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Received: 6 April 2023 | Revised: 4 October 2023  |Accepted: 8 October 2023   P|blished online: 21 November 2023 DOI: 10.1002/ijgo.15211 C L I N I C A L A R T I C L E Gy n e c o l o g y The global burden of disease due to benign gynecological conditions: A call to action 1 1 2 3 Dileep Wijeratne  | Joanna F. E. Gibson  | Alison Fiander  | Elizabeth Rafii-Tabar  | 4 Ranee Thakar 1Department of Obstetrics and Gynaecology, Leeds Teaching Hospitals, Abstract Leeds, UK 2 Objective: Focusing on low- and middle-income countries (LMICs), this article uses School of Medicine, Cardiff University, Cardiff, UK data from the Global Burden of Disease (GBD) database to highlight the burden of 3Centre for Women's Global Health, morbidity due to benign gynecological conditions (BGCs). Royal College of Obstetricians and Methods: We analyzed 2019 morbidity data for all BGCs, measured as years lost to Gynaecologists, London, UK 4Royal College of Obstetricians and disability (YLDs). Disease burden was calculated for individual conditions, BGCs over- Gynaecologists, London, UK all, and percentages of overall disease burden from all conditions. The same data ex- traction was performed for malaria, tuberculosis, and HIV/AIDS for comparison. The Correspondence Ranee Thakar, Royal College of data were subcategorized by age and World Bank income level. Obstetricians and Gynaecologists, London, UK. Results: BGCs are major causes of disease morbidity worldwide. For women aged Email: rthakar@rcog.org.uk 15 years and over in high-income countries (HICs), 3 588 157 YLDs (3.94% of all YLDs) were due to BGC. In LMICs, 18 242 989 YLDs (5.35% of all YLDs) were due to BGCs. Funding information Royal College of Obstetricians and The highest burden of BGCs is seen during the reproductive years where conditions Gynaecologists driven or exacerbated by reproductive hormones are the major causes of morbidity. In LMICs, for women aged 15–49, 14 574 100 YLDs (7.75% of all YLDs) were due to BGCs, declining to 3 152 313 YLDs (3.04%) in women aged 50–69 and 529 399 YLDs (1.06%) in women age 70+. Conclusion: These data demonstrate a huge burden of morbidity due to BGCs. There is an urgent need for international stakeholders to prioritize the treatment and pre- vention of BGCs. K E Y W O R D S abortion, global women's health, gynecology, inequality, menstrual, morbidity, reproductive health 1  |  INTRODUCTION middle-income countries (LMICs), are causing a large burden of unrec- ognized morbidity, preventable suffering, and poor quality of life for The last 30 years have seen significant progress in global women's women and girls. Although the Sustainable Development Goals (SDGs) health with much of the focus on maternal health and cervical can- have broadened the scope of women's health priorities to include is- cer. Benign gynecological conditions (BGCs), particularly in low- and sues such as gender equality, there remains serious neglect of BGCs. 1 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Int J Gynecol Obstet. 2024;164:1151–1159. wileyonlinelibrary.com/journal/ijgo   1151 8 9 1152     | WIJERATNE et al . 