{"paper_id":"e27beddb-70e9-4421-a3d8-554cbb214e04","body_text":"Quality of Life Assessment by the Endometriosis Health\nProfile (EHP-30) Questionnaire Prior to Treatment for\nOvarian Endometriosis in Brazilian Women\nAvaliação da qualidade de vida através do questionário\nEndometriosis Health Pro file (EHP-30) antes do tratamento da\nendometriose ovariana em mulheres Brasileiras\nAndré Vinícius de Assis Florentino 1 Ana Maria Gomes Pereira 1 João Alfredo Martins 1\nReginaldo Guedes Coelho Lopes 1 Raquel Martins Arruda 1\n1 Department of Gynecology, Division of Endometriosis, Hospital do\nServidor Público Estadual, São Paulo, SP, Brazil\nRev Bras Ginecol Obstet 2019;41:548 –554.\nAddress for correspondence André Vinícius de Assis Florentino, MD,\nHospital do Servidor Público Estadual, Av. Ibirapuera, 981,\nIndianópolis, São Paulo, SP 04028-000, Brazil\n(e-mail: f.andrevinicius@gmail.com).\nKeywords\n► endometriosis\n► endometrioma\n► pelvic pain\n► dysmenorrhea\n► quality of life\nAbstract Objective To evaluate the existence of an association between ultrasound findings\nand epidemiological and clinical factor s using results obtained from the EHP-30\nquestionnaire in women with ovarian endometriosis.\nMethods A cross-sectional observational study was performed between July 2012\nand May 2015, in which patients with chronic p elvic pain suggestive of endometrioma,\nas indicated by the results from a transvaginal pelvic ultrasonography, completed the\nstandardized Endometriosis Health Pro file - 30 (EHP-30) questionnaire to access\nquality-of-life scores before beginning treatment for endometriosis. A total of 65\npatients were included. The data was analyzed in the statistical program IBM SPSS\nStatistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) for the comparison\nof data through linear multiple regression.\nResults The suitability of the linear regression model was con firmed by the histogram\nof the dependent variable and the residue distribution plot, con firming the trend of\nlinearity as well as the homogeneous dispersion of the residues. The mean age of the\npatients was 39.7 /C6 7.1 years old. The majority was Caucasian (64.5%), had completed\nhigher education (56.5%) and was nulligravida (40.3%). Infertility was present in 48.4%\nof the patients studied. Out of the total sample, 80.6% of the cases were symptomatic\nand complained mainly of acyclic pain, 79% of dysmenorrhea, and 61.3% of dyspar-\neunia. This re flects the negative in fluence of endometriosis on the quality of life of\npatients with this disease.\nConclusion Dyspareunia and acyclic pain were independent factors of correlation\nwith high scores in the EHP-30 questionnaire, re flecting a worse quality of life.\nAndré Vinícius de Assis Florentino's ORCID is https://orcid.org/\n0000-0002-8005-3174.\nreceived\nJanuary 13, 2019\naccepted\nMay 27, 2019\nDOI https://doi.org/\n10.1055/s-0039-1693057.\nISSN 0100-7203.\nCopyright © 2019 by Thieme Revinter\nPublicações Ltda, Rio de Janeiro, Brazil\nOriginal Article\nTHIEME\n548\nPublished online: 2019-09-03\n\nIntroduction\nEndometriosis is a chronic disease that is de fined as the\npresence of endometrium-like tissue (glands and/or stroma)\noutside the uterine cavity that affects young, sexually active\nwomen of childbearing age. 1\nThe most commonly reported complaint by patients is\npain that can be expressed in a variety of symptoms, includ-\ning dysmenorrhea, dyspareunia, chronic pelvic pain, and\ninfertility. These symptoms affect social, emotional and\nphysical well-being. The quality of life and relationships of\nthe patients are signi ficantly affected by the presence of\ndyspareunia.\n2–5\nAccording to the main international guidelines, endome-\ntriosis should be seen as a disease that requires an individu-\nalized planning for life, and repetitive surgical procedures\nshould be avoided. 6 Its de finitive diagnosis is surgical, and\nthe gold standard is laparoscopy with con firmation through\nthe anatomic -pathological study of the lesion. However,\nsuspicion and clinical diagnosis are starting points to reduce\nthe delay between the onset of symptoms and the recogni-\ntion of the disease,\n7–9 since a delay of up to 9 years is reported\nprior to the de finitive diagnosis. 10,11\nKnowing that one of the most common locations of\nendometriosis is ovarian, transvaginal ultrasonography\n(TVUSG) emerges as the most accessible imaging method\nto diagnose pelvic endometriosis, and is still the preferred\nmethod to differentiate endometriomas from other ovarian\ncysts.