{"paper_id":"b3f58486-5e70-4a02-b52d-0020dc42754b","body_text":"Rodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525  \nhttps://doi.org/10.1186/s12905‑022‑02066‑5\nRESEARCH\n© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco \nmmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.\nOpen Access\nEmotional dysregulation in women \nwith endometriosis with cyclical \nand non‑cyclical chronic pelvic pain\nDulce Carolina Rodríguez‑Lozano1, María del  Pilar Meza‑Rodríguez2*, Olivier Paul Cruz‑Orozco3, \nBrenda Sánchez‑Ramírez3, Andrea Olguin‑Ortega3, José Roberto Silvestri‑Tomassoni3, \nGuillermo Corona‑Barsse3, Luis Fernando Escobar‑Ponce3, Juan Mario Solis‑Paredes4, \nBenjamín Dominguez‑Trejo5 and Ignacio Camacho‑Arroyo1* \nAbstract \nBackground: Endometriosis is a pathophysiological condition characterized by glands and stroma outside the \nuterus in regions such as the bladder, ureter, fallopian tubes, peritoneum, ovaries, and even in extra pelvic sites. One \nof the main clinical problems of endometriosis is chronic pelvic pain (CPP), which considerably affects the patients’ \nquality of life. Patients with endometriosis may, cyclically or non‑cyclically (80% of cases) experience CPP . High levels \nof anxiety and depression have been described in patients with endometriosis related to CPP; however, this has not \nbeen evaluated in endometriosis women with different types of CPP . Therefore, the research question of this study \nwas whether there is a difference in the emotional dysregulation due to the type of pain experienced by women with \nendometriosis?\nMethods: This work was performed in the National Institute of Perinatology (INPer) in Mexico City from January 2019 \nto March 2020 and aimed to determine if there are differences in emotional dysregulation in patients with cyclical and \nnon‑cyclical CPP . 49 women from 18 to 52 years‑old diagnosed with endometriosis presenting cyclical and non‑cycli‑\ncal CPP answered several batteries made up of Mini‑Mental State Examination, Visual Analog Scale, Beck’s Depression \nInventory, State Trait‑Anxiety Inventory, and Generalized Anxiety Inventory. Mann–Whitney U and Student’s t‑test \nfor independent samples to compare the difference between groups was used. Relative risk estimation was per‑\nformed to determine the association between non‑cyclical and cyclical CPP with probability of presenting emotional \ndysregulation.\nResults: We observed that patients with non‑cyclical CPP exhibited higher levels of depression and anxiety (trait‑\nstate and generalized anxiety) than patients with cyclical pain, p < 0.05 was considered significant. No differences \n*Correspondence:  mezapilar@yahoo.com; camachoarroyo@gmail.com; \ncamachoarroyo@gmail.com\n1 Unidad de Investigación en Reproducción Humana, Instituto Nacional \nde Perinatología‑Facultad de Química, Universidad Nacional Autónoma de \nMéxico, 04510 Mexico City, (CD MX), Mexico\n2 Departamento de Neurociencias, Instituto Nacional de Perinatología, Av. \nMontes Urales # 800. Col. Lomas de Virreyes, 11000 Mexico City, CD MX, \nMexico\nFull list of author information is available at the end of the article\n\nPage 2 of 9Rodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \nwere observed in pain intensity, but there was a higher probability of developing emotional dysregulation (anxiety or \ndepression) in patients with non‑cyclical CPP . No differences were observed in cognitive impairment.\nConclusions: Our data suggest that patients with non‑cyclical (persistent) CPP present a higher emotional dysregu‑\nlation than those with cyclical pain.\nKeywords: Chronic pelvic pain, Anxiety, Depression, Endometriosis, Menstrual cycle, Emotions\nIntroduction\nEndometriosis is a disease distinguished by a tissue simi -\nlar to the lining of the uterus growing outside it causing \npain and infertility [1, 2]. 