Prevalence of Abuse in Women with Endometriosis and Relationship to Pain Symptoms: A Cross-Sectional Questionnaire Study

doi:10.21203/rs.3.rs-3889054/v1

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Prevalence of Abuse in Women with Endometriosis and Relationship to Pain Symptoms: A Cross-Sectional Questionnaire Study

https://doi.org/10.21203/rs.3.rs-3889054/v1

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Background

Sexual and physical abuse are associated with endometriosis, but their relationship to pain in endometriosis patients has not been studied. The aim of this study was to characterize the prevalence of sexual and physical abuse history in an endometriosis population and its relationship to severity and type of pain symptoms.

Methods

This was a cross-sectional questionnaire study conducted from May 2017 to May 2018 at a tertiary care gynecology clinic. Women with clinically suspected or surgically confirmed endometriosis were included. Patients completed the Endometriosis Phenome and Biobanking Harmonization Project (EPHect) Clinical Questionnaire, the International Pelvic Pain Society Pelvic Pain Assessment Form, and the Medical Outcome Survey (SF-36). Relationships between history of sexual abuse or physical abuse, pelvic pain type and severity, anxiety/depression diagnosis, quality of life, and demographics were analysed using Chi square, independent t-tests, Mann-Whitney U test, and logistic regression models.

Results

Forty-four women were surveyed. Severity and type of pain symptoms were similar in patients with and without a history of sexual or physical abuse. Forty-three percent (n = 19) of patients with endometriosis reported history of physical abuse and 43% (n = 19) reported history of sexual abuse with a 68% overlap between both groups. Patients with a history of sexual abuse had significantly higher rates of depression (53% vs 16%; p = 0.012) and anxiety (58% vs 12%; p = 0.001) than those reporting no history of sexual abuse and reported significantly lower mean SF-36 mental component summary scores (34 ± 14 vs 42 ± 12, p = 0.028).

Conclusions

No differences in severity and type of pain symptoms in patients with a history of sexual or physical abuse were observed compared to those without. More than 40% (n = 19) of patients with endometriosis reported a history of sexual abuse, with more anxiety and depression and lower mental quality of life scores compared to patients who reported no history of sexual abuse. This highlights the need for sexual abuse and mental health screening in an endometriosis population.

Gynecology

women’s health

endometriosis

abuse

mental health

quality of life

depression

questionnaire study

pelvic pain

Endometriosis is an estrogen-dependent chronic inflammatory disease, where endometrial-like tissue is found outside of the uterine cavity [1]. The gold standard for definitive diagnosis has traditionally been laparoscopy with histologic confirmation [2], however with improved attention to history, physical examination, and expert guided imaging, it can also be diagnosed clinically [3–5]. Endometriosis affects an estimated 1 in 10 women of reproductive age [6 − 8]. Despite multiple theories and on-going investigations, the etiology remains largely undetermined [1] and diagnosis may be delayed for 4–10 years after onset of pain symptoms [8–13]. Endometriosis has a negative impact on quality of life [14, 15], affecting mental health [16], work productivity [17], and social and intimate relationships [18]. While symptoms vary, pelvic pain is a key clinical feature including dysmenorrhea, dyspareunia, dyschezia, dysuria, and non-cyclic pelvic pain. If left untreated, endometriosis-related pain may progress to chronic pelvic pain [19–21].

Many studies have suggested that early life stressors such as childhood sexual and physical abuse are associated with pain conditions such as endometriosis, chronic pelvic pain, fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome (IBS) [22–32]. Specifically, several studies have linked a history of childhood abuse to endometriosis, although results have been conflicting [29–34]. In one study, Harris et al. (n = 60 595) showed that there is a higher rate of laparoscopically-confirmed endometriosis in women with a history of childhood sexual or physical abuse, and severity and chronicity of abuse showed a dose-response association with endometriosis risk [29]. A study by Thomas et al. (n = 98) found significantly higher rates of sexual abuse history but not physical abuse history when comparing women with concurrent chronic pelvic pain and endometriosis to pain-free controls [30]. This is supported by Liebermann et al. (n = 842) who report higher prevalence of childhood sexual abuse in women with endometriosis compared to the general population control group [31]. In contrast, other reports of abuse history in women with endometriosis found only significant associations with physical abuse [32] or no associations at all with history of physical or sexual abuse [33, 34]. To date there is no causal link between history of abuse and diagnosis of endometriosis, although possible explanations have been proposed [35–38].