\n12\nIt is estimated that the current prevalence of endometriosis\nis /C24 between 6 and 10% in the general population, but this\nnumber is still uncertain. About 17 to 44% of these patients also\npresent endometriomas that are de fined as ovarian pseudo-\ncysts due to the growth of ectopic endometrial tissue, which\nprogressively invaginates the ovarian cortex.\n13–16\nAssessments of the real impact of pelvic pain on the\nmental health and on the health-related quality of life of\nwomen have not yet yielded conclusive results.\n17 Several\nquestionnaires aim to evaluate the quality of life of patients\nwith endometriosis, but until recently, the most used are\ngeneric instruments that do not accurately re flect the reality\nof this speci fic type of patient, because they do not collect\ninformation on all of the areas of well-being that may be\nrelevant to women with endometriosis. Two endometriosis-\nspecific questionnaires have been developed and used in\nprevious researches, but the validity of these instruments is\nquestionable, given that most of the items were derived by\nclinicians and/or were scales taken from generic health-\nstatus questionnaires.\n18,19\nIn 2001, Jones et al20 developed an endometriosis-specific\nquestionnaire entitled Endometriosis Health Pro file - 30\n(EHP-30). This questionnaire differs from others because it\nis a patient-generated instrument, in which all of the\nparticipants included had surgically-con firmed endometri-\nosis and were symptomatic at the time of diagnosis. They\nperformed psychometric tests using the 87 items of the\nquestionnaire to identify the most salient dimensions of\nendometriosis that affect the quality of life of each patient.\nResumo Objetivo Avaliar a existência de associação entre os achados ultrassonográ ficos e os\nfatores epidemiológicos e clínicos com os re sultados obtidos no questionário EHP-30\nem mulheres com diagnóstico de endometriose ovariana.\nMétodos Realizou-se um estudo observacional transversal entre julho de 2012 e maio\nde 2015, no qual as pacientes com dor pélvica crônica com imagem sugestiva de\nendometrioma na ultrassonogra fia pélvica transvaginal preencheram o questionário\npadronizado Endometriosis Health Pro file - 30 (EHP-30) para acessar os escores de\nqualidade de vida antes de iniciar qualquer tratamento para a endometriose. Foram\nincluídas 65 pacientes. Os dados foram analisados no programa estatístico IBM SPSS\nStatistics for Windows, Versão 22.0 (IBM Corp., Armonk, NY, EUA) para a comparação\ndos dados através de regressão múltipla linear.\nResultados A adequabilidade do modelo de regressão linear foi con firmada através\ndo histograma da variável dependente e do grá fico de distribuição dos resíduos,\nconfirmando a tendência de linearidade, assim como a dispersão homogênea dos\nresíduos. A idade média das pacientes foi de 39,7 /C6 7,1 anos. A maioria era caucasiana\n(64,5%), apresentava ensino superior completo (56,5%), e era nuligesta (40,3%).\nInfertilidade estava presente em 48,4% das pacientes estudadas. Do total de casos\n80,6% eram sintomáticas e queixaram-se principalmente de dor acíclica, 79%de\ndismenorreia , e 61,3% de dispareunia em , re fletindo a in fluência negativa da\nendometriose sobre a qualidade de vida das pacientes portadores desta doença.\nConclusão Dispareunia e dor acíclica foram fatores independentes de correlação com\naltos escores no EHP-30, re fletindo uma pior qualidade de vida.\nPalavras-chave\n► endometriose\n► endometrioma\n► dismenorreia\n► dor pélvica\n► qualidade de vida\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosi s Health Profile (EHP -30) Questionnaire Florentino et al. 549\n\n\nThe EHP-30 has been extensively tested and validated in\ndifferent cultural environments in the American, Australian,\nDutch, Italian, Chinese, Iranian, Portugal and Brazilian\nPortuguese versions.\n20–26 The use of these questionnaires\nallows for more complete assessments, and they are also\nimportant in evaluating the perception of women of disease\nimpact and treatment effectiveness in clinical scenarios.\nStudies that used both speci fic or generic questionnaires\nshowed a lower quality of life in patients with endometriosis.