{"paper_id":"d2ee17f3-fdc1-4d79-96c7-092d7d78fea0","body_text":"Citation: El-Maraghy M, Labib K, El-Din WS and Ahmed AB. The Impact of Endometriosis Symptoms on Health \nRelated Quality of Life and Work Productivity in Egypt. Austin J Obstet Gynecol. 2017; 4(3): 1078.\nAustin J Obstet Gynecol - Volume 4 Issue 3 - 2017\nSubmit your Manuscript | www.austinpublishinggroup.com \nEl-Maraghy et al. © All rights are reserved\nAustin Journal of Obstetrics and Gynecology\nOpen Access\nAbstract\nIntroduction: Endometriosis, usually called as “cancer of the career-\nwoman”, is being recognized as a “social disease” for its prevalence and its \ndebilitating impact on young women, leading to a high socio-economic burden \nof the disease. It is defined as the presence of endometrial tissue outside the \nuterus and is found in women of all ethnic and social groups. The prevalence \nhas been reported around 10% of the general female population and up to 50% \nin women with pelvic pain or infertility.\nAim of the Work: To assess the impact of endometriosis-related symptoms \non work productivity and health-related quality of life (HRQoL) in Egypt.\nMaterials and Methods: This is a cross sectional study that was \nperformed from December 2016 to July 2017 at the Department of Gynecology \nand Obstetrics at Ain Shams University, anonymous questionnaires were \nadministered individually to a total of 250 women with surgically diagnosed \nendometriosis. The questionnaires consisted of three sections: Patient Health \nSurvey (SF-12), the Endometriosis Health Profile (EHP-5), and the Work \nProductivity and Activity Impairment Survey (WPAI).\nResults: The study confirm that endometriosis has a significant negative \nimpact on work productivity and HRQoL of affected women, leading to high \neconomic burden and huge costs to society, the WPAI showed absenteeism 16% \nof work time. Presenteeism 44% impairment. Percent overall work impairment \ndue to health: 15.6%. Percent activity impairment due to health: 51% of regular \ndaily activities disturbed.\nConclusion: Although endometriosis is not a life-threatening disease, \nthis study confirmed that it can substantially affect women’s work productivity \nand HRQOL. Thus, endometriosis can be both physically and emotionally \ndebilitating. Therefore it is time to make serious investment in preventing this \ndebilitating condition in the next generation of women improving the collective \nlevel of awareness of endometriosis, its detection, and its treatment.\nKeywords: Endometriosis; Work productivity; Quality of life; Pelvic pain; \nEgypt\nResearch Article\nThe Impact of Endometriosis Symptoms on Health \nRelated Quality of Life and Work Productivity in Egypt\nMohamed El-Maraghy1*, Labib K1, Waleed  Salah \nEl-Din2 and Ahmed AB1\n1Department of Obstetrics and Gynecology, Ain Shams \nUniversity, Egypt\n2Department of Community Medicine, Ain Shams \nUniversity, Egypt\n*Corresponding author:  Mohamed El-Maraghy, \nDepartment of Obstetrics and Gynecology, Ain Shams \nUniversity, Egypt\nReceived: November 02, 2017; Accepted: November \n27, 2017; Published: December 04, 2017\nIntroduction\nEndometriosis is a chronic disease, which is under diagnosed, \nunder-reported, and under-researched Gao X et al. [1]. It is defined \nas the presence of endometrial tissue outside the uterus and is found \nin women of all ethnic and social groups. The prevalence has been \nreported around 10% of the general female population Giudice LC \net al. [2], Berek JS et al. [3] and up to 50% in women with pelvic pain \nor infertility.\nEndometriosis is often labeled ‘the missed disease’ Overton C et \nal. [4] and the average time between onset of pain and diagnosis is \nnearly 8 years in the United Kingdom, and 12 years in the United \nStates of America Hadfield R et al. [5].