{"paper_id":"ca10b236-2a02-4621-b1f7-aa5491936cd3","body_text":"JMIR Preprints Afrose et al\nEvaluation of Endometriosis Risk Factors and Clinical\nTreatments in Bangladesh: A Cross-sectional Study.\n Afsana Afrose, Dr. Munima Haque, Nusrat Mahmud, Jannatun Noor Mukta\nSubmitted to: Interactive Journal of Medical Research\non: March 17, 2025\nDisclaimer: © The authors. All rights reserved. This is a privileged document currently under peer-review/community\nreview. Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for\nreview purposes only. While the final peer-reviewed paper may be licensed under a CC BY license on publication, at this\nstage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nTable of Contents\nOriginal Manuscript ....................................................................................................................................................................... 5\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nEvaluation of Endometriosis Risk Factors and Clinical Treatments in\nBangladesh: A Cross-sectional Study.\nAfsana Afrose1* MSc, BSc; Dr. Munima Haque1* phd, MSc, BSc; Nusrat Mahmud2* MBBS, MSc; Jannatun Noor\nMukta3* Phd, Msc, Bsc\n1Department of Mathematics and Natural Science (MNS) BRAC University Dhaka BD\n2Department of Gynecology & Obstetrics. Bangladesh Institute of Research and Rehabilitation for Diabetes Endocrine and Metabolic Disorders\nDhaka BD\n3Department of Computer Science and Engineering BRAC University Dhaka BD\n*these authors contributed equally\nCorresponding Author:\nDr. Munima Haque phd, MSc, BSc\nDepartment of Mathematics and Natural Science (MNS)\nBRAC University\nKha 224, Bir Uttam Rafiqul Islam Ave\nDhaka\nBD\nAbstract\nBackground: Endometriosis is a gynecological condition that involves the implantation of endometrial tissue outside the uterine\ncavity. About 1.2 million women are suffering from this disease in Bangladesh.\nObjective: The purpose of this study was to explore the risk factors, symptoms, and clinical treatment in Bangladesh\nMethods: In this cross-sectional study, out of 162 infertile women 82 had endometriosis confirmed with laparoscopy and 80\nwere included in the control group. All were asked to fill out a questionnaire containing demographics, reproductive, and\nmenstrual status. Comparisons between the two groups were done using an Independent T-test, Chi-square test, and logistic\nregression model.\nResults: The prevalence of endometriosis was higher with, age, marital status, and BMI (P < 0.05). The most common\nsymptoms were dysmenorrhea, excessive bleeding, cramping etc. Infertility (OR:2.21; %95CI: 1.07–4.53; P = 0.03), thyroid\nimbalance (OR:3.44; %95CI: 1.47–8.03; P = 0.004), irregular menstruation (OR:5.76; %95CI: 2.12–15.60; P = 0.001), age at\nmenarche (OR:2.54; %95CI: 1.04–6.21; P = 0.04) and abortion (OR:2.75; %95CI: 1.31–5.74; P = 0.007) were associated with\nendometriosis risk. Endometriosis was diagnosed most frequently by TVS (transvaginal ultrasound) at 41.1%, NSAI\n(nonsteroidal aromatase inhibitors) at 22.8% was the most commonly utilized medicine, and 13.6% of patients undergo\nlaparoscopy.\nConclusions: Endometriosis is a considerable public health issue because it affects many women and is associated with\nsignificant morbidity. In this study, we developed a model that can be used to predict the risk of endometriosis in infertile women\nin Bangladesh Clinical Trial: BRAC university Institutional Review Board (IRB) under the IRB number\nBRACUIRB_220240006\n(JMIR Preprints 17/03/2025:74063)\nDOI: https://doi.org/10.2196/preprints.74063\nPreprint Settings\n1) Would you like to publish your submitted manuscript as preprint?\nPlease make my preprint PDF available to anyone at any time (recommended).\nPlease make my preprint PDF available only to logged-in users; I understand that my title and abstract will remain visible to all users.\nOnly make the preprint title and abstract visible.\nNo, I do not wish to publish my submitted manuscript as a preprint.\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\n2) If accepted for publication in a JMIR journal, would you like the PDF to be visible to the public?