In certain pain conditions such as IBS and fibromyalgia, childhood abuse is associated with increased pain severity [39, 40]. This association of pain severity and childhood abuse was also shown in patients with substance use disorders and chronic pain [41]; this association with pain severity has not been shown in the chronic pelvic pain population [42–45]. To date, no studies have looked specifically at the relationship between pain severity and history of childhood abuse in an endometriosis population.

As such, the primary purpose of our research was to assess whether there is a difference in severity and type of pain symptoms in patients with endometriosis that report a history of sexual and/or physical abuse compared to patients with no abuse history. Secondary objectives are to characterize any differences in quality of life and mental health in patients with concurrent pelvic pain and endometriosis between individuals with a history of physical and sexual abuse and those without.

Study design

This is a cross-sectional cohort questionnaire study.

Study population

Seventy-two patients were recruited from a Canadian tertiary care gynecology clinic, specializing in endometriosis and pelvic pain, between May 2017 to May 2018. All patients presenting with suspected or confirmed endometriosis were eligible for inclusion. Inclusion criteria included age of 18 years or older, pre-menopausal, and capable of filling out the questionnaire. Patients were excluded from the study if they continued to surgical intervention and endometriosis was not confirmed by histology, and if they did not complete the study questionnaires.

Data collection

Patients who consented to be part of the study completed a set of questionnaires about their medical and surgical history as well as their quality of life as it related to endometriosis. The set of questionnaires included: the Endometriosis Phenome and Biobanking Harmonization Project (EPHect) Clinical Questionnaire [46], the International Pelvic Pain Society (IPPS) Pelvic Pain Assessment (IPPS-PPA) Form [47], and the Medical Outcome Survey (SF-36) [48]. Patient reported demographics, pelvic pain symptoms, and medical and surgical history were extracted from EPHect and IPPS-PPA questionnaires. Demographic variables included age, body mass index (BMI), parity, gravidity, ethnicity, cigarette smoking, alcohol consumption, marital status, and education level.

Pelvic pain symptoms included: history of dysmenorrhea, dysuria, dyschezia, dyspareunia, and non-cyclic pelvic pain. Dysmenorrhea was separated into categories including mild (medication never or rarely needed), moderate (medication usually needed), and severe (medications and bed rest needed). Severity of pain was defined in the standardized EPHect questionnaire as a time in the patient’s life when the pelvic pain was at its worst and quantified on a numeric rating scale of 0 to 10 (0 = no pain; 10 = worst imaginable pain). Medical and surgical history included medical co-morbidities (including depression and anxiety), age of endometriosis diagnosis, age symptoms started, and previous abdominal surgeries. The SF-36 was used to quantify mental and physical quality of life using the mental component summary (MCS) and physical component summary (PCS) scores from SF-36, respectively, as described by Ware et al [49]. On the SF-36, a lower score is representative of reduced quality of life in each domain. Patient reports of sexual and physical abuse were extracted from the IPPS-PAA using validated questions from Leserman et al [50]. Physical abuse was defined as having someone hit, kick, beat, or seriously threaten the life of the respondent. Sexual abuse was defined as any act that ranged from unwanted exposure to rape.

Patients were also classified into three groups based on their endometriosis type: superficial endometriosis, ovarian endometriomas, or deep endometriosis [51]. Endometriosis type was determined using surgical diagnosis or radiological imaging performed at a tertiary care centre with expertise in endometriosis imaging, using the International Deep Endometriosis Analysis group guidelines [52, 53]. If patients had no previous surgical diagnosis and if imaging was negative, their endometriosis was classified as superficial based on history and clinical presentation, as superficial endometriosis is difficult to detect on imaging such as ultrasound [54].

Statistical analysis

The data were summarized using descriptive statistics. The number (percentage) of patients with a history of sexual and/or physical abuse was calculated based on a patient reporting “yes” to any of the statements or questions in the sexual and physical abuse section of the IPPS-PPA form [47]. Pelvic pain prevalence and severity, rate of depression and anxiety, quality of life, and demographics were compared between patients with a history of sexual abuse and patients with no history of sexual abuse. Similarly, these variables were compared between patients with a history of physical abuse and patients without a history of physical abuse. Group comparisons were examined using Chi square tests for categorical variables, independent t-tests for continuous variables, and Mann Whitney U test for non-normal distribution variables (parity, education level and pain severity).

