{"paper_id":"f42906be-be9a-47f2-b9dc-b636e5425297","body_text":"Aleksandra Andysz\nAleksandra Jacukowicz\nDorota Merecz-Kot\nAnna Najder\nNofer Institute of Occupational Medicine, Łódź, Poland\nDepartment of Health and Work Psychology\nAbstract\nThe aim of the article was to summarize the results offered in the research on occupational functioning of women with endome -\ntriosis. We followed PRISMA guidelines. Database search was done in November 2017 using EBSCO. In the review were included \nthe articles clearly referring to the relationships between endometriosis and work or any aspect of work (e.g., work productivity, \nwork ability, absenteeism). Eight papers were included in the final review. Seven studies were cross-sectional, 1 retrospective. The \nmajority of researchers used standardized research measures, such as Work Ability Index , Work Productivity and Activity Impair-\nment Questionnaire  or Health Related Productivity Questionnaire . Only in 2 studies the reference group was considered, one of \nthem consisted of healthy women. The results clearly indicate that endometriosis is a disease that causes major disturbance in \noccupational functioning of the suffering women. In the future the researchers should search for individual and organizational \ncorrelates of the improvement of occupational functioning in this group of patients. The methodology of the existing studies has \nbeen evaluated and the methodological cues for future research has been given. Med Pr 2018;69(6):663–671\nKey words: pain, quality of work life, sickness absence, work ability, women’s health, chronic disease\nCorresponding author: Aleksandra Andysz, Nofer Institute of Occupational Medicine, Department of Health and Work Psychology, \nśw. Teresy 8, 91-348 Łódź, Poland, e-mail: aleksandra.andysz@imp.lodz.pl\nReceived: January 2, 2018, accepted: March 27, 2018\nMedycyna Pracy 2018;69(6):663–671\nhttp://medpr.imp.lodz.pl/en\nENDOMETRIOSIS – THE CHALLENGE FOR OCCUPATIONAL LIFE  \nOF DIAGNOSED WOMEN: A REVIEW OF QUANTITATIVE STUDIES\nREVIEW PAPER\nINTRODUCTION\nEndometriosis is an estrogen-related disorder of a still \nunknown etiology and it is reported to affect  10% of \nwomen of reproductive age [1]. The core pathology of \nthis disease is the presence of endometrium cells out -\nside the uterus. Ectopic endometrial cells spread and \nform endometriosis foci mainly in the organs of pelvic \n(ovaries, uterosacral ligaments and intestines) but also \noutside the pelvis. These ectopic cells are affected by \ncyclic hormonal fluctuations similarly to endometrial \ncells in the uterus – they proliferate and slough off but \nare not expelled from the body during menstruation. \nThis process causes chronic inflammation in the area of \nendometriosis foci, as well as pain, adhesions and ana -\ntomic distortion in pelvic.\nThere is a considerable delay in the diagnosis of en -\ndometriosis [2–5]. Frequently do women seek advice \nfrom numerous doctors before anyone recognizes the \nsymptoms correctly. The symptoms are commonly ne-\nglected or ignored by women themselves as well as their \nrelatives or doctors. Sometimes even severe menstrual \npain is considered as normal. Moreover, because some of \nthe symptoms are considered embarrassing (e.g., pain-  \nful sexual intercourses or defecation) the suffering wom-\nen refrain from consulting their discomfort with a doc -\ntor, which defers the accurate diagnosis. \nThe endometriosis treatment usually includes hor -\nmone therapy and surgery interventions. Yet, despite \na great pharmacology and medical technology develop -\nment, current therapies are still not fully effective and \nthe disease tends to recur. \nLiving with endometriosis\nSymptoms of endometriosis adversely affect patients’ ev-\neryday lives, thus, the life of a  woman suffering from \nendometriosis could be described as “shaped by pain” [6]. \nThe pain accompanies periods ( dysmenorrhea), sexual  \nhttps://doi.org/10.13075/mp.5893.00737\nFunding: prepared within a statutory project of the Nofer Institute of Occupational Medicine (project No. IMP 21.9 entitled “Is there a po- \nsitive aspect of living with endometriosis? Research on determinants of posttraumatic growth in diagnosed women, ” project manager:  \nAleksandra Andysz, M.A.).\n\nA. Andysz et al.\n664\nNr 6\nintercourses (dyspareunia), defecation (dyschezia), and \nurination ( dysuria) [7]. Patients often complain about \nnausea [8–10] and chronic fatigue [11,12]. Importantly, \nwomen with endometriosis report high levels of stress [13], \ndepressive symptoms and anxiety [14].\nEndometriosis is found to be one of the leading caus-\nes of infertility [15]. This, in turn, leads to subsequent \npsychological consequences that affect mental health of \nwomen with endometriosis more than those with other \ngynaecological problems [16]. Women suffering from \nendometriosis experience crises in their relationships \nand also their partners’ quality of life is affected by the \nillness [17]. Depending on the stage of the illness and \nthe severity of pain, social functioning of women with \nendometriosis is significantly impaired as well [12,18].\nSocial costs of endometriosis\nDue to its social costs, it is postulated to consider endo-\nmetriosis as a social disease [19]. The costs result mainly \nfrom the diagnostic delay, ineffective treatment, high in-\ndex of hospital admissions, surgery procedures and con-\ncomitant health problems (infertility, mental health prob-\nlems). Endometriosis affects women of productive age,  \nhence it influences women’s occupational functioning.