\nYes, please make my accepted manuscript PDF available to anyone at any time (Recommended). \nYes, but please make my accepted manuscript PDF available only to logged-in users; I understand that the title and abstract will remain visible to all users (see Important note, above). I also understand that if I later pay to participate in JMIR’s PubMed Now! service service, my accepted manuscript PDF will automatically be made openly available.\nYes, but only make the title and abstract visible (see Important note, above). I understand that if I later pay to participate in JMIR’s PubMed Now! service service, my accepted manuscript PDF will automatically be made openly available.\nNo. Please do not make my accepted manuscript PDF available to anyone.\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nOriginal Manuscript\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nTitle: Evaluation of Endometriosis Risk Factors and Clinical Treatments in Bangladesh: A Cross-\nsectional Study.\nAuthors Details:\nAfsana Afrose1, Dr. Munima Haque1*, Nusrat Mahmud2, Jannatun Noor3\n1. Biotechnology program, Department of Mathematics and Natural Sciences, Brac University,\nMerul Badda, Dhaka, Bangladesh\n2. Division of Reproductive Medicine & Infertility, Dept. of BIRDEM Women and Children\nHospital, Dhaka, Bangladesh\n3. Computing for Sustainability and Social Good (C2SG) Research Group, Department of Computer\nScience and Engineering, Brac University, Dhaka, Bangladesh\n*Correspondence: Dr. Munima Haque munima.haque@bracu.ac.bd\nAbstract\nIntroduction: Endometriosis is a gynecological condition that involves the implantation of\nendometrial tissue outside the uterine cavity. About 1.2 million women are suffering from this\ndisease in Bangladesh. The purpose of this study was to explore the risk factors, symptoms, and\nclinical treatment in Bangladesh.\nMethod: In this cross-sectional study, out of 162 infertile women 82 had endometriosis confirmed\nwith laparoscopy and 80 were included in the control group. All were asked to fill out a questionnaire\ncontaining demographics, reproductive, and menstrual status. Comparisons between the two groups\nwere done using an Independent T-test, Chi-square test, and logistic regression model. \nResult: The prevalence of endometriosis was higher with, age, marital status, and BMI (P < 0.05).\nThe most common symptoms were dysmenorrhea, excessive bleeding, cramping etc. Infertility\n(OR:2.21; %95CI: 1.07–4.53; P = 0.03), thyroid imbalance (OR:3.44; %95CI: 1.47–8.03; P = 0.004),\nirregular menstruation (OR:5.76; %95CI: 2.12–15.60; P = 0.001), age at menarche (OR:2.54;\n%95CI: 1.04–6.21; P = 0.04) and abortion (OR:2.75; %95CI: 1.31–5.74; P = 0.007) were associated\nwith endometriosis risk. Endometriosis was diagnosed most frequently by TVS (transvaginal\nultrasound) at 41.1%, NSAI (nonsteroidal aromatase inhibitors) at 22.8% was the most commonly\nutilized medicine, and 13.6% of patients undergo laparoscopy.\nConclusion: Endometriosis is a considerable public health issue because it affects many women and\nis associated with significant morbidity. In this study, we developed a model that can be used to\npredict the risk of endometriosis in infertile women in Bangladesh.\nKeywords: Endometriosis, Infertility, Laparoscopy, Abortion, Bangladesh. \nIntroduction\nEndometriosis is a gynecological condition that involves the implantation of endometrial tissue\noutside the uterine cavity [1]. The prevalence of endometriosis is 10%–15% of all women of\nreproductive age and symptoms include, chronic pelvic pain, dysmenorrhea, and alterations in\nmenstrual cycles [2,3]. Endometriosis is commonly associated with infertility. This is one of the\nleading causes of female infertility [4].\nIn addition to these challenges, women afflicted by endometriosis frequently experience lower\nhealth-related quality of life compared to those without the condition [5,6]. The lack of sufficient\ninformation about endometriosis often leads to misconceptions and stigmatization of women.\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nThese factors can significantly contribute to the likelihood of experiencing higher levels of stress and\ndepressive symptoms among affected women [7,8]. Impacting sexual functioning, self-confidence,\nand the couple’s relationship has been observed in women suffering from endometriosis [9,10].\nThere is no reliable serum maker for this disease, and imaging is still a diagnostic dilemma.