{"paper_id":"866f295b-a64a-40d0-be02-fad15640f0d5","body_text":"Creative Commons licenses: This is an Open Access article distributed under the terms of the Creative Commons  \nAttribution-NonCommercial-ShareAlike 4.0 International (CC BY -NC -SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/).\n*Corresponding author:\nQingjian Ye\nDepartment of Gynecology\nThe Third Affiliated Hospital \nof Sun Yat-sen University\nGuangzhou, China\nE-mail: yeqjian@mail.sysu.\nedu.cn\nDepartment of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, \nGuangzhou, China\nSubmitted: 12 December 2024; Accepted: 22 July 2025\nOnline publication: 6 September 2025\nArch Med Sci 2025; 21 (5): 1985–1996\nDOI: https://doi.org/10.5114/aoms/208502\nCopyright © 2025 Termedia & Banach\nRelationship between endometriosis and mental \nhealth. A systematic review and meta-analysis\nWenwei Li, Huiyan Feng, Qingjian Ye*\nAbstract\nIntroduction: The chronic gynecological condition endometriosis affects \nabout 10 percent of reproductive aged women and imposes a heavy physical \nand psychological burden. The impact of pain and infertility is well docu-\nmented, but the link between endometriosis and mental health (depressive \nand anxiety), in particular, is not well studied. In this systematic review and \nmeta-analysis, we synthesize evidence on the association between endo-\nmetriosis and mental health outcomes, specifically anxiety and depression.\nMethods: PubMed, Cochrane Library and Google Scholar were searched \ncomprehensively to identify studies that have reported the association of \nendometriosis and mental health outcomes. Nine studies were included af-\nter applying predefined inclusion and exclusion criteria from 1,632 articles \nscreened. The Newcastle-Ottawa Scale (NOS) was used to assess study qual-\nity and random effects meta-analyses were performed using R. Relative risk \n(RR) values for anxiety and depression among women with endometriosis \nwere pooled as the primary outcomes.\nResults: The meta-analysis revealed a significant association between en-\ndometriosis and anxiety (pooled RR = 2.82; 95% CI: 1.69–4.68, p  < 0.001) \nand depression (pooled RR = 2.93; 95% CI: 1.63–5.25, p  < 0.001). Substantial \nheterogeneity was observed in both analyses (I ² = 100%), reflecting vari-\nability in study designs and populations. Funnel plots showed moderate \nasymmetry, suggesting potential publication bias. Statistical heterogeneity \nwas further quantified with τ ² values of 0.6032 for anxiety and 0.794 for de-\npression, indicating considerable between-study variability. These findings \nunderscore the heightened mental health burden in women with endome-\ntriosis.\nConclusions: Endometriosis patients are more likely to develop anxiety and \ndepressive symptoms due to pain and diagnostic evaluation and related \npsychosocial factors. This study stresses the importance of integrated care, \nwhich involves screening and treatment for mental health problems in addi-\ntion to conventional medical care. Future work should aim to reduce hetero-\ngeneity and examine potential pathways through which these relationships \nexist in order to develop specific prevention strategies.\nKey words: endometriosis, anxiety, depression, mental health, systematic \nreview, meta-analysis, Newcastle-Ottawa Scale.\nIntroduction\nEndometriosis is a chronic gynecological disease, and this disease \nis defined by the presence of endometrial tissue outside the uterine \nObstetrics and Gynecology \nSystematic review/Meta-analysis\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1986 Arch Med Sci 5, October / 2025\ncavity, which can cause inflammation, pain and \ninfertility [1, 2]. The incidence of endometriosis \nis about 10% of reproductive-aged women world-\nwide, and it is a  significant source of physical \nand mental health loss [3]. The condition is often \nassociated with menstrual cramps, pain during \nintercourse, and chronic pelvic pain that signifi-\ncantly interferes with daily activities and well-be-\ning [4, 5]. Over the past few years, there has \nbeen an increased emphasis on the psychologi-\ncal effects of endometriosis. Research conducted \nby various authors indicates that this condition \nelevates the risk of developing depression and \nanxiety [6, 7].\nEndometriosis and mental health relate to \ndifferent biopsychosocial factors. Pelvic pain \ncaused by endometriosis has a negative impact \non both physical well-being and psychological \nwell-being, reducing the ability to cope with \nstress and increasing feelings of hopelessness \n[8–10]. Patients with endometriosis are usually \ndiagnosed late, which leads to a longer duration \nof suffering and frustration [11]. Moreover, due \nto cultural taboos regarding pain and gynecolog-\nical problems, women often lack social support \nfor the psychological ramifications of the disease \n[12]. These challenges highlight the need to ex-\nplore the mental health aspects of endometriosis \nin detail to enhance the understanding of man-\nagement approaches [13].\nEndometriosis and mental health issues are \nintertwined and cannot be easily separated [14]. \nThe pain is often chronic and thus can cause de-\npression and psychological distress; there is often \na  delay in receiving a  diagnosis, and menstrual \npain is still viewed as normal by society, which \nmakes women feel unheard and unappreciated \n[15]. Moreover, it has been proposed that there is \na bidirectional relationship between endometrio-\nsis and mental health which may be mediated by \nsuch common factors as inflammation, hormon-\nal imbalance, and neuroendocrine alterations in \nresponse to stress [16]. Despite the increasing \nawareness of such challenges, however, systemat-\nic reviews of the literature examining this relation-\nship are still scarce [17].\nThis study reviewed and meta-analyzed the \nliterature on the relationship between endome-\ntriosis and mental health, hoping to identify the \nrisk factors that can predict the mental health of \npatients with endometriosis and provide certain \nrecommendations for clinical treatment.\nMethods\nThe present systematic review and meta-anal-\nysis adhered to the guidelines set out by the \nPRISMA statement. This meta-analysis has been \nregistered in PROSPERO, and the PROSPERO ID of \nthis study is 1067012. The following sections de-\nscribe the methodological approach used in this \nresearch.