Knowledge and concern towards endometriosis among Lebanese women: a cross-sectional study

A cross-sectional study was carried out, from February 1, 2024 to March 1, 2024, across all Lebanese governorates (Beirut, Mount Lebanon, South Lebanon, Baalbek-Hermel, Nabatieh, Akkar, and North Lebanon) in order to ensure a diverse representation of the population as a whole. In order to be eligible for participation in the study, a female participant had to be over the age of 18, have the Lebanese nationality, reside in Lebanon, and complete the questionnaire completely. Participants who did not fulfill the inclusion criteria were excluded from the analysis. The G*Power software was used to determine the sample size. An estimated sample size of 400 participants were calculated, considering an alpha error of 5%, a power of 90%, a minimal model r-square of 5%, and allowing a maximum of 10 predictors to be included in the multivariable model. Leveraging a comprehensive review of the existing literature, a team of three physicians developed a structured questionnaire specifically tailored to the research aims. The questionnaire underwent further refinement to guarantee clarity, conciseness, and elimination of ambiguity in the questions (supplementary material). The survey was pilot tested on ten women before data collection to ensure its comprehensibility, readability, and cultural relevance. Changes had been made in response to the input, and the survey was uploaded to the Google form platform. A social media link to the survey was shared in order to enlist participants and collect a sample of the intended audience through the snowballing technique (using WhatsApp). Participants were informed about the voluntary and anonymous nature of their participation in the study prior to any data collection. The questionnaire was available in Arabic, the official language in Lebanon, and took about 10 to 15 min to complete. The survey was divided into seven sections, comprising 61 questions. The participants’ sociodemographic information (age, residence governate, education level, professional status, height, weight, marital status, and monthly family income) was covered in the first section. The second section addressed queries on reproductive factors (length of menstrual cycle, menstruation, history of infertility, cesarean section, abortion and usage of oral contraceptives). The third section had only three multiple-choice questions about gynecological checkups (frequency of visits, previous ultrasonography examination, and premarital gynecological consultation). The lifestyle and behavioral characteristics pertaining to smoking and physical activity level were evaluated in the fourth section. Knowledge section including 11 questions assessing women’s knowledge about endometriosis related information. The correct answer was assigned 1 point while incorrect answers were assigned 0 points. The overall knowledge score, obtained by the sum of the questions, ranged between 0 and 11. Based on Bloom’s cut off point participants with scores ≥ 60% (≥ 7 points) was categorized as good knowledge, while those with scores < 80% (< 7 points) were considered having a poor knowledge score [ 16 ]. Items towards concern related to endometriosis evaluated menstrual symptoms and the presence of self-suspected endometriosis. The final section addressed the participants’ medical history. The Cronbach alpha coefficient value, used to check questionnaire reliability, was observed to be 0.896 for the section knowledge. The data of pilot study was removed from final analysis. Further modifications were done after feedback retrieval from the participants. This study protocol has been approved by the research ethics committee of the Islamic Health Society (reference number: 201123-06) on November the 20th 2023, which acts as the Coordinator of Ethical Issues. The research ethics guidelines laid down in the Declaration of Helsinki of the World Medical Association Assembly was respected [ 17 ]. All participants agreed to participate and provided an electronic informed consent. Before proceeding to the first part of the questionnaire, participants had to electronically indicate their informed consent by checking three mandatory options confirming their comprehension of the voluntary and confidential nature of their participation and their agreement to be enrolled in the study. Data were checked for completeness and consistency, and the analysis was performed using IBM SPSS Statistics for Windows version 26.0. Socio-demographic, behavioral, reproductive, gynecological and medical characteristics of the participants were described using the mean (standard deviation) for continuous variables, and the number (percent) for qualitative variables. Categorical variables were compared in univariate analyses (Pearson chi square test) and the means of continuous variables with the student’s t-test. A multivariate logistic regression models was performed on the knowledge as a dependent variable (poor knowledge versus good knowledge). Age (< 35 versus ≥ 35), marital status (married versus others), Education (Bachelor’s degree and below versus master’s degree and above), profession ( active versus housewife and without profession), number of previous pregnancies, number of live births, history of abortion, use of oral contraceptives, gynecologist visit regularity, last time of pelvic or vaginal echography (< 6 months versus ≥ 6 months), family history of endometriosis, history of pelvic inflammatory disease, history of uterine or ovarian conditions, history of pelvic surgeries, and autoimmune inflammatory diseases were assessed as potential predictors in univariate analyses. Variables with a p-value ≤ 0.2 in univariate model were eligible for the multivariate model. The collinearity between variables was tested. Variables presenting collinearity were not simultaneously included in the same multivariate model. The variable that has a high variance inflation factor was removed. A stepwise selection approach was then used to select the final multivariate model. 95% confidence interval was calculated. All tests were two-sided and statistical significance was set at p-value < 0.05.