50% of infertile women exhibit \nendometriosis worldwide. Therefore, it is considered \nthe most common gynecological disease in women of \nreproductive age and in perimenopausal women [3]. \nIn Mexico, epidemiological reviews have estimated an \nendometriosis incidence of 34.5% in women diagnosed \nwith primary and secondary infertility at the National \nInstitute of Perinatology [4].\nEndometriosis symptoms are infertility, dyspareunia, \nheavy menstrual bleeding, chronic fatigue, fibromyal -\ngia, migraine, and central sensitization syndrome [5–7]. \nHowever, the main clinical problem of endometriosis is \nchronic pelvic pain (CPP), which is defined as intermit -\ntent or constant pain in the lower abdomen or pelvis of at \nleast six months, not occurring exclusively with menstru-\nation or intercourse, and not associated with pregnancy \n[8, 9]. One of the most common causes of CPP in women \nis endometriosis (24–40%). Other associated condi -\ntions such as interstitial cystitis/bladder pain syndrome, \nchronic urinary tract infections, vulvodynia, irritable \nbowel syndrome, and inflammatory bowel disease may be \ncomorbid with endometriosis [10–12].\nCPP is a persistent and debilitating condition associ -\nated with high costs and morbidity. Significant costs \nare associated with CPP , including absences from work, \nincreased surgeries, and heavy burden to the health -\ncare system [13]. CPP and infertility in women with \nendometriosis are associated with high levels of stress \nand uncertainty, reducing their quality of life and mak -\ning challenging the performance of daily activities and \nthe development of interpersonal relationships [14, 15]. \nAdditionally, the difficulty experienced by these women \nfrom the onset of the first symptoms until diagnosis \nincreases the probability of presenting emotional altera -\ntions. The average time between the onset of symptoms \nand the seeking help is from 3.7 to 5.7  years, extending \nup to 8 years for timely diagnosis [7, 16, 17].\nThe mechanisms by which CPP is generated in endo -\nmetriosis have not been clearly defined. However, it \noccurs near endometriotic glands, and blood vessels in \nperitoneal endometriotic lesions innervated by sensory \nA delta, sensory C, cholinergic and adrenergic nerve \nfibers [18]. Nerve fiber densities are increased in the \nmyometrium of women with endometriosis compared \nwith those presented in women without this pathol -\nogy [19, 20]. Although these nerve fibers may play an \nessential role in the mechanisms of pain generation in \nendometriosis, the emotional dysregulation can medi -\nate the nociceptive experience by brain regions such \nas the anterior insula and the anterior cingulate cortex \n[21, 22].\nVariable and broad symptoms and social implications \nof endometriosis have been considered disruptive to \nmental health, exhibiting high anguish, anxiety, depres -\nsion, and chronic stress [23– 26]. It has been described \nthat the presence of CPP affects mental health [14], \nregardless of endometriosis stage or type [27], and it \ndid not always decrease after medical treatment or sur -\ngery. Patients with endometriosis may experience CPP \ncyclically or non-cyclically (80% of cases) defined as \nnon-menstrual pain [28, 29]; however, whether there is \na difference in levels of anxiety and depression between \nthese two patient groups has not been evaluated. There -\nfore, it is not known how different CPP affects the emo -\ntional state of women with endometriosis. This study \naimed to determine if there are differences in emotional \ndysregulation in patients with cyclic and non-cyclic \nC P P.