\nSearch strategy\nAn effective search plan was designed to iden-\ntify studies that have examined the link between \nendometriosis and mental health, concentrating \non depressive episodes. These databases includ-\ned PubMed, Cochrane Library, and Google Schol-\nar. Search terms included combinations of the \nfollowing keywords: “endometriosis”, “mental \nhealth”, “depression”, “anxiety”, “psychological \ndistress”, and “quality of life”. The MeSH terms \nare “endometriosis” and “mental illness”, and \nthe free words are “mental health”, “depres-\nsion”, “anxiety”, “psychological distress”, and \n“quality of life”. MeSH terms + free terms were \nused for searching. The use of Boolean operators \nsuch as AND and OR was used to narrow down \nthe search outcomes. The following limitations \nwere applied while searching: Only articles in the \nEnglish language were considered, and no year \nlimitations were imposed to ensure comprehen-\nsiveness of coverage. It should be noted that \nthe presented search was updated in [specific \nmonth and year].\nInclusion and exclusion criteria\nStudies were included if they met the following \ncriteria:\n1.  Participants were women with a confirmed di-\nagnosis of endometriosis.\n2.  The study assessed mental health outcomes, \nspecifically depressive events.\n3.  Original research studies utilizing cross-section-\nal, cohort, case-control, or population-based \ndesigns.\n4.  Studies reporting quantitative data on depres-\nsion linked to endometriosis.\n5.  Articles published in peer-reviewed journals.\nExclusion criteria included:\n1.  Studies with insufficient data on mental health \noutcomes.\n2.  Non-original research articles, including reviews, \neditorials, and case reports.\n3.  Studies focusing solely on interventions without \nbaseline mental health assessment.\n4.  Non-English language articles.\nStudy screening\nSelection of studies for the review was done \nin three steps. First, titles and abstracts of the \narticles identified through the database search-\nes were reviewed for relevance. Second, the titles \nand abstracts of the searched publications were \nscreened to determine the applicability of the in-\n\nRelationship between endometriosis and mental health. A systematic review and meta-analysis\nArch Med Sci 5, October / 2025 1987\nclusion and exclusion criteria to the full-text ar -\nticles. The screening process was conducted in \na  blinded manner by two authors, and any dis-\nagreements were resolved through conferencing \nor consulting with a third author. \nData extraction\nData extraction was conducted manually by \ntwo authors using a data extraction form. Data \nelements extracted were the study details such \nas author, year, country, study type, sample size, \nand diagnostic criteria used, participant char -\nacteristics, mental health outcomes such as \nprevalence of depression, and statistical data \nsuch as effect size and confidence intervals. In \ncase of inconsistency in the extracted data, the \nproblem was discussed and resolved among the \nreviewers.\nQuality assessment\nThe quality of the included studies was as-\nsessed based on the Newcastle-Ottawa Scale \n(NOS) for case-control studies. NOS was used \nto score all the included literature, and the fol-\nlowing 8 questions were judged and scored. In \naddition to the maximum of 2 stars for com-\nparability, there was a  maximum of 1 star for \nother items, and the total possible score was  \n9 stars – the higher the score, the higher the \nquality of the study [18]. The NOS assesses \nthree domains: inclusion criteria, matching of \nthe groups, and definition of the outcomes. \nBoth authors separately reviewed each study \nand resolved any difference in opinion to reach \na consensus. Table I shows the quality assess-\nment of the studies involved in the systematic \nreview and meta-analysis. \nTable I. Quality assessment of included studies using the Newcastle-Ottawa Scale (NOS)\nStudy  \nauthors\nSelection  \n(max. 4)\nComparability  \n(max. 2)\nOutcome/Exposure  \n(max. 3)\nTotal score  \n(max. 9)\nFriedl et al., \n2015\n4 Representativeness \nof sample, selection \nof controls, definition \nof exposure, ascertainment \nof endometriosis\n2 Adjustment for \nconfounders, e.g., age\n3 Adequacy of follow-\nup, blinded outcome \nassessment, validated \nmeasurement tools\n9\nŠkegro et \nal., 2021\n4 Representativeness \nof sample, consecutive \npatients, exposure \ndefinition, ascertainment \nof endometriosis\n2 Adjustment for pain \nseverity, age\n3 Validated tools for \nmental health, blinded \noutcome assessment, \nstatistical clarity\n9\nGao et al.,  \n2020\n4 Population-based registry, \nvalidated exposure definition, \nrepresentativeness, large \nsample\n2 Adjustment for \nconfounders, e.g., age, \ncomorbidities\n3 Administrative database, \nblinded outcome data, \nvalidated registry\n9\nEstes et al., \n2021\n3 Validated exposure \ndefinition, representativeness, \nincomplete description \nof controls\n2 Adjustment for pain, \ncomorbidities\n3 Validated outcome \nmeasurement, large \ncohort, use of health \nclaims\n8\nChen et al., \n2016 [30]\n4 Large sample size, validated \nexposure, population-based \nregistry, representativeness\n2 Adjustment for \ndemographics, \ncomorbidities\n3 Adequate follow-up, \nregistry-based outcome \nassessment, statistical \nrobustness\n9\nMárki et al., \n2017\n3 Small sample size but \nwell-defined criteria, \nvalidated exposure, limited \nrepresentativeness\n1 Adjustment for \ndemographics only\n3 Validated tools for \nmental health, appropriate \nfollow-up\n7\nMarschall \net al., 2021\n3 Small sample size, well-\ndefined criteria, limited \nrepresentativeness\n2 Adjustment for narrative \nidentity, pain\n3 Validated mental health \ntools, robust statistical \nmethods, blinded \nassessment\n8\nWang et al., \n2023\n4 Population-based \nregistry, large sample, \nrepresentativeness, validated \nexposure\n2 Adjustment for \ndemographic and clinical \nfactors\n3 Validated tools for \npsychiatric assessment, \nlong follow-up\n9\nFacchin  \net al., 2017\n3 Limited sample, validated \nexposure definition, \nrepresentativeness issues\n1 