Psychological aspects of endometriosis: Differences between patients with or without pain on four psychological variables

Abstract

Objective

Women with endometriosis often have pain symptoms that seemingly do not relate to the stage of disease. It has been suggested that psychological factors may contribute to this disproportion. The purpose of this study was to compare patients with and without pain symptoms to see whether they differed in profile on four psychological parameters.

Study design

Sixty-three women with laparoscopically diagnosed endometriosis of whom 20 were symptom free, completed four psychometric tests assessing coping, emotional inhibition, depression, and anxiety.

Results

Significant positive correlations were found between coping and depression/anxiety, and between pain severity and subjective psychosocial impairment. There were no significant differences between the two groups on depression or anxiety and no correlations between pain severity and depression/anxiety.

Conclusion

Coping appears to be of major importance to the psychological consequences of endometriosis. This may have implications for the treatment of endometriosis. The study could not confirm previous findings of pain related to endometriosis being associated with a higher prevalence of depression and anxiety.

Introduction

Endometriosis is a gynaecological disease where tissue from the uterus is located outside the uterus, usually in the abdominal cavity and the surrounding areas. This condition often causes pelvic pain, pain related to the period, pain during intercourse, and/or difficulties in getting pregnant; symptoms likely to cause incapability to work and to affect social and psychological functioning. Endometriosis affects approximately 5% of the female population [1].

Some women with endometriosis suffer from chronic, disabling pain while others appear symptom free, apparently independently of stage of disease, i.e. patients with mild endometriosis may suffer from severe pain symptoms, and vice versa [2]. There may be purely physiological explanations to this inverse relationship, such as decreased sensitivity due to scarring; however, psychological factors could also influence pain experience in various ways. Affective state, attention, interpretations, and beliefs about the pain (e.g. about its cause, duration, and controllability) are important elements of pain perception, which modify pain experience. In addition, chronic pain may have a range of negative effects both on the personal and the social level, including loss of working ability, limitations in social activities, lack of understanding and support from the surroundings, and reduced quality of life [3]. Individual differences in the extent and degree of such negative implications of pain, i.e. the individual's level of functioning, may also bear on psychological/behavioural factors.

A stress-model is often used to illustrate the process in which subjective experience and interpretations of a symptom, in this case pain, mediates the level of mental (emotional) and physical functioning [4], [5]. How the individual responds emotionally to the experience of pain (e.g. with depression or anxiety) results from an appraisal of the nature and implications of the pain. The appraisal also determines which actions are perceived as useful ways of coping with the pain. The overall level of functioning is thus determined both by the emotional response to the pain and the behavioural efforts aimed at coping with the pain, all based on beliefs about its nature (e.g. its cause, durability, and curability) and how it is best managed, or if it is at all manageable. The concept of coping is further described below.

A few studies of psychological characteristics of patients with endometriosis have been carried out with contradictory results. One study found elevated levels of neuroticism, anxiety, and psychiatric morbidity (but not depression) in patients with endometriosis compared with healthy women, as well as significantly higher scores on psychoticism, introversion, and anxiety compared with another group of women with benign gynaecological symptoms [6]. Contrary, another study found elevated levels of depression in patients with pain compared to both healthy controls and women with asymptomatic endometriosis but no differences in anxiety between the groups [7]. Further, a recent study found a higher prevalence of depression in women with chronic pain caused by endometriosis when comparing those to patients with no pain [8].

The main goal of this study was to study potential differences in a small Danish sample, between women with pain related to endometriosis compared with pain-free patients on four psychometric tests, secondarily to examine the effects of pain caused by endometriosis on psychosocial functioning. The psychological variables in focus were coping, emotional inhibition, depression, and anxiety; psychological factors that have often been related to somatic illness in general, including endometriosis and chronic pain.