\nMethods\nDesign of the study\nWe conducted a transversal study at the National Insti -\ntute of Perinatology (INPer, Neuroscience Department, \nMexico City) from January 2019 to March 2020. Approval \nfrom the Institution Ethical and Scientific Committee \nwas obtained before the beginning of the study (reference \nnumber: INPer, 2019–1-51). Women with endometriosis \nwere invited to participate in the study when coming to \ntheir gynecology interview at Department of Gynecology \nat INPer. Patients who voluntary participated in the study \nwere requested to sign a written informed consent.\nDuring the initial interviews at the Gynecology and \nNeuroscience Departments, we assessed the patients’ eli-\ngibility according to the inclusion criteria. Participants \ngynecological, sociodemographic, and psychological \ncharacteristics were recorded in a database.\n\nPage 3 of 9\nRodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \n \nParticipants\nPatients recruited into the study were attending at the \nGynecology Department in the INPer. The recruited \npopulation comprised women from 18 to 52 years old \nwith a diagnosis of endometriosis (by laparoscopic or \nmagnetic resonance) and CPP for at least 1  year. The \nmedical staff carried out a complete clinical evalua -\ntion and an analysis of sociodemographic variables was \ndone, including marital status, education level, and \nworking status. Participants were asked to complete \nself-reported questionnaires used to measure cogni -\ntive impairment, the intensity of pelvic pain, general \ndiscomfort, depression, and anxiety: Mini-Mental State \nExamination (MMSE), Visual Analog Scale (VAS), Beck \nDepression Inventory (BDI), State-Trait Anxiety Inven -\ntory (STAI) and Generalized Anxiety Disorder Screener \n(GAD).\nFifty-four patients were recruited, but 5 were dis -\ncarded for not completing evaluations. Forty-nine par -\nticipants were included in the study and divided into \ntwo groups according to the type of CPP they experi -\nenced. If the patient suffered from CPP only during her \nmenstrual period, she was classified in the cyclical CPP \ngroup (n = 21), if the patient presented persistently CPP \nregardless of the menstrual phase, she was classified in \nthe group of non-cyclical CPP group (n = 28). A psy -\nchometric evaluation was performed when the patients \nwith cyclical CPP were in the menstrual phase, while the \npatients with non-cyclical pain reported permanent pain \nduring the menstrual phase. Then, the evaluation was \nperformed in the same phase of the cycle.\nInstruments\nThe Mini-Mental State Examination (MMSE) is a test \nused to detect mild cognitive impairment through tests \nof orientation, memory, attention, calculation, and lan -\nguage. If the score is ≤ 24, probable cognitive impairment \nis suspected and if it is > 24, the result was \"without cog -\nnitive impairment\" [30].\nWong-Baker FACES ® Pain Rating Scale is a visual \nanalog scale (VAS) that self-reported the intensity of CPP . \nThe scale is made up of six faces drawn with ratings from \n0 to 10, where 0 is equivalent to the minimum pain and \n10 to the maximum pain that have experienced [31].\nBeck Depression Inventory (BDI) is a 21-item meas -\nure of depression equivalent to the Diagnostic and Sta -\ntistical Manual of Mental Disorders (DSM) symptoms of \ndepression [32]. Patients chose their responses on a 0–3 \nLikert-type scale. Scores of BDI can range from 0 to 63 \nwith the following cut- offs: 0–13, minimally depressed; \n14–19, mildly depressed, 20–28, moderately depressed, \nand 29–63, severely depressed [33, 34].\nState-Trait Anxiety Inventory (STAI) is used to meas -\nure two different dimensions of anxiety: State Anxiety \nScale evaluated the current state of anxiety, asking how \npatients feel “right now”; and Trait Anxiety Scale evalu -\nated relatively stable aspects of “anxiety proneness” [35]. \nScores of both scales range from 20 to 80. Scores between \n20 and 31 indicated minimal anxiety, 32 to 43 mild anxi -\nety, 44 to 55 moderate anxiety, 56 to 67 severe anxiety, \nand 68 to 80 maximum anxiety [36].