Adjustment for pain only 3 Validated mental health \ntools, rigorous statistical \nanalyses\n7\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1988 Arch Med Sci 5, October / 2025\nSensitivity/heterogeneity tested by one-by-\none elimination method\nAfter eliminating each included study in se-\nquence, a  meta-analysis was re-conducted on \nthe remaining studies to observe the changes in \nthe combined effect size and confidence interval. \nIf significant changes occur after excluding one \nstudy, it indicates that the original conclusion may \nhave been overinfluenced by that study, is at risk \nof bias, or lacks robustness. \nHeterogeneity of binary categorical \nvariables\nThe L ‘Abbe plot was used for the meta-anal-\nysis heterogeneity test of the binary variable \ndata from RCTs. In this study, the presence or \nabsence of depression and anxiety can be de-\ntermined, which was applicable to binary cate-\ngorical variables. The incidence of events in the \ntreatment group was plotted relative to that in \nthe control group for each study. If the study \nresults were homogeneous, all points would be \nlinearly distributed. Significant deviations from \nthis line indicated heterogeneity in the study \nresults.\nMeta-regression analysis\nA regression model to explore the relationship \nbetween research characteristics (covariates) and \neffect size (relative risk – RR) was established, \nthereby explaining the heterogeneity among dif-\nferent studies. This study conducted a  meta-re-\ngression analysis using a  random effects model. \nThe random effects model assumes that the stud-\nies did not have a common effect scale, but rather \neach had its own effect scale, which was defined \nas a random variable that follows a normal distri-\nbution.\nData synthesis\nMeta-analysis was performed using R software, \nversion 4.2.3. Depressive events concerning endo-\nmetriosis were evaluated employing random-ef-\nfects models as a way of managing heterogeneity \nof the studies. The main measure of interest was \nthe overall pooled prevalence of depressive symp-\ntoms in women with endometriosis compared \nto the control group. The heterogeneity was es-\ntimated by the I² statistic. Stata 17 software was \nused to plot the heterogeneity shown by the elim-\nination method and the meta-regression analysis \ngraph.\nResults\nWhen the databases were searched exhaus-\ntively, 1632 articles were found. After excluding \nthe duplicate records and using the inclusion and \nexclusion criteria, nine articles were included in \nthis systematic review. The PRISMA flow diagram \noutlining the selection of the included studies is \nshown in Figure 1. The quality of the included \nstudies was evaluated with the Newcastle-Otta-\nwa Scale (NOS) for selection, comparability, and \noutcome/exposure. Table I  presents the quality \nassessment of the included studies, where all the \nselected articles have met the methodological \nstandards. NOS scores of all included documents \nwere greater than or equal to 7, and the docu-\nments [19–21] were scored with a full score of 9. \nThe overall quality of the included literature was \nrelatively high.\nStudy characteristics\nThe combined studies presented in this review \nreflect various populations, designs, and geo-\ngraphical areas, providing a  broad perspective \nFigure 1. PRISMA flow diagram of included studies\nRecords identified from: Databases (n = 1632)\nRecords screened (n = 1053)\nReports sought for retrieval (n = 69)\nReports assessed for eligibility (n = 48)\nStudies included in review (n = 9) \nRecords removed before screening:\nDuplicate records removed (n = 579)\nRecords excluded (n = 984) \nReports not retrieved (n = 21) \nReports excluded: \n•\t Not specifically focusing on effect  \nof endometriosis oh mental health (30) \n•\t Unclear results (n = 5) \n•\t Lack of analysis of correlation between the \nvariables (4)\nIdentificationIncluded Screening\n\nRelationship between endometriosis and mental health. A systematic review and meta-analysis\nArch Med Sci 5, October / 2025 1989Table II. Detailed characteristics of included studies\nStudy \nauthors\nYear Country Study design Sample size Population Diagnostic \nmethod\nMental \nhealth  \noutcomes\nMeasure-\nment tools\nKey findings Conclusion\nFriedl \net al., \n2015\n2015 Austria Cross-\nsectional \nsurvey\n62 patients, \n61 controls\nWomen aged \n18–44 with \nconfirmed \nendometriosis\nHistological \nconfirmation\nAnxiety, \ndepression\nSF-36, \nHADS-D, \nEHP-30\nModerate to severe anxiety \n(29%) and depression (14.5%) \nin patients. SF-36 showed \nsignificant impairments in \ngeneral health and mental \nhealth in patients (p  < 0.001).\nNeed for psychosomatic \ntreatment due to elevated \nmental health burden in \npatients.\nŠkegro \net al., \n2021\n2021 Croatia Observational \ncross-\nsectional\n79 women Women with \nhistologically \nconfirmed \nendometriosis\nHistological \nconfirmation\nDepression, \nanxiety, \nstress\nEHP-5, \nDASS-21, \nVAS\nDepression (44.3%), anxiety \n(25.3%), stress (31.7%). \nModerate correlations between \nEHP-5 and mental health \nindicators (r  > 0.5).\nMultidisciplinary care required \nto address mental health \nand physical symptoms in \nendometriosis.\nGao et al., \n2020\n2020 Sweden Longitudinal \ncohort study\n854,361 \n(14,144 \npatients)\nWomen born \n1973–1990, \naged 14–43\nICD-9/10 \ncodes in \nnational \nregistry\nDepression, \nanxiety, \nADHD, \nalcohol/drug \ndependence\nNational \npatient \nregister\nWomen with endometriosis \nhad higher RRs for mental \nhealth outcomes: depression \n(RR = 1.89), anxiety (RR = \n1.82), alcohol dependence \n(RR = 1.93). Bidirectional \nassociations observed between \ndepression/anxiety and \nendometriosis.\nComorbidity with \ndepression/anxiety suggests \nshared familial liability. \nMultidisciplinary care \nrecommended.\nEstes \net al., \n2021\n2021 USA Retrospective \ncohort study\n72,677 \npatients, \n147,251 \ncontrols\nWomen aged \n18–50 with \nendometriosis\nICD-9/10 \ncodes and \nlaparoscopic \nconfirmation\nAnxiety, \ndepression, \nself-directed \nviolence\nClaims \ndata from \nhealth \ndatabase\nRRs: Anxiety (1.38), depression \n(1.48), self-directed \nviolence (2.03). Pain-related \ncomorbidities were significant \nrisk factors.