The Association Between Endometriosis Treatments and Depression and/or Anxiety in a Population-Based Pathologically Confirmed Cohort of People with Endometriosis

Emma Goodwin; Helena Abreu do Valle; Amanda Nitschke; Joseph Puyat; P J Yong; Gillian E Hanley

doi:10.1089/whr.2023.0068

Endometriosis · Associated Conditions

The Association Between Endometriosis Treatments and Depression and/or Anxiety in a Population-Based Pathologically Confirmed Cohort of People with Endometriosis

Goodwin E, Abreu do Valle H, Nitschke A, Puyat J, Yong PJ, Hanley GE

Published November 20, 2023 Women's health reports (New Rochelle, N.Y.)

DOI 10.1089/whr.2023.0068 PMID 38023374 PMC PMC10664573

Read our synopsis

RRM Academy Synopsis

Endometriosis with depression or anxiety links to more reoperation

A Vancouver study of 3815 people with surgically confirmed endometriosis found that those with depression or anxiety more often had repeat surgery and pain care. About 16 out of 100 had depression or anxiety before surgery. The study used past records and shows a link only.

Key Findings

Of 3815 patients, 603 (15.8%) had depression and/or anxiety during the two years before their first endometriosis surgery.
Afterward, 26.5% of the depression and/or anxiety group had an endometriosis-related reoperation, against 22.2% of the others (adjusted OR 1.32, 95% CI: 1.07-1.61).
From 3 to 24 months after surgery, 30.7% of the depression and/or anxiety group saw a physician for pelvic pain, against 20.2% of the others.
From 3 to 24 months after surgery, 35.7% of the depression and/or anxiety group filled NSAID prescriptions, against 21.5% of the others.
Between 3 and 24 months after surgery, the depression and/or anxiety group had adjusted odds of 2.06 (95% CI: 1.53-2.77) for filling an opioid prescription.

Interpretation

The study is a retrospective cohort built from linked health records in one region, with follow-up to 2017. The authors state that they cannot comment on causality. Diagnostic codes identified depression and anxiety, and the authors report some misclassification. The records show prescriptions filled and cannot show whether patients took them. The cohort entered through surgery, so people with endometriosis who did not have surgery fall outside the results. The authors suggest that the group with depression and anxiety may have had worse symptoms.

RRM Context

The authors write that endometriosis calls for care as a systemic condition. They say clinicians should consider depression and anxiety when assessing endometriosis and chronic pelvic pain. Restorative reproductive medicine takes a whole-person view of pelvic pain. The paper's main text does not compare excision with ablation. Across the cohort, 22.9% had a reoperation.

Our editorial summary of this paper, not the article's abstract.

Abstract

Objective

Endometriosis patients have a high rate of co-occurring anxiety and depression. There is currently no literature investigating how this may affect endometriosis treatment and outcomes. This study examines the prevalence of depression and anxiety in a pathologically confirmed population-based endometriosis cohort and examines how endometriosis treatments and outcomes differ by the presence of co-occurring depression and/or anxiety.

Methods

This retrospective cohort study using population-based administrative data sets included pathologically confirmed endometriosis patients identified from the complete pathology records of Vancouver Coastal Health Authority (British Columbia, Canada) between 2000 and 2008. These data were linked with population-based health data for follow-up to 2017. Bivariate analyses assessed differences between patients with depression and/or anxiety and those without. Odds ratios (ORs) were calculated to assess the odds of binary postsurgical outcomes.

Results

Our final cohort consisted of 3815 patients. There were 603 patients (15.8%) with depression and/or anxiety. They were more likely to visit a physician for pelvic pain, more likely to take some hormonal medications, and more likely to fill prescription-level analgesics, including opioids both before and after surgery. They also had a significantly higher risk of reoperation for their endometriosis than people without co-occurring depression and/or anxiety (OR 1.32, 95% confidence interval [CI]: 1.07-1.61).

Conclusion

Endometriosis patients with co-occurring depression and/or anxiety used more health services for pain, including prescription-level analgesics, and were more likely to have an endometriosis reoperation. We recommend that future study should aim to better understand the direction of this association between depression and/or anxiety and increased health services use.

Topics

By this author

Pelvic Pain · Chronic Pelvic Pain

Endometriosis, symptoms, and risk for depression and/or anxiety: a population-based retrospective study

Goodwin E et al., 2025 BMC women's health Free full text on PubMed Central

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). 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. 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). 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.

