The Tribune was held on the opposite side of Mexico City, creating a physical as well as philosophical separation of the two groups. [ 54 ]  The difference in format stemmed from position that the delegates participated in discussions on official policy; whereas, the NGO tribunal women dealt with means and methods of program implementation to improve women's educational opportunities, equality, economic position and collaboration. [ 55 ]  The Tribune hosted thirty-six planned meetings and nearly two hundred spontaneously organized additional sessions covering a wide variety of topics from  development ,  education ,  health , human rights,  peace  and  work  to  birth control ,  gender violence , lesbianism, prostitution, racism and  sexism . [ 54 ]  The dynamics of this conference were different from the official UN session because the participants were not governmental representatives, and delegates were free to discuss items openly avoided by the officials. [ 56 ]  But the free discussion also made apparent the divide separating the women.  Westernized  women focused on  individual freedom , Socialist women focused on the state's obligation to enforce the  collective rights  of all members of a society, [ 57 ]  and those from countries not aligned to either of these views pointed to the need for development, economic empowerment, food security [ 58 ]  and correction of the structural problems in systems. [ 59 ]


Women from developing nations pointed out issues such as how aid from industrialized nations was often harmful, as it displaced women practicing subsistence agriculture with technology. Without adequate training to utilize technology, women who had been the prevalent food producers no longer had means to support their families. If they were utilized by new industry, women tended to be exploited as a cheap labor source, as laws for equal pay were non-existent in many developing economies. [ 60 ]  In light of these survival issues, the demands of others asking for  sexual and reproductive health and rights  seemed frivolous and indicative of self-indulgence. [ 61 ]  Socialist women felt that equality could only come with a transformation of  geopolitical  relationships, which recognized the contributions of all members of society and denounced exploitation and discrimination on any basis. [ 62 ]  Amid the wide range of views, there were performances aimed at capturing media attention, with some attendees wearing  national costumes  and others wearing business attire, as well as rhetoric pitting ideologies against each other to gain a spotlight. [ 26 ] [ 47 ]  At one point, frustrated that they could not be part of the official dialogue, a group of radical feminists planned to stage a march through the streets of Mexico City. Instead, a group of fifteen delegates was chosen who presented amendments to Helvi Sipilä requesting that they be given to the official committees. It was the first time that a Tribune had ever been successful in presenting their input to the officials. The amendments the Tribune proposed included establishment of a UN office to monitor success of the Plan, issue annual progress reports, and investigate human rights abuse against women. They also asked for the UN to improve their internal hiring policies so that more women were not only hired, but promoted to management and executive positions. [ 63 ]


The conference adopted the official  World Plan of Action , as well as the  Declaration of Mexico on the Equality of Women and Their Contribution to Development and Peace , which was an indictment of the foreign policies that pushed  military  or corporatist  intervention  to coerce developing nations from determining their own path. The Declaration passed with a vote of eighty-nine in favor, three against, and eighteen nations abstaining. [ 2 ]  The Plan established minimum targets to be attained within the next five years to secure for women the equal access of the mechanisms to attaining equality and eliminating discrimination; to full participation in development and their integration in extant systems; and to their contributions toward world peace and non-aggression. To reach these goals, the conference made education, employment, family planning, health and nutrition, and housing key focal points. The Tribune played a uniting role, by bringing together people of diverse cultures and backgrounds to formulate the means to overcome differences in objective and create pathways for NGOs to participate in the policy-making process. The conference not only encouraged member countries to develop policies which would lead to the improvement of women's lives, but led to the establishment of the United Nations Decade for Women as a means to focus those policies, as well as establishing a series of conferences to follow-up. The first of these would be the  Second World Conference on Women  to be held in  Copenhagen . To assist in advancing women's development with research, operations support and training, the UN created the  International Research and Training Institute for the Advancement of Women  (INSTRAW) and the  United Nations Development Fund for Women  (UNIFEM). [ 43 ] [ 64 ]


For the first time, institutional collection within the UN evaluated the extent of problems and conditions of women in varying nations, specifically separating data by sex to bring to light the level of inequality and discrimination towards women. [ 64 ]  It was also one of the first international meetings of organized lesbians from multiple countries and cultures. [ 65 ]  Attitudes within the member nations and the UN itself began to change as a result of the focus on women brought about by the conference. [ 66 ]  Another benefit of the conference was that it connected women to other women in their struggles. Though in many ways the conference was not as effective in poor and undeveloped countries, because enforcement of the principals established and communication with women was harder in the developing world, [ 67 ]  there was a surge in women's activists coming together across the globe, as well as governmental understanding of the needs of their constituent women. [ 68 ] [ 45 ]


The text of the Mexico Declaration included a denunciation "of colonialism and neo-colonialism, foreign occupation, Zionism, apartheid and racial discrimination in all its forms" a precursor to the highly controversial  United Nations General Assembly Resolution 3379 , [ 69 ]  known colloquially as the "Zionism-is-racism" resolution. This debate elicited particularly strong responses from Jewish feminists, including Betty Friedan, Jewish author of the seminal feminist work "The Feminine Mystique" who noted that "anti-Zionist diatribes had been much more dominant at the Mexico City women's conference than at other UN gatherings." [ 70 ]  American Congresswoman Bella Abzug condemned the resolution, [ 70 ]  while feminist Lettuce Cottin Pogrebin wrote “I know Zionists who are racists, just as I know racist feminists, but that didn't make Zionism racism any more than a few bigoted women made feminism racism." On the other hand, groups such as Women Against Imperialism viewed the anti-Zionist rhetoric as an essential step towards securing the rights of women around the world. [ 71 ]


The  World Conference on Women, 1980,  or the  Second World Conference on Women,  took place between July 14 and July 30, 1980 in  Copenhagen , Denmark, as the mid-decade assessment of progress and failure in implementing the goals established by the  World Plan of Action  at the 1975 inaugural conference on women. The most significant event to come out of the conference was  the formal signing of the  Convention on the Elimination of All Forms of Discrimination Against Women , which took place during the opening ceremony of the conference. Marred by conflict and the politicization of international and national events that had little to do with women's issues, the conference was viewed by some participants as a failure. They were able to secure passage of a modified  World Programme of Action  to expand on previous targets to improve women's status and establish a follow-up conference for the end of the decade.


The 1980 Conference held from 14 and 30 July in  Copenhagen , Denmark [ 1 ]  was the direct result of the  First World Conference on Women , which had been held in Mexico City in 1975, establishing the  World Plan of Action  and  Declaration of Mexico on the Equality of Women and Their Contribution to Development and Peace . [ 2 ]  These documents took the United Nations themes—Development, Equality, and Peace—of their path for women and created guidelines for nations to reach long-term objectives to improve the lives of women. When they were adopted, the UN established 1975 to 1985 as the Decade for Women and put in motion a plan for subsequent conferences to evaluate progress being made. [ 3 ]  The format of the conference was the same, with the official session made up of delegates representing their governments and the Tribune, representing NGOs. [ 4 ]


As with the previous conference, the Copenhagen conference was beset by the  geopolitical  divides of the  Cold War  and whether economics, racism, or  sexism  was the more important factor in the subordination of women. [ 5 ]  Initially planned to occur in  Tehran , the  Iranian Revolution  of 1979 and the  Iran hostage crisis , escalated the political backdrop as did the continuing tensions of  conflict in the Middle East .  Palestinian women ,  refugees , and  Apartheid  became topics that were added to the agenda and ensured that the event would be  politicized  by the various participants, rather than remaining focused on women's issues. [ 2 ] [ 6 ]  To that end, the  United States Congress  issued instructions to its delegates that they would not approve any resolution which attempted to make what should be an apolitical conference into an indictment of government policy or any resolution which mentioned the word " Zionism ". [ 7 ]   Saudi Arabia  and South Africa boycotted the convention altogether. [ 6 ]  Having to hastily relocate the conference to Denmark, also impacted the accommodations available, in that there was no space large enough to accommodate the entire Tribune, which meant that rather than the entire group participating in exchange to create unity, the group was splintered into small venues. [ 8 ]


The conference was the mid-point review of the decade, and the conference president was  Lise Østergaard , Cultural Minister of Denmark. [ 9 ] [ 10 ]  The secretary-general of the conference was  Lucille Mair , a Jamaican academic and single mother, whose primary focus was on the development theme of the triad. [ 11 ]  Discussion on the  New International Economic Order  subverted the discussion from being about what women needed to what the various governments needed from women or for women to reach their national goals. [ 12 ]  At one point, it was suggested that if Westernized nations would provide more funding for  economic development , discrimination against women would vanish. [ 13 ] [ 14 ]  Partisan political issues, such as insertion of the socialist economic system into the section dealing with the historical perspective on women, the repeated interruption of Israeli delegates with Muslim drummers and singers, and a storming of the conference by women protesting the  Bolivian coup d'état  were just some of the manifestations of the divides. [ 7 ] [ 10 ]


One hundred forty-five states with around 1500 delegates participated in the official session, [ 15 ] [ 16 ]  including delegates like:  Aleksandra Pavlovna Biryukova  [ ru ]  of the USSR;  Shirley Field-Ridley  of  Guyana ; [ 17 ]   Ana Sixta González de Cuadros  of  Colombia ;  Helga Hörz  of  East Germany ;  Maïmouna Kane  of  Senegal ;  Sheila Kaul  of  India ;  Ifigenia Martínez  of  Mexico ; [ 18 ]   Gabriele Matzner-Holzer  [ de ]  of  Austria ; [ 17 ]   Inonge Mbikusita-Lewanika  of  Zambia ; [ 18 ]   Elizabeth Anne Reid  of Australia; [ 19 ]   Ginko Sato  of Japan; [ 17 ]   Umayya Toukan  of  Jordan ; [ 18 ]   Sarah Weddington , who headed the US delegation, among many others. [ 6 ]   May Sayegh  of Palestine was also present at the conference.  Sally Mugabe , the wife of  Robert Mugabe, prime minister of a newly-independent Zimbabwe, was elected vice president of the conference to honor the role of Zimbabwe's women in the anti-colonial struggle.


