The scale of the problem is difficult to overstate. Endometriosis occurs when tissue similar to the inner lining of the uterus grows outside of it, often causing severe pelvic pain, heavy menstrual bleeding and, in many cases, infertility. There is no cure, and management typically involves a combination of surgery, hormonal treatment and non-medical strategies such as pain management and lifestyle support. The World Health Organization estimates that the condition affects roughly 10 per cent of women of reproductive age globally, equivalent to about 190 million people. Data from the Australian Longitudinal Study on Women’s Health, one of the largest and longest-running studies of its kind, indicate that one in seven Australian women lives with the condition, underscoring how widespread it is even in high-income countries with advanced health systems.

Professor Gita Mishra, from the University of Queensland’s Australian Women and Girls’ Health Research Centre, led the analysis together with collaborators from the World Health Organization, senior board members of the World Endometriosis Society and representatives of patient groups. The team’s central finding was stark: 70 per cent of the guidelines they reviewed had not been informed by people with lived experience of endometriosis. In other words, the vast majority of the documents that determine how hundreds of millions of patients are diagnosed, treated and supported were written without direct input from the very people they are meant to serve. Professor Mishra noted that the gap was particularly pronounced in developing countries, with substantial gaps identified across Africa and the Eastern Mediterranean.

The review also revealed considerable variation in what the guidelines actually recommend. Recommendations differed widely across four critical domains: diagnosis, treatment, fertility care and non-medical management of the disease. This inconsistency matters because endometriosis is already notoriously difficult to diagnose. Symptoms frequently overlap with other conditions, and patients commonly wait years for a definitive answer. When national guidelines disagree about which diagnostic tests to order, which treatments to prioritise or how to approach fertility preservation, the result is a lottery of geography, in which the quality of care a patient receives depends largely on where she happens to live. Professor Mishra emphasised that the development of standardised international guidelines informed by patients is essential to ensure consistency in diagnosis, treatment and self-care across borders.

Compounding the problem, most existing guidelines originate from high-income settings, particularly Europe, leaving large portions of the world’s population without authoritative local guidance. Some countries have no endometriosis guidelines at all, which means, as Professor Mishra pointed out, that women in those settings are not screened or cared for the condition in any systematic way. In such contexts, the disease may go unrecognised entirely, with patients cycling through primary care, emergency departments and specialist clinics without ever receiving an accurate diagnosis or an evidence-based treatment plan. The absence of guidance also affects health professionals, who are left to make high-stakes clinical decisions without a shared evidence framework.

One of the most surprising findings of the review concerned adolescents. A quarter of the guidelines analysed had not been informed by evidence relating to adolescents, despite the fact that symptoms and diagnostic delays often begin during the teenage years. Endometriosis is frequently dismissed in young patients as normal period pain, and delayed diagnosis during adolescence can allow the disease to progress unchecked, potentially affecting fertility and quality of life for decades. The researchers argue that guidelines which fail to account for the adolescent experience leave clinicians without the tools to recognise the disease early in the population where early recognition matters most.

Inclusivity gaps extend beyond age. Only one in five of the reviewed guidelines explicitly acknowledged gender-diverse individuals, exposing what the researchers describe as persistent blind spots in the clinical literature. Gender-diverse people can and do experience endometriosis, yet guidance documents that frame the condition exclusively around cisgender women risk making these patients invisible to health systems, discouraging them from seeking care and leaving clinicians unprepared to provide it. The finding adds endometriosis to a growing list of conditions for which guideline development has not kept pace with a more inclusive understanding of who can be affected.

Dr Dereje Gete, from the University of Queensland’s School of Public Health, said identifying gaps in existing guidelines was a critical first step towards addressing global inequities in endometriosis care. He acknowledged that different countries face different challenges, including unequal access to treatment, but argued that minimum standardised guidelines are an important starting point in addressing healthcare inequities. In countries without any guidelines at all, he noted, even raising awareness of endometriosis, its symptoms and how it can be managed represents a meaningful step forward. Awareness campaigns and basic educational resources can begin to break the silence and stigma that surround the condition in many parts of the world, even before full clinical guidelines are in place.