7 , 0 , , Since 1990, the Global Burden of Disease (GBD) database has prolapse, endometriosis, miscarriage and abortion, ectopic preg - o w demonstrated a gradual shift towards non-communicable diseases nancy, pelvic inflammatory diseases (PID) (including gonococcal o 2 e (NCDs), such as BGCs, as major causes of morbidity. The conse- conditions, chlamydial conditions, and Trichomonas), and “other d o quences of BGCs extend beyond immediate symptoms. Menstrual gynecological diseases”. This “other” group included conditions h p disorders, for example, are strongly associated with girls' absentee- broadly split into two categories: “menstrual” and “non-men - / b ism from school. This exacerbates pre-existing gender disparities in strual” (Table 1). y o educational attainment, reducing a woman's opportunities for eco- The nine BGC categories were searched with the “GBD Results i l r nomic security and autonomy across her life course. There is a com- Tool” using YLDs as the indicator. Stratified analysis was undertaken y w plex interplay between reproductive health events and the risk of by gynecological condition, age group, and income category. Our e 4 c developing chronic disease. Prioritizing the management of BGCs analysis included all women aged 15 years and older, split into four m o could therefore help to address certain modifiable risk factors for age categories: 15+, 15–49, 50–69 and 70+. 1 5 1 other NCDs, which are of major public health concern. For each condition and age group, point estimates for the ab- 0 i To elevate gynecological conditions as global health priorities, solute numbers of YLDs and values for upper and lower 95% confi- o 5 the magnitude of the problem must be highlighted. One goal of the dence intervals were extracted. These absolute values were used to 1 b GBD database is to quantify disease burden and draw attention to determine the degree to which BGCs conditions contributed to the y s , otherwise low-profile, “unpopular” diseases, inform policy, and im- all-cause burden of YLDs for women (as %). For example, mathemat- i 6 y prove population health. Outside of the GBD database, there is a ically this can be expressed as: O n dearth of epidemiological BGC data. For an individual BGCs in women age 15–49: L b The aim of this study was to use GBD data to estimate the global r YLDc o burden of BGCs in terms of morbidity, measured through years lost %YLD_BGCs = 15−49 × 100 [ YLD 15−49 6 to disability (YLDs). 6 0 where YLDc represents the years of life lost due to disability of each 4 S BGC condition for each age group, and YLD represents the years of life e h T 2  |  MATERIALS AND METHODS lost due to disability for all causes together. m s For an individual BGCs for all women age 15+: n C This paper examined data from 2019 relating to BGCs included in n YLDc 15−49 + YLDc 50−49 + YLDc 70+ t the GBD database derived from surveys, censuses, vital statistics, %YLD_BGCs = × 100 n YLD 15−49 + YLD 50−49 + YLD 70+ ( and other health-related data (such as hospital admissions). Data p : described were based on 2019 YLD estimates from the Institute of In some BGCs, the value for the group 70+ is zero (e.g. maternal n n Health Metrics & Evaluation (IHME) Global Health Data Exchange, abortion and miscarriage or ectopic pregnancy). Malignant gyneco- i a which form the basis of the GBD study. The data were accessed logical diseases were excluded. y i y from the free-to-access database (www. healthdata.org) provided The same search was conducted for malaria, tuberculosis (TB), o / by IHME. YLDs are a widely used measure of the burden of living and HIV/AIDS, for comparative purposes as they are considered r s with a disease or disability in years, i.e., the disease morbidity. It is a major global health priorities. Analysis by income category was by n - component of disability-adjusted life years (DALYs), where DALYs are World Bank income classifications (Appendix S1). Statistical analysis n t the sum of years of potential life lost due to premature mortality and was conducted using Microsoft Excel and 95% confidence intervals n ) years of productive life lost due to disability. DALYs measure mor- were taken straight from the GBD