After opening remarks by  Kurt Waldheim ,  Secretary-General of the United Nations ,  Queen Margrethe II of Denmark  welcomed participants and expressed her hope that the conference would prove productive. [ 20 ]   Anker Jørgensen , Danish prime minister, spoke briefly, followed by opening remarks by Lise Østergaard, followed by the general discussion. [ 21 ]  Debates were strongly affected by  post-colonial  and socialist claims of women's advancement in centrally planned economies in which the state had an obligation to prevent and an accountability for discrimination against women. [ 22 ]  Having established mechanisms in the previous conference to gather data on the status of women, review of the statistical data showed that women's security had dwindled over the preceding five-year period. Among the documentation were statistics showing that while women put in two-thirds of all working hours, they received only one-tenth of the income, owning one-hundredth of its assets.  Economic stagnation  and industrialization in the period had led to significant increases in unemployment and benefits for women. [ 23 ]  Jobs which were available confined women to insecure, low-paid, and sex-stereotyped jobs and as much of their labor was toward unpaid production, it was still invisible in compiled economic reports. [ 24 ]  Decreased earnings had elevated health concerns. While literacy rates for middle class women increased, overall illiteracy among women increased. [ 23 ]  One of the most contentious issues discussed was the situation of households headed by women. Many officials denied that there could be such a thing, as legally in their countries women were not allowed to be the head of a household. [ 11 ]  On the other hand, one of the most memorable moments was when the delegates signed the  Convention on the Elimination of All Forms of Discrimination Against Women  (CEDAW) on 17 July. [ 16 ]


The first committee, under the chair Maïmouna Kane, with vice-chairs,  Rafidah Aziz  of  Malaysia ,  Maria Groza  of  Romania , and  Leónidas Páez de Virgili  of  Paraguay , with Rapporteur  Marijke Van Hemeldonck  of  Belgium , [ 18 ]  discussed the effects of Apartheid and the  Israeli-occupied territories  on women; the progress and obstacles in attaining the objectives of the World Plan of Action; and the proposal for the World Programme of Action for the second-half of the  Decade for Women . [ 25 ]  Of major concern was labor insecurity, caused either by the introduction of technologies which replaced women laborers or by the  informal nature  of many jobs open to women in developing countries. The committee discussed that more effort should be made to retrain laborers when their positions were eliminated by technological advances and that legal protections should be enacted. Also of grave concern was education of women to not only eliminate illiteracy but to make them aware of social and political processes and how they could be part of decision-making mechanisms. [ 26 ]  Apartheid and racism were condemned by the committee, as was the Zionist policy of Israel which was linked to racism. The discussion on the Palestinian right to self-determination was endorsed, though it was noted that when the Palestinian people as a whole were denied basic human rights, discussing the rights of only women was futile. [ 27 ]  Various draft resolutions, including resolutions to improve education and training, address women with disabilities, provide support for women migrants and refugees, provide economic security for elderly women, and to address violence against women. [ 28 ]  With modifications, the committee recommended approval of the Programme and accepted CEDAW with few reservations. [ 29 ]


The second committee, under the chair Sheila Kaul, with vice-chairs,  Nermin Abadan-Unat  of  Turkey ,  María de Lourdes Castro e Silva de Vincenzi  of  Brazil , and  Chavdar Kyuranov  of  Bulgaria , with Rapporteur Ali Benbouchta of  Morocco , [ 18 ]  discussed an agenda identical to the first committee's focal points. [ 30 ]  Apartheid was rejected and the committee recommended that with its eradication, women in South Africa and bordering refugee states should be compensated with the means to reconstruct their societies in ways that created avenues for women's participation. [ 31 ]  With regard to the review of the Programme, the committee noted that without change in socio-economic systems, equality for women remained elusive. It was noted that globalization led to an increasing need to pursue paths for disarmament, peace and international cooperation. [ 32 ]  It was also noted that regional systems needed to be fully integrated to allow women's participation but additionally new programs organized specifically for women should be explored. [ 33 ]  The situation of refugee women, their vulnerabilities to exploitation and violence and the need to protect their human rights. [ 34 ]  On the question of Palestinian women, the committee recognized that material assistance would do little to stop insecurity unless Israel ended its colonization, returned land to its owners and worked toward a durable peace. [ 35 ]  The committee examined several draft resolutions regarding peace initiatives, refugees, water insecurity, and adding women to census figures, [ 36 ]  as well as draft resolutions on health and welfare,  protecting families from defaulted support obligations , drug trafficking and  forced disappearance , and integrating women into the UN system and programs. [ 37 ]  With modifications, the committee recommended approval of the Programme. [ 38 ]


The planning of the 1980 Tribune, or Forum as it was called in Copenhagen, [ 39 ]  was led by  Edith Ballantyne , the executive secretary of the  Women's International League for Peace and Freedom  (WILPF) and president of the United Nations Conference of Non-governmental Organizations (CONGO).  Elizabeth Palmer , a representative of the  YWCA  chaired the actual Forum, [ 40 ]  which was hosted at the  Copenhagen University Amager Campus . [ 41 ]  The success of developing transnational networks of women was evident in the expansion of attendees at the NGO Tribune from 6000 participants in Mexico City to around 8000 in Copenhagen. [ 42 ]  Many complained of the inadequacy of the forum facilities, including the fact that child care had not been considered. [ 43 ] [ 44 ] [ 45 ]  The forum was split into small sessions consisting of around 200 meetings per day. Because of the lack of translators, and the fact that conferences were labeled as of concern to developed or developing nations, in-depth discussion was difficult and often barely touched the surface of issues. [ 39 ] [ 8 ] [ 45 ]   Peggy Antrobus  and  Charlotte Bunch , with sponsorship from the  University of the West Indies ' Women and Development Department and the  Asian Pacific Centre for Women and Development  (APCWD), recently relocated from Tehran to  Bangkok , organized an orientation video  Feminist Strategies for the Decade  which was shown daily. [ 5 ] [ 46 ]   Irene Tinker [ 7 ]


The politicization of the official conference also influenced the NGO Tribune, resulting in tensions and displays of nationalism, such as [ 47 ]  Iranian women holding a news conference to celebrate their revolution by calling for the use of the  hijab  as a protest against  colonialism  and Ukrainian women protesting for independence. [ 48 ]  When  Nawal El Saadawi  of Egypt presented a paper on  female circumcision , western feminists were advised that the issue was a developing world problem and not their concern. [ 49 ]  Lesbians attendees hosted five workshops, which were well attended and less controversial than at the 1975 conference. [ 45 ]  Some of the prominent women attendees were  Shulamit Aloni  of Israel; [ 44 ]   Marie Assaad  of  Egypt ; [ 13 ]   Charlotte Bunch , US lesbian activist; [ 50 ]   Phyllis Chesler  a US expert on refugees; [ 44 ]   Betty Friedan , founder of the  National Organization for Women  (NOW); [ 51 ]   Natalia Malakhovskaia , Soviet exile;  Marie-Angélique Savané  of  Senegal . [ 13 ]  As they had in Mexico City, the members of the Forum continued the tradition of presenting their additions to the Programme of Action at the official session. A group of women led by  Domitila Barrios de Chungara  were met by police and barred from entering the plenary meeting until Lucille Mair met with them and allowed the recommendations to be presented. [ 52 ]


The most significant outcome of the conference was the official signing of CEDAW by the delegates at the opening ceremony. [ 48 ]  The conference adopted the official  World Programme of Action  with a vote of ninety-four favorable votes, twenty-two abstentions, and four opposed—Australia, Canada,  Israel  and the United States. [ 7 ]  It included sections to create women's bureaus or agencies, defined the roles of NGO and  grassroots  organizations, and established target issues countries were to monitor. Those issues included  child care ,  households headed by women ,  migrants , rural women, unemployment, and youth. [ 11 ]  The Programme also included a section regarding water insecurity, [ 8 ]  but the most significant changes to the previous Plan of Action were sections devoted to ensuring equal access to education, employment opportunities, and adequate health care. [ 1 ]  The Conference established the  Third World Conference on Women  for the end of the decade to be hosted in  Nairobi ,  Kenya  in 1985 with a backup location in Tokyo. [ 53 ]


The conference was seen by those who rejected the Programme as having been a failed process. Rather than a serious discussion of the inequalities between men and women, the conference had limited discussion to politicizing international events, ideological principals and controversies, which obscured the real needs of women to participate in decision-making and economic development, and benefit equally in family matters, health, education and employment. [ 54 ]  Multiple countries which had abstained from voting expressed disappointment that the process, rather than dealing with women's issues, had duplicated work better suited for the General Assembly. [ 55 ]


Overall, the conference and forum conference were marred by conflict and politicization of international and national events which had little to do with women's issues. The official agenda was obscured by nationalist causes pitting the developing countries of the South and the developed countries of the North against each other. [ 48 ]  The question for continued participation in the conferences left many asking if the focus could be shifted away from political issues and return to the problems related to women: aging; credit for economic development; double duties between work and family; fertility versus infertility; shortage of heat and inadequate water, support systems and lack of them; women’s health; [ 43 ]  and violence against women. [ 56 ]


The  World Conference on Women, 1985  or the  Third World Conference on Women  took place between 15 and 26 July 1985 in  Nairobi , Kenya, as the end-of-decade assessment of progress and failure in implementing the goals established by the  World Plan of Action  from the  1975 inaugural conference on women  as modified by the  World Programme of Action  of the  second conference . Of significance during the conference was the result of the  Forward-looking Strategies for the Advancement of Women  being adopted by  consensus , unlike the previous two conferences. The conference marked the first time that  lesbian rights  were introduced in a UN official meeting and the turning-point for  violence against women  to emerge from being a hidden topic into one which needed to be addressed. Recognizing that the goals of the  Decade for Women  had not been met, the conference recommended and the General Assembly approved on-going evaluation of women's achievements and failures through the year 2000.


