Human Reproduction, Vol.32, No.9 pp.

1855–1861, 2017
Advanced Access publication on July 28, 2017 doi:10.1093/humrep/dex249

ORIGINAL ARTICLE Psychology and counselling

Mental health in women

with endometriosis: searching
for predictors of psychological distress

Downloaded from https://academic.oup.com/humrep/article-abstract/32/9/1855/4055583/ by guest on 04 October 2019

F. Facchin1,, G. Barbara2, D. Dridi2, D. Alberico2, L. Buggio2,
E. Somigliana2, E. Saita1, and P. Vercellini2
1
Faculty of Psychology, Catholic University of Milan, Largo A. Gemelli 1, Milan 20123, Italy 2Department of Clinical Sciences and Community
Health, Università degli Studi, and Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda 12, Milan 20122, Italy
*
Correspondence address. Faculty of Psychology, Catholic University of Milan, Milan, Italy. Tel: +39-02-7234-5942; Fax: +39-02-7234-5962;
E-mail: federica.facchin@unicatt.it

Submitted on April 26, 2017; resubmitted on June 8, 2017; accepted on June 10, 2017

AIM: What are factors that 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.
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 mea- sures 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).
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.
CONCLUSION: Endometriosis is characterized by remarkable variability in terms of symptoms, types of lesions, psychological and relational
outcomes. The ‘endometriosis ocean’ is vast and our study contributes to navi- gate only a small portion of it (see the R2 values presented in
Table II), which represents an important limitation. For instance, we did not examine the psychological impact of sexual functioning, which
is very often impaired in women with endometriosis The fact that endometriosis patients with poorer sexual functioning may be more
distressed represents a plausible hypothesis that requires investigation. Another limitation is the fact that our study is
cross-sectional and does not allow an understanding of the evolution of women’s endometriosis experience, for instance before and after
pregnancy. In this regard, we acknowledge the need for longitudinal studies in the field of endometriosis. Moreover, the role of infertility may
have been underestimated in our study because we simply com- pared participants who had and who did not have current infertility, without
controlling for the effects of possible past infertility. We also believe that cultural and gender issues may shape women’s subjective experience
of endometriosis (for example, the relationship between menstrual pain normalization and delayed diagnosis) and thus we encourage
research aimed at exploring their roles.

Key words: endometriosis / mental health / pelvic pain / self-efficacy / self-esteem

 Table I Individual differences and mental health Table II Hierarchical multiple regressions: model
variables: means and standard deviations. summary

Category Variable M ± SD Models R R F

....... .......... ......... .......... ......... .......... ......... .......... ......... .... . square square
Individual differences RSES 21.9 ± 4.8 (R2) change
ESE-NEG 25.1 ± 5.0 (ΔR2)
.. ... ... ... ... ... ... .. ... ... ... ... ... ... .. ... ... ... ... ... ... .. ... ... ... ... ... ... .. ... . .
ESE-POS 29.6 ± 4.5 Model 1 HADS-A 0.006 0.006 0.658
BES-Weight 8.7 ± 4.0 (demographic variables) HADS-D 0.02 0.02 2.073
BES-Appearance 11.8 ± 3.8 HADS-Total 0.013 0.013 1.313
BES-Attribution 7.7 ± 2.9 RRS 0.015 0.015 1.551
BES-Total 31.4 ± 9.0 Model 2 HADS-A 0.112 0.106** 3.597*
Mental health HADS-A 7.5 ± 3.9 (demographic variables HADS-D 0.116 0.096* 3.733*
HADS-D 6.1 ± 3.5 AND endometriosis-
related factors) HADS-Total 0.125 0.113** 4.073**
HADS-Total 13.6 ± 6.8 RRS 0.135 0.120** 4.446**
RRS 42.3 ± 10.3 Model 3 HADS-A 0.349 0.237** 13.291**
(demographic variables, HADS-D 0.466 0.350** 21.586**
RSES, Rosenberg Self-Esteem Scale; ESE-NEG, Emotional Self-Efficacy in Regulating endometriosis-related
Negative Emotions; ESE-POS, Emotional Self-Efficacy in Expressing Positive factors, AND ‘self’) HADS-Total 0.466 0.341** 21.620**
Emotions; BES, Body Esteem Scale. RRS 0.366 0.231** 14.304**

*P ≤ 0.001.
**P < 0.001.
HADS, Hospital Anxiety and Depression Scale; A: Anxiety; D: Depression.

