Endometriosis linked to higher risk of mental health conditions

Patients with endometriosis are at a significantly increased risk of mental health conditions, according to a recent study published in the American Journal of Obstetrics & Gynecology.¹

Approximately 1 in 10 women are impacted by endometriosis, which often leads to adverse impacts on quality of life because of chronic pelvic pain, dysmenorrhea, and infertility. The World Health Organization has cited depression, anxiety, fatigue, debilitating pain, and painful sex as outcomes of endometriosis.²

In a retrospective cohort study, endometriosis was also linked to increased pregnancy complications such as gestational diabetes, preeclampsia, preterm birth, and postpartum hemorrhage. While data has been collected about the psychological manifestations of endometriosis, interest about the condition’s impact on mental health has risen.¹

While studies have linked endometriosis to conditions such as anxiety and depression, these studies were conducted in varied health care landscapes and focused on a surgical diagnosis of endometriosis. Therefore, a study conducted in a universal, single-payer health care system is needed.

To evaluate the impact of endometriosis on mental health, investigators conducted a population-based, retrospective cohort study.¹ Participants included women aged 18 to 50 diagnosed with endometriosis for the first time between January 1, 2010, and July 1, 2020.

Data from a single-payer health care system was obtained through the Ontario Health Insurance Program (OHIP) and included physician claims, outpatient surgical claims, emergency department visits, demographics, and inpatient hospital records. Endometriosis was the primary exposure of the analysis, identified based on medical or surgical diagnosis criteria.¹

A medical diagnosis of endometriosis was based on 2 outpatient medical billings within 1 year with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code or an in-hospital visit with an ICD-10 code not associated with surgery. Patients with hysterectomy or bilateral salpingo-oophorectomy (BSO) before the index date were excluded.

A first occurrence of a mental health diagnosis was reported as the primary outcome. The observation window for this outcome occurred from study entry until death, loss of OHIP coverage, first malignant cancer diagnosis, or end of study period.

Diagnoses included anxiety, depression, substance use disorders, deliberate self-harm, psychosis, and others, and were identified using ICD-9 or ICD-10 codes. Secondary outcomes included severe mental health diagnoses.¹

Covariates included hysterectomy, BSO, pregnancy history, infertility, immigration status, index surgery, abnormal uterine bleeding, asthma history, hypertension, diabetes, fibroids, migraines, irritable bowel disorder, and nulliparity. Age and rurality at index were also used as covariates during the secondary analysis.

There were 35,944 women with endometriosis and no history of mental health conditions included in the analysis, 29.5% of whom were medically diagnosed, 60.5% surgically diagnosed, and 10% with a medical diagnosis subsequently confirmed surgically. These patients were matched to 71,888 unexposed women.¹

Most baseline characteristics were balanced between groups. However, gynecological characteristics such as abnormal uterine bleeding, uterine fibroids, and infertility were more common in the endometriosis group.

A mental health condition was diagnosed in 67% of patients with endometriosis and 51.2% without endometriosis over the study period. This indicated incidence rates of 105.3 events per 1000 person-years vs 66.5 events per 1000 person-years, respectively.¹

Adjusted hazard ratios for mental health conditions when compared to unexposed patients were 1.28 for medically diagnosed endometriosis patients, 1.33 for surgically diagnosed, and 1.36 for medically diagnosed then surgically confirmed patients. The year following an endometriosis diagnosis presented the highest mental health risk.

In each subsequent year after the initial endometriosis diagnosis, the risk of mental health diagnoses decreased. When stratified based on covariates, significant effect modification was observed for infertility, pregnancy after diagnosis, and hysterectomy. However, no impact was observed for BSO.

A severe mental health condition was reported in 7% of patients with endometriosis vs 4.6% without endometriosis. The risk of self-directed harm was highest in medically diagnosed patients. Risks of psychosis and self-harm were not observed in surgically diagnosed patients, but these individuals had increased risks of depression, anxiety, and substance use disorders.¹

These results indicated increased risks of mental health conditions among patients diagnosed with endometriosis. Investigators recommended additional research about the impact of mental health interventions on these patients.¹

References

1. Thiel PS, Bougie O, Pudwell J, et al. Endometriosis and mental health: a population-based cohort study. Am J Obstet Gynecol. 2024;230:649.e1-19. doi:10.1016/j.ajog.2024.01.023
2. Petronelli M. Rising endometriosis rates linked to increased pregnancy complications. Contemporary OB/GYN. May 19, 2024. Accessed June 18, 2024. https://www.contemporaryobgyn.net/view/rising-endometriosis-rates-linked-to-increased-pregnancy-complications