In 1975, the United Nations approved the celebration of  International Women's Year . As part of the celebrations they held the First World Conference on Women in 1975 in  Mexico City . At that meeting, it was proposed that the following decade be proclaimed UN Decade for Women and follow-up meetings to assess progress be held in 1980 and 1985. The General Assembly adopted a World Plan of Action with recommended targets for governments to integrate women's equality, development and participation in peace initiatives. The mid-point meeting was held in  Copenhagen , [ 1 ]  adding sections to the revised Programme of Action devoted to ensuring women equal access to education, employment opportunities, and adequate health care. [ 2 ]  Both of the previous conferences had struggled with the divide caused by  Cold War  politics and the needs of the developing world. [ 3 ] [ 4 ]  The geopolitical backdrop entering into the third conference was still contentious with a  worldwide debt crisis  soaring in  Africa  and  Latin America , protectionist policies under  Margaret Thatcher  and  Ronald Reagan  causing widespread uncertainty,  stagnation of the USSR , the  arms race  build up, and the  Soviet invasion of Afghanistan . The question would be whether the conference could remain focused on women's issues in the face of Soviet accusations that the United States imperialistic and war mongering tactics were undermining the goals of the Decade for Women and the US concerns that the  Eastern Bloc  attempts at politicization would derail any real improvement in the unique problems faced by women. [ 5 ]


The 1985 Conference held from 15 and 26 July in  Nairobi , Kenya was the final review of the decade [ 2 ]  and was led by conference president  Margaret Kenyatta . [ 6 ]   Leticia Shahani , widowed mother of three children and a  Philippine  diplomat served as the Secretary-General and made the crucial suggestion that off-the-record discussion by delegates would decrease the polarity which had plagued the previous conferences and would allow a more open discussion and lead to compromise. [ 7 ]  There were 157 countries represented with around 1,400 official delegates, including such prominent delegates as:  Phoebe Asiyo  of  Kenya ;  Ylva Ericsson  of  Sweden ; Saida Hassan of  Djibouti ; [ 8 ]   Elena Lagadinova  of  Bulgaria ; [ 9 ]   Carolyn McAskie  an official at the  Canadian International Development Agency ; [ 10 ]   Maureen O'Neill  head of the Canadian delegation, who was the coordinator for the  Minister of Status of Women ; [ 11 ] [ 12 ]   Maureen Reagan , daughter of the US president; [ 13 ]   Yvette Roudy , the French Minister of Women's Rights; [ 14 ]   Jean Spautz  of  Luxembourg ; [ 15 ]   Tom Vraalsen  of  Norway ; among others. [ 9 ]


After opening remarks by  Javier Pérez de Cuéllar ,  Secretary-General of the United Nations , [ 16 ]  Kenyan President  Daniel arap Moi  welcomed participants, expressing his hope that the conference would prove successful and that the objectives for women would not be obscured by distractions. [ 17 ]  Opening remarks by Margaret Kenyatta on the history of the conference were followed by the general discussion. [ 18 ]  The general session discussed that women ought to be able to live securely under conditions which granted them equality and justice, but there was a recognition that time is required to change traditional views and make people aware of needed change. It was noted that though legal equality had significantly improved, the disparity between the legal reality and practice was still broad. It was discussed that political tension and instability, as well as conflict added to curtailment of advancement, as did colonialism, racism, and economic stagnation. [ 19 ]  The conference noted gains in developed nations for parity of education, but significant gaps in girls education versus boys education in developing nations, which impacted future employment options as well. [ 20 ]  Though some progress had been made on women's employment, it was noted that wage gaps, higher unemployment for women than men, and child care services all contributed to women's instability. As for health, it was acknowledged that as women were typically the health care providers for their families, that more effort must be made to ensure that women were healthy to allow them to continue to serve their families. Inadequate education and health facilities, combined with high birth rates and customs or laws that allowed women to control their own fertility were continuing issues. [ 21 ]


Projects throughout the decade had drawn awareness to the need to advance women's opportunities and statistic gathering had improved to measure their progress or lack of advancement. Violence against women was a prevalent problem as was the insecurity of indigenous women, elderly women, migrant and refugee women and their children, and rural women. Water and food uncertainty needed to be addressed as women in many areas devoted the majority of their time into unpaid labors to maintain their families. [ 22 ]  Many UN programs had been expanded over the Decade for Women to incorporate women into their development programs, though it was noted that in general women's participation, and even employment in UN agencies though improved was still below targets. Programs directed at agriculture, economics, children, development, housing, health, technology and many others were examined and overall, improvement had been made in the inclusion of women's access. However, it was noted that making provisions for equality was not the same as attaining real equal opportunity. [ 23 ]  It was agreed that the cultural role in maintaining  sexism  and sex  stereotypes  was a complex issue which would involve dedicated effort to change school curricula and transform media messaging to enable women real access to socio-economic, cultural, legal and political parity. [ 24 ]  It was noted that for the first time,  lesbian rights  were introduced at an official UN conference by the Dutch delegate,  Annelien Kappeyne van de Coppello . [ 25 ] [ 26 ]


The first committee, under the chair  Cecilia López  of  Colombia , with vice-chairs,  Kulsum Saifullah  of  Pakistan ,  Olimpia Solomonescu  of  Romania , and  Laetitia van den Assum  of the  Netherlands , with Rapporteur  Diaroumeye Gany  of  Niger , [ 9 ]  discussed the first three chapters of the draft  Forward-looking Strategies for the Advancement of Women . [ 27 ]  The second committee, under the chair  Rosario Manalo  of the  Philippines , with vice-chairs, Dame  Billie Miller  of  Barbados ,  Konjit SineGiorgis  of  Ethiopia , and  Eva Szilagyi  of  Hungary , with Rapporteur  Helen Ware  of Australia, [ 9 ]  discussed the remaining chapters of the Strategies. [ 28 ]  Both committees recommended approving the draft and a discussion with the general session followed with a line by line review of the document. [ 29 ]  Though both committees evaluated a number of draft resolutions, there was inadequate time for the general session to review the resolutions and no formal action was taken upon them. [ 30 ]


Dame  Nita Barrow  of  Barbados  chaired and organized the Forum, [ 7 ]  with the assistance of  Edith Ballantyne , president of the United Nations' Conference of Non-governmental Organizations (CONGO). [ 31 ] [ 32 ]  It was attended by more than 15,000 people, of which 60% were representatives from non-industrialized nations, and was held at the  University of Nairobi . [ 7 ] [ 33 ]  Unlike the facilities in Copenhagen, in Kenya, a kindergarten was set up for delegates' children. [ 34 ]  A Peace Tent was set up on the lawn of the university and hosted sessions about conflict and its impact of war on women. [ 33 ]  Among prominent attendees were:  Charlotte Bunch , a US lesbian activist ; [ 33 ]   Betty Friedan , founder of the  National Organization for Women  (NOW); [ 35 ]   Eddah Gachukia  head of the Kenyan NGO committee; [ 36 ]  and others.


In addition to the basic themes of the official session, the Forum was asked to address issues concerning women who were poor, elderly, migrant or refugees, youth and address women in media. Round table discussions, workshops and two plenary sessions were established. [ 37 ]  The array of topics discussed in formal and impromptu meetings was vast, including such topics as childcare;  consumer education ; credit; family planning;  female genital mutilation ; the growth of women's studies; legal rights; literacy;  media portrayals of women ; motherhood and development programs for families; political prisoners; prostitution; systemic discrimination against women; violence; women and development; women and religion; women and technology; as well as lesbian workshops and many other topics in some 1200 workshops scheduled throughout the duration of the conference. [ 33 ] [ 38 ] [ 39 ]  The lesbian workshops were the "first public discussion of lesbianism in Kenya" [ 40 ]  and resulted in a lesbian press conference in which it was acknowledged that lesbianism wasn't a  Westernized  concept, but instead effected women's rights throughout the globe. [ 25 ]  It also resulted in a proposal from one of the Dutch representatives for lesbian rights to be addressed in the official conference documents. [ 33 ]  In a workshop on development,  Helen Safa  brought forward the idea that "Gender and Development" (GAD) should replace the former strategy "Women in Development" (WID) used by the  United Nations Commission on the Status of Women  (CSW). This mirrored the NGO,  Development Alternatives with Women for a New Era  (DAWN)'s belief that WID simply tried to insert women into existing systems without reducing or changing their  paternal nature . They recommended that GAD, a strategic long-term planning method, become the new standard, which focused on designing systems specifically related to women and their growth. [ 41 ]


In addition to the workshops, the United Nations Environment Programme's (UNEP) Senior Women Advisors,  Margaret Kenyatta ; Ms. Hawa Aden of Somalia; Mrs. Victoria Chitepo, Minister of Environment, Zimbabwe; Dr. Shafika Nasser, member, upper house of parliament in Egypt; Dr. Eideh M. Mutlag Qanah, Advisor to the Queen of Jordan; Hedia Bacca, environmental activist in Tunisia; Margarita Marina de Botero, environmental leader in Columbia; Yolanda Kakabadse, environmental leader in Ecuador; the Hon. Sheila Dikshit, Member of the Parliament, India; Ms. Soepardjo Roestam, wife of the Prime Minister of Indonesia and leader of the Family Welfare Service; Ms. Veronica Villavicencio, of the Philippines; H.R.H Khunying (Lady) A. Meesook, Thailand; Lt. Col. Christine Deborah, Minister of Natural Resources, Ghana (a graduate of Sandhurst, UK); Ms. Eva Szilagyi, Hungary; Fiona McConnell, British Foreign Ministry; Aira Kalela, Environment/Foreign Affairs Ministry, Finland; the notable Madame Simone Weil, France; the Hon. Claudine Schneider, (R. Rhode Island) U.S. Congress; and Wangari Maathia, founder of the Greenbelt Movement in Kenya [ citation needed ]  hosted an evening program the night prior to conference opening, to promote the inclusion of women in solving environmental problems, and women were invited to participate in a number of cultural events like the Nairobi Film Forum which showed films and videos by and about women and gave workshops; exhibitions of art and photography; folklore workshops; concerts; martial arts classes; field trips to local villages. [ 42 ]  Because of the favorable climate conditions, women were able to gather in the open-air for a variety of both scheduled and unscheduled functions to build networks with other participants. [ 34 ]  The Forum after 1985 shifted in a way that reflected the divide between  progressivism  versus conservatism, as opposed to the polarized capitalist-socialist divide which had split prior conferences. It was recognized by the participants that global problems were women's issues, but that within their governmental systems, there was either a desire to promote or curtail change. A fundamental shift occurred which recognized that no matter the system, women were subordinate and that promoting a world view from women's perspectives allowed them to transcend their differences and focus on the commonalities they shared. [ 43 ]  For example, aboriginal women recognized that where ever they were from, they battled for indigenous land rights; Arab and Israeli women discussed the need for peace; women lawyers whether from Islamic countries in South Asia or Catholic countries in Latin America recognized the struggle for women's rights under patriarchal religious systems. [ 36 ]


