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Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

3
1 Psychosocial impact of endometriosis: From
2
3 Q8 co-morbidity to intervention
4
5 Q7 Leen Aerts, Lorraine Grangier, Isabelle Streuli,
6
Q 10 €llenbach, Jean-Marie Wenger, Nichola Pluchino*
Patrick Da
7
8 Department of Gynaecology & Obstetrics, Geneva University Hospital, 30, bvd de la Cluse, 1205, Gen
eve,
Switzerland
9
10
11
12 a b s t r a c t
13 Keywords:
Endometriosis Endometriosis-associated pelvic pain is a major health concern in
14
Chronic genital pain women of childbearing age. Controlled studies have shown
15 Psychosocial function that endometriosis can adversely affect women and their partners'
16 Sexual dysfunctions general psychological well-being, relationship adjustment, and
17 Multidisciplinary approach overall quality of life. Furthermore, women with endometriosis
18 report significantly more sexual dysfunctions compared to healthy
19 women. Empirical studies indicate that specific psychosocial factors
20 may modulate pain experience, pain-related distress, and treat-
21 ment outcome. Research on psychosexual interventions in endo-
22 metriosis treatment is limited but shows to be effective in reducing
23 endometriosis-related pain and associated psychosexual outcomes.
24 An individualized, couple-centered, multimodal approach to care,
integrating psychosexual and medical management for endome-
25
triosis, is thought to be optimal.
26
© 2018 Published by Elsevier Ltd.
27
28
29
30
31
32 Q1 Introduction
33
34 Chronic pain problems involving the female reproductive system are major health concerns in
35 women of all ages. A case in point is chronic genital pain because of endometriosis. A population-based
36 study suggests that endometriosis affects 5e10% of the general female population in their reproductive
37 years [1]. As a condition that is often misdiagnosed, mismanaged, trivialized, or ignored [2],
38
39
40 * Corresponding author.
41 E-mail address: Nicola.Pluchino@hcuge.ch (N. Pluchino).

42 https://doi.org/10.1016/j.bpobgyn.2018.01.008
43 1521-6934/© 2018 Published by Elsevier Ltd.

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
 YBEOG1784_proof ■ 23 February 2018 ■ 2/9

