From Plastic to Pelvis: Two Decades of Evidence on Bisphenol A and Endometriosis in Indonesia’s Online Food Delivery Era

Endometriosis is an estrogen-dependent inflammatory disorder that may be influenced by bisphenol A (BPA), an endocrine-disrupting chemical commonly found in food-contact plastics. BPA has been implicated in altered steroidogenesis, immune dysregulation, oxidative stress, and epigenetic modifications associated with ectopic endometrial growth. In Indonesia, the rapid expansion of app-based online food delivery (OFD), which heavily relies on single-use plastic packaging, has raised concerns regarding dietary BPA exposure. This narrative review synthesizes evidence linking BPA to endometriosis and explores OFD-related plastic exposure in Indonesia within the broader Asian context over the past two decades. A narrative search of PubMed, Google Scholar, and manual sources identified English-language peer-reviewed studies published between 2005 and 2025 addressing BPA, endometriosis, food-contact plastics, dietary exposure, and OFD practices in Indonesia and Asia. Of 57 screened articles, 47 full texts were reviewed, including 18 primary studies focusing on clinical outcomes, biomarker assessment, and BPA migration from packaging materials. Mechanistic evidence demonstrates that BPA interacts with estrogen receptors and promotes pathways associated with ectopic endometrial proliferation. Epidemiological studies frequently report higher urinary or serum BPA levels among women with endometriosis, although findings remain heterogeneous. Dietary intake represents a major exposure route, particularly when plastics are exposed to heat, fat, and prolonged contact time. Indonesia’s OFD practices, including excessive plastic packaging and sealing methods, may further increase unnecessary exposure. Limitations include the narrative design, language restriction, and reliance on animal-based evidence. Overall, current evidence supports the need for safer food-packaging practices, public education, and region-specific biomonitoring studies to better define BPA-related risks and inform public health policy.

bisphenol A, endometriosis, online food delivery

Endometriosis is a chronic, estrogen-dependent gynecologic disorder characterized by the presence of endometrial-like tissue outside the uterine cavity, leading to pelvic pain, dysmenorrhea, dyspareunia, and subfertility.1,2 The global prevalence is estimated at around 10% among reproductive-age women and may be higher in infertility clinics, including in Southeast Asia.2,3 Although retrograde menstruation is widely accepted as a necessary step in lesion initiation, this mechanism alone does not explain interindividual variability in disease occurrence and severity, suggesting a role for genetic, immunologic, and environmental factors.1,3,4 Endometriosis is closely associated with immunological dysregulation and hormonal imbalance, both closely linked to the disruption of gut microbiota.5–7 In parallel with changing modern dietary behaviors, particularly the rapid expansion of app-based online food delivery (OFD), concerns have emerged regarding increased exposure to food-related environmental contaminants. Consequently, dietary exposure and food contamination have emerged as important contributions to disease progression, particularly through environmental endocrine-disrupting chemicals (EDCs), which are widely present in everyday products.1–4 Compounds such as BPA, phthalates, and dioxins can mimic or antagonize endogenous hormones, disrupt steroidogenesis, and modulate immune responses in ways that favor ectopic implantation and persistence of endometrial tissue.2–4 Among these compounds, BPA has attracted particular attention because of its ubiquity in food-contact plastics and epoxy resins and its measurable presence in human urine, serum, and tissues worldwide.8–10 Indonesia has experienced rapid growth in app-based OFD platforms, especially in urban centers, changing dietary patterns and increasing reliance on ready-to-eat meals packaged and delivered in plastic containers.11,12 Single-use plastic bowls, lids, sachets, and multilayer bags are frequently used for hot, oily foods, conditions that can enhance BPA migration from packaging to food.9,10,13 This raises concerns that OFD practices may be a previously underrecognized vector of BPA exposure for Indonesian women of reproductive age, potentially affecting endometriosis risk and disease burden.11,12,14 This narrative review aims to synthesize (1) mechanistic evidence linking BPA to endometriosis, (2) human epidemiological data on BPA exposure and endometriosis risk, (3) data on BPA migration from food-contact materials under conditions relevant to OFD, and (4) implications for Indonesia’s OFD ecosystem and public health policy. By integrating two decades of literature, this review seeks to highlight BPA as a modifiable environmental risk factor for endometriosis in Indonesia and comparable Asian settings and to identify key research and policy gaps.11,14,15

