Clinicopathological profile and risk factors of endometriosis among reproductive-aged women attending a tertiary care hospital: A study of 100 cases

Background: Endometriosis is a chronic , estrogen-dependent inflammatory gynecological disorder characterized by the presence of endometrial glands and stroma outside the uterine cavity. It pre dominantly affects women of reproductive age and is a major cause of dysmenorrhea , chronic pelvic pain and infertility. Despite its increasing recognition worl dwide, limited data exist regarding its clinicopathological profile and associated risk factors in peripheral tertiary care settings in Bangladesh.

To evaluate the clinicopathological characteristics and identify risk factors of endometriosis among reproductive-aged women attending a tertiary care hospital in Pabna, Bangladesh.

This hospital -based cross -sectional observational study included 100 diagnosed cases of endometriosis from January to December 2024. Diagnosis was confirmed by ultrasonography, laparoscopy, laparotomy, and histopathological examination. Data regarding socio-demographic profile , menstrual characteristics, reproductive history, clinical presentation, operative findings and histopathological results were collected using a structured questionnaire. Statistical analysis was performed using SPSS version 26.

The mean age of patients was 29.8 ±5.6 years. The majority (62%) were aged 21- 30 years. Dysmenorrhea (82%) was the most common symptom , followed by chronic pel vic pain (65%) and infertility (54%). Ovarian endometrioma was the most frequent anatomical site (58%). Early menarche (<12 years) was observed in 38% cases , nulliparity in 60% and positive family history in 18%. Advanced stage (Stage III- IV) disease was f ound in 46% of patients. Histopathology confirmed endometriosis in all surgically treated cases.

Endometriosis significantly affects young reproductive -aged women, with dysmenorrhea and infertility being predominant presentations. Early menarche, nulliparity and prolonged menstrual flow were significant risk factors. Early diagnosis and timely intervention are essential to reduce morbidity and improve reproductive outcomes.

Endometriosis, Reproductive-aged women, Dysmenorrhea, Chronic pelvic pain, Infertility, Ovarian endometrioma, Risk factors, rASRM staging, Clinicopathological profile, Bangladesh.

Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity [1]. It is a chronic inflammatory and estrogen -dependent condition that affects approximately 10 -15% of women of reproductive age worldwide [2]. Among women with infertility, its prevalence may rise to 30 -50% [3]. Despite its high prevalence , endometriosis remains u nderdiagnosed, particularly in developing countries due to limited awareness and diagnostic facil ities [4]. The pathogenesis of endometriosis remains controversial. Several theories have been proposed including Sampson’s theory of retrograde menstruation, coelomic metaplasia, stem cell theory and lymphovascular dissemination [5]. Retrograde menstruation is the most widely accepted mechanism , where menstrual debris flows backward through the fallopian tubes into the pelvic cavity and implants on peritoneal s urfaces [6]. However, since retrograde menstruation occurs in many women without disease developm ent, genetic predisposition and immunological dysfunction are thought to contribute significantly [7]. Endometriosis commonly involves ovaries, uterosacral ligaments, pouch of Douglas, and pelvic peritoneum [8]. Ovarian endometrioma , also known as “chocolate cyst ,” represents one of the most frequent forms [9]. Clinically , it presents with dysmenorrhea , chronic pelvic pain , dyspareunia, and infertility [10]. The severity of symptoms does not always correlate with International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1004 ~ disease stage [11]. The revised American Society for Reproductive Medicine (rASRM) classification categorizes endometriosis into four stages (I -IV) based on lesion size , depth and adhesions [12]. Diagnosis is primarily clinical and supported by imaging modalities such as transvaginal ultrasonography and MRI. However, laparoscopy with histopathological confirmation remains the gold standard [13]. Several risk factors have been identified including early menarche, short menstrual cycles , heavy menstrual bleeding, nulliparity, low body mass index and positive family history [14]. Protective factors include multiparity, prolonged lactation and use of combined oral contraceptive pills [15]. In Bangladesh , data regarding clinicopathological patterns and risk factors of endometriosis are limited , especially outside major metropolitan centers. Understanding the local demographic distribution , clinical presentation and associated risk factors is essential for imp roving diagnostic suspicion and management strategies. This study was conducted at the Department of Gynaecology and Obstetrics , 250 Bedded General Hospital , Pabna, to evaluate the clinicopathological profile and identify risk factors among reproductive -aged women diagnosed with endometriosis during 2024.

