1Risk for and consequences of endometriosis: A critical epidemiologic review
Section snippets
Endometriosis prevalence and incidence
Accurate measurement of the incidence and prevalence of endometriosis is complicated by the current requirement for surgical visualization to establish a definitive diagnosis. Factors influencing referral for/acceptance of surgery and access to surgical expertise create a biased sample among those who achieve a diagnosis. Prevalence estimates vary considerably among different populations, ranging from approximately 2-43% among asymptomatic women seeking tubal ligation [1], [2], [3], ∗[4] to
Methodologic issues in endometriosis-focused study design
The key methodologic issues for endometriosis discovery – whether clinical, population, or bench science – include choosing a valid (1) endometriosis case definition and (2) comparison group as well as (3) defining the appropriate etiologic window to capture the exposures, outcomes, and disease progression to address the study aims ∗[10], [15], [16], [17]. In general, case–control studies of endometriosis tend to be more vulnerable to bias owing to control selection and recall; however, these
Maternal exposure to environmental toxins
Prenatal exposure to diethylstilbestrol (DES), a synthetic estrogen, has been associated with a greater risk of endometriosis in the NHSII cohort (Rate Ratio [RR] = 1.8, 95% CI = 1.2–2.8) [26] and also the suggestion of greater risk in a population-based case–control study in western Washington State (Odds Ratio [OR] = 1.3, 95% CI = 0.5–3.6) [27]. In utero DES exposure, which has been linked to reproductive tract structural abnormalities and altered estrogen receptor expression, potentially
Endometriosis and chronic disease risk
A growing body of research suggests an association between endometriosis and other comorbid and chronic conditions ∗[95], [96]. However, the quality of the epidemiologic evidence, magnitude of association, and mechanism behind the association vary across different conditions. A key methodologic challenge is that women who are diagnosed with endometriosis may utilize treatments that alter their endometriosis disease (e.g., excision surgery) or that are directly related to other disease risk
Summary
While estimates of endometriosis prevalence and incidence are difficult to calculate due to the absence of a noninvasive diagnostic method, the best estimates conclude that approximately 10% of women of reproductive age are afflicted with endometriosis. Methodologic complexity associated with this disease requires application of an advanced study design and statistical methodology. Many different case definitions can be utilized validly and the type of women included in comparison/control
Conflict of interest
No funding directly supported development or finalization of this manuscript.
S.A.M. received grant funding from the US National Institutes of Health (NIH; HD40882, HD48544, HD52473, HD57210, and HD089511), the J. Willard and Alice S. Marriott Foundation and the Marriott Daughters' Foundation, and the Dana-Farber/Harvard Cancer Center (DF/HCC) A. David Mazzone Research Awards Program for endometriosis-associated aims. She has served as an advisor to and has scientific collaborations with AbbVie
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Contributed equally as first authors.