This narrative review followed structured approach to identify relevant literature on BPA, endometriosis, and food-contact plastics with a focus on Asian and Indonesian contexts. Electronic searches were conducted in PubMed and Google Scholar using combinations of keywords, including “bisphenol A”, “BPA”, “endometriosis”, “endometrioma”, “endocrine disruptor”, “food packaging”, “migration”, “online food delivery”, “Indonesia”, and “Asia”. The search was limited to peer-reviewed articles in English published between January 2005 and June 2025, capturing both early mechanistic studies and more recent epidemiological and migration data. Reference lists of key reviews and primary studies were manually screened to identify additional relevant publications, and selected documents from regulatory and technical sources were consulted for background information on BPA regulations and packaging practices. Inclusion criteria comprised human epidemiologic studies assessing BPA exposure and endometriosis or related gynecologic outcomes, in vivo or in vitro mechanistic studies directly relevant to endometriosis pathophysiology, and migration or exposure studies focusing on BPA release from food-contact materials under conditions reflective of typical consumer use. Of 57 articles initially screened based on titles and abstracts, 47 full texts were reviewed in detail, and 18 primary studies were selected as most relevant to the objectives of this narrative review because they addressed clinical outcomes, exposure biomarkers, or packaging-related migration in sufficient detail.5,9 Data were qualitatively synthesized, focusing on mechanistic plausibility, direction and magnitude of associations, contextual relevance to Indonesia, and limitations such as exposure misclassification or confounding. This study adheres to the 6-item checklist outlined in the Scale for the Assessment of Narrative Review Articles (SANRA) to ensure robustness.16 Due to the narrative nature of this review, no meta-analysis was conducted. Host-Microbiota Interactions in Female Health Endometriosis, characterized by the growth of endometrial tissue outside the endometrium, is closely linked to immunological dysregulation and hormonal imbalance.5 Endometriosis and adenomyosis are closely related and may share similar pathophysiological mechanism; however, adenomyosis is not the primary focus of the present review.17 Emerging evidence suggests that the gut and reproductive tract microbiota play a significant role in the development of gynaecologic diseases such as endometriosis, adenomyosis, polycystic ovarian syndrome (PCOS), ovarian, breast, and cervical cancer.7,18,19 Dysbiosis, defined as disruption of microbiota homeostasis, has been associated with both the occurrence and progression of endometriosis.6,7,20 This imbalance may impair immune function, leading to compromised immunosurveillance and immune cell profiles, increased proinflammatory cytokines and proangiogenic growth factors, all of which contribute to disease pathogenesis.6 In addition, gut dysbiosis may promote endometriosis through increased secretion of beta-glucuronidase (GUS), an enzyme that deconjugates estrogen in gastrointestinal tract, thereby increasing levels of biologically active estrogen capable of binding to estrogen receptor and initiating downstream physiological effects.7,18 Given these considerations, dietary exposure and food consumptions are essential factors in disease progression, as food contaminations may disrupt gut microbiota composition. One of the most relevant environmental exposures is BPA, given its widespread use in food packaging materials.21,22 Mechanistic Links Between BPA and Endometriosis Experimental studies support a biologically plausible link between BPA exposure and endometriosis through estrogenic and non-estrogenic pathways.1–4 BPA can bind to classical estrogen receptors (ERα and ERβ), membrane-bound estrogen receptors, and other nuclear receptors, altering gene expression in ways that promote proliferation, inflammation, and angiogenesis in endometrial and peritoneal tissues.2–4 Animal models demonstrate that developmental or perinatal exposure to BPA increases the occurrence of endometriosis-like lesions with histological and molecular features resembling human ectopic implants, including altered hormone receptor expression and progesterone resistance.1–3 At the cellular level, BPA has been shown to modulate steroidogenic enzymes, shift estrogen-to-progesterone ratios, and upregulate pro-inflammatory cytokines and chemokines in endometrial stromal cells, providing a microenvironment conducive to lesion implantation and survival.2–4 Furthermore, BPA exposure has been linked to increased oxidative stress and epigenetic modifications such as DNA methylation changes in genes relevant to hormone signaling and immune regulation, which may contribute to persistent alterations in endometrial function and increased susceptibility to endometriosis.3,4 These mechanistic insights collectively support the hypothesis that BPA can act as a trigger or promoter of endometriosis in genetically or hormonally susceptible women.2–4 Human Epidemiological Evidence Multiple case–control and population-based studies have examined associations between BPA exposure and endometriosis, typically using urinary or serum BPA as biomarkers.2,15,23 A case–control study among women with surgically confirmed endometrioma reported significantly higher urinary BPA concentrations in cases compared with controls, with an adjusted odds ratio of