Endometriosis: A Six-Year Epidemiological Study

& Objective: The etiology of endometriosis is unknown and many hormonal, inflammatory, genetic and environmental factors are effective in the formation of endometriosis. The present study investigated the epidemiology of endometriosis in patients referred to ShohadayeTajrish Hospital in six years.

& Methods: This descriptive study performed on endometriosis Iranian w omen who referred to ShohadayeTajrish Hospital between 2016 and 2022. The sample size of this study was determined using the census method, and 711 patients. For analysis, SPSS version 22 was used, and results were reported as mean ± SD.

Finally, 711 patients enrolled in this study and the average age of patients was 34.69± 7.53 years and the mean age of onset of disease was 29.97±4.61years. More than 55% of patients had a healthy weight and normal body mass index. 17.72 percent of patients had a history of infertility in their life’s.

Endometriosis patients’ life in many aspects, including their job, li festyle, education, marital status and health care is affected.

Endometriosis, Epidemiology, Prevalence, Pregnancy Received: 2023/10/16; Accepted: 2024/01/07; Published Online: 15 May 2024; Use your device to scan and read the article online Corresponding Information: Behnaz Nouri, The Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Email: [email protected] Copyright © 2024, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License which permits copy and redistribution of the material just in noncommercial usages with proper citation.

Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside of it, resulting in symptoms such as chronic pelvic pain, painful periods, painful intercourse, and infertility (1-5). Endometriosis is a common gynecological disorder affecting an estimated 10% of reproductive -aged women worldwide, with higher rates reported in infertile women (4-9). It is characterized by the growth of endometrial tissue outside the uterus, causing chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility (7-11). The economic burden of endometriosis is substantial, with estimated annual healthcare costs of $119 billion globally (3). In the United States, the prevalence of endometriosis is estimated to be between 6 -10% of women of reproductive age (8-12). With an annual incidence rate of 1 -2% (5). In Iran, the reported prevalence of endometriosis varies widely, ranging from 2% to 40% of women of reproductive age (6, 7). Despite the high prevalence and significant impact of endometriosis on the quality of life and economic productivity of affected women, there is still a limited understanding of the epidemiology and risk factors for the condition, particularly in the context of Iran (10- 13). This lack of knowledge and awareness about endometriosis in Iran can lead to underdiagnosis, delayed diagnosis, and inadequate treatment, resulting in unnecessary suffering and long -term complications for women (14-16). Therefore, identifying the epidemiological patterns and risk factors for endometriosis in Iranian women is essential for improving diagnosis and management strategies, enhancing public health awareness, and ultimately reducing the burden of the disease on individuals and society (9, 17).

This study is a descriptive studyperformed on endometriosis Iranian women who referred to Behnaz Nouri et al. 336 Volume 9, May – June 2024 Journal of Obstetrics, Gynecology and Cancer Research ShohadayeTajrish Hospital affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran between 2016 and 2022. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1395.362). The sample size of this study was determined using the census method, and 711 patients diagnosed with endometriosis were included in this study. All patients diagnosed with endometriosis by ultrasound, MRI, or surgery were included in the study. Demographic and clinical data of patients, such as age, body mass index, place of residence, education level, marital status, type of pregnancy, and its outcome were collected by a single interviewer through face -to-face interviews at the outpatient clinic after the diagnosis of endometriosis was confirmed. The data were entered into an Excel spreadsheet and analyzed using statistical methods. For analyzing used SPSS software version 22, and

were reported as mean ± SD.

Finally, 711 patients enrolled in this study and the average age of patients was 34.69± 7.53 years (min:14 and max:55) and the mean age of onset of disease was 29.97±4.61(min: 16 and max 54). Table 1 shows descriptive characteristics of patients. Table 1. Epidemiological and Demographical Characters Characters Frequency Marriage status Single Married /relationship 151 (21.23%) 560 (78.76%) Occupational status Unemployed Employed 464(65.26%) 247 (34.74%) Educational status Illiterate Diploma Bachelor Master and doctorate 14 (1.97%) 150 (21.10%) 326 (45.85%) 221 (31.08%) BMI <18.5 (underweight) 18.5 to <25 (healthy weight) 25.0 to <30 (overweight) 30 to < 35 (Class 1) 35 to < 40 (Class 2) 24.88±3.94 17.51± 0.65 (n=33, 4.64%) 22.72± 1.80(n=392, 55.13%) 27.65± 1.36(n=229, 32.21%) 32.45± 1.25(n=53, 7.45%) 39.25± 1.29(n=4, 0.57%) Place of living Capital County Village Abroad 309 (43.46%) 289 (40.65) 109 (15.33%) 4 (0.56%) Family History Yes No 60 (8.43%) 651 (91.57%) History of Pregnancy Yes No 505 (71.02%) 206 (28.98%) History of Infertility 337 Epidemiology of Endometriosis Volume 9, May – June 2024 Journal of Obstetrics, Gynecology and Cancer Research Characters Frequency Yes No 126 (17.72%) 585 (82.28%) History of Abortion Yes No 111 (15.61%) 600 (84.39%) Ectopic pregnancy Yes No 9 (2.27%) 702 (98.73%) History of death uterine Yes No 21(2.96%) 690(97.04%)