\nHowever, they did not distinguish peculiar (e.g., clinical,\nepidemiological) characteristics that could be associated\nwith worse scores. These prior works have also not\napproached the speci fic subgroup with ovarian endometri-\nosis who we hypothesized may have a different perception of\npain due to the anatomical distortion of the pelvis caused by\nthe endometrioma. With this in mind, the present study\naimed to evaluate the existence of an association between\nultrasound findings and epidemiological and clinical factors\nusing results obtained from the EHP-30 questionnaire in\nwomen with ovarian endometriosis.\nMethods\nA cross-sectional observational study was performed and was\napproved by the Brazilian research ethics committee. It\nincluded the patients of the Endometriosis and Chronic Pelvic\nPain Outpatient Clinic of the Hospital do Servidor Público\nEstadual Francisco Morato de Oliveira, São Paulo, state of São\nPaulo, Brazil, between July 2012 and May 2015. The sample\nsize was calculated using the Open Source Epidemiologic\nStatistics for Public Health (OpenEpi) software. Since the\nprevalence of ovarian endometriosis varies between 17 and\n44% of patients with endometriosis, up to 65 cases would be\nnecessary to obtain a 95% con fidence level.\n27\nThe participants were recruited until we reached the\nsample size calculation. A total of 65 sexually active Brazilian\nwomen of reproductive age with pelvic pain presenting\ntransvaginal ultrasound imaging suggestive of ovarian endo-\nmetriotic cysts, which were later con firmed by laparoscopy,\nwere included. The patients had no other chronic pathology\njustifying the pain symptoms, had not started any treatment,\nand also agreed to participate in the research and signed the\ninformed consent form after being briefed on the details of the\nstudy by a physician. The participants were assured that their\ndata would remain confidential and that they could withdraw\ntheir consent at any time. Three patients were excluded\nbecause they had no histological diagnosis of the disease. In\nthe first evaluation, we collected data regarding age, race,\nschooling, number of pregnancies, and symptoms such as\ndysmenorrhea and dyspareunia. Afterwards, the patients\nself-completed the standard EHP-30 questionnaire in its\nvalidated Brazilian Portuguese version in a private of fice to\naccess the baseline quality of life scores, in order to better\nunderstand the real impact of the disease without any inter-\nference of previous therapeutic approaches.\nThe EHP-30 is a self-reporting tool developed from inter-\nviews to assess health-related quality of life that is speci fi-\ncally designed for patients with endometriosis. It consists of\na central questionnaire composed of 30 items that assess 5\ndimensions (i.e., pain, control and impotence, emotional\nwell-being, social support, and self-image), and a modular\nquestionnaire composed of 23 items distributed into 6\nsections. The modular questionnaire sought to assess the\nimpact of the disease in the following six domains: work\n(Section A), relationship with children (Section B), sexual\nrelations (Section C), relationship with physician (Section D),\ntreatment (Section E), and infertility (Section F). These scales\nare transformed into a score from 0 to 100, in which 0\nindicates a better health status, while 100 indicates a worse\nquality of life.\nThe data collected was plotted using Microsoft Excel for\nWindows (Microsoft Corp., Redmond, WA, USA). The Statistical\nanalysis was performed through IBM SPSS Statistics for\nWindows, Version 22.0 (IBM Corp., Armonk, NY, USA) to\nprovide a descriptive analysis and a comparison of the data\nthrough linear multiple regression analysis to highlight\npotential correlations between the epidemiological factors\nand symptoms and the questionnaire scores. Linear multiple\nregression modeling was performed using the stepwise for-\nward technique to fit the best model. Statistical signi ficance\nwas attributed when p < 0.05, with a confidence interval (CI)\nof 95%.\nResults\nThe data collection process of the study is shown in ►Fig. 1 .\nThe epidemiological characteristics of the sample studied\nwere as follows: the mean age of the 62 patients was\n39.7 /C6 7.1 years old (with a minimum age of 20 and a\nmaximum of 54 years old). The majority was Caucasian\n(64.5%), had a high level of schooling with complete higher\neducation (56.5%), and was nulligravida (40.3%). Of these,\n48.4% of the patients studied were infertile.