2 L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9

1 endometriosis entails a great personal cost to patients and their partners and a significant financial cost
2 to society, due to both direct and indirect costs [4].
3 The experience of cyclic and chronic pain, combined with a lack of proper recognition by health
4 professionals [5] may generate varying degrees of psychological and interpersonal impairments, which
5 are as much a source of distress for the patient and her partner as the pain itself. Furthermore, pain
6 problems of the reproductive tract may carry an even heavier psychosocial burden in comparison
7 to other chronic pain problems common in women because of their deleterious effect on fertility,
8 sexuality, and romantic relationships [6].
9 Indeed, controlled studies in women with vulvodynia have shown that chronic genital pain can
10 adversely affect women and their partners' general psychological well-being, relationship adjustment,
11 and overall quality of life [7,8]. Many patients report feelings of shame, inadequacy, low self-esteem,
12 and body image concerns [9]. Compared to healthy women, women with chronic genital pain report
13 more state and trait anxiety [10] and higher depression scores [11]. Further, women with chronic
14 genital pain report more catastrophizing about their pain (i.e., an exaggerated and pessimistic
15 perspective with magnification, rumination, and feelings of helplessness) [12], higher levels of
16 hypervigilance toward the pain, more fear of pain, and lower levels of self-efficacy (i.e., the belief in
17 one's capacity to meet the challenges of managing pain) [13] compared to healthy women. In addition,
18 previous research has shown that the experience of chronic genital pain may disrupt all aspects of
19 sexual function [14] including sexual desire, arousal, orgasm, and sexual satisfaction. Moreover, chronic
20 genital pain may have consequences for the partners' psychological and sexual well-being [8,15], and it
21 may have a negative effect on the partner relationship and the couple's social well-being [16]. Finally,
22 cognitive (e.g., attributions or beliefs about the pain), behavioral, affective, and interpersonal factors
23 may modulate the pain experience and associated negative sequelae [14] and thus play a role in pain
24 modulation, management, and compliance to treatment.
25 However, psychosocial and sexual impairments associated with chronic genital pain have been
26 mainly assessed in patients with vulvodynia. Vulvodynia is characterized by superficial dyspareunia,
27 whereas endometriosis-associated pain is classically deep dyspareunia. Therefore, the findings cannot
28 be directly translated into the clinical setting of patients with endometriosis. Pain in endometriosis
29 may be nociceptive (including inflammatory), neuropathic, or a combination of both. It shares features
30 of other chronic pain syndrome such as hyperalgesia, allodynia, and central sensitization. Furthermore,
31 specific characteristics of endometriosis, such as being diagnosed with a chronic disease, the evolution
32 of disease/symptoms over time, the presence of chronic pelvic pain, long-term hormonal treatment,
33 fertility concerns, extensive pelvic surgery at a young age, and risk of recurrence, might exacerbate the
34 emotional/cognitive, sexual, and interpersonal elaboration of pain. Therefore, the aim of this review
35 is to outline the consequences of endometriosis on the psychological, sexual, and interpersonal
36 functioning of both patients and their partners. Second, treatment approaches from medical,
37 psychosocial, and integrated perspectives will be suggested, and recommendations for future research
38 will be formulated.
39
40 Psychological consequences and associated difficulties
41
42 Women with endometriosis may suffer from a wide range of pelvic pain. Nevertheless, pain and
43 pain-related distress seem to be independent of the stage of endometriosis [17], suggesting that
44 psychosocial factors may be involved in pain experience in women with endometriosis. In particular,
45 controlled cross-sectional studies showed that women with endometriosis report heightened psy-
46 chological distress including guilt toward their partner, lower feelings of femininity, alteration of body
47 image, feelings of loss of control over one's own body, worthlessness, hopelessness, and alexithymia
48 [18e21]. Compared to healthy women, women with endometriosis reported significantly higher levels
49 of pain catastrophizing [22], stress [23,24] and more depression, and anxiety [23e27] with prevalence
50 rates up to 87% [25]. In a cohort of patients with chronic pelvic pain due to endometriosis, pain cata-
51 strophizing played a pivotal role in pain experience, severity, and recurrence [28]. Catastrophizing was
52 found to predict poorer response to surgery [29] and persistent pain after 1-year follow-up [28].
53 Furthermore, a cross-sectional study of 236 women with endometriosis showed that higher pain
54 catastrophizing was associated with reduced quality of life, independent of other psychological

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
 YBEOG1784_proof ■ 23 February 2018 ■ 3/9