\nRegular screening and care \nfor mental health outcomes \nare crucial for women with \nendometriosis.\nChen \net al., \n2016 [30]\n2016 Taiwan Longitudinal \ncohort study\n10,439 \npatients, \n10,439 \ncontrols\nWomen aged \n≥ 18 with no \npsychiatric \nhistory\nICD-9-CM \ncodes, ultra-\nsonography\nMajor \ndepression, \nanxiety \nNHIRD \ndata\nRRs for depression (1.56), \nanxiety (1.44). Younger women \n(< 40 years) at higher risk.\nComprehensive care addressing \nphysical and psychological \nneeds is essential.\nMárki \net al., \n2017\n2017 Hungary Cross-\nsectional \nstudy\n193 women Women aged \n18–50 years\nGynecological \nevaluation, \nimaging\nAnxiety, \ndepression, \npsychological \ndistress\nSF-36, \nHADS, PSS, \nDERS\nAnxiety symptoms (54.79%), \ndepressive symptoms \n(20.32%). Pain and emotion \nregulation difficulties \nsignificantly reduced HRQoL.\nPain management and \nemotional regulation \ninterventions can enhance \nHRQoL.\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1990 Arch Med Sci 5, October / 2025\non the association between endometriosis and \nmental health. These studies were conducted in \ncountries such as Austria, Croatia, Sweden, United \nStates, Taiwan, Hungary, Denmark, and Italy and \nwere published between 2015 and 2023. The type \nof studies used in the review were cross sectional, \ncase control, prospective cohort, and population \nbased.\nThe sample sizes ranged from 62 participants \nin some research to more than 850,000 women in \nothers. Participants were mainly female endome-\ntriosis patients who were diagnosed using histo-\nlogical confirmation, imaging, or through registry \ndiagnostic codes. Table II displays the study char-\nacteristics such as diagnostic methods, mental \nhealth outcomes, and measurement tools. \nMental health outcomes in women with \nendometriosis\nPrevalence of depression and anxiety\nEach of the studies included in the systematic \nreview and meta-analysis found that women di-\nagnosed with endometriosis had a  significantly \nhigher rate of depression and anxiety, particularly \ndepression and anxiety, compared with the gener-\nal population. In their study, 27.7% of women with \nendometriosis had moderate to severe anxiety \nlevels and 14.5% had depressive symptoms [19]. \nSimilarly, high prevalence of depressive symp-\ntoms (44.3%), anxiety (25.3%), and stress (31.7%) \namong the participants was reported [20].\nSpecifically, pain severity was found to be \na  significant predictor of mental health disorder \nprevalence. In their cross-sectional study, higher \npain severity was positively associated with high-\ner anxiety and depressive symptoms and lower \nHRQoL [22]. This was in line with other studies \nshowing that pain has a significant effect on men-\ntal health status.\nFactors influencing psychological distress\nThe timing of diagnosis and patient charac-\nteristics were found to be significant predictors \nof psychological distress. It was established that \nshorter time between the diagnosis and the as-\nsessment was linked to increased anxiety levels \n[23]. In addition to this, greater self-esteem and \nself-efficacy were found to be protective factors \nand women with higher scores on both measures \nindicated lower levels of depression and anxiety. \nA  study showed the psychological consequenc-\nes of the narrative identity of women with en-\ndometriosis [24]. It was found that women who \nhad a  high level of endogenous factors related \nto endometriosis had higher levels of depressive \nsymptoms and lower life satisfaction. On the oth-\ner hand, higher agency and communion themes in \nStudy \nauthors\nYear Country Study design Sample size Population Diagnostic \nmethod\nMental \nhealth  \noutcomes\nMeasure-\nment tools\nKey findings Conclusion\nMarschall \net al., \n2021\n2021 Denmark Cross-\nsectional \nstudy\n120 women Women aged \n18–48 years\nMRI, \nultrasound, \nsurgery\nDepressive \nsymptoms, \nlife \nsatisfaction, \npsychological \nimpact\nBDI-II, \nSWLS, CES, \nnarrative \ncoding\nCentrality of endometriosis \nto identity correlated with \ndepressive symptoms (r  = 0.50) \nand reduced life satisfaction  \n(r = –0.41). Agency themes \nlinked to improved mental \nhealth outcomes.\nImportance of narrative \nidentity in understanding \nmental health in endometriosis \npatients.\nWang \net al., \n2023\n2023 Taiwan Population-\nbased cohort \nstudy\n100,770 \n(20,154 \npatients)\nWomen aged \n≥ 18\nICD-9-CM \ncodes in \nNHIRD\nAnxiety, \ndepression, \nsuicide, \nall-cause \nmortality\nNHIRD \ndata\nRRs: anxiety (2.494), \ndepression (2.773), suicide \n(1.447), all-cause mortality \n(2.315).\nPsychiatric follow-up and \nmultidisciplinary care are vital \nto improve outcomes.\nFacchin \net al., \n2017\n2017 Italy Cross-\nsectional \nstudy\n210 women Women aged \n19–51 years\nClinical and/\nor surgical \ndiagnosis\nDepression, \nanxiety, \nrumination\nHADS, RRS, \nRSES, BES\nPelvic pain severity correlated \nwith poorer mental health. \nHigh self-esteem and \nemotional self-efficacy \nassociated with lower \ndepression and anxiety  \n(p < 0.001).\nMultidisciplinary treatments \nshould address both physical \nand psychological needs, \nincluding self-esteem and \nemotional regulation.\nTable II. Cont.\n\nRelationship between endometriosis and mental health. A systematic review and meta-analysis\nArch Med Sci 5, October / 2025 1991\ntheir stories correlated with better psychological \nwell-being.\nAssociation with comorbidities and long-\nterm risks\nSeveral authors have described the presence \nof comorbid depression in patients with endome-\ntriosis. In the study by Gao et al. (2020) [21], the \nwomen with endometriosis had 1.89 times higher \nrisk of developing depression and 1.82 times high-\ner risk of developing anxiety. In a different study, \nendometriosis was associated with a  more than \ntwofold elevated risk of SV [25].\nFurthermore, it was also possible to identify \nlong-term outcomes including suicidality and all-\ncause mortality. In one study, women with endo-\nmetriosis were at a 44.7% higher risk of suicide \nand a  231.5% higher risk of all-cause mortality, \nproving the importance of a holistic approach [26].