BMC Women's Health Volume 21, Article Number: 381 (2021) Cite this article

Endometriosis is a considerable health challenge for women of childbearing age. There is little information about its prevalence among the Jordanian population. The purpose of this study is to evaluate the existence of endometriosis in gynecological patients undergoing laparoscopic surgery for various indications, and to correlate the findings of endometriosis with variables, including patient demographics and obstetric history , Type and indications for laparoscopic surgery.

From January 2015 to September 2020, a retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, Jordan University Hospital, a tertiary referral hospital in Jordan. The study involved 460 women who received different abdominal cavities for various indications. Mirror surgery.

The prevalence of endometriosis in this patient group is higher than that of the general population (13.7% vs. 2.5%), and the average age at diagnosis (31.9 years) is lower than the peak age of onset of the general population (35-45 years). ). This proportion was significantly higher in women with fewer pregnancies (p = 0.01) and fewer caesarean sections (p = 0.05), as well as in women whose surgical indications were associated with decreased fertility or pelvic pain (p = 0.02). Women whose fertility rate or surgical indications indicate normal fertility (such as family planning) are less likely to develop endometriosis.

To the best of our knowledge, this is the first study in Jordan to evaluate the prevalence of endometriosis in women undergoing gynecological laparoscopy. This study shows that the epidemiological trends of endometriosis in this region are similar to those previously documented in international literature, while emphasizing the need for further research on this important female health issue in this part of the world.

Endometriosis is a benign gynecological disease characterized by the presence of endometrial tissue in the form of stroma and glands outside the uterus, and is associated with a range of clinical manifestations, from asymptomatic women to pelvic pain and/ Or patients with fertility problems[1], 2].

The actual prevalence in the population is difficult to determine because diagnosis is often delayed or overlooked [2], but it is estimated that the disease affects up to 10% of women of childbearing age [3]. A cross-sectional population survey in the United States estimated that the prevalence of diagnosed endometriosis was 6.1% [4]; however, a study conducted in Italy showed that there were 10 cases of endometriosis in the general population Only 6 of the symptoms were diagnosed [5].

Jordan is a middle-income country in the Middle East, and endometriosis is considered to be a major public health problem affecting the quality of life of women of childbearing age [6]. Prevalence based on community survey of 15-55 year-old women by Al-Jefout et al. It was found to be 2.5% [6]. In another study, it was found that the prevalence of endometriosis in young Jordanian women who underwent laparoscopy due to intractable chronic pelvic pain was as high as 71.4% [7]. Therefore, depending on the type of population sample surveyed, there are considerable differences in prevalence.

The two main manifestations of endometriosis can be divided into pain associated with endometriosis, such as dysmenorrhea, chronic pelvic pain, painful intercourse, dysfunctional bowel movements, and infertility. Symptoms can be significantly destructive and affect women's quality of life. However, 20-25% of women are affected but are completely asymptomatic [8,9,10]. It was found that the peak age of onset was about 40 years old [11, 12].

There are challenges in diagnosing endometriosis. First, the patient’s symptoms may overlap with other diseases, such as adenomyosis, interstitial cystitis, and irritable bowel syndrome. Second, the patient may think that her pain is a normal manifestation of her menstrual cycle, leading to delays in seeking medical attention [1].

The gold standard for diagnosing endometriosis is direct visualization during laparoscopy [13,14,15]. According to the appearance of the lesions found during surgery, endometriosis can be divided into subtle, typical, cystic or deep [16]. Although this condition is usually diagnosed during laparoscopy in patients with symptoms of endometriosis [8, 17], it is clinically suspected for indications other than endometriosis and undergoing laparoscopic surgery It was also discovered accidentally in patients. For example, a meta-analysis of asymptomatic patients with clomiphene-resistant polycystic ovary syndrome and endometriosis found that the prevalence of surgically confirmed endometriosis was 7.7% [18]. Another study conducted by Rawson on women with asymptomatic endometriosis for laparoscopy to adapt to other indications found that the prevalence of endometriosis was as high as 43.5%, and indicated that it is denying the typical symptoms of the disease. Symptoms and reports of women with normal fertility usually find subtle endometriosis when undergoing laparoscopy. 19].

