{"paper_id":"6f6d6e8c-4741-4c66-b6fc-d363d59e9dae","body_text":"Vol:.(1234567890)\nReproductive Sciences (2025) 32:2190–2201\nhttps://doi.org/10.1007/s43032-025-01899-3\nENDOMETRIOSIS: ORIGINAL ARTICLE\nPsychological Factors Contributing to Health‑Related Quality of Life \nFollowing Endometriosis Surgery: Results of a Cross‑Sectional Study\nZ. Boersen1 · J. M. Oosterman2 · C. I. M. Aalders1 · D. D. M. Braat3 · C. M. Verhaak4 · A. W. Nap3 \nReceived: 14 March 2024 / Accepted: 2 June 2025 / Published online: 23 June 2025 \n© The Author(s) 2025\nAbstract\nIntroduction Endometriosis causes severe and chronic pain leading to impaired Health-Related Quality of Life (HRQoL). \nWhile endometriosis surgery does improve pain intensity, psychological factors have an important role in pain perception. \nThe current study aims to evaluate the independent contribution of pain catastrophizing and anxiety and depression to HRQoL \nbetween six months and nine years following endometriosis surgery.\nMethods This is a cross-sectional questionnaire study including women with endometriosis who were surgically treated \nfor endometriosis-related pain. Hierarchical multiple linear regression analysis was used to evaluate the relationship of pain \ncatastrophizing and a total score for anxiety and depression to HRQoL, in addition to the contributions of pain intensity, \nfatigue and sleep quality. In a sub-analysis, we evaluated this relationship in patients with a shorter and with a longer time \nsince surgery (TSS).\nResults The study included 195 participants, revealing significant correlations between HRQoL, pain catastrophizing and \nanxiety and depression. Subgroup analysis demonstrated that both pain catastrophizing and a combined anxiety and depres-\nsion score significantly predicted HRQoL in both the shorter and longer TSS groups. These associations were found in \naddition to the contribution of pain intensity, fatigue and sleep quality to HRQoL.\nConclusion The current study demonstrates that pain catastrophizing and a combination of anxiety and depression contribute \nto HRQoL in patients six months to nine years after surgical treatment of endometriosis. Extended post-surgical care could \nbe warranted to address these factors accordingly, for example with psychological care, in addition to surgery alone.\nKeywords Catastrophizing · Central sensitization · Chronic pain · Endometriosis · Psychology · Quality of life\nIntroduction\nEndometriosis is a condition in which functioning endo-\nmetrium-like tissue is located outside the uterus. It affects \napproximately 10% of women in their reproductive age \n[1]. It can affect multiple tissues and organs such as the \ngastrointestinal tract, female reproductive organs, or urinary \ntract [1 , 2]. The most common symptom is chronic pain, \nwhich impairs Health-Related Quality of Life (HRQoL) \n[1–3]. To reduce symptoms, treatment usually encompasses \npharmacological hormonal suppression. However, when \nthis is not successful, inappropriate, or not wished by the \npatient, surgery is often necessary, alone or in combina-\ntion with medication. Depending on the location and the \nextent of the endometriosis lesions, surgery can be limited \nto the removal of peritoneal lesions, extraperitoneal endo-\nmetriosis (e.g. in scar tissue of a caesarian section) and/\nor removal of ovarian endometriosis cysts. Additionally, in \ncase of deep endometriosis, more extensive surgery may be \nrequired, including segmental bowel resection and/or partial \nbladder resection, often in combination with adhesiolysis. \nHysterectomy with or without removal of the adnexa may \nalso be indicated. During surgery the severeness of endo-\nmetriosis is reported using the revised American Society for \n * A. W. Nap \n annemiek.nap@radboudumc.nl\n1 Department of Gynaecology and Obstetrics, Rijnstate, \nArnhem, The Netherlands\n2 Donders Institute for Brain, Cognition and Behaviour, \nRadboud University, Nijmegen, The Netherlands\n3 Department of Obstetrics and Gynaecology, Radboud \nUniversity Medical Centre, Radboud University, Nijmegen, \nThe Netherlands\n4 Department of Medical Psychology, Radboud University \nMedical Centre, Nijmegen, The Netherlands\n\n2191Reproductive Sciences (2025) 32:2190–2201 \nReproductive Medicine (rASRM) score which rates endo-\nmetriosis from stage I (minimal) to IV (severe). The score is \nbased on the location, depth and extent of the endometriosis \nlesions. However, the rASRM score does not consistently \ncorrelate with the pain intensity reported by patients with \nendometriosis [4 –6]. Therefore, it is essential to consider \npatients’ symptoms when determining the indication for sur-\ngery. Surgery for endometriosis can improve HRQoL signifi-\ncantly for all rASRM stages, but the degree of improvement \nmay vary depending on the stage of the disease, severity of \nsymptoms, type of surgery performed, the surgeons’ experi-\nence, success of the surgical eradication of the endometrio-\nsis lesions, and comorbidities [7–9]. Moreover, results from \nfollow-up studies have shown that recurrence of pain occurs \nin up to 40% of women within five years [10–12], even in the \nabsence of visible recurrence of endometriosis lesions [10, \n11, 13, 14]. This suggests that other determinants contribute \nto pain perception and consequently HRQoL, beyond the \neffects of the physical manifestation of endometriosis itself.\nTo identify additional determinants of pain perception, \nit is essential to examine the definitions of pain in more \ndetail, especially chronic pain. Chronic pain is a multidi-\nmensional symptom involving alterations in both ascend-\ning and descending pain pathways that contribute to pain \nperception. The ascending pathways are responsible for the \nprocessing of peripheral stimuli. They therefore respond, at \nleast initially, to traditional pain mitigation strategies such as \nanalgesics or surgery [15, 16]. Descending pathways involve \ntop-down mechanisms such as genetics, prior experiences, \nexpectations, emotions and mood. Descending pain path-\nways are important for pain modulation. If these descending \npathways become dysregulated due to ongoing pain, the pain \nprocessing system can enter an abnormal state of respon-\nsiveness [14, 16, 17], defined as central sensitization. This \ncentral sensitization to pain leads to a heightened perception \nof painful and even non-painful stimuli beyond the affected \narea, instead of reflecting the presence of noxious