Bridging epidemiological insights and clinical realities: toward a more equitable understanding of endometriosis: a correspondence

To the Editor, We read with great interest the recent article entitled “Global, regional, and national burden of endometriosis from 1990 to 2021 and projections to 2040” based on the Global Burden of Disease 2021 study[1]. This work provides one of the most comprehensive assessments to date of the prevalence, incidence, and disability-adjusted life years of endometriosis across 204 countries and regions. We particularly appreciate the innovative application of decomposition analysis to identify the drivers of temporal trends, the cross-national inequality metrics highlighting disparities across socioeconomic strata, and the age-specific burden analysis that underscored women aged 25–29 years as the highest-risk group. Furthermore, the projection of global burden through 2040 offers valuable foresight for health systems planning and resource allocation. Despite these strengths, several limitations merit further reflection. First, the study relies on aggregated case definitions that do not account for the heterogeneity of endometriosis, including clinical stages, lesion subtypes, and distinct symptom profiles. This may blur differences in disease severity and mask the disproportionate burden carried by women with deep infiltrating endometriosis or severe pain phenotypes[2]. Future research would benefit from stratifying burden estimates by disease subtype or severity to better inform tailored clinical and policy interventions. Second, the observed temporal decline in age-standardized incidence and prevalence may partly reflect shifts in diagnostic intensity rather than true epidemiological change. Increased use of imaging, wider access to laparoscopy, and greater awareness among clinicians and patients could inflate detection rates in some settings while persistent under-diagnosis continues in others. Modeling diagnostic capacity and health care access explicitly, or adjusting for health system expansion indicators, would help disentangle real epidemiologic trends from diagnostic artifacts. Third, the study’s projection model assumes relatively stable health care conditions, diagnostic practices, and policy environments. Yet, endometriosis management is rapidly evolving, with novel medical therapies (e.g., oral GnRH antagonists), robotic-assisted surgery, and expanding assisted reproductive technologies changing the treatment landscape[3,4]. Ignoring these dynamic clinical and policy shifts may limit the validity of long-term forecasts. Future analyses could incorporate scenario-based projections to account for technological advances and health policy reforms. Finally, while the cross-country inequality analysis is insightful, it overlooks within-country disparities that are often more pronounced than international differences. Socioeconomic status, urban–rural divides, and ethnic or cultural barriers heavily influence diagnostic delay and access to care. Integrating subnational data, patient-reported outcomes, and context-specific determinants of health care access into burden models would provide a more nuanced understanding of inequality and guide more targeted interventions. In summary, this article makes a significant contribution by mapping the global burden of endometriosis and projecting future trajectories. We commend the authors for their rigorous methodology and insightful analyses. At the same time, we suggest that incorporating disease heterogeneity, diagnostic intensity adjustments, dynamic treatment structures, and subnational disparities would further enhance the validity and policy relevance of future work. This study not only advances academic understanding but also provides a foundation for refining future global health assessments of endometriosis. We ensured compliance with the TITAN 2025 guidelines[5]. Ethical approval Not applicable. Consent Not applicable. Sources of funding Dalian City Outstanding Young Science and Technology Talent Program (No. 2023RY020). Dalian Municipal Life and Health Sector Guidance Program Project (NO.2023-243-8). Author contributions All authors contributed to the study conception and design. Study design: W.L. and J.F. Writing-original draft: W.L., J.F., and X.W. Writing-review and editing: W.L., J.F., and X.W. Supervision: J.F. and X.W. Conflicts of interest disclosure None of the authors has any conflicts of interest. Research registration unique identifying number (UIN) Not applicable. Guarantor Wangshu Li. Provenance and peer review Not commissioned. Data availability This study is a review of previously published articles, and no new data exist, so data sharing does not apply to this paper. Declaration of generative AI and AI-assisted technologies in the writing process The authors believe they did not use any generative AI and AI-assisted technologies in this study during the writing process.