When comparing the prevalence of different severity of dysmenorrhea, mild and moderate dysmenorrhea were classified under the value of 0 and severe dysmenorrhea was classified under the value of 1. The education level data was converted to ordinate data from 1–4 with 1 being less than 12 years of education and 4 being a postgraduate degree. To control for potential confounding factors of age, BMI, and parity, a binary logistic regression was conducted to evaluate the association between the outcomes of anxiety and depression, and a history of sexual and physical abuse (predictor, with no history as the reference category). An analysis of covariance for pain severity (outcome) compared in patients with and without a history of abuse (predictor) was conducted controlling for independent risk factors including depression, anxiety, mental quality of life, and physical quality of life. A p-value of 0.05 was considered statistically significant. Statistical analysis was performed using SPSS (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.).

Of the 72 patients recruited, 44 (61%) were included in the final analyses. Reasons for exclusion were no response (n = 17, 24%), incomplete questionnaires (n = 9, 12%), and histological confirmation of no endometriosis at time of surgery (n = 2, 3%). Diagnosis of endometriosis was surgically confirmed in 30/44 (68%) patients; 12/44 patients (27%) were diagnosed by ultrasound and 2/44 (5%) were diagnosed based on clinical symptoms.

Table 1 summarizes patient characteristics. In certain cases, patients checked more than one answer or did not answer; these discrepancies are noted where applicable. Thirty-four patients self-identified as Caucasian (n = 34, 72.3%). The mean age of patients was 37 years (standard deviation ± 6.6), with a mean BMI of 26 (± 6.0kg/m²). The average age at the time of diagnosis was 32 years (± 7.3) and the delay from symptom onset to diagnosis was 8.7 years (± 8.0). The median number of previous pregnancies (gravida) was 1 (range: 0–5) and median number of live births (parity) was 0 (range 0–3). Fifty-four percent (n = 24) of patients reported a history of infertility. Thirty-five patients (80%) presented with deep endometriosis, 4 (9%) with ovarian endometriomas, and 5 (11%) with superficial endometriosis.

Table 1

Study patient characteristics (N = 44)
Characteristics	Mean (SD)
Age	37.11 (6.61)
BMI	25.90 (6.02)
Age at endometriosis diagnosis^a Diagnosis delay^a	32.44 (7.27) 8.71 (7.98)
	Median (range)
Gravidity	1 (0–5)
Parity	0 (0–3)
	N (%)
Infertility	24 (54.5)
Type of endometriosis
Superficial	5 (11.4)
Ovarian/endometrioma	4 (9.09)
Deep	35 (79.5)
Abuse type
None	19 (43.2)
Physical Abuse	19 (43.2)
Sexual Abuse	19 (43.2)
Physical and Sexual Abuse	13 (29.5)
Physical and/or Sexual Abuse	25 (56.8)
Ethnicity (self-identified)^b
White	34 (72.3)
Black	2 (4.26)
Asian / Pacific / Oriental	2 (4.26)
Mixed ethnicity	1 (2.13)
Other	8 (17.0)
Cigarette smoking^c	6 (15.0)
Alcohol consumption	28 (63.6)
Marital status^d
Married	22 (44.9)
Separated	4 (8.16)
Committed relationship	12 (24.5)
Single	4 (8.16)
Divorced	7 (14.3)
Education level
Less than 12 years	1 (2.27)
High school graduate	4 (9.09)
College degree	22 (50.0)
Postgraduate degree	17 (38.6)
Some patients did not answer: ^an = 42, ^cn = 40. Some patients selected more than one answer: ^bn = 47, ^dn = 49. SD: standard deviation.

Twenty-five patients (57%) reported a history of abuse (sexual, physical, or both); of these 19 patients (43%) reported a history of physical abuse, and 19 patients (43%) reported a history of sexual abuse.

Patients with a history of physical abuse had a significantly higher mean age (40.16 ± 5.66 vs 34.80 ± 6.44, p = 0.006) and patients with a history of sexual abuse were more likely to be of Caucasian ethnicity than those without a history of sexual abuse (85% vs 63%) (Table 2).