database. n W tality and morbidity, whereas YLDs measure morbidity alone. YLDs Ethics committee approval was not sought for this study as it y O are calculated by multiplying the disorder prevalence by the short- involves data within the public domain and does not involve any data i e i or long-term loss of health associated with that disability (disability collected from human participants. Informed consent was also not a y weight) in a given population. Disability weights reflect the magni- required for this study for this reason. r u tude of health loss associated with specific health outcomes and are s f developed through detailed surveys of the general public. The differ- s O ent “weights” signify disability severity on a scale from 0 to 1, where 3  |  RESULTS A r 0 equals a state of full health and 1 equals death; for example, 0.020 l s for mild lower back pain, and 0.187 for blindness. In the 2019 GBD 7 Worldwide, for women aged 15+, BGCs accounted for 21 831 147 e o database, symptoms attributed to BGC diagnoses, for example endo- YLDs (5.05% of all YLDs). In HICs, 3 588 157 YLDs (3.95%) were due e e b metriosis, were included with mild abdominopelvic pain weighted as to BGCs. Across LMICs, 18 242 989 YLDs (5.35%) were due to BGCs. t 7 e 0.011, and severe restrictive abdominopelvic pain as 0.324. Thus, Based on these figures, 84% of the overall global burden of morbid- p i YLDs are particularly useful to illustrate disease burden of non-fatal ity due to BGCs is found in LMICs (Table 2). b e conditions,whichneverthelesshavesignificanthealthconsequences. The highest absolute burden of disease due to BGCs was in e t Nine categories of BGCs were analyzed: uterine fibroids, LMICs, where 88 832 382 (5.54%) were due to BGCs. In upper-mid- e o polycystic ovary syndrome (PCOS), female infertility, genital dle-income countries, BGCs accounted for 7 217 408 YLDs (4.67%). m o s c n e 8 9 WIJERATNE et al .      1|53 4 , 0 4 TABLE 1 Diseases included in “other gynecological diseases” category of Global Burden of Disease database by the International 3 D Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD 10) classification. w o d “Other gynecological conditions” d o Menstrual conditions ICD 10 code m t s Absent, scanty, rare menstruation N91-95.9 o g Excessive, frequent and irregular menstruation n n n Other abnormal bleeding (postcoital, contact bleeding) i a Menstrual pain and vaginismus . i Menopausal and perimenopausal disorders (postmenopausal bleeding, climacteric states, atrophic vaginitis) y o / Non-menstrual conditions ICD 10 code o 1 Vulvovaginal candidiasis B37.3–37.49 1 0 Inflammatory disorders of breast, non-malignant breast lumps, fat necrosis of breast, galactorrhea, breast atrophy, mastodynia, N61–64.9 i o nipple disorders 5 1 Inflammatory diseases of cervix (cervicitis) N72 b T s Bartholin's duct disorders, e.g., cyst abscess. Vaginal and vulval inflammatory conditions; acute and chronic vulvovaginitis; N75-N77.8 W vulval and vaginal ulceration. Infectious ulceration—e.g., herpetic/tuberculous. Autoimmune ulceration eg. Behçet's i y O Non-inflammatory disorders of ovary, fallopian tube, broad ligament; ovarian cysts; hematosalpinx. Endometrial polyps, N83-N8 i e cervical polyps, vulval and vaginal polyps. N88-N90.9 b a Endometrial hyperplasia, hematometra o n Cervical ectropion 6 0 2 Non-inflammatory cervical disorders: stenosis, leukoplakia, cervical incompetence. Non-inflammatory vaginal disorders, e.g., 2 atrophic vaginitis, vaginal stenosis, and adhesions. Hymenal disorders. Pessary ulcers. Non-inflammatory vulval disorders: . e vulvar dysplasia, atrophy, cysts t e e m a d In low-income countries (LICs) 2 175 175 