A total of 725 participants filled the questionnaire form and were distributed over different governorates. The mean age of women was 32.5 (9.5) years. The majority of participants were between 26 and 45 years old during the data collection period, married (69.5%), had completed bachelor’s degree (44.8%), and housewife (50.8%)(Table 1 ). Table 1 Sociodemographic and behavioral characteristics of the study participants ( N  = 725) Variables n % Age , mean (SD) 32.5 (9.5) Age categories 18–25 217 29.9 26–45 433 59.7 46–65 75 10.3 Governorate Beirut 217 29.9 Mont Lebanon 183 25.2 South Lebanon 158 21.8 Baalbeck-Hermel 50 6.9 Nabatieh 70 9.7 Bekaa 39 5.4 North Lebanon 8 1.1 Marital status Married 504 69.5 Single 191 26.3 Divorced 19 2.6 Widow 11 1.5 Education level Below primary school 126 17.4 High school 135 18.6 Bachelor’s degree 325 44.8 Master’s degree and above 139 19.2 Professional status Active 242 33.4 Without profession 115 15.9 Housewife 368 50.8 Household monthly income  900$ 93 12.8 Prefer not to answer 148 20.4 Smoking status (yes) 157 21.7 Physical activity (yes) 134 18.5 Abbreviation: n: number; %: frequency Sociodemographic and behavioral characteristics of the study participants ( N  = 725) Abbreviation: n: number; %: frequency The sample’s reproductive, gynecological, and medical characteristics are displayed in Table  2 . The mean age of menarche was 12.4 (1.5) years. The majority of women had regular cycles (70.8%) and visited a gynecologist when necessary (81.0%). More than half of the women had pelvic or vaginal echography performed more than one year ago (56.7%). Only 3.9% of participants had a history of endometriosis. Fig. 1 Responses about concern related to symptoms of endometriosis Responses about concern related to symptoms of endometriosis Table 2 Reproductive, gynecological and medical characteristics of the study participants ( N  = 725) Variables n % Age at menarche , mean (SD) 12.4 (1.5) Duration of menstrual bleeding mean (SD) 6.5 (2.1) Long of menstrual cycle mean (SD) 25.5 (14.3) Menstrual cycle regularity Regular 513 70.8 Irregular 212 29.2 Menstrual Flow Light 66 9.1 Moderate 523 18.8 Heavy 136 72.1 Number of previous pregnancies mean (SD) 2.2 (2.0) Number of Live Births mean (SD) 1.8 (1.6) History of Abortion (yes) 197 27.2 Use of oral contraceptives (yes) 60 8.3 Gynecologist visit regularity Regularly 73 10.1 Occasionally 65 9.0 When necessary 587 81.0 Last time of pelvic or vaginal echography  1 year 411 56.7 History of Endometriosis (yes) 28 3.9 History of Pelvic Inflammatory Disease (yes) 32 4.4 History of Uterine or Ovarian Conditions (yes) 192 26.5 History of pelvic surgeries (yes) 54 7.4 Autoimmune inflammatory diseases (yes) 52 7.2 Abbreviation: n: number; %: frequency Reproductive, gynecological and medical characteristics of the study participants ( N  = 725) Abbreviation: n: number; %: frequency Out of the 725 participants, only 188 (25.9%) demonstrated good knowledge. 74.1% of the participants lacked knowledge of endometriosis based on their wrong answers to the related questions. Table  3 describes participants’ answers regarding endometriosis knowledge items. Most respondents (60.8%) were aware of endometriosis as a potential cause of pelvic pain. Half of the responses indicated awareness of irregular vaginal bleeding as a symptom of endometriosis (50.1%). Poor knowledge was more evident in responses to questions regarding the origin of endometriosis (7.6% correct answer) and treatment of endometriosis (22.5% correct answer). The mean total knowledge score was 3.7 (SD = 3.2). Table 3 Responses of study participants to the endometriosis knowledge questions ( N  = 725) Knowledge items Correct answers Correct Wrong Do not know n % n % n % Endometriosis as potential etiology for pelvic pain Correct 441 60.8 9 1.2 275 37.9 Irregular vaginal bleeding as a symptom of endometriosis Correct 363 50.1 51 7.0 311 42.9 Pain with sexual intercourse as a symptom of endometriosis Correct 277 38.2 49 6.8 399 55.0 Heavy vaginal bleeding as a symptom of endometriosis Correct 275 37.9 57 7.9 393 54.2 Pain during period as a symptom of endometriosis Correct 271 37.4 90 12.4 364 50.2 Painful bowel movements during periods can be a symptom of endometriosis Correct 201 27.7 49 6.8 475 65.5 Endometriosis symptoms typically disappear after menopause Correct 115 15.9 103 14.2 507 69.9 Endometriosis originates from the uterus Wrong 257 35.4 55 7.6 413 57.0 Hormonal treatments can completely cure endometriosis Wrong 99 13.7 163 22.5 463 63.9 All women with endometriosis experience infertility Wrong 36 5.0 249 34.3 440 60.7 Endometriosis only affects women who have had children Wrong 21 2.9 276 38.1 428 59.0 Abbreviation: n: number; %: frequency Responses of study participants to the endometriosis knowledge questions ( N  = 725) Abbreviation: n: number; %: frequency Of all participants, 16.0% reported experiencing pelvic pain always with their periods in the last 3 months (Table  4 ). Half of the women did not report concern about any symptoms related to periods (51.3%) (Table  4 ). 9.9% suspected that their period-related symptoms were due to endometriosis (Fig.  1 ). Table 4 The concern of participants towards pelvic pain ( N  = 725) Concern items Always Often Occasionally Never n % n % n % n % Pelvic pain with periods in the last 3 months 116 16.0 103 14.2 255 35.2 251 34.6 Pelvic pain in between one period cycle and the next in the last 3 months 70 9.7 63 8.7 222 30.6 370 51.0 Pelvic pain while urinating or defecating during periods in the last 3 months 23 3.2 47 6.5 175 24.1 480 66.2 Concern about any symptoms related to periods 38 5.2 212 29.2 103 14.2 372 51.3 The concern of participants towards pelvic pain ( N  = 725) Table  5 presents variables significantly associated with knowledge in both bivariate and multivariate analyses. The bivariate analysis showed an association between good knowledge score and several factors: being younger than 35 years old (OR = 0.5; p  < 0.0001), Unmarried women (OR = 0.4; p  < 0.0001), women with Master’s degree and above (OR = 1.6; p  < 0.0001), active women with profession (OR = 1.5; p  = 0.01), low number of pregnancies (OR = 0.8; p  < 0.0001), low number of live birth (OR = 0.7; p  < 0.0001) ; without history of abortion (OR = 0.5; p  = 0.001), without a family history of endometriosis (OR = 0.6; p  < 0.0001), without a history of pelvic inflammatory disease (OR = 0.5; p  < 0.0001), without history of uterine or ovarian conditions (OR = 0.7; p  = 0.004), and without history of pelvic surgeries (OR = 0.7; p  < 0.0001) (Table  5 ). In multivariate regression, Women with a high number of pregnancies were 1.3 times more likely to have good knowledge than their counterparts (OR = 1.3; p  = 0.01). Women with a low number of live births are less likely to have good knowledge about endometriosis compared to women with a high number of live births. (OR = 0.62; p  = 0.01). Finally, women without a history of endometriosis (OR = 0.7; p  = 0.01), pelvic inflammatory disease (OR = 0.7; p  = 0.04), and autoimmune inflammatory diseases (OR = 0.7; p  = 0.03) were more likely to have good knowledge compared to their counterparts (Table  5 ). Table 5 Logistic regression analysis between endometriosis knowledge regarding sociodemographic, reproductive, gynecological and medical variables ( n  = 725) Bivariate analysis Multivariate analysis Poor knowledge n (%) Good knowledge n (%) OR (95% CI) p -value beta OR (95% CI) p -value Age < 35 311 (57.9) 139 (73.9) 0.48 (0.33;0.70) < 0.0001 ≥ 35 226 (42.1) 49 (26.1) Marital status Others 395 (73.6) 109 (58.0) 0.49 (0.35;0.70) < 0.0001 Married 142 (26.4) 79 (42.0) Education Bachelor’s degree and below 446 (83.1) 140 (74.5) 1.6 (1.12;2.5) 0.01 Master’s degree and above 91 (16.9) 48 (25.5) Profession Active 165 (30.7) 77 (41.0) 1.5 (1.1;2.2) 0.01 Housewife and without profession 372 (69.3) 111 (59.0) Number of previous pregnancies* 2.4 (2.0) 1.6 (2.0) 0.82 (0.75;0.90) < 0.0001 0.29 1.34 (1.06;1.70) 0.01 Number of Live Births* 2.0 (1.7) 1.2 (1.4) 0.74 (0.66;0.83) < 0.0001 -0.47 0.62 (0.47;0.82) 0.01 History of Abortion (yes) 163 (30.4) 34 (18.1) 0.5 (0.33;0.76) 0.001 -0.64 0.52 (0.30;0.92) 0.04 Use of oral contraceptives (yes) 49 (9.1) 11(5.9) 1.6 (0.82;3.17) 0.16 Gynecologist visit regularity Regularly 45 (8.4) 28 (14.9) Occasionally 45 (8.4) 20 (10.6) 0.5 (0.30; 0.83) 0.008 When necessary 447 (83.2) 140 (74.5) 0.7 (0.35;1.44) 0.35 Last time of pelvic or vaginal echography < 6 months 158 (29.4) 65 (34.6) 1.2 (0.89;1.80) 0.18 ≥ 6 months 379 (70.6) 123 (65.4) Family History of Endometriosis (yes) 12 (2.2) 16 (8.5) 0.64 (0.53;0.76) < 0.0001 -0.26 0.76 (0.61;0.94) 0.01 History of Pelvic Inflammatory Disease (yes) 17 (3.2) 15 (8.0) 0.54(0.41;0.69) < 0.0001 -0.32 0.72 (0.52;0.99) 0.04 History of Uterine or Ovarian Conditions (yes) 129 (24.0) 63 (33.5) 0.71 (0.56;0.89) 0.004 History of pelvic surgeries (yes) 36 (6.7) 39 (7.3) 0.70 (0.53;0.92) 0.01 History Autoimmune inflammatory diseases (yes) 39 (7.3) 13 (6.9) 0.55 (0.42;0.72) < 0.0001 -0.35 0.70 (0.51;0.97) 0.03 Abbreviations: beta: beta unstandardized regression coefficient Logistic regression analysis between endometriosis knowledge regarding sociodemographic, reproductive, gynecological and medical variables ( n  = 725) Abbreviations: beta: beta unstandardized regression coefficient

According to the world health organization endometriosis currently lacks established preventative strategies [ 18 ]. However, heightened awareness coupled with rapid diagnosis and management interventions may potentially impede disease progression, mitigate long-term symptom burden, and even lessen the risk of central nervous system pain sensitization [ 18 ]. We aimed in this study to assess the knowledge and concern towards endometriosis among Lebanese women. This assessment should evaluate women existing knowledge and health concerns regarding endometriosis. By analyzing this data, healthcare professionals and health policy makers can identify knowledge gaps and areas of specific concern, informing the development of targeted and effective educational programs. Only 25.9% of participants demonstrated good knowledge towards origin, symptoms and treatment of endometriosis and 74.1% of them lacked knowledge. Our result is higher than study conducted in Poland (2021), where only 16.1% of women ( n  = 200) had good knowledge and 84% of them had never heard about this disease [ 19 ]. As a result, a lack of awareness will limit early diagnosis as well as early treatment initiation. Our findings align with previous knowledge studies [ 19 – 21 ], demonstrating that over 60% of women lack awareness regarding key aspects of endometriosis, including its symptomatology, symptom resolution patterns, the role of hormonal therapy, and the potential link to infertility. In 2013, Shadbolt et al. showed that 52% of Australian women had heard of endometriosis, 89% thought teenagers should be educated about endometriosis [ 20 ]. Traditionally, healthcare professionals served as the primary source of information on endometriosis. However, current public health initiatives appear to prioritize other areas, potentially leading to a deficit in