\nUnfortunately, in the case of deep infiltrating endometriosis (DIE), uterosacral ligaments,\nrectovaginal septum, vagina, and bladder, there are controversies in diagnosis even with good\ntransvaginal ultrasound [11]. High-resolution magnetic resonance imaging (MRI) with bladder,\nvaginal, and rectal contrast has been a breakthrough in recent times.\nThere is a diagnostic delay of endometriosis all over the world. The typical duration between the\nonset of pain and diagnosis of endometriosis is over 8 years in the UK and 12 years in the USA,\nearning it the moniker “the missed disease” [12]. Furthermore, 25-50% of infertile women have\nendometriosis, while 30-50% of women with endometriosis are infertile [13]. \nEndometriosis is also a widespread health issue among women of reproductive age in Bangladesh, as\nit is in various regions of the world. The Endometriosis and Adenomyosis Society of Bangladesh\nestimates that there are approximately 1.2 million endometriosis patients in Bangladesh [14].\nThere is a scarcity of research on endometriosis in Bangladeshi women. Lack of knowledge and\nunderstanding of this disease many women suffer pain throughout their life without any medical\nhelp. \nWith this background, this study aims to understand the risk factors, clinical symptoms, and clinical\ntreatment in Bangladesh. This study will help to pave the way to create awareness among women\ndiagnosed with Endometriosis. Also, it will shed light on the millions of women who are afraid to\nattend hospitals because they are too embarrassed to talk about it.\nMethods\nThe study was conducted as a cross-sectional study between February 2023 and May 2024 on 162\ninfertile women (82 women with endometriosis and 80 Controls) in BIRDEM Women and Children\nHospital in Dhaka, Bangladesh. The inclusion criteria of the study were reproductive-age women\nfrom 15-45 years, diagnosed with endometriosis by clinical presentation and confirmed by\nultrasonography/ laparoscopy, and a control group consisting of 80 inertial women with normal\npelvic ultrasound. A control group was selected at the same time as the case group. Controls were\nselected randomly and matched on age, education, and duration of infertility. Ethical approval for the\nstudy was secured from the BRAC university Institutional Review Board (IRB) under the IRB\nnumber BRACUIRB_220240006. Patients and/or their legal guardians gave consent to publication\nand participate in the study (in the case of minors). They were given a thorough background on the\nresearch and its purpose. The responders' names were also concealed. \nDuring this study, a structured questionnaire was applied to collect information. The weight and\nheight of all participants in the clinic are measured. A socio-demographic checklist including\nquestions about socioeconomic status (such as age, educational level, occupational status, income,\nand habitation) was completed. The following, questions were asked about menstrual and\nreproductive characteristics (such as menstrual pattern, cycle regularity, menstrual duration, amount\nof menstrual bleeding, length of the menstrual cycle, menarche age, presence of dysmenorrhea,\ndyspareunia and pelvic pain, low back pain, dyscheazia, history of using contraception).\nData were analyzed using SPSS for Windows (version 26; SPSS Inc., Chicago, IL, USA). All\ncategorical variables were summarized as counts and percentages. Comparisons between the two\ngroups were done using Independent T-test, Chi-square test, and Fisher’s exact and logistic\nregression model. P-value < 0.05 was considered statistically significant.\nResult\nConsidering demographic and lifestyle characteristics, age (p = 0.001), marital status (p = 0.05), BMI\n(p = 0.00), dysmenorrhea (p = 0.00), excessive bleeding (p = 0.008), cramping (p = 0.01), low back\npain (p = 0.01), pelvic pain (p = 0.01), dysuria (p = 0.001), and dyscheazia (p = 0.02) were all linked\nto endometriosis prevalence. There was no significant association between education, occupation,\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\ndysuria, family infertility history, and the prevalence of endometriosis (P > 0.05) (Table 1).