Endometriosis Psychological Aspects: A Literature Review

Women's reproductive mental health: currently available evidence and future directions for research, clinical practice and health policy

Sex and gender differences in the epidemiology of mental disorders are well documented. Less well understood are the drivers of these differences. Reproductive health represents one of the gendered determinants of mental health that may affect women throughout their life course. In this paper, we review common reproductive events that may be associated with mental ill health, including menstruation (with premenstrual dysphoric disorder appearing for the first time in recent classifications of mental disorders), contraception, abortion, sexual dysfunction, hypersexuality, sexual violence, reproductive coercion, infertility and associated gynaecological conditions, and menopause. Such reproductive events may differentially affect women globally via a range of potential biological and psychosocial mechanisms. These include, for example, vulnerability to the physiological changes in hormone levels across the menstrual cycle; side effects of treatment of mental disorders; inflammation underpinning endometriosis and polycystic ovarian syndrome as well as mental disorders such as depression; intersections with gender disadvantage manifesting, for example, as structural barriers in accessing menstrual products and sanitation, contraception and abortion, underscoring the broader social determinants impacting women's mental health. Greater understanding of these mechanisms is guiding the development of effective interventions, which are also reviewed here. However, key evidence gaps remain, partly as a result of the historic gender bias in mental health research, and the neglect of reproductive health in clinical practice. Furthermore, while several women's health strategies have recently been proposed internationally, they do not usually include a focus on mental health across the life course, particularly for women with severe mental illness. Integrating co-designed reproductive health interventions into primary and secondary mental health care settings, providing tailored care, increasing the evidence base on effective interventions, and empowering women to make informed choices about their reproductive health, could improve not only reproductive health but also women's mental health across the life course.

Self-inflicted chronic laparoscopic wounds in endometriosis-unveiling major depressive disorder: a case report

To our knowledge, there are no reported cases in literature of adolescents with endometriosis with major depressive disorder that manifested as chronic laparoscopic wounds. Major depressive disorder in patients with endometriosis is a common occurrence, but self-directed violence is rare. We present the case of an adolescent female with chronic pelvic pain who was treated with medical management that proved ineffective. She then underwent laparoscopic excision of endometriosis. After surgery, she continued to experience oozing of a brown colored discharge from the primary umbilical port site, and it became a chronic nonhealing wound with associated pelvic pain. Four months later, she underwent re-exploration of the umbilical wound and laparoscopy. Subsequently, she had multiple and frequent hospital visits including ward admissions. The laparoscopic wounds remained as flesh wounds for 11 months despite multidisciplinary treatment, including care from a plastic surgeon. Patient was seen by a psychiatrist and a diagnosis of major depressive disorder was made. She was started on antidepressants, and subsequently, the wounds healed. This case report discussed a young adolescent female who underwent surgical treatment for endometriosis but who presented with a cryptic manifestation of major depressive disorder- chronic postlaparoscopic wounds. This case illustrates the need for early recognition of nonreproductive complications of endometriosis and timely multidisciplinary involvement.

Effectiveness of psychological interventions in endometriosis: a systematic review with meta-analysis

Introduction

Endometriosis is a chronic gynecological disease associated with chronic debilitating pain, poor mental health and quality of life. The objective of this paper is to evaluate the effectiveness of psychological interventions aimed at improving the pain, quality of life and mental health of women with endometriosis.

Methods

A systematic review (SR) of the literature with meta-analysis (MA) was carried out. MEDLINE, Embase, PsycINFO and CENTRAL were searched to locate Randomized Controlled Trials (RCTs). The risk of bias assessment of each study was conducted using the Cochrane Collaboration's RoB 2.0 tool.

