{"paper_id":"5e2c3f84-32e4-476e-adbb-32d69fedb0a8","body_text":"Systematic Review Article | JOGCR. 2023; 8(4): 315-326 \n     Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nEndometriosis and COVID-19: Clinical Presentation and Quality of Life, a \nSystematic Review \n \nPoorya Davoodi1,2, Delaram J. Ghadimi3,4, Malihe Rezaei4,5,6, Mohammad Amin Khazei Tabari7,8,  \nAryan Shirani4,5, Behnaz Nouri9, Noosha Samieefar4,5, Meisam Akhlaghdoust2,10*  \n \n1. Department of Molecular Medicine, University of Padua, Padua, Italy \n2. USERN Office, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences; Tehran, \nIran \n3. School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran \n4. USERN Office, Shahid Beheshti University of Medical Sciences, Tehran, Iran \n5. Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran \n6. Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran \n7. Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran \n8. USERN Office, Mazandaran University of Medical Sciences, Sari, Iran \n9. Department of Obstetrics and Gynecology, School of Medicine, Shohada-e-Tajrish Hospital, Shahid Beheshti University \nof Medical Sciences, Tehran, Iran \n10. Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, \nShahid Beheshti University of Medical Sciences, Tehran, Iran \n \nArticle Info  ABSTRACT \n  \n          10.30699/jogcr.8.4.315 \n \n \n \nBackground & Objective:  Endometriosis, a common disease of the female \nreproductive system, could affect many aspects of women’s lives. Along with many \nother diseases, COVID-19 has affected the diagnostic or treatment approaches towards \nendometriosis. This systematic review aims to investigate COVID-19 in endometriosis \npatients in terms of prognosis, diagnosis, treatment, and quality of life during the \npandemic. \nMaterials & Methods : Relevant studies were identified through searching for \nendometriosis and COVID -19 in different databases, including PubMed, Medline, \nScopus, and Web of Science, on 17 January 2022. Peer- reviewed published articles \nevaluating COVID-19 and endometriosis written in English were included. \nResults: Out of 115 articles, 9 manuscripts met our criteria. Endometriosis does not \nintensify the risk of COVID-19 infection. However, COVID-19 has changed the health \ncare of endometriosis patients.  \nConclusion: COVID-19 has affected endometriosis patients’ life in many aspects, \nincluding their job, lifestyle, and health care. Further studies are recommended to \nevaluate how the pandemic has affected endometriosis patients. \nKeywords: Coronavirus disease, COVID -19, Endometriosis, Pandemic, SARS -\nCoV-2, Gynecology  \nReceived:  2022/04/16; \nAccepted: 2022/06/28; \nPublished Online: 07 July 2023; \n \n \nUse your device to scan and read the \narticle online \n \n \nCorresponding Information:  \nMeisam Akhlaghdoust, \nFunctional Neurosurgery Research Center, \nShohada Tajrish Neurosurgical \nComprehensive Center of Excellence, Shahid \nBeheshti University of Medical Sciences, \nTehran, Iran \nEmail: Akhlaghdoust@sbmu.ac.ir \n \n \nCopyright © 2023, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License \nwhich permits copy and redistribution of the material just in noncommercial usages with proper citation. \n \n \nIntroduction\nEndometriosis is the ectopic presence of endometrial \nglands that causes chronic inflammation, pain, and \ninfertility (1-3). Estimates show that approximately \n10% of women of reproductive age have \nendometriosis, and most of them are symptomatic (4 -\n7). The co nsequences of the disease can affect the \npatients' mental health, quality of life and interfere with \ninterpersonal relationships and occupation (6, 8) . The \nstandard diagnosis of endometriosis warrants surgical \ninvestigation and histopathologic confirmation , while \nclinical diagnosis is a challenge (3, 8). \nAfter the Coronavirus disease (COVID -19) \npandemic, medical care has experienced a dramatic \nchange and reduced patient access on a global scale (9). \nEndometriosis patients have not been an exception, and \n\n\nPoorya Davoodi et al. 316 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nthe diagnostic or treatment approaches towards them \nhave altered (10) . Besides, patients with chronic \nillnesses like endometriosis are experiencing mental \nhealth problems during social isolation (10 -12). It is \nknown that the COVID -19 imposes a greater risk of \nsevere outcomes in patients with chronic and \ninflammatory diseases (12, 13), but it has not been clear \nwhether it has worse outcomes in endometriosis \npatients or not, nor do we know how the pandemic has \naffected the mental health and quality of life in \nendometriosis patients (14). \nTherefore, we conducted a systematic review to shed \nlight on the impact of the COVID -19 pandemic on \npatients with endometriosis. Our objectives