Quality of life and symptoms of pain in patients with endometriomas compared to those with other endometriosis lesions: a cross-sectional study

doi:10.21203/rs.3.rs-3734629/v1

Background

Endometriomas are genetically distinct from other endometriosis lesions and could be associated with a predisposition to excessive inflammation. However, differences in clinical presentation between types of endometriosis lesions remain understudied. This study aimed to investigate the quality of life and pain scores among patients with endometrioma compared to those with other types of endometriosis lesions.

Methods

A cross-sectional observational study was conducted between January 2020 and August 2023. Patients diagnosed with endometriosis completed the Endometriosis Health Profile 30 pain subscale questionnaire for their quality of life score and rated their endometriosis-associated pain symptoms using an 11-point numerical rating scale. Data were analyzed for comparison through multivariable linear regression models.

Results

A total of 248 patients were included and divided into endometrioma (81, 33%) and non-endometrioma (167, 67%) groups. The mean age of the patients was 37.1 ± 7.5 years old. Most participants were Canadian or North American (84%). One-third of the patients reported experiencing up to four concurrent pain symptoms. The most reported pain included deep dyspareunia (90%), chronic pelvic pain (84%) and lower back pain (81%). The mean quality of life score was 45.9 ± 25.9. We observed no difference in quality of life score between patients with and without endometriomas. Patients with endometriomas had lower mean scores for deep dyspareunia of 0.8 (95%CI, [0 to 1.5]; p = 0.049) and higher for superficial dyspareunia of 1.4 (95%CI, [0.2 to 2.6]; p = 0.028).

Conclusion

Among patients with endometriosis, the presence of endometriomas is not associated with a greater or lesser quality of life but difference in specific symptoms of dyspareunia.

Endometriosis

endometrioma

quality of life

Endometriosis Health Profile-30

pelvic pain

infertility

Endometriosis is a common gynecological disorder that affects millions of women worldwide. It is characterized by the presence of endometrial tissue outside of the uterus. Endometrioma, which is the presence of an ovarian mass arising from ectopic endometrial tissue, is one of the most common manifestations of endometriosis [1]. The largest ever study on the genetics of endometriosis, involving DNA from more than 760,000 women, found endometrioma is genetically distinct from other types and indicated there may be a genetic predisposition to excessive inflammation in people with the condition [2]. However, differences in clinical presentation between types of endometriosis lesions remain understudied. Moreover, improving quality of life (QoL) is a primary goal of endometriosis treatment, and the European Society of Human Reproduction and Embryology has suggested studying how surgery impacts pain and QoL parameters in different subtypes of endometriosis [3].

This study aimed to investigate the QoL among patients with endometrioma compared to those with other types of endometriosis. Additionally, we sought out to examine pain scores in patients with endometrioma versus those with other types of endometriosis.

Study design and participants

This cross-sectional study was conducted as part of an ongoing prospective cohort focusing on patients seeking care at the gynecological outpatient clinic for initial or follow-up visits related to endometriosis. The cohort consists of participants from [center deleted to maintain the integrity of the review process]. Prior to enrolling participants, ethical approval ([reference number deleted to maintain the integrity of the review process]) was obtained from the research ethics committee of [center deleted to maintain the integrity of the review process].

The study lasted from January 2020 to August 2023. The target population consisted of premenopausal individuals who were invited to participate and underwent a comprehensive history and physical examination. To be included in the study, an individual had to be diagnosed with endometriosis, regardless of the method of diagnosis (ultrasound and/or magnetic resonance imaging in the last year, visualization of lesions during surgery or histological confirmation), be aged 18 or over, be willing to participate, and be able to read and understand French language and to complete a questionnaire. Participants were excluded if they did not report any symptom of pain (as the primary outcome was assessed using questions relating to pain) or their clinical evaluation did not allow for differentiation between endometrioma and other types of endometriosis, as imaging examinations and histopathology were not available at the time of the study. Study flow chart is shown in Fig. 1.