L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9 3

1 comorbidities and pain severity [22]. Recently, more attention has been given to factors that can predict
2 mental health status in the endometriosis population. Age, time since diagnosis, time from symptom-
3 onset to diagnosis, and pelvic pain severity may affect anxiety and depression [25,30,31]. Physical pain,
4 emotion regulation difficulties (i.e., goal-directed processes functioning to influence how people
5 experience and express the intensity, type, and duration of an emotion), and psychological stress
6 (anxiety, depression, and distress) are interrelated and explained 41% of the variation in physical health-
7 related quality of life (HRQoL) and 55% of the variation in mental HRQoL, at the SF36 questionnaire [32].
8 Physical component of HRQoL was explained by a high negative effect of pain symptoms and moderate
9 negative effect of psychological variables. Pain was significantly and substantially associated with the
10 mental component of HRQoL but only indirectly, through psychological stress [32]. In addition to pain
11 severity, additional factors have been found to be associated with mental health: greater self-esteem,
12 body esteem, and emotional self-efficacy were correlated with better psychological outcomes [33].
13 Furthermore, being in a stable relationship has been found to be associated with decreased rumination
14 [33], supporting the crucial role of the social context in which pain is experienced.
15 Sexual function, pregnancy, infertility, and cultural differences may in turn affect psychological
16 distress in women with endometriosis. Infertility can affect emotional status in a range of ways [34]:
17 self-esteem may be deflated, paired with a perceived failure to fulfill traditional gender roles, and/or
18 external pressures to conceive [35,36]. Although the psychological impact of infertility has received
19 increasing awareness over the past two decades, the consequences on the psychological distress of
20 being diagnosed infertile in addition to endometriosis have not received much attention.
21
22 Sexual consequences and associated difficulties
23
24 Although the prevalence of deep dyspareunia and chronic pelvic pain has been widely investigated in
25 endometriosis, female sexual function has been scantly examined in the past decades. Studies show that
26 cumulative prevalence of sexual dysfunction and distress was 32% and 78%, respectively, with a signif-
27 icant correlation between the stage of disease, dyspareunia, and the score on both questionnaires (56% of
28 patients had sexual dysfunction at AFS stage 4). In this cohort, more than half of the women (66%) were
29 afraid of pain before/during sexual intercourse. When sexual dysfunction was diagnosed, patients also
30 had significantly fewer episodes of sexual intercourse per month and greater fear of separation because
31 of coital pain than patients without sexual dysfunction [37]. These results are consistent with those
32 reported in two other studies using FSFI [38,39], which showed a crude prevalence of 70e75% of
33 sexual dysfunction among patients with endometriosis. Specifically, compared with the patients with
34 no-to-mild pelvic pain, those with moderate-to-severe pelvic pain had a 3.4-fold (CI 1.3e8.8) higher risk
35 of having sexual dysfunction. Patients with stage III or IV had a 4.4-fold (CI ¼ 1.3e15.5) higher risk than
36 those with stage I or II [38]. The presence of advanced states of disease also affected the desire domain, in
37 addition to sexual satisfaction, orgasm, and pain, when analyzed separately [40,41]. On the basis
38 Q 2 of available data, endometriosis appears to have an impact on all domains of sexual func-
39 tionddesire/arousal, orgasm, satisfaction, and paindleading to sexual dysfunction and distress in
40 70e75% of patients, at least in advanced/chronic cases. According to the motivation/incentive-based
41 cycle of sexual response, repetitive painful experiences and the absence of reward (negative outcome)
42 likely shift sexual response from motivation/arousal to hypervigilance and from desire to fear and
43 avoidance, leading to sexual distress in symptomatic patients with endometriosis. Among predictors, a
44 recent study shows that dyspareunia (OR ¼ 0.54; 95% CI ¼ 0.39e0.75) and depressive symptoms
45 (OR ¼ 0.761; 95% CI ¼ 0.58e0.99) were independent and significant negative predictors for sexual
46 functioning. Chronic pelvic pain (OR ¼ 0.53; 95% CI ¼ 0.35e0.81) and depressive symptoms (OR ¼ 0.65;
47 95% CI ¼ 0.44e0.96) were independent and significant negative predictors for quality of life at SF-12 [42].
48
49 Partner's physiological and sexual perspective: relationship consequences
50
51 The impact of chronic pain on psychosocial and sexual well-being may extend to partners. A recent
52 qualitative research has shown that male partners of women with endometriosis also suffer from the
53 consequences of their partner's pain, showing increased rates of psychological distress (feelings of
54 helplessness, frustration, worry, and anger) Similarly, sex and intimacy, planning for and having

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
 YBEOG1784_proof ■ 23 February 2018 ■ 4/9

