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Association between the C-reactive protein-triglyceride–glucose index and endometriosis: a cross-sectional study using data from the national health and nutrition examination survey, 1996–2006

BMC Women's Health volume 25, Article number: 13 (2025) Cite this article

Abstract

Background

The C-reactive protein–triglyceride glucose index (CTI) is a promising new marker for evaluating the severity of inflammation. Endometriosis (EM) is a prevalent chronic inflammatory condition influenced by estrogen, primarily affecting women of reproductive age. However, no study has demonstrated an association between the CTI and EM.

Methods

This cross-sectional study sourced data from females 20–50 years of age from the National Health and Nutrition Examination Survey (NHANES) 1996–2006, and included those with self-reported diagnoses of EM and sufficient information to calculate the CTI, computed as 0.412 × ln (C-reactive protein [CRP]) + ln (triglycerides [mg/dL] × fasting plasma glucose [mg/dL]/2). Multivariate logistic regression, restricted cubic splines, and subgroup analyses were performed to examine the association between the CTI and EM.

Results

Data from 2235 women (175 [7.82%] with EM, 2060 [92.18%] without EM [controls]), were included: those with EM exhibited a tendency toward higher CTI (p = 0.005), and CTI was positively associated with the prevalence of EM (p = 0.011). In Model 1, a 1 mg/dL increment in CTI was associated with a 56% higher prevalence of EM (odds ratio [OR] 1.563 [95% confidence interval (CI) 1.295–1.885]; P < 0.001). This association in Model 2 (OR 1.609 [95% CI 1.334–1.941]; p < 0.001) and Model 3 (OR 1.565 [95% CI 1.246–1.966]; p < 0.001) remained significant. Notably, individuals in the uppermost remnant cholesterol tertile exhibited a notably higher prevalence of EM than those in the lowest tertile (OR 3.029, p = 0.051). Restricted cubic splines revealed a nonlinear positive association between CTI and the prevalence of EM. In addition, greater EM prevalence was observed with CTI in those > 40 years of age (OR 1.57 [95% CI 1.16–2.13]), body mass index ≥ 25 kg/m2 (OR 1.38 [95% CI 1.06–1.80]), smoking ≥ 100 cigarettes (OR 1.43 [95% CI 1.06–1.96]), married or living with partner (OR 1.41 [95% CI 1.09–1.85]), and oral contraceptive use (OR 1.35 [95% CI 1.07–1.69]).

Conclusions

CTI was positively associated with EM in women in the United States. Use of the CTI as an indicator of inflammation may provide new insights for the prevention and management of EM.

Peer Review reports

Background

Endometriosis is a common, chronic, inflammatory, and benign gynecological disorder characterized by the growth of endometrioid tissue outside the uterine cavity, with a prevalence of approximately 10% in women of childbearing age [1,2,3]]. The standard method for diagnosing endometriosis is laparoscopy-guided biopsy [4, 5]], which often leads to significant delays in diagnosis, typically ranging from to 6–11 years [6]]. The development of innovative diagnostic methods and predictive biomarkers is essential for improving diagnostic accuracy and sensitivity and, ultimately, enhancing patient quality of life.

The C-reactive protein (CRP)–triglyceride (TG)–glucose index (CTI) is gaining recognition as a new metric for thorough evaluation of the severity of inflammation and insulin resistance (IR). The CTI was calculated using the following formula: 0.412 × ln(CRP) + ln[TG (mg/dL) × fasting plasma glucose [FPG] (mg/dL)/2]. A novel metric, termed the “CTI”, provides a comprehensive assessment of both inflammatory status and IR [7]. The CTI is the sole metric that combines the intensity of inflammation and IR, and has been recognized to be valuable in predicting survival rates in the Chinese cancer population [7]. Additionally, the CTI is a straightforward and rapid indicator that incurs no additional costs beyond standard laboratory investigations. Consequently, in the general population, there is no further f [8]inancial burden on patients or the healthcare system. Elevated CRP levels indicate a systemic inflammatory response [9]. Endometriosis is a complex chronic inflammatory disease [10]. The classification of endometriosis as an inflammatory disorder is supported by various lines of evidence, including alterations in the peritoneal environment of affected women, the recruitment of numerous immune cells to endometriotic lesions, and the abnormal production of pro-inflammatory cytokines and regulatory proteins [11]. Elevated levels of pro-inflammatory markers, such as CRP, have been consistently observed in women diagnosed with endometriosis. These inflammatory responses are believed to promote lesion survival, vascularization, and cell proliferation, exacerbating the disease [12]. Recent studies have suggested a link between IR and inflammatory pathways in endometriosis, highlighting the multifaceted role of inflammation in disease development [8, 13, 14]. Considering these perspectives, it is important to investigate the potential link between CTI and the risk for developing endometriosis. As such, our aim was to explore the relationship between the CTI and endometriosis by analyzing data from the National Health and Nutrition Examination Survey (NHANES, 1999–2006), with the intention of offering compelling evidence supporting this association.