awareness campaigns and educational interventions specifically targeting endometriosis. In our research, a higher level of knowledge was demonstrated by young educated women. Similar results were showed in the paper of Shadbolt et al. in Australia, who, conclude that young educated women are keen to learn about endometriosis, particularly its symptoms [ 20 ]. A possible explanation for this result is increased exposure to communication and educational materials about reproductive health in recent years, especially, on the social media platforms. In the same context, our study identified a knowledge gap regarding endometriosis among women with higher pregnancy and birth rates. This highlights the need for targeted educational interventions for this specific population group. Our analysis revealed an association between self-reported endometriosis, pelvic inflammatory disease, and autoimmune inflammatory diseases, and lower levels of knowledge regarding endometriosis. However, the etiology of endometriosis remains unclear, and there is a paucity of research investigating the potential links between these conditions. To address this knowledge gap, future exploratory studies are warranted to elucidate these relationships. As far as we are aware, this is the first Lebanese study that assesses knowledge towards endometriosis. However, the findings of the present study should be considered in light of several limitations. First, no validated tool for the assessment of knowledge towards endometriosis was available. We have formulated items from previous publications and from WHO updates. The cross-sectional nature of this study limits the assessment of temporality and therefore causality. Nonetheless, a temporal relationship is plausible for associations such as professional status, age, and education level. The lack of universal internet access in Lebanon and the potential for computer illiteracy among older generations may have created a response barrier for some participants. Furthermore, the snowballing technique used on social media may have resulted in a biased sample, as participants were likely self-selected and may have had a pre-existing interest in endometriosis. However, the study also has several strengths. The findings may provide evidence for policymakers and public health experts to plan an evidence-based involvement across Lebanon to improve women’s knowledge on endometriosis. Moreover, a higher sample size distributed across all Lebanese governorates further strengthens the study by including a more representative population. These findings highlight a critical need for public health interventions to improve awareness and understanding of endometriosis among Lebanese women. It is essential to emphasize the significance of regular gynecological check-ups for early detection of endometriosis, especially during adolescence. Routine examinations can help identify potential signs and symptoms, such as pelvic pain, heavy bleeding, and infertility, leading to earlier diagnosis and treatment. Moreover, hormonal therapy plays a crucial role in managing endometriosis and its associated symptoms. By understanding the disease and its treatment options, individuals can improve their quality of life and reduce the long-term consequences of endometriosis. Limited knowledge about symptoms can lead to delayed diagnosis and potentially worsen health outcomes. By implementing educational campaigns and promoting open communication between women and healthcare providers, this can empower Lebanese women to recognize potential symptoms and seek timely medical evaluation. Early diagnosis and intervention are crucial for managing endometriosis effectively and improving women’s overall well-being.

