Addressing mental health risks in endometriosis patients

Addressing mental health risks in endometriosis patients | Image Credit: © terovesalainen - © terovesalainen - stock.adobe.com.

Mental health management in endometriosis patients should be performed through a holistic approach by gynecologists and mental health professionals, according to a recent study published in Fertility and Sterility.¹

Up to 15% of reproductive aged women are impacted by endometriosis. This condition has been linked to multiple physical symptoms, but recent data has also indicated a potential association with mental health conditions such as anxiety and depression. Endometriosis may also be linked to eating disorders.²

These mental health disorders have been linked to reduced quality of life, making quality treatment more difficult.¹ This indicates a need to understand the link between endometriosis and mental health.

To evaluate the impact of endometriosis on mental health, investigators conducted a systematic literature review. Articles published between January 2003 and October 2023 were identified through searches of the PubMed and Cochrane databases.

Eligibility criteria included being a full-length article published in English and reporting on the association of endometriosis with anxiety, depression, eating disorders, or sexual function through a validated screening tool. Imaging techniques, surgery, and clinical criteria were used to identify endometriosis.

Either a validated multiitem scale or registered diagnosis was used to evaluate mental health conditions, including anxiety, depression, eating disorders, and sexual function. These conditions were compared between symptomatic endometriosis patients and either pain-free endometriosis patients, healthy controls with no pain, or chronic pelvic pain (CPP) patients without endometriosis.

Results highlighted an association between endometriosis and an increased risk of anxiety symptoms. Anxiety has a prevalence of 6% in the general population according to the World Health Organization, but 2 symptomatic reviews indicated a range of 10% to 87.5% among women with endometriosis.

In a comorbidity cluster analysis, this rate was up to 38% among endometriosis patients with musculoskeletal disorders. This indicates a relationship between perceived pain from endometriosis and anxiety symptoms. In one study, women with daily pain, cyclical pain, and no pain had anxiety rates of 68.4%, 57.5%, and 29.6%, respectively.

CPP has been considered a key factor of the link between endometriosis and anxiety. Increased connectivity to pain-related regions, which has been linked to anxiety, was reported in endometriosis patients with CPP. Genetic predisposition may also impact the prevalence of anxiety in women with endometriosis.

Data has also indicated a link between endometriosis and depression, with a rate of 9.8% to 98.5% in endometriosis patients vs 6.6% to 9.3% in controls. Symptomatic patients had greater levels of depression than asymptomatic patients, indicating an increased risk from endometriosis-associated pain.

Depression was reported in up to 86% of endometriosis patients with CPP vs 28% of those without pain. A 1.48-fold increased risk of being diagnosed with depression was reported in women with endometriosis, with the risk further increased by comorbidity with other chronic conditions.

The risk of depression may also be increased in women with endometriosis through body image disturbances, sleep disturbance and fatigue, prior gonadotropin-releasing hormone agonist use, and oral contraceptives. The impact of infertility on this association remains unclear.

Sexual dysfunction is also more prominent in women with endometriosis, ranging from 32% to 79%, vs 17.6% to 40% in controls. However, it remains unclear whether pain impacts sexual function.

One study reported significantly reduced Female Sexual Function Index scores in women with pain, but this study lacked questionnaires that may have identified other factors impacting sexual function. Other studies have highlighted a complex association between pain, sexual function, sexual distress, and psychological aspects.

An increased risk of being diagnosed with endometriosis has been identified among women with certain psychiatric disorders, including eating disorders. However, this order of manifestation indicates chronic pain alone may not explain this association.

Among women born in Sweden between 1973 and 1990, 14,144 were diagnosed with endometriosis by 2016 based on International Classification of Diseases codes. A diagnosis was more common in women with eating disorders.

Notably, one study reported impaired eating disorders among endometriosis patients with pain. Beliefs, feelings, thoughts, and behaviors toward eating significantly varied between patients with no pain, mild pain, and moderate to severe pain.

These results highlighted significant rates of anxiety, depression, and sexual dysfunction in women with endometriosis, with CPP significantly increasing these risks. Investigators concluded early diagnosis is vital for preventing psychosocial comorbidities in endometriosis patients.

References

1. Lena Zippl A, Reiser E, Seeber B. Endometriosis and mental health disorders: identification and treatment as part of a multimodal approach. Fertility and Sterility. 2024;121(3):370-378. doi:10.1016/j.fertnstert.2023.12.033
2. Gao M, Koupil I, Sjöqvist H, et al. Psychiatric comorbidity among women with endometriosis: nationwide cohort study in Sweden. Am J Obstet Gynecol. 2020;223:415.e1-16. doi:10.1016/j.ajog.2020.02.033