The composition of the guideline development teams themselves also came under scrutiny. All of the international guidelines reviewed were informed by gynaecologists, which is perhaps unsurprising for a condition managed largely within specialist gynaecological care. Yet fewer than half included input from general practitioners. Dr Gete argued that this needs to change, because general practitioners are often the patient’s first port of call and play a pivotal role in early symptom recognition and referral. A patient whose family doctor does not recognise the warning signs of endometriosis may never reach a gynaecologist at all, or may reach one only after years of unnecessary suffering. Guidelines that ignore the primary care interface therefore miss the point at which the diagnostic journey most often begins.

Despite the global inconsistencies the review documented, the researchers point to Australia as a model of what better looks like. The 2025 publication of the Australian Living Evidence Guideline: Endometriosis represents a new generation of guidance designed to be continuously updated as evidence evolves, rather than frozen at the moment of publication. The living guideline approach is particularly suited to a condition like endometriosis, where research is advancing rapidly and patients have long complained that clinical practice lags behind the science. Building on the momentum of the review, the research team will next work with the World Health Organization to develop standardised global guidelines, an effort that, if it succeeds in embedding patient voices, adolescent perspectives and inclusivity from the outset, could begin to close the gaps that have left so many of the 190 million people living with endometriosis without the care they need.

Subject of Research: Global inequities and gaps in endometriosis clinical guidelines

Article Title: Global guidelines needed to address inequities in endometriosis care

Article References: Global guidelines needed to address inequities in endometriosis care. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: endometriosis, clinical guidelines, health inequity, women's health, University of Queensland, World Health Organization, adolescent health, gender-diverse health, patient involvement, diagnostic delay, global health, Communications Medicine

The significance of the study lies partly in the sheer ubiquity of the exposure. Fungal infections are among the most frequent ailments in pregnancy, driven by hormonal and immunological changes that alter the body’s microbial balance. They are typically treated with azole antifungals, a broad family of compounds that includes both prescription drugs and, crucially, over-the-counter topical products such as creams and vaginal tablets. As Gylli Mola, a researcher and medical doctor at Rigshospitalet, points out, this is what makes the result particularly noteworthy: the treatments in question were primarily non-prescription topical preparations, which have traditionally been regarded as safe to use during pregnancy. If even these low-intensity, locally applied formulations are associated with hormonal signals in offspring, the assumption of safety may need to be re-examined with more rigorous data than currently exists.

The study rested on an unusually broad evidentiary base. The researchers analysed data from 589 Danish mother–child pairs, drawing on Denmark’s rich national registers and biobanks to compare children whose mothers had used azole antifungals during pregnancy with those who had not. Crucially, the epidemiological signal did not stand alone. The team supplemented the population data with laboratory experiments using human fetal adrenal tissue, allowing them to observe directly how azole compounds interact with the steroid-producing machinery of the gland. They also carried out studies in pregnant rats, examining both blood and adrenal tissue from the fetuses to see whether the same hormonal disruptions appeared in a controlled experimental setting. According to Monica Kam Draskau, a researcher at the DTU National Food Institute who worked on the experimental analyses, the fact that the findings in children are supported by results from both human fetal adrenal tissue and rat experiments strengthens the hypothesis that there is a genuine link with the use of azole-based antifungal medicines.

To understand why the adrenal gland matters here, it helps to consider what azoles actually do. Azole antifungals work by inhibiting enzymes in the cytochrome P450 family that fungi need to build ergosterol, an essential component of their cell membranes. The trouble is that humans rely on closely related P450 enzymes to manufacture steroid hormones, including the cortisol and other adrenal steroids that the fetus begins producing as its adrenal gland develops. A compound designed to block fungal steroid synthesis can, in principle, also interfere with human steroidogenesis, and the fetal adrenal gland is an extraordinarily active steroid-producing organ during gestation. The new findings are consistent with that mechanism: prenatal exposure to azoles appears to disrupt fetal steroidogenesis, and the disruption seems to leave traces that persist at least into early infancy.