\nEndometriosis is defined as the presence of endometrial-like \ntissue outside the uterus Kennedy et al. [6]. Like the uterine lining, this \ntissue builds up and sheds in response to monthly hormonal cycles. \nHowever, there is no natural outlet for the blood discarded from these \nimplants. Instead, it falls onto surrounding organs, causing swelling \nand inflammation. Endometriosis triggers a chronic inflammatory \nreaction resulting in pain and adhesions. Adhesions develop when \nscar tissue attaches separate structures or organs together. The \nactivity and the complaints due to endometriosis may vary during the \nwoman’s menstrual cycle as hormone levels fluctuate. Consequently, \nsymptoms may be worse at certain times in the cycle, particularly \njust prior to and during the woman’s menstrual period. While some \nwomen with endometriosis experience severe pelvic pain, others \nhave no symptoms at all or regard their symptoms as simply being \n‘ordinary menstrual pain’(Endometriosis association of Ireland).\nThe primary symptoms of endometriosis are pain and infertility. \nEndometriosis can be associated with dysmenorrhea, dyspareunia, \ndysuria, chronic pelvic pain, abnormal bleeding Simoens S et al. [7]. \nThe prevalence of endometriosis increases dramatically to as high \nas 25%–50% in women with infertility and 30-50% of women with \nendometriosis have infertility Verkauf BS et al. [8]. The severity of \n\nAustin J Obstet Gynecol 4(3): id1078 (2017)  - Page - 02\nMohamed El-Maraghy Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\npain does not correspond with the number, location, or extent of \nendometriosis lesions. Some women with only a few small lesions \nexperience severe pain; other women may have very large patches of \nendometriosis, but only experience little pain. (American College of \nObstetricians and Gynecologists. (2008), Stratton P et al. [9].\nChronic pelvic pain is a debilitating condition that may affect \nmillions of women worldwide with a significant financial cost to \nboth the individual and society Mathias SD et al. [10]. Specifically, \nendometriosis-associated pain is the major cause of physical, psycho-\nsocial, emotional and work related impairment among these women \nOehmke F et al. [11]. Therefore endometriosis can be considered \na debilitating disease which has a detrimental effect on the health-\nrelated quality of life (HRQoL) Mathias SD et al. [10]. in a large \nnumber of patients, as reported by several studies Mathias et al. [10], \nBodner et al.[11], Gao et al. [12], Bianconi et al. [12].\nHRQoL is a multidimensional, dynamic concept that encompasses \nphysical, Psychological and social aspects associated with a disease \nor its treatment Guyatt GH et al. [13]. Generic instruments most \ncommonly used to assess HRQoL include the Patient Health Survey \nSF36v2, its abbreviated form SF12v2 capture practical, reliable and \nvalid information about functional health and well-being from the \npatient’s point of view. Another generic instrument created to evaluate \nthe impact of a disease on productivity loss and daily life activities \nis the Work Productivity and Activity Impairment Questionnaire \n(WPAI), validated for use in many diseases but not in endometriosis \nReilly MC et al. [14]. The only validated disease-specific HRQoL \nscales for endometriosis are the Endometriosis Health Profile EHP-\n30 and its shorter version, EHP-5 Jones G et al. [15].\nThe objectives of the study was to describe the effect of \nendometriosis-related symptoms on physical, mental health status, \nsexuality and work-related aspects (absenteeism, presenteeism, work \nproductivity, and activity impairment) on a sample of 250 patients \nbased on anonymous questionnaires.\nMaterial and Methods \nStudy design\nThis is a cross-sectional study.\nPlace and duration of the study\nThe study was performed from December 2016 to July 2017 at the \nDepartment of Gynecology and Obstetrics at Ain Shams university \nhospitals.\nSample size\n250 female patients attending to the Ob/Gyn clinics with \nlaparoscopic or histological diagnosis of endometriosis aged 15-45, \nwith no other chronic or debilitating disease were asked to participate \nin the study, the patients were asked to fulfill the questionnaires with \nthe assistance of a trained medical supervisor.