Several other factors have been found to be related to the presence of endometriosis. The meta-analysis by Yong and Weiyuan showed that a higher body mass index may be associated with a lower risk of endometriosis [20]. This finding is consistent with the views of Ferrero et al. Who proves that women with endometriosis have a lower body mass index, and the frequency of obesity is lower than that of women without endometriosis [21]. In addition, Matalliotakis et al. It was found that women with endometriosis were lighter than women without endometriosis seeking infertility treatment, and had fewer previous pregnancies, selective abortions, and ectopic pregnancies [22]. A negative correlation between pregnancy and endometriosis was also found in the subgroup of subjects undergoing diagnostic laparoscopy [23].

This study aims to elaborate on the prevalence of endometriosis in Jordanian women undergoing laparoscopy for different indications.

This is a retrospective cohort study involving a sample of 460 women who underwent different laparoscopic surgeries with different indications in the Department of Obstetrics and Gynecology, Jordan University Hospital, a tertiary referral hospital in Jordan between January 2015 and September 2020.

The purpose of this study was to determine the prevalence of endometriosis diagnosed during laparoscopy and to correlate the findings of endometriosis with several variables, including age, body mass index (BMI), Obstetric history, type of laparoscopic surgery, and indications for surgery.

The inclusion criteria for this study are as follows: (1) women of childbearing age (16-50 years old) and (2) patients who underwent gynecological laparoscopy between January 2015 and September 2020. 16 years or older, or if they have been diagnosed or treated for endometriosis before index surgery.

Identify patients undergoing gynecological laparoscopy from clinical and surgical records. A total of 460 patients were eligible for inclusion. Data collection is carried out through retrospective review of patients’ electronic medical records. The diagnosis of endometriosis was made by one of six consultants with long-term experience in laparoscopic surgery and endometriosis diagnosis. According to the existence records of endometriotic lesions (subtle, typical, cystic or deep) in the electronic surgical records of laparoscopic surgery, the positive cases are determined. Where a histological examination of tissue samples is available, this is related to clinical findings, and there is 100% agreement between clinical and histological diagnosis.

Before starting data collection, the institutional review board of the Jordan University Hospital granted ethical approval. Reference number 1012021/3168.

We used SPSS version 26.0 (Chicago, USA) in our analysis. The mean (± standard deviation) is used to describe continuous variables (for example, age and BMI). Count (frequency) is used to describe other nominal variables.

We first performed the Chi-square test, and then performed the Z-test ratio to analyze the difference in the frequency of surgery, indications, parity, abortion, ectopic pregnancy, and caesarean section between patients with and without endometriosis . We used an independent sample t-test to analyze the average difference between measurements (such as age and BMI) and the presence of endometriosis. We use an ap value of 0.05 as the significance threshold.

We performed logistic regression analysis to find factors related to endometriosis at the multivariate level. We included variables with p-values ​​<0.1 in the univariate analysis. We report the model classification accuracy and Nagelkerke R Square. We report the odds ratio for a variable with a p-value of 0.05 and its 95% confidence interval (CI).

This study included a total of 460 patients who underwent gynecological laparoscopic surgery between 2015 and 2020, with an average age of 33.09 (±7.45) years (SD). The characteristics of the included samples, including age; body mass index; parity; and the number and number of abortions, ectopic pregnancies and caesarean sections are shown in Table 1.

