Mental health in women with endometriosis: Searching for predictors of psychological distress

STUDY QUESTION: What factors affect the mental health of women with endometriosis? SUMMARY ANSWER: Not only pelvic pain, but also individual characteristics (i.e. self-esteem, body esteem and emotional self-efficacy), time from diagnosis and intimate relationship status influence the psychological health of endometriosis patients. WHAT IS KNOWN ALREADY: The negative impact of endometriosis on mental health has been widely demonstrated by the research literature, along with the fact that presence and severity of pelvic pain are associated with anxiety and depression. However, endometriosis is a complex multidimensional disease and factors other than pelvic pain, including individual differences, may contribute to explain the variability in women's mental health. STUDY DESIGN, SIZE, DURATION: This cross-sectional study was conducted between 2015 and 2017 at an Italian academic department of obstetrics and gynaecology. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 210 consecutive endometriosis patients (age: 36.7 ± 7.0 years) were included. Demographic and endometriosis-related information was collected. Individual differences were assessed using validated measures evaluating self-esteem, body esteem and emotional self-efficacy. The Hospital Anxiety and Depression Scale (HADS) and the Ruminative Response Scale (RRS) were used to evaluate mental health. MAIN RESULTS AND THE ROLE OF CHANCE: Based on the extant literature, we identified three categories of putative predictors (demographic variables, endometriosis-related factors and individual differences i.e. 'self), whose psychological impact was examined using a hierarchical multiple regression approach. Being in a stable relationship (coded 1 ['yes'] or 0 ['no']) was associated with decreased rumination (RRS: β = -0.187; P = 0.002). A shorter time from diagnosis was associated with greater anxiety (HADS-A: β = -0.177; P = 0.015). Pelvic pain severity and 'self were associated with all mental health variables (Ps < 0.01). Greater self-esteem, body esteem, and emotional self-efficacy were correlated with better psychological outcomes (Ps < 0.01). LIMITATIONS REASONS FOR CAUTION: Sexual functioning, pregnancy, infertility, cultural differences and gender beliefs have been found to be important in women with endometriosis. In our regression model, we did not test the psychological impact of these variables and this should be acknowledged as an important limitation. Moreover, the cross-sectional (rather than longitudinal) nature of this study does not allow a full examination of the temporal relationship between endometriosis and psychological outcomes. WIDER IMPLICATIONS OF THE FINDINGS: Factors other than pelvic pain can significantly affect the mental health of women with endometriosis, and the role of individual differences requires further investigation. Targeted multidisciplinary interventions should include evaluation and enhancement of self-esteem and self-efficacy to improve women's psychological health.