Materials and methods

Study population

NHANES, a nationally representative study approved by the Research Ethics Review Board of the National Center for Health Statistics (NCHS), was conducted by the Centers for Disease Control and Prevention. Informed consent was obtained from all participants at the time of enrollment.

Data were sourced from 41,474 individuals in 4 consecutive two-year NHANES cycles (1999–2000, 2001–2002, 2003–2004, 2005–2006). Ultimately, data from 2235 female participants 20–50 years of age were included. Inclusion criteria were as follows: female sex; age 20–50 years; and available data regarding endometriosis diagnosis and relevant variables, including the CTI and other covariates. Individuals without complete data regarding endometriosis, CTI, or covariates such as body mass index (BMI), smoking status, or other relevant factors, were excluded. Additionally, individuals < 20 years of age and those with incomplete clinical data were also excluded. Participants who fulfilled the inclusion criteria were assigned to the endometriosis or control group according to their diagnosis.

Endometriosis

A questionnaire-based survey asking, “Has a doctor or other health professional ever told you that you had endometriosis (age at interview, 20–54 years)?” was collected to diagnose endometriosis. Participants who responded affirmatively were allocated the endometriosis group; otherwise, they were allocated to the control group. Although relying on questionnaire responses to determine the primary study outcome may introduce some degree of uncertainty, the lack of direct diagnostic methods, such as laparoscopy or pathological confirmation, in the NHANES dataset complicated the precise identification of endometriosis cases. However, previous studies have demonstrated the feasibility and acceptance of using questionnaires to identify the presence of endometriosis among NHANES participants [15,16,17,18].

Calculation of the CTI

The CTI [7] was calculated as follows: CTI = 0.412 × ln (CRP) + TyG (TyG = ln [fasting triglyceride (TG) (mg/dL) × fasting glucose (FPG) (mg/dL)/2]) [19]. Blood samples were collected in the morning after an 8.5 h fast and processed in NCHS-certified laboratories. Serum TG levels were assessed using chemistry analyzers (Modular P and Cobas 6000, Roche Diagnostics, Basel, Switzerland), whereas FPG levels were assessed using the oxygen rate method on a laboratory analyzer (DxC800, Beckman-Coulter Diagnostics, Brea, CA, USA) [20, 21]. CRP levels were determined using latex-enhanced nephelometry (CSL Behring, King of Prussia, PA, USA) [22]. Additional details regarding the laboratory procedures are available on the official NHANES website. An elevated CTI usually suggests a more severe level of inflammation and IR [19].

Covariables

Covariates included age, age at menarche (years), poverty income ratio (PIR), and BMI, smoked ≥ 100 cigarettes, race/ethnicity, marital status, education level, hypertension, diabetes, alcohol intake, oral contraceptive use, infertility, CRP (mg/dL), fasting TG (mg/dL), FPG (mg/dl), TG glucose index (TyG), total cholesterol (mg/dL), and CTI. Age was categorized into 2 groups according to clinical relevance (≤ 40 and > 40 years); BMI was classified as normal (< 25 kg/m2) or overweight (≥ 25 kg/m2), based on clinical significance; and smoking status was categorized as having smoked at least 100 cigarettes in one’s lifetime (yes, no). There were 3 levels for PIR: < 1.3; 1.5–3.0; and ≥ 3.0.

Statistical analysis

To assess differences between the 2 groups, the Student’s t-test was used for continuous variables. This test helps determine whether there are statistically significant differences in the means between the 2 groups. For categorical variables, the chi-squared test was used to evaluate whether there was a significant association between categorical outcomes across groups. By selecting the appropriate statistical method(s), the analysis ensured robust data evaluation.

Logistic regression models were constructed to assess the relationship between CTI and endometriosis. Three models were constructed: Model 1 (unadjusted); Model 2 (adjusted for age and ethnicity); and Model 3 (additionally adjusted for PIR, BMI, education level, marital status, smoking habits, hypertension, diabetes, drinking status, age at menarche, total cholesterol, and use of oral contraceptives). The relationship between an increase in CTI of 1 mg/dL and endometriosis was determined. In addition, stratified analyses were performed according to participant age, BMI, age at menarche, smoking, drinking and marital status, and use of oral contraceptives. Prevalence was calculated as odds ratio (OR) and corresponding 95% confidence interval (CI). To flexibly model the association between CTI and the prevalence of endometriosis, restricted cubic splines with three knots was used. Statistical analysis was performed using R version 4.2 (R Foundation for Statistical Computing, Vienna, Austria) and EmpowerStats version 5.0 (http://www.empowerstats.net). Differences with P < 0.05 were considered to be statistically significant.