Data collection

Participants provided written consent and self-completed a set of questionnaires either online or on paper before or after their outpatient clinic visit. The questionnaires were supplemented by findings from review of medical records.

The main outcome measure was evaluated using the validated Endometriosis Health Profile-30 (EHP-30) questionnaire pain subscale consisting of the first 11 questions. The response options are “never,” “rarely,” “sometimes,” “often,” and “always.” The recall period is the last four weeks. This assessment examines how endometriosis-related pain affects QoL [4]. The QoL was assessed using the Canadian French version of the EHP-30 questionnaire [5]. The resulting score was then transformed into a scale ranging from 0 (indicating optimal QoL) to 100 (indicating worst QoL) [4]. The secondary outcomes included reports in the last three months of superficial dyspareunia, deep dyspareunia, dysmenorrhea, dyschezia, lower back pain and chronic pelvic pain. Participants rated these symptoms in intensity using an 11-point numerical rating scale (NRS) recommended for endometriosis research [6]. NRS scores ranged from 0 (indicating no pain) to 10 (indicating worst pain imaginable) [6].

Statistical analysis

Our statistical analysis was completed using R software (version 4.3.1) [7]. The participants were divided into two groups based on the type of endometriosis: endometrioma and non-endometrioma groups. Continuous data were presented as mean ± standard deviation and/or median and range (minimum-maximum). Categorical data were reported as frequency (percentage). Comparison tests were performed between individuals with endometrioma vs. non-endometrioma using two-sample Wilcoxon-Mann-Whitney tests for continuous variables, and chi-square tests of independence or Fisher's exact tests for categorical variables when appropriate.

Multivariable linear regression models were used to compare the primary (EHP-30 score for QoL) and secondary outcomes (NRS scores for symptoms of pain) between the endometrioma and non-endometrioma groups. The models were adjusted for age, body mass index, ethnicity, age of menarche, parity, education level, employment status, marital status, annual income, and hormone use in the last three months. Sub-group analyses were performed to determine whether differences in either QoL score or NRS pain scores (when comparing endometrioma group to non-endometrioma group) were associated with potential modification factors. To do so, an interaction term between each factor and variable of interest was added to the models. The factors were the diagnosis method (imaging modalities/histology), concurrent pain symptoms (1–4/5–6), comorbid infertility (yes/no), presence of adenomyosis (yes/no), presence of fibroma (yes/no), moderate symptoms of depression (yes/no), moderate symptoms of anxiety (yes/no), pain catastrophizing (yes/no) and central component of pain (yes/no). To aid in clinical interpretation, analyses with cutoffs were conducted using multivariable logistic regression models. The EHP-30 score was categorized as impaired (score ≥ 75th centile of EHP-30 score population distribution) or best (score < 75th centile of EHP-30 score population distribution) quality of life. The pain NRS scores were categorized as severe (7–10) or mild-moderate (1–6) intensity.

We estimated the point estimates, i.e., linear regression coefficients (β) as mean differences for either QoL or pain symptoms scores, and odds ratios (OR) as ratios of the odds of probability for having either impaired QoL or each severe pain symptom. The estimates were supplemented by their confidence intervals (CI) of 95%. Statistical significance was established for values of p < 0.05 for all analyses. A p < 0.05 for the interaction term in sub-group analyses indicated that there was a statistically significant difference in effect of the variable of interest on the outcome regarding the whole factor. No sample size calculation was conducted. Participants were included over a complete period to obtain a representative sample of patients with frequent hospital visits. We therefore performed a post hoc power calculation to assess the statistical power of our main analyses [8]. This allowed us to determine that the study was adequately powered to detect minimal clinical differences relevant to patients or healthcare providers [9–11] (Figure S1).

