test on scores of Knowledge and Wellbeing \n                                                                                                                                        N=85 \nVariable         Knowledge         Wellbeing             p value \n   N=85 \n   N=85 \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 8 \n \nKnowledge                -              .058  \n            .598 \nWellbeing              .058                 - \np > .05, not significant  \n \n \n \nDiscussion: \n       In the present study majority 33 (38.8%) of the women in age group of 21 -30 years were diagnosed \nwith Endometriosis, the women experiencing lower abdominal pain during menstruation were 43 (50.6%), \n27 (31.8%) of women were having dyspareunia. \n \n       These findings of the literature which was supported by  Adamson. D.et.al.(2010)  was found that  \naffects women of age group between 26 – 35 years 100 (10%).  The prevalence of Endometriosis is higher \nin women with dysmenorrhea 600 (60%), dyspareunia 440 (44%), pelvic pain 800 (80%).). \n \n        In the present study majority of the women 36 (42.4%) had attained menarche at the age of 14 years, \n6 (7.1%) of women attained their menarche at the age of 12 years. 30 (35.3%) women had attained \nmenarche at the age of 13 years and 13 (15.3%) women had attained menarche at the age of 15 years. \n \n       These findings of the study are contradicted by Nnoaham, k.E., Webster,P., et.al (2012) found that \nthere are probability of 55% of women with Endometriosis had an early menarche (below 12 years of age) \nand the study concludes that there is a small increased risk of Endometriosis and early menarche 10. \n \n   In the present study majority 85 (100%) of the women did not have any family history of \nEndometriosis. \n \nThese findings of the study are contradicted by Moen, M.H., & Magnus, P (2009) was found that \nthe relative risk of Endometriosis in first degree relative was 7.2% (95% CI). Severe manifestation was \nfound among patient with family history 107 (26%) than among women without family history 18 (12%) \np < 0.01. Thus the study concluded that there was seven fold increase risk of Endometriosis with family \nhistory 11. \n \nIn the present study 45 (52.9%) of the women were not diagnosed to have infertility and 40 (47.1%) \nof the women were diagnosed to have infertility. \n \n       These findings of the study was supported by J. Prescott, L.V Farland (2016) identified that 83% of \nthe women who were diagnosed with Endometriosis were infertile and showed two fold increase risk o f \ninfertility of women who were diagnosed with Endometriosis with Hazard ratio of 2.12(95% CI) 6. \n \nKnowledge regarding Endometriosis \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 9 \n \n        In the present study shows that 50 (58.8%) women have good knowledge, 35 (41.2%) women have \naverage knowledge and there is no poor knowledge regarding Endometriosis among women diagnosed \nwith Endometriosis.  \n \n        The findings of the study are contradicted by Shah, D. K., Moravek, M. B., Vahratian, A., Dalton, V. \nK., & Lebovic, D. I. (2010).  results showed that the knowledge of  Endometriosis was 91% and their \nincrease in knowledge was associated with their education level, regular health care, and their exposure to \nindividuals with the disease 12. \n \nWellbeing of women diagnosed with Endometriosis \n         In the present study majority 81 (95.3%) of women have average wellbeing, 4 (4.7%) women have \nhigh wellbeing and there was no low wellbeing among women diagnosed with Endometriosis. \n \n          The findings of the study contradicted by De Graaff, A.A., et.al (2013) showed that Endometriosis \naffected the work in 51% of women and affected relationship in 50% of women, dysmenorrhea was \nreported among 59% of women and dyspareunia by 56% of women and thus the study result showed that \nthe quality of life of the women with Endometriosis were impaired 13.  \n \n          A study conducted by Culley, L., et.al (2013) reveled that Endometriosis had significant impact on \nsocial and psychological impact on women living with Endometriosis among the 42 papers that were \nreviewed 9. \n \n The limitations of the study were that even though women who were diagnosed with endometriosis for a \nlonger time didn’t have much knowledge regarding their health condition. Due to limited sample size it \nrestricted the generalization of the study findings.  