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Explanation of the relevance of our disease with references, suitable for a scientific audience 

Known for its elusive nature and lack of known cause or trigger, Endometriosis is rapidly becoming a common disease within the female population. Endometriosis is categorised as a chronic condition in which growth of endometrial tissue (Farquhar, 2007) is present in areas of the pelvic cavity; such as most commonly, the ovaries. It is known to affect women of all age brackets but women at peak reproductive age of between 18-30 are most susceptible (Kennedy et al., 2005) to developing the condition. Recent years has seen a spike in diagnosis, with 830,000 Australian women (~11%) (Endometriosis Australia, 2018) being diagnosed with the disease. An estimated 1 in 9 women is affected globally (Endometriosis Australia, 2018), translating to 200 million women worldwide. Therefore, the relevance of endometriosis is quite prominent as women are faced with life-changing symptoms such as severe pelvic pain before or while menstruating, ovulating, urinating or excreting. As well as fatigue, heavy or irregular periods, infertility, frequent urination, abdominal bloating and lastly, vaginal discomfort (Culley et al., 2017). 

Despite severe symptoms, there is an ever-present delay in diagnosis (Farquhar, 2007). This can be attributable to symptoms being of a subjective nature between patients, often overlapping gynaecological and gastrointestinal issues with similar symptoms (Surrey, 2020 ). Risk factors include heavy menstrual flow, short menstrual cycle or family history (Culley et al., 2017). In addition, there is a lack of health literacy regarding the aetiology (Rowlands, 2021) and the risk factors aligned with the progression and development of the disease. Thus, there is an apparent decrease in quality of life that significantly impacts an individual’s daily life both pre and post-diagnosis.

Endometriosis impacts not only the individual living with the chronic condition but also surrounding family members and the burden on the healthcare system is just as profound. Partners are often marginalised (Endometriosis UK, 2018) and neglected regarding challenges faced such as working and financial aspects, everyday tasks, or the social lives for couples. A common life goal among women within peak reproductive ages, is to have children of their own (Ameratunga, 2017). Unfortunately, endometriosis can make this goal a little less effective to pertain. Thus, not only does the condition impact the female’s quality of life, but also her partner’s. This creates a sense of blame, loss, guilt and frustration within the relationship (Fernandez, 2006).

With no known cure, the only hope for improved health within the condition is via management of the condition through the use of painkillers, laparoscopy abdominal surgeries or hormonal contraceptives (Dunselman et al. 2014).  In 2016 – 17, Australia saw approximately 34,200 hospitalisations due to Endometriosis (AIHW, 2019). A 2018 report from the Australian government, the cost of Endometriosis on the Australian society annually is approximate $9.7 billion (Endometriosis Australia, 2018) including $2.5 billion in healthcare costs.  

Prevention is mostly unattainable as there is no known cause, cure, or trigger for Endometriosis (Todd, 2020). The only known ways to prevent the condition include pregnancy and the use of oral contraceptives with high amounts of progestin (Wong, 2011)

Justification as to why the target audience should be educated on our disease with references, suitable for the scientific audience 

As uterine tissue is found only in women, it is specifically women whom are affected by Endometriosis. Yet, the intended target audience is women aged 18-30, as this age bracket is between menopause and puberty (Zondervan et al., 2018) and considered peak reproductive age. It is vital for these women to gain access to health information specific to their reproductive, health as this allows that impacted individuals to seek the medical care they require for diagnosis and treatment.

This particular demographic is targeted for increased information regarding Endometriosis as it is common for these women to be diagnosed at a later stage with most women being diagnosed in their early 30’s where fertility has already started to decline (Rowlands et al., 2020). With this in mind, Endometriosis has a 30-50 percent infertility rate within females thus reducing their chances of conceiving (Bulletti, Coccia, Battistoni & Borini, 2010). This proves to be a challenge for both first time mothers and mothers at a later age as their chances of enduring a successful full term pregnancy are quite low, as well as the baby’s health being at risk, as is the mother’s (AIHW, 2020).

As it affects approximately 11% of Australian women, widespread information promotes education and recognition of symptom progression that can lead women to seek diagnosis and treatment (endometriosis Australia, 2018). However, many women either misinterpret their symptoms for common menstrual pain or do not show symptoms . Thus, there is a high prevalence regarding lack of diagnosis (Endometriosis Australia, 2018). As Endometriosis is commonly undetected, the need to provide this target audience with resources encourages these women to seek a proper diagnosis and treatment to ensure the chronic condition is manageable in day to day life (endometriosis Australia, 2018).

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As Endometriosis can show hereditary links regarding numerous genetic factors and environmental influence, by providing education to the aforementioned target audience, a flow effect is created (Rahmioglu et al., 2014). Meaning, by educating one individual, they have the ability to further educate more both within their immediate female family and others. Thus creating broader interpersonal community understanding for individuals with an increased risk such as the hereditary link or due to their age bracket being within the peak reproductive age (Rahmioglu et al., 2014). 