The overall prevalence of endometriosis in all patients was 13.7% (Table 2). Diagnostic laparoscopy was the most common operation performed on 251 (54.6%) patients. In 177 (38.5%) patients, infertility was the most common indication. The surgeon makes a diagnosis and determines the characteristics of endometriosis. Based on the description of the lesion in the patient’s medical record, the surgeon determined the type of endometriosis (subtle, typical, cystic, or deep) during the operation. Thirteen patients (21% of patients with clinical evidence of endometriosis) underwent histopathological examination of tissue samples for suspected endometriosis and, where available, were consistent with clinical findings The sex is 100%. These patients agreed to remove cystic lesions or oophorectomy before surgery, and made an intraoperative diagnosis of ovarian endometriosis based on the general appearance. This was confirmed by histopathology in all cases. Histopathological examination was performed by one of two pathologists with special interest and expertise in gynecological diseases.

Eighteen patients (28.6%) underwent some form of surgical treatment (endometriosis, ablation of endometriotic lesions, or adhesion lysis during the initial surgery) because of previous suspicion of pathology; therefore, The patient agreed to further surgical treatment. For the other 10 (15.9%) patients, after obtaining proper consent and preparing the patients, they were recommended to undergo further surgery to treat endometriosis as the second step. In the remaining patients, the discovery of endometriosis has nothing to do with disease-related symptoms; therefore, it is considered accidental and no surgical treatment is required at that stage.

Tables 3 and 4 contain the types of laparoscopic surgery performed on the patient samples in this study and their indications.

By comparing the incidence of endometriosis among different groups, we found that the prevalence of endometriosis in patients undergoing laparoscopy according to the indications has statistically significant differences (p = 0.020), See Table 5 for details. In the proportional post hoc Z test, the difference in family planning was the most significant. Among them, all 37 (100%) patients who underwent laparoscopy for family planning indications were negative, while for chronic pelvic pain, 5 (31.3 %) The endoscopy result was positive. The most common indication for this condition in laparoscopy is chronic pelvic pain (31.3%), followed by infertility (16.9%), recurrent miscarriage (16.7%), ovarian cyst (16%), and diagnosis after suspected perforation ( 9.7%)) and ectopic pregnancy (4.3%). In patients who underwent laparoscopy (for example, tubal ligation) for family planning purposes, no cases of endometriosis were found.

When comparing different procedures with the presence of endometriosis, we found no significant difference (p = 0.059). Table 6 details the frequency. In total, 50% of patients undergoing laparoscopic assisted vaginal hysterectomy have endometriosis; however, since this group includes only two patients, it may not be representative. Endometriosis was found in 15.9% of patients undergoing diagnostic laparoscopy, followed by patients who underwent laparoscopic ovarian cystectomy (14.9%). Rarely, the findings of endometriosis are related to laparoscopic salpingectomy or tubal stoma (8.3%), and no endometriosis was found in patients who underwent laparoscopic ovariectomy or tubal ligation Cases of disease.

As shown in Table 7, the average age of patients with endometriosis is 31.97 (SD 6.55) years, while the average age of patients with non-endometriosis is 33.27 (SD 7.58) years. This difference was not statistically significant (p = 0.155).

In the study population, no significant association was found between the patient's body mass index (BMI) and the presence of endometriosis (p = 0.13). Patients with positive endometriosis had an average BMI of 26.4 (SD 4.3) kg/m2, while patients without endometriosis had an average BMI of 27.0 (SD 4.7) kg/m2 (Table 7).

Among the 460 participants, 436 patients’ previous obstetric medical history data were available. In patients with a lower number of births (p = 0.008) and C-sections (p = 0.035), endometriosis was significantly higher (Table 8). In terms of parity, endometriosis was found in patients with 4 parities, and most of them did not find endometriosis during delivery. The prevalence of women who have not given birth is 19%. The first birth rate was 19.7%, the second birth rate was 5.3%, the third birth rate was 19.0%, and the fourth birth rate was 2.4%.

The prevalence of endometriosis is the highest among women who have never had a C-section (17.4%), and the prevalence of women who have had one to five C-sections is lower than that of the entire study population.