This hospital -based cross -sectional observational study was conducted in the Department of Gynaecology and Obstetrics , 250 Bedded General Hospital, Pabna, Bangladesh, from January 2024 to December 2024. Study Population A total of 100 reproductive -aged women (18 -45 years) diagnosed with endo metriosis were included. Diagnosis was made based on clinical features , ultrasonography, operative findings (laparoscopy or laparotomy) and confirmed by histopathological examination wherever tissue was obtained. Inclusion Criteria • Women aged 18-45 years • Clinically suspected and surgically or radiologically confirmed cases of endometriosis • Willing to provide informed consent Exclusion Criteria • Women with pelvic inflammatory disease • Gynecological malignancy • Adenomyosis without evidence of endometriosis • Incomplete medical records Data Collection Data were collected using a structured questionnaire and hospital records. Variables included: • Socio-demographic characteristics • Age at menarche • Menstrual cycle pattern and duration • Parity status • Family history • Clinical symptoms • Infertility history • Imaging findings • Operative staging (rASRM classification) • Histopathological findings Statistical Analysis Data were entered and analyzed using SPSS version 26. Quantitative data were expressed as mean ± standard deviation. Categorical variables were presented as frequency and percentage. Associations between risk factors and severity were analyzed using chi -square test. A p -value <0.05 was considered statistically significant. Ethical Consideration Ethical approval was obtained from the hospital ethical review committee. Informed written consent was taken from all participants.

A total of 100 reproductive -aged women dia gnosed with endometriosis were included in this study. Table 1: Age Distribution of Patients (n=100) Age Group (years) Frequency Percentage 18-20 8 8% 21-30 62 62% 31-40 25 25% 41-45 5 5% Total 100 100% The majority of patients belonged to the 21 -30 years age group , accounting for 62% of cases , indicating that endometriosis predominantly affected young reproductive -aged women in this cohort. The second most affected group was 31- 40 years (25%). Only 8% were between 18 -20 years and 5% were aged 41 -45 years. The mean age of the study population was 29.8±5.6 years, reflecting peak disease occurrence in the late twenties. Table 2: Presenting Symptoms of Endometriosis (n=100) Symptom Frequency Percentage Dysmenorrhea 82 82% Chronic pelvic pain 65 65% Infertility 54 54% Dyspareunia 40 40% Menorrhagia 36 36% Irregular menstruation 28 28% Pelvic mass 22 22% Dysmenorrhea was the most common presenting complaint , reported by 82% of patients , making it the hallmark symptom in this study. Chronic pelvic pain was present in 65% of cases , highlighting the significant burden of persistent pain among affected women. Infertility was observed in 54% of patients , emphasizing the reproductive implications of the disease. Dyspareunia was reported in 40% of wome n, while menorrhagia occurred in 36%. Irregular menstruation was noted in 28% and 22% presented with a palpable pelvic mass , commonly associated with ovarian endometrioma. Table 3: Menstrual and Reproductive Risk Factors (n=100) Risk Factor Frequency Percentage Early menarche (<12 years) 38 38% Nulliparity 60 60% Parity ≥1 40 40% Cycle length 5 days 48 48% Family history of endometriosis 18 18% History of infertility 54 54% Among reproductive risk factors , nulliparity was found in 60% of patients, suggesting a strong associatio n between absence of International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1005 ~ childbirth and endometriosis. Early menarche before 12 years of age was observed in 38% of cases. Short menstrual cycles (5 days) in 48% , both of which may increase expos ure to retrograde menstruation. A positive family history of endometriosis was identified in 18% of patients , indicating possible genetic predisposition. More than half (54%) of the study population had a history of infertility. Table 4: Anatomical Distribution of Endometriotic Lesions (n=100) Site of Lesion Frequency Percentage Ovary 58 58% Uterosacral ligament 15 15% Pouch of Douglas 12 12% Pelvic peritoneum 10 10% Rectovaginal septum 3 3% Others 2 2% Total 100 100% Ovarian involvement was the most common anatomical site , seen in 58% of patients , predominantly presenting as ovarian endometrioma (chocolate cyst). Uterosacral ligament involvement accounted for 15% of cases , while 12% had lesions in the pouch of Douglas. Pelvic peritoneal deposits were observed in 10% of women. Less commonly , rectovaginal septum involvement was found in 3% , and other rare sites accounted for 2%. This distribution indicates a predominance of ovarian disease in this population. Table 5: Stage of Endometriosis According to rASRM Classification (n=100) Stage Frequency Percentage Stage I (Minimal) 18 18% Stage II (Mild) 36 36% Stage III (Moderate) 28 28% Stage IV (Severe) 18 18% Total 100 100% Based on the revised American Society for Reproductive Medicine (rASRM) classification, Stage II (mild) endometriosis was the most common, accounting for 36% of cases. Stage III (moderate) disease was observed in 28% of patients. Minimal disease (Stage I) was present in 18% , while severe disease (Stage IV) was also seen in 1 8%. Overall , advanced stages (Stage III and IV combined) constituted 46% of cases, indicating a considerable proportion of women presented with moderate to severe disease. Table 6: Histopathological Confirmation (n=100) Histopathological Finding Frequency Percentage Confirmed endometriosis (glands + stroma) 92 92% Endometriotic cyst (ovarian) 58 58% Fibrosis with hemosiderin-laden macrophages 46 46% Deep infiltrating endometriosis 12 12% Histopathological examination confirmed the presence of both endometrial glands and stroma in 92% of surgically treated specimens. Ovarian endometriotic cysts were identified in 58% of cases , correlating with the clinical findings. Fibrosis with hemosiderin-laden macrophages , indicative of repeated hemorrhage, was present in 46% of specimens. Deep infiltrating endometriosis was observed in 12% of patients , representing more aggressive disease.