stimuli \n[17]. In the case of chronic pain, the fear-avoidance model \ncan be used to further understand and identify factors related \nto its manifestation and sustainment [18]. This model illus-\ntrates how interpreting pain as a threat can initiate a cycle of \nfear, avoidance, and disability. A key factor in the fear-avoid-\nance model is pain catastrophizing. Pain catastrophizing is \na cognitive strategy in which individuals interpret pain as \nthreatening. It encompasses thoughts like “I can’t handle this \npain—it’s only going to get worse”. In the fear-avoidance \nmodel, pain catastrophizing leads to an exaggerated nega-\ntive orientation toward pain [3]. Patients who catastrophize \ntend to avoid activities that could provoke pain, resulting in \nphysical inactivity and isolation. Importantly, this avoidance \nbehavior is reinforced by the relief of emotional distress, \nwhich has become the primary driver of continued avoid-\nance, rather than the initial painful stimulus. Compared to \nhealthy controls, endometriosis patients show significantly \nhigher levels of pain catastrophizing [3 ]. Although results \nfrom a prospective study showed that pain catastrophiz-\ning improved one-year post-surgery compared to baseline \nmeasurements, pain catastrophizing was still associated with \nhigher pain intensity levels in patients with endometriosis \n[19]. Moreover, pain catastrophizing relates negatively to \nHRQoL, independent of pain intensity [ 3]. However, this \nwas not specifically investigated after surgical treatment of \nendometriosis. Moreover, studies evaluating the relation-\nship between pain catastrophizing and pain only focused on \nshort-term outcomes (one year) or did not report the mean \nduration post-surgery altogether [19, 20].\nAdditionally, anxiety and depression [16] can also modu-\nlate pain perception, thereby influencing HRQoL. The preva-\nlence of depression and anxiety in women diagnosed with \nendometriosis has been shown to be higher compared to \npatients with other chronic pain conditions including chronic \nlow back pain and rheumatoid arthritis [21]. However, the \ncontribution of anxiety and depression to HRQoL has only \nbeen evaluated relatively shortly after surgery or has not \nbeen investigated at all after surgical treatment of endome-\ntriosis [22–26].\nDue to the high recurrence rate of pain and the dimin-\nished HRQoL after endometriosis surgery, there is a need to \nidentify additional factors contributing to HRQoL, both at \nshort-term and long-term follow-up after surgery. This could \nprovide insight into potential psychological factors that can \nbe targeted to preserve or improve HRQoL in the short- and \nlong-term following surgery.\nTherefore, we conducted a cross-sectional study to deter-\nmine the contribution of pain catastrophizing and anxiety \nand depression to HRQoL up to nine years following endo-\nmetriosis surgery. Additionally, a sub-group analysis was \nperformed to explore the contribution of pain catastrophiz-\ning and anxiety and depression to HRQoL in patients with \nshorter and longer post-surgery durations. We hypothesize \nthat pain catastrophizing, and anxiety and depression will \nindependently contribute to HRQoL in patients surgically \ntreated for endometriosis, irrespective of the time that has \nelapsed since surgery.\nMethods\nStudy Population and Recruitment\nAll women aged 18 years or older at the moment of inclu-\nsion who underwent surgery for endometriosis-related pain \nin the secondary referral center Rijnstate Hospital between \n2012 and July 2020 were eligible for this study. The surgi-\ncal indication in Rijnstate Hospital was established through \nshared decision-making, taking into account the severity of \n\n2192 Reproductive Sciences (2025) 32:2190–2201\nsymptoms, extent of the disease, patient’s current and future \nreproductive desires and personal preferences. Patients were \nexcluded from the study if no endometriosis was found dur-\ning surgery or in the removed tissue during histopathological \nassessment/evaluation post-surgery, or if they had insuffi -\ncient understanding of the Dutch language making it impos-\nsible for them to complete the questionnaires. In January \n2021, during the COVID-19 pandemic, all patients meeting \nthe inclusion criteria were contacted by email asking them \nto participate in this study. The invitation contained a URL \nwhich patients could use to log in online and choose whether \nthey wanted to participate in the study. After two weeks, a \nreminder was sent to all participants who had not responded. \nAfter four weeks all patients who had not responded to this \nreminder were contacted by phone by one of the members \nof the research team, asking them to participate in the study. \nPatients for whom no email address was available, received \na written invitation and were contacted by phone asking if \nthey were willing to participate in the study. If these patients \nchose to participate, their email address was collected and \nthey received an electronic invitation as well.\nMeasures\nDemographic and Endometriosis Related Information\nA complete overview of the demographic variables that were \ncollected is provided in Table  1. Part of the demographic \ninformation was collected from the questionnaires. Addition-\nally, researchers collected the following data from patients’ \nmedical file including age, age at the first endometriosis-\nrelated surgery, number of endometriosis-related surgeries, \nand time that elapsed since the most recent endometriosis-\nrelated surgery that was performed in the hospital where \nthe study was conducted (Time Since Surgery or TSS). \nThe Body Mass Index (BMI) of patients was consistently \nreported in the medical records prior to the most recent \nendometriosis-related surgery. This enabled us to calcu-\nlate the BMI change between the most recent surgery and \ncompletion of the questionnaires. Furthermore, information \nabout the rASRM classification established during the most \nrecent surgery was collected. In addition, we collected the \nextent of all endometriosis-related surgeries from patient’ \nmedical records. Because the results from a study showed \nthat the extent of the endometriosis-related surgery could be \nconsidered as risk factor for worse surgical outcomes [27], \nwe hypothesized that the extent of the patients’ endometri-\nosis-related surgical history could serve as a potential con-\nfounder for HRQoL. To incorporate the extent of the surgery \nin the analysis, we created a categorization scheme based \non the extensiveness of the surgeries. The categorization \nscheme ranged on a scale from 0 to 5, with a higher score \ncorresponding with more extensive surgery: (0) diagnostic \nlaparoscopy without removal of endometriosis lesions, (1) \nremoval of endometriosis located in the abdominal wall (e.g. \nlocated in old cesarean scar tissue or near the umbilical), (2) \nremoval of peritoneal endometriosis and/or adhesiolysis, (3) \nremoval of ovarian endometriosis (cystectomy, tubectomy, \novariectomy), (4) hysterectomy without removal of ovarian \nendometriosis and (5) hysterectomy with removal of ovarian \nendometriosis and/or removal of deep endometriosis (e.g. \nintestinal or bladder endometriosis). If a patient received \nmultiple scores on a single operation (e.g. 2 and 5) or had \nundergone multiple endometriosis-related surgeries, the \nhighest score was used.