General Gynecology · Pelvic Pain
RRM Academy Synopsis
Pain without endometriosis tied to more depression or anxiety than with it
People with pelvic pain but no endometriosis faced higher depression and anxiety risk. The comparison group had pain and endometriosis. This Vancouver cohort study looked back at 3640 surgery patients. Endometriosis with and without pain showed no statistically significant difference in risk.
Key Findings
- The retrospective cohort held 3640 people whose surgery in Vancouver Coastal Health between 2000 and 2008 produced a pathology report naming endometriosis or related terms.
- Groups: 2729 symptomatic with endometriosis, 585 symptomatic without endometriosis on pathology, and 326 asymptomatic with endometriosis.
- Symptomatic people without endometriosis had an adjusted hazard ratio of 1.23 (95% CI 1.06-1.41) for depression and/or anxiety, compared with symptomatic endometriosis.
- Asymptomatic endometriosis versus symptomatic endometriosis gave an adjusted hazard ratio of 0.94 (95% CI 0.76-1.17), a difference that was not statistically significant.
- In the two years before surgery, 432 of 585 (73.8%) symptomatic people without endometriosis had a pelvic pain visit, against 1414 of 2729 (51.8%) with endometriosis.
Interpretation
A retrospective cohort links existing health records, so the results show association only. Diagnostic codes and prescriptions defined depression and anxiety, counted as one combined outcome. The records held no direct measure of pain and no healthy comparison group. Some people in the group without endometriosis may have had disease the surgery missed. Requiring a pathology diagnosis may favor more severe cases. The authors suggest that both a pain pathway and a disease pathway may operate. The sensitivity analyses include some small groups, so the authors urge caution reading them.
RRM Context
Restorative reproductive medicine starts by finding the cause of pelvic pain. Here, people with pain and no pathology diagnosis had a higher risk than the group with pain and endometriosis. The authors raise the possibility that pain plus diagnostic uncertainty is itself a risk factor, a hypothesis they say needs further study. The finding fits the restorative principle of a thorough search for the cause before treating symptoms.
Abstract
Background
Endometriosis is a chronic and inflammatory condition that often presents with chronic pelvic pain, dysmenorrhea, and dyspareunia, thus having important effects on quality of life. There are two proposed hypotheses to describe the known association between endometriosis and depression and anxiety: (1) the disease hypothesis, where the inflammatory nature of endometriosis is driving increased risk for depression and anxiety; and (2) the pain hypothesis, where it is the painful symptoms underlying the increased risk. We aimed to shed further light on these two hypotheses by assessing the risk for depression and/or anxiety in three groups of patients pathologically assessed for endometriosis: symptomatic endometriosis patients (Symp Endo), symptomatic patients with no pathological endometriosis diagnosis (Symp No Endo), and asymptomatic endometriosis patients (Asymp Endo).
Methods
This study included pathologically-confirmed endometriosis patients identified from the pathology records of Vancouver Coastal Health Authority between 2000 and 2008. These data were linked with population-based administrative health data for follow-up to 2017. Depression and anxiety were identified through diagnostics codes from health services use data and prescriptions for antidepressants. Bivariate analyses were performed to assess differences between groups. Cox proportional hazards models were run to generate hazard ratios for incident depression and/or anxiety between the groups.
Results
There were 2729 people in Symp Endo, 585 in Symp No Endo, and 326 in Asymp Endo. Symp No Endo was more likely than Symp Endo to be visiting a physician for pelvic pain and to be taking prescription-level pain medications (p < 0.001). After adjusting for several covariates, Symp No Endo had a significantly higher risk of incident depression and/or anxiety (adjusted HR: 1.23, 95% CI: 1.06-1.41) compared to Symp Endo. There was no statistically significant difference in risk of depression and/or anxiety between Symp Endo and Asymp Endo (adjusted HR: 0.94, 95% CI: 0.76-1.17).
Conclusions
These results point toward the pain focused hypotheses as Symp No Endo patients were at higher risk for depression/anxiety than the Symp Endo group. However, the results also suggest the disease hypothesis is at play, because the Symp Endo and Asymp Endo groups were at the same level of risk for depression/anxiety.