Characteristics of the study population and outcomes distributions

Out of the 335 individuals who were screened, a total of 248 participants (74%) met the criteria for inclusion in our study and were divided into the endometrioma group (81/248; 33%) and non-endometrioma group (167/248; 67%) (Fig. 1). The mean age of the patients was 37.1 ± 7.5 years old, with an average body mass index of 26.6 ± 5.7 Kg/m². Most participants were Canadian or North American, accounting for 84% of the sample population. A large proportion of the participants (78%) had their first menstrual period at or before the age of 13, while more than half (54%) was nulliparous. One-third of the patients reported experiencing up to four pain symptoms simultaneously (34%). The non-endometrioma group showed a longer duration of pain symptoms (p = 0.047), lower prevalence of presentation of up to four concurrent pain symptoms (p = 0.031) and higher prevalence of adenomyosis (p = 0.02). No statistically significant difference between endometrioma and non-endometrioma patients emerged across other variables (Table 1). On average, the QoL score was 45.9 ± 25.9. The most reported pain symptoms included deep dyspareunia (90%), chronic pelvic pain (84%) and lower back pain (81%). In cases of severe symptoms (pain intensity of 7 or above), the most common symptoms reported were dysmenorrhea (66%), deep dyspareunia (58%), and chronic pelvic pain (50%) (Table 2).

Table 1

Main characteristics of the study population
Variables	Endometriosis¹		Total (N = 248)	p-value²
Variables	Endometrioma (n = 81)	Non endometrioma (n = 167)	Total (N = 248)	p-value²
Age (years)	37.0 ± 7.1	37.1 ± 7.8	37.1 ± 7.5	0.86
Body mass index (Kg/m²)	26.4 ± 5.6	26.7 ± 5.8	26.6 ± 5.7	0.83
Canadian or North American	69 (85.2%)	139 (83.2%)	208 (83.9%)	0.70
University level	40 (50.0%)	62 (37.1%)	102 (41.3%)	0.15
Working currently	71 (87.7%)	133 (79.6%)	204 (82.3%)	0.12
In a relationship/married/spouse	66 (81.5%)	143 (85.6%)	209 (84.3%)	0.40
Menarche ≤ 13 years old	60 (74.1%)	133 (79.6%)	193 (77.8%)	0.32
Nulliparous	46 (56.8%)	88 (52.7%)	134 (54.0%)	0.54
Years since onset of pain symptoms	9 (3–18)	12 (5–22)	11 (5–20)	0.047
Smoking	5 (17.9%)	15 (29.4%)	20 (25.3%)	0.26
Hormonal suppression in the last 3 months	41 (64.1%)	90 (60.0%)	131 (61.2%)	0.58
Comorbid infertility	13 (16.0%)	20 (12.0%)	33 (13.3%)	0.38
Reporting 1–4 concurrent pain symptoms	31 (44.3%)	40 (29.2%)	71 (34.3%)	0.031
Adenomyosis	2 (4.9%)	12 (21.8%)	14 (14.6%)	0.020
Fibroma	12 (57.1%)	38 (79.2%)	50 (72.5%)	0.060
Pain catastrophizing (PCS ≥ 27)	19 (23.5%)	48 (28.7%)	67 (27.0%)	0.38
Moderate anxiety (GAD-7 ≥ 10)	6 (23.1%)	14 (23.0%)	20 (23.0%)	0.99
Moderate depression (PHQ-9 ≥ 10)	9 (34.6%)	21 (34.4%)	30 (34.5%)	0.99
Central component of pain (CSI ≥ 40)	5 (11.1%)	15 (17.9%)	20 (15.5%)	0.31
Abbreviations: PCS, Pain Catastrophizing Scale; GAD-7, Generalized Anxiety Disorder; PHQ-9, Patient Health Questionnaire-9; CSI, Central Sensitization Inventory. ¹ Values are given in mean ± standard deviation, median (interquartile range), and frequency (percentage). ² Wilcoxon rank sum test for continuous variables; and Pearson’s Chi-squared test or Fisher’s exact test otherwise.

