Introduction
Endometriosis is defined as an estrogen-dependent condition with
presence of endometrium-like tissue outside the uterus [1]. The
prevalence has been estimated between 2% to 10% in women of
reproductive age and up to 50% in women with chronic pelvic pain (CPP)
or fertility problems [2,3]. A combination of retrograde
menstruation, defective immune clearance and changes in the peritoneal
environment that stimulate cell growth is the most widely accepted
explanation with regard to etiopathogenic mechanisms [4].
Dysmenorrhea, CPP, dyspareunia, fatigue/weariness and infertility are
the leading symptoms [5,6,7], and the non-specific presentation of
these symptoms often causes a delay concerning diagnosis [8-10].
Severity of the disease, pelvic pain, infertility, and a higher number
of years since diagnosis are associated with higher costs of societal
relevance, as symptoms affect physical, mental, sexual, and social
well-being, as well as work productivity [11-13]. Furthermore, the
extent of endometriosis is not directly related to the degree of
symptoms [14] and recurrence of symptoms after surgical or medical
interventions occurs frequently [15]. Hence, the perception of
symptoms may be associated with psychological distress, such as in
depression and anxiety disorders [16,17]. Depression and anxiety
disorders are classified by the DSM-V psychiatric diagnostic criteria
[18], and the global prevalence of depressive and anxiety disorders
ranges from 4.5-7% and 5.5-6% respectively in women of reproductive
age [19]. A relationship between depression, anxiety and
endometriosis has been described from 1979 onward [20]. Demographic
characteristics, social and disease-specific factors may predict
psychological ill-health in endometriosis patients and could therefore
lead to potential prediction models for the risk of developing
depression or anxiety disorders in these patients.
The aim of this systematic review is to give an overview of what
is known about the association between endometriosis and symptoms of
depression or anxiety regarding its strength and direction, and to
further examine which factors are associated. In addition, this review
may help to elucidate the importance of psychiatric screening and to
evaluate which patients are vulnerable for developing depression or
anxiety disorders. This is important for clinical practice since the
presence of anxiety and depression may influence the perception of
symptoms, the prognosis, compliance with treatment and quality of life
[21].
Methods
This systematic review was registered in PROSPERO (CRD42018106983) and
was conducted following the PRISMA guidelines [22,23].