Sociodemographic and clinical characteristics of patients with endometriosis: a facility-based cross-sectional study from Bangladesh

The mean age of the participants was 29.9 (SD 8.1) years, and 55% of them aged between 18 and 30 years. Almost half of them resided in rural areas and belonged to middle-income families. A majority of them (87%) were married. Their mean BMI was 24.99 (SD 3.96) kg/m 2 with a prevalence of overweight of 30% and obesity of 16.4% according to the WHO Asian criteria ( Table  1 ) . Table 1 Sociodemographic characteristics of the patients with endometriosis ( n  = 396) Characteristic n (%) Age (years), mean (SD) 29.96 (8.07) Age group (years)   40 47 (11.87) Educational attainment  No formal education 21 (5.30)  Primary 85 (21.46)  Secondary/higher secondary 179 (45.20)  University graduate 111 (28.03) Family income  Low ( BDT 40000) 107 (27.02) Occupation  Housewife 292 (73.74)  Student 59 (14.90)  Job 45 (11.36) Residence  Rural 174 (43.94)  Urban 222 (56.06) Marital status  Married 345 (87.12)  Unmarried 51 (12.88) BMI (kg/m 2 ) 24.99 (3.96) BMI group  Underweight (BMI < 18.5 kg/m²) 14 (3.54)  Normal weight (BMI 18.5–22.9 kg/m²) 199 (50.25)  Overweight (BMI 23.0–24.9 kg/m²) 118 (29.80)  Obese (BMI ≥ 25.0 kg/m²) 65 (16.41) Sociodemographic characteristics of the patients with endometriosis ( n  = 396) The mean age at menarche of the women included in this study was 12.4 years (SD 2.8). Almost 80% of women reported having a regular menstrual cycle. The mean duration of the menstrual cycle was 28.7 days (SD 4.3). Most participants experienced bleeding for three to seven days, typically with a self-reported moderate flow during menstruation. Around 36% of the women with endometriosis had a history of infertility among whom 58% had the history for more than three years ( Table  2 ). Table 2 Menstrual characteristics of the patients with endometriosis ( n  = 396) Characteristic n (%) Age at menarche (years), mean (SD) 12. 37 (2.86) Date of last menstruation  Within 3 months 373 (94.67)  3–6 months 19 (4.82)  > 6 months 2 (0.51) Regularity of menstrual cycle  Regular 315 (79.55)  Irregular 81 (20.45) Duration of menstrual cycle (days), mean (SD) 28.73 (4.27) Duration of menstrual bleeding   7 days 48 (12.12) Flow of menstrual bleeding  Spotting 13 (3.39)  Mild 53 (13.84)  Moderate 229 (59.79)  Heavy 88 (22.98) Previous pregnancy 242 (63.52) History of infertility 141 (35.61) Duration of infertility   3 years 61 (58.65) Menstrual characteristics of the patients with endometriosis ( n  = 396) Dysmenorrhea was the most frequently presented symptom among the women with endometriosis (92.6%) followed by non-menstrual pelvic pain (64.5%) and dyspareunia (50%). Their mean age of onset of pain was 26 years (SD 8.1) and the majority (78%) had the pain for less than one year since onset. Almost two-third of the participants reported moderate pain (VAS score 5–7) while 25% reported mild pain (VAS score 1–4) and 12% reported severe pain (VAS 8–10) ( Table  3 ). The mean VAS score was 5.1 (SD 1.9). A marginally significant difference in pain severity was observed among dysmenorrhea, NMPP, and dyspareunia (mean VAS scores 5.3, 4.7, and 5.4, respectively; p  = 0.051), with NMPP being comparatively less severe ( Fig.  1 ). Table 3 Clinical presentations of the patients with endometriosis ( n  = 396) Characteristic n (%) Type of pain  Dysmenorrhea 365 (92.64)  NMPP 245 (64.47)  Dyspareunia 182 (50.28) Age at onset of pain (years), mean (SD) 26.02 (8.15) Duration of pain   5 years 25 (6.31) Severity of pain  VAS score, mean (SD) 5.14 (1.90)  Mild 99 (25.00)  Moderate 248 (62.63)  Severe 49 (12.37) Other symptoms ( n  = 279)  Polyuria 114 (40.86)  Dysuria 74 (26.52)  Diarrhea 39 (13.98)  Constipation 21 (7.53)  Others 19 (6.81) Drugs taken to alleviate pain ( n  = 317)  Hormonal therapy 60 (18.93)  NSAID 249 (78.55)  Others 8 (2.52) Sonographic findings ( n  = 303)  Adnexal cyst 248 (81.85)  Adenomyosis 23 (7.59)  Uterine fibroids 22 (7.26)  Polyps 2 (0.66)  Rectovaginal nodule 2 (0.66)  Others 6 (1.98) Deeply infiltrative endometriosis (DIE) 65 (16.41) Location of DIE  Pelvic side wall 29 (42.65)  Posterior 14 (20.59)  Rectum 12 (17.65)  Sigmoid 6 (8.82)  Ureter 7 (10.29) Clinical presentations of the patients with endometriosis ( n  = 396) Fig. 1 Severity of different types of pain of the patients with endometriosis ( p -value 0.051) Severity of different types of pain of the patients with endometriosis ( p -value 0.051) Other symptoms presented by the women with endometriosis were polyuria (40.9%), dysuria (26.5%), diarrhea (14%) and constipation (7.5%), which may be related to disease severity. Almost 16.4% of the patients had deeply infiltrative endometriosis (DIE) as identified by transvaginal sonography. The most common locations of DIE were the pelvic side wall (42.6%), posterior wall (20.6%), rectum (17.6%), sigmoid (8.8%), and ureter (10.3%). Multiple lesion sites were observed in several patients, resulting in overlapping percentages across anatomical locations ( Table  3 ). The majority of patients reported using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief (78.5%), followed by hormonal therapy (19%) and other treatments (2.5%). Some patients reported using more than one form of therapy concurrently ( Table  3 ).

This was a facility-based cross-sectional descriptive study conducted in the Department of Gynecology at Chattogram Medical College Hospital (CMCH) from January 2023 to December 2023. Women aged between 16 and 55 years who were clinically diagnosed with endometriosis were included in the present study. This age range was selected to include the full spectrum of reproductive-age women, from adolescents to those approaching menopause, as endometriosis can affect a wide age group and present with variable clinical features. Clinical criteria for diagnosis included the presence of symptoms suggestive of endometriosis (dysmenorrhea, non-menstrual pelvic pain, and dyspareunia) in the absence of other explanations for the pain including adenomyosis, fibroids, ovarian cysts, and musculoskeletal abnormalities [ 8 ]. However, those who had adenomyosis, fibroids, ovarian cysts as secondary findings were included. Exclusion criteria were confirmed pregnancy or breastfeeding and confirmed alternative causes for pelvic pain. The required sample size was calculated using the formula: \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:n=\frac{{z}^{2}p(1-p)}{{d}^{2}}$$\end{document} , where z is the standard normal deviate at 95% confidence level (considered as 1.96), p was considered as 0.5 to obtain the maximum sample size, and d is the margin of error (considered as 0.05). Allowing for a 10% non-response rate, the final target sample size was 422 participants. A total of 425 women were screened for eligibility. Of those, 29 were excluded due to other causes of pelvic pain, including pelvic inflammatory disease ( n  = 16), urinary tract infection ( n  = 11), and gastrointestinal disorders ( n  = 2). Finally, 396 participants were enrolled based on clinical diagnosis. To support diagnostic accuracy, pelvic ultrasonography was advised and scheduled for all participants; 303 (76.5%) attended the imaging sessions, while the remaining did not respond to the appointments. The study was approved by the Ethical Review Committee of Chattogram Medical College Hospital (CMCH). After inclusion in the study, an informed written consent was obtained from each participant. Then their socio-demographic and clinical data were collected by face-to-face interview and a thorough physical examination by the attending gynecologist. For collection of clinical data, a semi-structured questionnaire was prepared based on the recommendations of the endometriosis participant questionnaire (EPQ) which was developed in the Endometriosis Phenome and Biobanking Harmonization Project (EPHect) by the World Endometriosis Research Foundation (WERF) [ 10 ]. This questionnaire was developed with an aim to harmonize non-surgical clinical participant characteristic data relevant