\nExclusion criteria\n•\t Patients beyond the age limits\n•\t Patients with no surgical prove of endometriosis\n•\t Patients suffering from any form of chronic illness\n•\t Patients with psychological disorders\nStudy questionnaires\nThree questionnaires, the SF-12, EHP-5, and WPAI, have been \nadministered: The SF-12 provides patient-reported outcomes (PRO) \ndata by measuring patients’ perceptions of their general health status \nduring the past 4 weeks in eight dimensions: physical functioning, \nsocial functioning, role limitations due to physical problems, role \nlimitations due to emotional problems, mental health, energy and \nvitality, pain, and general perception of health.\nQuestions are subdivided into 10 questions that refer to the \nphysical and emotional status during the past month, and whether \npatients felt that these had interfered with performing daily life \nactivities Fourquet J et al. [16].\nThe Endometriosis Health Profile is a Health Related Quality of \nLife (HRQoL) patient self-report, used to measure the wide range \nof effects that endometriosis can have on women’s lives. The EHP is \nthe only condition-specific designed from the patient’s perspective \nto assess health related quality of life in endometriosis. The EHP-5 \nconsists of 11 questions that assess whether and how much symptoms \nof endometriosis interfere with work and daily activities during the \npast 4 weeks. Other aspects of the impact of endometriosis measured \nare mood and appearance changes, perception that others do not \nunderstand, and feelings that pain controls one’s life. Also, the impact \non sexual life, childcare, relationship with doctor, treatment efficacy, \nand maternity are also measured.\nThe Work Productivity and Activity Impairment (WPAI) is a \n6-item questionnaire was used to measure the impact of health on \nwork performance. The WPAI consists of six questions about work \nexperiences and perceptions of productivity levels at work. The impact \non work aspects is measured using a scale, from 0 (not affected) to 100 \n(could not work at all), and information is obtained regarding the \ntotal number of working hours, number of missed work hours due to \nsymptoms, and perceived productivity at work.\n Frequency Percent Valid Percent Cumulative Percent\nValid Not at all 39 15.6 15.6 15.6\nA little bit 84 33.6 33.6 49.2\nModerately 53 21.2 21.2 70.4\nQuite a bit 47 18.8 18.8 89.2\nExtremely 27 10.8 10.8 100\nTotal 250 100 100  \nTable 1: During the past 4 weeks, how much did pain interfere with your normal \nwork (including both work outside the home and housework)?\n Frequency Percent Valid Percent Cumulative Percent\nValid Never 37 14.8 14.8 14.8\nRarely 51 20.4 20.4 35.2\nSometimes 69 27.6 27.6 62.8\nOften 56 22.4 22.4 85.2\nAlways 37 14.8 14.8 100\nTotal 250 100 100  \nTable 2: During the last 4 weeks, how often, because of your endometriosis, \nhave you felt as though your symptoms are ruling your life?\n\nAustin J Obstet Gynecol 4(3): id1078 (2017)  - Page - 03\nMohamed El-Maraghy Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\nThe WPAI yields four types of scores expressed as impairment \npercentages: absenteeism (work time missed), presenteeism \n(impairment at work/reduced on-the-job effectiveness), work \nproductivity (overall work impairment/absenteeism presenteeism), \nand activity impairments. Higher WPAI percentages indicate greater \nimpairment and less productivity Fourquet J et al. [16].\nConsent\nThe purpose of the study was explained to all participants and an \noral informed consent was obtained.\nEthical approval\nThe study protocol was approved by the ethical committee of the \ndepartment of obstetrics and gynecology at Ain shams university.\nData management\nData collected were entered into Excel, then Data were analyzed \nusing Stata\n® version 14.2 (Stata Corp LLC, College Station, TX, USA). \nNormality of numerical data distribution was examined using the \nShapiro-Wilk test. Non-Normally distributed numerical data were \npresented as median and interquartile range and categorical data as \nnumber and percentage.\nResults\nThe questionnaire was completed by 250 women. The mean age of \nthe population was 37.3 years (range: 24 to 45 years).188 participants \nof the 250 only were employers, while 162 participants of the 250 had \nchildren.