Table 2

Distribution of the outcomes
Variables¹	Endometriosis²		Total (N = 248)
Variables¹	Endometrioma (n = 81)	Non endometrioma (n = 167)	Total (N = 248)
Quality of life
EHP-30 score	42.4 ± 25.2	47.6 ± 26.2	45.9 ± 25.9
Impaired (EHP-30 score ≥ 66)	21 (25.9%)	48 (28.7%)	69 (27.8%)
Not available	0	0	0
Superficial dyspareunia
Have reported	37 (49.3%)	98 (64.1%)	135 (59.2%)
Intensity	5.0 ± 2.6	4.1 ± 2.6	4.3 ± 2.6
Severe (intensity ≥ 7)	10 (27.0%)	20 (20.4%)	30 (22.2%)
Not available	6	14	20
Deep dyspareunia
Have reported	68 (89.5%)	138 (90.2%)	206 (90.0%)
Intensity	6.0 ± 2.5	6.7 ± 2.2	6.5 ± 2.3
Severe (intensity ≥ 7)	35 (51.5%)	85 (61.6%)	120 (58.3%)
Not available	5	14	19
Dysmenorrhea
Have reported	57 (75.0%)	124 (81.6%)	181 (79.4%)
Intensity	6.6 ± 2.7	7.4 ± 2.3	7.1 ± 2.4
Severe (intensity ≥ 7)	36 (63.2%)	83 (66.9%)	119 (65.7%)
Not available	5	15	20
Dyschezia
Have reported	50 (61.7%)	135 (81.8%)	185 (75.2%)
Intensity	4.9 ± 2.4	5.0 ± 2.5	5.0 ± 2.4
Severe (intensity ≥ 7)	14 (28.0%)	39 (28.9%)	53 (28.6%)
Not available	0	2	2
Lower back pain
Have reported	64 (79.0%)	137 (82.0%)	201 (81.0%)
Intensity	5.6 ± 2.3	6.4 ± 2.1	6.1 ± 2.2
Severe (intensity ≥ 7)	24 (37.5%)	65 (47.4%)	89 (44.3%)
Not available	0	0	0
Chronic pelvic pain
Have reported	64 (79.0%)	143 (85.6%)	207 (83.5%)
Intensity	6.3 ± 2.0	6.6 ± 2.3	6.5 ± 2.2
Severe (intensity ≥ 7)	27 (42.2%)	76 (53.1%)	103 (49.8%)
Not available	0	0	0
Abbreviation: EHP-30, Endometriosis Health Profile-30.
¹ Pain intensity is the numerical rating scale score ranging from 0 (indicating no pain) to 10 (indicating worst pain imaginable); the EHP-30 score ranges from 0 (indicating optimal quality of life) to 100 (indicating worst quality of life); each “Not available” row displays the number of missing values; each “Have reported” row denotes the number of cases that reported the corresponding symptom of pain.
² Values are given in mean ± standard deviation and frequency (percentage).

Association between QoL and endometriomas

The unadjusted and adjusted analyses for QoL scores indicated no difference between patients with and without endometriomas (mean difference of -4.9 (95%CI, [-12.7 to 2.9]; p = 0.214) and − 2.9 (95%CI, [-10.5 to 4.8]; p = 0.458) respectively) (Fig. 2).

No statistically significant difference in QoL score between participants with endometriomas and those without emerged across the modifying factors. When considering only participants reporting moderate symptoms of depression, there was significantly lower mean QoL score at 29.3 (95%CI, [3.9 to 54.8]) for patients with endometriomas compared to those without (Fig. 3).

Association between pain scores and endometriomas

Participants with endometriomas versus those without endometriomas exhibited significantly higher mean scores for superficial dyspareunia of 1.4 (95%CI, [0.2 to 2.6]; p = 0.028), and significantly lower mean scores for deep dyspareunia of 0.8 (95%CI, [0 to 1.5]; p = 0.049) in adjusted analyses. For other pain symptoms (dysmenorrhea, dyschezia, lower back pain, chronic pelvic pain), there was no statistically significant differences in mean differences (Fig. 2).