4 L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9

1 children, working lives, and household income had a negative effect [43]. However, another cross-
2 sectional study of 74 male partners of women with endometriosis showed that sexual functioning
3 was comparable between male partners of women with endometriosis and male partners of women
4 attending an outpatient clinic for issues related to contraception [43]. In terms of partner relationship,
5 the WERF Endocost study showed that 67% of women with affected relationships declared significant
6 problems with their partner caused by endometriosis (34% of women), while 19% of them considered
7 endometriosis as a cause of their divorce (10% of women) [30]. These results are in line with the
8 findings of a retrospective qualitative study showing that 15% of women with endometriosis had
9 serious problems in their relationships and 7.7% suffered from a broken relationship due to the
10 symptoms of endometriosis, over a period of 15 years [44].
11 Finally, partner responses to the pain, both positive and negative, may play a role in the experience
12 of chronic genital pain. Several studies on the dyadic aspects of vulvodynia showed that not only
13 greater partner solicitousness, that is, demonstrations of sympathy, but also greater partner hostility,
14 that is demonstrations of anger, were significantly associated with higher levels of pain during
15 intercourse [9,45]. Furthermore, the associations were mediated by greater patient and partner pain
16 catastrophizing and self-efficacy [45,46]. In fact, partner pain catastrophizing and self-efficacy directly
17 predicted patient pain, suggesting that the partner's view of the pain may modulate patient
18 symptomatology [12]. Lower negative partner responses were associated with more sexual satisfaction
19 in women [45,46] and facilitative partner responses, defined as partner responses that encourage a
20 patient's efforts at adaptive coping with the pain (e.g., decreased avoidance), were associated with
21 lower genital pain and higher sexual satisfaction [47]. Taken together, findings concerning the psy-
22 chosocial correlates of chronic genital pain suggest that the context within which this pain is expe-
23 rienced do matter. How women and their partners think, feel, and communicate about this pain
24 influence the extent to which they can adapt to it, may reduce its intensity, and maintain a healthy sex
25 Q 3 life and relationship despite pain. Nevertheless, to date, research on the role of interpersonal factors in
26 the experience of pain and associated negative sequelae in patients with endometriosis is still lacking.
27
28 Social consequences and associated difficulties
29
30 Endometriosis symptoms have a detrimental impact on daily life and physical functioning [23,31].
31 Between 16% [27] and 61% [26] of women experience difficulties with mobility, daily activities, and/or
32 self-care. Further, endometriosis may have a negative effect on education and working life. While some
33 studies reported that endometriosis had affected study activity and grades of women and had caused
34 some to leave education before completion [48,49], others reported that only a minority of women had
35 experienced negative consequences on their education [44]. However, several studies suggested that
36 endometriosis symptoms of women diminished their working ability and their working productivity
37 [50]. The limitations placed on their working lives caused some women to quit their jobs or change jobs
38 owing to an inability to perform them or the overexpenditure of allocated sick leave [50]. Notably,
39 women often do not inform employers of their diagnosis or symptoms for a range of reasons including
40 the potential implications of this and because they find it difficult to discuss a private and gender-
41 specific condition [49]. In addition, between 19% and 48% of women with endometriosis experience
42 detrimental impact on their social lives [44,51,52] Women reported a reduction in social activities due
43 to pain, fatigue, and the need for toilet access or worry about the onset of pain while they were out,
44 leaving them feeling depressed, moody, and angry [31,49]. Between 23% [52] and 71% [51] of women
45 with endometriosis reported that household and housekeeping activities were affected by their dis-
46 ease, and 45% of women reported a negative effect on childcare [51]. Global impression from qualitative
47 studies is that being diagnosed with endometriosis controls and restricts the lives of women. They are
48 reluctant to discuss their experiences with others, as they feel their accounts are not always believed
49 [53,54] leading to feelings of loneliness and isolation.
50
51 Psychosocial and sexual interventions
52
53 Physical, mental, sexual, and social health are strongly interrelated in patients with endometriosis.
54 Hitherto, research and daily clinical practice have mainly focused on hormonal and surgical treatment

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
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L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9 5