\nGeneralized Anxiety Disorder Screener (GAD) is a \n7-item self-report for screening of Generalized Anxi -\nety Disorder which are rated on a 4-point Likert-type \nindicating symptom frequency, ranging from 0 (not at \nall sure) to 3 (nearly every day), yielding a value in the \nresponse range from 0 to 21 points. Higher scores indi -\ncate higher levels of GAD symptoms [37]. All the instru -\nments have been translated to the local language and \nvalidated in the local setting [33, 36, 37].\nStatistical analysis\nDemographic parameters and sociomedical conditions \nwere expressed as mean ± SD or N (%), Bonferroni’s cor-\nrection was used to reduce type 1 error. Inferential analy-\nsis was performed with a chi-square (nominal variables), \nMann–Whitney U (ordinal variables), and Student’s t-test \nfor independent samples (scalar variables) to compare \nthe difference between groups. Relative risk estimation \nwas performed to determine the association between \nnon-cyclical and cyclical CPP with probability of present-\ning emotional dysregulation. Statistical analyzes were \nperformed with SPSS v.24.0 software (Armonk, New \nYork: IBM Corp). For all statistical analyses, p < 0.05 was \nconsidered significant.\nResults\nDemographics characteristics\nTable 1 shows the sociodemographic characteristics of \nwomen with endometriosis with cyclical (n = 21) and \nnon-cyclical CPP (n = 28). There were no differences \nin age, years of study, working status and marital status \nbetween the two groups. However, results indicate that \nonly 23.8% of women with cyclic pain and 53.5% with \nnon-cyclical pain were married or cohabiting.\nMedical characteristics of patients are described in \nTable 2. The percentage of nulliparous women is higher \nin women with non-cyclical CPP (78.6%) than in cycli -\ncal CPP women (45.6%). In both cases about 60% of \npatients report disabling pain for about 10  years and \nmore than 70% of all women described at least another \nsymptom associated with endometriosis. Most patients \nin both groups have received at least one surgery to \nmanage symptoms including cleaning of endometrial \nfocuses by laparoscopy (conservative surgery), which \n\nPage 4 of 9Rodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \nwas the most common surgery in these patients. Addi -\ntionally, all women reported consumption of some drug \nfor the endometriosis symptoms, mainly non-steroidal \nanti-inflammatory drugs (NSAIDs). No differences were \nfound in disabling CPP perception, years reporting disa -\nbling pain, other presenting symptoms, previous surgery \nendometriosis, or disruptions, comorbidities between \nwomen with cyclical and non-cyclical pain.\nTo determine differences in global scores on psycho -\nmetric scales applied between endometriosis patients \nwith cyclical and non-cyclical CPP , a normal distribution \nof the results was corroborated with the Shapiro wilk test \nfor n ≥ 30 and Levene’s test showed equality of variances. \nThen, the global scores of each scale were analyzed using \na Student’s t test for independent samples. The global \nscores obtained in depression, anxiety as a trait and state, \nand generalized anxiety were higher in women with non-\ncyclical chronic pain than in those with cyclical pain \n(Table 3). Student’s t test for cognitive impairment could \nnot be calculated because the standard deviation of both \ngroups was equal to 0.