\nSF-12 results\nThe majority of participants rated their general health status as, \nata minimum, ‘‘good’’ (n 197 of 250; 78%). More than half of the \nparticipants reported daily activities have been extremely (n 79 of \n250; 31.6%) or moderately (n 84 of 250; 33.6%) limited by symptoms. \nThe majority of women reported that work-related activities were \naffected due to their physical health; (66.4%) accomplished less than \nexpected, (56.8%) reported physical limitations.\nMost of the women (n 137 of 250; 54.8%) reported that pain did \ninterfere a little bit or moderately, while (n 74 of 250; 29.6%) reported \nthat pain did interfere quite a bit or extremely on normal work (Table \n1). The majority of the participants were employed (n 171of 250; \n68.4%) were employed for a mean of 27.2 hours during the last week \n(standard deviation {SD} 7.1 hours). \nPatients were asked to rate the impact of endometriosis-related \nsymptoms on productivity loss and daily life using a scale of 0 to 10. \nOut of the 171 participants only 25\nth percentile choose 2 and below, \nwhile 50 th percentile scored between 2 and 7, and 25 th percentile \nchoose above 7 which is severely affected, Based on this scale, loss of \nproductivity had a mean score of 4.4 (SD_2.8) (Figure 1). As for daily \nactivities out of the 250 participants; 25\nth percentile choose scores \nabove 7, with a mean score of 5.1 (SD_2.7).\nOut of the 171 working participants, 123 reported missing hours \nfrom work in the past seven days due their health problem (mean loss \nin work time 5.2 hours; SD_ 4.7 hours). The effects of endometriosis \nsymptoms on the four domains measured by WPAI were quantified \nas,\n•\t Percent work time missed due to health (absenteeism): 16% \nof work time.\n•\t Percent impairment while working due to health \n(presenteeism): 44% impairment.\n•\t Percent overall work impairment due to health: 15.6% \n•\t Percent activity impairment due to health: 51 % of regular \ndaily activities disturbed (activity impairment).\nEHP results\nMany participants (47.2%) reported that pain severely interfered \nwith walking substantially (i.e., often or always) during the last \nmonth. Many participants (37.2%) reported that the symptoms of \nendometriosis severely controlled their life (i.e., often or always) \nduring the last month (Table 2).\nDiscussion\nThis cross-sectional study on 250 Egyptian women with \nendometriosis supports the evidence gathered by other studies \nconducted in other populations, indicating that endometriosis-related \nsymptoms have a negative impact on HRQoL and work productivity.\nNowadays this issue is of growing interest in a society where \nincreased health care costs and limited resources are of increasing \nconcern. For this reason in recent years, the studies quantifying the \ncosts of endometriosis Nnoaham KE et al. [17], Simoens S et al. [7] \nand the impact of the disease on health, work productivity, and daily \nlife activities have increased. Damario MA et al. [18], Oehmke F \net al. [11], Reilly MC et al. [14], Fourquet J et al. [16]. To quantify \nthe impact of endometriosis-related symptoms in these important \naspects of a person’s life, we compiled questions from three validated, \nstandardized questionnaires into one instrument. The questionnaires \nused were (SF-12, WPAI, and EHP 5+6), these questionnaires were \npreviously for assessment of endometriosis in different countries but \nthis is the first to be done in Egypt or the Middle east.\nThere were 17 papers (14 quantitative and 3 qualitative) which \nreported findings relating to the impact of endometriosis on QoL \nFigure 1: Box plot showing the response to WAPI Q2 to Q4. Box represents \nthe range from the 25 th to 75 th percentiles (interquartile range). Line inside \nthe box represents the 50th percentile. Whiskers represent the minimum and \nmaximum values excluding outliers (dots). Minimum value and 25th percentile \nare overlapping in the plots of WAPI Q2 and WAPI Q3 As for daily activities \nout of the 250 participants; 25 th percentile choose scores above 7, with a \nmean score of 5.1 (SD_2.7).