The global burden of disease due to benign gynecological conditions: A call to action

Focusing on low‐ and middle‐income countries (LMICs), this article uses data from the Global Burden of Disease (GBD) database to highlight the burden of morbidity due to benign gynecological conditions (BGCs).

Since 1990, the Global Burden of Disease (GBD) database has demonstrated a gradual shift towards non-communicable diseases (NCDs), such as BGCs, as major causes of morbidity. 2The consequences of BGCs extend beyond immediate symptoms.Menstrual disorders, for example, are strongly associated with girls' absenteeism from school. 3This exacerbates pre-existing gender disparities in educational attainment, reducing a woman's opportunities for economic security and autonomy across her life course.There is a complex interplay between reproductive health events and the risk of developing chronic disease. 4Prioritizing the management of BGCs could therefore help to address certain modifiable risk factors for other NCDs, which are of major public health concern. 5 elevate gynecological conditions as global health priorities, the magnitude of the problem must be highlighted.One goal of the GBD database is to quantify disease burden and draw attention to otherwise low-profile, "unpopular" diseases, inform policy, and improve population health. 6Outside of the GBD database, there is a dearth of epidemiological BGC data.
The aim of this study was to use GBD data to estimate the global burden of BGCs in terms of morbidity, measured through years lost to disability (YLDs).
for mild lower back pain, and 0.187 for blindness. 7In the 2019 GBD database, symptoms attributed to BGC diagnoses, for example endometriosis, were included with mild abdominopelvic pain weighted as 0.011, and severe restrictive abdominopelvic pain as 0.324. 7Thus, YLDs are particularly useful to illustrate disease burden of non-fatal conditions, which nevertheless have significant health consequences.
The nine BGC categories were searched with the "GBD Results Tool" using YLDs as the indicator.Stratified analysis was undertaken by gynecological condition, age group, and income category.Our analysis included all women aged 15 years and older, split into four age categories: 15+, 15-49, 50-69 and 70+.
For each condition and age group, point estimates for the absolute numbers of YLDs and values for upper and lower 95% confidence intervals were extracted.These absolute values were used to determine the degree to which BGCs conditions contributed to the all-cause burden of YLDs for women (as %).For example, mathematically this can be expressed as: For an individual BGCs in women age 15-49:   where YLDc represents the years of life lost due to disability of each BGC condition for each age group, and YLD represents the years of life lost due to disability for all causes together.

For an individual BGCs for all women age 15+:
In some BGCs, the value for the group 70+ is zero (e.g.maternal abortion and miscarriage or ectopic pregnancy).Malignant gynecological diseases were excluded.
The same search was conducted for malaria, tuberculosis (TB), and HIV/AIDS, for comparative purposes as they are considered major global health priorities.Analysis by income category was by World Bank income classifications (Appendix S1).Statistical analysis was conducted using Microsoft Excel and 95% confidence intervals were taken straight from the GBD database.
Ethics committee approval was not sought for this study as it involves data within the public domain and does not involve any data collected from human participants.Informed consent was also not required for this study for this reason.
Based on these figures, 84% of the overall global burden of morbidity due to BGCs is found in LMICs (Table 2).Using the GBD data, we found that the morbidity from BGCs was higher in LMICs than in HICs (50.35% vs.  outweighing the combined global YLDs from malaria, TB, and HIV/ AIDS, which was 1.08%.This finding is consistent across all income groups.
For specific gynecological conditions, the leading cause of morbidity varied between age and income classification; however, the data showed low morbidity after ectopic pregnancy and miscarriage.
This is likely to their potentially fatal consequences.
To the best of our knowledge, this is the first attempt to estimate the global burden of disease for BGCs.Prior studies have focused on surgical conditions including malignancy 8 or used the GBD database to examine broader priorities. 9The main benefit of using the database is that it contains information for every country and incorporates data from research studies, as well as hospital episode statistics and health registries.This study's limitations relate to the GBD database and the lack of primary data for some regions. 2For example, LMIC data have mostly been extrapolated from small-scale studies or models based on hospital statistics from HICs.Additionally, several important BGCs are absent, including female urinary incontinence and vesicoand recto-vaginal (obstetric) fistulae, which have severe detrimental effects on quality of life. 10Because of these limitations, it is likely that the disease burden due to BGCs is underestimated.
Another problem is the lack of universally accepted diagnostic criteria for gynecological conditions, For example, endometriosis statistics in the GBD database include diagnosis by laparoscopy, pathology, self-reported symptoms, and hospital admissions. 7Delays in the diagnosis of endometriosis are widely experienced in HICs due to stigma, and the under-prioritization of women's health issues.
In LMICs this is compounded by a huge unmet need for access to surgical services such as laparoscopy. 11In addition, while some menstrual dysfunction may be captured by a diagnosis of fibroids, PCOS, endometriosis and "other gynecological conditions", the true morbidity associated with these could be many magnitudes greater than captured by the database.
To address the global burden of BGCs and their broader socioeconomic consequences, a sustained focus is required to make them a global political priority.This means funding for programs focused on prevention, early identification, and prioritization of the management of BGCs by policymakers, governments, and non-governmental organizations (NGOs).
Historical trends demonstrate that aligning neglected conditions with pre-existing agendas is a powerful way to increase attention.Maternal health became a major global health priority in the 1990s by emphasizing close links with a well-established child health agenda. 12BGCs are closely linked to other major priorities such as maternal health, gynecological malignancies, and NCDs.For example, multiparity is a risk factor for genital prolapse, highlighted in a study from Gambia which showed high parity as the largest risk factor for pelvic organ prolapse. 13Anemia from untreated heavy menstrual bleeding increases the risk of morbidity and mortality from postpartum hemorrhage.evidence suggests hormonal changes relating to early menarche are associated with increased risk of type 2 diabetes mellitus 15 and cardiovascular disease (CVD).Early menopause also increases the risk of developing chronic diseases, including CVD. 16,17 Therefore, treatments to manage BGCs could be framed as essential preventive strategies for certain chronic diseases.