Results

Seven RCTs were included (N = 757). The data obtained suggest that psychological interventions reduce dyspareunia [standardized mean difference (SMD): -0.54, 95% CI: -0.86, -0.22] and dyschezia [mean difference (MD): -2.90, 95% CI: -4.55, -1.26] and increase mental health levels (SMD: 0.70, 95% CI: 0. 42, 0.99); they also point to a large reduction in levels of trait anxiety (MD: -6.63, 95% CI: -8.27, -4.99) and depression (MD: -2.49, 95% CI: -3.20, -1.79), and a likely reduction in state anxiety (MD: -9.72, 95% CI: -13.11, -6.33) experienced by women with endometriosis. It was also identified that psychological interventions probably slightly reduce pelvic pain and may increase physical health. However, most of the included studies have a high overall risk of bias or have certain concerns, which limit conclusions about the certainty of the evidence.

Discussion

The available evidence indicates that psychological interventions are effective in improving the pain, quality of life and mental health variables of women with endometriosis.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42024516100.

Association between the Exposure to Phthalates and the Risk of Endometriosis: An Updated Review

Endometriosis is a chronic gynecological disease, primarily associated with pelvic pain and infertility, that affects approximately 10% of the women of reproductive age. Estrogen plays a central role in endometriosis, and there is growing evidence that endocrine disruptors, such as phthalates, may contribute to its development. This review aimed to determine whether there is a causal relationship between phthalate exposure and the development of endometriosis, as well as the possible effects of phthalates on fertility, by analyzing epidemiological data. After a literature search with a combination of specific terms on this topic, we found that although there are limitations to the current studies, there is a clear association between phthalate exposure and endometriosis. Phthalates can interfere with the cellular processes of the endometrium; specifically, they can bind to PPAR and ER-α and activate TGF-β, promoting different signaling cascades that regulate the expression of specific target genes. This may lead to inflammation, invasion, cytokine alteration, increased oxidative stress, and impaired cell viability and proliferation, culminating in endometriosis. Nevertheless, future research is important to curb the progression and development of endometriosis, and strategies for prevention, diagnosis, and treatment are a priority. In this regard, public policies and recommendations to reduce exposure to phthalates and other endocrine disruptors should be promptly implemented.

Factors influencing health-related quality of life in women with endometriosis: A cross-sectional study

This study aimed to assess the health-related quality of life and identify its associated factors in women with endometriosis. A cross-sectional correlation study design and convenience sampling were conducted in the gynecological outpatient clinic of a teaching hospital in northern Taiwan. A total of 216 women with endometriosis were recruited. The data were collected using structured questionnaires and analyzed using descriptive and inferential statistics. Participants reported a moderate level of health-related quality of life. The most significant impact of endometriosis on health-related quality of life was emotional well-being, followed by feeling of control or powerless, pain, social support, and self-image. Educational attainment, menstrual cycle, period length, perceived menstrual flow, symptom distress, and self-management strategies explained 66% of the variance in health-related quality of life. Factors influencing health-related quality of life in women with endometriosis play a key role in promoting women's well-being. Interventions based on these related factors should be developed and taken into practice to effectively manage the disease-related symptoms for women with endometriosis and thereby improve their overall health-related quality of life.

Associations between psychological flexibility and daily functioning in endometriosis-related pain

OBJECTIVES

Processes of psychological flexibility (PF) are positively associated with health and wellbeing in several chronic pain disorders. However, these processes have not been investigated in endometriosis, a chronic pain disorder affecting 5-10 % of women worldwide. This study is a preliminary investigation of the associations between PF or psychological inflexibility (PI) and daily functioning in people with a primary diagnosis of endometriosis.

METHODS

This study is based on a secondary analysis of survey data from Swedish-speaking adult participants with chronic pain recruited online. The current study included only those reporting a diagnosis of endometriosis and significant long-term pain. All participants completed the Multidimensional Psychological Flexibility Inventory (MPFI), a measure of PF and PI, as well as other measures of PF, and measures of pain and daily functioning. Correlation and multiple regression analyses were performed to examine relations of PF and PI with measures of pain and daily functioning.