approximately 1.7 per unit increase in BPA, suggesting a positive dose–response relationship.23 A population-based study using NHANES data found that higher urinary BPA was associated with increased odds of non-ovarian pelvic endometriosis but not ovarian endometriosis, indicating that anatomical subtypes may differ in their sensitivity to BPA exposure.15 Other studies have reported elevated serum or urinary BPA levels in women with endometriosis or bowel endometrioma compared with controls, although effect sizes and statistical significance vary.24,25 Some investigations have yielded null associations, often attributed to small sample sizes, single time-point exposure measurements, and potential confounding by other EDCs or lifestyle factors. Overall, the epidemiologic literature generally supports an association between higher BPA exposure and increased endometriosis risk, but heterogeneity and methodological limitations prevent definitive causal inference.2,14,15 Nevertheless, the consistency of positive findings together with strong mechanistic plausibility positions BPA as a potentially modifiable environmental risk factor for endometriosis.2–4 BPA in Food Contact Materials and Migration Dynamics BPA is primarily used in the production of polycarbonate plastics and epoxy resins, which are common in reusable bottles, can linings, and certain rigid or coated food-contact containers and lids.8–10 Migration of BPA from packaging into food is influenced by multiple factors, including polymer type, initial BPA content, temperature, duration of contact, and the physicochemical properties of the food, particularly fat content and acidity. Experimental migration studies consistently show increased BPA release at higher temperatures and longer contact times, with fatty food simulants often exhibiting greater uptake than aqueous matrices.9,10,13 Figure 1 illustrates the proposed pathways linking online food delivery–related BPA exposure to endometriosis development and progression. Recent work has demonstrated that heating food or simulants in plastic containers at elevated temperatures can significantly enhance BPA migration compared with storage at ambient conditions, even when total heating time is relatively short.9,10 Contact time often follows a square-root relationship with migration, meaning prolonged storage or repeated use can cumulatively increase BPA transfer to food.10,13 These findings have direct relevance for OFD, where hot, oily dishes may be poured into plastic containers immediately after cooking and remain in contact during transport and subsequent handling, thereby combining high temperature, high fat content, and non-trivial contact times.9,11 Online Food Delivery Practices and BPA Exposure In Indonesia and other rapidly urbanizing Asian countries, OFD platforms have expanded rapidly, encouraging frequent consumption of restaurant-prepared meals delivered in disposable plastic packaging.11,12 Common practices include the use of thin plastic bowls, lids, multilayer bags, and plastic accessories such as cutlery and sauce sachets, often in direct contact with hot foods or beverages.11,26 While some of these plastics may not contain BPA, the overall plastic load and frequent combination of heat, oil, and prolonged containment create conditions favorable for migration of BPA and other EDCs where present.9,10,13 To date, few studies have specifically quantified BPA exposure from OFD meals in Indonesia, but regional data show that diet is a dominant pathway of BPA intake, particularly through canned foods, beverages, and plastic-packaged ready-to-eat products.8,9,12,27 Local reports highlight BPA in various food-contact applications and note public concern over potential health risks, prompting regulatory attention to labeling and migration limits.12,26,28 Given the rapid growth of OFD use among younger, reproductive-age adults, it is plausible that OFD-related packaging contributes substantially to daily BPA exposure in Indonesian women, though targeted biomonitoring and exposure assessment studies are urgently needed to confirm this.11,12,25 Integrating Mechanistic and Epidemiologic Evidence The convergence of mechanistic, experimental, and epidemiological data supports a role for BPA in the pathogenesis of endometriosis, although causality cannot yet be definitively established.1–4,14,15 Mechanistic studies demonstrate that BPA can mimic estrogen, alter progesterone responsiveness, promote inflammatory and oxidative pathways, and induce epigenetic changes, all of which align with contemporary models of endometriosis biology.1–4 Human studies, despite limitations, generally show higher BPA levels in women with endometriosis compared with controls and suggest that particular phenotypes such as non-ovarian pelvic disease may be especially associated with BPA exposure.15,23–25 Importantly, BPA rarely acts in isolation; co-exposure to phthalates, dioxins, and other EDCs is common, and these compounds may have additive or synergistic effects on endometriosis risk.2–4,14 This complicates attribution of risk to BPA alone but underscores that reducing BPA exposure could contribute to a broader strategy of lowering total endocrine-disrupting burden in susceptible populations.3,4,14 For clinicians and policymakers, BPA can