The strength of the study was, women visited the \ninfertility clinic it was eaiser to collect the information from them. \n \nConclusion: \n         Endometriosis is a gynaecological disorder, as the ectopic endometrial tissue grows outside the \nuterus. Endometriosis affects 8%–10% of women of reproductive age; in 30% of the women, the condition \nis associated with primary or secondary infertility.  The present study revealed that the knowledge of \nwomen diagnosed with Endometriosis was good and the wellbeing of women diagnosed with \nEndometriosis was high. The study concludes that the psychological wellbeing of the women with \nendometriosis is affected and thus counselling, and the leaflet includes lifestyle modifications which \nincludes diet and complementary therapies like yoga, meditation and deep breathing exercises must be \ntaught to the women so it helps in their day to day life.  \n \nThe nurses must encourage women of reproductive age group regarding endometriosis and how to ajust \nwith symptoms and life style modifications which includes diet and complementary therapies like yoga \nand deep breathing exercises. The study concluded that t here is a need to spread awarness regarding \nEndometriosis to improve the wellbeing of women diagnosed with Endometriosis.  \n \nFinancial support and sponsorship: Nil \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23034142 Volume 5, Issue 3, May-June 2023 10 \n \nConflicts of interest There are no conflicts of interest. \n \nREFERENCE \n1. Statistics by Country for Endometriosis available \nfromhttp://www.wrongdiagnosis.com/e/endometriosis/stats-country.htm \n2. Rai.R, Sathyamoorthy.A, D’souza.C, Umb ilicalEndometriosis, Journal of clinical & Diagnostic \nResearch, 2008, 2, 1203-1206. \n3. Mark Perloe M.D. and Linda Gail Christie; Endometriosis : Conquering the Silent Invader; Miracle \nBabies: Chapter 17, available from www.google.com. \n4. Goura A, Gourakkal N, Navya N, Goura A. Rare presentation of asymptomatic endometriosis \ndiagnosed accidently during lower segment caesarean section. Governing Council. 2015 Dec;4(2):43. \n5. Mendes N, Figueiredo B. Psychological approach to endometriosis: women's pain experience and \nquality of life improvement. Psicologia, Saúde e Doenças. 2012;13(1):36-48. \n6. Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, Rich -Edwards JW, \nBarbieri RL, Missmer SA. A prospective cohort study of endometriosis and subsequent risk of \ninfertility. Human reproduction. 2016 Jul 1;31(7):1475-82. \n7. Chiaffarino F, Bravi F, Cipriani S, Parazzini F, Ricci E, Viganò P, La Vecchia C. Coffee and caffeine \nintake and risk of endometriosis: a meta -analysis. European journal of nutrition. 2014 Oct \n1;53(7):1573-9. \n8. Isono W, Wada‐Hiraike O, Akino N, Terao H, Harada M, Hirata T, Hirota Y, Koga K, Fujii T, Osuga \nY. The efficacy of non‐assisted reproductive technology treatment might be limited in infertile patients \nwith advanced endometriosis in their 30s. Journal of Obstetrics and Gynaecology Research. 2019 \nFeb;45(2):368-75. \n9. Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, Raine-Fenning N. The social and \npsychological impact of endometriosis on women's lives: a critical narrative review. Human \nreproduction update. 2013 Nov 1;19(6):625-39. \n10. Nnoaham KE, Webster P, Kumbang J, Ken nedy SH, Zondervan KT. Is early age at menarche a risk \nfactor for endometriosis? A systematic review and meta-analysis of case-control studies. Fertility and \nsterility. 2012 Sep 1;98(3):702-12. \n11. Moen MH, Magnus P. The familial risk of endometriosis. Acta ob stetricia et gynecologica \nScandinavica. 1993 Jan 1;72(7):560-4. \n12. Shah DK, Moravek MB, Vahratian A, Dalton VK, Lebovic DI. Public perceptions of endometriosis: \nperspectives from both genders. Acta obstetricia et gynecologica Scandinavica. 2010 May;89(5):646-\n50. \n13. De Graaff AA, D'hooghe TM, Dunselman GA, Dirksen CD, Hummelshoj L, WERF EndoCost \nConsortium, Simoens S, Bokor A, Brandes I, Brodszky V, Canis M. The significant effect of \nendometriosis on physical, mental and social wellbeing: results from an internati onal cross-sectional \nsurvey. Human reproduction. 2013 Oct 1;28(10):2677-85.","source_license":"CC0","license_restricted":false}