Forward-looking Strategies for the Advancement of Women  was adopted by consensus because of a strategy developed which allowed delegates to express reservations on the basis of individual paragraphs, rather than of the document as a whole. Because of stronger transnational relationships had been forged by the previous two conferences [ 44 ]  increased understanding by governments of the needs of their women constituents, a willingness of donors to help women integrate into development and increased effectiveness of NGOs in their activism, the list of topics covered in the Strategies was more extensive, including topics such as: agriculture, communications, constitutional and legal issues, education, employment, energy needs, environmental and water concerns, food security, health, housing, science and technology, social services, social and political equality as well as increased participation. The major themes development, equality, and peace were retained as were focuses on racism and refugees. [ 7 ]  The document endorsed new strategies moving to the year 2000 and replaced the words  Apartheid  and  Zionism  with the more general term racism, to maintain the focus on women rather than polarizing issues. [ 45 ] [ 8 ]


Out of the conference forum, several women's groups emerged that would become influential:  Asian-Pacific Forum on Women, Law and Development  (APWLD),  Comité de América Latina y El Caribe para la Defensa de los Derechos de la Mujer  (CLADEM),  Women in Law and Development in Africa  (WILDAF), [ 33 ]  and the  Tanzania Media Women's Association . [ 46 ]  These were indicative of the types of exponential growth in NGOs dealing with women and their issues which were founded after the conference ended. Many of the organizations were information-sharing groups which pooled their resources and strategies to create innovative solutions. [ 47 ]  These networks, shifted the flow of activism and scholarship from the global North toward the Southern hemispheres and from top-down social structures to those which forge coalitions across cultural, racial and social boundaries. [ 48 ]  The conference also marked a turning point in the silence regarding  violence against women , which would ultimately lead to the passage of the  Declaration on the Elimination of Violence Against Women  in 1993. [ 49 ]  Since the objectives of the Decade for Women had not achieved the goals set out in 1975, the  United Nations General Assembly  made a decision after Nairobi to conduct world surveys on women every five years in a continuing effort to follow-up on the implementation of the Strategies for women. [ 50 ]  One of the most important outcomes was moving women out of obscurity and establishing specific mechanisms for measuring women's progress. [ 51 ]


The  Fourth World Conference on Women: Action for Equality, Development and Peace  was the name given for a conference convened by the United Nations during 4–15 September 1995 in  Beijing , China. [ 1 ]


At this conference, governments from around the world agreed on a comprehensive plan to achieve global  legal equality , known as the Beijing Platform for Action.


The  founding United Nations charter (1945)  included a provision for equality between men and women ( chapter III, article 8 ). Subsequently, from 1945 to 1975 various female officials within the United Nations and leaders of women's movements on the global stage attempted to turn these principles into action. The  United Nations General Assembly  passed a resolution ( resolution 3010 ) that 1975 should be  International Women's Year . In December 1975, the UN General Assembly passed a further resolution ( resolution 31/136 ) that 1976–1985 should be the "Decade of Women". [ 2 ]


In conjunction with  International Women's Year , the first world conference on women was held in Mexico City in 1975. [ 1 ]  It resulted in the  Declaration of Mexico on the Equality of Women and Their Contribution to Development and Peace . [ 3 ]


The second world conference on women was held in Copenhagen in 1980. [ 1 ]  The conference agreed that the 1979  Convention on the Elimination of All Forms of Discrimination against Women  was an important milestone. The Copenhagen conference also acknowledged the gap between rights being secured for women and women's ability to exercise those rights. It was also agreed that it was action on the three areas of: equal access to education; employment opportunities; and adequate health care services are essential to achieve the goals set out in Mexico. [ 4 ]


The third world conference on women was held in Nairobi in 1985. [ 1 ]  The Nairobi conference set out areas by which progress in women's equality could be measured: constitutional and legal measures; equality in social participation; equality in political participation; and decision-making. The conference also acknowledged that women need to participate in all areas of human activity, not just those areas that relate to gender. [ 5 ]


Delegates had prepared the UNDP Beijing Express Declaration aimed at achieving greater equality and opportunity for women. [ 6 ] [ 7 ]


The conference was attended by representatives of 189 governments, UN agencies, [ 8 ]  intergovernmental organizations such as the  European Union  and  League of Arab States , as well as activists and organizations from across the world. There were 17,000 participants, with a further 30,000 activists attending a parallel Forum. [ 9 ]


Gertrude Mongella  of Tanzania was the secretary-general of the conference. [ 10 ]


Aung San Suu Kyi  delivered the  keynote  address at the conference. [ 11 ]


A full list of the statements made by attendees  can be found on the UN website .


Hillary Clinton , at the time the  First Lady of the United States , gave the speech  Women's Rights Are Human Rights  at the conference on 5 September 1995. [ 12 ]  That speech is considered to be influential in the women's rights movement, and in 2013 Clinton led a review of how women's rights have changed since her 1995 speech. [ 13 ]  The 1995 speech was listed as No. 35 in American Rhetoric's Top 100 Speeches of the 20th Century (listed by rank). [ 14 ]


"If there is one message that echoes forth from this conference, it is that human rights are women's rights.... And women's rights are human rights.


Let us not forget that among those rights are the right to speak freely. And the right to be heard.


Women must enjoy the right to participate fully in the social and political lives of their countries if we want freedom and democracy to thrive and endure." [ 15 ]


--Hillary Rodham Clinton


Beverley Palesa Ditsie  became the first African lesbian woman to address the  United Nations  about  LGBT  rights when she made her speech on 13 September 1995. [ 16 ]


"No woman can determine the direction of her own life without the ability to determine her sexuality.  Sexuality is an integral, deeply ingrained part of every human being's life and should not be subject to debate or coercion.  Anyone who is truly committed to women's human rights must recognize that every woman has the right to determine her sexuality free of discrimination and oppression.


I urge you to make this a conference for all women, regardless of their sexual orientation, and to recognize in the Platform for Action that lesbian rights are women's rights and that women's rights are universal, inalienable, and indivisible human rights." [ 17 ]


--Beverley Palesa Ditsie


Many other speeches were also given at the conference, on behalf of governments, the United Nations and inter-governmental organizations, and non-governmental organizations. [ 18 ] [ 19 ] [ 20 ] [ 21 ]


The Beijing Declaration and Platform for Action is widely known as the most progressive blueprint for advancing  women's rights .


The framework covers 12 areas of concern:


A major result of the conference was the Beijing Declaration of Indigenous Women, signed at the NGO Forum in the Indigenous Women's Tent. [ 22 ]  This document seeks, in part, to reconcile the tension felt by Indigenous women activists and Indigenous movements dominated by men. [ 23 ]  It was a significant step forward towards Indigenous women's rights and a significant victory for  Indigenous feminism  practice.


The 50-point declaration provides the rationale and a clear call to action for governments navigating Indigenous issues across the globe. The demands in the document are "that all governments and international non-governmental and governmental organizations recognize the right of Indigenous peoples to self-determination, and enshrine the historical, political, social, cultural, economic, and religious rights of the Indigenous peoples in their constitutions and legal systems." [ 22 ]  From that premise, the declaration goes on to specify areas for action including self-determination; development, education and health; human rights violations and violence against Indigenous women; intellectual and cultural heritage; and political participation.


The document addresses the unique problems Indigenous women suffer in addition to those suffered by Indigenous men, which include erosion of culture (and gender roles therein), loss of traditional land, and compromised identity and status in the spaces they inhabit. [ 24 ]


As its bases, the declaration cites the "UN Declaration of the International Decade of the World's Indigenous Peoples, the Draft Declaration of the Rights of the Indigenous peoples, the  Convention on the Elimination of All Forms of Discrimination Against Women , the Nairobi Forward-Looking Strategies for the Advancement of Women,  Agenda 21  and the  Rio Declaration on Environment and Development , the  Cairo Declaration on Human Rights in Islam , and the Copenhagen Social Summit Declaration." [ 25 ]


Global Focus: Women in Art and Culture  was a project founded by artist and project director  Nancy Cusick  and gave women artists the opportunity to participate in the dialogue at the World Conference of Women. Women artists from around the world used their chosen media as a vehicle to produce work that evoked the universal issues paramount to women, their lives, and their position within the framework of society. Co-sponsored by the  National Museum of Women in the Arts  (NMWA), Global Focus presented an art exhibition, a video festival, slide presentations, performance pieces, and workshops that showed the artistic accomplishments and creativity of women. Most of the 880 artworks, produced by women artists from 27 countries, were displayed at the World Trade Center in  Beijing, China . A smaller group of works were also exhibited in  Huairou , China. These artworks formed a visual landscape of powerful images that immortalized the women's issues and themes which encompassed the conference—Equality, Development, and Peace.


Following the exhibition of the Global Focus artworks in Beijing, China, the corpus of works traveled to various international locations. Immediately after the close of the Beijing exhibit, a selection of 53 American paintings were displayed at the Elite Gallery in  Moscow  from October to November 1995. Subsequently, in November 1995, a selection of 200 works adorned the walls of the art gallery at the United States Department of Health and Human Services in  Washington D.C.  Simultaneously, another group of artworks from the collection were exhibited at the United States Information Agency also in Washington D.C. On March 20, 1996, the first public showing of the collection in the United States opened at NMWA in Washington D.C., with a day-long celebration revisiting and reflecting upon the experiences in Beijing. This exhibition, titled "Look at the World Through Women’s Eyes", was on display through April 21, 1996. On September 28, 1996, the collection was exhibited at  George Washington University  in Washington D.C., during the National Women's Satellite Conference hosted by First Lady  Hillary Rodham Clinton . From April to June 1997, a selection of 300 works from the collection were exhibited at the Peace Museum in Detroit. The last public display of the Global Focus exhibit was shown during the 20th Anniversary Celebration of the 1977 Spirit of Houston Conference in Washington D.C. After this final showing, the large group of artworks ended its journey, and the entire collection was presented by the project co-directors Nancy Cusick and Mal Johnson to the archives of the National Museum of Women in the Arts.