were to \ndetermine COVID -19 prognosis in endometriosis \npatients, its influence on diag nosis and treatment, and \npatients' experience of their disease during the \npandemic. \n \nMethods \nIn accordance with \"Preferred Reporting Project for \nSystematic Evaluation and Meta-Analysis” (PRISMA) \nguidelines (15), a systematic search on endometriosis \nand COVID-19 was conducted in different databases: \nPubMed/Medline, Scopus, and Web of Science on 17 \nJanuary 2022. The search keywords are brought in the \nsupplementary Table 1\n. \n \nTable 1. Employed keywords in detail. \nDatabase Search string Results \nPubMed \n(\"Endometriosis\"[Mesh] OR “Endometriosis”) AND \n“COVID” OR “COVID19” OR “COVID 19” OR “COVID-19” OR “Coronavirus \nDisease-19” OR “Coronavirus Disease 19” OR “Coronavirus Disease-2019” OR \n“Coronavirus Disease 2019” OR “Coronavirus infection-19” OR “Coronavirus \ninfection 19” OR “Coronavirus infection-2019” OR “Coronavirus infection 2019” \nOR “Coronavirus-19” OR “Coronavirus 19” OR “Coronavirus19” OR “Coronavirus-\n2019” OR “Coronavirus 2019” OR “Coronavirus2019” OR “nCoV19” OR “nCoV \n19” OR “nCoV-19” OR “nCoV2019” OR “nCoV 2019” OR “nCoV-2019” OR \n“2019nCoV” OR “2019 nCoV” OR “2019-nCoV” OR “2019 Novel Coronavirus” \nOR “2019-Novel Coronavirus” OR “Novel Coronavirus 19” OR “Novel \nCoronavirus-19” OR “Novel Coronavirus 2019” OR “Novel Coronavirus-2019” OR \n“SARS-Coronavirus-2” OR “SARS Coronavirus-2” OR “SARS-Coronavirus 2” OR \n“SARS Coronavirus 2” OR “severe acute respiratory syndrome coronavirus 2” OR \n“severe acute respiratory syndrome coronavirus-2” OR “severe acute respiratory \nsyndrome-coronavirus 2” OR “severe acute respiratory syndrome-coronavirus-2” OR \n“SARS-CoV-2” OR “SARS CoV-2” OR “SARS-CoV 2” OR “SARS-CoV2” OR \n“SARS CoV-2” OR “SARS-CoV 2” OR “SARS CoV 2” OR “SARS CoV2” OR \n\"COVID-19\"[Mesh] \n \n31 \nScopus \n( \"Endometriosis\" )  AND  ( \"COVID\"  OR  \"COVID19\"  OR  \"COVID \n19\"  OR  \"COVID-19\"  OR  \"Coronavirus Disease-19\"  OR  \"Coronavirus Disease \n19\"  OR  \"Coronavirus Disease-2019\"  OR  \"Coronavirus Disease \n2019\"  OR  \"Coronavirus infection-19\"  OR  \"Coronavirus infection \n19\"  OR  \"Coronavirus infection-2019\"  OR  \"Coronavirus infection \n2019\"  OR  \"Coronavirus-19\"  OR  \"Coronavirus \n19\"  OR  \"Coronavirus19\"  OR  \"Coronavirus-2019\"  OR  \"Coronavirus \n2019\"  OR  \"Coronavirus2019\"  OR  \"nCoV19\"  OR  \"nCoV 19\"  OR  \"nCoV-\n19\"  OR  \"nCoV2019\"  OR  \"nCoV 2019\"  OR  \"nCoV-\n2019\"  OR  \"2019nCoV\"  OR  \"2019 nCoV\"  OR  \"2019-nCoV\"  OR  \"2019 Novel \nCoronavirus\"  OR  \"2019-Novel Coronavirus\"  OR  \"Novel Coronavirus \n19\"  OR  \"Novel Coronavirus-19\"  OR  \"Novel Coronavirus 2019\"  OR  \"Novel \nCoronavirus-2019\"  OR  \"SARS-Coronavirus-2\"  OR  \"SARS Coronavirus-\n2\"  OR  \"SARS-Coronavirus 2\"  OR  \"SARS Coronavirus 2\"  OR  \"severe acute \nrespiratory syndrome coronavirus 2\"  OR  \"severe acute respiratory syndrome \ncoronavirus-2\"  OR  \"severe acute respiratory syndrome-coronavirus 2\"  OR  \"severe \nacute respiratory syndrome-coronavirus-2\"  OR  \"SARS-CoV-2\"  OR  \"SARS CoV-\n2\"  OR  \"SARS-CoV 2\"  OR  \"SARS-CoV2\"  OR  \"SARS CoV-2\"  OR  \"SARS-CoV \n2\"  OR  \"SARS CoV 2\"  OR  \"SARS CoV2\" ) \n \n49 \nWOS \nAll= (“COVID” OR “COVID19” OR “COVID 19” OR “COVID-19” OR \n“Coronavirus Disease-19” OR “Coronavirus Disease 19” OR “Coronavirus Disease-\n2019” OR “Coronavirus Disease 2019” OR “Coronavirus infection-19” OR \n“Coronavirus infection 19” OR “Coronavirus infection-2019” OR “Coronavirus \ninfection 2019” OR “Coronavirus-19” OR “Coronavirus 19” OR “Coronavirus19” \n35 \n\n317 Endometriosis and COVID-19 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nDatabase Search string Results \nOR “Coronavirus-2019” OR “Coronavirus 2019” OR “Coronavirus2019” OR \n“nCoV19” OR “nCoV 19” OR “nCoV-19” OR “nCoV2019” OR “nCoV 2019” OR \n“nCoV-2019” OR “2019nCoV” OR “2019 nCoV” OR “2019-nCoV” OR “2019 \nNovel Coronavirus” OR “2019-Novel Coronavirus” OR “Novel Coronavirus 19” OR \n“Novel Coronavirus-19” OR “Novel Coronavirus 2019” OR “Novel Coronavirus-\n2019” OR “SARS-Coronavirus-2” OR “SARS Coronavirus-2” OR “SARS-\nCoronavirus 2” OR “SARS Coronavirus 2” OR “severe acute respiratory syndrome \ncoronavirus 2” OR “severe acute respiratory syndrome coronavirus-2” OR “severe \nacute respiratory syndrome-coronavirus 2” OR “severe acute respiratory syndrome-\ncoronavirus-2” OR “SARS-CoV-2” OR “SARS CoV-2” OR “SARS-CoV 2” OR \n“SARS-CoV2” OR “SARS CoV-2” OR “SARS-CoV 2” OR “SARS CoV 2” OR \n“SARS CoV2”) AND All= (“Endometriosis”) \n \nAfter omitting duplicate results, two reviewers \nscreened titles and abstracts; in case of disagreement, a \nshared decision was made by discussion.  \nThe inclusion criteria were: 1) articles that their \nmajor aim was to evaluate COVID -19 and \nendometriosis in the following aspects: prognosis, \ntreatment, diagnosis, and quality of life; 2) published \narticles in English; and 3) peer -reviewed published \narticles indexed in PubMed/Medline, Scopus and Web \nof Science. \nPreprints, reviews, short communications, editorials, \nletters to the editor, comments, conference abstracts, \nconference papers, and articles that did not aim to study \nCOVID-19 and endometriosis were excluded. Also, \ncitations were searched for relevant articles. Finally, 10 \narticles were recruited and appraised, of them, 9 \narticles were considered except for one that was not in \nline with our objectives.  \nTwo independent reviewers collected data from \neligible articles, and a third one revised the data. \n \nResults \nSearch results \nA total of 115 articles were evaluated, and following \nthe title screening process and removing duplication, \n72 articles were included in this review. Finally, 9 \narticles met all the criteria. (See Fig. 1\n). The summary \nof the articles is provided in two categories: 1. Studies \nabout the COVID-19 effect on diagnosis and treatment \nof endometriosis patients (see \nTable 2) and 2. Studies \nabout the mental health and quality of life in thes e \npatients (see Table 3). \n \nFigure. 1. PRISMA guidelines \n\n\nPoorya Davoodi et al. 318 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nTable 2. Summary of the articles evaluating the diagnosis and treatment of endometriosis patients during the COVID -\n19 pandemic \nAuthors/ \ncountry \nStudy type/ \nparticipant \nnumber \nMean age Highlights \n(16) \n \nInternet-based \nsurvey collected \n6,729 \n32.50 \n(Range: 18 –73) \n20.3% had difficulty obtaining repeat prescriptions, 4.5% \nchanged their hormone treatments, 7.0% changed \npainkillers, 3.4% stopped the hormone treatment, 6.6% \nstopped the painkiller treatments, and 64.6% reported no \nimpact on the availability of the usual treatments. \nCancelled/postponed gynecologist appointments, primary \ncare appointments, surgeries, and fertility treatment \nprocedures in 50.0%, 14.7%, 27.0%, and 12.0%, \nrespectively \n(17) \nweb-based cross-\nsectional survey \nRetrospective \n285 \n32.05 \n(Range: 27 – 36) \n15.9% increased the intake of over-the-counter \npainkillers (p = 0.31), and   15.9% added to the \nprescription-only pain drugs (p = 0.91). \n45.30%, 40.50%, and 14.20% reported improvement, \nworsening and no change in pain intensity of \ndysmenorrhea, respectively (p=0.025). \nNo significant change was reported in other pain \nassociated symptoms? with endometriosis (p>0.05) \n43.6% (p<0.001) reported increase in frequent aware of \npain, 37.2% (p = 0.09) experienced stress due to pain, \n29.3% (p = 0.02) expressed pain as a distressing matter, \nand 30.0% (p<0.001) expressed pain as a threat. \n40.0% (p=0.08) reduction in possibility to relax despite \nthe pain, and 43.9% (p = 0.09) no change in ability of \npain management were reported. \n36.6% (p = 0.001) decrease in verbalization of pain was \nreported. \n(18) \n \ncross-sectional \ncohort study \n181 \n35.00 \n(Range: 31.00 – \n40.50) \n41.8% and 36.8% enhancement of social and \noccupational functioning (p<0.001), respectively, and \n29.9% enhancement of sexual functioning (p= 0.001) \nwere reported. \n32.4% enhancement in recreational functioning (p= \n0.138), 36.7% worsening in family (p = 0.026), 19.2% \nimprovement in self-care and life support (p > 0.05) were \nreported. \n48.2% reported improvement of global physical \nimpairment (p = 0.032).  27.07% (n = 49) and 8.83% (n = \n16) reported increase and decrease in complaints, \nrespectively. \n(19) \ncase–control study \n507 cases \n520 controls \n29.08 ± 14.29 \nNo significant difference in COVID-19 infection (3.2% \nvs. 3%; P = 0.942) was observed. \nHigher frequency of asymptomatic infection (95.7% vs. \n94.5%; P < 0.001) in control group was reported. \nHigher frequency of fever (1.6% vs. 0%; P = 0.004) in \nthe control was reported. However, no significant \ndifference in the frequency of sore throat, stuffy nose, \ncough, dyspnea, headache, weakness, and myalgia was \nreported. \nAnosmia and/or ageusia and eye problems did not differ \nbetween the two groups (all p > 0.05). \nHigher frequency of rare symptoms in the case group (P \n< 0.001) and no difference in disease period (P = 0.694) \nwas observed. \n\n319 Endometriosis and COVID-19 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nAuthors/ \ncountry \nStudy type/ \nparticipant \nnumber \nMean age Highlights \n(20) \nlongitudinal \nexamination \n162 \n30.8 ± 7.1 (18–50) \n67% and 3% changed the physical appointments to \ntelephone and video consultations appointments, \nrespectively. \n60% overall reported change in healthcare. 