Correlating factors with depression and anxiety in endometriosis
patients.
The role of endometriosis related pain and the association with
depression and anxiety was the most commonly described factor. Facchin
et al (2017) reported an increase of 9.6% in depression and 10.6%
increase in anxiety symptoms in case of endometriosis-related predictors
(hormonal treatment, surgical interventions, infertility, time from
diagnosis, and pain severity) [36]. Four out of five studies
comparing endometriosis patients with pain with pain-free endometriosis
patients found significant higher rates of depression, up to 86% in the
pain-group [28,35,47,62]. As-Sanie et al (2012) and Facchin et al
(2015) also found significant differences for anxiety scores between
these groups. However, Eriksen et al (2008) reported, except for
slightly higher anxiety scores in the pain group, no significant
correlation between the degree of pain and depression or anxiety scores
[34]. There was no consensus on the association concerning the type
of pain (CPP, dysmenorrhea, dyspareunia).
Infertility was the second most investigated factor that was
hypothesized to contribute to depression or anxiety in endometriosis
patients. However, comparison of infertile with fertile endometriosis
patients [59] or with infertile patients without endometriosis
[61,62] did not show any significant difference on depression or
anxiety symptoms. In addition, Shaw et al, 1995 described that in women
with endometriosis related pain, depression occurred more frequently
(23.5%) compared with endometriosis patients with infertility (13%)
[62].
Studies that investigated other factors than pain or infertility,
reported that higher scores of depression or anxiety in endometriosis
patients were correlated to poorer quality of sleep [27], fatigue
[52], poorer quality of life [32,49,50,52], gastrointestinal
symptoms [70], lower self-esteem [36], lower emotional
self-efficacy [36], lower sexual functioning [32,51],
dysfunction on social adjustment [54], pain imagery [42] and
clinical signs of pain sensitization [68]. In addition, it was
reported that patients who used positive coping strategies had less
depression [33,34]. Furthermore, in the included studies, it was
described that depression and anxiety occurred more frequently in
patients with advanced age [38,63], lower cortisol levels [55],
metabolic syndrome [31] and comorbid pain syndromes [65], and,
the presence of depression and anxiety was independently associated with
increased costs [45].
No correlation was found between depression or anxiety and endometriosis
stage [30,63], being childless [37], experiencing no pain relief
after surgery [41] or oral contraceptive therapy [72].
Correlations of anxiety and depression in endometriosis patients
concerning time of diagnosis were described contradictorily
[36,63,69].
Discussion Main Findings
The aim of this systematic review was to give an overview on the
association between endometriosis and symptoms of depression and anxiety
and the factors that are correlated to this association. A total of 47
articles comprising 1,933,846 subjects were reviewed. Data from 17
studies using validated outcome measures was pooled for a random effects
meta-analysis comparing 677 endometriosis patients with 636 healthy
controls and 407 CPP patients without endometriosis. Reviewed articles
showed a prevalence ranging from 10-86% for depression and 10-79% for
anxiety, whereas the global prevalence of depressive and anxiety
disorders ranges from 4.5-7% and 5.5-6% respectively in women of
reproductive age [19]. Derived from the pooled data, the
standardized mean differences in anxiety and depression scores is
significantly higher in studies of endometriosis patients compared with
healthy controls but not in comparison to CPP patients. Hence, this
elevated prevalence, seems to be not specific for endometriosis but is
comparable to women with other conditions representing CPP. This
systematic review included mostly studies with a cross-sectional design
and does not allow for analysis of causal inference. Nevertheless, two
studies with a longitudinal design showed an elevated likelihood of
developing depression and anxiety disorders in endometriosis
[31,39]. In addition, women with a previously diagnosed depression
or anxiety disorder, were more likely to be later diagnosed with
endometriosis [31,39]. Regrettably, the authors did not evaluate the
impact of endometriosis related factors such as pain on the risk of mood
disorders.
The majority of cross-sectional studies investigating pain as a
dependent factor, reported a positive association between pain intensity
and scores for depressive symptoms and anxiety. This is a well-known
phenomenon in pain being part of functional psychosomatic syndromes
[103]. In endometriosis studies however, there was no consensus on
the relation between the type of pain (CPP, dysmenorrhea, dyspareunia)
and affective symptoms. Facchin et al. (2015) was the first to test the
‘disease-focused hypothesis’ and the ‘pain-focused hypothesis’ in
endometriosis by comparing asymptomatic endometriosis patients,
endometriosis patients with pelvic pain and healthy pain-free controls.
Their findings offered the conclusion that painless endometriosis does
not necessarily involve psychological pain or discomfort. However, the
researchers did not control for the effect of diagnostic and demographic
factors. Other studies included in this review suggest that factors
correlated to affective symptoms in endometriosis patients include age,
quality of life, quality of sleep, fatigue, sexual function,
gastrointestinal symptoms, comorbidity, self-esteem, emotional
self-efficacy, coping style, social adjustment, pain imagery and pain
sensitization. This indicates that other factors are involved in symptom
burden and treatment refractoriness in women suffering from
endometriosis. As in other complex patients, these aspects remain
frequently undetected, which could lead to misdiagnosis and puzzled
treatment pathways [104,105].