\nHRQoL\nParticipants were asked to complete two questionnaires eval-\nuating HRQoL: the Endometriosis Health profile (EHP-30) \nand the Dutch version of the Short Form 36 (RAND-36). \nThe EHP-30 is a disease-specific HRQoL questionnaire \nwhich has been validated for use in Dutch endometriosis \npatients [28 , 29]. It measures the impact of the disease on \nphysical, mental, and social aspects of daily life. The ques-\ntionnaire is divided into two parts. The core questionnaire \nconsists of five subscales: pain, control and powerlessness, \nemotional well-being, social support, and self-image. The \nsecond part consists of six subscales: work, relationship \nwith children, sexual intercourse, infertility, medical pro-\nfession, and treatment. The EHP-30 ranges from 0 to 100 \nwith a higher score corresponding to worse HRQoL. In the \nanalysis we used both parts of the EHP-30. To measure gen-\neral HRQoL, we used the validated standardized RAND-36 \n[30] version 2.0. The RAND-36 is a multipurpose, general \nhealth survey which is applied to measure HRQoL in nine \ndifferent domains: physical functioning, social functioning, \nrole limitations due to physical health, role limitations due \nto emotional problems, emotional well-being, vitality, pain, \ngeneral health, and health change. The RAND-36 score \nranges from 0 to 100 with a higher score corresponding to \na better HRQoL.\nPain Catastrophizing\nPain catastrophizing was measured using the validated Pain \nCatastrophizing Scale (PCS) [31]. The PCS evaluates pain \ncatastrophizing by measuring feelings of rumination, magni-\nfication, and helplessness, and consists of 13 items reflecting \non patients’ thoughts and feelings during a painful experi -\nence on a 5-point Likert scale. Scores can range from 0 to 52 \nwith a higher score corresponding to more catastrophizing. \nA score higher than 30 is usually considered as clinically \nrelevant catastrophizing.\n\n2193Reproductive Sciences (2025) 32:2190–2201 \nAnxiety and Depression\nAnxiety and depression symptoms were measured by the \nHospital Anxiety and Depression Scale (HADS). The \nHADS has been validated for a variety of conditions such \nas lupus erythematosus and chronic fatigue syndrome [32, \n33] and contains 14 questions which patients can score on \na 4-point Likert scale. In this questionnaire, a set of seven \nquestions rate feelings of anxiety and seven questions rate \nfeelings of depression. The HADS depression and anxiety \nscores can range from 0 to 21 with a higher score indicating \nworse symptoms. A score from 0 to 7 on corresponds with \nno anxiety or depression. Scores of 8 to 10 and 11 to 21 \ncorrespond with possible and likely anxiety or depression, \nrespectively.\nPain Intensity\nTo measure pain intensity, patients were asked to complete \na Numerical Rating Scale (NRS). This scale is widely used \nin a variety of chronic pain conditions such as low back \nand neck pain [34, 35]. Specifically, patients were asked \nto perform two ratings, one evaluating the overall worst \nand one evaluating the overall average pain that patients \nTable 1  Patients’ demographics\nTSS Time Since surgery; BMI Body Mass Index; rASRM revised American Society for Reproductive Medicine. Patients’ educational attainment \nwas scored using a 7 point rating scale [39]: (1) unfinished primary school, (2) finished primary school, (3) unfinished low-level secondary edu-\ncation, (4) lower vocational training, (5) advanced vocational training or lower professional education, (6) finished higher professional education \nor senior general secondary education, and (7) obtained a university degree\n Short TSS  Long TSS  Total TSS\nN (N (%)) 101 (51.8) 94 (48.2) 195 (100.0)\nAge years (mean (SD)) 39.2 (7.5) 40.5 (7.2) 39.9 (7.4)\nAge at first surgery years (mean (SD)) 30.4 (6.2) 33.4 (6.8) 31.8 (6.6)\nBMI at most recent surgery Kg/m2 (mean (SD)) 25.5 (4.5) 26.0 (4.8) 25.7 (4.6)\nBMI change Kg/m2 (mean (SD)) 0.0 (2.1) 0.9 (2.4) 0.5 (2.3)\nTTS months (mean (SD)) 28.0 (12.4) 70.3 (15.1) 48.4 (25.2)\nEducation level (median (25–75 percentile)) 6 (5–6) 6 (5–6) 6 (5–6)\nPaid work (N (%))\n No  22 (21.8)  15 (16.0)  37 (19.0)\n Yes 79 (78.2) 79 (84.0) 158 (81.0)\nMarital status (N (%))\n Single  13 (12.9)  9 (8.0)  23 (11.8)\n Married/living with partner 83 (82.2) 97 (86.6) 160 (82.1)\n Separated/divorced 4 (4.0) 5 (4.5) 11 (5.6)\n Widow 1 (1.0) 1 (0.9) 1 (0.5)\nNullipara (N (%))\n No  57 (56.4)  55 (58.5) 112 (57.4)\n Yes 44 (43.6) 39 (41.5) 83 (42.6)\nCurrent use of analgesics (N (%))\n No 56 (55.4) 60 (63.8) 123 (63.1)\n Yes 38 (37.6) 34 (36.2) 72 (36.9)\nCurrent use of hormonal medication (N (%))\n No 56 (55.4) 55 (58.5) 111 (56.9)\n Yes 45 (44.6) 39 (41.5) 84 (43.1)\nExtensiveness of surgery (N (%))\n Removal of extra peritoneal endometriosis 1 (1.0) 1 (1.1) 2 (1.0)\n Removal of peritoneal endometrioses and/or adhesiolysis 8 (7.9) 6 (6.4) 14 (7.2)\n Removal of ovarian endometriosis 11 (10.9) 13 (13.8) 24 (12.3)\n Hysterectomy without removal of ovarian endometriosis 25 (24.8) 24 (25.5) 49 (25.1)\n Hysterectomy with removal of ovarian endometriosis and/or removal of deep  \n   endometriosis\n3 (3.0) 6 (6.4) 9 (4.6)\nrASRM score (median (25–75 percentile)) 44 (46.8) 97 (49.7) 3 (2–4)\nNumber of endometriosis related surgeries (median (25–75 percentile)) 2 (1–3) 2 (1–3) 2 (1–3)\n\n2194 Reproductive Sciences (2025) 32:2190–2201\nhad experienced over the past seven days. Both items were \nscored on a scale ranging from 0 (no pain) to 10 (worst pain \npossible).