to endometriosis research (Supplementary file 1). As the questionnaire was not available in Bangla, the relevant sections were adopted and translated using the back-translation method. The translation was initially reviewed by two bilingual experts to ensure conceptual equivalence with the original tool. The translated version was then pre-tested among 30 patients with endometriosis who were not included in the final analysis, and feedback was obtained to verify linguistic clarity and cultural appropriateness. The following variables were collected from the participants: Socio-demographic characteristics: age, educational attainment, occupation, family income, residence, marital status, and body mass index (BMI). BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²) and categorized according to the World Health Organization (WHO) Asian criteria: underweight (< 18.5 kg/m²), normal weight (18.5–22.9 kg/m²), overweight (23.0–24.9 kg/m²), and obese (≥ 25.0 kg/m²). Menstruation-related characteristics: age at menarche, duration and regularity of menstrual cycle, duration and self-reported flow of bleeding, history of previous pregnancy, and infertility. Clinical characteristics of endometriosis: Nature of pain (dysmenorrhea, non-menstrual pelvic pain [NMPP], or dyspareunia) Onset and duration of pain Severity of pain Presence of other symptoms Presence of deeply infiltrative endometriosis (DIE) identified based on findings from transvaginal ultrasonography (TVS) performed by an experienced gynecologist using standardized protocols History of drugs taken to alleviate pain Pain severity was assessed using a visual analogue scale (VAS) ranging from 1 to 10 and categorized as mild (1–4), moderate (5–7), or severe (8–10) [ 11 ] Socio-demographic characteristics: age, educational attainment, occupation, family income, residence, marital status, and body mass index (BMI). BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²) and categorized according to the World Health Organization (WHO) Asian criteria: underweight (< 18.5 kg/m²), normal weight (18.5–22.9 kg/m²), overweight (23.0–24.9 kg/m²), and obese (≥ 25.0 kg/m²). Menstruation-related characteristics: age at menarche, duration and regularity of menstrual cycle, duration and self-reported flow of bleeding, history of previous pregnancy, and infertility. Clinical characteristics of endometriosis: Nature of pain (dysmenorrhea, non-menstrual pelvic pain [NMPP], or dyspareunia) Onset and duration of pain Severity of pain Presence of other symptoms Presence of deeply infiltrative endometriosis (DIE) identified based on findings from transvaginal ultrasonography (TVS) performed by an experienced gynecologist using standardized protocols History of drugs taken to alleviate pain Pain severity was assessed using a visual analogue scale (VAS) ranging from 1 to 10 and categorized as mild (1–4), moderate (5–7), or severe (8–10) [ 11 ] Nature of pain (dysmenorrhea, non-menstrual pelvic pain [NMPP], or dyspareunia) Onset and duration of pain Severity of pain Presence of other symptoms Presence of deeply infiltrative endometriosis (DIE) identified based on findings from transvaginal ultrasonography (TVS) performed by an experienced gynecologist using standardized protocols History of drugs taken to alleviate pain Pain severity was assessed using a visual analogue scale (VAS) ranging from 1 to 10 and categorized as mild (1–4), moderate (5–7), or severe (8–10) [ 11 ] All the statistical analyses were conducted using STATA version 17.0 (StataCorp, College Station, Texas, United States). Socio-demographic and clinical characteristics of the patients were summarized using descriptive statistics. The mean with standard deviation (SD) was calculated for the continuous variables and the frequency with percentage was calculated for the categorical variables. Differences in pain severity across dysmenorrhea, non-menstrual pelvic pain (NMPP), and dyspareunia were compared using one-way ANOVA. A p-value of < 0.05 was considered as statistically significant.