YLDs (8.11%) were due to same age category in HICs, where a total of 916 957 YLDs (3.14%) o d BGCs (Appendix S2). were due to BGCs, of which 776 817 YLDs (2.64% of all YLDs) were o s h Across LMICs, within BGCs categories, “other gynecological due to “other gynecological diseases” and 78 502 YLDs (0.21%) were p / diseases”accountedforthehighestnumberofallYLDs(13 608 444 due to fibroids (Appendix S2). n e [3.99%]), followed by endometriosis (1 970 577 YLDs [0.57%]), fi- Across LMICs, 529 399 YLDs (1.07% of all YLDs) in women aged b a broids (998 398 YLDs [0.29%]), female infertility (620 283 YLDs 70+ were due to BGCs: 0.92% due to “other gynecological diseases”, . l [0.18%]), PCOS (400 301 YLDs [0.11%]), PID (313 622 YLDs 50 521 YLDs (0.1%) from genital prolapse, 17 907 YLDs (0.04%) from . o / [0.09%]), and genital prolapse (290 089 YLDs [0.09%]) (Table 2, fibroids and 6514 YLDs (0.01%) from PID (Table 3). As a proportion m s Figure 1). of all-cause morbidity, genital prolapse increased with decreasing n c In LMICs, for women age 15+, overall, 18 242 989 YLDs (5.3%) income classification and was a particular problem in LICs where it n t were due to BGCs. The highest percentage was in women of repro- accounted for 2959 YLDs (0.14%) of all-cause YLDs in women aged n ) ductive age (15–49); in this group, 14 574 100 YLDs (7.75%) were due 70+. In upper-middle- and lower-middle-income countries, 28 345 n W to BGCs. This percentage declined with age; in women aged 50–69, YLDs and 19 174 YLDs, respectively (0.1% of all YLDs), were due to e O l 3 152 313 YLDs (3.04%) were due to BGCs and in the 70+ age group, genital prolapse in women aged 70+. In HICs, genital prolapse ac- e i the figure was 529 399 YLDs (1.06%) (Table 3). counted for 30 411 YLDs (0.12% of all YLDs) in women aged 70+ a y In women aged 15–49, “other gynecological diseases” which, (Appendix S2). o u crucially, include menstrual – ectopic pregnancy, miscarriage, and For comparison, YLDs resulting from BGCs in LMICs for women s o abortion–accountedfor41 290YLDs,only0.02%ofallYLDs(Table3). aged 15+ (18 242 989 YLDs [5.3% of all YLDs]) were greater than s ; AcrossHICs,inthe15–49agegroup,BGCsaccountfor2 358 422 the combined morbidity from malaria, TB, and HIV/AIDS, which ac- A a c YLDs (6.71%), of which “other gynecological diseases” contributed counted for 4 552 233 YLDs (1.34% of all YLDs). In LICs, 1 357 649 s r the largest number of YLDs (1 732 640 [4.87%]) followed by endo- YLDs (5.02% of all YLDs) were due to malaria, TB, and HIV/AIDs g v metriosis (255 990 YLDs [0.72%]) (Appendix S2). whereas BGCs accounted for 2 140 193 YLDs (8.11% of all YLDs) n d In LMICs for women aged 50–59, 3 152 313 YLDs (3.04% of (Figure 2). In sub-Saharan Africa 3 645 680 YLDs (8.65% of YLDs) y h YLDs) were due to BGCs, with “other gynecological diseases” hav- resulted from BGCs, compared with 1 671 927 YLDs (3.88% of all a p c ing the largest contribution, accounting for 2 621 660 YLDs (2.53%). YLDs) due to HIV/AIDS, 737 241 YLDs (1.71% YLDs) due to malaria, l C Fibroids were the second largest BGC contributor, accounting for and 464 782 YLDs (1.08% YLDs) resulting from TB – a total of 6.67% e i 245 052 YLDs (0.24%) (Table 3). These results are in line with the (Figure 3). e o m n s c n e 8 9 1154     | WIJERATNE et al . 