\nSleep Quality and Fatigue\nSleep quality and fatigue were measured with an NRS over \nthe past four weeks. Sleep quality [36] ranged from 0 (very \npoor sleep quality) to 10 (excellent sleep quality). Fatigue \n[37] was also measured ranging from 0 (no fatigue) to 10 \n(worst fatigue imaginable).\nData Analysis\nIn order to identify the independent contribution of the PCS \nand HADS scores to the HRQoL score, the following steps \nwere taken.\nFirst, an average score for HRQoL was calculated. For \nthis, the subscales of the EHP-30 and RAND-36 were sepa-\nrately averaged into an EHP-30 and RAND-36 total score. \nThen both the RAND-36 total score and the EHP-30 total \nscore were standardized by calculating z-scores. For sev -\neral participants, no scores on the EHP-30 part one were \navailable (n  = 38); in those instances, only the available \ndata (e.g., EHP-30 part 1 and/or 2 and/or RAND-36 scores) \nwere used. Next, the EHP-30 score was multiplied by −1 so \nthat a higher score indicated better HRQoL, after which the \nRAND-36 and EHP-30 questionnaires were averaged into a \nsingle HRQoL score. This score was used in the analysis as \nan indicator for HRQoL. This way, we combined the general \nHRQoL score as measured by the RAND-36 together with \nthe disease specific HRQoL measured by the EHP-30, to \nget a more comprehensive assessment of HRQoL. At the \nsame time this also reduced the number of separate analyses \nneeded, a decision supported by the good reliability of the \ncombined HRQoL domain score (Cronbach’s alpha 0.0816).\nNext, we assessed which factors contributed to HRQoL. \nFor this, we performed hierarchical multiple linear regres-\nsion analyses with bootstrapping (1000 samples). In the first \nstep, potential confounding variables were entered (Table 2). \nIn the second step, the NRS scores for pain intensity, fatigue, \nand sleep quality were entered. In the final step, PCS and \nHADS scores were entered. To avoid multicollinearity, we \ncalculated an average NRS score for pain intensity by add-\ning the mean and worst pain intensity scores and dividing \nthem by two. For the same reason we used the total HADS \nscore instead of the two individual subscales for anxiety and \ndepression.\nIn a sub-analysis, we used hierarchical multiple linear \nregression to evaluate if the PCS and HADS total scores \ncontributed to HRQoL both in patients with a shorter and \nlonger post-surgery period. For this, we divided the study \nsample into two equal groups based on the median TSS: \n6 to 47 months (group with a shorter time since surgery; \nSTSS) and 48 to 108 months (group with a longer time since \nsurgery; LTSS) so that both groups have a comparable sam-\nple size. This enabled us to investigate the relationship and \ndirection between HRQoL and the predictors of interest for \ndifferent post-operative TSSs.\nFor the potential confounding variables, we selected \nfactors based on the literature and expert opinion of the \nresearchers, namely age, age at first surgery, change in BMI \nover post-surgery duration, paid work, current use of analge-\nsics and current use of hormonal medication, nulliparity and \nextensiveness of the endometrioses-related surgeries [38]. \nEducation, measured with an ordinal scale, was divided into \n‘low’ (score 1–4, reflecting less than primary education to \nlower secondary education), ‘middle’ (score 5, indicating \nsecondary vocational education) and ‘high’ (score 6 & 7, \nreflecting higher secondary and higher vocational educa-\ntion, and university degree) education [39]. Because most \nparticipants in this study reported middle or high education, \nTable 2  Spearman’s rank \ncorrelations between potential \nconfounders and HRQoL\n*  = Significant; HRQoL Health-Related Quality of Life; TSS Time Since Surgery; BMI Body Mass Index\nCorrelation coefficient\nShort TSS Long TSS Total TSS\nAge .335* .360* .358*\nAge at first surgery -.093 -.038 -.040\nBMI change -.048 -.178 -.111\nTSS - - .107\nEducation level .047 -.017 .017\nPaid work .276* .355* .312*\nNullipara -.069 -.189 -.127\nCurrent use of analgesics -.490* -.474* -.486*\nCurrent use of hormonal medication -.238* -.105 -.180*\nExtensiveness of surgery .224* .033 .131\nNumber of endometriosis related surgeries .125 .075 .098\n\n2195Reproductive Sciences (2025) 32:2190–2201 \nleaving a limited number of patients with score 1 to 4 (n  = \n16), we combined the low and middle scores (scores 1–5) \ninto a single ‘low’ variable. The variable “high education” \nstill consisted of scores 6 and 7. Next, a binary variable was \ncreated with low education scored as 0 and high education \nscored as 1. The analysis did not include the rASRM-score \nas a potential confounder because it primarily assesses ana-\ntomical findings and has been shown to poorly correlate \nwith patient-reported symptoms [5 ]. To reduce the number \nof confounding variables entered in the regression model, we \nfirst explored which potential confounding demographic and \nclinical factors contributed to HRQoL in a separate Spear -\nman’s rank correlation analysis. The TSS was only included \nin the explorative confounder analysis of the first, main anal-\nysis, because in the subgroup analysis we split the group in \ntwo based on the TSS. Factors that significantly correlated \nwith HRQoL were considered to be confounders and were \ntherefore included in the first step of the regression analyses.\nAll analyses were conducted using the SPSS software \npackage (version 29). The statistical significant level was \nset at p ≤ 0.05.\nResults\nA total number of 337 patients who underwent endome-\ntriosis surgery between January 2012 and July 2020 were \nidentified. Of these, 293 patients were eligible for inclu-\nsion. Reasons for exclusion were: indication for surgery \nwas only fertility related (n  = 26), missing contact infor -\nmation (n  = 1), the most recent endometriosis operation \nwas after July 2020 (n  = 5), no endometriosis was found \nduring surgery or in histopathological investigation post-\nsurgery (n  = 10), or patients were unable to complete the \nquestionnaires due to insufficient understanding of the \nDutch language (n  = 2). Two thirds (n  = 195; 66.6%) of \neligible patients participated in this study. Reasons for the \n98 patients who did not participate were diverse. Some \npatients did not complete the questionnaires in time (n  = \n30). Others reported that they had no time to participate (n \n= 27) or did not want to be reminded about endometriosis \n(n = 7). In some cases the researcher was unable to contact \nthe patient (n  = 17), or the reason was not provided (n  = \n14). Three patients provided other reasons to refrain from \nparticipation in this study. Figure  1 contains an overview \nof patient flow throughout the study.