Sexual Pain · Dyspareunia

Female Dyspareunia and the Relationship to Neurophysiologic Mechanisms: A Scoping Review

Cook E et al., 2026 Journal of minimally invasive gynecology

This scoping review aims to evaluate recent studies that examine the relationship between dyspareunia and neurophysiologic factors, and to synthesize their results as it pertains to the development and treatment of introital/vulvar dyspareunia and deep dyspareunia A comprehensive search was conducted in PubMed (NLM), Embase (Elsevier), CINAHL (EBSCOhost), Web of Science (Clarivate), Psycinfo (ProQuest), and Cochrane Library (Wiley) to find peer reviewed studies written in English published in 2000 or later that discussed how neurophysiology is related to dyspareunia. Search terms: dyspareunia; painful intercourse; genito-pelvic pain; penetration disorder; neuropsychology; central nervous system sensitization; neur; central sensitization. A total of 1101 studies were screened and 108 were included in the review. Abstract and full text screening were performed by 4 authors. Articles were also excluded if they did not include an objective diagnostic tool or objective treatment outcome of dyspareunia. We included original peer-reviewed published research in the form of randomized control trials, cohort studies, case control studies, case series of greater than 20 participants, and systematic reviews. Multiple study types were noted: 22 randomized control trials, 9 prospective cohort studies, 3 retrospective cohort studies, 30 case control, 16 case series, 17 cross-sectional, and 11 systematic reviews. Of these articles, 72 focused on introital/superficial dyspareunia, 23 focused on deep dyspareunia, and 13 on both. Data was synthesized in text and table format, separated by type of dyspareunia (introital vs deep) and either etiology/diagnosis or treatment. There are complex neurophysiologic mechanisms that influence both introital and deep dyspareunia, highlighting the roles of peripheral and central sensitization, nerve fiber density, and neuroplasticity in this condition. There are several promising treatments, including TENS, botulinum toxin A, physical therapy, and various multimodal approaches; but further research is needed to establish standardized therapeutic guidelines.

Pelvic Pain · Chronic Pelvic Pain

Pain sensitivity questionnaire in endometriosis

Gentles AJ et al., 2025 The journal of pain Free to read

There is increasing recognition that nociplastic pain and central sensitization may play a role in endometriosis-associated pain. The Pain Sensitivity Questionnaire Minor (PSQ-M) evaluates subjective widespread pain sensitivity, and is linked to pain outcomes in chronic pain populations. However, evidence connecting the PSQ-M to central sensitization in endometriosis is limited. Using the Central Sensitization Inventory (CSI) as a comparison, this study compared the PSQ-M as a clinical proxy for central sensitization in endometriosis individuals. Data collected from 983 endometriosis participants (mean age of 34 years), between January 2020 and December 2022, were analyzed from a prospective registry. A significant but weak positive correlation was observed between PSQ-M and CSI scores (r=0.099, p<0.001). A significant but weak correlation was found between the number of central sensitivity syndromes and pelvic pain-related comorbidities with the PSQ-M (r=0.093, p<0.001), compared to a stronger correlation with the CSI (r=0.687, p<0.05). PSQ-M scores were not significantly associated with baseline (r=0.013, p=0.797) or post-operative (r=-0.046, p=0.801) quality-of-life. There was no change in the PSQ-M and a small change in CSI after endometriosis surgery, suggesting that surgical treatment of endometriosis does not directly address central sensitization. In conclusion, the PSQ-M may not be the optimal clinical proxy for central sensitization in endometriosis. This study evaluates the Pain Sensitivity Questionnaire - Minor (PSQ-M) as a proxy for central sensitization in endometriosis. The PSQ-M showed weak correlations with central sensitivity syndromes and pain scores and was not associated with post-surgical quality-of-life, suggesting it may not be the optimal tool for assessing central sensitization in endometriosis.

Surgical Treatment · Excision Surgery

Endometriosis Clinical and Surgical Care During the COVID-19 Pandemic: A Comparison of Virtual-Only Care to Virtual and In-Person Care Combined