Cardoso-1 and colleagues from Argentina, in a retrospective study of 237 patients over 6 years, examined the demographic factors of age [29-39], body mass index [18.5- 24.9], and symptoms. The average time to diagnosis was 5 years. Endometrioma and deep infiltrating endometriosis (DIE) had the highest prevalence (17). In study Eisenberg, Weil (18) which examined the epidemiology of endometriosis based on data from 2 million participants, the prevalence age was 40-44 with an average age of 34, and infertility was present in 37% of patients (18). Al-Jefout, Alnawaiseh (19) from the University of Arabia in 2018 reported a prevalence of endometriosis of 1.5% in a study of 3572 individuals with an average age of 20 -29 and irregular and long menstrual periods of equal to or greater than 7 days. Endometriosis was reported more in divorced individuals (19). Parasar, Ozcan and Terry (20) study from Boston Women's Hospital in 2017 reported that early menarche, short menstrual periods, higher height to waist ratio, and higher body mass index are associated with a higher incidence of endometriosis. Pregnancy, higher body mass index, and smoking reduce the incidence of the disease (20) . Alshammari, Alrajhi (21) reported on a retrospective cohort study of 460 patients who presented to a university hospital over 5 years, with an average age of 31.9 years and a peak incidence of 35 –45 years. The incidence was l ess in pregnant patients and those who had undergone cesarean section (21) . In their literature review, Smolarz, Czerw (22) found that 10- 15% of women in the peak age range of 25 -45 have endometriosis, and 7% have a family history of the disease. It is diagnosed in 20% of women during tubal ligation and in 17% after oophorectomy surgery. It has the highest prevalence in Asian women and the lowest in Black women (22-24).

Endometriosis patients’ life in many aspects, including their job, lifestyl e, education, marital status, pregnancy and childbirth and health care is affected. Acknowledgments None. Authors' Contribution Study concept and design: BN and SN; Drafting of the manuscript: BN and SN; Critical revision of the manuscript: BN and MA; Statistical analysis: SN. All the authors have given final approval of the version to be published. Conflict of Interest The authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non- financial interest in the subject or