\nDemographic data show that the mean age of the par -\nticipants was 39.9 (SD 7.4) years, while the mean age at \nfirst surgery of the participants was 31.8 (SD 6.6) years. \nThe median education level according to Verhage [39] \nwas 6, corresponding with finished higher professional \neducation or senior general secondary education. Most \nwomen were married or living with a partner (82.1%). \nAverage BMI prior to the most recent surgery was 25.7 \n(SD 4.6), whereas since then the BMI increased 0.5 (SD \n2.3) on average. In addition, 42.6 percent of women were \nnullipara. Almost two thirds of patients (63.1%) reported \nthat they did not currently use any analgesics medication \nand 56.9% did not currently use any hormonal medication. \nIn 97 patients (49.7%) the surgery consisted of removal of \ndeep endometriosis and/or hysterectomy with removal of \novarian endometriosis. The median number of surgeries \nwas 2. The median rASRM score was 3, corresponding \nwith moderate endometriosis. Mean TSS was 48.4 (SD \n25.2) months. A complete overview of the demographic \ndata is provided in Table  1 and mean scores of the ques-\ntionnaires are presented in Table  3.\nFig. 1  Patient flow throughout the study\n\n2196 Reproductive Sciences (2025) 32:2190–2201\nTable 3  Patients’ mean scores to questionnaires regarding Health-Related Quality of Life, stress, anxiety, depression, pain and fatigue\nSTSS shorter Time Since Surgery; LTSS longer Time Since Surgery; EHP Endometriosis Health Profile; RAND Research And Development; NRS Numerical Rating Scale; PCS Pain Catastrophiz-\ning Scale; HADS Hospital Anxiety and Depression Scale; SD Standard deviation; aA higher score of the RAND-36 corresponds with better Health-Related Quality of Life, and a lower score of \nthe EHP-30 corresponds with better Health-Related Quality of Life; bMissing data n = 2; cMissing data n = 38\nMean (SD)\n STSS  LTSS  Total\nRAND-36a\n Physicalb 69,8 (23,2) 73,3 (23,0) 71,5 (23,1)\n Mentalb 69,3 (22,5) 71,7 (21,9) 70,5 (22,2)\nEHP-  30a\n Corec 30.1 (22.2) 28.9 (21.3) 29.6 (21.7)\n General 27.0 (20.9) 22.6 (19.6) 24.9 (20.4)\nPCS 13.8 (12.2) 11.2 (12.1) 12.6 (12.2)\nHADS\n Anxiety 5.7 (4.6) 4.9 (4.3) 5.3 (4.4)\n Depression 4.2 (4.4) 3.9 (4.0) 4.1 (4.2)\n Combined 9.9 (8.6) 8.8 (7.6) 9.3 (8.1)\nNRS\n Average  3.0 (2.6)  2.4 (2.5)  2.7 (2.6)\n Worse 3.6 (3.2) 3.2 (3.1) 3.4 (3.1)\n Combined 3.3 (2.9) 2.8 (2.8) 3.0 (2.8)\nFatigue 5.1 (2.4) 4.9 (2.7) 5.0 (2.6)\nSleep quality 6.0 (2.1) 6.0 (2.1) 6.0 (2.1)\n\n2197Reproductive Sciences (2025) 32:2190–2201 \nHierarchical Multiple Regression Analysis\nThe assumptions for linear regression regarding linear -\nity, homoscedasticity and independence were all met; no \nsevere violations of normality were observed, and Boot-\nstrapped results are reported. Furthermore, the Variance \nInflation Factor (VIF) was lower than 3 between variables \nindicating low multicollinearity (a VIF score above 5 is \nconsidered to indicate severe multicollinearity).\nTo assess which confounders significantly related to \nHRQoL, we first performed a correlation analysis. The \nresults are presented in Table  3. This showed that age, \npaid work, the current use of pain and hormonal medi-\ncation all significantly correlated with HRQoL. These \nvariables were therefore included as confounders in the \nfirst step of the multiple regression analysis. The sec-\nond step showed that, in addition to the confounders, the \nNRS scores for pain intensity (B = −0.162; p  < 0.001) and \nfatigue (B = −0.084; p  < 0.001) significantly correlated \nwith HRQoL. However, sleep quality did not. The PCS (B \n= −0.016; p < 0.001) and HADS total (B = −0.039; p  < \n0.001) scores, entered in the last step, both significantly \ncontribute to HRQoL and higher scores on these factors \nwere related to a lower HRQoL score. Together these two \nvariables explained 10% of the variance in HRQoL. An \noverview of the analysis is presented in Table  4.\nSub‑Group Analysis\nFor both sub-groups we used the correlation analysis to \ndetermine which confounders needed to be included in \nthe regression analyses (Table  3). In the STSS group, the \nNRS score for pain intensity (B = −0.191; p  < 0.001) and \nfatigue (B = −0.089; p < 0.001) significantly correlated \nwith HRQoL. In addition, PCS (B = −0.011; p  = 0.041) \nand HADS total (B = −0.042; p  < 0.001) scores showed \na significant, negative association with HRQoL. These \ntwo variables explained 9% of the variance of HRQoL, \nin addition to the variables entered in the first and second \nstep. The analysis for the LTSS group showed that the \nNRS scores for pain intensity (B = −0.128; p  < 0.001) and \nfatigue (B = −0.083; p  = 0.005) significantly contributed \nto HRQoL. In addition, the scores for PCS (B = −0.024; \np < 0.001) and HADS (B = −0.034; p  < 0.001) also sig-\nnificantly contributed to HRQoL. The extra variance \nexplained by these two variables of interest was 13%. The \nNRS score for sleep quality did not significantly contrib-\nute to HRQoL in either the STSS or LTSS group. Table  4 \ncontains an overview of the analyses.\nDiscussion\nThe goal of the present study was to evaluate the independ-\nent contribution of pain catastrophizing together with anxi-\nety and depression to HRQoL in patients who underwent \ntheir most recent endometriosis-related surgery within the \npast nine years. In particular, the contribution of anxiety \nand depression to the HRQoL was analyzed in the same \ncomparison subcategory. The results of all three analyses \nshowed that pain catastrophizing, and the combined anxi-\nety and depression score negatively contributed to HRQoL \nindependent of pain intensity, fatigue, and sleep quality.