\nRegarding the symptoms, the patients reported acyclic\npain (80.6%), dysmenorrhea (79%), and dyspareunia (61.3%);\n21% had bilateral ovarian cysts (i.e., endometriomas), with a\nmean cyst size of 37 mm (10 –95 mm). For the evaluation of\nthe averages, of the standard deviations (SDs), and of the\nminimum and maximum scores in the central and modular\nquestionnaires of the EHP-30, the scales were transformed\ninto a scoring system that ranged from 0 to 100 (\n►Table 1 ).\nThe completion rate of all items in the central questionnaire\nwas 100% (62/62). Regarding the modular questionnaire,\nconsidering that not all dimensions are applicable to all\npatients, the filling rate ranged from 56.45% (35/62) in Section\nB to 96.77% (60/62) in Section D. For the multiple statistical\nanalyses, the distribution of the outcome variable (i.e., the\ndependent variable) was confirmed as a normal distribution. A\nunivariate analysis was performed between the outcome\nvariable and the clinical and epidemiological factors, and a\nlinear multiple regression was conducted (\n►Table 2 ).\nIn the multiple analyses for the general questionnaire score,\nwe observed that dyspareunia and acyclic pain were indepen-\ndent correlation factors for a higher total EHP-30 score adjusted\nfor dysmenorrhea, cyst bilateralism, and larger cyst diameter.\nThe suitability of the linear regression model was confirmed by\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosis Health Profile (EHP-30) Questionnaire Florentino et al.550\n\n\nthe residue distribution graph, which con firmed the trend of\nlinearity as well as the homogeneous dispersion of residues.\nWhen we applied the statistical model to the modular ques-\ntionnaire, in Section A, no variable was significantly correlated\nwith an increase in the score. When applied to Section B, the\nvariables age and Caucasian women were presented as inde-\npendent correlation factors with higher scores, and age was\ninversely correlated with score, while Caucasian women had\ndirect correlation and were adjusted by the variables dyspar-\neunia and acyclic pelvic pain (\n►Table 3 ).\nWhen Section C was evaluated, the only variable that\npresented a positive correlation with score in this section\nwas dyspareunia ( p ¼ 0.015), adjusted for abortion, parity,\nacyclic pain, and greater cyst diameter. In Sections D and E, all\nvariables in the final statistical model, even after being\nadjusted, did not present a signi ficant correlation with the\nEHP-30 scores. Conversely, in Section F, it was observed that\ndysmenorrhea and dyspareunia were associated with higher\nscores in this section (\n►Table 4 ).\nDiscussion\nEndometriosis can occur in any woman who menstruates, and\na higher risk has been found in women aged between 35 and\n44 years old .28 The mean age of the patients in our study was\n39.7 /C6 7.1 years old, corresponding to the age range in which\nendometriosis is usually diagnosed. Complaints of acyclic pain\n(80.6%), of dysmenorrhea (79%), of dyspareunia (61.3%), and of\ninfertility (48.4%) were slightly higher than those found by\nBellelis et al (2010), showing a profile of clinical-epidemiologi-\ncal characteristics among population samples.\n29\nIn the present study, the EHP-30 questionnaire was\napplied to evaluate the quality of life of patients with\nendometriosis. It is important to mention that a cutoff point\nfor the scores obtained in this questionnaire has not yet been\nestablished in the literature, and this makes it dif ficult to\nfully understand impairments in quality of life. Therefore,\ncomparisons were made to correlate linearity through the\nregression analysis.\nCompared with the data presented in the other studies that\nvalidated the EHP-30 in several countries, in the modular\nquestionnaire, we obtained the highest mean scores related\nto impact on work, sexual intercourse, and relationship with\nchildren, and the lowest mean scores regarding infertility.\nAfter a multiple linear regression analysis,\n►Table 2\nshows that dyspareunia and acyclic pain presented as inde-\npendent factors of positive correlation with the total score of\nthe EHP-30 questionnaire, and that the high prevalence of\nEligible patients\n(N=65)\nComplete the questionnaire \n(N=65)\nExclusion, (N=3)\n-3 without proof of \nendometriosis in \nlaparoscopy\nIncluded for analysis\nat baseline (N=62)\n- With ovarian endometriosis in \nlaparoscopy\n- No chronic pathology \n- No previous treatment\nFig. 1 Flowchart of the recruitment process of the patients.