\nTo determine differences in pain perception and emo -\ntional dysregulation between patients with cyclical and \nnon-cyclical CPP according to the clinical classification \nof each psychometric scales, a Mann–Whitney U test was \nperformed. Most patients with non-cyclical pelvic pain \nexhibited mild state anxiety (α = 0.007) and depression \nfrom mild to severe (α = 0.018) compared to women with \ncyclical CPP that presented a lower emotional affectation \n(Fig.  1). No differences were observed in pain intensity, \nanxiety as a trait or generalized anxiety according to the \nclinical classification. However, it was found that 70% of \nendometriosis women with cyclical CPP and more than \n90% of the non-cyclical population reported severe to \nmaximum pain; and more than 60% of patients with non-\ncyclic pain presented mild to severe generalized anxiety.\nA relative risk estimation was performed to determine \nthe association between non-cyclical or cyclical CPP and \nthe probability of presenting depression or anxiety as \nrisk factors. Results demonstrated a significant relative \nrisk (> 1) in depression (4.5) and state anxiety (2.85) in \npatients with non-cyclical pain. Relative risk   of patients \nwith cyclical chronic pain was not significant (Table 4).\nDiscussion\nEndometriosis is a long-term, disabling medical con -\ndition that affects the quality of life and mental health \nassociated with CPP . Patients with endometriosis may \nexperience CPP in a cyclical manner such as dysmenor -\nrhea or in a noncyclical manner defined as non-menstrual \npain. Several reports suggest that chronic experience of \npain increases emotional dysregulation [38–40] and that \npsychiatric disorders are more common among women \nwith endometriosis [41–44], however, differences in emo-\ntional dysregulation based on CPP experience in women \nwith endometriosis had not been explored. Therefore, \nthe objective of this study was to determine if there are \ndifferences in the levels of emotional dysregulation in \npatients with cyclical and non-cyclical CPP . This is one of \nthe few studies carried out in Latin America where spe -\ncialized endometriosis care centers are very limited [29, \n45].\nHigh levels of depression and anxiety were found in \nboth groups of patients with CPP , which coincided with \nprevious studies [41–44], however, the present work \nis the first one in demonstrating higher global scores \nin depression, anxiety as a trait and state, and general -\nized anxiety in women with non-cyclical CPP . In addi -\ntion, more women with endometriosis experiencing \nnon-cyclic CPP suffered from mild to severe depression \nand mild state anxiety compared to women experienc -\ning cyclical pain. Menorrhagia and persistent pain are \ntwo variables that may be associated with greater emo -\ntional dysregulation, however, in this study, patients with \ncyclical pain did not show a difference in the frequency \nof these symptoms compared to patients with non-\ncyclical pain [46, 47]. However, it is essential to consider \nthe complexity of the disease and the emotional care of \nthese women to improve their quality of life. Relative risk \nestimation associated with pain intensity determined \nTable 1 Sociodemographic characteristics of endometriosis \nwomen with CPP\nThe parametric t‑test was used to detect statistical differences between \ndemographic measures age, years of study. The chi‑square test was used to \ndetermine differences in marital status, working status between women with \ncyclical and non‑cyclical pain. Bonferroni´s correction was used. n = 49\nParticipants Cyclical pain Non-cyclical pain p-value\nn = 49 n = 21 n = 28\nAge Mean (SD) Mean (SD) .80\n35.2 (6.9) 34.7 (6.47)\nMarital status N (%) N (%) .36\n  Never married 15 (71.4) 10 (35.7)\n  Married 3 (14.3) 9 (32.1)\n  Divorced 1 (4.8) 3 (10.7)\n  Cohabiting 2 (9.5) 6 (21.4)\nYears of study Mean (SD) Mean (SD) .40\n14.4 (3.4) 15.1 (3.13)\nWorking status N (%) N (%) .96\n  Employee 5 (23.8) 5 (17.9)\n  Unemployed 2 (9.5) 4 (14.3)\n  Home labor 5 (23.8) 7 (25)\n  Commerce 3 (9.5) 4 (14.3)\n  Profession 4 (19.4) 6 (21.4)\n  Study 1 (4.8) 2 (7.1)\n\nPage 5 of 9\nRodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \n \nTable 2 Medical