\nTable 1: Character Case\n(n = 82)\nControls\n(n = 80)\nP value\nAge\n 15-25\n 26-35\n 36-45\n 46-50\n49(30.2)\n23(14.2)\n8(4.9)\n2 (1.2)\n26(16.0)\n35(21.6)\n14(8.6)\n5(3.1)\n0.001*\nEducation\n Primary\n Secondary \n Higher Secondary \n Graduate\n Post Graduate\n3(1.9)\n12(7.4)\n16(9.9)\n37(22.8)\n14(8.6)\n5(3.1)\n16(9.9)\n18(11.1)\n34(21.0)\n7(4.3)\n0.45\nMarital status\n Married\n Unmarried\n54(33.3)\n28(17.3)\n68(42.0)\n12(7.4)\n0.05*\nOccupation\n House wife\n Service holder\n Student\n34(21.0)\n26(16.0)\n22(13.6)\n50(30.9)\n20(12.3)\n10(6.2)\n0.16\nBMI\n Underweight\n Normal\n Overweight\n Obese\n10(6.2)\n12(7.4)\n52(32.1)\n8(4.9)\n10(6.2)\n50(30.9)\n14(8.6)\n6(3.7)\n0.00*\nDysmenorrhea 68(42.0) 34(21.0) 0.00*\nExcessive Bleeding 69(42.6) 53(32.7) 0.008*\nCramping 52(32.1) 35(21.6) 0.01*\nLow back pain 59(35.4) 43(26.5) 0.01*\nPelvic pain 60(37.0) 43(26.5) 0.01*\nDysuria 44(27.2) 23(14.2) 0.001*\nDyscheazia 35(29.0) 21(13.0) 0.02*\nDyspareunia 33(20.4) 34(21.0) 0.77\nFamily Infertility\nHistory\n20(12.3) 13(8.0) 0.19\nData are demonstrated as n (%) or mean ± SD, BMI Body mass index\n*p value < 0.05\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nDemographic lifestyle and characteristics of endometriosis cases and control women\nTable 2 indicates the risk factors in women with endometriosis, infertility (OR:2.21; %95CI: 1.07–\n4.53; P = 0.03), thyroid imbalance (OR:3.44; %95CI: 1.47–8.03; P = 0.004), irregular menstruation\n(OR:5.76; %95CI: 2.12–15.60; P = 0.001), age at menarche (OR:2.54; %95CI: 1.04–6.21; P = 0.04)\nand abortion (OR:2.75; %95CI: 1.31–5.74; P = 0.007) were associated with endometriosis risk.\nThere was no significant relationship between contraceptive and endometriosis risk (P > 0.05). \nTable 2: Association of risk factors of endometriosis cases and control women\nCharacteristic Cases\n(n = 82)\nControl\ns\n(n = 80)\nP value OR 95% C.I.\nLower Upper\nInfertility\nYes\n No\n56(34.6\n)\n26(16.0\n)\n30(18.5)\n50(30.9)\n.030 2.212 1.079 4.535\nContraceptive\nYes\nNo\n6(3.7)\n76(46.9\n)\n8(4.9)\n72(44.4)\n.738 .802 .221 2.911\nThyroid Imbalance .004 3.441 1.473 8.034\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nYes\nNo\n33(20.4\n)\n49(30.2\n)\n19(9.9)\n64(39.5)\nIrregular Menstrual\nYes\nNo\n73(45.1\n)\n9(5.6)\n54(33.3)\n26(16.0)\n.001 5.763 2.128 15.602\nAge at menarche\nLess than 11\nMore than 12\n14(8.6)\n68(42.0\n)\n23(14.2)\n57(35.2)\n.040 2.546 1.042 6.219\nAbortion\nYes\nNo\n51(31.5\n)\n31(19.1\n)\n35(21.6)\n45(27.8)\n.007 2.750 1.317 5.744\nTable 3 indicates the treatment frequency of endometriosis women, those who were diagnosed by\nTVS 45.1% and CA-125 (5.6%). As a treatment modality, 37% were stimulated with Aromatase\ninhibitors as part of infertility treatment (3rd generation Aromatase inhibitors, letrozole), 10% GnRH\n(gonadotropin-releasing hormone), 18% NSAID (nonsteroidal anti-inflammatory medications), and\n17% estrogen-progestogen combinations were recommended. 37% of women with endometriosis did\nnot undergo any surgical interventions and 13.6% underwent laparoscopy as a surgical intervention.\nIt has been observed from this study that in 42% of women suffering from endometriosis with pain,\ntheir quality of life has deteriorated (data not shown).\nTable 3: Treatment frequency of endometriosis cases and control women\nCharacteristic Cases\n(n = 82)\nControls\n(n = 80)\nDiagnosis\nTVS\nCA-125\n73(45.1)\n9(5.6)\n64(39.5)\n16(9.9)\nMedication\nNSAI\nGnRH\nNSAID\nEstrogen–progestogen combinations\n37(22.8)\n10(6.2)\n18(11.1)\n17(10.5)\n28(17.3)\n13(8.0)\n22(13.6)\n17(10.5)\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\nSurgical Treatment\nNo surgery\nLaparoscopy\n60(37.0)\n22(13.6)\n60(37.0)\n14(8.6)\nData are demonstrated as n (%), NSAI nonsteroidal aromatase\ninhibitor, NSAID Non-steroidal anti-inflammatory drugs, IUI\nIntrauterine insemination\nDiscussion\nThe current study was designed to understand the prevalence of endometriosis between women with\nand without endometriosis. The main finding of the current study showed that there is an association\nbetween age, marital status, BMI, and endometriosis. The prevalence of endometriosis was higher\nbetween the ages of 15 to 25 (49%). In consistence with our results, a study showed that married\nwomen were more likely to experience endometriosis and it is more prevalent among younger, more\nsexually active women than among older and less sexually active women. Patient weight plays an\nimportant role in the development of endometriosis. Another study demonstrated that Women who\nwere overweight had a higher risk of clinically suspected endometriosis than women of normal\nweight without endometriosis [15,16]. Dysmenorrhea, excessive bleeding, cramping, low back pain,\npelvic pain, dysuria, and dyscheazia were the most common symptoms in endometriosis women.