discussed in the manuscript. Data Reproducibility The data set presented in the study is available on request from the corresponding author during submission or after its publication. Ethical Approval This study was approved by the ethical committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Funding/Support The author(s) received no financial support for the research, authorship, and/or publication of this article. Informed Consent All participants filled out and signed an informed consent form to participate in the study. Behnaz Nouri et al. 338 Volume 9, May – June 2024 Journal of Obstetrics, Gynecology and Cancer Research 1. Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261-75. [DOI:10.1038/nrendo.2013.255] [PMID] 2. Johnson NP, Hummelshoj L. Consensus on current management of endometriosis. Hum Reprod. 2013; 28(6):1552-68. [DOI:10.1093/humrep/det050] [PMID] 3. Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011;96(2): 366-73.e8. [ DOI:10.1016/j.fertnstert.2011.05.090] [PMID] [PMCID] 4. Moradi M, Niazi A, Parker M, Sneddon A, Lopez V, Ellwood D. Endometriosis -associated Symptoms and Diagnostic Delay: An Online Survey. J Obstet Gynecol Cancer Res. 2022;7(6): 479-88. [DOI:10.30699/jogcr.7.6.479] 5. Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98(3):511-9. [PMID] [PMCID] [DOI:10.1016/j.fertnstert.2012.06.029] 6. Mollazadeh S, Mirzaii Najmabadi K, Mirghafourvand M, Latifnejad Roudsari R. Sexual Activity during Menstruation as A Risk Factor for Endometriosis: A Systematic Review and Meta - Analysis. Int J Fertil Steril. 2023;17(1):1-6. 7. Akbarzadeh-Jahromi M, Shekarkhar G, Sari Aslani F, Azarpira N, Heidari Esfahani M, Mo mtahan M. Prevalence of Endometriosis in Malignant Epithelial Ovarian Tumor. Arch Iran Med. 2015; 18(12):844-8. 8. Davoodi P, J. Ghadimi D, Rezaei M, Khazei Tabari MA, Shirani A, Nouri B, et al. Endometriosis and COVID-19: Clinical Presentation and Quality of Life, a Systematic Review. J Obstet Gynecol Cancer Res. 2023;8(4):315-26. [DOI:10.30699/jogcr.8.4.315] 9. Nouri B, Arab M, Nasiri M. Endometriosis: Clinical, Magnetic Resonance Imaging and Pathologic Findings. J Obstet Gynecol Cancer Res. 2023;8(5):481-7. [DOI:10.30699/jogcr.8.5.481] 10. Moazzami B, Chaichian S, Samie S, Zolbin MM, Jesmi F, Akhlaghdoust M, et al. Does endometriosis increase susceptibility to COVID-19 infections? A case- control study in women of reproductive age. BMC Womens Health. 2021; 21(1):119. [ DOI:10.1186/s12905-021-01270-z] [PMID] [PMCID] 11. Hoorsan H, Alavi Majd H, Chaichian S, Mehdizadehkashi A, Hoorsan R, Akhlaqghdoust M, et al. Maternal An thropometric Characteristics and Adverse Pregnancy Outcomes in Iranian Women: A Confirmation Analysis. Arch Iran Med. 2018;21(2):61-6. 12. Sarbazi F, Akbari E, Nouri B. Pain Management in Endometriosis. Interv Pain Med Neuromod. 2022;2(1):e128043. [DOI:10.5812/ipmn-128043] 13. Sarbazi F, Akbari E, Karimi A, Nouri B, Noori Ardebili SH. The Clinical Outcome of Laparoscopic Surgery for Endometriosis on Pain, Ovarian Reserve, and Cancer Antigen 125 (CA - 125): A Cohort Study. Int J Fertil Steril. 2021; 15(4):275-9. 14. Nouri B, Roshandel S. Is Artificial Intelligence a New Diagnostic Approach for Patients with Endometriosis? Interv Pain Med Neuromod. 2022; 2(1):e128720. [DOI:10.5812/ipmn-128720] 15. Hoorsan H, Mirmiran P, Chaichian S, Moradi Y, Akhlaghdoust M, Hoorsan R, et al. Diet and risk of endometriosis: a systematic review and meta - analysis study. Iran Red Crescent Med J. 2017; 19(9):e41248. [DOI:10.5812/ircmj.41248] 16. Nouri B, Baghestani AR, Pooransari P. Evening Primrose versus Misoprostol for Cervical Dilatation before Gynecologic Surgeries; a Double- blind Randomized Clinical Trial. J Obstet Gynecol Cancer Res. 2021;6(2):87-94. [DOI:10.30699/jogcr.6.2.87] 17. Reza M, Mohsen M, Ansari A. In: Endometriosis [Internet]. Endometriosis - Basic Concepts and Current Research Trends. InTech; 2012. Available from: [DOI:10.5772/32760] 18. Eisenberg VH, Weil C, Chodick G, Shalev V. Epidemiology of endometriosis: a large population- based database study from a healthcare provider with 2 million members. BJOG. 2018;125(1):55- 62. [DOI:10.1111/1471-0528.14711] [PMID] 19. Al-Jefout M, Alnawaiseh N, Ajarmeh H, Alqudah M. Prevalence and clinical presentation of endometriosis among women with infertility or chronic pelvic pain at a university hospital in Jordan. Int J Womens Health. 2018(10):11-7. 20. Parasar P, Ozcan P, Terry KL. Endometriosis: Epidemiology, Diagnosis and Clinical Management. Curr Obstet Gynecol Rep. 2017;6(1): 34-41. [DOI:10.1007/s13669-017-0187-1] [PMID] [PMCID] 21. Alshammari SM, Alrajhi NN, Al -Rumayh SS, Alosaimi MA, Alsharyufi RM, Bukhari YS, et al. An Overview on Pelvic Inflammatory Disease Diagnosis and Management Approach. Arch Pharm Pract. 2021;12(2):103-5. [DOI:10.51847/1jlwKjj2kw]

339 Epidemiology of Endometriosis Volume 9, May – June 2024 Journal of Obstetrics, Gynecology and Cancer Research 22. Smolarz B, Czerw A, Szymanowski K, Kaminski P. Endometriosis - a comprehensive review of epidemiology, pathogenesis, clinical a spects and available therapeutic methods. Arch Med Sci. 2021;17(6):1404-18. 23. Nouri B, Hashemi SH, Ghadimi Dj, Roshandel S, Akhlaghdoust M. Machine Learning in the Detection of Endometriosis: Retrospective Study. Int J Fertil Steril. 2024; (Articles in Press). 24. Nouri B, Alemi M, Baghestani AR. The Effect of Laparoscopic Radical Surgery for Endometriosis on Serum Levels of Lipid Profile and Vitamin D. J Obstet Gynaecol Cancer Res. 2022;7(5):429- 36. [DOI:10.30699/jogcr.7.5.429] How to Cite This Article: Nouri, B., Naz Agili, S., Arab, M. Endometriosis: A SixYear Epidemiological Study. J Obstet Gynecol Cancer Res. 2024;9(3):335-9. Download citation: RIS | EndNote | Mendeley |BibTeX |