therefore be viewed as a sentinel compound, where targeted reduction policies may simultaneously reduce exposures to related chemicals and yield meaningful reproductive health benefits.3,4,15 Relevance to Indonesia’s Online Food Delivery Ecosystem Indonesia’s OFD ecosystem provides a unique lens through which to view BPA exposure, particularly among urban, reproductive-age women who are both high users of OFD and at risk for endometriosis.11,12 The combination of hot, oily foods with single-use plastic containers, sealed bags, and reheating practices may create repeated, chronic dietary exposure to BPA and other migrants, layered onto background exposures from canned foods, bottled beverages, and thermal papers.8–10,13 While Indonesia has established specific migration limits and labeling requirements for BPA in certain food-contact materials, enforcement, public awareness, and coverage of newer OFD-related packaging materials remain variable.12,26,28 Given the rising recognition of endometriosis as a significant cause of pain, infertility, and reduced quality of life in Indonesian women, addressing modifiable environmental contributors such as BPA is increasingly relevant to reproductive health policy.2,3,15 OFD platforms, food vendors, packaging manufacturers, and regulators share responsibility for transitioning toward safer packaging materials, minimizing heating in plastic, and educating consumers about lower-exposure practices (for example, transferring hot foods to glass or ceramic containers before storage or reheating).9,11,13 Aligning these interventions with broader waste reduction and environmental sustainability initiatives would yield co-benefits for both human and ecosystem health.13,29

Two decades of evidence indicate that BPA is a biologically plausible and epidemiologically supported contributor to endometriosis risk, acting through estrogenic, inflammatory, oxidative, and epigenetic pathways.1–4 Human studies generally show higher BPA levels in women with endometriosis, though heterogeneity and methodological limitations mandate cautious interpretation and further research.2,15,23,24 In Indonesia, the rapid rise of OFD and heavy reliance on plastic packaging likely amplifies dietary BPA exposure in reproductive-age women, raising concerns for the burden of endometriosis and broader reproductive health impacts.8,11,12 Addressing this challenge will require integrated policy action on food-contact materials, changes in OFD packaging practices, and targeted research to characterize exposures and outcomes in local populations.10,12,26,28,29 Recognizing BPA as a modifiable risk factor provides an opportunity to reduce environmental influences on endometriosis and improve women’s health amid Indonesia’s evolving food systems.3,11,14,15 However, several limitations should be addressed. First, this review is narrative in design, therefore may be subject to selection bias and lacks the quantitative synthesis of evidence. Second, potential language bias is present, as only English-language studies were included. Third, a substantial proportion of pathophysiological evidence is derived from animal studies, which may limit direct generalizability to human populations. Further longitudinal research, particularly prospective cohorts, are needed to strengthen existing evidence. Artificial Intelligence (AI) Declaration for Figure Preparation Figure 1 was created with the assistance of OpenAI’s ChatGPT image-generation tool (GPT-5.5 with integrated image generation, June 2026 version) to develop a conceptual illustration of the proposed pathways linking online food delivery–related bisphenol A (BPA) exposure to endometriosis development and progression. The authors designed the scientific content, conceptual framework, and figure structure, and provided prompts describing the intended mechanisms, exposure pathways, and public health implications. The resulting image was subsequently reviewed, revised, and verified by the authors. The authors confirm that the originality and scientific accuracy of the figure content have been independently assessed and validated. The authors have reviewed the terms of use of the AI tool and confirm that the generated image is suitable for academic publication and that they have the right to publish the image. Any necessary permissions have been obtained where applicable. The authors retain records of the prompts used and relevant versions of the generated images and will provide them upon reasonable request. The authors take full responsibility for the integrity, accuracy, and interpretation of all content presented in the figure, including consistency with the cited literature and references. Ethical Issues This narrative review used only previously published data and did not involve human or animal subjects; therefore, ethical approval was not required. The present study was conducted in accordance with the principles of the Declaration of Helsinki. Funding This publication charge is funded by Unpad through the Indonesian Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under the EQUITY Program (Contract No. 4303/B3/DT.03.08/2025 and 3927/UN6. RKT/HK.07.00/2025). Disclosure The author(s) report no conflicts of interest in this work.

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