\nWhile pain catastrophizing and the combined score \nof anxiety and depression contributed to HRQoL inde-\npendent of pain intensity, pain intensity did contribute to \nHRQoL in all three analyses. Notably, post-surgical pain \nscores in our sample were low—3.3 in the STSS group \nand 2.8 in the LTSS group—below the commonly used \nclinical threshold for initiating medical treatment [40]. \nThese results demonstrate that chronic pain is a multifac-\neted symptom, challenging to treat, and contributes to low \nHRQoL even after surgical treatment of endometriosis. \nBased on our results, pain catastrophizing is an interest-\ning factor because it independently contributes to HRQoL \nat total, short and long TSS. The contribution to HRQoL \ncould be explained within the context of the fear-avoidance \nmodel [19, 41]. Based on this model, it can be speculated \nthat patients with endometriosis continue to catastrophize \nafter surgical treatment, which results in avoidance of \nactivities that might evoke pain, and isolation. Ultimately, \nthis contributes to a reduced HRQoL. We speculate that \naddressing pain catastrophizing with a targeted treatment \nhas the potential to further improve HRQoL after the sur -\ngical treatment of endometriosis-related chronic pain.\nIn correspondence with other studies, the results from \nthis study show that higher levels of anxiety and depres-\nsion correlated with lower HRQoL [42]. Additionally, our \nresults reveal that these associations were true for all TSSs \nand that higher levels of anxiety and depression contrib-\nuted to HRQoL directly, independent of pain intensity, \nfatigue and sleep quality. However, anxiety and depres-\nsion might also indirectly influence HRQoL by influenc-\ning the perception of pain. The perception of pain can be \nmodulated by a variety of factors like prior experiences, \nexpectations, emotions and mood [14, 16, 17]. Therefore, \nhigher levels of anxiety and depression could reduce the \ndown-regulation of the pain processing system, increase \nperception of pain intensity and reduce HRQoL. Specula-\ntively, reducing anxiety and depression could both directly \nand indirectly (via its effect on pain) influence HRQoL.\nBoth pain catastrophizing and anxiety and depression \ncan be targeted with psychological therapy. In chronic \n\n2198 Reproductive Sciences (2025) 32:2190–2201\npain conditions such as back pain and irritable bowel syn-\ndrome, psychological interventions proved to be effec-\ntive in reducing pain and improving HRQoL [43– 45]. To \ndate, there is emerging evidence that psychological inter -\nventions could help endometriosis patients as well [46]. \nTherefore, a psychological intervention, aimed at improv -\ning catastrophizing, pain cognitions and mood, can be con-\nsidered in all women with endometriosis-related chronic \npain symptoms. Even when a patient does not show any \nclinical signs of an anxiety or depression disorder, the \nresults from this study show that these factors can still \ninfluence HRQoL. This psychological therapy should be \ncombined with either pharmacologically induced suppres-\nsion or surgical removal of the endometriotic lesions [47].\nStrengths and Limitations\nAn important strength of this study is the long post-sur -\ngery duration of up to nine years, not often reported in \nliterature. This duration enabled us to evaluate the relation \nbetween HRQoL and its predictors up to nine years after \nsurgical treatment of endometriosis. This long duration \nTable 4  Multiple hierarchical \nregression analyses\n*  statistically significant (p ≤ 0,05); TSS Time Since Surgery; BMI Body Mass Index; Confounders included \nin the analysis were: (1) Age, Paid work, Use of analgesics, Use of hormonal medication; (2) Age, Paid \nwork, Use of analgesics, Use of hormonal medication Extensiveness of surgery; (3) Age, Paid work, Use of \nanalgesics\nB Significance\n(2-tailed)\n95% Confidence \nInterval\nΔR 2 F\nLower Upper\nTotal  TSS1\nModel 2 Pain intensity -.162  <.001* -.196 -.128\nFatigue -.084  <.001* -.129 -.046\nSleep quality .038 .078 -.005 .078\n.321 65.648*\nModel 3 Pain intensity -.111  <.001* -.144 -.078\nFatigue -.031 .060 -.063 .002\nSleep quality .003 .864 -.032 .038\nPain catastrophizing -.016  <.001* -.024 -.009\nAnxiety and depression -.039  <.001* -.049 -.029\n.104 89.497*\nShort  TSS2\nModel 2 Pain intensity -.191  <.001* -.232 -.146\nFatigue -.089 .006* -.143 -.028\nSleep quality .034 .219 -.019 .090\n.351 35.014*\nModel 3 Pain intensity -.142  <.001* -.175 -.101\nFatigue -.029 .284 -.076 .027\nSleep quality .004 .844 -.041 .043\nPain catastrophizing -.011 .041* -.022 -.001\nAnxiety and depression -.042  <.001* -.056 -.026\n.089 46.502*\nLong  TSS3\nModel 2 Pain intensity -.128  <.001* -.188 -.078\nFatigue -.083 .005* -.130 -.029\nSleep quality .043 .186 -.023 .098\n.278 29.386*\nModel 3 Pain intensity -.080 .006* -.141 -.022\nFatigue -.032 .133 -.068 .016\nSleep quality .017 .565 -.035 .082\nPain catastrophizing -.024  <.001* -.036 -.013\nAnxiety and depression -.034  <.001* -.054 -.018\n.126 40.556*\n\n2199Reproductive Sciences (2025) 32:2190–2201 \nstrengthens the conclusions of this study about the impor -\ntance of psychological factors in the management of \nHRQoL in endometriosis patients over time. Another \nstrength is the fact that all patients were selected by eval-\nuating their medical records, providing detailed and reli-\nable information from the participants’ medical records. \nThe group of participants is potentially smaller than when \nselection was conducted by online recruitment via patient \nsupport groups, but it enabled us to verify the medical data \nusing patients’ medical records. If patients are asked to \nreport medical data themselves, this introduces bias even \nrisking to include patients that were not diagnosed with \nendometriosis at all.\nThis study has some limitations too. The most impor -\ntant limitation is that we do not have data about pre-sur -\ngical and early post-surgical HRQoL and factors that may \ninfluence this HRQoL. This would have provided impor -\ntant additional information and insights including the \neffect of surgery on these factors, how these variables have \nchanged over time and if the relationship and/or direc-\ntion between HRQoL and the predictors changed. Regard-\nless, our results are valuable and hold promise to catalyze \nfurther research initiatives. Another limitation is that we \naveraged the NRS scores and combined the HADS sub-\nscales, which limits the ability to distinguish the individual \neffects of mean pain, worst pain, anxiety, and depression. \nHowever, this was necessary to avoid multicollinearity \nin the analysis. In addition, the surgeons’ experience is a \nmajor determinant in the postoperative surgical outcome \nand recovery. Unfortunately, we had limited information \nregarding the surgeon’s experience dating back to 2012. \nTherefore, this was not included in the analysis. Finally, \nHRQoL and all the other questionnaires were completed \nby patients during the COVID-19 pandemic, at a time \nwhen COVID-restrictions were harsh in the Netherlands: \npeople were forced to stay at and work from home, schools \nwere closed as well as restaurants, stores, and museums. \nAlthough not evaluated in this study, it could be hypoth-\nesized that this influenced the HRQoL and/or the pain and \npsychological complaints reported by patients.