\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosi s Health Profile (EHP -30) Questionnaire Florentino et al. 551\n\n\nthese symptoms signi ficantly interferes with the personal\nand sexual lives of the patients, which may re flect a greater\nnegative impact on their quality of life. This finding is\ncorroborated by de Freitas Fonseca et al. 30\nLukic et al31 studied women with pelvic endometriosis and\nfound that the symptom perceived as being most responsible\nfor the deterioration of quality of life for women with endome-\ntriosis is dyspareunia. They also found that, after surgery, these\nwomen experienced a significant decrease in this symptom. In\nthe specific group of patients with ovarian endometriosis, we\nbelieve that pain may also be due to the anatomical distortion\nthat endometriomas create in the pelvis, which does not\nrespond completely to conservative treatment, thus indicating\nthat the localization of endometriotic foci are responsible for\nthe intensity of the pain symptoms.\nIn the present study, a higher score is observed in the\nmodular questionnaire in Section C, which evaluates the effects\nof endometriosis on sexual relations. The mean score was\n66.98 /C6 22.77 (20 –100), and this trend measure could also\npotentially interfere with the prevalence of the dyspareunia\nsymptom found in the studied population (61.3%). Previous\ns t u d i e sh a v ea l s os h o w nt h a tw o m e nw i t he n d o m e t r i o s i sa n d\ndyspareunia experience worse sexual function than women\nTable 1 Trend measures and descriptive statistics of the central and modular EHP-30 questionnaires\nVariables of EHP-30 Average Standard deviation Minimum grade Maximum grade\nCentral questionnaire ( n ¼ 62)\nModular questionnaire\n61.61 18.37 20 95.33\nSection A\nWork\n(n ¼ 54)\n54.49 22.72 20 92\nSection B\nRelationship with children\n(n ¼ 35)\n50.28 25.26 20 100\nSection C\nSexual Relations\n(n ¼ 55)\n66.98 22.77 20 100\nSection D\nRelationship with physician\n(n ¼ 60)\n37.58 20.65 20 90\nSection E\nTreatment\n(n ¼ 42)\n50 21.75 20 93.33\nSection F\nInfertility\n(n ¼ 39)\n51.07 24.21 16 100\nTotal score 55.52 15.85 19.53 83.59\nTable 2 Linear multiple regression for the analysis of clinical\nand ultrasound factors correlated with the weighted overall\nEHP-30 score ( n ¼ 62)\nAnalyzed\nvariable\nUnadjusted analysis\np-value (CI)\nFinal adjusted model\np-value (CI)\nDyspareunia 0.000 (9.18 –23.56) 0.001 (5.72 –19.84)\nAcyclic pain 0.001 (7.09 –25.82) 0.001 (6.37 –22.78)\nDysmenorrhea 0.032 (0.93 –20.13) 0.131 (- 1.95 –14.70)\nBilateralism 0.159 (- 2.81 –16.81) 0.229 (- 3.15 –12.89)\nLarger cyst\ndiameter\n0.177 (- 0.72 –0.38) 0.725 (- 0.15 –0.22)\nAbbreviation: CI, con fidence interval.\nTable 3 Linear multiple regression for the analysis of clinical\na n du l t r a s o u n df a c t o r sc o r r e l a t e dw i t hw e i g h t e ds c o r e sf o r\nEHP-30 Section B (children) ( n ¼ 35)\nAnalyzed\nvariable\nUnadjusted analysis\np-value (CI)\nFinal adjusted model\np-value (CI)\nAge 0.002 (- 3.04 –-0.72) 0.020 (- 2.71 –- 0.24)\nCaucasian 0.014 (5.02 –40.57) 0.036 (1.35 –37.64)\nDyspareunia 0.023 (2.90 –36.14) 0.249 (- 6.75 –25.04)\nAcyclic pain 0.051 (- 0.09 –47.43) 0.501 (- 15.13 –30.26)\nAbbreviation: CI, con fidence interval.\nTable 4 Linear multiple regression for the analysis of clinical\nand ultrasound factors correlated with weighted scores for EHP-\n30 Section F (infertility) ( n ¼ 39)\nAnalyzed\nvariable\nUnadjusted analysis\np-value (CI)\nFinal adjusted model\np-value (CI)\nDysmenorrhea 0.022 (4.33 –53.02) 0.007 (8.69 –50.29)\nDyspareunia 0.046 (0.32 –32.25) 0.022 (2.74 –33.18)\nAge 0.156 (- 1.61 –0.27) 0.153 (- 1.58 –0.26)\nAbortion 0.717\n(- 16.49 –11.47)\n0.686\n(- 16.26 –10.82)\nAbbreviation: CI, con fidence interval.\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosis Health Profile (EHP-30) Questionnaire Florentino et al.552\n\n\nwithout endometriosis. 32–34 We know that endometriosis\naffects young and sexually active women; therefore, sexual\nhealth should be a primary concern in the clinical management\nof this disease. This negative impact between endometriosis,\npain and sexual function have also been confirmed by Vercellini\net al.