Results

Baseline characteristics

Between 1999 and 2006, the NHANES included 6508 participants. Among them, 951 participants were excluded due to endometriosis, 3050 due to CTI, and 272 due to incomplete covariate data. Ultimately, data from 2235 participants were included in the final analysis. Based on the diagnosis of endometriosis, 175 (7.83%) participants comprised the endometriosis group while 2060 (92.17%) comprised the control group (Fig. 1). Participant characteristics are summarized in Table 1. Participants with endometriosis were more likely to have used oral contraceptives for birth control and were more often non-Hispanic White than those without endometriosis. Moreover, patients with endometriosis exhibited higher rates of smoking and marriage, and were more likely to be obese. Notably, CRP, TyG, fasting TG, total cholesterol, and CTI were higher in patients with endometriosis than in those without (Table 1).

Fig. 1
figure 1

Flow chart of eligible participants selection

Full size image
Table 1 Characteristics of participants
Full size table

Association between CTI and endometriosis

Results reflecting the association between the CTI and endometriosis, analyzed using the 3 different models, are summarized in Table 2. In all models, a continuous increase in CTI was significantly associated with an elevated prevalence of endometriosis. Specifically, in the unadjusted model (i.e., Model 1), the OR for continuous CTI was 1.563 (95% CI 1.295–1.885; p < 0.001), whereas in the model adjusted for age and ethnicity (i.e., Model 2), the OR increased slightly to 1.609 (95% CI 1.334–1.941; p < 0.001). After further adjustment for various factors, including BMI, PIR, education level, and lifestyle habits (i.e., Model 3), the OR remained significant (1.565 [95% CI 1.246–1.966]; p < 0.001), indicating a consistent relationship between higher CTI and the risk for endometriosis. When stratified according to quartiles, the highest CTI quartile (Q4) was associated with significantly increased odds of endometriosis across all models, with ORs of 3.430 (95% CI 1.589–7.402; p = 0.002) in Model 1, 3.615 (95% CI 1.667–7.839; p = 0.002) in Model 2, and 3.029 (95% CI 1.306–7.025; p = 0.011) in Model 3. These results suggest that an elevated CTI is strongly associated with an increased risk for endometriosis even after controlling for multiple demographic and clinical factors.

Table 2 Association between CTI and endometriosis
Full size table

Relationships between the predicted values were visualized by plotting restricted cubic splines (Fig. 2). A nonlinear positive relationship between CTI and the prevalence of endometriosis was observed (nonlinearity, p = 0.603), with a breakpoint identified at 8.053.

Fig. 2
figure 2

Restricted cubic splines for associations between CTI and endometriosis

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Subgroup analyses

The results of the stratified assessment according to age, age at menarche, BMI, smoking, drinking, marital status, and oral contraceptive use are presented in Fig. 3. Individuals > 40 years of age, a BMI ≥ 25 kg/m2, smoked ≥ 100 cigarettes, married or living with a partner, and oral contraceptive use exhibited more vulnerability. Following the stratification of analyses based on alcohol consumption habits, comparable results were found regarding positive associations between the CTI and the prevalence of endometriosis.

Fig. 3
figure 3

Subgroup analysis of the association between the remnant CTI and endometriosis

Full size image

Furthermore, a higher endometriosis prevalence was observed among those with CTI in > 40 years of age (OR 1.57 [95% CI 1.16–2.13]), BMI ≥ 25 kg/m2 (OR 1.38 [95% CI 1.06–1.80]), smoking ≥ 100 cigarettes (OR 1.43 [95% CI 1.06–1.96]), being married or living with a partner (OR 1.41 [95% CI 1.09–1.85]) and oral contraceptive use (OR 1.35 95% CI 1.07–1.69]).

Discussion

This cross-sectional study, involving data from 2235 representative participants, found positive associations between the CTI and endometriosis, with a threshold concentration of approximately 8.053 mg/dL. Our results indicate that individuals with endometriosis were generally older and primarily non-Hispanic White. The diagnosis of endometriosis is frequently delayed, typically occurring 6–11 years after the initial symptoms appear, which likely accounts for the older age of these patients [6]. The increased incidence among White individuals may be associated with greater racial susceptibility. Additionally, we found that individuals with obesity or those with a history of smoking were more likely to develop endometriosis. This may be due to the inflammatory response triggered by smoking [23, 24], whereas higher estrogen levels in patients with obesity could promote the development of endometriosis [25].