Table 2 Patient characteristics according to abuse history
Characteristics		Groups
	No sexual abuse (n = 25)	Sexual abuse (n = 19)	p -value	No physical abuse (n = 25)	Physical abuse (n = 19)	p -value
Age, Mean (SD)	35.76 (7.44)	38.89 (4.98)	0.102	34.80 (6.44)	40.16 (5.66)	0.006
BMI, Mean (SD)	25.67 (5.69)	26.21 (6.58)	0.774	26.39 (6.09)	25.26 (6.03)	0.543
Parity, Median (range)	0 (0–2)	0 (0–3)	0.482	0 (0–2)	1 (0–3)	0.062
Ethnicity (self-identified), N (%)^c
White	17 (62.96)^a	17 (85.00)^b		20 (74.07)^a	14 (70.00)^b
Black	1 (3.70)^a	1 (5.00)^b		0 (0.00)^a	2 (10.00)^b
Asian / Pacific / Oriental	2 (7.41)^a	0 (0.00)^b		2 (7.41)^a	0 (0.00)^b
Mixed ethnicity	1 (3.70)^a	0 (0.00)^b		0 (0.00)^a	1 (5.00)^b
Other	6 (22.22)^a	2 (10.00)^b		5 (18.52)^a	3 (15.00)^b
Education level, N (%)			0.875			0.439
Less than 12 years	0 (0.00)	1 (5.26)		1 (4.00)	0 (0.00)
High school graduate	3 (12.00)	1 (5.26)		3 (12.00)	1 (5.26)
College degree	12 (48.00)	10 (52.63)		9 (36.00)	13 (68.42)
Postgraduate degree	10 (40.00)	7 (36.84)		12 (48.00)	5 (26.32)
Some patients selected more than one answer: ^an = 27, ^bn=20. ^cA p-value was not calculated for ethnicity given the numerous groups that led to a very small sample size in each group. SD: standard deviation.

There was no significant difference between patients with a history of sexual abuse and those with no history of sexual abuse in the prevalence of general non-cyclic pain (74% vs 64%, p = 0.495), dyschezia (71% vs 82%, p = 0.409), dyspareunia (79% vs 96%, p = 0.096), dysuria (44% vs 50%, p = 0.726), and severe dysmenorrhea (83% vs 64%, p = 0.163). Similarly, there was no significant difference between patients with a history of physical abuse and those with no history of physical abuse in the prevalence of general non-cyclic pain (68% vs 68%, p = 0.976), dyschezia (67% vs 86%, p = 0.324), dyspareunia (84% vs 91%, p = 0.480), dysuria (38% vs 54%, p = 0.159), and severe dysmenorrhea (74% vs 71%, p = 0.836)(Table 3). There was no significant difference between patients with a history of sexual abuse and those with no history of abuse in terms of severity of dysmenorrhea when the pain was at its worst (9.11 vs 8.46, p = 0.318), dyspareunia (7.33 vs 6.80, p = 0.755), and general non-cyclic pain (8.85 vs 8.56, p = 0.589); no difference between patients with a history of physical abuse and those with no abuse in the severity of dysmenorrhea when the pain was at its worst (8.79 vs 8.70, p = 0.765), dyspareunia (7.44 vs 6.68, p = 0.481), and general non-cyclic pain (8.77 vs 8.63, p = 0.846)(Table 4).

Table 3

Prevalence of different types of pelvic pain according to abuse history
Type of pelvic pain	No sexual abuse (n = 25), % of patients	Sexual abuse (n = 19), % of patients	p-value	No physical abuse (n = 25), % of patients	Physical abuse (n = 19), % of patients	p -value
General non-cyclic	64.00	73.68	0.495	68.00	68.42	0.976
Dyschezia	81.82^a	70.59^c	0.409	85.71^e	66.67^d	0.324
Dyspareunia	95.65^b	78.95	0.096	91.3^b	84.21	0.480
Dysuria	50.00^a	44.44^d	0.726	54.54^a	38.49^d	0.159
Dysmenorrhea			0.163^g			0.836^g
Mild	8.00	0.00^d		4.17^f	5.26
Moderate	28.00	16.67^d		25.00^f	21.05
Severe	64.00	83.33^d		70.83^f	73.68
Some patients did not answer: ^an = 22, ^bn = 23, ^cn = 17, ^dn = 18, ^en = 21, ^fn = 24. ^g= when calculating the p-value, mild and moderate dysmenorrhea were classified under the value of 0 and severe dysmenorrhea was classified under the value of 1 Mild dysmenorrhea defined as medication never or rarely needed. Moderate dysmenorrhea defined as medication usually needed. Severe dysmenorrhea defined as medication and bed rest needed.