The prevalence of endometriosis is the highest among those who have not had a miscarriage (16.6%), followed by those who have had one (11.7%), three (8.3%), or two (3.6%) miscarriages. None of the patients who miscarried four or more times was found to have endometriosis. In terms of ectopic pregnancy, the prevalence rate of patients with no previous ectopic pregnancy was 15.1%, the prevalence rate of patients with two previous ectopic pregnancies was 33.3%, and the prevalence rate of patients with a history of ectopic pregnancy was 33.3%. None of them were found to have the disease. No statistically significant association was found between endometriosis and the number of ectopic pregnancies and miscarriages.

We performed logistic regression analysis to find factors related to endometriosis at the multivariate level. We included variables with p-values ​​<0.1 in the univariate analysis. The classification accuracy of this model is 86.4%, and the Nagelkerke R Square is 0.094. Parity and cesarean section were significantly associated with endometriosis (p-values ​​of 0.036 and 0.046, respectively). Their odds ratios were 0.8 (95% CI 0.65–0.9) and 0.54 (95% CI 0.3–0.9), respectively.

It was recognized a long time ago that the epidemiology of endometriosis needs to be investigated [24]. Due to many factors, it is difficult to determine the true prevalence of endometriosis in any given population. The estimated prevalence varies depending on the geographic area, the patient group under investigation, the presence or absence of symptoms, and the method of diagnosis. In addition, a large number of cases may never be diagnosed because patients will not seek medical advice due to lack of symptoms or normalization of existing symptoms [1,2,3,4,5,6,7]. Since the diagnosis is usually only confirmed after laparoscopy, there may be a lack of data involving asymptomatic patients [25].

In addition, the epidemiological study of endometriosis faces many methodological challenges, such as disease definition, selection bias, and challenges related to conducting cohort or case-control studies [16, 26].

The study found that of the 480 women who underwent gynecological laparoscopic surgery between 2015 and 2020, 13% had evidence of endometriosis. This is considered to be higher than the prevalence of the general population (2.5%) [6]. For some of these patients, laparoscopy revealed diseases that may be associated with endometriosis, such as infertility (37.1%) and chronic pelvic pain (3.3%), while for others, this indication is related to this disease There is no obvious connection, such as family planning (7.7%).

The average age of women found to have endometriosis is 31.97 (SD 6.55) years. This is smaller than the peak age of endometriosis reported in previous studies by Eisenberg and others. And Abbas et al. Who said that the prevalence reached its peak in the late 1930s and early 1940s [2, 27]. There was no statistically significant difference in the average age or BMI between patients diagnosed with endometriosis and patients who were not diagnosed with endometriosis. This is in contrast to previous studies, which show that women with endometriosis tend to have lower body mass index than the general population [21,22,23].

There was a statistically significant correlation between the indications for laparoscopy and the percentage of patients found to have endometriosis (p = 0.02). This proportion is the highest among patients with indications of chronic pelvic pain (31.2%) and infertility (16.9%). Patients undergoing laparoscopy due to recurrent miscarriage and ovarian cyst accidents also found that the incidence of endometriosis was 13% higher than the overall rate. The prevalence of endometriosis in other indication groups is relatively low, and the prevalence of endometriosis in people who undergo laparoscopy for family planning purposes is obviously 0%. In contrast, a study by Mahmood and Templeton evaluated the prevalence of endometriosis in premenopausal white women who underwent laparoscopy based on indications, and found that 21 patients who underwent laparoscopy for infertility %, 15% of patients with chronic abdominal pain, and 6% of women undergoing laparoscopic sterilization [28].

There is no significant difference in the prevalence of endometriosis when it is related to the type of laparoscopic surgery. It should be noted, however, that no cases of endometriosis were found in the subgroup of patients who underwent laparoscopic tubal ligation or oophorectomy.

The prevalence of endometriosis is significantly higher in patients with fewer cesarean sections and fewer cesarean sections. This can be explained by the known association between endometriosis and infertility [10, 29].

No significant correlation was found between the prevalence of endometriosis and the number of previous miscarriages or ectopic pregnancies, but it was found that there was a significantly higher proportion of women who had had two ectopic pregnancies (33.3%) Suffering from endometriosis. This is consistent with previous publications, which indicate an association between the occurrence of ectopic pregnancy and the presence of endometriosis [30, 31].