Endometriosis is a chronic condition, prevalent among women of reproductive age, that affects approximately 10% of this population [2, 3, 26]. There are several hypotheses regarding the pathogenesis of endometriosis, with the leading being that ectopic endometrial-like glands and stroma may arise from metaplasia of local tissue or from the transplanted ectopic endometrium [27, 28]. This finding implies that normal endometrial cells may undergo changes in other parts of the body, resulting in the formation of new pathological tissue(s). Furthermore, elevated levels of local estrogen are believed to play a crucial role in this process because they not only aid in the survival and implantation of ectopic endometriotic lesions, but also promote their proliferation [3, 25]. However, its exact pathophysiology remains unclear. Recent studies have highlighted the potential contributions of inflammation and oxidative stress in this context [29,30,31,32,33]. A cohort study from Japan also suggested that consuming a diverse range of anti-inflammatory foods, such as vegetables, may ultimately affect perinatal mortality and morbidity in patients with endometriosis [34, 35]. A recent cross-sectional analysis revealed that the dietary inflammatory index is positively associated with the prevalence of endometriosis [34, 36]. The inflammatory nature of endometriosis is well-established [37, 38]. Considering the central role of inflammation in the pathogenesis of endometriosis, addressing inflammatory dysfunction has emerged as a promising strategy for developing new treatments [17, 39]. This approach provides an avenue for exploring innovative options for prevention and management of this disease.

The results of our investigation are consistent with those of earlier studies reporting the significant association between inflammation and endometriosis [40]. Similarly, several studies have shown that chronic inflammation plays a crucial role in the pathogenesis of endometriosis [17, 35]. For example, research using the Dietary Inflammatory Index revealed a positive association between pro-inflammatory diets and the prevalence of endometriosis [18, 41]. Similar to our findings, higher levels of inflammatory indicators, such as CRP and the TyG index, are significantly associated with endometriosis [42,43,44,45]. This similarity emphasizes the role of systemic inflammation in the progression of endometriosis, and supports the hypothesis that inflammatory processes are central to disease development [43, 46].

Furthermore, the roles of demographic and lifestyle factors, including smoking and BMI [47, 48], were more prominently analyzed in our study, revealing that these factors may modulate the relationship between inflammation and endometriosis. This provides a more nuanced understanding of how lifestyle and metabolic factors interact with inflammatory processes to influence the risk for endometriosis.

The key strength of this study is its foundation in a weighted and representative population with a substantial sample size. It should be emphasized that we also performed restricted cubic splines analysis. Nevertheless, this study had several limitations, the first of which was its cross-sectional design, making it difficult to determine causation between CTI and endometriosis. Second, because participants < 20 years of age were excluded, these findings may not be generalizable to younger patients. Third, because most of the data were gathered through self-report questionnaires or interviews, the control group may have unintentionally included individuals with undiagnosed endometriosis, potentially resulting in recall and reporting bias. Finally, due to limitations of the database, we could not incorporate data regrading all covariates related to endometriosis and inflammation levels to ensure a sufficiently large sample size. Therefore, future research should involve a more diverse population and consider additional potential covariates to clarify the causal association between the CTI and endometriosis.

Conclusion

Results of the present study revealed a strong positive association between the CTI and endometriosis. Therefore, actively managing blood glucose levels and minimizing inflammatory responses may aid in decreasing the prevalence of endometriosis; however, additional foundational research is necessary to investigate the possible relationships between them.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

BMI:

Body mass index

CI:

Confidence interval

CTI:

C-reactive protein–triglyceride–glucose index

FPG:

Fasting plasma glucose

NHANES:

National Health and Nutrition Examination Survey

OR:

Odds ratio

PIR:

Poverty income ratio

TyG index:

Triglyceride–glucose index

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Acknowledgements

We would like to thank the NHANES for the database.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei, China

    Yanan Ren, Ren Xu, Junqin Zhang, Ying Jin, Di Zhang & Yazhuo Wang

  2. Physical Examination Center, Hebei General Hospital, Shijiazhuang, Hebei, China

    Luyang Su

Authors
  1. Yanan Ren
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  2. Ren Xu
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  3. Junqin Zhang
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  4. Ying Jin
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  5. Di Zhang
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  6. Yazhuo Wang
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  7. Luyang Su
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Contributions

RY, XR, and SL designed the research. RY, ZJ, and JY collected and analyzed the data and drafted the manuscript. SL and WY revised the manuscript. All the authors contributed to the article and approved the submitted version.

Corresponding author

Correspondence to Luyang Su.

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Ethics approval and consent to participate

The portions of this study involving human participants, human materials, or human data were conducted in accordance with the Declaration of Helsinki and were approved by the NCHS Ethics Review Board. The patients/participants provided written informed consent to participate in this study.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Ren, Y., Xu, R., Zhang, J. et al. Association between the C-reactive protein-triglyceride–glucose index and endometriosis: a cross-sectional study using data from the national health and nutrition examination survey, 1996–2006. BMC Women's Health 25, 13 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-024-03541-x

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-024-03541-x

Keywords

BMC Women's Health

ISSN: 1472-6874

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