4 , 0 4 TABLE 2 Percentage of all years lost to disability (YLDs) and absolute numbers of YLDs due to benign gynecological conditions (BGCs) 3 D in women aged 15 years and above categorized by World Bank Income Classifications (Global Burden of Disease database 2019). w o d Low- and middle-income High income d countries countries o m t % All-cause YLDs Absolute number YLDs % All-cause YLDs : o g Condition 95% CI 95% CI 95% CI . n e All BGCs 5.3% (4.2–6.5%) 18 242 989 (1 087 883–28 635 205) 3.94% (3.16–4.73%) b a w Ectopic pregnancy 0.0016% (0.0011–0.002%) 5637 (2995–9139) 0.0006% (0.0004–0.0008%) l . Endometriosis 0.57% (0.46–0.71%) 1 970 577 (1 167 282–3 140 260) 0.3% (0.24–0.36%) o d Female Infertility 0.18% (0.08–0.33%) 620 283 (211 444–1 475 957) 0.042% (0.01–0.08%) i 0 0 Genital prolapse 0.085% (0.052–0.12%) 290 089 (133 866–555 022) 0.08% (0.056–0.13%) 2 g Maternal abortion and 0.01% (0.007–0.013%) 35 635 (19 116–57 762) 0.002% (0.001–0.003%) . 2 miscarriage 1 b Pelvic inflammatory 0.09% (0.04–0.14%) 313 622 (134 246–621 998) 0.046% (0.02–0.07%) T t diseases W e Polycystic ovarian 0.11% (0.06–0.18%) 400 301 (166 426–810 676) 0.17% (0.1–0.27%) y n syndrome n L Uterine fibroids 0.29% (0.06–0.42%) 998 398 (465 528–1 891 361) 0.27% (0.16–0.4%) r y Other gynecological 3.99% (3.38–4.56%) 13 608 444 (8 577 924–20 073 026) 3.01% (2.54–3.41%) o [ conditions / 6 All causes 100% – 340 692 930 (253 337 380–440 158 881) 100% – 0 4 S Abbreviation: CI, confidence interval. e h T m s n C n t n ( t : o n l r y w y c m e m a - o d o ) n W e y n n L r y o r e o u ; O a i e a FIGURE 1 Percentage of years lost to disability (YLDs) by individual benign gynecological conditions for women aged 15+, according to e v groups of income levels (Global Burden of Disease database, 2019). r d b h 4  |  DISCUSSION due to conditions driven or exacerbated by reproductive hormones. e p c Morbidity due to BGCs impacted across the life course. This was b C Using the GBD data, we found that the morbidity from BGCs was most notable in LMICs where the morbidity due to BGCs outweighed e i higher in LMICs than in HICs (50.35% vs. 3.94%). In LMICs, in women that of multiple other conditions which are major global health pri- e o of reproductive years, 7.75% of morbidity was due to BGCs, likely orities. For example, globally, 5.06% of all YLDs were due to BGCs, m o s c n e 8 9 WIJERATNE et al .      1|55 7 , 0 , , o n o e f Global m h p Absolute number YLDs % All-cause YLDs Absolute number YLDs / b n 95% CI 95% CI 95% CI o n l 3 588 157 (2 142 820–5 573 575) 5.05% (4.0–6.13%) 21 831 147 (13 021 651–34 208 781) r y 612 (326–992) 0.001% (0.001–0.0018%) 6249 (3322–10 132) i y 273 451 (165 758–427 074) 0.51% (0.41–0.63%) 2 244 029 (1 333 040–3 567 335) o m 38 581 (10 106–94 781) 0.15% (0.06–0.28%) 658 864 (221 550–1 570 739) o 1 1 81 077 (38 010–153 569) 0.08% (0.05–0.12%) 371 166 (171 876–708 591) 0 j 2413 (1270–3853) 0.008% (0.006–0.01%) 38 049 (20 386–61 615) o 5 1 b 42 460 (18 157–85 688) 0.082% (0.04–0.12%) 356 083 (152 403–707 686) T s W e 161 747 (70 931–319 974) 0.13% (0.07–0.2%) 562 049 (237 358–1 130 650) y n n L 247 861 (112 671–471 164) 0.28% (0.18–0.42%) 1 246 259 (2 362 525–578 200) r y 2 739 951 (1 725 588–4 016 477) 3.78% (3.2–4.31%) 16 348 395 (10 303 513–24 089 504) n 0 0 / 90 997 971 (67 883 877–117 653 435) 100% – 431 690 901 (321 021 257–557 812 317) 2 ] S e e e m outweighing the combined global YLDs from malaria, TB, and HIV/ surgical services such as laparoscopy. 11 In addition, while some men- a d AIDS, which was 1.08%. This finding is consistent across all income strual dysfunction may be captured by a diagnosis of fibroids, PCOS, o d groups. endometriosis and “other gynecological conditions”, the true mor- o s t For specific gynecological conditions, the leading cause of mor- bidity associated with these could be many magnitudes greater than s o bidity varied between age and income classification; however, the captured by the database. l e data showed low morbidity after ectopic pregnancy and miscarriage. To address the