To date, little information is available on the true prevalence of endometriosis in Jordan. Depending on the type of population examined in any given study, these numbers vary widely. To the best of our knowledge, this is the first study in Jordan to evaluate the prevalence of endometriosis in women undergoing gynecological laparoscopy. These patients formed a heterogeneous group with regard to the indications that prompted the procedure.

In this study, laparoscopy found that the overall existence of endometriosis (13%) was higher than the global prevalence of this condition; however, the study sample does not represent the general population, and the prevalence is estimated to be 2.5%, but a group of patients with some gynecological diseases that require laparoscopic diagnosis or treatment. We also found that when the prevalence of endometriosis was investigated in a sample of people undergoing laparoscopic gynecological surgery, the average age of the affected patients was lower than the general peak age of the condition.

Based on a variety of factors, there are significant differences in the prevalence of endometriosis in these patients.​​​ The results of this study show that among Jordanian women undergoing gynecological laparoscopy, endometriosis is more commonly found in women with fewer pregnancies and women whose surgical indications are related to decreased fertility or pelvic pain. Women whose fertility rate or surgical indications indicate normal fertility (such as family planning) are less likely to have endometriosis.

In the study population, patient age and BMI did not appear to be significantly associated with endometriosis.

Endometriosis is an important public health problem in Jordan because it is worldwide, but its epidemiology in the region is still poorly understood. We hope that this research will increase our understanding of the epidemic of this disease in the Middle East and promote further research in this field.

This study was limited because it was a retrospective single-center study of a relatively small sample of patients. Due to the retrospective nature of the study, not all cases can be histologically diagnosed. Our center does not routinely perform biopsies to diagnose endometriosis cases, and because this study is retrospective, only available data in patient records can be extracted and analyzed. Additional surgical procedures require informed consent, and in many cases, the discovery of endometriosis is accidentally discovered during surgical procedures with unrelated indications. However, in those cases where it is available, there is a 100% correlation with clinical findings. Further large-scale multicenter prospective studies are needed to deepen our understanding of endometriosis in Jordan and the Middle East.

The data set used and/or analyzed during the current study can be obtained from the corresponding author upon reasonable request.

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The authors would like to thank the Jordan University Hospital for their help in promoting this research.

This research does not require funding.

Department of Obstetrics and Gynecology, Faculty of Medicine, University of Jordan, Queen Rania Street, Amman, 11942, Jordan

Nadia Muhaidat, Shawqi Saleh, Kamil Fram and Mohammed Nabhan

Department of Family Medicine, Faculty of Medicine, University of Jordan, Amman, 11942, Jordan

Department of Ophthalmology, University of Jordan School of Medicine, Amman, 11942, Jordan

Saif Aldeen Alryalat & Mutasem Elfalah

Jordan University School of Medicine, Amman, 11942, Jordan

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NM is responsible for the conceptualization and design of this research. NM, SS, KF, MN, NA, SAA, ME and ME contributed equally to data collection, analysis, interpretation and drafting of the manuscript. The final manuscript read and approved by all authors.

According to the Declaration of Helsinki (reference number 1012021/3170), the study was ethically approved by the Institutional Review Board (IRB) of the Jordan University Hospital. The confidentiality of participants is protected. Since the study was conducted by retrospectively retrieving data from hospital records, and patient information was processed anonymously, participation does not require informed consent, as approved by the aforementioned IRB.

The authors declare that they have no competing interests.

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Muhaidat, N., Saleh, S., Fram, K. etc. The prevalence of endometriosis in women undergoing laparoscopic surgery for various gynecological indications at the Jordanian referral center: an in-depth understanding of the epidemiology of an important women’s health problem. BMC Women's Health 21, 381 (2021). https://doi.org/10.1186/s12905-021-01530-y

DOI: https://doi.org/10.1186/s12905-021-01530-y

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