Pathophysiology explanation appropriate for a scientific audience:

Endometriosis is a disease characterised by the presence of endometrial tissue including glands and stroma in extrauterine spaces (Burney & Giudice, 2012). It is an estrogen dependent chronic inflammatory condition that affects women during the reproductive cycle, commonly causing pain and infertility (Vercellini et.al., 2014). Endometriosis does not yet have a clearly defined known cause and as such it is classified as idiopathic (Bulletti et.al., 2010).  The disease is multifactorial and no unifying theory of the pathogenesis of the disease currently exists (Foti et.al., 2018). However common pathophysiological theories that explain the origin of extrauterine implantation of endometriotic lesions are the regurgitation theory, benign metastases theory, metaplastic theory, and the extrauterine stem cell theory (Kumar et.al., 2017). Currently the regurgitation theory is favoured suggesting a backflow of refluxed menstrual endometrial tissue through the fallopian tubes leading to implantation (Klemmt & Starzinski-Powitz, 2018). The cells that exit the fallopian tubes are able to attach to the surface of adjacent organs and form a blood supply (Holoch & Lessey, 2010). The mechanism for endometriotic pain is a complex mix of nociceptive including pain from the inflammatory nature of the disease, and neuropathic pain. Well vascularised endometriotic lesions can bleed during menstruation as is characteristic of functional endometriotic tissue as the endometrial lining is shed and regenerated (Brosens, 1997). The extrauterine menstrual bleeding from endometriotic lesions, can influence the innate immune system causing inflammation and subsequent pain, as well as activating sensory nerves which carry nociceptive signals (Laux-Biehlmann et.al., 2015). Endometriotic lesions can also produce high levels of aromatase which induces the biosynthesis of estrogen (Harel, 2008). In normal uterine menstruation high estrogen levels result in the production of a thicker endometrial lining which presents clinically as heavier flow of menstrual blood, however in the extrauterine lesions high estrogen also has the effect of increasing tissue formation and survival (Hapangama & Bulmer, 2016). As endometriosis is an estrogen dependent disease (Rižner, 2009) and hormone level can influence pain perception this can also affect the expression of pain as an endometriosis symptom (Morotti et.al., 2017). Depending on where the endometriotic lesions implant will depend on the type of pelvis pain felt. As common anatomical locations are the ovaries, fallopian tubes, uterus, bladder, ureters resulting pain often clinically presents as dysuria, dyspareunia, and dysmenorrhea (Foti et.al, 2017). A key example of endometriosis pain is ovarian cysts, in this instance endometriotic cysts form in the estrogen rich environment, the cysts contain old menstrual blood and when they rupture it causes pain (Holoch & Lessey, 2010). Infertility typically can also occur in endometriosis patients this is due to chronic inflammation of the pelvis, and the presence of adhesions that disturb pelvic anatomy, the inflammation is more typical in newer cases, and the adhesions are more often a problem in older instances (Vercellini et.al., 2014).

Pathophysiology explanation appropriate for chosen target audience:

Endometriosis, is an estrogen-dependent inflammatory condition affecting women of reproductive age, but what is it? Within your reproductive system contains the uterus which houses endometrial tissue. During your menstrual cycle the tissue builds and grows, if fertilisation of the egg doesn't happen this endometrial tissue is shed during menstruation. In endometriosis this endometrial tissue grows in the extrauterine space, in areas such as the fallopian tubes, ovaries and other tissues within the pelvis (And in rare cases may spread to non-pelvic organs). This endometrial tissue then proceeds to do its normal function of building and shedding but in an area, it is not supposed to and this is where complications occur. This process can lead to the development of chronic inflammation leading to scar tissue and adhesions that can lead to pelvic organs and tissues sticking together. Due to this endometriosis can lead to pain as well as problems with fertility.

Researchers are still trying to determine the exact cause for this extrauterine implantation and therefore we don't know have a definitive reason. However, there are 4 main theories including the benign metastases theory, metaplastic theory, extrauterine stem cell theory and the most favoured theory being the regurgitation theory. The regurgitation theory suggests the black flow of menstrual endometrial tissue through the fallopian tubes leading to the implantation of other areas within the pelvic region. Once menstruation ends and the cycle begins again this endometrial tissue begins to perform its normal function of building itself up in preparation for fertilisation, including the process of producing blood vessels to have a rich blood supply. This again may lead to chronic inflammation which can lead to adhesions

The pain associated with endometriosis relates to the inflammatory nature of the disease which causes pain most commonly in the pelvic region. When this is coupled with endometriosis being estrogen-dependent and estrogen being a known influence on pain perception there can be a heightened expression of pain. Pain may vary depending on the location of implantation and based on location may present during intercourse, defecation, urination or as worsened menstrual cramps. A common example may be pain from ovarian cysts where cysts form in the estrogen rich environment of the ovaries and upon rupture will cause pain.

The potential decline in fertility is due to a combination of chronic inflammation in the pelvic region and the presence of lesions and adhesions. In chronic inflammation, the body experiences low amounts of tissue damage, in conjunction with increased collagen production leading to greater scar tissue formation which translates to a lesion or adhesion. Lesions and adhesions the body tries to do its normal healing process where scar is formed, unfortunately, scar on the inside of our bodies can cause many issues, one of these issues is known as contracture where the collagen associated with scar tissue shortens which alters and disturbs the pelvic anatomy. Between these two factors, the reproduction system may have a decline in functionality and therefore a decrease in fertility.