conditions of endometriosis women with CPP\nCyclical pain Non-cyclical pain p-value\nParitya N (%) N (%) .024*\n  Nulliparous 10 (45.6) 22 (78.6)\n  ≥ 1 11 (52.4) 6 (21.4)\nDisabling CPP perception N (%) N (%) .61\n  Yes 12 (57.1) 18 (64.3)\n  No 9 (42.9) 10 (35.7)\nYears reporting disabling CPP Mean (SD) Mean (SD) .51\n9.38 (8.36) 10.8 (8.10)\nOther symptomsa N (%) N (%)\n  No  otherb 7 (33.3) 7 (25) .52\n  Menorrhagia 6 (28.6) 14 (50) .131\n  Dyspareunia 7 (33.3) 10 (35.7) .862\n  Widespread pain 2 (9.52) 4 (14.3) .615\n  Amenorrhea 2 (9.52) 3 (10.7) .892\n  Chronic fatigue 1 (4.76) 4 (14.3) .276\n  Inflammation 4 (19.0) 1 (3.57) .077\n  Rectal tenesmus 0 2 (7.14) .211\nInfertility 0 2 (7.10) ..211\n  Dysuria 1 (4.76) 1 (3.57) .835\n  Premenstrual dysphoria 1 (4.76) 0 .243\n  Subinfertility 1(4.8) 0 .73\nPrevious endometriosis surgery N (%) N (%) .84\n  0 6 (28.6) 8 (28.6)\n  1 9 (42.9) 10 (35.7)\n  ≥ 2 6 (28.6) 10 (35.7)\nSurgery for endometriosisa N (%) N (%)\n  Endometrial focuses 5 (23.8) 9 (32.1) .52\n  Oophorectomy 6 (28.6) 5 (17.9) .37\n  Hysterectomy 3 (14.3) 5 (17.9) .74\n  Colectomy 2 (9.52) 1 (3.57) .39\nPharmacotherapya N (%) N (%)\n   NSAIDsc 15 (71.4) 26 (92.9) .04\n  Hormones 7 (33.3) 8 (28.6) .72\n  Antispasmodic 1 (4.8) 3 (10.7) .45\n  Anxiolytics 2 (9.52) 2 (7.14) .76\n  Opioid analgesic 2 (9.52) 0 .09\n  Cannabis 0 2 (7.14) .21\nDisruptionsa N (%) N (%)\n  None 9 (42.9) 5 (17.8) .11\n  Work/School 5 (23.8) 10 (35.7) .37\n  Relationship 6 (28.6) 8 (28.6) 1\n  Next surgery 5 (23.8) 6 (21.4) .84\n  Social 3 (14.3) 5 (17.9) .74\n  Desire to be a mother 3 (14.3) 4 (14.3) 1\n  Family 0 5 (17.9) .07\n  Economy 1 (4.76) 1 (3.57) .83\nComorbiditiesa N (%) N (%)\n  None 10 (47.6) 19 (67.9) .15\n  Polycystic ovary 3 (14.3) 3 (10.7) .71\n\nPage 6 of 9Rodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \na higher probability of developing depression, and state \nanxiety in patients with non-cyclical pain. In fact, the \nrisk of presenting emotional disturbances is more than \ndoubled in the group of women with noncyclic pain than \nin those with cyclical pain, which gives us clinically sig -\nnificant and relevant data for the diagnosis and manage -\nment of these patients [48, 49].\nPain intensity was assessed using the VAS, since it \nhas been shown to be effective for most patients with \nendometriosis (64%) during the painful experience and \nindeed, one month after the experience [50]. However, no \nstatistically significant differences were found in inten -\nsity of pain between CPP groups. In both cases most \npatients report severe to maximum pain and perceive it \nas a disabling pain for about a decade, which could sig -\nnificantly affect their quality-of-life [51]. The relationship \nbetween reports of pain and physical pathology is still \ndebated. Authors suggest a complete evaluation of the \npain considering location, duration, sensory and affective \nTable 2 (continued)\nCyclical pain Non-cyclical pain p-value\n  Hypothyroidism 3 (14.3) 0 .04\n  Myomatosis 3 (14.3) 0 .04\n  Adenomyosis 2 (9.52) 1 (3.57) .39\n  Overactive bladder 2 (9.52) 0 .09\n  Obesity 0 1 (3.57) .38\n  Anemia 0 1 (3.57) .38\n  Heart disease 1 (4.76) 0 .24\nThe parametric t‑test was used to detect statistical differences between years reporting disabling CPP . The chi‑square test was used to determine differences disabling \nCPP , parity, other presenting symptoms, previous surgery for endometriosis, pharmacotherapy, disruptions, and comorbidities between women with cyclical and non‑\ncyclical pain. n = 49; *p < 0.05. Bonferroni´s correction was used\na Different options can be associated with the same patient\nb No other symptoms of endometriosis besides CPP\nc NSAIDs, Non‑steroidal anti‑inflammatory drugs\nTable 3 Cognitive impairment, pain perception, and emotional \ndysregulation global scores in endometriosis women with \ncyclical and non‑cyclical pain\nTable shows the mean ± SD, n = 49, *p < 0.05\nType of chronic pelvic pain Cyclical Non-cyclical p-value\nCognitive impairment 28.80 (1.28) 28.35 (1.06) .11\nPain intensity 7.90 (2.79) 8.85 (1.48) .13\nDepression 11.14 (2.42) 17.46 (1.92)* .04\nTrait anxiety 37.42 (3.23) 47 (2.02)* .01\nState anxiety 39.33 (2.52) 47.35 (1.89)* .02\nGeneralized anxiety 5.14 (1.08) 8.46 (1.05)* .03\nFig. 1 Pain perception and emotional dysregulation in endometriosis women with cyclical and non‑cyclical pelvic pain. n = 49, **p < 0.01\n\nPage 7 of 9\nRodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \n \ndescription, functional status in daily activities [52]; and \nthe hours or sleep disturbances derived from pain [23]. \nBesides, Api [53] highlights that other symptoms of \nendometriosis such as painful intercourse or dyspareunia \ncan mediate the intensity of CPP; however, in this study \nno differences were found in other symptoms of endo -\nmetriosis between patients with cyclical and non-cyclical \npain.\nFor the management of endometriosis symptoms, \nall the patients reported drug use, mainly analgesics. \nBecause cognitive impairment is common in patients \nwith chronic pain for excessive use of analgesics includ -\ning opioids, increased vulnerability to endocrine dis -\nrupting chemicals, and age-related cognitive decline \n[54–56], MMSE test was applied. However, no cogni -\ntive impairment was found in women with endometrio -\nsis using MMSE. Nevertheless, cognitive impairments \nwere reported by Wassink [57], through EGG and event-\nrelated potentials in these patients. It is recommended to \nexplore specific cognitive functions with neuropsycho -\nlogical batteries to improve rehabilitation for future stud-\nies [58].\nIn this study, most patients reported disruptions associ-\nated with symptoms of endometriosis, at work, relation -\nships and family. In addition, it was observed that most \nwomen with cyclical pain had not been married, and \nmost women with non-cyclical pain do not have children. \nLow social support and family networks must maintain \ndepressive and anxious states [59, 60], so women with \nendometriosis may be more vulnerable to living with \nchronic emotional dysregulation, which is associated \nwith low quality of life [45]. Marital status and number \nof children are not predictors of emotional well-being in \nmidlife in women, but rather the quality of relationships \n[51, 61, 62]. Intensity of pain and emotional dysregula -\ntion in women with endometriosis can be mediated by \npsychosocial variables such as emotional suppression, \npain catastrophism, personality, and a passive coping \nstyle, which can also affect patients’ interactions [63–65].\nDifferent comorbid conditions have been implicated \nin CPP in endometriosis, such as pelvic floor tender -\nness, painful bladder syndrome, sexual assault, higher \nbody mass index, current smoking, physical activity, \ndepression, and anxiety [66, 67]. This is the first study \nthat describes differences in emotional dysregulation \naccording to the type of CPP experienced by patients \nwith endometriosis. Therefore, continued research is \nrequired to validate these psychosocial factors and deter -\nmine if any of them is potentially modifiable for improv -\ning the quality of life of women with endometriosis.\nConclusions\nOur data suggest that non-cyclical (persistent)  CPP is \nassociated with a higher emotional dysregulation than \nthose with cyclical pain women with endometriosis, and \nthat non-cyclical CPP may make patients more vulner -\nable to developing emotional dysregulation.\nAbbreviations\nCPP: Chronic pelvic pain; INPer: National Institute of Perinatology; MMSE: \nMini‑Mental State Examination; VAS: Visual Analog Scale; BDI: Beck Depression \nInventory; DSM: Diagnostic and Statistical Manual of Mental Disorders; STAI: \nState‑Trait Anxiety Inventory; GAD: Screener; NSAIDs: Non‑steroidal anti‑\ninflammatory drugs.