\n35\nAnother relevant finding of our study was the association\nof dysmenorrhea and dyspareunia with high scores on the\nquestion of infertility. This association largely reiterates the\nnegative in fluence of pain on the general quality of life and\nsexual satisfaction that, in turn, interferes with the repro-\nduction of patients with endometriosis. It is well-established\nin the literature that chronic pelvic pain and the experience\nof pain during intercourse affects negatively the lives of the\npatients.\n36 Authors have also shown that endometriosis\naffects negatively several aspects of the quality of life of\nwomen – both physically and mentally. 10,37\nIn addition, we found a correlation between a worse\nquality of life and the relationship with children and Cauca-\nsian women, but this fact may be only associated with the\nhigher prevalence of Caucasians in our study. Soliman et al\nalso found a higher prevalence of white patients with\nendometriosis in their case studies.\n38\nOne of the most dif ficult moments in the management of\novarian endometriosis is deciding when to opt for surgical\ntreatment, because it is known that patients have had both\npain and endometrioma recurrence even after laparoscopy.\n39\nBecause the treatment for endometriosis aims to improve the\nquality of life, we believe that a perspective for further studies\nwith this speci fic subgroup of endometriosis patients could\nexplore the prognostic value of the EHP-30 to de fine a cutoff\npoint in which the patient with endometrioma would benefit\nmore from surgical or clinical treatment. This could potentially\nguide gynecologists and surgeons in carefully tailoring their\nstrategies to each individual case. Currently, the EHP-30 has\nnot been greatly applied in the clinical practice of gynecolo-\ngists, neither in studies evaluating quality of life in patients\nwith endometriosis.\n20\nThe strengths of the present study include the fact that we\nhave only selected women with ovarian endometriosis who\nalso had not begun any treatment before answering the\nquestionnaire. This enabled us to understand the real impact\nof the disease without any in fluences. To our knowledge, this\nis the first Brazilian study that has tried to correlate clinical\nand epidemiological factors with quality of life scores using a\ndisease-specific questionnaire in women presenting with\novarian endometriosis.\nThe limitations of the present study were derived from the\nstudy design, from the small sample size, and from the fact that\nwe have only evaluated women at baseline. Results after\nsurgical intervention were not yet analyzed, which could limit\nthe interpretation and the external validity of the results of the\npresent study. However, we have already developed a research\nline to continue the longitudinal investigation with a larger\nsample to compare quality of life before and after treatment.\nThese results might help to better understand the effects of\ntherapeutic interventions on the quality of life of these patients.\nConclusion\nThe results of the present study showed an association\nbetween dyspareunia and acyclic pain, exerting a negative\ninfluence on the overall EHP-30 score at baseline prior to any\ntreatment. This re flects a worse quality of life among\npatients with ovarian endometriosis who present those\nclinical factors. Also, it reinforces that endometriosis affects\nseveral areas in the lives of women and that improved\ngeneral well-being should be the main goal of gynecologists.\nContributors\nFlorentino A. V. A. , Pereira A. M. G., Martins J. A., Lopes R.\nG. C., and Arruda R. M. contributed with the project and\ninterpretation of data, the writing of the article, the\ncritical review of the intellectual content, and with the\nfinal approval of the version to be published.\nConflicts of Interests\nThe authors have no con flicts of interests to declare.\nReferences\n1 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C.