\nConclusions\nTaken together, the current study demonstrates that pain \ncatastrophizing and anxiety and depression show an inde-\npendent negative contribution to the HRQoL in patients six \nmonths to nine years after surgical treatment of endome -\ntriosis. More research is warranted to assess the interplay \nbetween these factors, the effect of surgery and HRQoL, \nand the potential benefits of an integrated psychological and \nsurgical interventions aimed at improving HRQoL.\nAcknowledgements We thank all participating women for their time \nand willingness to complete the questionnaires. Without their input this \nstudy would not have been possible.\nAuthors' Contributions AN conceived the study. AN, ZB and JO devel-\noped the study design and ZB conducted the study. JO provided sta-\ntistical expertise in the design and analysis. CV, DB and CA reviewed \nthe manuscript and had valuable input. All authors contributed to the \nrefinement of the study protocol, revised different versions of the manu-\nscript and approved the final manuscript.\nFunding This study was supported by the Radboudumc-Rijnstate PhD \nfunding (Grant number W.000003.1).\nData Availability Original data will be available on request ( https:// \ndoi. org/ 10. 17026/ dans- x8v- gnhy) in accordance with the conditions \nof ethics approval. If participants wish, they will be notified of the \nfindings when they are available.\nCode Availability Not applicable.\nDeclarations \nConflict of interest The authors have no competing interests to declare \nthat are relevant to the content of this article.\nEthical Approval Due to the methodology of this study, medical ethical \napproval was waived for this study by the medical ethics committee of \nthe region Arnhem-Nijmegen from the Radboud University Medical \nCentre on August 6th 2020. This study was performed in accordance \nwith the ethical standards as laid down in the 1964 Declaration of \nHelsinki and its later amendments or comparable ethical standards.\nConsent to Participate All participants provided informed consent \nprior to participation.\nConsent for Publication Not applicable.\nOpen Access  This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article's Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article's Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a \ncopy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.\nReferences\n 1. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl \nJ Med. 2020;382:1244–56. https:// doi. org/ 10. 1056/ NEJMr a1810 \n764.\n 2. Becker CM et al. ESHRE guideline: endometriosis. Human \nReproduction Open. 2022.https:// doi. org/ 10. 1093/ hropen/ hoac0 \n09.\n 3. van Aken MAW et al. Pain cognition versus pain intensity in \npatients with endometriosis: toward personalized treatment. Fertil \nSteril. 2017.  https:// doi. org/ 10. 1016/j. fertn stert. 2017. 07. 016. \n\n2200 Reproductive Sciences (2025) 32:2190–2201\n 4. Vercellini P et al. Association between endometriosis stage, lesion \ntype, patient characteristics and severity of pelvic pain symp-\ntoms: a multivariate analysis of over 1000 patients. Hum Reprod. \n2007.  https:// doi. org/ 10. 1093/ humrep/ del339.\n 5. Vercellini P et al. Endometriosis and pelvic pain: relation to dis-\nease stage and localization. Fertil Steril. 1996.  https:// doi. org/ 10. \n1016/ S0015- 0282(16) 58089-3.\n 6. Fauconnier A, Chapron C. Endometriosis and pelvic pain: epi-\ndemiological evidence of the relationship and implications. Hum \nReprod Update. 2005.https:// doi. org/ 10. 1093/ humupd/ dmi029.\n 7. Arcoverde FVL et al. Surgery for endometriosis improves major \ndomains of quality of life: A systematic review and meta-analysis. \nJ Minim Invasive Gynecol. 2019.https:// doi. org/ 10. 1016/j. jmig. \n2018. 09. 774.\n 8. Tan BK et al. A retrospective review of patient-reported out-\ncomes on the impact on quality of life in patients undergoing total \nabdominal hysterectomy and bilateral salpingo-oophorectomy for \nendometriosis. Eur J Obstet Gynecol Reprod Biol. 2013.https://  \ndoi. org/ 10. 1016/j. ejogrb. 2013. 07. 030.\n 9. Ekin M et al. The effect of new cross linked hyaluronan gel on \nquality of life of patients after deep infiltrating endometriosis sur-\ngery: a randomized controlled pilot study. J Obstetr Gynaecol. \n2021. https:// doi. org/ 10. 1080/ 01443 615. 2020. 17556 28.\n 10. Vercellini P et al. The effect of surgery for symptomatic endo-\nmetriosis: the other side of the story. Hum Reprod Update. \n2009.  https:// doi. org/ 10. 1093/ humupd/ dmn062.\n 11. Guo S-W. Recurrence of endometriosis and its control. Human \nReproduction Update. 2009.https:// doi. org/ 10. 1093/ humupd/  \ndmp007.\n 12. Comptour A et al. Long-term evolution of quality of life and \nsymptoms following surgical treatment for endometriosis: Dif-\nferent trajectories for which patients? J Clin Med. 2020.  https:// \ndoi. org/ 10. 3390/ jcm90 82461.\n 13. Cheong Y et al. Laparoscopic surgery for endometriosis: How \noften do we need to re-operate? J Obstet Gynaecol. 2008.  https:// \ndoi. org/ 10. 1080/ 01443 61070 18117 61.\n 14. Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: \ntranslational evidence of the relationship and implications. Hum \nReprod Update. 2011.  https:// doi. org/ 10. 1093/ humupd/ dmq050.\n 15. Fitzcharles MA et al. Nociplastic pain: towards an understand-\ning of prevalent pain conditions. Lancet. 2021.  https:// doi. org/ 10. \n1016/ s0140- 6736(21) 00392-5.\n 16. Murphy AE et al. Identifying and managing nociplastic pain in \nindividuals with rheumatic diseases: A narrative review. Arthritis \nCare Res (Hoboken). 2023.  https:// doi. org/ 10. 1002/ acr. 25104.\n 17. Latremoliere A, Woolf CJ. Central sensitization: a genera-\ntor of pain hypersensitivity by central neural plasticity. J Pain. \n2009.  https:// doi. org/ 10. 1016/j. jpain. 2009. 06. 012.\n 18. Lethem J et al. Outline of a fear-avoidance model of exagger -\nated pain perception—I. Behav Res Ther. 1983.  https:// doi. org/ \n10. 1016/ 0005- 7967(83) 90009-8.\n 19. Martin CE et al. Catastrophizing: a predictor of persistent pain \namong women with endometriosis at 1 year. Hum Reprod. \n2011.  