On 28 September 2004, the Fourth World Conference on Women Commemorative Park was officially opened in  Huairou District , where the NGO forum was held. [ 26 ]


In 2014  UN Women  began its commemoration of the 20th anniversary of the Fourth World Conference on Women with the  Empowering Women, Empowering Humanity: Picture It!  campaign, also called the Beijing+20 campaign. [ 27 ] [ 28 ]


In 2019,  UN Women  launched the Generation Equality Campaign and Generation Equality Forum to "tackle the unfinished business of empowering women through a new groundbreaking, multi-generational campaign,  Generation Equality: Realizing women’s rights for an equal future ." [ 29 ]  Also called Beijing +25, the campaign and forum are being organized in collaboration with members of civil society, and are meant to serve as the planning events, along with the 64th Session of the UN's  Commission on the Status of Women  (CSW), in the lead up to a  UN General Assembly  high-level meeting in New York on September 23, 2020. [ 30 ]  In 2019, at the 73rd session of the UN General Assembly, governments agreed to present their commitments and planned activities to bring about gender equality by 2030 at a one-day session during the 74th session in 2020. [ 31 ]  The demands of the Generation Equality Campaign include "equal pay, equal sharing of unpaid care and domestic work, an end to sexual harassment and all forms of violence against women and girls, health-care services that respond to their needs, and their equal participation in political life and decision-making in all areas of life." [ 32 ]  The Generation Equality Forum is being convened by UN Women, and co-chaired by Mexico and France. The Forum will begin in Mexico City, May 7–8, 2020 and will conclude in Paris, France from 7-10 of July, 2020. [ 33 ]  Discussions and reviews of progress on the  Beijing Platform for Action  and the  Convention on the Elimination of All Forms of Discrimination Against Women  (CEDAW) will also take place at the 64th session of the Commission on the Status of Women, in New York, on March 9–20, 2020. [ 34 ]


On 1 October 2020, the High-Level Meeting on the 25th Anniversary of the Fourth World Conference on Women was held, where China proposed another Global Leaders' Meeting on Gender Equality and Women's Empowerment in 2025. [ 35 ]


In 2015 a documentary called "MAKERS: Once And For All", about the Fourth World Conference on Women, premiered. [ 36 ] [ 37 ]


The  Abortion Services (Safe Access Zones) (Scotland) Bill  was introduced by  Gillian Mackay ,  Scottish Greens  MSP for  Central Scotland  on 5 October 2023. It received  Royal assent  on 22 July 2024 and became an Act of the Scottish Parliament.  The Abortion Services (Safe Access Zones) Act (Scotland) 2024  creates safe access zones around abortion clinics in Scotland with a radius of 200 metres.


On 14 April 2022, there was a protest of 100 people outside the  Queen Elizabeth University Hospital  held by the anti-abortion group 40 Days for Life. [ 1 ]


The Northern Ireland Assembly passed similar legislation in 2023: the  Abortion Services (Safe Access Zones) Act (Northern Ireland) 2023 . The UK Parliament included a section which created safe zones for abortion clinics in the  Public Order Act 2023 .


The Royal College of Nursing Scotland released a statement in support of the bill in December 2023. [ 2 ]


On 25 March 2024, there was a large protest outside the  Queen Elizabeth University Hospital . [ 3 ]


In April, experts questioned why the law created 200 metre safe access zones rather than 150 metre safe access zones, but Gillian Mackay said she was resisting a change and intended to keep the 200 metre restrictions. [ 4 ]


On 22 July 2024, the legislation gained Royal Assent. [ 5 ]


The  Abortion Services (Safe Access Zones) Act (Northern Ireland) 2023  received  Royal assent  on 6 February 2023 and creates safe access zones around abortion clinics in Northern Ireland with a radius of 100 metres.


In 2020, a report by the NI Abortion and Contraception Taskgroup protest exclusion zones. [ 2 ]


In 2021, a majority of Northern Ireland's political parties supported protest exclusion zones. [ 3 ]


In 2022, the Northern Ireland Assembly voted in favour of the bill. [ 4 ]  The  Attorney General for Northern Ireland  referred it to  the Supreme Court , which unanimously ruled that the legislation was compatible with the European Court of Human Rights - it declared that "The right of women in Northern Ireland to access abortion services has now been established in law through the processes of democracy" - and that this legal right should not be obstructed by "opponents of the legislation based, some might think ironically, on the liberal values protected by the convention". [ 5 ]


Concealed ovulation  or  hidden estrus  is the lack of any perceptible change (e.g., a change in appearance or scent) when an adult female is fertile and near  ovulation . Some examples of perceptible changes are  swelling and redness of the vulva  in  baboons  and  bonobos , and  pheromone  release in the feline family.  In contrast, the females of  humans  and a few other species [ 1 ]  that undergo hidden estrus have few external signs of  fecundity , making it difficult for a mate to consciously deduce, by means of external signs only, whether or not a female is near ovulation.


In humans, an adult woman's fertility peaks for a few days during each roughly monthly cycle. The frequency and length of fertility (the time when a woman can become pregnant) is highly variable between women, and can slightly change for each woman over the course of her lifespan. Humans are considered to have concealed ovulation because there is no outward physiological sign, either to a woman herself or to others, that ovulation, or biological fertility, is occurring. Knowledge of the fertility cycle, learned through experience or from educational sources, can allow a woman to estimate her own level of fertility at a given time ( fertility awareness ). Whether other humans, potential reproductive partners in particular, can detect fertility in women through behavioral or invisible biological cues is highly debated. Scientists and laypersons are interested in this question because it has implications for human social behavior, and could theoretically offer biological explanations for some human sexual behavior. However, the science here is weak, due to a relatively small number of studies.


Several small studies have found that fertile women appear more attractive to men than women during infertile portions of her menstrual cycle, or women using  hormonal contraception . [ 2 ] [ 3 ]  It has also been suggested that a woman's voice may become more attractive to men during this time. [ 4 ]  Two small studies of  monogamous  human couples found that women initiated sex significantly more frequently when fertile, but male-initiated sex occurred at a constant rate, without regard to the woman's phase of menstrual cycle. [ 5 ]  It may be that a woman's awareness of men's courtship signals [ 6 ]  increases during her highly fertile phase due to an enhanced olfactory awareness of chemicals specifically found in men's body odor. [ 7 ] [ 8 ]


Analyses of data provided by the post-1998 U.S. Demographic and Health Surveys found no variation in the occurrence of coitus in the menstrual phases (except during menstruation itself). [ 9 ]  This is contrary to other studies, which have found female sexual desire and  extra-pair copulations  (EPCs) to increase during the midfollicular to ovulatory phases (that is, the highly fertile phase). [ 10 ]  These findings of differences in woman-initiated versus man-initiated sex are likely caused by the woman's subconscious awareness of her ovulation cycle (because of hormonal changes causing her to feel increased sexual desire), contrasting with the man's inability to detect ovulation because of its being "hidden". [ citation needed ]


In 2008, researchers announced the discovery in human semen of hormones usually found in ovulating women. They theorized that  follicle stimulating hormone ,  luteinising hormone , and  estradiol  may encourage ovulation in women exposed to semen. These hormones are not found in the semen of chimpanzees, suggesting this phenomenon may be a human male counter-strategy to concealed ovulation in human females.  Other researchers are skeptical that the low levels of hormones found in semen could have any effect on ovulation. [ 11 ]  One group of authors has theorized that concealed ovulation and menstruation were key factors in the development of  symbolic culture  in early human society. [ 12 ] [ 13 ]


Evolutionary psychologists  have advanced a number of different possible explanations for concealed ovulation. [ 14 ]   Some posit that the lack of signaling in some species is a trait retained from evolutionary ancestors, not something that existed previously and later disappeared. If signaling is supposed to have existed and was lost, then it could have been merely due to reduced adaptive importance and lessened selection, [ 15 ]  or due to direct adaptive advantages for the concealment of ovulation. Yet another possibility (regarding humans specifically) is that while highly specific signaling of ovulation is absent, human female anatomy evolved to mimic permanent signaling of fertility. [ 16 ]


The  paternal investment  hypothesis is strongly supported by many evolutionary biologists. [ 14 ]  Several hypotheses regarding human evolution integrate the idea that women increasingly required supplemental paternal investment in their offspring.  The shared reliance on this idea across several hypotheses concerning human evolution increases its significance in terms of this specific phenomenon.


This hypothesis suggests that women concealed ovulation to obtain men's aid in rearing offspring.  Schröder [ 14 ]  summarizes this hypothesis outlined in Alexander and Noonan's 1979 paper:  if women no longer signaled the time of ovulation, men would be unable to detect the exact period in which they were fecund.   This led to a change in men's mating strategy:  rather than mating with multiple women in the hope that some of them, at least, were fecund during that period, men instead chose to mate with a particular woman repeatedly throughout her menstrual cycle.  A mating would be successful in resulting in conception when it occurred during ovulation, and thus, frequent matings, necessitated by the effects of concealed ovulation, would be most evolutionarily successful. A similar  hypothesis  was proposed by Lovejoy in 1981 that argued that concealed ovulation, reduced canines and  bipedalism  evolved from a reproductive strategy where males provisioned food resources to his paired female and dependent offspring. [ 17 ] [ 18 ]


Continuous female sexual receptivity  suggests human sexuality is not solely defined by reproduction; a large part of it revolves around conjugal love and communication between partners.  Copulations between partners while the woman is pregnant or in the infertile period of her menstrual cycle do not achieve conception, but do strengthen the bond between these partners.  Therefore, the increased frequency of copulations due to concealed ovulation are thought to have played a role in fostering  pair bonds  in humans. [ 19 ]


The pair bond would be very advantageous to the  reproductive fitness  of both partners throughout the period of pregnancy, lactation, and rearing of offspring.  Pregnancy, lactation and caring for post-lactation offspring require vast amounts of energy and time on the part of the woman.  She must at first consume more food, then provide food to her offspring, while her ability to forage is reduced throughout.  Supplemental male investment in the mother and her offspring is advantageous to all parties.  While the man supplements the woman's limited gathered food, the woman is enabled to devote the necessary time and energy to the care of their offspring.  The offspring benefits from the supplemental investment, in the form of food and defense from the father, and receives the full attention and resources of the mother.  Through this shared parental investment, both man and woman would increase their offspring's chances for survival, thereby increasing their reproductive fitness.   In this way, natural selection would favor the establishment of pair bonds in humans.  To the extent that concealed ovulation strengthened pair bonding, selective pressure would favor concealed ovulation as well.