This preliminary study revealed a lack of knowledge regarding endometriosis among Lebanese women. These findings underscore the critical need for targeted public health interventions in Lebanon to improve awareness and understanding of endometriosis. Educational campaigns tailored to the Lebanese women, along with efforts to promote open communication between women and healthcare professionals, are crucial. By empowering women with accurate knowledge about endometriosis, this can encourage them to seek timely medical evaluation, ultimately leading to earlier diagnosis, improved management, and potentially reduced long-term complications.

Endometriosis refers to the existence of functional endometrial-like tissue outside of the uterus that causes a chronic inflammatory response [ 1 ]. Endometriosis afflicts approximately 18% of women globally [ 2 ]. A comprehensive meta-analysis conducted in 2021 revealed that nearly 12.9% of women in the Middle East underwent laparoscopic procedures for various medical indications [ 3 ]. Given the high prevalence of laparoscopic procedures in the region, it is possible that a significant number of these women may be undiagnosed cases of endometriosis. According to the latest guidelines of the European Society of Human Reproduction and Embryology (ESHRE) 2022, clinicians are recommended to use imaging (Ultrasound or MRI) in the diagnostic work-up for endometriosis. However, they must be aware that a negative finding does not exclude endometriosis and that laparoscopy may still be necessary [ 4 ]. The lack of reliable data on endometriosis risk factors in the region was also shown by this study [ 3 ]. There is no endometriosis epidemiology data available for Lebanon, a Middle Eastern nation. The etiology of endometriosis has been a subject of major debate, with the classical theory being that of retrograde menstruation [ 5 ]. Women suffering from endometriosis typically experience chronic pelvic pain as well as pain during menstruation, sexual intercourse, and excretion [ 6 ]. This diverse array of pain-related symptoms could lead to dysfunctionality in different aspects of life [ 7 ]. Another remarkable feature is infertility, impacting 30–50% of women [ 8 ]. Moreover, eight to twelve years can pass before a definitive diagnosis is made [ 9 ]. This is aberrant considering that prompt intervention can reduce morbidity and protect fertility [ 10 ]. While the exact cause of endometriosis remains enigmatic, several risk factors related to reproduction and menstruation have been identified. Reduced menstrual cycle duration, younger age of menstruation onset, and heavy menstrual bleeding were associated with increased risk [ 6 , 11 , 12 ]. Conversely, pregnancy and higher parity were associated with decreased risk [ 13 ]. Data on endometriosis among Lebanese women population were found to be extremely limited. Only 2 case-control studies have been published, one conducted in 1986 considered the risk factors associated with endometriosis, and the other one published in 2023 considered the association with sexual satisfaction. The first one compared 170 cases with 170 controls undergoing laparoscopy at the same Medical Center between 1979 and 1981 revealing a positive association with first-class admissions, negative association with parity and gravidity, and no correlation with occupational status, nationality, religion, marital status, or past medical history [ 14 ]. The second study compared 65 cases and 252 controls (1:3 ratio) and found a significantly higher mean sexual satisfaction score in women with endometriosis compared to controls, and no correlation in terms of couple satisfaction, depression, anxiety, stress, and perceived partner responsiveness [ 15 ]. The lack of comprehensive data on endometriosis in the Lebanese community highlights the need for more research that measures the levels of awareness and understanding unique to this population. This is considered of vital importance as it can help prompt early referral and detection, increase awareness, decrease healthcare burden, and improve patient outcomes. It can further help identify any stigma surrounding endometriosis that prevents Lebanese women from seeking help. Hence the purpose of this cross-sectional study is to assess the level of knowledge and concern towards endometriosis among Lebanese women and to investigate factors associated with knowledge regarding endometriosis in Lebanon.

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 1