Table 4

Severity of pelvic pain when it was at its worst according to abuse history
Type of pelvic pain	No sexual abuse (n = 25), mean ± SD	Sexual abuse (n = 19), mean ± SD	p -value	No physical abuse (n = 25), mean ± SD	Physical abuse (n = 19), mean ± SD	p -value
Dysmenorrhea^a	8.46 ± 2.15^b	9.11 ± 1.28^e	0.318	8.70 ± 1.87^h	8.79 ± 1.84	0.765
Dyspareunia^a	6.80 ± 2.61^c	7.33 ± 1.84^f	0.755	6.68 ± 2.52ⁱ	7.44 ± 2.00^d	0.481
General non-cyclic^a	8.56 ± 1.55^d	8.85 ± 1.57^g	0.589	8.63 ± 1.59^d	8.77 ± 1.54^g	0.846
^aSeverity ranges from 0 to 10. Some patients did not answer: ^bn = 24, ^cn = 20, ^dn = 16, ^en = 18, ^fn = 15, ^gn = 13, ^hn = 23, ⁱn = 19. SD: standard deviation.

The analysis of covariance assessing severity of dysmenorrhea, dyspareunia, and non-cyclic pain in patients with a history of sexual abuse and no sexual abuse and in patients with a history of physical abuse and no physical abuse, respectively, showed no significant difference when controlling for depression, anxiety, mental quality of life, and physical quality of life (p > 0.05)(Table 5).

Table 5

Analysis of covariance comparing the severity of types of pain according to abuse history
Type of pelvic pain	No sexual abuse (n = 25), Group mean ± SD	Sexual abuse (n = 19), Group mean ± SD		No physical abuse (n = 25), Group mean ± SD	Physical abuse (n = 19), Group mean ± SD	p-value
Dysmenorrhea^a	8.64 ± 0.40^b	8.85 ± 0.47^e	0.757	8.85 ± 0.39^h	8.59 ± 0.42	0.644
Dyspareunia^a	7.17 ± 0.60^c	6.99 ± 0.72^f	0.860	6.88 ± 0.60ⁱ	7.31 ± 0.62^d	0.638
General non-cyclic^a	8.50 ± 0.50^d	8.72 ± 0.57^g	0.799	8.39 ± 0.47^d	8.81 ± 0.49^g	0.578
^aSeverity ranges from 0 to 10. Some patients did not answer: ^bn = 24, ^cn = 20, ^dn = 16, ^en = 18, ^fn = 15, ^gn = 13, ^hn = 23, ⁱn = 19. SD: standard deviation.

In our study population, rates of anxiety were significantly higher among patients with a history of sexual abuse (58%) than those without (12%) (p = 0.001). Rates of depression were also significantly higher among patients with a history of sexual abuse (53%) than those with no history of sexual abuse (16%) (p = 0.012). There was no significant difference in rates of anxiety (p = 0.202) or depression (p = 0.054) between those patients with a history of physical abuse and those without (Table 6). When controlling for age, BMI, and parity with a binary logistic regression, a statistically significant effect of a history of sexual abuse on anxiety and depression was demonstrated, with persons reporting no history of sexual abuse being less likely to have anxiety (OR = 0.10, 95%CI = 0.02–0.48; p = 0.004) or depression (OR = 0.18, 95%CI = 0.04–0.77; p = 0.020). Whereas, in patient a history of physical abuse, no statistically significant effect was seen on anxiety (OR = 0.43, 95%CI = 0.10–1.82; p = 0.251) and on depression (OR = 0.26, 95%CI = 0.06–1.17; p = 0.079)(Table 7).