\nAnother study found that dysmenorrhea, dyspareunia, dyschezia, and dysuria were the symptoms\nthat endometriosis patients often present [17]. \nOur study revealed that infertility, thyroid imbalance, irregular menstruation, age at menarche, and\nabortion were associated with endometriosis risk. A prior study found that endometriosis had a\nsignificant connection with infertility [18]. Endometriosis patients have a higher chance of thyroid\ndysfunction. A study demonstrated that RNA molecules and proteins involved in thyroid metabolism\nwere altered in people with endometriosis. These affect endometriotic cells, T4 production was\nincreased and T3 was reduced [19]. Women who had irregular menstrual periods had a lower risk of\ndeveloping the condition of endometriosis [20], but This study reported an inverse result, so irregular\nmenstruation may be a risk factor for endometriosis. In consistence with our results, several\nobservational studies and a meta-analysis have found some evidence that early menarche increases\nthe incidence of endometriosis [21].\nThe majority of patients were diagnosed with TVS (transvaginal ultrasound), suggesting that TVS\ncould be a viable alternative to laparoscopy as a first-line diagnostic tool. According to a Mata\nanalysis study, TVS should continue to be the main instrument for evaluating endometriosis patients\n[22]. NSAI (nonsteroidal aromatase inhibitors) are a potential therapeutic option for women affected\nby endometriosis, it is improving endometriosis-related pain symptoms [23]. According to the\nfindings of this study, the majority of patients received NSAI treatment which acts both as ovulation-\ninducing agents for infertility treatment and on pain management. The surgical treatment frequency\nwas relatively low; the majority of the patients did not get any surgical treatment. This study\ndemonstrated that only 13.6 of patients with endometriosis underwent laparoscopy. To our\nknowledge, this survey is the first research that shows original data on endometriosis risk factors and\nclinical treatment. The use of validated questionnaires and confirmed diagnosis through\nultrasound/laparoscopy are other strengths of this study. Despite the strengths of the study, some\nlimitations should be noted, First The research data are insufficient to depict a global scenario.\nConclusion\nEnsuring reproductive health is crucial for women worldwide, but particularly challenging in low-\nand middle-income countries like Bangladesh. Most Bangladeshi women have menstrual\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]\n\n\nJMIR Preprints Afrose et al\ndiscomfort, but due to a lack of information, many do not address it or consider it a sickness. women\nare uninformed of the treatment for endometriosis, and the condition spreads to the next generation,\ncausing infertility. Therefore, counseling and awareness about reproductive health in women is\nrecommended.\nCompeting Interest: There are no competing interests for any author. \nFunding: This research received no external funding.\nReference\n1. Giudice LC, Kao LC. Endometriosis. Lancet [Internet]. 2004 Nov 1;364(9447):1789–99.\nhttps://doi.org/10.1016/s0140-6736(04)17403-5 \n2. Parasar P, Ozcan P, Terry KL. Endometriosis: Epidemiology, Diagnosis and Clinical\nmanagement. Current Obstetrics and Gynecology Reports [Internet]. 2017 Jan 27;6(1):34–41.\nhttps://doi.org/10.1007/s13669-017-0187-1 \n3. Giudice LC. Endometriosis. 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Aromatase inhibitors for\nthe treatment of endometriosis: a systematic review about efficacy, safety and early clinical\ndevelopment. Expert Opinion on Investigational Drugs [Internet]. 2020 Nov 26;29(12):1377–\n88. https://doi.org/10.1080/13543784.2020.1842356 \nPowered by TCPDF (www.tcpdf.org)\nhttps://preprints.jmir.org/preprint/74063 [unpublished, non-peer-reviewed preprint]","source_license":"CC0","license_restricted":false}