Goodwin E et al., 2025 Journal of minimally invasive gynecology Free to read

Endometriosis is a chronic and inflammatory condition that affects approximately 10% of the reproductive-age population. During the COVID-19 pandemic, there was a shift towards virtual care for endometriosis. Our aim was to evaluate the diagnostic and treatment outcomes of virtual-only care, compared to those who had both virtual and in-person visits. Retrospective descriptive analysis of registry data. This study was conducted in British Columbia, Canada, at a tertiary referral center for endometriosis and pelvic pain. In this cohort (n = 389), we examined patients who received an initial virtual assessment followed by virtual care alone (Virtual Only group, n = 203) and those who had an initial virtual assessment followed by an in-person physical exam (Physical Exam group, n = 186). Virtual care at the center during the COVID-19 pandemic. The Physical Exam group was more likely to have surgery compared to the Virtual Only group (45.7% vs. 16%, p <.001). At the time of surgery, the groups did not differ based on type of surgery (e.g., excision of endometriosis and/or hysterectomy), endometriosis anatomic findings (e.g., stage and anatomic subtype), surgical complexity or surgical complications. At baseline, the two groups did not differ in their pain, mental health or quality of life scores. At 1-year follow-up, the two groups did not differ in these outcome measures. There was a lower rate of surgery, but no differences in surgical findings or complications, nor in 1-year outcomes, after virtual only care for endometriosis compared to patients that had a virtual visit and then underwent a physical exam. These results support a hybrid model, where a virtual visit is the first contact and serves as a triage tool to determine whether a patient is appropriate for virtual only care or would benefit from a physical exam. Future research could incorporate population-based administrative data or qualitative approaches to understanding patient experiences and physician perspectives on virtual care for the treatment of endometriosis.

Related research

Diagnosis · Diagnostic Delay

Prevalence and Symptomatic Burden of Diagnosed Endometriosis in the United States: National Estimates from a Cross-Sectional Survey of 59,411 Women

Fuldeore MJ et al., 2017 Gynecol Obstet Invest

Background/aims: To estimate the prevalence of diagnosed endometriosis (DE) in women in the United States and assess the associated symptomatic burden. An online, cross-sectional survey of women aged 18-49 years was conducted from August 6, 2012, through November 14, 2012. Survey data (weighted by age, race, education, income, geographical distribution, and propensity score) were used to estimate the prevalence and symptomatic burden of DE in women in the United States. Weighted logistic regressions were used to assess differences in symptom burden between women with and without endometriosis. The prevalence of DE was estimated at 6.1% (2,922 of 48,020 women surveyed); 52.7% of women were 18-29 years of age when they were diagnosed with endometriosis. Most (86.2%) women experienced symptoms before diagnosis. More women with (vs. without) DE had menstrual pelvic pain/cramping (52.7 vs. 45.2%), non-menstrual pelvic pain/cramping (36.7 vs. 14.3%), infertility (11.6 vs. 3.4%), and dyspareunia (29.5 vs. 13.4%). Women with endometriosis were also more likely to report severe symptoms (OR (95% CI) 2.7 (2.3-3.1) for menstrual pelvic pain/cramping, 2.2 (1.7-2.9) for non-menstrual pelvic pain/cramping, and 2.4 (1.8-3.2) for dyspareunia). The prevalence of DE among US women is notable, and affected women experience a substantial symptom burden.

Associated Conditions · Comorbid Conditions

Endometriosis and cardiovascular disease: a population-based cohort study

Blom JN et al., 2023 CMAJ open Free full text on PubMed Central

Endometriosis, a prevalent condition among females of reproductive age, may be associated with increased risk of cardiovascular disease (CVD) through chronic inflammation and early menopause. The objective of this study was to estimate the association between endometriosis and subsequent risk of CVD. We conducted a population-based cohort study using administrative health data from Ontario residents from 1993 to 2015. We compared the incidence of CVD and cardiovascular health outcomes between females with endometriosis and 2 age-matched females without endometriosis. The primary outcome was hospital admission for CVD. Secondary outcomes included in-hospital CVD events of interest and emergency department visits for CVD. We used Cox proportional hazards models to estimate adjusted hazard ratios (HRs) between endometriosis and CVD events. We identified 166 835 eligible patients with endometriosis and matched 333 706 patients without endometriosis. The mean age of those with endometriosis was 36.4 years. Patients with endometriosis had a higher incidence of hospital admission for CVD (195 admissions/100 000 person-years) compared with those without endometriosis (163 admissions/100 000 person-years). Similarly, the incidence of secondary CVD events was slightly higher among patients with endometriosis (292 cases/100 000 person-years) than among those without endometriosis (224 cases/100 000 person-years). Females with endometriosis had an increased risk of hospital admission (adjusted HR 1.14, 95% confidence interval [CI] 1.10-1.19) and secondary CVD events (adjusted HR 1.26, 95% CI 1.23-1.30). In this large, population-based study, endometriosis was associated with a small increased risk of CVD events. Future studies need to investigate potential etiological mechanisms and strategies to decrease long-term CVD risk in patients with endometriosis.