\nQuality of life and mental health\nIn all the studies reviewed, endometriosis was \nfound to be significantly related to decreased \nHRQoL. There was a  statistically significant de-\ncrease in the general health, vitality, and mental \nhealth aspects of the HRQoL scales [19, 22]. These \noutcomes were mainly associated with psycho-\nlogical distress, pain severity, and the presence of \nemotional dysregulation.\nData synthesis\nAnxiety outcomes\nThe meta-analysis revealed a  significant associa-\ntion between endometriosis and anxiety (Figure 2),  \nwith a  pooled relative risk (RR) of 2.82 (95%  CI: \n1.69–4.68, p < 0.001) under a  random-effects \nmodel. This finding indicates that women with en-\ndometriosis have nearly three times the risk of de-\nveloping anxiety compared to control groups. The \nheterogeneity among the studies was substantial, \nas reflected by an I² value of 100% and τ² = 0.6032 \n(p < 0.001), suggesting variability in study popula-\ntions, methodologies, and diagnostic criteria.\nThe precision of the pooled effect was support-\ned by the log-transformed RR (logRR = 0.59) and \nits standard error (SE = 0.12), confirming the ro-\nbustness of the findings. The 95% confidence in-\nterval spanned from moderate (RR = 1.69) to high \nrisk (RR = 4.68), further emphasizing the signifi-\ncant burden of anxiety among women with endo-\nmetriosis.\nThe funnel plot for anxiety outcomes (Figure 3)  \ndisplayed moderate asymmetry, which may sug-\ngest the presence of publication bias or small-\nstudy effects. This observation was supported by \nvisual inspection and statistical heterogeneity val-\nues. The clustering of smaller studies near higher \neffect sizes, as evident in the plot, highlights the \nneed for sensitivity analyses to ensure the stabili-\nty of the pooled estimates.\nDepression outcomes\nFor depression, the meta-analysis demonstrat-\ned a pooled relative risk (RR) of 2.93 (95% CI: 1.63–\n5.25, p < 0.001) using a  random-effects model \nStudy  logHR  SE(logHR)  Hazard ratio  HR  95% CI  Weight  Weight\n      (common)  (random) \nFriedl et al., 2015  0.2900  0.0204   1.34  [1.28; 1.39]  19.9%  11.2% \nSkegro et al., 2021  0.2530  0.0153   1.29  [1.25; 1.32]  35.3%  11.2% \nGao et al., 2020  1.8200  0.0485   6.17  [5.64; 6.82]  3.5%  11.1% \nEstes et al., 2021  1.3800  0.0408   3.97  [3.67; 4.31]  5.0%  11.1% \nChen et al., 2016  1.4400  0.1225   4.22  [3.39; 5.47]  0.6%  10.9% \nMarki et al., 2017  0.5480  0.0357   1.73  [1.62; 1.86]  6.5%  11.2% \nMarschall et al., 2021  0.5000  0.0255   1.65  [1.57; 1.73]  12.7%  11.2% \nWang et al., 2023  2.4940  0.1020   12.11  [9.97; 14.88]  0.8%  11.0% \nFacchin et al., 2017  0.6260  0.0230   1.87  [1.79; 1.95]  15.7%  11.2% \nCommon effect model     1.66  [1.63; 1.69]  100.0% \nRandom effects model     2.82  [1.69; 4.68]   100.0% \nHeterogeneity: I2 = 100%, τ2 = 0.6032, p = 0 \nFigure 2. Forest plot for anxiety outcomes. The pooled relative risk (RR) of 2.82 (95% CI: 1.69–4.68) indicates a sig-\nnificantly higher risk of anxiety among women with endometriosis\n 0.1 0.5 1 2 10\nFigure 3. Funnel plot for anxiety outcomes. The \nplot shows slight asymmetry, suggesting potential \npublication bias\n 2 5 10\nHazard ratio\n0\n0.02\n0.04\n0.06\n0.08\n0.10\n0.12 Standard error\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1992 Arch Med Sci 5, October / 2025\n(Figure 4). This result indicates that women with \nendometriosis have nearly a threefold higher risk \nof experiencing depressive symptoms or clinical \ndepression compared to controls. The heterogene-\nity was pronounced, with I² = 100% and τ² = 0.794 \n(p < 0.001), reflecting variability across studies in \nterms of sample sizes, population characteristics, \nand measurement tools.\nThe log-transformed RR for depression out-\ncomes (logRR = 0.61) and its standard error (SE = \n0.15) further validated the precision of the pooled \neffect. The 95% confidence interval showed \na wide range, from moderate risk (RR = 1.63) to \nsubstantial risk (RR = 5.25), indicating that the \nimpact of endometriosis on depression may vary \nbased on pain severity, disease stage, and psycho-\nsocial factors.\nThe funnel plot for depression outcomes (Fig-\nure 5) revealed some asymmetry, which could be \nattributed to potential publication bias or meth-\nodological differences across studies. Studies with \nsmaller sample sizes tended to show larger effect \nsizes, as visualized in the plot. The presence of \noutliers and clustering in specific regions of the \nplot suggests that further analyses, such as trim-\nand-fill methods, may be necessary to address po-\ntential biases.\nOne-by-one elimination method outcomes\nThe outcomes of this study concerned 9 stud-\nies, each study being excluded in turn. The com-\nbined results of the remaining 8 studies were not \nStudy  logHR  SE(logHR)  Hazard ratio  HR  95% CI  Weight  Weight\n      (common)  (random) \nFriedl et al., 2015  0.1450  0.0128   1.16  [1.13; 1.19]  38.0%  11.2% \nSkegro et al., 2021  0.4430  0.0204   1.56  [1.49; 1.62]  14.8%  11.2% \nGao et al., 2020  1.8900  0.0587   6.62  [5.93; 7.46]  1.8%  11.1% \nEstes et al., 2021  1.4800  0.0332   4.39  [4.06; 4.62]  5.6%  11.2% \nChen et al., 2016  1.5600  0.1862   4.76  [3.46; 7.17]  0.2%  10.7% \nMarki et al., 2017  0.2030  0.0357   1.23  [1.14; 1.31]  4.8%  11.2% \nMarschall et al., 2021  0.6070  0.0281   1.83  [1.73; 1.93]  7.8%  11.2% \nWang et al., 2023  2.7730  0.1020   16.01  [13.46; 20.09]  0.6%  11.0% \nFacchin et al., 2017  0.6060  0.0153   1.83  [1.79; 1.90]  26.4%  11.2% \nCommon effect model     1.61  [1.58; 1.63]  100.0% \nRandom effects model     2.93  [1.63; 5.25]   100.0% \nHeterogeneity: I2 = 100%, τ2 = 0.7940, p = 0 \nFigure 4. Forest plot for depression outcomes. The pooled relative risk (RR) of 2.93 (95% CI: 1.63–5.25) highlights \nthe elevated risk of depression among women with endometriosis\n 0.1 0.5 1 2 10\nFigure 5. Funnel plot for depression outcomes. \nSlight asymmetry in the plot suggests potential \nbias or heterogeneity among the included studies\nFigure 7. L ‘Abbe plot\n 1 2 5 10\nHazard ratio\n 0 0.25 0.50 0.75 1.00\nEvent rate group 2\n0\n0.05\n0.10\n0.15\n1.00\n0.75\n0.50\n0.25\n0\nStandard error\nEvent rate group 1 \n 2.66 2.70 2.90 3.08 3.10\n Lower CI limit         Estimate        Upper CI limit\nFigure 6. One-by-one elimination method diagram\nFriedl 2015 \nSkegro 2021 \nGao 2020 \nEstes 2021 \nChen 2016 \nMarki 2017 \nMarschall 2021 \nWang 2023 \nFacchin 2017\nMeta-analysis estimates,  \ngiven named study is omitted\n\nRelationship between endometriosis and mental health. A systematic review and meta-analysis\nArch Med Sci 5, October / 2025 1993\nstatistically significant (95% CI included 2.82 and \n2.93), which was consistent with the original com-\nbined results (RR = 2.90, 95% CI = 2.70 to 3.08, p < \n0.001) (Figure 6), indicating that the results were \nrelatively stable. \nHeterogeneity of binary categorical \nvariables\nIt can be seen from Figure 7 that some points \nwere far from the reference line, indicating hetero-\ngeneity in the study results.