The present study provides baseline evidence on the sociodemographic and clinical characteristics of patients with endometriosis in Bangladesh, addressing a significant gap in regional data where epidemiological information remains scarce. By characterizing the clinical presentation and patient profile in a low-resource setting, this study contributes to improving early recognition, diagnosis, and management strategies for endometriosis in similar contexts. The majority of our patients with endometriosis presented in their late twenties, a pattern consistent with previous findings from high-income countries. In the USA, the mean age at diagnosis has been reported as 25.6 (SD 6.7) years, whereas in the UK it was 28.0 (SD 7.1) years [ 12 ]. In our study, the mean age at menarche was 12.4 (SD 2.8) years, which aligns with prior reports [ 12 , 13 ], but is slightly lower than the average age of menarche among Bangladeshi girls (mean 13.1, SD 1.2 years). This discrepancy may reflect differences in genetic predisposition, nutritional status, environmental exposures, or early hormonal influences, which could contribute to earlier symptom onset or more severe disease manifestation. Some studies suggest that early menarche increases the risk of endometriosis, a relationship that is biologically plausible due to prolonged lifetime estrogen exposure and associated retrograde menstruation [ 14 ]. However, large-scale epidemiological studies have produced inconsistent findings, suggesting that menarche alone may not fully explain the risk of developing endometriosis [ 15 , 16 ]. Other factors, such as healthcare-seeking behavior, sociocultural barriers to gynecological consultation, and delays in diagnosis, may also influence the observed age pattern. Collectively, these findings emphasize the need for comprehensive, well-designed prospective cohort studies in Bangladesh to clarify the interaction between menarche timing, genetic and environmental factors, and the clinical presentation of endometriosis. Improved understanding of these relationships could facilitate earlier recognition, tailored management, and the development of culturally appropriate screening strategies in this population. Other characteristics of the menstrual cycle, including cycle length, duration, and flow of bleeding, were reported to be within normal clinical ranges, which corroborates a previous study that found no significant differences in menstrual characteristics between women with and without endometriosis [ 13 ]. Dysmenorrhea was the most commonly reported symptom in our study, affecting over 92% of patients. Besides, NMPP and dyspareunia were also prevalent in a substantial proportion of women. The high frequency of dysmenorrhea may reflect the underlying pathophysiology of endometriosis, including ectopic endometrial tissue causing inflammatory responses and heightened uterine contractility, which often correlates with disease severity [ 2 ]. These pain symptoms are considered cardinal features of endometriosis. Evidence suggests that most patients commonly experience severe dysmenorrhea, chronic pelvic pain, and dyspareunia, frequently associated with deep thrusting during intercourse [ 17 , 18 ]. In addition, urinary symptoms such as dysuria, frequency, urgency, and hematuria, as well as gastrointestinal symptoms including abdominal bloating, dyschezia, hematochezia, constipation, and diarrhea, were reported both in our cohort and in previous studies [ 17 ]. The presence of these multisystemic symptoms highlights the heterogeneity of endometriosis and the need for comprehensive clinical evaluation to identify associated urinary and gastrointestinal involvement, which may indicate more extensive or deeply infiltrative disease. The majority of women in our study reported moderate pain, which aligns with previous studies reporting similar levels of pain in women with endometriosis [ 19 , 20 ]. Dysmenorrhea and dyspareunia tended to have higher pain scores compared to NMPP. These findings are consistent with prior research, which also reported that dysmenorrhea is often more severe compared to NMPP [ 19 – 21 ]. NSAIDs were the most frequently utilized medication for relieving pain among our patients, although, the duration of taking these medication were not collected. Notably, the percentage of oral contraceptive (OC) users was low in our participants, which may have implications for symptom control, potential disease progression, and missed opportunities for early medical management, highlighting the need for improved awareness and access to hormonal therapies [ 22 ]. However, a detailed investigation of medication use and other coping mechanisms for pain was not conducted in the present study. These findings have direct implications for everyday clinical practice. By finding the typical age of presentation, predominant pain patterns, and associated urinary and gastrointestinal symptoms in Bangladeshi women with endometriosis, clinicians can maintain a higher index of suspicion and recognize the disease earlier. Awareness of the moderate severity and common use of NSAIDs for symptom relief can guide individualized pain management strategies and support timely referral for further evaluation, ultimately improving