Table III Hierarchical multiple regressions: significant effects and coefficients

Unstandardized Standardized Sig. 95% Confidence

coefficients coefficients Interval
.. ... .. .. .. ... .. .. .. ... .. .. . .................. ...... ...........................
Category Predictors B Std. β P Lower Upper
Error Bound Bound
........... ................ ............... ............... ................ ............... ................ ............... ............... ................ ............... ................ ....... .
Demographic variables Intimate relationship RRS −4.747 1.529 −0.187 0.002 −7.763 −1.731
status
Endometriosis-related Time from diagnosis HADS-A −0.122 0.050 −0.177 0.015 −0.220 −0.024
factors HADS-Total −0.170 0.079 −0.140 0.033 −0.325 −0.014
‘Pelvic pain severity’ HADS-A 0.846 0.237 0.218 0.000 0.379 1.313
HADS-D 0.699 0.195 0.197 0.000 0.314 1.085
HADS-Total 1.545 0.377 0.226 0.000 0.802 2.288
RRS 2.606 0.619 0.253 0.000 1.384 3.827
Individual differences ‘Self’ HADS-A −1.933 0.228 −0.498 0.000 −2.381 −1.484
HADS-D −2.140 0.188 −0.606 0.000 −2.511 −1.769
HADS-Total −4.073 0.362 −0.598 0.000 −4.785 −3.359
RRS −5.059 0.595 −0.492 0.000 −6.233 −3.885

HADS, Hospital Anxiety and Depression Scale; A: Anxiety; D: Depression.

ENDOMETRIOZISLI KADINLARDA RUH SAĞLIĞI

AMAÇ: Endometriozisli kadınların ruh sağlığını etkileyen faktörler nelerdir.

GEREÇ VE YÖNTEM: Toplam 210 ardışık endometriozis hastası (yaş: 36.7 ± 7.0)
alındı. Demografik ve endometriozis ile ilgili bilgiler toplandı. Bireysel farklılıklar
benlik saygısı, vücut saygısı ve duygusal özyeterliği değerlendiren doğrulanmış
ölçütler kullanılarak değerlendirildi. Ruh sağlığını değerlendirmek için Hastane
Anksiyete ve Depresyon Ölçeği (HADS) ve Ruminatif Tepki Ölçeği (RRS)
kullanılmıştır.

SONUÇ: Endometriozis semptomlar, lezyon tipleri, psikolojik ve ilişkisel sonuçlar

açısından dikkat çekici değişkenlik ile karakterizedir. “Endometriozis okyanusu”
çok geniştir ve çalışmamız önemli bir sınırlamayı temsil eden sadece küçük bir
kısmını taramaya katkıda bulunur. Örneğin, endometriozisli kadınlarda çok sık
bozulmuş olan cinsel işlevsellikteki psikolojik etkiyi incelemedik. Cinsel işlev
bozukluğu olan endometriozis hastalarının daha sıkıntılı olabileceği gerçeği,
araştırma gerektiren makul bir hipotezi temsil ediyor. Diğer bir sınırlama ise
çalışmamızın olmasıdır.
kesitseldir ve örneğin endometriozis deneyiminin, örneğin hamilelik öncesi ve
sonrası evriminin anlaşılmasına izin vermez. Bu bağlamda, endometriozis
alanında uzunlamasına çalışmalara ihtiyaç duyulduğunu kabul ediyoruz. Dahası,
çalışmamızda kısırlığın rolü göz ardı edilmiş olabilir çünkü olası kısırlığın etkilerini
kontrol etmeden mevcut kısırlığa sahip olan ve olmayan katılımcıları karşılaştırdık.
Ayrıca kültürel ve toplumsal cinsiyet sorunlarının kadınların öznel endometriozis
deneyimini şekillendirdiğine inanıyoruz ve bu nedenle rollerini araştırmaya
yönelik araştırmaları teşvik ediyoruz.