Adrenal hormones are far from peripheral players in human physiology. They help regulate many functions in the body, including glucose metabolism, blood pressure, immune function, and growth and reproductive development. The adrenal gland also undergoes a remarkable transformation around the time of birth, known as the zona reticularis transition, when the fetal zones of the gland regress and adult-type steroid production takes over. Hormonal disturbances during this window could, in theory, ripple across multiple organ systems as a child grows. That is precisely why the Danish team is cautious but concerned: the hormone levels they measured at three months of age were still within the normal range, yet the pattern of change suggests that fetal development may have been affected in ways that standard clinical thresholds do not capture.

Professor Terje Svingen from the DTU National Food Institute, who led the work, described the persistence of the signal as striking. It is one thing, he noted, for a medicine to produce a transient hormonal blip that resolves within days; it is quite another for the use of azole-based antifungals during pregnancy to appear to affect adrenal hormone levels in children long after birth. The three-month timepoint means the differences survived the profound hormonal upheaval of delivery and the establishment of infant adrenal function. Svingen’s framing captures the careful middle ground the study occupies: the results suggest that fetal development may have been affected, but they stop well short of demonstrating harm, and the researchers are explicit that they do not know whether the differences will affect the children’s health or their ability to have children later in life.

That caution is scientifically essential. The study is observational in its human component, and it cannot directly establish that azole-based antifungal medicines cause the hormonal changes observed in children. Mothers who used antifungals may differ in other ways from those who did not, from infection severity to other medication use, and no observational design can fully exclude such confounding. Nor can the researchers conclude from this study that commonly used antifungal medicines are harmful to children. What the results do is raise a hypothesis, supported by converging lines of evidence, that now needs to be tested with dedicated studies. The authors argue that the safety of widely used antifungals during pregnancy warrants further investigation, and the triangulation of human data, human tissue experiments and animal studies gives that argument unusual weight for a finding of this kind.

The research was carried out as part of the MERLON research project and was funded by the Danish Environmental Protection Agency through the Danish Centre on Endocrine Disrupters, with additional support from the Rigshospitalet Research Council. IRSET in France was a partner in the study. That funding provenance is telling: endocrine disruption, the interference of chemicals with the body’s hormone systems, has become a major focus of European regulatory science, and medicines are increasingly scrutinised alongside industrial chemicals for their potential to perturb hormonal development. The authors declare no conflicts of interest, and the study appeared under the title ‘Prenatal antifungal exposure disrupts fetal steroidogenesis and is associated with persistent effects in children’.

For pregnant women, the immediate practical message is one of reassurance rather than alarm. Untreated fungal infections carry their own risks, and no current evidence indicates that a course of azole treatment harms a child; the measured hormone levels in the study remained within normal limits. The researchers themselves stress that they cannot conclude the medicines are harmful. The appropriate response, they suggest, is not for women to avoid needed treatment but for regulators, clinicians and researchers to generate the data needed to confirm or refute the signal. Larger cohorts, longer follow-up of exposed children, and mechanistic work clarifying which azoles, doses and exposure windows matter most would all help determine whether the hormonal differences observed at three months of age are a transient footprint or a marker of lasting developmental change.

The study also speaks to a broader lesson in pharmacology and public health: medicines assumed to be safe because they are old, familiar and available without prescription are not automatically free of subtle developmental effects. Topical preparations deliver lower systemic doses than oral drugs, but pregnancy is a period of exquisite hormonal sensitivity, and the fetal adrenal gland is one of the most hormonally active tissues in the body. The Danish findings do not overturn clinical practice, but they add an important data point to the ongoing effort to make medication use in pregnancy evidence-based rather than assumption-based. Until that evidence matures, the study stands as a carefully hedged but consequential reminder that even the most routine treatments of pregnancy deserve continued scientific scrutiny.

Subject of Research: Effects of prenatal azole antifungal exposure on fetal steroidogenesis and infant adrenal hormone levels

Article Title: New study raises questions about antifungal treatments during pregnancy

Article References: New study raises questions about antifungal treatments during pregnancy. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: azole antifungals, pregnancy, fetal development, adrenal hormones, steroidogenesis, endocrine disruption, Communications Medicine, DTU National Food Institute, Rigshospitalet, over-the-counter medicines, child health, pharmacovigilance