Pelvic Pain · Chronic Pelvic Pain

Endometriosis as a Comorbid Condition in Chronic Fatigue Syndrome (CFS): Secondary Analysis of Data From a CFS Case-Control Study

Boneva RS et al., 2019 Frontiers in pediatrics Free full text on PubMed Central

Endometriosis (EM) is a recognized co-morbid condition in women with chronic fatigue syndrome (CFS). This analysis evaluates the impact of EM on the health of women with CFS by comparing selected health characteristics and laboratory parameters in women with CFS with and without EM (CFS+EM and CFS-only). This secondary analysis included all 36 women with CFS from a cross-sectional study of CFS in Wichita, KS, conducted between 2002 and 2003. The health characteristics and laboratory parameters of interest included functioning, fatigue, CFS-related symptoms, gynecologic history, routine laboratory parameters, inflammatory markers, cortisol levels, allostatic load, and sleep parameters (overnight polysomnography). We used parametric or non-parametric tests to compare group differences in the selected health characteristics and laboratory parameters. For examining the association between EM and variables of interest, logistic regression models were performed and odds ratios (OR) with 95% confidence intervals (CI) were reported for the magnitude of associations. Statistical significance was set at 0.05 (two-sided). The mean age of this study sample was 50.9 years. Of women with CFS, 36.1% reported having EM. Age and body mass index (BMI) did not differ between CFS+EM and CFS-only groups. When examining the impact of EM, compared to women with CFS-only, women with both CFS and EM were more likely to report chronic pelvic pain [OR = 9.00 (95% CI, 1.47-55.25)] and hysterectomy [OR = 10.3 (1.82-58.39)], had more CFS symptoms (6.8 ± 0.3 vs. 5.5 ± 0.3, p = 0.02), younger mean age at menopause onset (36.4 ± 3.0 vs. 47.0 ± 2.7 years, p = 0.03), higher mean number of obstructive apnea episodes per hour (20.3 vs. 4.4, p = 0.05) and reported more negative life events (15.8 vs. 4.4, p = 0.05). Other parameters did not differ significantly between the two groups. We found more than a third of women with CFS reported endometriosis as a comorbid condition. The endometriosis comorbidity was associated with chronic pelvic pain, earlier menopause, hysterectomy, and more CFS-related symptoms. However, endometriosis in women with CFS did not appear to further impact functioning, fatigue, inflammatory markers, or other laboratory parameters. Further investigations including younger women are warranted.

Sleep and Circadian Health · Sleep Quality

A Quantitative Analysis of Sleep Quality in Women with Endometriosis

Arion K et al., 2020 Journal of women's health (2002)

Endometriosis is a complex condition that can negatively affect a woman's quality of life, including her sleep. This study aims to assess the multifactorial variables associated with poorer quality of sleep in women with endometriosis. Data from the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC) data registry were analyzed for women who underwent surgery at the BC Women's Center for Pelvic Pain and Endometriosis with histopathological confirmation of endometriosis (June 2015 to June 2017). The primary outcome was quality of sleep preoperatively, from the Chronic Pain Sleep Inventory (0-100 VAS). Bivariate analysis and multivariable linear regression were done to determine any significant associations between preoperative patient variables and overall quality of sleep, based on p-value of 0.05. Two hundred and seventy-five women met the study criteria. Poorer overall quality of sleep was independently associated with poorer functional quality of life (EHP-30) (b = -0.18, p = 0.0026), more depressive symptoms (PHQ-9) (b = -1.62, p < 0.001), and painful bladder syndrome (PBS) (b = -5.82, p = 0.035). This indicates that a 1 point increase in the EHP-30 (worsening quality of life), a 1 point increase in the PHQ-9 (worsening depression), and the presence of PBS increased the primary outcome (i.e., toward poorer quality of sleep) by 0.18, 1.62, and 5.82 points. Poorer quality of sleep in women with endometriosis is associated with poorer quality of life, more depressive symptoms, and bladder pain. Research into interventions that improve sleep is warranted as part of the management of some women with endometriosis.

Endometriosis › Associated Conditions › Comorbid Conditions · General Gynecology › Pelvic Pain › Chronic Pelvic Pain · Mental Health and Psychosocial Care › Mood and the Cycle › Hormonal Medication and Mood

Emma Goodwin, Helena Abreu do Valle, Amanda Nitschke, Joseph Puyat, Gillian E Hanley

E Goodwin, H Valle, A Nitschke, Joe Puyat, Joey Puyat, J Puyat, G Hanley

PMID 38023374 38023374 DOI 10.1089/whr.2023.0068 10.1089/whr.2023.0068 Goodwin et al. 2023, Goodwin 2023