Another, more recent, hypothesis is that concealed ovulation is an adaptation in response to a promiscuous mating system, similar to that of our closest evolutionary relatives,  bonobos  and  chimpanzees . The theory is that concealed ovulation evolved in women to lessen paternity certainty, which would both lessen the chances of infanticide (as a father is less likely to kill offspring that might be his), and potentially increase the number of men motivated to assist her in caring for her offspring ( partible paternity ). This is supported by the fact that all other mammals with concealed ovulation, such as dolphins and  gray langurs , are promiscuous, and that the only other ape species that have multi-male communities, as humans do, are promiscuous. It is argued that evidence such as the  Coolidge effect , showing that a man does not seem to be naturally geared towards sexual mate-guarding behavior (that is, preventing other males from having access to his sexual partner), supports the conclusion that sexual monogamy (though perhaps not  social monogamy  and/or pair bonding) was rare in early modern humans. [ 20 ]


This hypothesis suggests the adaptive advantage for women who had hidden estrus would be a reduction in the possibility of  infanticide  by men, as they would be unable to reliably identify, and kill, their rivals' offspring. [ 14 ]  This hypothesis is supported by recent studies of wild  hanuman langurs , documenting concealed ovulation, and frequent matings with males outside their fertile ovulatory period. [ 21 ]  Heistermann et al. hypothesize that concealed ovulation is used by women to confuse paternity and thus reduce  infanticide in primates .  He explains that as ovulation is always concealed in women, men can only determine paternity (and thus decide on whether to kill the woman's child) probabilistically, based on his previous mating frequency with her, and so he would be unable to escape the possibility that the child might be his own, even if he were aware of promiscuous matings on the woman's part.


Schröder [ 14 ]  reviews a hypothesis by Symons and Hill, that after hunting, men exchanged meat for sex with women.   Women who continuously mimicked estrus may have benefited from more meat than those that did not.  If this occurred with enough frequency, then a definite period of estrus would have been lost, and with it sexual signaling specific to ovulation would have disappeared.


Schröder [ 14 ]  presents the idea of a "gradual diminution of mid-cycle estrus and concomitant continuous sexual receptivity in human women" because it facilitated orderly social relationships throughout the menstrual cycle by eliminating the periodic intensification of male–male aggressiveness in competition for mates. [ 14 ]  The extended estrous period of the bonobo (reproductive-age females are in heat for 75% of their menstrual cycle) has been said to have a similar effect to the lack of a "heat" in women.  While concealed human ovulation may have evolved in this fashion, extending estrus until it was no longer a distinct period, as paralleled in the bonobo, this theory of why concealed ovulation evolved has frequently been rejected. Schröder outlines the two objections to this hypothesis: (1) natural selection would need to work at a level above the individual, which is difficult to prove; and (2) selection, because it acts on the individuals with the most reproductive success, would thus favor greater reproductive success over social integration at the expense of reproductive success.


However, since 1993 when that was written, group selection models have seen a resurgence. [ 22 ] [ 23 ] [ 24 ]  (See  group selection ,  reciprocal altruism , and  kin selection .)


Schröder in his review writes that Benshoof and Thornhill hypothesized that estrus became hidden after monogamous relationships became the norm in  Homo erectus . [ 14 ]   Concealed ovulation allowed the woman to mate secretly at times with a genetically superior man, and thus gain the benefit of his genes for her offspring, while still retaining the benefits of the pair bond with her usual sexual partner.  Her usual sexual partner would have little reason to doubt her fidelity, because of the concealed ovulation, and would have high, albeit unfounded, paternity confidence in her offspring.  His confidence would encourage him to invest his time and energy in assisting her to care for the child, even though it was not his own.  Again, the idea of a man's investment being vital to the child's survival is a central fixture of a hypothesis regarding concealed ovulation, even as the evolutionary benefits accrue to the child, the woman, and her clandestine partner, and not to her regular sexual partner.


Pawlowski [ 25 ]  presents the importance of  bipedalism  to the mechanics and necessity of ovulation signaling.  The more open savannah environment inhabited by early humans brought greater danger from predators.  This would have caused humans to live in denser groups, and, in such a scenario, the long-distance sexual signaling provided by female genital swellings would have lost its function.  Concealed ovulation is thus argued to be a loss of function evolutionary change rather than an adaptation.   Thermoregulatory  systems were also modified in humans with the move to the  savannah [ clarification needed ]  to conserve water.  It is thought that female genital swellings would have incurred added cost because of ineffective evaporation of water from the area.  Pawlowski continues by saying the change to bipedalism in early hominins changed both the position of female genitals and the line of vision of males.  Since males could no longer constantly see the female genitals, swelling of them during estrus as a mode of signaling would have become useless.  Also, anogenital swelling at each ovulatory period may have interfered with the mechanics of bipedal locomotion, and selection may have favored females who were less hindered by this occurrence.  This hypothesis ultimately concludes that bipedalism, which was strongly selected for, caused the physiological changes and a loss of function of sexual signaling through female genital swelling, leading to the concealed ovulation we now observe.


Pawlowski's paper offers views that differ from the other hypotheses regarding concealed ovulation in that it pinpoints physiological changes in early humans as the cause of concealed ovulation rather than social or behavioral ones. [ 25 ]   One of the strengths of this is derived from the other hypotheses' weaknesses – it is difficult to track the evolution of a behavior as it leaves no verifiable evidence in the form of bone or DNA.  However, the fact that the  hanuman langurs  also display some concealed ovulation and that it is not directly caused by a physiological change to bipedalism may suggest bipedalism was not, at least, the sole cause of concealed ovulation in humans.  As stated earlier, it is possible for many elements of different hypotheses to be true regarding the selective pressures for concealed ovulation in humans.


Dam betulim  ( Hebrew :  דם בתולים ,  lit.   'blood [of the] virgin[al]') in Judaism refers to the emission of  vaginal  blood that is often exuded upon the first time a woman has sexual intercourse and her  hymen  is penetrated. After the blood exudes, the woman becomes a  niddah  ( Hebrew :  נִדָּה ), and the couple must refrain from further sexual intercourse until the woman completes her purification process. For this reason, it has sometimes been practice for couples to refrain from sexual intercourse until several days after marriage in order to be able to remain physically intimate for a longer period directly following the wedding. [ 1 ]


This  Judaism -related article is a  stub . You can help Wikipedia by  expanding it .


Emmenagogues  (also spelled  emmenagogs ) are  herbs  which stimulate  blood  flow in the  pelvic  area and  uterus ; some stimulate  menstruation . Women may use emmenagogues to stimulate menstrual flow when menstruation is absent for reasons other than pregnancy, such as hormonal disorders or conditions like  oligomenorrhea  (infrequent menses).


According to Riddle, [ 1 ] [ page needed ]  these herbs were also used to assist women whose menstruation was "delayed", for the reason that they had conceived. There are a large number of substances which can act as emmenagogues. Many, such as  Mentha pulegium , European pennyroyal, or  tansy , may bring on menses when administered as a tea. However, if a concentrated dose is taken, such as by consuming an oil, they can pose serious medical risks including organ damage and incomplete abortions. [ 2 ] [ 3 ]  Rue ( Ruta graveolens ) and wild rue ( Peganum harmala ) are other commonly available emmenagogues which can result in serious harm. [ 4 ]


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Endometriosis  is a disease in which  cells  like those in the  endometrium , the layer of  tissue  that normally covers the inside of the  uterus , grow outside the uterus. [ 8 ] [ 9 ]  It occurs in humans and a limited number of  menstruating mammals . Endometrial tissue most often grows on or around reproductive organs such as the  ovaries  and  fallopian tubes , on the outside surface of the uterus, or on the tissues surrounding the uterus and the ovaries ( peritoneum ). [ 3 ]  It can also grow on other organs in the pelvic region like the  bowels ,  stomach ,  bladder , or the  cervix . [ 10 ]  Rarely it can also occur in other parts of the body. [ 3 ]


Symptoms can be very different from person to person, varying in range and intensity. About 25% of individuals have no symptoms, [ 1 ] [ 11 ]  while for some it can be a debilitating disease. [ 12 ]  Common symptoms include  pelvic pain , heavy and painful periods, pain with bowel movements, painful urination,  pain during sexual intercourse  and  infertility . [ 1 ] [ 13 ]  Nearly half of those affected have  chronic pelvic pain , while 70% feel pain during  menstruation . [ 1 ]  Up to half of affected individuals are infertile. [ 1 ]  Besides physical symptoms, endometriosis can have an effect on the mental health and social life of people. [ 14 ]


Diagnosis is usually based on symptoms and  medical imaging ; [ 3 ]  however, a definitive diagnosis is made through laparoscopy and   biopsy . [ 3 ]  Other causes of similar symptoms include  pelvic inflammatory disease ,  irritable bowel syndrome ,  interstitial cystitis , and  fibromyalgia . [ 1 ]  Endometriosis is often misdiagnosed and many patients report being incorrectly told their symptoms are trivial or normal. [ 14 ]  Patients with endometriosis see an average of seven physicians before receiving a correct diagnosis, with an average delay of 6.7 years between the onset of symptoms and surgically obtained biopsies, the  gold standard  for diagnosing the condition. [ 15 ]


It is estimated that globally around 10% of the female population, 190 million women are affected by endometriosis. [ 16 ]  Ethnic differences have been observed in endometriosis, as  Southeast Asian  and  East Asian  women are significantly more likely than  White  women to be diagnosed with endometriosis. [ 17 ] [ 18 ]