patient care in low-resource settings. Despite its strengths, this study had several limitations. Firstly, clinical diagnostic criteria were used to include patients instead of the ‘gold-standard’ laparoscopy, which may have introduced misclassification. This approach was chosen because laparoscopy is often not feasible in low-resource settings such as Bangladesh, where access to surgical diagnosis is limited. Secondly, the cross-sectional design precluded assessment of changes in pain severity and other clinical manifestations over time or in response to therapeutic interventions, limiting insights into disease progression and treatment effectiveness. Thirdly, data on clinical presentations and pain severity relied on patient self-report, which may have been affected by recall bias. Patients may have under- or over-reported the onset, frequency, or intensity of pain and other symptoms, potentially influencing the observed associations. Fourthly, consecutive sampling was used based on inclusion and exclusion criteria, which may reduce the representativeness of the study population. As a result, the findings may not be fully generalizable to all women with endometriosis in Bangladesh or similar low-resource settings. Additionally, selection bias may have been introduced because inclusion relied on symptom-based clinical diagnosis. Asymptomatic women or those with well-controlled symptoms due to effective hormonal treatment, such as oral contraceptives, may have been underrepresented. Consequently, the findings may not fully reflect the broader population of women with endometriosis in Bangladesh or similar low-resource settings. Future research should consider multicenter recruitment, longitudinal designs, and objective diagnostic measures to validate and extend these findings, thereby improving understanding of the clinical spectrum and natural history of endometriosis in this population.

In conclusion, women with endometriosis in Bangladesh typically present in their late twenties to early thirties, most commonly with dysmenorrhea, non-menstrual pelvic pain, and dyspareunia, along with occasional urinary and gastrointestinal symptoms. Pain is generally of moderate severity across different types. These real-world findings provide valuable insights into the epidemiology and clinical profile of endometriosis in Bangladesh, which can inform earlier recognition, targeted management, and the development of context-appropriate strategies for improving patient care.

Endometriosis is a chronic gynecological condition characterized by the ectopic presence of endometrial-like tissue outside the uterine cavity [ 1 , 2 ]. This aberrant tissue, responding to hormonal fluctuations, undergoes cyclic changes resembling normal endometrium, resulting in inflammation, scarring, and adhesions within the pelvic cavity [ 2 ]. Clinically, endometriosis commonly presents with symptoms such as dysmenorrhea, dyspareunia, and chronic non-menstrual pelvic pain. Other frequently reported manifestations include abdominal or back pain, dyschezia, bloating, and infertility [ 2 , 3 ]. The global age-standardized prevalence rate of endometriosis is around 1123 per 100,000 women [ 4 ]. Despite chronic pelvic pain, dysmenorrhea and dyspareunia being the cardinal features of endometriosis, these symptoms may overlap with several other gynecological conditions. Moreover, patients may also present with non-gynecological symptoms, which further complicates and delays the diagnosis of endometriosis [ 5 ]. Such delays in diagnosis impede the early initiation of effective therapeutic interventions which results in significant deterioration of the patient’s quality of life and imposes a considerable economic burden. Most clinical management guidelines recommend histological confirmation through an invasive surgical procedure (laparoscopy) for the diagnosis of endometriosis [ 6 ]. However, this approach is often not practical, particularly in resource-poor healthcare settings such as those in low- and middle-income countries like Bangladesh [ 7 ]. Clinicians now emphasize a more comprehensive clinical approach based on symptoms, signs, and examination findings rather than relying mainly on surgical confirmation. This approach is seen as more practical for making an earlier diagnosis and starting timely treatment [ 8 ]. However, since patients with endometriosis present with diverse, non-pathognomonic features, a better understanding of the epidemiology in specific populations could help improve clinical diagnosis and management of the disease. A study reported that women of Southeast Asian ethnicity have a higher risk of developing moderate-to-severe endometriosis [ 9 ]. This increased risk may be partly due to delayed care-seeking during the early stages of the disease, as well as genetic and environmental factors that predispose these women to more severe forms of endometriosis. However, there is limited evidence regarding the epidemiological and clinical characteristics of endometriosis among women in Bangladesh. This study aims to describe the sociodemographic and clinical characteristics of Bangladeshi women with endometriosis, providing baseline data for future research.

Supplementary Material 1. Supplementary Material 1.