Comorbid infertility (p = 0.049) was found to be a factor that influenced the results for superficial dyspareunia, with an average difference in scores of 4.6 (95%CI, [1.2 to 8.1]) if infertility vs 0.9 (95%CI, [-0.3 to 2.2]) otherwise (Figure S2). The central component of pain (p = 0.041) emerged as a factor that modified the potential average difference in scores for chronic pelvic pain (2.54; 95%CI, [-0.4 to 5.5] if central component of pain vs -0.7; 95%CI, [-1.8 to 0.3] otherwise (Figure S3).

Considering solely the levels of modifying factors, statistically significant mean score differences were found between participants with endometriomas and those without (i.e., 95% confidence intervals did not include zero). These differences were observed in individuals reporting up to four concurrent symptoms of pain, comorbid infertility, moderate symptoms of anxiety and pain catastrophizing for superficial dyspareunia (Figure S2), absence of a central component in pain experience and no pain catastrophizing for deep dyspareunia (Figure S4), and presence of a central component in pain experience and no pain catastrophizing for lower back pain (Figure S5). No such differences were identified for chronic pelvic pain (Figure S3), dysmenorrhea (Figure S6), dyschezia (Figure S7).

Odd radios of impaired QoL and severe pain symptoms

The OR for impaired QoL (endometrioma vs non-endometrioma) was 1.05 (95%CI, [0.5 to 2.19]; p = 0.89). For symptoms of pain, the OR ranged from 0.52 (95%CI, [0.25 to 1.08]; p = 0.08) for severe deep dyspareunia to 2.11 (95%CI, [0.60 to 7.43]; p = 0.24). Endometrioma was not associated with impaired QoL or any severe symptoms of pain, but the confidence intervals in adjusted analyses indicated that the data were compatible with an OR both greater than and less than 1 (Fig. 4).

In this study, we found no difference in quality of life between patients with and without endometriomas. In terms of pain scores, there were differences in deep and superficial dyspareunia. The study echoes research aiming to better quantify and compare endometriosis-associated pain experienced by different women or identify different subpopulations of women with endometriosis. Since no current cure exists for endometriosis, this research supports the development of targeted treatments appropriate to a group with similar clinical experience or to a given subpopulation's underlying biological differences [2, 12].

The study focused on the quality of life of patients with endometriosis who have different types of lesions. It specifically looks at how endometriosis, as a chronic inflammatory illness, affects their quality of life rather than just considering the presence or absence of pain symptoms. Indeed, the study only involved people who had experienced at least one symptom of pain. These findings add to the limited evidence in terms of the variation in pain and quality of life across endometriosis types. The findings echo earlier research indicating that endometriosis, regardless of type, significantly impacts patients’ quality of life and pain experiences. Patients with endometriosis seem to have an overall impaired quality of life compared to patients from the general population, including daily tasks, marital/sexual relationships, social life, and employment, as well as physical and psychological aspects of life [13–20]. In contrast to these previous studies, it should be emphasized that we focused on evaluating quality of life specifically about the experience of pain.

While patients with endometriomas indicated significantly higher scores for superficial dyspareunia, lower scores were noted for deep dyspareunia. This finding supports that the pain experience in endometriosis may vary by symptom and endometriosis subtype [21] since pain may also be due to the anatomical distortion that endometriomas create in the pelvis [22]. Endometriomas often co-occur with deep endometriosis [1]. In this study, the endometrioma group included all cases of endometrioma, regardless of other subtypes. Our study highlights the complex impact of endometriosis and co-occurring conditions (like depression) on quality of life, underscoring the importance of personalized care strategies, including medical, psychological, and non-medical interventions such as physical therapy and lifestyle changes. It also emphasizes the need for the development of targeted medical and surgical treatments to improve patient outcomes. Variations in the perception, nature, and intensity of pain among individuals can account for the differences observed in the results. Additionally, there may be associations between different pain symptoms that contribute to these variations. The finding that associated conditions such as depression could significantly affect quality of life in endometrioma patients compared to non-endometrioma suggests that healthcare providers should consider diagnostic strategies to identify such conditions and involve them in the overall management approach. Other studies will be required to understand which factors explained differences in quality of life among patients with endometriosis.