global burden of BGCs and their broader socio- b r This is likely due to their potentially fatal consequences. economic consequences, a sustained focus is required to make them w e To the best of our knowledge, this is the first attempt to esti- a global political priority. This means funding for programs focused c m mate the global burden of disease for BGCs. Prior studies have fo- on prevention, early identification, and prioritization of the manage- e m cused on surgical conditions including malignancy or used the GBD 8 ment of BGCs by policymakers, governments, and non-governmen- a d database to examine broader priorities. The main benefit of using tal organizations (NGOs). o d the database is that it contains information for every country and Historical trends demonstrate that aligning neglected condi- o s n incorporates data from research studies, as well as hospital episode tions with pre-existing agendas is a powerful way to increase at- W e statistics and health registries. tention. Maternal health became a major global health priority in O n This study's limitations relate to the GBD database and the lack the 1990s by emphasizing close links with a well-established child e 2 12 L of primary data for some regions. For example, LMIC data have health agenda. BGCs are closely linked to other major priorities r y mostly been extrapolated from small-scale studies or models based such as maternal health, gynecological malignancies, and NCDs. For o u on hospital statistics from HICs. Additionally, several important example, multiparity is a risk factor for genital prolapse, highlighted s f BGCs are absent, including female urinary incontinence and vesico- in a study from Gambia which showed high parity as the largest risk s ; and recto-vaginal (obstetric) fistulae, which have severe detrimental factor for pelvic organ prolapse. 13 Anemia from untreated heavy A r effects on quality of life. 10 Because of these limitations, it is likely menstrual bleeding increases the risk of morbidity and mortality c s 14 e that the disease burden due to BGCs is underestimated. from postpartum hemorrhage. Recent research has also begun g e Another problem is the lack of universally accepted diagnostic to explore links between women's reproductive health across the e d criteria for gynecological conditions, For example, endometriosis life course and NCDs, which are now public health priorities world- y e statistics in the GBD database include diagnosis by laparoscopy, pa- wide. The International Collaboration for a Life Course Approach p 7 i thology, self-reported symptoms, and hospital admissions. Delays to Reproductive Health and Chronic Disease Events (InterLACE) b e in the diagnosis of endometriosis are widely experienced in HICs project has pooled individual participant data from cohort and r t due to stigma, and the under-prioritization of women's health issues. cross-sectional studies to explore how sex-hormone differences can e o In LMICs this is compounded by a huge unmet need for access to affect the complex causal pathways for various NCDs. 4 Emerging m o s c n e 8 9 1156     | WIJERATNE et al . 