Women with endometriosis have greater psychological and sexual distress, study finds


A study has found that women with a diagnosis of endometriosis have significantly greater depressive symptomatology, sexual distress, and catastrophizing than age-paired healthy women.

The study in the journal Health Care for Women International, which assessed psychological and cognitive factors implicated in pain experience in women with endometriosis, also concluded that these women have higher scores on worry traits than for low pain severity.

The study consisted of 60 women with a diagnosis of endometriosis, all of whom were recruited from a hospital in North Italy between December 2016 to April 2018 to participate in the prospective case-control study.

The control group comprised 62 healthy women recruited from the general population.

During the enrollment phase, subjects completed a range of self-report questionnaires, along with a clinical interview with a trained psychologist and a gynecologist. Participants were evaluated at study entry and at 3 months.

At study entry, metacognitive beliefs significantly predicted subsequent sexual distress, over and above previous pain severity and sexual distress scores.

“These findings confirm previous literature, add significant novelty to current research on this population and lead to important clinical implications. Pain severity matters,” wrote the authors.

Pain greatly impacts quality of life, sexual distress and depression, according to the authors, noting that women with high-pain endometriosis had the lowest physical quality of life compared to those with low-pain endometriosis and the control group.

Likewise, women with low-pain endometriosis demonstrated lower physical quality of life than healthy women. Sexual distress and depressive symptomatology were also higher in women with high-pain endometriosis than in the control group.

“Therefore, pain symptomatology is associated with worse physical quality of life and higher levels of sexual distress and depressive symptomatology,” wrote the authors.

Over the decades, various cognitive and neurophysiological hypotheses have emerged about the link between anxiety and pain experience. For instance, the biopsychosocial model of chronic pain and disability surmises that the experience of pain is the result of a dynamic interaction between physiological, psychological, and social factors.

The authors noted that pain affects different domains of mental health in the study population, whereas coping strategies, metacognitive beliefs and worry traits might modulate pain experience and psychological distress.

Noteworthy, the study found a modest deficit in positive cognitive coping strategies, such as refocus planning and positive reappraisal, in women with low-pain endometriosis compared to healthy subjects.

Beliefs about one’s own worries also may result in a dysfunctional way to cope with stressors like catastrophizing and ruminating about one’s own problems. This indirectly leads to the onset and maintenance of distress, according to the authors.

Three study limitations are the small sample size, the short-term follow-up, and lack of control for specific medical conditions like surgery, medication, and disease stage occurring at study entry and between study entry and after 3 months.

“These conditions have been assessed and reported, but their control was not possible due to the high heterogeneity of the sample and the complexity of the disorder,” wrote the authors. “Endometriosis represents a complex condition, in which control of each of such medical categories would request a bigger sample size and a forced-categorization of a series of variables.”

Moreover, all participants were enrolled from a single institution, thus potentially reducing the generalizability of the findings.


Zarbo C, Brugnera A, Compare A, et al. Psychological and cognitive factors implicated in pain experience in women with endometriosis. Health Care Women Int. Published online September 10, 2021. doi:10.1080/07399332.2021.1959592

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