What factors affect mental health in women with endometriosis? Towards the development of a comprehensive explanatory model

Study question: What specific factors affect the mental health of women with endometriosis? Summary answer: The psychological health of women with endometriosis can be affected by age, intimate relationship status, time from diagnosis, pelvic pain, and self-concept. What is known already: Although it is well known that endometriosis as a chronic disease has a negative impact on mental health and quality of life, recent studies have shown that women’s experience of endometriosis is characterized by remarkable variability in psychological outcomes. Such variability is partly explained by the presence of pelvic pain, which is associated with impaired mental health and whose severity can be influenced by personality. However, endometriosis is a multidimensional disease that involves a complex interaction of multiple variables (including individual characteristics such as self-concept) and further research is necessary to identify what specific factors may affect women’s mental health. Study design, size, duration: A total of 187 consecutive endometriosis patients were included in this cross-sectional study conducted between 2015 and 2017 at an Italian academic department of obstetrics and gynaecology located in Northern Italy. Participants/materials, setting, methods: Participants were 187 endometriosis patients (mean age: 36.8 ± 7.1 years). Demographic and endometriosis-related information (i.e. surgical and hormonal treatment, pelvic pain severity [dysmenorrhea, dyspareunia, chronic pelvic pain, dyschezia], time from diagnosis) was collected. Self-concept was assessed using three validated measures evaluating self-esteem (Rosemberg Self-Esteem Scale), emotional self-efficacy (Emotional Self-Efficacy Scale), and body image (Body Esteem Scale). Mental health was assessed using the Hospital Anxiety and Depression Scale (HADS) and the Ruminative Response Scale (RRS). Main results and the role of chance: A multivariable approach (i.e. hierarchical multiple regression) was used to examine the psychological impact of three sets of putative predictors identified on the basis of the extant literature: Set 1 – demographic factors (age and intimate relationship status); Set 2 – endometriosis-related factors (hormonal treatment; surgical interventions; current infertility; time from diagnosis; global pelvic pain severity); Set 3 – global self-concept (a single factor, derived from principal component analysis [KMO test = .64, Bartlett’s test of sphericity = 91.65, ps < .001], summarizing the information of the three self-concept scales to avoid multicollinearity problems). Significance tests were performed at P < .05. A shorter time from diagnosis was associated with greater anxiety (HADS-A: β = -.256; p = .001) and rumination (RRS: β = -.189; p = .014). Pelvic pain severity affected all psychological variables (ps < .01). Younger women displayed higher levels of depression (HADS-D: β = -.207; p = .003). Being in a stable relationship (coded 1 [‘yes’] or 0 [‘no’]) was associated with decreased rumination (RRS: β = -.231; p < .001). Greater self-concept led to better psychological outcomes in all dependent variables (ps < .001). Limitations, reasons for caution: A comprehensive model explaining how endometriosis can negatively affect mental health should test the impact of cultural differences, gender believes, and the quality of couple relationships. These variables were not included in our model and our sample was entirely composed of Caucasian women. These should be acknowledged as important limitations. Wider implications of the findings: Although most endometriosis research focused on the role of pelvic pain, other factors should be considered to explain the psychological impact of the disease. Newly diagnosed younger women, especially with low self-esteem, may present higher levels of distress, which indicates the importance of timely psychological intervention aimed at empowering patients. Study funding/competing interest(s): None. Trial registration number: Not applicable.