4 9 2 4 TABLE 3 Percentage of all years lost to disability (YLDs) and absolute numbers of YLD due to benign gynecological conditions (BGCs) in 3 D low and middle-income countries in women, by age category (Global Burden of Disease database, 2019). w n a Age 15+ Age 15–49 e f m % All-cause YLDs Absolute number YLDs % All-cause YLDs Absolute number YLDs h p / Condition 95% CI 95% CI 95% CI 95% CI b y o All BGCs 5.3% (4.2–6.5%) 18 242 989 (1 087 883–28 635 205) 7.75% (6.36–9.35%) 14 574 100 (8 775 399–22 919 082) l e b r Ectopic pregnancy 0.0016% (0.0011–0.002%) 5637 (2995–9139) 0.0016% (0.0011–0.002%) 5635 (2995–9136) w l y o Endometriosis 0.57% (0.46–0.71%) 1 970 577 (1 167 282–3 140 260) 1.005% (0.8–1.2%) 1 888 683 (1 121 678–3 009 031) / o Female infertility 0.18% (0.08–0.33%) 620 283 (211 444–1 475 957) 0.33% (0.15–0.6%) 620 626 (211 573–1 476 708) 1 1 Genital prolapse 0.085% (0.052–0.12%) 290 089 (133 866–555 022) 0.04% (0.03–0.07%) 93 863 (43 560–182 954) 0 i Maternal 0.01% (0.007–0.013%) 35 635 (19 116–57 762) 0.018% (0.012–0.02%) 35 655 (19 127–57 793) o 5 abortion and 1 miscarriage y e Pelvic 0.09% (0.04–0.14%) 313 622 (134 246–621 998) 0.13% (0.08–02%) 260 575 (114 230–505 171) , W inflammatory e diseases O l e Polycystic ovarian 0.11% (0.06–0.18%) 400 301 (166 426–810 676) 0.2% (0.11–0.32%) 390 893 (162 578–792 298) L syndrome r y Uterine fibroids 0.29% (0.06–0.42%) 998 398 (465 528–1 891 361) 0.39% (0.25–0.56%) 736 148 (346 246–1 392 050) o [ / Other 3.99% (3.38–4.56%) 13 608 444 (8 577 924–20 073 026) 5.6% (4.8–6.3%) 10 542 018 (6 753 410–15 493 937) 6 gynecological 0 4 conditions . e All causes 100% – 340 692 930 (25 333 7380–440 158 881) 100% – 187 872 200 (137 857 206–245 073 873) h T r s n Abbreviation: CI, confidence interval. d o d o s h p / n n i a y i y c m e m a d o d i s o n i y O i e i a y o u e o u ; O a i e a e o r e b y FIGURE 2 Percentage of years lost to disability (YLDs) from benign gynecological conditions, compared with HIV/AIDS, malaria, and e p tuberculosis in women aged 15 and above, according to World Bank income levels (Global Burden of Disease database, 2019). i a e evidence suggests hormonal changes relating to early menarche risk of developing chronic diseases, including CVD. 16,17 Therefore, C a 15 v are associated with increased risk of type 2 diabetes mellitus and treatments to manage BGCs could be framed as essential preventive C m cardiovascular disease (CVD). Early menopause also increases the strategies for certain chronic diseases. m n L c s e 8 9 WIJERATNE et al .      1|57 4 , 0 4 3 D w l d Age 50–69 Age 70+ d r m % All-cause YLDs Absolute number YLDs % All-cause YLD Absolute number YLDs t s o 95% CI 95% CI 95% CI 95% CI g n 3.04% (2.29–3.67%) 3 152 313 (1 789 730–4 918 344) 1.06% (0.85–1.32%) 529 399 (321 304– n n 817 664) i a 5.4 × 10 %6 (3.8 × 10 −6– 6.7 5.5 (3–9) 0 0 0 0 y −6 w × 10 %) y c 0.08% (0.05–0.09%) 83 361 (46 462–133 559) 0 0 0 0 m o 0 0 0 0 0 0 0 0 1 1 0.14% (0.08–0.2%) 145 915 (66 591–280 239) 0.1% (0.06–0.14%) 50 521 (23 817–92 242) 0 / −06 o 5.6% (3.6 × 10 –7.4 5.8 (2.9–10) 0 0 0 0 1 × 10 −06%) 2 1 y e 0.04% (0.022–0.076%) 46 532 (17 563–102 536) 0.013% (0.006–0.02%) 6514 (2452–14 290) , W e O l 0.009% (0.006–0.014%) 9785 (4006–19 134) 0 0 0 0 e i r y 0.23% (0.13–0.34%) 245 052 (111 643–464 825) 0.036% (0.021–0.058%) 17 907 (7976–35 939) n 0 0 2.53% (1.98–2.93%) 2 621 660 (1 543 457–3 918 030) 2.5% (1.9–2.9%) 454 455 (287 057– / 675 292) 0 ] S e 100% – 103 518 164 (77 889 632–133 680 965) 100% 49 537 295 (77 889 632– e T 133 680 965) m s d C n 18 t from preventable diseases. SDG3 also recognizes that more effort n ( is required to address neglected and emerging health issues. SDG5, t : which aims to “end discrimination against women and girls”, is also o i 19 l highly relevant. r y There are clear ways in which healthcare professionals and pol- w e icymakers can improve the care of women with BGCs, including c m increasing access to evidence-based conservative treatments, im- e m proving decision-making, and safe surgical intervention. Many BGCs a d o can be managed conservatively using established treatments, such d i as contraception for menstrual conditions, fibroid symptoms, and s o pelvic pain. Improving