\nMeta-regression analysis\nMeta-regression analysis was conducted on 9 \nincluded studies. As shown in Table III, I2 = 76.37% \n(I2 > 50%), indicating that this meta-analysis has \ncertain heterogeneity. However, the p-value > 0.05 \nsuggests that there was no need for subgroup \nanalysis.\nDiscussion\nThis systematic review focuses on understand-\ning the association between endometriosis and \nmental health, providing a  detailed analysis of \nthe interconnection between the two. The results \nsupport the hypothesis that women with endo-\nmetriosis have significantly elevated prevalence \nof depression, anxiety, and psychological distress \ncompared to the general population. This review \noffers a  more complex view of the contributing \nfactors, which include pain severity, diagnostic \nlatency, and patient-level factors such as self-es-\nteem and emotional self-efficacy, which supports \na biopsychosocial model of treatment.\nThe burden of endometriosis on mental \nhealth\nEndometriosis is defined as a chronic and se-\nvere disease that has negative impacts on the \nmental state of women. In line with previous \nresearch, the current review shows that women \nwith endometriosis experience high levels of de-\npression and anxiety, indicating that the psycho-\nlogical toll of the disease remains high. The high \nprevalence of these mental health conditions \nshould be attributed to the pain and uncertainty \nthe patients experienced as well as the burden of \nthe disease on their overall functioning.\nPain was identified as an important factor that \naffected mental health. It was confirmed that se-\nvere pelvic pain, dysmenorrhea, and chronic pain \nwere associated with depressive and anxious \nsymptoms [22]. Chronic pain not only impacts \nphysical performance but also leads to emotion-\nal fatigue, decreased ability to cope with stress, \nand increased risk of psychological distress. This \nfinding supports the biopsychosocial model of \npain, which holds that pain is not only a  physi-\ncal phenomenon, but its perception and experi-\nence are influenced by biological, psychological, \nand social factors. An observational case-control \nstudy included 344 patients with endometriosis \nand found that among them, 119 patients had \nmental disorders and 70 patients had depression. \nPatients with depression (EM-D) or mental state \n(EM-P) dyspareunia and dyschezia occurred more \nfrequently. A total of 27,840 women from six Eu-\nropean countries were included in the study by \nBecker et al. (2021) [27]. The most common symp-\ntoms related to endometriosis are dysmenorrhea \n(61.8%), massive/irregular bleeding (50.8%), and \npelvic pain (37.2%). Women reported that en-\ndometriosis affected their emotions; 55.6% of \npeople felt “frustrated”, depressed or desperate, \nand 53.2% felt defeated or disappointed with \ntheir family/friends [28]. These research results \nare consistent with the conclusion of this study. \nEndometriosis can cause both physical pain and \nmental distress for patients. Medical staff and \nsociety should pay attention to the mental condi-\ntion of patients with endometriosis. From January \n2019 to March 2020, 104 women were included in \na prospective observational study, and their anx-\niety levels decreased after assessment (STAI-Y6 \n60.0 ±15.0 vs. 40.8 ±14.2). Patients with a high-\ner baseline anxiety level (test. change –24.3; 95% \nconfidence interval: –29.2 to –19.5) experienced \na decrease in anxiety level after the physical ex-\namination [29, 30].\nDiagnostic delays and psychological \nimplications\nOne of the significant trends identified in the \nreviewed research is the psychological impact of \ndiagnostic delays. Endometriosis is often diag-\nnosed only after years of enduring symptoms, \nduring which time women may experience chron-\nic pain, mistreatment, and a lack of acknowledg-\nment from healthcare providers. This protracted \ndiagnostic journey, characterized by frustration \nand uncertainty, can exacerbate emotional dis-\ntress [23]. The fact that a shorter time from the di-\nTable III. Meta-regression analysis results\nVariable Coef. Std. err. t P > |t| 95% Conf. Interval\nStudy period –0.0359408 0.0498238 –0.54 0.441 –0.1391346 0.089493\n_cons 46.29132 94.07384 0.53 0.413 –179.2943 293.5463\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1994 Arch Med Sci 5, October / 2025\nagnosis is related to increased anxiety also points \nto the difficulties that women experience in deal-\ning with the first stage of accepting an illness that \nis chronic and cannot be cured.\nThe diagnostic delay carries significant social \nand cultural implications. The tendency to post-\npone or avoid seeking care, coupled with the \nstigma surrounding menstrual and pelvic pain, \ncontributes to these delays, leaving many wom-\nen feeling isolated and unheard. Addressing these \nsystemic issues requires enhanced education for \nboth medical professionals and the public, as well \nas improved diagnostic practices aimed at identi-\nfying endometriosis more promptly and accurately.\nIndividual characteristics and protective \nfactors\nIn addition to the physical and diagnostic ap-\nproaches to endometriosis, this article explores \nthe influence of personality traits on mental \nhealth. Higher self-esteem, enhanced emotional \nself-efficacy, and supportive intimate relation-\nships are associated with improved psychologi-\ncal outcomes [23, 24]. These findings have signif-\nicant implications for endometriosis, indicating \nthat individual resilience and social support can \nprevent a  significant amount of the mental \nhealth burden. Women with higher disease cen-\ntrality are more likely to report depressive symp-\ntoms and lower levels of life satisfaction [24]. \nOn the other hand, the narratives of control are \nrelated to improved mental health, implying that \nthe interventions designed to alter the narrative \nmight be beneficial.