1 of endometriosis with the purpose of pain control, prevention of disease recurrence, fertility preser-
2 vation, and reduction of anatomical damage. As pain severity affects physical and mental health in
3 patients with endometriosis [22,55], medical treatment alleviating endometriosis-associated pain may
4 improve HRQoL scoring [56]. However, HRQol scoring is generally poor in population with endome-
5 triosis, and improvement is mainly documented in pain subscales. Decreasing dyspareunia by medical
6 intervention does not consistently allow a recovery of a normal sexual function [57]. A recent study
7 shows that 11%e19% of women with endometriosis derived no pain relief at all from medical therapy,
8 and 5%e59% had pain remaining at the end of treatment. Recurrence of pain symptoms after treatment
9 cessation is reported in 17%e34% of treated women [58].
10 There is accumulating evidence suggesting that psychosocial factors interfere with pain experience,
11 severity, maintenance, and recurrence [28,29] and independently influence HRQoL in women with
12 endometriosis [22]. Therefore, interventions in the management of endometriosis should address the
13 multidimensional nature of the disease.
14 The goals of most psychosexual interventions are multiple: (1) to help patients and their partners
15 view the chronic genital pain as a multidimensional problem influenced by a variety of factors including
16 thoughts, emotions, behaviors, and couple interactions; (2) to modify those factors associated with the
17 chronic genital pain with a view to increasing adaptive coping and decreasing pain intensity; (3) to
18 improve the quality of their sexual functioning, including sexual desire, which is often significantly low
19 in this population, steering the focus away from intercourse while developing a more positive attitude
20 toward other pleasurable sexual activities; and (4) reduce avoidance of physical intimacy by working
21 with their fear of pain [6]. Despite the increasing amount of evidence on the efficacy of psychosexual and
22 multidisciplinary interventions in the treatment in other genital pain conditions [59e63], research
23 systematically exploring the effect of such interventions with patients with endometriosis is still scarce.
24 In a recent study, Meissner et al. investigated whether psychotherapy with somatosensory stimu-
25 lation (i.e., different acupuncture-point stimulation techniques) was effective for the treatment of pain
26 and quality of life in patients with endometriosis. Sixty-seven patients were randomly assigned to
27 the intervention or to a waiting list. The findings suggested that psychotherapy with somatosensory
28 stimulation not only improved global pain, pelvic pain, dyschezia, and quality of life at 3 months of
29 follow-up but also that these positive changes remained stable during the 2 years of follow-up [64].
30 Next, a mindfulness-based psychological intervention comprising mindfulness training, visualization
31 techniques, counseling, group support, and patient education with a specific focus on fatigue, quality of
32 sleep, job, relationships, and family issues has shown to induce a long-lasting improvement on HRQoL
33 during a 6-year follow-up in a group of 10 women suffering from endometriosis-related chronic pelvic
34 pain [65]. Zhao et al. investigated the impact of progressive muscle relaxation (PMR) training on anxiety,
35 depression, and HRQoL of 100 women with endometriosis undergoing GnRH agonist therapy. Patients
36 were randomly assigned to a PMR group receiving 12 weeks of PMR training versus a control group.
37 Finding suggested that PMR training is effective in improving anxiety, depression, and HRQoL of patients
38 with endometriosis under GnRH agonist therapy [66]. Unfortunately, to date, research evaluating the
39 efficacy of sex therapy, couple therapy, and pelvic floor physical therapy and research evaluating a
40 biopsychosocial and multidisciplinary approach in the treatment of endometriosis are still lacking.
41
42 Limitations of previous research and future research directions
43
44 To date, research about the impact of endometriosis on psychosexual functioning and HRQoL is
45 characterized by heterogeneity in association with research methods and stage of endometriosis.
46 Similarly, biopsychosocial analysis of symptoms and treatment outcome is rarely performed. This gap is
47 surprising, given the recommendations of the Initiative of Methods, Measurement and Pain Assess-
48 ment in Clinical Trials (IMMPACT) to assess the multiple dimensions of pain in chronic pain clinical
49 trials [67]. Further, research on the psychological factors that moderate pain experience, pain-related
50 distress, and response to treatment is limited, whereas research on the role of interpersonal factors
51 such as the response of the partner to the pain, attachment styles, and sexual intimacy in patients with
52 endometriosis is completely lacking. Finally, research systematically exploring the effectiveness of
53 psychosexual and multidisciplinary interventions (psychotherapy, sex therapy, couple therapy, etc.) in
54 the treatment of endometriosis is still scarce.

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
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6 L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9

