Why Ethnicity Matters in Endometriosis

Endometriosis affects around one in nine women worldwide and manifests in the familiar triad of dysmenorrhoea, pelvic pain, and infertility.¹ However, there are meaningful differences across ethnic groups not captured in the data. Emerging studies from North America and Europe show variation in prevalence, symptom presentation, and diagnostic delay.^2-4 Australia’s National Action Plan for Endometriosis highlights the need for data on culturally and linguistically diverse communities⁵—yet Australian-specific evidence remains limited. Our study aimed to address that gap.

What We Undertook

We conducted a retrospective review of 570 laparoscopic gynaecological cases at a single tertiary pelvic-pain service (July 2019 – June 2021). Ethnicity was self-identified and categorised per ABS standards: Oceanian, Asian, European, African/Middle Eastern, and People of the Americas. Demographic details, surgical indication, symptom profile and histology were extracted from the electronic record. Statistical analysis was performed with Stata 17; p < 0.05 was considered significant.

Exploring the Drivers

1. Cultural pain narratives
Some cultures emphasise endurance or downplay of menstrual symptoms.⁶ We found Asian women reporting mild symptoms despite extensive disease.

Clinical tip: Use open-ended questions (“How does this affect your daily life?”) and multilingual pain tools.

2. Access and health priorities
Migration studies indicate that women arriving to Australia as adults often prioritise family and employment over personal health, which may delay seeking care until infertility arises.⁷ Barriers include Medicare eligibility, language, rural access, specialist availability and health literacy.

Clinical tip: Routinely incorporate endometriosis screening into reproductive/ family planning health visits, especially in migrant populations.

3. Bias in diagnosis
Historical literature frames endometriosis as a “white, nulliparous” disease.⁸ Implicit bias may still influence patterns and interpretation of imaging. The higher prevalence we observed in Asian and South American women could partly reflect growing clinician awareness and lower diagnostic thresholds in these groups.

Clinical tip: Regularly reflect on individual practice by performing a “bias check” – consciously apply identical criteria for imaging or laparoscopy regardless of ethnicity or socioeconomic status.

Box 1: Key Findings – Snapshot for Practice

Box 2: Practice Challenges and Strategies

Where to Next?

1. Multicentre, prospective studies to explore ethnic differences in diagnostic timelines and disease severity.
2. Socioeconomic mapping of participants to clarify the role of social determinants.
3. Integrated care models combining pain, fertility, mental health, and cultural safety training for providers.
4. Education initiatives for trainees and GPs on cultural narratives and implicit bias.

Conclusion

Ethnicity matters in endometriosis – not because the disease is biologically confined to one group, but because culture shapes how patients tell their stories, access care, and interact with clinicians. Our cohort demonstrated that Asian and South American women had higher diagnosed disease burden yet presented later and with subtler symptoms. Bridging this gap requires culturally informed history-taking, proactive fertility planning, and equitable referral pathways—fully aligned with RANZCOG’s patient-centred guidelines.⁷ When every consultation begins with curiosity and humility, we move closer to true equity beyond the statistic of “one in nine.”