Strengths of this study included a substantial sample size for main analyses (with sufficient power to detect clinically relevant mean difference), the use of a validated measure for quality of life in the endometriosis population (EHP-30) and the use of appropriate and validated statistical methods to analyze the data. We considered a wide range of modifying factors (such as adenomyosis, comorbid infertility, and psychological factors), which provides a more comprehensive view of factors influencing quality of life and pain in endometriosis patients. The focus on comparing quality of life and pain experiences between endometrioma and other types of endometriosis (comparisons among patients with endometriosis) is a distinct feature of this study, which contributes unique findings to the research field. However, the study was limited by its cross-sectional design, which prevents the ability to establish cause-effect relationships between different types of endometrioses and quality of life or pain experiences. The participants were recruited from a specific clinical setting, which might limit the representativeness of the findings to all patients with endometriosis.

Future research could benefit from a longitudinal design to determine changes in quality of life and pain scores over time, helping to explore in more depth the relationships between different types of endometrioses, quality of life, specific pain experiences, and other influencing factors. This could lead to more effective approaches to improve the quality of life of endometriosis patients. Further exploration of personalized treatment plans based on the type of endometriosis and the patient's symptoms and assessments of quality of life could be valuable.

Among patients with endometriosis, the presence of endometriomas was not associated with a greater or lesser quality of life but difference in specific symptoms of dyspareunia. Further studies will be required to understand which factors explained differences in quality of life among patients with endometriosis.

CI: Confidence interval

EHP-30: Endometriosis Health Profile-30

NRS: numerical rating scale

OR: odds ratios

QoL: quality of life

Ethics approval and consent to participate

Ethical approval (#2020-4972) was obtained from the research ethics committee of Centre Hospitalier Universitaire de Québec-Université Laval. Written informed consent was obtained from each participant before participating in the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to privacy/ethical restrictions but are available from the corresponding author (FSK) on reasonable request and with permission of SML.

Competing interests

The authors declare that they have no conflicts of interest and nothing to disclose.

Funding

This research project was funded by the Canadian Institutes of Health Research. S.M.-L. is the recipient of a Career Award from the Fonds de Recherche Québec-Santé. The sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

Authors' contributions

Study Conception and Design: FSK, VA, SML

Data Collection: FSK, VA, SML

Statistical Analysis: FSK

Data Analysis and Interpretation of Results: FSK, VA, SML

Writing - Original Draft: FSK

Writing - Review and Editing: FSK, VA, SML

Supervision: SML

Acknowledgements

Not applicable.

Authors' information

FSK, MD, MPH: Doctoral student in epidemiology (Reproduction, mother and youth health).

VA, MSc: Nurse clinician and research professional (Reproduction, mother and youth health).

SML, MD, PhD: Gynecologist, clinician-researcher and assistant professor (Reproduction, mother and youth health).

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No competing interests reported.

Supplementaryfile.docx

Quality of life and symptoms of pain in patients with endometriomas compared to those with other endometriosis lesions: a cross-sectional study

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Abstract

Background

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Results

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Background

Materials and methods

Study design and participants

Data collection

Statistical analysis

Results

Characteristics of the study population and outcomes distributions

Association between QoL and endometriomas

Association between pain scores and endometriomas

Odd radios of impaired QoL and severe pain symptoms

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

Authors' information

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1