\nPsychiatric comorbidities and long-term \nrisks\nThe significant association between endometri-\nosis and depression found in this review provokes \nquestions regarding the common mechanisms of \npathogenesis. Women with endometriosis were at \na higher risk of developing depressive and anxiety \nthan those without the disease, and the wom-\nen who already had depression and anxiety had \na  higher likelihood of developing endometriosis \n[21]. Some of these mechanisms include inflam-\nmation, hormonal changes, and hypothalamic-pi-\ntuitary-adrenal axis abnormalities, which need to \nbe explored in future studies.\nFurthermore, the increased odds of self-\nharmed/suicide and all-cause mortality supported \nthe potentially lethal consequences of untreated \npsychological symptoms in women with endome-\ntriosis [25, 26]. These results underscore the need \nto include mental health assessment and treat-\nment as part of standard care for individuals with \nendometriosis.\nImplications for clinical practice\nThe outcomes of this review also have import-\nant implications for the medical treatment of \nendometriosis. First, there is a  need for mental \nhealth interventions to be incorporated into the \ntreatment of endometriosis. Depression, anxiety, \nand other psychological symptoms should be \nscreened as part of routine practice, and patients \nshould be guided on where to access psycholog-\nical support. Second, the management of pain \nshould be comprehensive, encompassing not only \na physical perception of pain, but also psycholog-\nical and emotional. Other methods may include \ncognitive behavioral therapy, mindfulness practic-\nes, and narrative therapy to support medical and \nsurgical management.\nThird, this systematic review on the mental \nhealth burden of endometriosis has implications \nfor training of healthcare providers. The nature of \nthe disease requires that the providers acknowl-\nedge the psychosocial aspects of the illness and \nmanage to reassure patients about their feelings. \nFinally, patient education and involvement should \nbe prioritized. Women should be empowered with \nresources that will improve their self-esteem, \nemotional self-efficacy, and coping mechanisms \nto improve their mental health.\nHeterogeneity analysis\nThe sample size of the included literature was \nin line with the efficacy analysis. The results of the \none-by-one elimination analysis to test the het-\nerogeneity of this study showed that after all the \nincluded studies were eliminated one by one, the \nconfidence interval and total RR were still within \nthe fluctuation range calculated by the forest plot, \nindicating that the bias of all the included stud-\nies was controllable and stable. The L ‘Abbe plot \nwas used to conduct heterogeneity analysis on \nbinary variables. Basically, all the included studies \nshowed a linear relationship, and the research re-\nsults were basically homogeneous, which was of \ncertain significance. The results of the meta-re-\ngression analysis indicated that the included lit-\nerature could already yield meaningful results and \nthere was no need for subgroup analysis. Hetero-\ngeneity analysis indicates that there was a certain \ndegree of heterogeneity in this study, but the anal-\nysis results were still significant.\nStrengths, limitations, and future directions\nOne of the major strengths of this review is the \nbroad coverage of the studies, originating from \nvarious geographic and cultural backgrounds, \nwhich increases the external validity of the find-\nings. Furthermore, the application of standardized \nassessment instruments throughout the studies \n\nRelationship between endometriosis and mental health. A systematic review and meta-analysis\nArch Med Sci 5, October / 2025 1995\nenhances the credibility of the documented re-\nsults.\nHowever, there were also some limitations. \nMany publications were horizontal, which means \nit was difficult to establish a  causal relationship \nbetween endometriosis and mental health. More \nlongitudinal studies are needed to conduct longi-\ntudinal investigations into this relationship, with \na focus on diagnosing the consequences of delays \nand the outcomes of intervention measures. Fur -\nthermore, the variability of research types, par -\nticipants, and measured mental health impacts \ncomplicated the analysis and comparison. Only  \n9 studies were included in this analysis. The num-\nber was too small, which leads to certain het-\nerogeneity in the meta-analysis, and the results \nlacked certain persuasiveness. In future research, \nwe will search as many databases as possible and \ninclude as many studies as possible in the me-\nta-analysis. Additionally, we will extend our search \nto Embase, Scopus, and gray literature to mini-\nmize publication bias and improve the complete-\nness of evidence. Meanwhile, we will also conduct \nsubgroup analyses on the research design of the \nincluded literature, the family economic income of \npatients with endometriosis, marital status, etc., \nso that the obtained results are meaningful for the \nactual treatment. It is also necessary to consider \nhow other aspects such as race, economic status, \nand cultural customs affect endometriosis and its \ntreatment. Exploring the connection between en-\ndometriosis and depression/anxiety is helpful for \nformulating intervention and treatment plans.\nIn conclusion, this systematic review focuses \non the high mental health cost that has been re-\nported among women with endometriosis, with \nincreased depression, anxiety, and psychological \ndistress recorded. Many factors were found to be \nassociated with these outcomes. They included \npain severity, diagnostic delay, and presence of \ncomorbid conditions. In the same vein, self-es-\nteem, emotional self-efficacy, and social support \nwere revealed as moderators that could buffer the \neffects of the disease.