\nDeep endometriosis infiltrating the recto-sigmoid: critical factors\nto consider before management. Hum Reprod Update 2015;21\n(03):329–339. Doi: 10.1093/humupd/dmv003\n2 Kennedy S, Bergqvist A, Chapron C, et al; ESHRE Special Interest\nGroup for Endometriosis and Endometrium Guideline Development\nGroup. ESHRE guideline for the diagnosis and treatment of endome-\ntriosis. Hum Reprod 2005;20(10):2698–2704. Doi: 10.1093/humrep/\ndei135\n3 Moradi M, Parker M, Sneddon A, Lopez V, Ellwood D. Impact of\nendometriosis on women ’s lives: a qualitative study. BMC\nWomens Health 2014;14:123. Doi: 10.1186/1472-6874-14-123\n4 Denny E, Mann CH. Endometriosis-associated dyspareunia: the\nimpact on women ’s lives. J Fam Plann Reprod Health Care 2007;\n33(03):189–193. Doi: 10.1783/147118907781004831\n5 Ferrero S, Esposito F, Abbamonte LH, Anserini P, Remorgida V,\nRagni N. Quality of sex life in women with endometriosis and\ndeep dyspareunia. Fertil Steril 2005;83(03):573 –579. Doi:\n10.1016/j.fertnstert.2004.07.973\n6 Practice Committee of the American Society for Reproductive\nMedicine. Treatment of pelvic pain associated with endometrio-\nsis: a committee opinion. Fertil Steril 2014;101(04):927 –935.\nDoi: 10.1016/j.fertnstert.2014.02.012\n7 Dunselman GA, Vermeulen N, Becker C, et al; European Society of\nHuman Reproduction and Embryology. ESHRE guideline: man-\nagement of women with endometriosis. Hum Reprod 2014;29\n(03):400–412. Doi: 10.1093/humrep/det457\n8 Jacobson TZ, Duffy JMN, Barlow D, Koninckx PR, Garry R. Laparo-\nscopic surgery for pelvic pain associated with endometriosis.\nCochrane Database Syst Rev 2009;(04):CD001300. Doi: 10.1002/\n14651858.CD001300.pub2\n9 Arruda MS, Petta CA, Abrão MS, Benetti-Pinto CL. Time elapsed\nfrom onset of symptoms to diagnosis of endometriosis in a cohort\nstudy of Brazilian women. Hum Reprod 2003;18(04):756 –759.\nDoi: 10.1093/humrep/deg136\n10 Nnoaham KE, Hummelshoj L, Webster P, et al; World Endometriosis\nResearch Foundation Global Study of Women’s Health consortium.\nImpact of endometriosis on quality of life and work productivity: a\nmulticenter study across ten countries. Fertil Steril 2011;96(02):\n366–373.e8. Doi: 10.1016/j.fertnstert.2011.05.090\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosi s Health Profile (EHP -30) Questionnaire Florentino et al. 553\n\n\n11 Culley L, Law C, Hudson N, et al. The social and psychological\nimpact of endometriosis on women ’s lives: a critical narrative\nreview. Hum Reprod Update 2013;19(06):625–639. Doi: 10.1093/\nhumupd/dmt027\n12 Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB.\nThe efficiency of transvaginal ultrasonography in the diagnosis of\nendometrioma. Fertil Steril 1993;60(05):776 –780. Doi: 10.1016/\nS0015-0282(16)56275-X\n13 Burney RO, Giudice LC. Pathogenesis and pathophysiology of endo-\nmetriosis. Fertil Steril 2012;98(03):511 –519. Doi: 10.1016/j.\nfertnstert.2012.06.029\n14 TanboT, Fedorcsak P . Endometriosis-associated infertility: aspects of\npathophysiological mechanisms and treatment options. Acta Obstet\nGynecol Scand 2017;96(06):659–667. Doi: 10.1111/aogs.13082\n15 Gruppo Italiano per lo Studio Dell ’Endometriosi. Prevalence and\nanatomical distribution of endometriosis in women with selected\ngynaecological conditions: results from a multicentric Italian study.\nGruppo italiano per lo studio dell’endometriosi. Hum Reprod 1994;\n9(06):1158–1162. Doi: 10.1093/oxfordjournals.humrep.a138650\n16 Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic\nimplications of the anatomic distribution. Obstet Gynecol 1986;\n67(03):335–338\n17 Eriksen HL, Gunnersen KF, Sørensen JA, Munk T, Nielsen T,\nKnudsen UB. Psychological aspects of endometriosis: differences\nbetween patients with or without pain on four psychological\nvariables. Eur J Obstet Gynecol Reprod Biol 2008;139(01):\n100–105. Doi: 10.1016/j.ejogrb.2007.10.002\n18 Bodner CH, Garratt AM, Ratcliffe J, Macdonald LM, Penney GC.\nMeasuring health-related quality of life outcomes in women with\nendometriosis–results of the Gynaecology Audit Project in Scot-\nland. Health Bull (Edinb) 1997;55(02):109 –117\n19 Colwell HH, Mathias SD, Pasta DJ, Henning JM, Steege JF. A health-\nrelated quality-of-life instrument for symptomatic patients with\nendometriosis: a validation study. Am J Obstet Gynecol 1998;179\n(01):47–55. Doi: 10.1016/S0002-9378(98)70250-9\n20 Jones G, Kennedy S, Barnard A, Wong J, Jenkinson C. Development\nof an endometriosis quality-of-life instrument: The Endometrio-\nsis Health Pro file-30. Obstet Gynecol 2001;98(02):258 –264. Doi:\n10.1016/S0029-7844(01)01433-8\n21 Khong SY, Lam A, Luscombe G. Is the 30-item Endometriosis Health\nProfile (EHP-30) suitable as a self-report health status instrument for\nclinical trials? Fertil Steril 2010;94(05):1928–1932. Doi: 10.1016/j.