22% reported \nno impact on their daily functioning. \n76% reported an impact on daily functioning. \n12% reported the positive impact of limitation due to \nCOVID-19, while 77% reported no change in their \nsymptoms. \nIn 23% exacerbating of symptoms, stress, and decreased \ncoping strategies were observed. \n \n \nTable 3. Summary of the articles about the mental health and quality of life of endometriosis patients during COVID-19 \nNumbe\nr \nAutho\nr \nMethod of \nassessment \nMonths \nafter the \nstart of \nthe \npandemi\nc \nSampl\ne size \nCountry \nof study \nMean \nage ±SD \nOr \nmedian \nJob Disease \nseverity Outcomes \n1.  (21) \nImpact of \nCOVID-19 \non lifestyle \nand \nendometriosi\ns; \nPeri-\ntraumatic \ndistress \ninventory \n(PDI) \n3 82 Puerto \nRico 33.2±9.31 \nFull time \n(51.2%) \nStudent \n(22%) \nMostly \nmoderat\ne-to-\nsevere \nIncreased \njob affection \nIncreased \nperi-\ntraumatic \nstress \nChanges in \nrisk \nbehaviors \n2.  (22) \nEndometrios\nis health \nprofile 5 \n(EHP-5) \nThe Italian \nversion of \nGeneralized \nAnxiety \nDisorder-7 \n(GAD-7) \nSpilberg \nState Trait \nAnxiety \nInventory \nY6 (STAI-\nY6) \nImpact of \nEvent Scale-\nRevised \n(IES-R) \n5 468 Italy 38.8±7.7 \nWorking \nfrom home \n(37.8%) \nUnemploye\nd (15%) \nStopped \nworking \n(18%) \nWent to \nwork \n(28.6%) \nMostly \nmoderat\ne to \nsevere \nIncreased \njob affection \nIncreased \nrisk of PTSD \nIncreased \nanxiety \n3.  (23) \nSelf-\nadministered \nonline \nsurvey \ndesigned by \n4 261 Turkey 34.19±5.9\n0 - Mild \nIncreased \nPTSD, \ndepression, \nand anxiety; \nfear of \n\nPoorya Davoodi et al. 320 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nNumbe\nr \nAutho\nr \nMethod of \nassessment \nMonths \nafter the \nstart of \nthe \npandemi\nc \nSampl\ne size \nCountry \nof study \nMean \nage ±SD \nOr \nmedian \nJob Disease \nseverity Outcomes \nTurkish \nendometriosi\ns and \nadenomyosis \nsociety \nhaving \nendometriosi\ns-related \nproblems \nand lack of \ngynecologic\nal help \nduring the \npandemic \nPostponed \nelective \nsurgery \nDecreased \nquality of \nsexual \nactivity \nIncreased \nrelaxing \nactivities \nincluding \nbreathing \nexercises, \nrelaxing \nsleep, and \nmeditations \nIncreased \nattention to \nhand \nhygiene \n4.  (16) \nA survey \ndesigned by \nthe \nUniversity \nof Oxford in \nEnglish and \ntranslated \ninto French, \nGerman, \nSpanish, and \nPortuguese \n5,6 6729 \nGlobal \nstudy \n(Europe, \nOceania, \nNorth \nAmerica, \nLatin \nAmerica, \nand \nCaribbean\n) \n32.5 - - \nIncreased \nfear of being \nvulnerable to \nCOVID-19; \npostponed \nappointment\ns and \nprocedures; \nneed for \nmental \nhealth \nsupport \n5.  (18) \nFertility-\nrelated \nquality of \nlife \n(FertiQol) \nPatient-\ncenteredness \nof \nendometriosi\ns care \nquestionnair\ne  (ECQ) \n \n5 to 10 330 Netherlan\nds 33.00 - \nMostly \nmoderat\ne to \nsevere \nIncreased \nlevel of \nstress \nDecreased \nquality of \nlife \n\n321 Endometriosis and COVID-19 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nNumbe\nr \nAutho\nr \nMethod of \nassessment \nMonths \nafter the \nstart of \nthe \npandemi\nc \nSampl\ne size \nCountry \nof study \nMean \nage ±SD \nOr \nmedian \nJob Disease \nseverity Outcomes \n6.  (20) \nThe fear of \nCOVID-19 \nscale \n5 to 7 162 Australia 30.8 ± 7.1 \nFull time \n(41%) \nPart-time \n(25%) \nStudent \n(11%) \nHome-\nmaker ( \nhouseholde\nr) (5%) \nSelf-\nemployed \n(3%) \nUnemploye\nd (9%) \n-  \nIncreased \nfearand \nstress, \nreduced \ncoping \nstrategies \n(like sport, \nand less \naccess to \nhealthcare) \n \nEffect of COVID-19 on Endometriosis care \nAmong Nine studies, four studies evaluated \nalternations of the care of the endometriosis during \nsocial isolation or quarantine due to the COVID -19 \npandemic. One online questionnaire -based survey \nreported a negative impact of the COVID-19 pandemic \non the current or planned treatments of 80.7% [95% CI \n(79.7, 81.6)] among 6729 patients. Regarding the \ncurrent treatment, difficulty obtaining repeated \nprescriptions, changing and/or stopping the hormone \nand painkiller were reported by participants. However, \nbesidesthe impacts on planned care were more \nremarkable, with gynecologist appointments, primary \ncare appointments, sur geries, and fertility treatment \nprocedures were canceled or postponed (16). One study \ndemonstrated that 60% of participants delineated that \npandemic and related restrictions had changed their \nmedical care, a range of unavailable or compromised \nproviders and treatments, including fertility treatments, \nsurgery/laparoscopy, medications, general practitioner \nand specialist appointment availability, and access to \nallied health, including pelvic physiotherapists (20). In \nanother study, it has been demonstrated th at 70% of \npatients with endometriosis mentioned that physical \nappointments were changed to telephone and video \nconsultation appointments (18). Another study showed \nboth the intake