https:// doi. org/ 10. 1093/ humrep/ der292.\n 20. McPeak AE, et al. Pain catastrophizing and pain health-related \nquality-of-life in endometriosis. The Clinical Journal of Pain. \n2018;34(4):349–56. https:// doi. org/ 10. 1097/ ajp. 00000 00000 \n000539.\n 21. Sullivan-Myers C et al. Delineating sociodemographic, medical \nand quality of life factors associated with psychological distress \nin individuals with endometriosis. Human Reproduction. 2021. \nhttps:// doi. org/ 10. 1093/ humrep/ deab1 38.\n 22. La Rosa VL et al. An overview on the relationship between endo-\nmetriosis and infertility: the impact on sexuality and psychological \nwell-being. J PsychosomObstetr Gynecol. 2020.  https:// doi. org/ \n10. 1080/ 01674 82X. 2019. 16597 75.\n 23. Laganà AS et al. Analysis of psychopathological comorbidity \nbehind the common symptoms and signs of endometriosis. Eur \nJ Obstet Gynecol Reprod Biol. 2015.  https:// doi. org/ 10. 1016/j. \nejogrb. 2015. 08. 015.\n 24. Chen LC et al. Risk of developing major depression and anxi-\nety disorders among women with endometriosis: A longitudinal \nfollow-up study. J Affect Disord. 2016.  https:// doi. org/ 10. 1016/j. \njad. 2015. 10. 030.\n 25. Soliman AM et al. The burden of endometriosis symptoms on \nhealth-related quality of life in women in the United States: a \ncross-sectional study. J Psychosom Obstetr Gynecol. 2017. https:// \ndoi. org/ 10. 1080/ 01674 82X. 2017. 12895 12.\n 26. Pope CJ et al. A systematic review of the association between \npsychiatric disturbances and endometriosis.J Obstetr Gynaecol \nCanada. 2015.  https:// doi. org/ 10. 1016/ S1701- 2163(16) 30050-0.\n 27. Tummers FHMP et al. Evaluation of the effect of previous endo-\nmetriosis surgery on clinical and surgical outcomes of subsequent \nendometriosis surgery. Arch Gynecol Obstetr. 2023.  https:// doi. \norg/ 10. 1007/ s00404- 023- 07193-4.\n 28. van de Burgt TJ, Hendriks JC, Kluivers KB. Quality of life in \nendometriosis: evaluation of the Dutch-version Endometriosis \nHealth Profile-30 (EHP-30). Fertil Steril. 2011.  https:// doi. org/ \n10. 1016/j. fertn stert. 2010. 11. 009.\n 29. Jones G, Jenkinson C, Kennedy S. Evaluating the responsiveness \nof the Endometriosis Health Profile Questionnaire: the EHP-30. \nQual Life Res. 2004.  https:// doi. org/ 10. 1023/B: QURE. 00000 \n21316. 79349. af.\n 30. van der Zee K, Sanderman R. Het meten van de algemene \ngezondheidstoestand met de RAND-36. Noordelijk Centrum voor \nGezondheidsvraagstukken, reeks meetinstrumenten. 1993;3.\n 31. Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: \nDevelopment and validation. Psychol Assess. 1995.  https:// doi. \norg/ 10. 1037/ 1040- 3590.7. 4. 524.\n 32. Kwan A et al. Assessment of the psychometric properties of \npatient-reported outcomes of depression and anxiety in systemic \nlupus erythematosus.Semin Arthritis Rheum. 2019.  https:// doi. \norg/ 10. 1016/j. semar thrit. 2019. 03. 004.\n 33. van Ballegooijen W et al. Validation of online psychometric \ninstruments for common mental health disorders: a system-\natic review. BMC Psychiatry. 2016.  https:// doi. org/ 10. 1186/ \ns12888- 016- 0735-7.\n 34. Lemeunier N et al. Reliability and validity of self-reported ques-\ntionnaires to measure pain and disability in adults with neck pain \nand its associated disorders: part 3-a systematic review from the \nCADRE Collaboration. Eur Spine J. 2019.  https:// doi. org/ 10. \n1007/ s00586- 019- 05949-8.\n 35. Chiarotto A et al. Measurement properties of visual analogue \nscale, numeric rating scale, and pain severity subscale of the \nbrief pain inventory in patients with low back pain: A systematic \nreview. J Pain. 2019. https:// doi. org/ 10. 1016/j. jpain. 2018. 07. 009.\n 36. Snyder E et al. A new single-item sleep quality scale: Results of \npsychometric evaluation in patients with chronic primary insom-\nnia and depression. J Clin Sleep Med. 2018.  https:// doi. org/ 10. \n5664/ jcsm. 7478.\n 37. Temel JS et al. Feasibility and validity of a one-item fatigue screen \nin a thoracic oncology clinic. J Thoracic Oncol. 2006.  https:// doi. \norg/ 10. 1016/ S1556- 0864(15) 31611-7.\n 38. Mutubuki EN et al. The longitudinal relationships between pain \nseverity and disability versus health-related quality of life and \ncosts among chronic low back pain patients. Qual Life Res. \n2020.  https:// doi. org/ 10. 1007/ s11136- 019- 02302-w.\n 39. Verhage F. Intelligentie en leeftijd: Onderzoek bij Nederlanders \nvan twaalf tot zevenenzeventig jaar. van Gorcum; 1964.\n 40. van Dijk JF et al. The relation between patients' NRS pain scores \nand their desire for additional opioids after surgery. Pain Pract. \n2015.  https:// doi. org/ 10. 1111/ papr. 12217.\n\n2201Reproductive Sciences (2025) 32:2190–2201 \n 41. Sullivan MJ et al. Theoretical perspectives on the relation between \ncatastrophizing and pain. Clin J Pain. 2001.  https:// doi. org/ 10. \n1097/ 00002 508- 20010 3000- 00008.\n 42. Sepulcri RdP, Amaral VFd. Depressive symptoms, anxiety, and \nquality of life in women with pelvic endometriosis. Eur J Obstetr \nGynecol Reprod Biol. 2009. https:// doi. org/ 10. 1016/j. ejogrb. 2008. \n09. 003.\n 43. Archer KR et al. Cognitive-behavioral-based physical therapy \nfor patients with chronic pain undergoing lumbar spine surgery: \nA randomized controlled trial. J Pain. 2016.  https:// doi. org/ 10. \n1016/j. jpain. 2015. 09. 013.\n 44. Richmond H et al. The effectiveness of cognitive behavioural \ntreatment for non-specific low back pain: A systematic review \nand meta-analysis. PLoS One. 2015. https:// doi. org/ 10. 1371/ journ \nal. pone. 01341 92.\n 45. Creed F et al. The cost-effectiveness of psychotherapy and par -\noxetine for severe irritable bowel syndrome.Gastroenterology. \n2003.  https:// doi. org/ 10. 1053/ gast. 2003. 50055.\n 46. Evans S et  al. Psychological and mind-body interventions \nfor endometriosis: A systematic review. J Psychosom Res. \n2019.  https:// doi. org/ 10. 1016/j. jpsyc hores. 2019. 109756.\n 47. Nijs J et al. Treatment of central sensitization in patients with \n'unexplained' chronic pain: an update. Expert Opin Pharmacother. \n2014.  https:// doi. org/ 10. 1517/ 14656 566. 2014. 925446.\n 48. Chronic pain (primary and secondary) in over 16s: assessment of \nall chronic pain and management of chronic primary pain. London: \nNational Institute for Health and Care Excellence (UK). 2021.\nPublisher's Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}