\nfertnstert.2010.01.047\n22 Jenkinson C, Kennedy S, Jones G. Evaluation of the American version\nof the 30-item Endometriosis Health Profile (EHP-30). Qual Life Res\n2008;17(09):1147–1152. Doi: 10.1007/s11136-008-9403-9\n23 van de Burgt TJM, Hendriks JCM, Kluivers KB. Quality of life in\nendometriosis: evaluation of the Dutch-version Endometriosis\nHealth Profile-30 (EHP-30). Fertil Steril 2011;95(05):1863 –1865.\nDoi: 10.1016/j.fertnstert.2010.11.009\n24 Nojomi M, Bijari B, Akhbari R, Kashanian M. The assessment of\nreliability and validity of Persian version of the endometriosis\nhealth pro file (EHP-30). Iran J Med Sci 2011;36(02):84 –89\n25 Nogueira-Silva C, Costa P, Martins C, et al. Validation of the\nPortuguese Version of EHP-30 (The Endometriosis Health Pro-\nfile-30). Acta Med Port 2015;28(03):347 –356\n26 Mengarda CV, Passos EP, Picon P, Costa AF, Picon PD. [Validation of\nBrazilian Portuguese version of quality of life questionnaire for\nwomen with endometriosis (Endometriosis Health Pro file Ques-\ntionnaire–EHP-30)]. Rev Bras Ginecol Obstet 2008;30(08):\n384–392. Doi: 10.1590/S0100-72032008000800003\n27 Mereu L, Florio P , Carri G, Pontis A, Petraglia F, Mencaglia L. Clinical\noutcomes associated with surgical treatment of endometrioma\ncoupled with resection of the posterior broad ligament. Int J Gynae-\ncol Obstet 2012;116(01):57–60. Doi: 10.1016/j.ijgo.2011.08.017\n28 Abbas S, Ihle P, Köster I, Schubert I. Prevalence and incidence of\ndiagnosed endometriosis and risk of endometriosis in patients with\nendometriosis-related symptoms:findings from a statutory health\ninsurance-based cohort in Germany. Eur J Obstet Gynecol Reprod\nBiol 2012;160(01):79–83. Doi: 10.1016/j.ejogrb.2011.09.041\n29 Bellelis P, Dias JA Jr, Podgaec S, Gonzales M, Baracat EC, Abrão MS.\nEpidemiological and clinical aspects of pelvic endometriosis –a\ncase series. Rev Assoc Med Bras (1992) 2010;56(04):467 –471.\nDoi: 10.1590/S0104-42302010000400022\n30 de Freitas Fonseca M, Aragao LC, Sessa FV, Dutra de Resende JA Jr,\nCrispi CP. Interrelationships among endometriosis-related pain\nsymptoms and their effects on health-related quality of life: a\nsectional observational study. Obstet Gynecol Sci 2018;61(05):\n605–614. Doi: 10.5468/ogs.2018.61.5.605\n31 Lukic A, Di Properzio M, De Carlo S, et al. Quality of sex life in\nendometriosis patients with deep dyspareunia before and after\nlaparoscopic treatment. Arch Gynecol Obstet 2016;293(03):\n583–590. Doi: 10.1007/s00404-015-3832-9\n32 Ferrero S, Abbamonte LH, Giordano M, Ragni N, Remorgida V.\nDeep dyspareunia and sex life after laparoscopic excision of\nendometriosis. Hum Reprod 2007;22(04):1142 –1148. Doi:\n10.1093/humrep/del465\n33 Fritzer N, Haas D, Oppelt P, et al. More than just bad sex: sexual\ndysfunction and distress in patients with endometriosis. Eur J\nObstet Gynecol Reprod Biol 2013;169(02):392 –396. Doi:\n10.1016/j.ejogrb.2013.04.001\n34 Shum LK, Bedaiwy MA, Allaire C, et al. Deep dyspareunia and\nsexual quality of life in women with endometriosis. Sex Med\n2018;6(03):224–233. Doi: 10.1016/j.esxm.2018.04.006\n35 Vercellini P, Somigliana E, Buggio L, Barbara G, Frattaruolo MP,\nFedele L. “Ic a n ’tg e tn os a t i s f a c t i o n”: deep dyspareunia and\nsexual functioning in women with rectovaginal endometriosis.\nFertil Steril 2012;98(06):1503 –11.e1. Doi: 10.1016/j.\nfertnstert.2012.07.1129\n36 De Graaff AA, D’Hooghe TM, Dunselman GA, Dirksen CD, Hummel-\nshoj L, Simoens S; WERF EndoCost Consortium. The signi ficant\neffect of endometriosis on physical, mental and social wellbeing:\nresults from an international cross-sectional survey. Hum Reprod\n2013;28(10):2677–2685. Doi: 10.1093/humrep/det284\n37 Chaman-ara K, Bahrami MA, Moosazadeh M, Bahrami E. Quality of\nlife in women with endometriosis: a systematic review and meta-\nanalysis. WCRJ 2017;4:e839\n38 Soliman AM, Coyne KS, Zaiser E, Castelli-Haley J, Fuldeore MJ. The\nburden of endometriosis symptoms on health-related quality of life\nin women in the United States: a cross-sectional study. J Psychosom\nObstet Gynaecol 2017;38(04):238 –248. Doi: 10.1080/0167482X.\n2017.1289512\n39 Porpora MG, Pallante D, Ferro A, Crisafi B, Bellati F, Benedetti Panici\nP . Pain and ovarian endometrioma recurrence after laparoscopic\ntreatment of endometriosis: a long-term prospective study. Fertil\nSteril 2010;93(03):716–721. Doi: 10.1016/j.fertnstert.2008.10.018\nRev Bras Ginecol Obstet Vol. 41 No. 9/2019\nQuality of Life Assessment by the Endometriosis Health Profile (EHP-30) Questionnaire Florentino et al.554","source_license":"CC0","license_restricted":false}