of over -the-counter pain medication \nand prescription -only pain medication wa s increased \nby 15.9% of 278 and 276 patients, respectively (p = \n0.31 and p = 0.91, respectively) (17). \nImpact of COVID- 19 pandemic on the pain \nintensity and cognition of Endometriosis \nOne of the nine  studies assessed the alternations in \npain experience and the influence of social isolation or \nquarantine on endometriosis patients during the \nCOVID-19 pandemic. The study indicated that of 247 \nparticipants who answered the questions regarding the \npain magnitude (measured by visual analogue scale) of \ndysmenorrhea, 45.30%, 40.50%, and 14.20% \nexperienced improvement, worsening, and no change \nin pain, respectively. This result implies that the \ndysmenorrhea pain intensity decreased significantly \nduring isolatio n or quarantine of COVID -19 in \ncomparison with the pain intensity before quarantine \n(P = 0.025<0.05). However, the other pain associated \nwith endometriosis, such as lower back pain, non -\ncyclic pain, dyspareunia, dyschezia, and dysuria did \nnot show a signif icant change (all P  >0.05). Of 280 \npatients, 43.6% (P<0.001) reported significantly more \nfrequent awareness of pain or more pain \nhypervigilance, 37.2% ( P = 0.09), 29.3% ( P = 0.02) \nand 30.0% ( P <0.001) more participants experienced \nstress due to pain, pain as a disturbing event and pain \nas a threat, respectively. Nevertheless, the possibility to \nrelax despite the pain was reduced in the 40.0% ( P \n=0.08) of patients, and 43.9% ( P = 0.09) of patients \nreported that the ability of pain management did not \nchange. Verbalization of pain experience was \nsignificantly decreased in 36.6% (P = 0.001) of patients \n(17).  \nImpact of COVID-19 pandemic on the disability \ndue to Endometriosis \nOf Nine studies, two of them aimed to investigate the \ndeterioration of functional disability -induced \nendometriosis caused by social isolation or quarantine \nduring the COVID -19 pandemic. One study assessed \nthe disability due to endometriosis -induced pain via \nusing Pain Disability Index (PDI) during social \nisolation in respect of the period prior to isolation. The \nresult of this survey showed a significant enhancement \nof social, occupational ( P <0.001), and sexual ( P = \n0.001) functioning. However, recreational functioning \n\nPoorya Davoodi et al. 322 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \ndid not exhibit a significant alternation. Taken \ntogether, the sum scores of the mentioned discretionary \nactivities significantly improved ( P = 0.001). But, the \ndeterioration of family functioning was observed in the \ncontrary direction (P = 0.026). Basic activity, including \nself-care and life support, remained unchanged during \nwhat (P = 0.218), and also, the global PDI score, which \ncan reflect global physical impairment, demonstrated a \nsignificant improvement (improvement of 48.20% vs \nworsening of 40.90%, P = 0.032) (17). A study showed \nthat 76% of patients reported the impact of the COVID-\n19 pandemic on daily functioning, most of them felt \nthat life was now harder, including social exclusion, \ndecreased work, and financial challenges. There were \nsome reports indicating that the physiological function \nof these patients was affected in terms of anxiety and \nstress. Nevertheless, reduced function was not reported \nby all. Twenty women (12%) reported the positive \noutcomes from COVID -19 caused restrictions, \nincluding the convenience of telehealth, working from \nhome, more opportunities to rest, and increased \nopportunities to obtain healthier habits (20).  \nImpact of COVID- 19 pandemic on the social \nsupport of patients with Endometriosis \nOne survey reported that the empathy and social  \nsupport received from the partner regarding pain \nexperience showed no significant changes (both P  \n>0.05); whereas, the empathy and social support \nreceived from family and friends were significantly \nreduced during the social isolation (all P <0.05) (17). \nConcerns of endometriosis patients in COVID -\n19 pandemic \nOne study reported that more than half (54.2%) of \npatients had concerns of increasing their vulnerability \nto COVID- 19 due to endometriosis (95% CI = 53.0, \n55.4) (16). Another study reported that 35.9% of the \n181 endometriosis patients experienced an increase in \nstress due to the delayed treatment during the pandemic \n(P < 0.001), and also 51.9% reported that they are able \nto overcome the changing health care system owing to \nthe COVID-19 pandemic (P < 0.001) (18). One study \ndemonstrated that higher fear of COVID-19 prophesied \ngreater odds of reporting influenced healthcare, \nsymptoms and daily functioning (odds ratio = 0.93, \n95% confidence interval: 0.87–0.98; odds ratio = 0.88, \n95% confidence interval: 0.82–0.95; odds ratio = 0.92, \n95% confidence interval: 0.85– 0.99, respectively)  \n(20).  \nImpact of COVID- 19 pandemic on the \nendometriosis-related complaints \nTwo studies investigated COVID -19 impacts on the \nsymptoms of endometriosis. One study indicated that \n33.1% of 181 patients (n = 60) reported their \nendometriosis-related complaints during COVID -19 \nhad changed, in such 81.7% (n = 49) and 26.7% (n = \n16) reported increase and decrease in complaints, \nrespectively (18). Another study demonstrated that \n77% of 162 participants reported that COVID -19 had \nnot affected their symptoms. Other patients (23%) \nreported worsening of symptoms such as pain, stress, \nand decreased withstanding strategies (for instance, \nsport and less access to healthcare) (20). \nEndometriosis and  susceptibility to COVID -19 \ninfection \nOnly one study compared the COVID -19 \ncharacteristics between women with (n = 507) and \nwithout (n = 520) endometriosis. This manuscript \nshowed there was no significant difference between \npatients with and without endometriosis with regard to \nCOVID-19 infection (3.2% vs 3%; P  = 0.942). \nFrequency of asymptomatic infection (95.7% vs. \n94.5%; P < 0.001) and fever (1.6% vs. 0%; P = 0.004) \nwere higher in the control group, while the frequency \nof sore throat, nasal congestion, cough, dyspnea, \nheadache, weakness and myalgia, anosmia and/or \nageusia and eye problems did not differ between two \ngroups (all P  > 0.05). However, other infrequent \nsymptoms were more prevalent in the endometriosis \ngroup (P < 0.001). The average disease period was the \nsame (14 days) in both groups ( P = 0.694). Frequency \nof H1N1 vaccination, recent traveling to high -risk \nregions, social distancing, exposure to infected \npatients, frequency of implementing screening test, \nadmission, and isolation due to COVID -19 had no \nsignificant difference between the two groups ( P > \n0.05). But the case group significantly had a higher \nfrequency of symptoms (P < 0.05) and H1N1 infection \n(P < 0.001). Also, this study indicated that close \ncontact is the most significant risk factor for COVID -\n19 infection in both groups (r = 0.331; P < 0.001 in the \ncase group and r = 0.244; P < 0.001 in the control \ngroup). Whereas the association between COVID -19 \ninfection and other variables like social distancing, \ntraveling, underlying diseases, thyroid diseases, and \nstage of endometriosis was not significant(P > 0.05) \n(19). \nThe impact of COVID -19 on endometriosis \npatients’ mental health \nThere is a growing concern about the effect of the \nCOVID-19 pandemic on the mental state of people \nworldwide. \nA total of 8,032 people were studied in a report, with \nan average age of 20 to 50 years. All the studies were \nperformed within the first year of the pandemic, \nranging from 3 to 10 months after the outbreak. The \nstudy surveys were given to women from Puerto Rico, \nItaly, Turkey, the Netherlands, and Australia. Just one \nstudy was performed globally in Europe, Oceania, \nNorth America, Latin America, and the Caribbean (16). \nThe disease severity was mostly in mild to moderate \nstages. Most of the participants were full-time workers, \nremote workers, students, and self -employed workers. \nThe general effects of COVID -19 on patients with \nendometriosis are negative and positive effects. \nNegative effects include increased job affection, peri -\ntraumatic stress, job affection,  Post-Traumatic Stress \n\n323 Endometriosis and COVID-19 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nDisorder (PTSD), anxiety, depression, worry of having \nendometriosis-related problems, lack of gynecological \nhelp during the pandemic, fear of being vulnerable to \nCOVID-19, and need for mental health support. Other \nnegative effects include postponed elective surgery and \nappointments and a decrease in quality of sexual \nactivity, quality of life, and coping strategies (such as \nsport and less access to healthcare). Positive effects \ninclude increased relaxing activities, including \nbreathing exercises, relaxing sleep and meditation, and \nincreased attention to hand hygiene (16, 18, 20-23).  \n The impact of COVID -19 on endometriosis \npatients’ quality of life  \nAccording to the Ramos et al.  study, many of the \npatients reported that their job status was affected. \n17.3% of these patients had lost their jobs. On the other \nhand, healthy behaviors were also affected. 40% of the \npatients in this study reported a decreasing time in their \nexercise. 