access to newer, long-acting agents such as W i the levonogestrel intrauterine system (IUS) has the potential to man- y O age symptoms and reduce the need for surgical intervention. There i e is also a scarcity of data on who provides care for BGCs. Survey b a y data in 2014 showed only 45% of the multidisciplinary capacity for r u sexual, reproductive, maternal, and newborn health was met in 41 s 20 f African countries. Training sufficient numbers of providers and s FIGURE 3 Percentage of years lost to disability (YLDs) from ; using task-shifting where appropriate is essential. Programs such A benign gynecological conditions, compared with HIV/AIDS, malaria, r as the Royal College of Obstetricians and Gynecologists (RCOG) c and tuberculosis in women ages 15 and above in sub-Saharan Africa s (Global Burden of Disease database, 2019). r “Gynaecological Health Matters”, which trains healthcare workers g v to provide evidence-based management for BGCs, can improve the n d Aligning BGCs with the SDGs could also be used to elevate their efficient use of pre-existing resources. y h importance amongst governments, policymakers and NGOs. SDG3, In line with the Lancet commission on Global Surgery, 11 gov- a p which states “Ensure healthy lives and promote well-being for all ernments and NGOs should improve access to appropriate surgical a l C at all ages”, contains multiple elements relevant to BGCs, includ- intervention for women with BGCs In addition to training and safe e v ing achieving health and wellbeing across the life course, address- surgery interventions such as the WHO checklist, there should be a e o ing NCDs, improving reproductive health, and preventing suffering strong focus on decision-making, emphasizing the need for surgical m n L c n e 8 9 1158     | WIJERATNE et al . 7 , 0 4 , intervention only after unsuccessful conservative options. Healthcare DATA AVAILABILITY STATEMENT D w professionals and professional organizations, including the RCOG and Data sharing is not applicable to this article as no new data were cre - o d the International Federation for Gynecology and Obstetrics (FIGO), ated or analyzed in this study. d o m also have a role in developing universally accepted definitions for t ORCID : BGCs. This will help to address data collection challenges resulting b Dileep Wijeratne https://orcid.org/0000-0003-3656-2729 y from the unavailability of diagnostic techniques including laparoscopy o l Joanna F. E. Gibson https://orcid.org/0000-0001-8782-8748 e and ultrasound in LMICs, and a lack of universally accepted diagnostic b Alison Fiander https://orcid.org/0000-0002-3866-1707 r criteria for conditions. Improved data collection will demonstrate how w Ranee Thakar https://orcid.org/0000-0002-5279-141X e prevention, early management, and patient-centered care for BGCs c m may be cost-saving, compared with late-stage intervention, aiding de- d / REFERENCES . cision-makers to prioritize investment in gynecological services. 0 1. Wijeratne D, Fiander A. Gynaecological disease in the developing / g world: a silent pandemic. Obstet Gynaecol. 2018;20(4):237-244. 1 2 2. Abbafati C, Abbas KM, Abbasi-Kangevari M, et al. Global burden 1 5  |  CONCLUSION y of 369 diseases and injuries in 204 countries and territories, 1990– e 2019: a systematic analysis for the global burden of disease study , W 2019. Lancet. 2020;396(10258):1204-1222. Accessed May 18, e Overall, BGCs are a hugely under-reported and under-resourced O 2021. https:// pubmed.ncbi.nlm.nih.gov/33069326/ l area of global women's health. This is a marker of continuing gender e 3. Arafa A, Saleh L, Shawky S. 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