\n\nAustin J Obstet Gynecol 4(3): id1078 (2017)  - Page - 04\nMohamed El-Maraghy Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\nand everyday activities. All of the studies demonstrate reduced QoL \namong women with endometriosis Marques A et al. [19], Petrelluzzi \nKF et al. [20], Siedentopf F et al. [21], Bernuit D et al. [22], Tripoli \nTM et al. [23], and one study demonstrated that a minority of women \nconsider themselves to have a current state of health ‘worse than \ndeath’ Simoens S et al. [7]. \nPain is consistently reported as a central and destructive feature \nof life with endometriosis and several studies report a negative \ncorrelation between pain and QoL Sepulcri et al. [24], Nnoaham et \nal. [18], Souza et al. [25], Tripoli et al. [23]. Endometriosis symptoms, \nand specifically pain, have a detrimental impact on daily life and \nphysical functioning (e.g. sleeping, eating, moving) Jones G et al. [15], \nPetrelluzzi KF et al. [19]. Between 16% and 61% of women experience \ndifficulties with mobility, daily activities and/or self-care. Fourquet \nJ et al. [16], Simoens et al. [16]. Fourquet et al [16]. also found that \nwomen had SF-12 scores denoting statistically significant disability in \nphysical and mental health components, indicating that the women \nin this study experienced substantial disability and Nnoaham et al. \n[18] found that women with endometriosis had reduced physical \nhealth compared with the normative population. Sleeping has also \nbeen found to be negatively affected by endometriosis Fourquet. et \nal. [16].\nA focus on the impact of endometriosis on education has been \nincluded in a small number of papers with inconclusive findings. \nWhilst some studies reported that endometriosis had affected \nwomen’s study activity and grades, and had caused some to leave \neducation before completion Huntington et al. [20], Gilmour et al. \n[18], others reported that only a minority of women had experienced \nnegative consequences on their education Fagervold et al. [26].\nMore commonly, researchers have explored how endometriosis \nhas impacted on women’s working lives. Several papers suggest that \nwomen’s endometriosis symptoms, particularly pain symptoms, \nimpact on productivity at work with between 23 and 66% reporting \nlimitations in their ability to perform work-related activities Fourquet \net al. [16]; 2011, Bernuit et al. [17]. Fourqu et al. [16] so reported that \n84–85% of women described a decrease in their quality of work, and \nelsewhere these authors report an average rate of work impairment \nand reduced effectiveness of 65% (presenteeism) and an average loss \nof efficiency levels of 64% (work productivity loss) Fourquet et al. [16]. \nInforming employers of their diagnosis of endometriosis and of its \nsymptoms causes tensions for women, as while it is felt to be a private \ncondition, women also need support in employment Gilmour et al. \n[18]. Women do not always inform employers of their diagnosis or \nsymptoms for a range of reasons including the potential implications \nof this and because they find it difficult to discuss a gender-specific \ncondition with male employers Gilmour et al. [18].  The study by \nGilmour suggested that the decision to disclose may be affected by \nwomen’s past experiences of being disbelieved.\nWPAI was used to measure the impact of health on work \nperformance. WPAI results showed a substantial impact of symptoms \nin both work productivity (moderately affected) and daily life \nactivities (extremely affected).\nOur WPAI results showed the mean loss in work time was \n(5.2hours; SD_4.7hours) with a mean of 27.2  hours actually worked \nduring the last 7 days, which were compared to other studies using \nthe same utilities, one Study held at University of Rome, Sant’ Andrea \nHospital, Rome, Italy by Donatella showed the mean loss in work time \nwas (2.3 hours; SD_ 5.3 hours) with a mean of 36.4 hours actually \nworked during the last 7 days. While another study held by Fourqu et \nat. [16] Ponce School of Medicine and Health Sciences in Puerto Rico \nshowed that the mean loss in work time (7.41 hours; SD_ 8.97 hours) \nwith a mean of 24.6 hours actually worked during the last 7 days.