RESULTS

In general, PF facet scores from the MPFI did not correlate with pain interference but did correlate with depression, with the exception of acceptance. The overall facets of PI appeared to perform better as correlates and in regression. Established measures of PF performed in correlation and regression analyses generally as has been observed in other chronic pain populations, with significant positive associations.

CONCLUSIONS

In this preliminary analysis of PF and PI in participants with endometriosis-related pain, these processes appear relevant, especially in understanding depression, but results varied along with the measures used. Specifically, when employing the MPFI, the PI facets emerged as stronger correlates. The findings underscore the potential benefit of incorporating assessments of PF and PI as process variables in endometriosis-research, but also that careful consideration should be given when selecting instruments.

Understanding Psychological Symptoms of Endometriosis from a Research Domain Criteria Perspective

Endometriosis is currently the second most common gynecological disease and is associated with severe pain, vegetative impairment, and infertility. In association, there are considerable psychological symptoms that limit the quality of life of those affected. In this narrative review, the Research Domain Criteria (RDoC) framework was utilized to display the different transdiagnostic processes involved in disease progression and maintenance in regard to psychosocial functioning. Using the RDoC framework, it becomes clear that immune/endocrinological dysregulation is interlocked with (pelvic) pain chronification processes and psychological symptoms such as depressive mood, loss of control, higher vigilance toward the onset or worsening of symptoms, social isolation, and catastrophizing. This paper will discuss and identify promising treatment approaches, in addition to medical care, as well as further research implications. Endometriosis can come with substantial psychosomatic and social burden, requiring more research to understand the interdependence of different factors involved in its chronic development pathway. However, it is already clear that standard care should be extended with multifaceted treatments addressing pain, as well as the psychological and social burden, in order to halt the cycle of aggravation of symptoms and to improve quality of life for patients.

Effect of self-care counselling on depression and anxiety in women with endometriosis: a randomized controlled trial

BACKGROUND

Considering the prevalence of endometriosis and consequent depression and anxiety as well as the resultant effects on the body, mind, and quality of life of patients, this study aimed to determine the effects of self-care counselling on depression and anxiety (primary outcome) and on quality of life (secondary outcome) among women with endometriosis.

METHOD

This randomized controlled clinical trial was conducted on 76 women with endometriosis who were treated at Al-Zahra Teaching and Treatment Center of Tabriz within the 2015-2019 period. The random blocking method was employed to divide the patients into intervention (counselling) and control groups. In the intervention group, seven self-care group counselling sessions were held on a weekly basis. The control group received routine care. A sociodemographic questionnaire, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory (STAI) and the SF-36 Quality of Life Questionnaire were completed by the researcher through an interview before and 4 weeks after the intervention.

RESULTS

There was no significant difference between the intervention and control groups in terms of sociodemographic characteristics (p > 0.05). After the intervention, the mean scores of state anxiety (mean difference: - 0.12, 95% confidence interval: - 9.6 to - 14.4, p < 0.001) and trait anxiety (mean difference: - 10.9: 95% confidence interval: - 9.1 to - 12.7, p = 0.001) were significantly lower in the counselling group than those of the control group. The mean score of depression was lower in the counselling group than in the control group; however, it was not significant (p = 0/565). The mean score of quality of life for physical health (mean difference = 17.2, 95% confidence interval: 13.8 to 20.5, p < 0.001) and for mental health (mean difference = 12.0, 95% confidence interval: 9.0 to 14.9, p < 0.001) were significantly higher in the counselling group than in the control group.

CONCLUSION

Self-care counselling affects the anxiety and quality of life of women with endometriosis. Therefore, in addition to other therapies, this method is proposed to improve quality of life and mental health of patients with endometriosis.

TRIAL REGISTRATION

IRCT Registration Number: IRCT 20111219008459 N13, registered on February 10, 2019 ( https://irct.ir/user/trial/35915 ).