This hospital -based cross -sectional study evaluated the clinicopathological profile and associated risk factors of endometriosis among reproductive -aged women attending a tertiary care hospital in Pabna , Bangladesh. The findings demonstrate that endometriosis predominantly affects young women in their most productive and reproductive years , with significant implications for pain, fertility and quality of life. In the present study , the mean age of the patients was 29.8 ±5.6 years, and the majority (62%) belonged to the 21- 30 years age group. This observation is consistent with global epidemiological data indicating th at endometriosis most commonly affects women between 25 and 35 years of age [2, 16]. The relatively lower proportion of women above 40 years may be explained by declining estrogen levels and reduced disease activity with advancing age. Dysmenorrhea was the most common presenting symptom (82%), followed by chronic pelvic pain (65%) and infertility (54%). These findings align with previous studies reporting dysmenorrhea as the hallmark symptom of endometriosis [10, 17]. The high prevalence of chronic pelvic p ain reflects the inflammatory nature of ectopic endometrial implants and associated adhesions. Infertility observed in more than half of the patients underscores the strong association between endometriosis and subfertility , as reported in earlier research showing prevalence rate s of 30 -50% among infertile women [3, 18]. The mechanisms include distorted pelvic anatomy, adhesions, altered peritoneal environment , and impaired ovulatory function. Ovarian involvement was the most frequent anatomical site (58%) , predominantly presenting as ovarian endometrioma. This finding is consistent with other studies indicating the ovary as the most common location of endometriotic lesions [9, 19]. The predilection for ovarian tissue may be related to repeated ovulation and local hormonal influences. Uterosacral ligament and pouch of Douglas involvement were also observed , reflecting the typical posterior pelvic distribution described in the literature [8]. According to the revised American Society for Reproductive Medicine (rASRM) classification, Stage II disease was most common (36%) , while advanced stages (Stage III and IV) comprised 46% of cases. The relatively high proportion of moderate to severe disease suggests delayed diagnosis , which may be due to lack of awareness , normalization of menstr ual pain and limited access to advanced diagnostic facilities in peripheral settings [4, 20]. Importantly , symptom severity did not always correlate with disease stage, supporting previous observations that minimal disease can produce severe pain , while advanced disease may remain asymptomatic [11]. Regarding risk factors , nulliparity was identified in 60% of patients , reinforcing the hypothesis that uninterrupted menstrual cycles increase exposure to retrograde menstruation and impl antation of endometrial cells [6, 14]. Early menarche (<12 years) was present in 38% of cases , suggesting prolonged lifetime estrogen exposure as a contributing factor. Short menstrual cycles and prolonged menstrual flow were also common, both of which have been associated with increased retrograde menstruation and disease risk [14]. A positive family history in 18% of cases indicates a possible genetic predisposition, consistent with evidence demonstrating familial International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1006 ~ aggregation and higher concordance among first-degree relatives [7, 21]. Histopathological examination confirmed the diagnosis in the majority of cases , demonstrating endometrial glands and stroma along with hemosiderin- laden macrophages , a classical feature of the disease. Deep infiltrating endo metriosis observed in a subset of patients reflects more aggressive pathology and may contribute to severe pain and fertility impairment. The study has certain limitations. Being a single -center hospital - based study , it may not represent the general popula tion. Additionally, the sample size was relatively small and long-term follow-up outcomes were not assessed. However , this research provides valuable regional data that contribute to understanding the clinicopathological characteristics of endometriosis in a peripheral tertiary care setting in Bangladesh. Overall , the findings highlight the importance of early recognition of symptoms such as dysmenorrhea and chronic pelvic pain, particularly among nulliparous women with early menarche and abnormal menstrual patterns. Increased awareness among healthcare providers and patients may facilitate earlier diagnosis and timely management, ultimately improving quality of life and reproductive outcomes.

Endometriosis predominantly affects young reproductiv e-aged women and commonly presents with dysmenorrhea , chronic pelvic pain , and infertility. Ovarian involvement is most frequent. Nulliparity , early menarche and prolonged menstrual bleeding are important risk factors. Increased awareness , early diagnosis, and timely management are essential to reduce morbidity and improve reproductive outcomes in Bangladesh. Source of Funding This research received no external funding. Conflict of Interest The authors declare no conflict of interest.

The authors express their sincere gratitude to the Department of Gynaecology and Obstetrics , 250 Bedded General Hospital , Pabna, Bangladesh, for providing the opportunity and necessary institutional support to conduct this study. We are thankful to all the pa tients who willingly participated in this research and s hared their clinical information. Their cooperation made this study possible. The authors also acknowledge the contribution of the operating theatre staff , nursing personnel, and the pathology departm ent for their assistance in specimen processing and histopathological confirmation. Finally, we appreciate the support of hospital administration for facilitating ethical approval and smooth data collection throughout the study period (January-December 2024).

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