\nIn order to extrapolate the total annual societal burden of \nendometriosis, a recent multi-center study was conducted by \nSimoens et al. [17] in 10 countries. The authors, using a theoretical \nmodel, reported that the average annual total cost per woman affected \nby endometriosis was €9579 (95% confidence interval €8559-€10599) \nand costs of productivity loss of €6298 per woman were double the \nhealth care costs of €3113 per woman, showing that the economic \nburden of endometriosis arises predominantly from productivity \nloss. They also extrapolated the total annual societal costs for \nendometriosis in Italy, which was € 9.3 billion.\nRegarding the impact of the disease on HRQoL, Jia et al. [19] \nrecently reviewed all the available literature on the subject and the \nauthors concluded that HRQoL is impaired in such women, and \nmedical or surgical treatment to alleviate pain could partially restore \nthis impairment Jia et al. [19].\nAlthough endometriosis is not a life-threatening disease, this \nstudy confirmed that it can substantially affect women’s work \nproductivity and HRQOL. Thus, endometriosis can be both physically \nand emotionally debilitating. Physically, endometriosis pain can \nimpair work and daily activities. Psychologically, the disease can lead \nto depression, anxiety and feelings of low self-esteem, which in turn \nlead to impairment in work productivity and HRQoL Lemaire et al. \n[25].\nConclusion\nThis cross sectional quantitative study provides tangible evidence \nof the negative impact of endometriosis on important aspects related \nto work and daily life, as shown before qualitatively and the review has \nidentified a large number of studies which address the psychological \nand social impact of endometriosis on women’s lives, with the \nmajority identifying a significant impact across several domains [26-\n30].\nEndometriosis generally affects women during the most productive \nyears of their lives, when they should be finishing education, starting a \ncareer and probably have a family. Although endometriosis is known \nto have relevant impact on different aspects of patients’ daily lives, \nthe disease often remains misdiagnosed. Consequently, the burden \nof endometriosis on women and society remains under-estimated. \nFor these women to have their productivity impaired, their quality of \nlife compromised and their chances for starting a family reduced, is \nsomething society can no longer afford to ignore. Therefore it is time \nto make serious investment in preventing this debilitating condition \nin the next generation of women improving the collective level of \nawareness of endometriosis, its detection, and its treatment.\nReferences\n1. Gao X, Yeh YC, Outley J, Simon J, Botteman M, Spalding J. Health-related \nquality of life burden of women with endometriosis: a literature review. Curr \nMed Res Opin. 2006; 22: 1787-1797.\n\nAustin J Obstet Gynecol 4(3): id1078 (2017)  - Page - 05\nMohamed El-Maraghy Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\n2. Giudice LC. Endometriosis. N Engl J Med. 2010; 36: 2389-2398.\n3. Berek JS. Berek& Novak’s Gynecology. 15th edition. Lippincott Williams & \nWilkins, North American Edition edition. 2012.\n4. Overton C, Park C. Endometriosis: more on the missed disease. BMJ. 2010; \n341: c3727.\n5. Hadfield R, Mardon H, Barlow D, Kennedy S. Delay in the diagnosis of \nendometriosis: a survey of women from the USA and the UK. Hum Reprod. \n1996; 11: 878-880.\n6. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Saridogan E. ESHRE \nSpecial Interest Group for Endometriosis and Endometrium Guideline \nDevelopment Group. ESHRE guideline for the diagnosis and treatment of \nendometriosis. Hum Reprod. 2005; 20: 2698-2704.\n7. Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I, \net al. The burden of endometriosis: costs and quality of life of women with \nendometriosis and treated in referral centres. Hum Reprod. 2012; 2: 1292-\n1299.\n8. Verkauf BS. Incidence, symptoms, and signs of endometriosis in fertile and \ninfertile women. J Fla Med Assoc. 1987; 74: 671-675.\n9. Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: Translational \nevidence of the relationship and implications. Hum Reprod Update. 2011; \n17: 327-346.\n10. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. \nChronic pelvic pain: prevalence, health-related quality of life, and economic \ncorrelates. Obstet Gynaecol. 1996; 87: 321-327.\n11. Oehmke F, Weyand J, Hackethal A, Konrad L, Omwandho C, Tinneberg HR. \nImpact of endometriosis on quality of life: a pilot study. Gynecol Endocrinol. \n2009; 25: 722-725.\n12. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. \nAnn Intern Med. 1993; 118: 622-629.\n13. Reilly MC, Gooch KL, Wong RL, Kupper H, van der Heijde D. Validity, \nreliability and responsiveness of theWork Productivity and Activity Impairment \nQuestionnaire in ankylosing spondylitis. Rheumatology (Oxford). 2010; 49: \n812-819.\n14. Jones G, Jenkinson C, Kennedy S. The impact of endometriosis upon quality \nof life: a qualitative analysis. J Psychosom ObstGyn. 2004; 25: 123-133.\n15. Fourquet J, Báez L, Figueroa M, Iriarte RI, Flores I. Quantification of the \nimpact of endometriosis symptoms on health-related quality of life and work \nproductivity. Fertil Steril. 2011; 1: 107-112.\n16. Nnoaham KE, Hummelsho JL, Webster P, d’Hooghe T, de Cicco Nardone \nF, Jenkinson C, et al. Impact of endometriosis on quality of life and work \nproductivity: a multicenter study across ten countries. Fertil Steril. 2011; 2: \n366-373.\n17. Damario MA, Rock JA. Pain recurrence: a quality of life issue in endometriosis. \nInt J Gynaecol  Obstet. 1995; 50: S27-42.\n18. Gilmour J, Huntington A, Wilson H. The impact of endometriosis on work and \nsocial participation. Int J Nurs Pract. 2008; 6: 443-448.\n19. Jia SZ, Leng JH, Shi JH, Sun PR, Lang JH. Health-related quality of life in \nwomen with endometriosis: a systematic review. J Ovarian Res. 2012; 5: 29.\n20. Marques A, Bahamondes L, Aldrighi JM, Petta CA. Quality of life in \nBrazilian women with endometriosis assessed through a medical outcome \nquestionnaire. J Reprod Med. 2004; 2: 115-120.\n21. Petrelluzzi KF, Garcia MC, Petta CA, Grassi-Kassisse DM, Spadari-Bratfisch \nRC. Salivary cortisol concentrations, stress and quality of life in women with \nendometriosis and chronic pelvic pain. Stress. 2008; 5: 390-397.\n22. Siedentopf F, Tariverdian N, Ru¨cke M, Kentenich H, Arck PC. Immune \nstatus, psychosocial distress and reduced quality of life in infertile patients \nwith endometriosis. Am J Reprod Immunol. 2008; 5: 449-461.\n23. Bernuit D, Ebert AD, Halis G, Strothmann A, Gerlinger C, Geppert K, et al. \nFemale perspectives on endometriosis: findings from the uterine bleeding \nand pain women’s research study. J Endometriosis. 2011; 2: 73-85.\n24. Tripoli TM, Sato H, Sartori MG, de Araujo FF, Girão MJ, Schor E. Evaluation \nof quality of life and sexual satisfaction in women suffering from chronic pelvic \npain with or without endometriosis. J Sex Med. 2011; 2: 497-503.\n25. Sepulcri RD, Amaral VF. Depressive symptoms, anxiety, and quality of life in \nwomen with pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2009; \n1: 53-56.\n26. Souza CA, Oliveira LM, Scheffel C, Genro VK, Chaves MF, Filho J. Quality \nof life associated to chronic pelvic pain is independent of endometriosis \ndiagnosis: a crosssectional survey. Health Qual Life Out. 2011; 1: 41-45.\n27. Fagervold B, Jenssen M, Hummelshoj L, Moen MH. Life after a diagnosis \nwith endometriosis: a 15 years follow-up study. ActaObstetGyn Scan. 2009; \n8: 914-919.\n28. Lemaire GS. More than just menstrual cramps: symptoms and uncertainty \namong women with endometriosis. J Obstet Gynecol Neonatal Nurs. 2004; \n33: 71-79.\n29. Huntington A, Gilmour J. A life shaped by pain: women and endometriosis. J \nClin Nurs. 2005; 9: 1124-1132.\n30. Donatella C, Giulia B, Eleonora R, Eleonora M, Flaviano M. Impact of \nEndometriosis on Work Productivity and Quality of Life: a Survey from Italy. \nInt J Manage Scien Busin Res. 2013; 2: 42-48. \nCitation: El-Maraghy M, Labib K, El-Din WS and Ahmed AB. The Impact of Endometriosis Symptoms on Health \nRelated Quality of Life and Work Productivity in Egypt. Austin J Obstet Gynecol. 2017; 4(3): 1078.\nAustin J Obstet Gynecol - Volume 4 Issue 3 - 2017\nSubmit your Manuscript | www.austinpublishinggroup.com \nEl-Maraghy et al. © All rights are reserved","source_license":"CC0","license_restricted":false}