The exact cause of endometriosis is not known. Possible causes include problems with menstrual period flow, genetic factors, hormones, and problems with the immune system. [ 3 ]  Endometriosis is associated with elevated levels of the female sex hormone  estrogen , as well as  estrogen receptor  sensitivity. [ 19 ]  Estrogen exposure worsens the inflammatory symptoms of endometriosis by stimulating an immune response. [ 20 ] [ 21 ]


While there is no cure for endometriosis, several treatments may improve symptoms. [ 1 ]  This may include  pain medication , hormonal treatments or surgery. [ 3 ]  The recommended pain medication is usually a  non-steroidal anti-inflammatory drug  (NSAID), such as  naproxen . [ 3 ]  Taking the active component of the  birth control pill  continuously or using an  intrauterine device with progestogen  may also be useful. [ 3 ]   Gonadotropin-releasing hormone agonist  (GnRH agonist) may improve the ability of those who are infertile to conceive. [ 3 ]  Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments. [ 3 ]


Pain and infertility are common symptoms, although 20–25% of affected women are asymptomatic. [ 1 ]  Presence of pain symptoms are associated with the type of endometrial lesions as 50% of women with typical lesions, 10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain. [ 22 ]


A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the  pelvis , in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis. [ 23 ]  The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress. [ 24 ]  Symptoms of endometriosis-related pain may include:


Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. [ 28 ]  Individual pain areas and pain intensity appear to be unrelated to the surgical diagnosis, and the area of pain unrelated to the area of endometriosis. [ 28 ]


There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" during menstruation. The blood accumulates locally if it is not cleared shortly by the immune, circulatory, and lymphatic systems. This accumulation can  lead to swelling, which triggers inflammation with the activation of  cytokines , resulting in pain. Another source of pain is organ dislocation that arises from  adhesion  binding internal organs together. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can all be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods. [ 29 ]


Additionally, endometriotic lesions can develop their own nerve supply, creating a direct and two-way interaction between lesions and the  central nervous system . This interaction can produce a variety of individual differences in pain that, in some cases, become independent of the disease itself. [ 23 ]  Nerve fibers and blood vessels are thought to grow into endometriosis lesions by a process known as  neuroangiogenesis . [ 30 ]


About a third of women with infertility have endometriosis. [ 1 ]  Among those with endometriosis, about 40% are infertile. [ 1 ]  The  pathogenesis  of infertility varies by disease stage: in early-stage disease, it is hypothesised to result from  an inflammatory response that impairs various aspects of conception, whereas in later stages, distorted pelvic anatomy and adhesions contribute to impaired fertilisation. [ 31 ]


Bowel endometriosis may include symptoms like  diarrhea ,  constipation , tenesmus, dyschezia, and, rarely, rectal bleeding. Other symptoms include  chronic fatigue ,  nausea  and  vomiting ,  migraines , low-grade  fevers ,  heavy  (44%) and/or  irregular periods  (60%), and  hypoglycemia . [ 25 ] [ 32 ] [ 26 ]  Endometriosis is associated with certain types of cancers, notably some types of  ovarian cancer , [ 33 ]   non-Hodgkin's lymphoma  and  brain cancer . [ 34 ]  Endometriosis is however unrelated to  endometrial cancer . [ 35 ]


Rarely, endometriosis can cause endometrium-like tissue to be found in other parts of the body.  Thoracic endometriosis  occurs when endometrium-like tissue implants in the  lungs  or pleura. Manifestations of this include  coughing up blood , a  collapsed lung , or  bleeding into the pleural space . [ 17 ] [ 36 ]  Endometriosis may also affect the nearby colon which in rare situations may progress to partial  obstruction  requiring emergency surgery. [ 37 ]


Stress may be a contributing factor or a consequence of endometriosis. [ 38 ]


Complications of endometriosis include internal scarring, adhesions, pelvic  cysts , ovarian  chocolate cysts , ruptured cysts, and  bowel  and ureter obstruction resulting from pelvic adhesions. [ 39 ]   Endometriosis-associated infertility  may result from scar formation and anatomical distortions caused by the condition. [ 3 ]


Ovarian endometriosis may complicate  pregnancy  through  decidualization , abscess formation and/or rupture. [ 40 ]


Thoracic endometriosis  can be associated with recurrent  thoracic endometriosis syndrome  which manifests during menstrual periods. It includes  catamenial  pneumothorax in 73% of women, catamenial  hemothorax  in 14%, catamenial hemoptysis in 7%, and pulmonary  nodules  in 6%. [ 41 ] [ 42 ]


A 20-year study involving 12,000 women with endometriosis found that individuals under 40 are three times more likely to develop heart problems compared to their healthy peers. [ 43 ]


A study indicated that 39% of women with surgically confirmed non-graded endometriosis had a 270% higher risk for  ectopic pregnancy  and a 76% higher risk for  miscarriage  compared to their peers. For women with deep endometriosis (>5 mm invasion, ASRM Stage II and higher), the risk of miscarriage increased by 298%. [ 44 ] [ 45 ]


Women with endometriosis also face a significantly increased risk of experiencing  ante-  and  postpartum hemorrhage [ 45 ]   as well as a 170% increased risk of severe  pre-eclampsia [ 46 ]  during pregnancy.


Endometriosis slightly increases the risk (about 1% or less) of developing ovarian, breast and thyroid cancers compared to women without the condition. [ 47 ]


The mortality rates associated with endometriosis are low, with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000, respectively. [ 6 ]


Sciatic endometriosis also called catamenial or cyclical sciatica, is a rare form where endometriosis affects the sciatic nerve. Diagnosis is usually confirmed through  MRI  or  CT-myelography . [ 48 ]


Endometriosis can also impact a woman's  fetus  or  neonate , increasing the risks for  congenital malformations ,  preterm delivery  and higher  neonatal death  rates. [ 46 ]


Endometriosis can lead to ovarian cysts (endometriomas), adhesions, and damage to the fallopian tubes or ovaries, all of which can interfere with ovulation and fertilization. Treatment for endometriosis often includes hormonal therapies, pain management, and in some cases, surgery to remove the endometrial tissue. For women who struggle with infertility due to endometriosis, assisted reproductive technologies such as in vitro fertilization (IVF) may be recommended, sometimes in combination with surgical treatment to improve fertility outcomes.


"Endometriosis is associated with an elevated risk of developing depression and anxiety disorders". [ 49 ]  Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients.


"It has been demonstrated that pelvic pain has significant negative effects on women's mental health and quality of life; in particular, women who suffer from pelvic pain report high levels of anxiety and depression, loss of working ability, limitations in social activities and a poor quality of life"  [ 50 ]


Mental health concerns like depression and anxiety can also result due to poor diagnostic procedures related to cultural norms where women's concerns are devalued or ignored, especially by medical professionals. [ 51 ] [ 52 ]


Endometriosis is a  heritable condition  influenced by both genetic and  environmental factors , [ 53 ]  a genetic disorder of  polygenic/multifactorial inheritance [ 54 ]  acquired via affected genes from either  a person's father or mother . For example, children or siblings of women with endometriosis are at higher risk of developing endometriosis themselves; low  progesterone  levels may be genetic, and may contribute to a hormone imbalance. [ 55 ]  Individuals with an affected first-degree relative have an  approximate six-fold increase incidence of endometriosis. [ 56 ]


Inheritance is significant, but not the sole risk factor for endometriosis. Studies attribute 50% of risk to genetics, the other 50% likely to environmental factors. [ 57 ]  It has been proposed that endometriosis may result from a series of multiple mutations, within target genes, in a mechanism similar to the development of cancer. [ 53 ]  In this case, the mutations may be either  somatic  or  heritable . [ 53 ]


A 2019  genome-wide association study  (GWAS) review enumerated 36 genes with mutations associated with endometriosis development. [ 58 ]  Nine  chromosome loci  were robustly replicated: [ 59 ] [ 60 ] [ 61 ] [ 62 ]


There are many findings of altered  gene expression  and  epigenetics , but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of  miRNAs . [ 53 ]


Some factors associated with endometriosis include:


Potential  toxins :


A growing body of evidence has shown a correlation between an imbalance in the vaginal  microbiome  and the appearance of endometriosis. [ 71 ]  This correlation is mediated by an  immune system  overload in the context of retrograde menstruation, in which it fails to detect and kill cells that come outside of the vaginal environment. By disrupting normal immune function, dysbiosis leads to elevated levels of proinflammatory cytokines, a compromised immunosurveillance system and altered immune cell profiles. Indeed, the activation of  Toll-like receptors  in  macrophages  leads to a greater activity of this immune cell type. They, in turn, secrete factors (such as the pro-inflammatory cytokine  interleukin 8 ) that help creating an inflammatory environment, ultimately favoring the proliferation and adhesion of endometrial cells. [ 71 ] [ 72 ]


While the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other. The  pathophysiology  of endometriosis is likely to be  multifactorial  and to involve an interplay between several factors. [ 53 ]


The main theories for the formation of the ectopic endometrium-like tissue include retrograde menstruation, Müllerianosis, coelomic metaplasia, vascular dissemination of  stem cells , and surgical transplantation were postulated as early as 1870. Each is further described below. [ 17 ] [ 73 ] [ 74 ]


The theory of retrograde menstruation (also called the  implantation theory  or  transplantation theory ) is the most commonly accepted theory for the dissemination and transformation of ectopic endometrium into endometriosis. It suggests that during a woman's  menstrual flow , some of the endometrial debris flow backward through the fallopian tubes and into the peritoneal cavity, attaching itself to the  peritoneal surface  (the lining of the abdominal cavity) where it can proceed to invade the tissue as or transform into endometriosis. It is not clear at what stage the transformation of endometrium, or any cell of origin such as stem cells or coelomic cells (see those theories below), to endometriosis begins. [ 53 ] [ 73 ] [ 75 ]


Proofs in support of the theory are based on retrospective epidemiological studies that an association with endometrial implants attached to the peritoneal cavity, which would develop into endometrial lesions and retrograde menstruation; and the fact that animals like rodents and non-human primates whose endometrium is not shed during the estrous cycle don't develop naturally endometriosis contrary to animals that have a natural menstrual cycle like rhesus monkeys and baboons. [ 76 ]