1 Future research and treatment progress in the field of endometriosis will require an expansion of
2 our research methodologies and greater use of rigorous designs. First, prospective and longitudinal
3 cohort studies would enable us to more adequately capture the psychosocial and sexual impact of
4 endometriosis on afflicted women and their partners. It would further allow us to identify psycho-
5 logical and interpersonal risk factors and moderators of pain experience, pain-related distress, and
6 treatment outcome. Second, studies assessing sexual life of women with endometriosis should not only
7 focus on the presence of deep dyspareunia but also evaluate all aspects of sexual well-being. Third,
8 although sexual problems may be very distressing for many women, there may be variability in the
9 way they are experienced, as women may display different coping strategies. Some women will decide
10 to avoid pain by avoiding sexual intercourse, while other women will try to adapt their sexual life, for
11 example, by exploring nonpenetrative sex or changing positions. Future studies should examine the
12 role of these individual differences and coping strategies to reach a broader understanding of sexual
13 dysfunction associated with endometriosis. Fourth, evaluation of other dimensions that affect intimate
14 relationships, such as infertility, would be of value. Fifth, future research should include both
15 members of the couple to examine the role of dynamic interpersonal processes in the experience of
16 endometriosis. Sixth, there is a great need for studies on psychosocial, sexual, and physical therapy
17 interventions, with multiple measures administered during treatment to capture potential mecha-
18 nisms of change. Seventh, as for all treatment research, RCTs should be considered to provide evidence-
19 based treatment options to patients and their partners. Finally, the fragmentation of disciplines im-
20 pedes progress in our field. There is an urgent need for (1) increased dialog among sub-disciplines and
21 across disciplines and (2) research endeavors that incorporate both biomedical and psychosocial
22 variables, and questions focusing on the interactions therein. Such studies will contribute to the
23 development of more refined, biopsychosocial models of chronic genital pain and will inform the
24 development of targeted interventions.
25
26 A multidisciplinary approach to care
27
28 Given the multifaceted impact and modulation of endometriosis, a treatment model that can target
29 pain as well as its associated psychological, sexual, and relational consequences will have a presumed
30 advantage over interventions exclusively focused on reducing pain. To adequately deal with all the
31 repercussions that women with endometriosis may experience, a multidisciplinary team comprising
32 gynecologists, sexologists, psychologists/psychotherapists, and physiotherapist is crucial. In addition, it
33 is recommended to include the partner in therapy given the interpersonal factors involved in chronic
34 genital pain. Indeed, healthcare practitioners need to take a more couple-centered, biopsychosocial
35 approach toward the treatment of endometriosis, inclusive of partners and relationship issues.
36 Moreover, this couple-centered approach should be individualized, proposing the best treatment
37 options based on the different symptoms and problems distressing the patient and her partner and
38 considering their preferences and priorities. From a clinical standpoint, the advantages of this model
39 are numerous and often include an accelerated, more focused treatment process, less patient resistance
40 to any one single biomedical or psychosocial intervention, more motivated and persistent patients
41 and health-care providers, increased coherence among the various health disciplines involved, and
42 multiple facets of chronic genital pain being targeted simultaneously [68].
43
44 Conclusion
45
46 Chronic endometriosis-associated pain has a detrimental impact on the psychosocial adjustment
47 and sexual function of afflicted women and their partners. Furthermore, psychological and interper-
48 sonal factors may modulate the patients' pain experience, the pain-related distress, and treatment
49 outcome. Therefore, an individualized, couple-centered biopsychosocial approach in the treatment of
50 endometriosis is crucial. It is essential that patients and their partners receive this holistic care
51 from centers with appropriate multidisciplinary teams including gynecologists, sexologists, psychol-
52 ogists/psychotherapists, and physiotherapist. In addition, there is an urgent need for prospective
53 research and RCTs that incorporate both biomedical and psychosocial variables and questions focusing
54 on the interactions therein.

Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
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L. Aerts et al. / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2018) 1e9 7

1
2 Practice points
3
4  Patients and their partners need an individualized, couple-centered biopsychosocial
5 approach in the treatment of endometriosis, which is crucial.
6  Patients and their partners need to receive care from centers with appropriate multidisci-
7 plinary teams including gynecologists, sexologists, psychologists/psychotherapists, and
8 physiotherapist.
9
10
11
12
Research agenda
13
14
 Prospective research and RCTs that incorporate both biomedical and psychosocial variables
15
and questions focusing on the interactions therein.
16
17
18
19 Q4 Conflicts of interest
20
21 None.
22
23 Uncited reference
24
25 [3].
Q6
26
27
28 References
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Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
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10.1016/j.bpobgyn.2018.01.008
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to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008
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Please cite this article in press as: Aerts L, et al., Psychosocial impact of endometriosis: From co-morbidity
to intervention, Best Practice & Research Clinical Obstetrics and Gynaecology (2018), https://doi.org/
10.1016/j.bpobgyn.2018.01.008