Table 6

Anxiety and depression prevalence and summary component scores according to abuse history
	No sexual abuse (n = 25)	Sexual abuse (n = 19)	p-value	No physical abuse (n = 25)	Physical abuse (n = 19)	p-value
Psychiatric conditions
Anxiety, N (%)	3 (12%)	11 (57.89%)	0.001	6 (24%)	8 (42.10%)	0.202
Depression, N (%)	4 (16%)	10 (52.63%)	0.012	5 (20%)	9 (47.37%)	0.054
Summary component scores^a
MCS, mean ± SD	42.31 ± 12.52^b	34.23 ± 14.08^c	0.028	41.78 ± 13.33^d	35.30 ± 13.54	0.063
PCS, mean ± SD	43.05 ± 10.85^b	41.85 ± 11.52^c	0.366	43.48 ± 10.41^d	41.40 ± 11.90	0.275
^aScores range from 0 to 100, with higher scores indicating better health. Some patients did not answer: ^bn = 24, ^cn = 18, ^dn = 23 MCS: mental component summary; PCS: physical component summary; SD: standard deviation.

Table 7

Binary logistic regression comparing mental health conditions according to abuse history
Psychiatric conditions	History of sexual abuse			History of physical abuse
Psychiatric conditions	Odds ratio	95% CI	p-value	Odds ratio	95% CI	p-value
Anxiety	0.098	0.020–0.475	0.004	0.429	0.101–1.819	0.251
Depression	0.182	0.043–0.767	0.020	0.262	0.059–1.167	0.079

Patients with a history of sexual abuse had a significantly lower mean mental component summary score than patients with no history of sexual abuse (34.2 ± 14.1 vs 42.3 ± 12.5, p = 0.028); this difference was not significant for history of physical abuse (p = 0.063). No between group differences were observed for physical component summary scores (Table 6).

In patients with endometriosis and pelvic pain, pelvic pain symptoms and severity were similar in patients with and without a history of abuse. Moreover, there was also no significant difference when controlling for confounders including depression, anxiety, mental quality of life, and physical quality of life. This suggests that there is no apparent association between the prevalence or severity of different types of pelvic pain and a history of physical or sexual abuse in an endometriosis population.

This is consistent with previously published literature in patients with chronic pelvic pain [42–44], whereby there is no association with increased pain severity in patients with chronic pelvic pain with a history of abuse compared to non-abused controls. Furthermore, our data suggests there is no difference in the type of pain between abused and non-abused patients with endometriosis.

Harris et al. observed an association between the incidence of laparoscopically-confirmed endometriosis and a history of abuse in a dose-responsive manner and noted a strong association between early life abuse and endometriosis-associated pain. However, their population also included a pain-free subset that presented with infertility that did not show this same relationship [29]. Our study presents data on a homogenous population of patients with endometriosis and pain symptoms, which indicates that factors influencing pain severity likely relate to unmeasured confounding factors. This is consistent with other studies that have identified an association between early life abuse and chronic pain in general, rather than a causal relationship to pelvic pain specifically [42, 55, 56]. Physiologically, endometriotic lesions account for only one component of the mechanisms that contribute to pain in patients with endometriosis, which also includes chronic inflammation, dysregulation of central stress response systems, peripheral sensitization, and neuroangiogenesis [1, 57, 58]. As such, it is important to consider a multifactorial approach to management of pain in endometriosis patients regardless of abuse history [59, 60].

Previous studies have shown that women with endometriosis often have high rates of anxiety and depression [16] and overall low mental quality of life [14, 15]. In our study, these findings were worse in patients with endometriosis who also have a history of sexual abuse, with even higher reported rates of anxiety and depression and lower overall mental quality of life. The difference in anxiety and depression remained statistically significant after controlling for age, BMI, and parity and there was no significant difference of pain type or severity between groups. These findings demonstrate the need to screen for mental health as well as abuse history, and the importance of being able to advocate for accessibility of mental health support in an endometriosis population. Ideally, health care resources for mental health services should be incorporated as part of comprehensive endometriosis care and be readily available if needed.

An unanticipated finding of this study was the incidence of abuse in our population. Fifty seven percent of our population reported a history of any abuse, with 43% reporting a history of physical abuse, and 43% reporting a history of sexual abuse, and a 68% overlap between both groups. Canadian rates for child and adult abuse in women have been reported as 12% and 30% respectively for sexual abuse, and 22% and 26% respectively for physical abuse [61, 62]. As such, our study reports a higher prevalence of abuse history than what is reported in the general population. This is consistent with other published literature demonstrating that history of abuse ranges from 45–65% in chronic pain populations in general, with no difference between types of chronic pain conditions [63–66]. There is an established link between adverse childhood adverse events, such as abuse, and poor mental and physical health [67]. Our study was not designed to ascertain the reason for this discrepancy, but given these findings addressing a history of abuse should be a part of any assessment for patients with endometriosis.