Retrograde menstruation alone is not able to explain all instances of endometriosis, and additional factors such as genetics, immunology, stem cell migration, and coelomic metaplasia (see "Other theories" on this page) are needed to account for disseminated disease and why many individuals with retrograde menstruation are not diagnosed with endometriosis. In addition, endometriosis has shown up in people who have never experienced menstruation including cisgender men, [ 77 ]  fetuses, [ 78 ]  and prepubescent girls. [ 79 ] [ 80 ]  Further theoretical additions are needed to complement the retrograde menstruation theory to explain why cases of endometriosis show up in the  brain [ 81 ]  and lungs. [ 82 ]


Researchers are investigating the possibility that the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to  autoimmune disease ,  allergic  reactions, and the impact of toxic materials. [ 20 ] [ 83 ]  It is still unclear what, if any, causal relationship exists between toxic materials or autoimmune disease and endometriosis. There are immune system changes in people with endometriosis, such as an increase of macrophage-derived secretion products, but it is unknown if these are contributing to the disorder or are reactions from it. [ 84 ]


Endometriotic lesions differ in their biochemistry, hormonal response, immunology, inflammatory response when compared to endometrium. [ 17 ] [ 85 ]  This is likely because the cells that give rise to endometriosis are a side population of cells. [ 53 ]  Similarly, there are changes in, for example, the  mesothelium  of the peritoneum in people with endometriosis, such as loss of  tight junctions , but it is unknown if these are causes or effects of the disorder. [ 84 ]


In rare cases where  imperforate hymen  does not resolve itself prior to the first menstrual cycle and goes undetected, blood and endometrium are trapped within the uterus until such time as the problem is resolved by surgical incision. Many health care practitioners never encounter this defect, and due to the  flu-like symptoms  it is often misdiagnosed or overlooked until multiple menstrual cycles have passed. By the time a correct diagnosis has been made, endometrium and other fluids have filled the uterus and Fallopian tubes with results similar to retrograde menstruation resulting in endometriosis. The initial stage of endometriosis may vary based on the time elapsed between onset and surgical procedure. [ citation needed ]


The theory of retrograde menstruation as a cause of endometriosis was first proposed by  John A. Sampson . [ 73 ] [ 86 ]


Most often, endometriosis is found on the:


Less common pelvic sites are:


Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision, known as "scar endometriosis." [ 97 ]  Rectovaginal or bowel endometriosis affects approximately 5-12% of those with endometriosis, and can cause severe pain with bowel movements. [ 98 ] [ citation needed ]


Deep infiltrating endometriosis (DIE) has been defined as the presence of endometrial glands and stroma infiltrating more than 5 mm in the subperitoneal tissue. The prevalence of DIE is estimated to be 1 to 2% in women of reproductive age. Deep endometriosis typically presents as a single nodule in the vesicouterine fold or in the lower 20 cm of the bowel. Deep endometriosis can be associated with severe pain. However, it can be present without severe levels of pain. [ 99 ]


Endometriosis has been reported in people  assigned male at birth .  Prostate  endometriosis has been reported following estrogen therapy for prostate cancer [ 100 ]  and  feminizing hormone therapy . [ 101 ]


Abdominal endometriosis also happens in men following cirrhosis. [ 102 ]


Rarely, endometriosis appears in extrapelvic parts of the body, such as the lungs, brain, and  skin . [ 3 ] [ 42 ] [ 97 ]  "Scar endometriosis" can occur in surgical abdominal incisions. [ 97 ]  Risk factors for scar endometriosis include previous abdominal surgeries, such as a hysterotomy or cesarean section, or ectopic pregnancies, salpingostomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair. [ 103 ] [ 104 ] [ 105 ]


Endometriosis may also present with skin lesions in  cutaneous endometriosis . [ 97 ]


Less commonly lesions can be found on the diaphragm or lungs. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict the cyclic pain of the right  scapula  (shoulder) or  cervical area  (neck) during a menstrual period. [ 106 ]  Pulmonary endometriosis can be associated with a  thoracic endometriosis syndrome  that can include  catamenial  (occurs during menstruation) pneumothorax seen in 73% of women with the syndrome, catamenial hemothorax in 14%, catamenial hemoptysis in 7%, and pulmonary nodules in 6%. [ 42 ]


A health history and a physical examination can lead the health care practitioner to suspect endometriosis. There is a clear benefit for performing a  transvaginal ultrasound  (TVUS) as a first step of testing for endometriosis. [ 99 ]


Definitive diagnosis is based on the  morphology  (form and structure) of the pelvic region, determined by observation (surgical or non-invasive imaging), classified into four different stages of endometriosis. The American Society of Reproductive Medicine's scale, revised in 1996, gives higher scores to deep, thick lesions or intrusions on the ovaries and dense, enveloping adhesions on the ovaries or fallopian tubes. [ 107 ]  Additionally,  histological  studies, when performed, should show specific findings.


For many patients, there are significant delays in diagnosis. Studies show an average delay of 11.7 years in the United States. Patients in the UK have an average delay of 8 years and in Norway of 6.7 years. [ 108 ]  A third of women had consulted their GP six or more times before being diagnosed. [ 108 ]


The most common sites of endometriosis are the ovaries, followed by the Douglas pouch, the posterior leaves of the broad ligaments, and the sacrouterine ligaments. [ 25 ]


As for deep infiltrating endometriosis, TVUS,  TRUS  and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity. [ 109 ]


Laparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to accurately diagnose the extent and severity of pelvic/abdominal endometriosis. [ 110 ]  Laparoscopy is not an applicable test for extrapelvic sites such as umbilicus, hernia sacs, abdominal wall, lung, or kidneys. [ 110 ]


Reviews in 2019 and 2020 concluded that 1) with advances in imaging, endometriosis diagnosis should no longer be considered synonymous with immediate laparoscopy for diagnosis, and 2) endometriosis should be classified a syndrome that requires confirmation of visible lesions seen at laparoscopy in addition to characteristic symptoms. [ 111 ] [ 112 ]


Laparoscopy permits lesion visualization unless the lesion is visible externally (e.g., an endometriotic nodule in the vagina) or is extra-abdominal. [ 110 ]  If the growths (lesions) are not visible, a biopsy must be taken to determine the diagnosis. [ 113 ]  Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.


During a laparoscopic procedure, lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. Lesions vary in size. [ 114 ]  Some within the pelvis walls may not be visible, as normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases. [ 115 ]  Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominal areas. [ 114 ]  Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as  endometriomas  or "chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old blood. [ 114 ]


Frequently during diagnostic laparoscopy, no lesions are found in individuals with chronic pelvic pain, a symptom common to other disorders including  adenomyosis , pelvic adhesions, pelvic inflammatory disease,  congenital anomalies  of the  reproductive tract , and ovarian or tubal masses. [ 116 ]


Vaginal ultrasound can be used to diagnosis endometriosis, or for localizing endometrioma before surgery. [ 117 ]  This can be used to identify the spread of disease in individuals with well-established clinical suspicion of endometriosis. [ 117 ]  Vaginal ultrasound is inexpensive, easily accessible, has no contraindications and requires no preparation. [ 117 ]  By extending the ultrasound assessment into the posterior and anterior pelvic compartments a sonographer is able to evaluate structural mobility and look for deep infiltrating endometriotic nodules. [ 118 ]  Better sonographic detection of deep infiltrating endometriosis could reduce the number of diagnostic laparoscopies, as well as guide disease management and enhance patient quality of life. [ 118 ]


MRI is another means of detecting lesions in a non-invasive manner. [ 110 ]  MRI is not widely used due to its cost and limited availability, although it can be used to detect the most common form of endometriosis (endometrioma) with a sufficient accuracy. [ 110 ]  A 2020 article recommended administering an anti-spasmodic agent (i.e.  hyoscine butylbromide ) and a big glass of water (if the bladder is empty), and scanning in the supine position with an abdominal strap, for better image quality. [ 119 ]  It also recommended using  pelvic-phased array coils  and T1 (spin-lattice) weighted scanning, with and without suppression of fat for endometriomas, and sagittal, axial and oblique 2D T2 (spin-spin) weighting for deep infiltrating endometriosis. [ 119 ]


By surgical observation, endometriosis can be classified as stage I–IV by the 1996 scale of the  American Society of Reproductive Medicine  (ASRM). [ 107 ]  The scale uses a point system that assesses lesions and adhesions in the pelvic organs. It is important to note that staging assesses physical disease only, not the level of pain or infertility. [ 120 ]  A person with Stage I endometriosis may have a little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. The various stages are summarized by:


Stage I (Minimal)


Stage II (Mild)


Stage III (Moderate)


Stage IV (Severe)


An area of research is the search for endometriosis  markers . [ 121 ]


In 2010, essentially all proposed biomarkers for endometriosis were of unclear medical use, although some appear to be promising. [ 121 ]  The one biomarker that has been in use over the last 20 years is  CA-125 . [ 121 ]  A 2016 review found that this biomarker was present in those with symptoms of endometriosis; and, once ovarian cancer has been ruled out, a positive CA-125 may confirm the diagnosis. [ 122 ]  Its performance in ruling out endometriosis is low. [ 122 ]  CA-125 levels appear to fall during endometriosis treatment, but it has not shown a correlation with disease response. [ 121 ]


Another review in 2011 identified several putative biomarkers upon biopsy, including findings of small sensory nerve fibers or defectively expressed  β3 integrin  subunit. [ 123 ]  It has been postulated a future diagnostic tool for endometriosis will consist of a panel of several specific and sensitive biomarkers, including both substance concentrations and genetic predisposition. [ 121 ]


A 2016 review of endometrial biomarkers for diagnosing endometriosis was unable to draw conclusions due to the low quality of the evidence. [ 124 ]


MicroRNAs have the potential to be used in diagnostic and therapeutic decisions. [ 125 ]


For a histopathological diagnosis, at least two of the following three criteria should be present: [ 126 ]


Immunohistochemistry  has been found to be useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and confirm the presence of stromal cells and sometimes glandular tissue is identified that was missed on routine  H&E staining . [ 127 ]


The most common  pain scale  for quantification of endometriosis-related pain is the  visual analogue scale  (VAS); VAS and  numerical rating scale  (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and for more detailed pain measurement in clinical practice, VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the  clinical global impression  (CGI) and a  quality of life  scale, are used. [ 128 ]