29.2% of these patients reported that their \nalcohol consumption had increased after the start of the \npandemic. Fortunately, smoking was not increased. \nThe Peri-traumatic Distress Inventory (PDI) score was \nincreased significantly after the pandemic began (21) . \nGrowing concern about access to gynecologic care was \nreported in women in a study by Arena et al. The older \nage was demonstrated to be a risk factor for PTSD in \nthis study. Up to 71.8% of the participants were \ndiagnosed with severe anxiety. Although the pandemic \naffected the job status negatively, the author s declared \nthat women who could leave home from work had \nbeneath levels of PTSD (22) . Yalçın Bahat and \ncoworkers also showed that although endometriosis is \nassociated with increased chronic stress, the COVID -\n19 pandemic clearly leads to psychological probl ems \nincluding PTSD, psychological distress, depression, \nand anxiety. Most of the patients were concerned about \nproblems that may arise from endometriosis during the \npandemic. While other studies showed an increase in \npostponed elective surgery, in this study, the surgery \nwas mostly not postponed. It was also demonstrated \nthat patients were becoming adapted to social \ndistancing as well as paying more attention to hand \nhygiene. Eating habits were also reported to be \nhealthier, and the diet became healthier than before the \npandemic. Most of the patients believed that their \nsexual life was not highly affected by the pandemic \n(23). Demetriou et al. study was the only global study \nof all included studies. The patients in this study, \nmostly (over 50%), believed tha t their disease makes \nthem more susceptible to COVID -19. Mental health \nwas one of the highest priorities among the patients \n(20% of all) worldwide (16) . A study in the \nNetherlands indicated that 35.9% of the patients with \nendometriosis experienced an increased stress level \nsince the beginning of the pandemic. 35.9% of the \npatients experienced stress due to the delay in their \ntreatment (21). In a study by Evans et al.  it was \ndemonstrated that just a quarter of the patients had no \ndysfunction in their lives, while the rest experienced \nharder lives. They reported that the patients missed \nsocial communications, their jobs were affected, and \nthey experienced financial problems. Other \npsychological disorders were discovered in these \npatients, including stress, fatigue, and other symptoms \nof anxiety and depression. Although the pandemic \naffected the endometriosis patients negatively, it had \nhidden benefits including having more rest, increased \nopportunities for healthier lifestyle in both nutritional \nhabits and physical activity (20). \n \nDiscussion \nOur study shows that endometriosis does not raise \nthe risk of SARS -CoV-2 infection; However, \nMoazzami et al.  indicated that endometriosis could \nincrease the chance of symptomatic COVID -19 \ncompared with patients without endometriosis. Of \nnote, quarantine resulting from the COVID -19 \npandemic has not induced exacerbation of pain in \nendometriosis patients (19) . Nons teroidal anti -\ninflammatory drugs play a major role in relieving the \npain of the patients. Actually, besides estrogen and \nprogesterone compounds, they are first -line therapies \nfor Endometriosis (24). Thus, providing these agents \nefficiently and making them available in this condition \ncould be a rational reason for the concept that women \nwith endometriosis could control their symptoms as \nmuch as before the pandemic. Furthermore, multiple \nstudies signify the leading cause of painful symptoms \nin dysphoric mood and even depression of the patients \n(25, 26). This evidence warrants the meaningful role of \nsymptom control of endometriosis in this situation. In \nthe COVID -19 pandemic, virtual management is one \nof the alternative ways to manage patients. Particularly, \nstudies show that endometriosis patients do more \nfrequent virtual and telephone management. Although \nthis type of management has general interests and \nobvious advantages in the pandemic, a reasonable issue \nof that is the lack of physical examination. As a \nconsequence, we can suggest virtual and telephone \nvisits and consultation for the patients, especially those \nwith severe symptoms, just as a good alternative, not \nfurther (18, 27). It is worth noting that the COVID -19 \npandemic has provided strategies known a s \nteleworking, in which employees can work from their \nhomes and perform their tasks without attendance at \nthe workplace. A cross -sectional study indicated that \nwomen with endometriosis could have more efficient \nmanagement of their symptoms, as working hours have \nbeen decreased, and teleworking and remote work have \nbeen prominent (28).  \nIn such wise, one study reported improvement in \ndysmenorrhea pain intensity, which signifies the favor \nof teleworking. Despite the prevailing wisdom, Bahat \net al. declared that many endometriosis patients do not \nconsider their disease a risk factor for COVID -19. \nHowever, this study also showed that most of the \npatients were concerned about being more \nsymptomatic during the pandemic. While considering \nthis issue besides their lifestyle concerns, including \n\nPoorya Davoodi et al. 324 \n      Volume 8, July – August 2023       Journal of Obstetrics, Gynecology and Cancer Research \nsleep and sexual disturbances, it can be concluded that \nthe pandemic negatively impacted mental health, \nwhich adversely affects the patients' peace of mind and \nquality of life (23). Thus, contrariety between studies \nabout lifes tyle changes is prominent, and further \nevaluation should be considered. \nAccording to a recent study not included in our \nprimary search, women with endometriosis are \nexposed to an increased risk of psychological and \npsychiatric disorders, including PTSD (24 ), which \ncould be related to the fear of access to the health \nsystem services. However, medication availability \nseems to remain intact in the pandemic. However, we \ncannot deny disorganization and difficulties resulting \nfrom the postponement of visits, whic h make it \ntroublesome for patients to plan (16) . A rational factor \nfor challenging the mental health of the patients seems \nto be thinking of COVID -19 exposure resulting from \ntreatment procedures. Endometriosis patients for many \ncauses, including infertilit y, may need surgical \ninterventions; as shown in one of the studies, \nminimally invasive procedures are generally safe and \ncould be performed without concern of increased risk \nof COVID -19 (29). This paper has a considerable \nlimitation, mainly related to the narrow populations of \nthe studies. Target populations were from developed \nand developing countries, where health services are \neasily accessible, and several strategies are \nimplemented to minimize COVID -19 effects on the \nhealth system. On the other hand, undeveloped \ncountries are more vulnerable to and have less \ncompliance against the pandemic troubles because of \nless developed health care. This consideration \nhighlights the need for further studies, especially in \nundeveloped countries, where data collection is more \ndifficult.  \nAnother limit to consider is the lack of valid \ndocumentation of the patients. Data gathering by online \nquestionnaires has limitations, such as patients’ \nhonesty in terms of proven endometriosis and their \nmedical history. Although, this type of survey resulted \nin the evaluation of more diverse samples around the \nworld. \n \nConclusion \nOur systematic review showed that the COVID -19 \npandemic resulted in minor psychological problems for \nwomen with endometriosis, although the risk of being \ninfected by COVID-19 was not increased. In addition, \nstrategies obtained in the pandemic, including \nteleworking, remarkably provide some benefits in their \nlifestyle. As the effect of COVID-19 upon the severity \nof endometriosis symptoms remains controversial, \nfurther evaluations are needed to draw a definitive \nconclusion. \n \nCompeting interests \nNone declared.  \n \nAcknowledgments \nNone. \n \nContributions \nP.D. participated in the search strategy, the research \ndesign of systematic review and the data analysis. \nD.G., M.R., M.K. and A.S. drafted the manuscript, and \ndid articles screening.  N.S. and B.N. critically revised \nthe manuscript for important intellectual content, and \napproved the final version to be published. M.A. \nsupervised the study, and revised the manuscript for  \nimportant intellectual content. All authors have read \nand approved the manuscript. \n \nConflict of Interest \nNone.\n \n \n1. Denny E. Women's experience of endometriosis. J \nAdv Nurs. 2004;46(6):641-8.  \n[DOI:10.1111/j.1365-2648.2004.03055.x] [PMID] \n2. Berkley KJ, Rapkin AJ, Papka RE. The pains of \nendometriosis. 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Nicolás I, Martínez-Zamora MÁ, Gracia M, Feixas \nG, Rius M, Carmona F. Impact of SARS -COV2 \npandemic on patients with endometriosis and their \nhealth care. J Womens Health. 2022;31(4):480- 6. \n[DOI:10.1089/jwh.2021.0323] [PMID] \n28. Armour M, Ciccia D, Stoikos C, Wardle J. \nEndometriosis and the workplace: Lessons from \nAustralia's response to COVID -19. Aust N Z J \nObstet Gynaecol. 2022;62(1):164-7.  \n[DOI:10.1111/ajo.13458] [PMID] [PMCID] \n29. Crispi CP, de Almeida Nogueira E, Balthar PC, \nGuerra CGS, de Freitas Fonseca M. Endometriosis \nSurgery during the First Wave of the COVID -19 \nPandemic: A Brazilian Single Institution \nExperience. Case Rep Obstet Gynecol. 2021;2021: \n5040873. [ DOI:10.1155/2021/5040873] [ PMID] \n[PMCID] \n  \nHow to Cite This Article:  \nDavoodi, P., J. Ghadimi, D., Rezaei, M., Khazei Tabari, M. A., Shirani, A., Nouri, B., et al. Endometriosis and \nCOVID-19: Clinical Presentation and Quality of Life, a Systematic Review . J Obstet Gynecol Cancer Res. 2023; \n8(4):315-26. \n \nDownload citation:                            RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}