\nAcknowledgements\nThis study was supported by INPer Project No. 2019‑1‑51, and by CONACYT \nfor the first author’s doctoral grant, no. 749741 with scholarship number (CVU) \n780154.\nAuthors’ contributions\nMPMR designed and conducted the study. DCRL wrote the body of the \nmanuscript. ICA and BDT were major contributors in reviewing the data and \nbody of the manuscript and amending several areas of the manuscript. OPCO, \nBSR, AOO, JRST, GCB, LFEP conducted the clinical intervention in women \nwith endometriosis to assesses the recruitment of patients into the study. \nDCRL and MPMR applied and scored the psychometric instruments to the \nparticipants. DCRL, MPMR and JMSP contributed to the statistical analysis of \ndata. The author(s) read and approved the final manuscript.\nFunding\nThis study was supported by INPer Project No. 2019–1‑51, and by CONACYT \nfor the first author’s doctoral grant, No. 74974 1with scholarship number (CVU) \n780154.\nAvailability of data and materials\nThe datasets generated and/or analyzed during the current study are not pub‑\nlicly available due institutional policies but are available from the correspond‑\ning author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nWe received the approval of the clinical study from the head of the Ethical \nand Research Committee of National Institute of Perinatology, Isidro Espinosa \nde los Reyes, (Montes Urales # 800, Col Lomas de Virreyes, 11000, CD MX, \nMexico) with the project No. 20191–51. The written Informed Consent was \nTable 4 Relative risks of patients with cyclical and non‑cyclical pain\nTable shows relative risk scores and SD\na Represents a significant relative risk (> 1). n = 49\nType of CPP Depression Trait anxiety State anxiety Generalized anxiety\nCyclical 0.23 (0.07–0.66) 0.44 (0.16–1.18) 0.35 (0.15–0.78) 0.54 (0.28–1.07)\nNon-cyclical 4.25 (1.43–12.6)a 2.25 (0.88–5.99) 2.85 (1.27–6.38)a 1.82 (0.92–3.57)\n\nPage 8 of 9Rodríguez‑Lozano et al. BMC Women’s Health          (2022) 22:525 \nalso obtained from all participants recruited in the present study All methods \nwere performed in accordance with the relevant guidelines and regulations in \ncompliance with the Helsinki Declaration.\nConsent for publication\nNot applicable\nCompeting interests\nThe authors declare that they have no competing financial and non‑financial \ninterests that could influence the publishing of the final version of the \nmanuscript.\nAuthor details\n1 Unidad de Investigación en Reproducción Humana, Instituto Nacional de \nPerinatología‑Facultad de Química, Universidad Nacional Autónoma de Méx‑\nico, 04510 Mexico City, (CD MX), Mexico. 2 Departamento de Neurociencias, \nInstituto Nacional de Perinatología, Av. Montes Urales # 800. Col. Lomas de \nVirreyes, 11000 Mexico City, CD MX, Mexico. 3 Departamento de Ginecología, \nInstituto Nacional de Perinatología, Mexico City, Mexico. 4 Departamento de \nGenética y Genómica Humana, Instituto Nacional de Perinatología, Mexico \nCity, Mexico. 5 Facultad de Psicología, Universidad Nacional Autónoma de \nMéxico, Mexico City, Mexico. \nReceived: 30 June 2022   Accepted: 11 November 2022\nReferences\n 1. Surrey E, Carter CM, Soliman AM, Khan S, Di Benedetti DB, Snabes MC. \nPatient‑completed or symptom‑based screening tools for endometriosis: \na scoping review. Arch Gynecol Obstet. 2017;296(2):153–65. https:// doi. \norg/ 10. 1007/ s00404‑ 017‑ 4406‑9.\n 2. World Health Organization (WHO). International Classification of Diseases, \n11th Revision (ICD‑11). WHO: Geneva; 2018.\n 3. National Guideline Alliance (UK). Endometriosis: diagnosis and manage‑\nment. London: National Institute for Health and Care Excellence (NICE); \n2017.\n 4. 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