Limitations

There are a number of methodologic limitations in this study. A key limitation is the small sample size. A larger sample size might have shown a significant difference in depression rates and the mental component summary scores when comparing women with a history of physical abuse and no history of physical abuse, whereas in our population there was only a trend towards significance. Previous studies have found an association between a history of physical abuse and higher rates of anxiety and depression as well as lower quality of life in the general population [68–70].

Confounders were controlled by using depression, anxiety, mental quality of life, and physical quality of life as covariates for the analysis of covariance of pelvic pain severity according to abuse history. Also, demographics such as age, BMI and parity were used as control variables in the logistic regression evaluation abuse history on rates of anxiety and depression.

Another limitation of the study is generalizability, as our patients were recruited from a tertiary care center and most presented with deep endometriosis. However, our quality of life values are similar to those of a national survey of Canadian women with endometriosis and therefore comparable to non-tertiary centers [14].

Further, the history of abuse and degree of pain when it was at its worst are subject to recall bias. Many studies have examined the validity of retrospective pain assessments, and the results are mixed ranging from underestimation to often overestimation [71, 72]. Another study showed that childhood sexual abuse was underreported, and therefore likely underestimated [73]. Of note, the IPPS-PPA questionnaire includes the patient’s life being seriously threatened by another as one of the statements under physical abuse, which is not included in the revised Conflict Tactics Scale [74] or Childhood Trauma Questionnaire [75] used for the evaluation of physical abuse in other studies. However, patients that were included in the physical abuse group under these criteria only account for two out of the nineteen patients that reported physical abuse and therefore does not change the high rate of abuse.

Finally, there was a proportion of our population that did not receive pathologic confirmation of a diagnosis of endometriosis. Although the cause of these patients’ pelvic pain could be due to other factors, these individuals have forgone surgical intervention diagnosis of endometriosis as they responded to specific treatment for this condition, thereby allowing the omission of an invasive procedure [3–5].

In this study, no difference was observed between severity and type of pain symptoms in patients with endometriosis and a history of sexual or physical abuse compared to patients with endometriosis and no history of abuse. This brings into question a biological association between endometriosis symptom severity and abuse, and offers potential for future avenues of research. However, more than 40% of women with endometriosis in our population had a history of sexual abuse which is higher than rates in the general population. Furthermore, 57% of women in this population reported some form of abuse (sexual, physical, or both). Therefore, mental health and abuse screening in patients with endometriosis is critical to providing comprehensive care. The findings of this study call attention to the need for mental health resources in an endometriosis population to address patients’ psychosocial as well as physical needs as early and effectively as possible to provide the highest level of care. Our findings may assist healthcare professionals and patients to act as advocates to obtain additional funding for research and for programs that focus on comprehensive women’s health.

EPHect

Endometriosis Phenome and Biobanking Harmonization Project

IPPS-PPA

International Pelvic Pain Society Pelvic Pain Assessment

SF-36

Medical Outcome Survey

IBS

irritable bowel syndrome

BMI

body mass index

odds ratio

Ethics approval and consent to participate:

Ethics approval was obtained by the Ottawa Health Science Network Research Ethics Board (OHSN-REB 2017007701H). Informed consent was obtained from all participants in this study.

Consent for publication: Not applicable

Availability of data and materials: Data available on request. Subject to local institutional privacy/ethical restrictions. Please contact Dr Lortie for any request.

Competing Interests: SSS has no conflicts of interest to declare. He reports grants and personal fees from Abbvie, grants and personal fees from Bayer outside the submitted work. The other authors declare that they have no competing interests.

Funding: This study has not received any funding.

Authors’ contributions: AG, CAJ, and TF contributed to conception and design, data analysis and interpretation, and drafting and critical revision of the article. KL contributed to conception and design. CAJ, TF, SSS, and KL contributed to data acquisition. KL and SSS provided critical revisions for the article. All authors have provided final approval for the article to be published and agree to act as guarantors for the work.

Acknowledgements: The authors would like to acknowledge Dr. Arendas and Dr. Chen as well as the Minimally Invasive Gynecology Research Group at The Ottawa Hospital for their contributions in patient recruitment and data collection.

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Prevalence of Abuse in Women with Endometriosis and Relationship to Pain Symptoms: A Cross-Sectional Questionnaire Study

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