F I G U R E 2
Percentage of years lost to disability (YLDs) from benign gynecological conditions, compared with HIV/AIDS, malaria, and tuberculosis in women aged 15 and above, according to World Bank income levels (Global Burden of Disease database, 2019).

TA B L E 3
Percentage of all years lost to disability (YLDs) and absolute numbers of YLD due to benign gynecological conditions (BGCs) in low and middle-income countries in women, by age category (Global Burden of Disease database, 2019).Abbreviation: CI, confidence interval.
Aligning BGCs with the SDGs could also be used to elevate their importance amongst governments, policymakers and NGOs.SDG3, which states "Ensure healthy lives and promote well-being for all at all ages", contains multiple elements relevant to BGCs, including achieving health and wellbeing across the life course, addressing NCDs, improving reproductive health, and preventing suffering from preventable diseases. 18SDG3 also recognizes that more effort is required to address neglected and emerging health issues.SDG5, which aims to "end discrimination against women and girls", is also highly relevant. 19ere are clear ways in which healthcare professionals and pol- In line with the Lancet commission on Global Surgery,

| CON CLUS ION
Overall, BGCs are a hugely under-reported and under-resourced area of global women's health.This is a marker of continuing gender inequality and highlights an urgent need to prioritize holistic healthcare for women.The authors make an urgent call to action to improve the poor quality of life currently suffered by many women and girls and afford them their human right to health.
3.94%).In LMICs, in women of reproductive years, 7.75% of morbidity was due to BGCs, likely due to conditions driven or exacerbated by reproductive hormones.Morbidity due to BGCs impacted across the life course.This was most notable in LMICs where the morbidity due to BGCs outweighed that of multiple other conditions which are major global health priorities.For example, globally, 5.06% of all YLDs were due to BGCs, F I G U R E 1 Percentage of years lost to disability (YLDs) by individual benign gynecological conditions for women aged 15+, according to groups of income levels (Global Burden of Disease database, 2019).TA B L E 2 Percentage of all years lost to disability (YLDs) and absolute numbers of YLDs due to benign gynecological conditions (BGCs) in women aged 15 years and above categorized by Bank Income Classifications (Global Burden of Disease database 2019).
icymakers can improve the care of women with BGCs, including increasing access to evidence-based conservative treatments, improving decision-making, and safe surgical intervention.Many BGCs can be managed conservatively using established treatments, such as contraception for menstrual conditions, fibroid symptoms, and pelvic pain.Improving access to newer, long-acting agents such as the levonogestrel intrauterine system (IUS) has the potential to manage symptoms and reduce the need for surgical intervention.There is also a scarcity of data on who provides care for BGCs.Survey data in 2014 showed only 45% of the multidisciplinary capacity for sexual, reproductive, maternal, and newborn health was met in 41 African countries.20Training sufficient numbers of providers and using task-shifting where appropriate is essential.Programs such as the Royal College of Obstetricians and Gynecologists (RCOG) "Gynaecological Health Matters", which trains healthcare workers to provide evidence-based management for BGCs, can improve the efficient use of pre-existing resources.

F I G U R E 3
Percentage of years lost to disability (YLDs) from benign gynecological conditions, compared with HIV/AIDS, malaria, and tuberculosis in women ages 15 and above in sub-Saharan Africa (Global Burden of Disease database, 2019).intervention only after unsuccessful conservative options.Healthcare professionals and professional organizations, including the RCOG and the International Federation for Gynecology and Obstetrics (FIGO), also have a role in developing universally accepted definitions for BGCs.This will help to address data collection challenges resulting from the unavailability of diagnostic techniques including laparoscopy and ultrasound in LMICs, and a lack of universally accepted diagnostic criteria for conditions.Improved data collection demonstrate how prevention, early management, and patient-centered care for BGCs may be cost-saving, compared with late-stage intervention, aiding decision-makers to prioritize investment in gynecological services.
Dileep Wijeratne and Joanna F. E. Gibson (joint first authors): statistical analysis of data extracted from Global Burden of Disease Database; Creation of data tables and figures; contribution of written original material; review and analysis of the INTERLACE survey; analysis of disability weighting data; editing of drafts; review and final approval of the manuscript.Ranee Thakar: writing of original material for the introduction and abstract; editing; review and final approval of the manuscript.Alison Fiander: title of the paper; writing original material; editing; review of tables and figures; review and final approval of the manuscript.Elizabeth Rafii-Tabar: title of the paper; writing original material for the discussion and introduction; literature review; editing; review and final approval of the manuscript.

Age 50-69 Age 70+ % All-cause YLDs Absolute number YLDs % All-cause YLD Absolute number YLDs
11governments and NGOs should improve access to appropriate surgical intervention for women with BGCs In addition to training and safe surgery interventions such as the WHO checklist, there should be a strong focus on decision-making, emphasizing the need for surgical