\nThese conclusions stress the necessity for an \ninterdisciplinary approach to the treatment of \nendometriosis, in which the evaluation and treat-\nment of mental health issues should be included \nin addition to pain relief and pharmacological \ntreatment. The study highlighted that early diag-\nnosis and effective care management models for \nendometriosis are vital to enhance both somatic \nand psychiatric recovery for affected females. Fu-\nture studies should aim to identify the long-term \noutcomes of these interventions and the under -\nlying common pathways between endometriosis \nand depression and anxiety. As highlighted in this \nreview, various interrelated factors need to be ad-\ndressed with a  view to improving the quality of \nlife of millions of affected women.\nFunding\nNo external funding.\nEthical approval\nThis study was approved by the Institutional Re-\nview Board of the Third Affiliated Hospital of Sun \nYat-sen University (Approval NO: II 2023-292-01).\nConflict of interest\nThe authors declare no conflict of interest.\nReferences\n1. Ahn SH, Singh V , Tayade C. Biomarkers in endometrio-\nsis: challenges and opportunities. Fertil Steril 2017; 107: \n523-32.\n2. Lukac S, Schmid M, Pfister K, Janni W, Schäffler H, Da- \nyan D. Extragenital endometriosis in the differential di-\nagnosis of non-gynecological diseases. Dtsch Ärztebl Int \n2022; 119: 361-7.\n3. Choi EJ, Cho SB, Lee SR, et al. Comorbidity of gyneco-\nlogical and non-gynecological diseases with adenomy-\nosis and endometriosis. Obstet Gynecol Sci 2017; 60:  \n579-86.\n4. Taylor HS, Kotlyar AM, Flores VA. Endometriosis is \na chronic systemic disease: clinical challenges and novel \ninnovations. Lancet 2021; 397: 839-52.\n5. Verit FF , Yucel O. Endometriosis, leiomyoma and adeno-\nmyosis: the risk of gynecologic malignancy. Asian Pacific \nJ Cancer Prev 2013; 14: 5589-97.\n6. Horne AW, Missmer SA. Pathophysiology, diagnosis, \nand management of endometriosis. BMJ 2022; 379: \ne070750.\n7. Kvaskoff M, Mu F , Terry KL, et al. Endometriosis: a high-\nrisk population for major chronic diseases? Human Re-\nprod Update 2015; 21: 500-16.\n8. Ghiasi M, Kulkarni MT, Missmer SA. Is endometriosis \nmore common and more severe than it was 30 years \nago? J Minim Invasive Gynecol 2020; 27: 452-61.\n9. Mehedintu C, Plotogea M, Ionescu S, Antonovici M. En-\ndometriosis still a challenge. J Med Life 2014; 7: 349-57.\n10. Saavalainen L, Lassus H, But A, et al. Risk of gynecologic \ncancer according to the type of endometriosis. Obstet \nGynecol 2018; 131: 1095-102.\n11. Acién P , Velasco I. Endometriosis: a disease that remains \nenigmatic. ISRN Obstet Gynecol 2013; 2013: 242149.\n12. Laganà AS, La Rosa VL, Rapisarda AMC, et al. Anxiety \nand depression in patients with endometriosis: impact \nand management challenges. Int J Women’s Health \n2017; 9: 323-30.\n13. Sasson IE, Taylor HS. Stem cells and the pathogenesis \nof endometriosis. Ann N Y Acad Sci 2008; 1127: 106-15.\n14. Falcone T, Lebovic DI. Clinical management of endome-\ntriosis. Obstet Gynecol 2011; 118: 691-705.\n15. Márki G, Vásárhelyi D, Rigó A, Kaló Z, Ács N, Bokor A. \nChallenges of and possible solutions for living with en-\ndometriosis: a qualitative study. BMC Women’s Health \n2022; 22: 20.\n16. Agarwal SK, Foster WG, Groessl EJ. Rethinking endome-\ntriosis care: applying the chronic care model via a multi-\n\nWenwei Li, Huiyan Feng, Qingjian Ye\n1996 Arch Med Sci 5, October / 2025\ndisciplinary program for the care of women with endo-\nmetriosis. Int J Women’s Health 2019; 11: 405-10.\n17. Takebayashi A, Kimura F , Kishi Y, et al. The association \nbetween endometriosis and chronic endometritis. PLoS \nOne 2014; 9: e88354.\n18. Simadibrata DM, Lesmana E, Fass R. A systematic review \nand meta-analysis of the efficacy of vonoprazan for pro-\nton pump inhibitor-resistant gastroesophageal reflux \ndisease. J Gastroenterol Hepatol 2024; 39: 796-805.\n19. Friedl F , Riedl D, Fessler S, et al. Impact of endometriosis \non quality of life, anxiety, and depression: an Austrian \nperspective. Arch Gynecol Obstet 2015; 292: 1393-9.\n20. Škegro B, Bjedov S, Mikuš M, et al. Endometriosis, pain \nand mental health. Psychiatr Danub 2021; 33 (Suppl 4): \n632-6.\n21. Gao M, Koupil I, Sjöqvist H, et al. Psychiatric comorbidity \namong women with endometriosis: nationwide cohort \nstudy in Sweden. Am J Obstet Gynecol 2020; 223: 415.\ne4-415.e16.\n22. Márki G, Bokor A, Rigó J, Rigó A. Physical pain and \nemotion regulation as the main predictive factors of \nhealth-related quality of life in women living with endo-\nmetriosis. Human Reprod 2017; 32: 1432-8.\n23. Facchin F , Barbara G, Dridi D, et al. Mental health in wom-\nen with endometriosis: searching for predictors of psy-\nchological distress. Human Reprod 2017; 32: 1855-61.\n24. Marschall H, Hansen KE, Forman A, Thomsen DK. Sto-\nrying endometriosis: examining relationships between \nnarrative identity, mental health, and pain. J Res Person-\nal 2021; 91: 104062.\n25. Estes SJ, Huisingh CE, Chiuve SE, Petruski-Ivleva N, Miss-\nmer SA. Depression, anxiety, and self-directed violence in \nwomen with endometriosis: a retrospective matched-co-\nhort study. Am J Epidemiol 2021; 190: 843-52.\n26. Wang TM, Lee YL, Chung CH, et al. Association between \nendometriosis and mental disorders including psychi-\natric disorders, suicide, and all-cause mortality-a  na-\ntionwide population-based cohort study in Taiwan.  \nInt J Women’s Health 2023; 15: 1865-82.\n27. Becker K, Heinemann K, Imthurn B, et al. Real world \ndata on symptomology and diagnostic approaches of \n27,840 women living with endometriosis. Sci Rep 2021; \n11: 20404.\n28. Arena A, Orsini B, Degli Esposti E, et al. The unbearable \nburden of endometriosis: results from a  large cohort \nabout anxiety reduction during the first outpatient eval-\nuation. J Psychosom Res 2021; 147: 110512.\n29. Dietrich H, Knobel C, Portmann L, et al. Endometriosis \nfeatures and dienogest tolerability in women with de-\npression: a case-control study. Eur J Contracept Reprod \nHealth Care 2023; 28: 198-204.\n30. Chen LC, Hsu JW, Huang KL, et al. Risk of developing \nmajor depression and anxiety disorders among women \nwith endometriosis: a longitudinal follow-up study. J Af-\nfect Disord 2016; 190: 282-5.","source_license":"CC0","license_restricted":false}