\nIn 2006, the World Endometriosis Research Founda-\ntion (WERF) [20] initiated the EndoCost Study to assess \nthe direct and indirect costs of the disease born by soci-\nety (including costs of productivity loss) and by the diag-\nnosed women themselves. Data was collected in 12 me-  \ndical centers from 10 countries (N = 909). The average an- \nnual total cost was calculated to over EUR 9000 per wom-\nan and the costs of productivity loss (approx. EUR 6000 \nper woman) were twice as high as healthcare costs (sur-\ngeries, monitoring tests, hospitalizations and physicians \nvisits). The data showed that economic burden associ -\nated with endometriosis was similar to the one tied to \nother serious chronic diseases such as diabetes, Crohn’s \ndisease or rheumatoid arthritis [21].\nRationale and the aim of the article \nThe purpose of our review was to find research and \nsummarize what is already known on the impact of en-\ndometriosis on the occupational functioning of women \nsince such summary has not been done yet.\nMETHODS\nSelection of articles – eligibility criteria and search \nConducting the review search and analysis, we fol -\nlowed the PRISMA guidelines. To find relevant papers, \nwe searched the following databases using the EBSCO: \nMEDLINE Complete, OAIster, MasterFILE Premier \nand JSTOR Journals with no limits as regards the ear -\nliest date of publication. The search was performed in \nNovember  2017. Exact duplicates were automatically \nexcluded from the results. We searched only for arti -\ncles written in English and published in peer-reviewed \njournals. \nFirst, we used the following keywords: “endometri -\nosis” and “work;” “endometriosis” and “occupation*” \n(asterisk was used for retrieving variations of a searched \nword) in the title; “endometriosis” in the title and “work” \nin the abstract or keywords.\nRESULTS\nStudy selection\nForty-four records met the primary criteria and were \nscreened for eligibility for further analysis. We exclud -\ned: qualitative studies (N = 4), a review (N = 1), unpub -\nlished PhD thesis (N = 1), articles in which “work” did \nnot refer to paid work (N = 6), articles in which “work” \noccurred in the abstract but was only a part of the in -\ntroduction (N  =  8), papers considering the influence \nof work on the risk of endometriosis (N = 4), articles \nin which researchers studied the influence of different \ntherapies, on, e.g., functioning at work (N  =  5), arti -\ncles in which the main topic was not endometriosis but \nendometriosis-related symptoms (N  =  2) and articles \nfocused on estimating costs of endometriosis (N = 3). \nNext, 3 out of the 11 remaining papers were excluded \ndue to their significant methodological shortcomings. \nEventually, a total of 8 papers were included in the final \nreview. The stages of study selection are presented in \nthe flow diagram (Figure 1).\nCharacteristics of selected studies\nData collection\nIn the reviewed studies, women were identified in \npatients’ registers and invited to the study by post or \ne-mail [8,10,16,22,23] or they were recruited from hos-\npital wards [9,24,25].\nStudy samples\nWith the exception of Nnoaham et al. study [24] that was \nconducted in 16 clinics in 10 European countries, North \nand South America and Asia, all the other studies referred \nto local societies: central America [10,16], Denmark [8], \nItaly [25], Norway [9] and USA [23]. The smallest study \ngroup included 78 women [9] and the largest – 1318 [23]. \n\nEndometriosis – The challenge for occupational life\n665\nNr 6\nThe diagnosis of endometriosis was the inclusion criteri- \non in all studies, but the accepted basis of the diagnosis \nvaried between the reviewed studies (Table 1). \nStudy designs\nAll the reviewed studies were cross-sectional, only one \nwas a 15-year-long retrospective study [9]. Two studies \nincluded control groups – 1 consisted of women from \nthe general population [8], the other – of symptomatic \n(pelvic pain and subfertility) women without endome -\ntriosis and women to be sterilized [24].\nMeasures\nMost authors used standardized tools to measure work- \nrelated variables: Work Productivity  and Activity Im -\npairment Questionnaire  [16,24,25], a short version of \nWork Ability Index [8], Global Study of Women’s Health \nQuestionnaire [24], work-related module of the Endo -\nmetriosis Health Profile  [8] or Health-Related Produc-\ntivity Questionnaire [23]. Two teams of researchers de-\nveloped their own surveys [9,16].\nResearch areas\nHaving analyzed the content of the selected papers, we \ndistinguished the following research areas:\n ■ impact of endometriosis-induced pain on occupa -\ntional functioning,\n ■ deterioration of work ability, work performance and \nquality of work caused by endometriosis,\n ■ productivity loss caused by endometriosis-related \nsymptoms.\nThe summary of the studies included in the review \nis presented in the Table 1.\nThe impact of endometriosis-induced pain \non occupational functioning\nTwo publications by Fourquet et  al. [10,16] depict the \nsituation of women suffering from endometriosis in \nSouth America. At least 66% of the studied women ex -\nperienced pain-related difficulties in work,  43% iden -\ntified these difficulties as severe [10]. For 60% of them \n(N = 64) the pain was the reason for missed working \ndays [16].\nIn a study by Caserta et al. [25], nearly 30% of the \nstudied women considered the impact of endometri -\nosis on work as extreme, 35% as moderate and 23% as \nminimal. Only 12% of them reported no impact of endo-\nmetriosis on their work. The percentage of women who \nexperienced extreme negative influence of endometriosis \non work was even higher in Fourquet’s study – 43% [10]. \nIn a  study by De Graaf et  al. [22]  51% of the partici -\npants reported that endometriosis negatively affected \ntheir work.\nHansen et al. [8] showed the range of pain intensity \nand pain-related consequences at work in the case of \nwomen with diagnosed endometriosis in comparison \nto a reference group of the general female population.\n Women with endometriosis took sick leaves due to \ntheir pain significantly more often than healthy wom -\nen from the reference group. Up to 59% of the respon -\ndents felt the endometriosis pain impaired their work \nefficiency. In the case of  53% it decreased concentra -\ntion, 30% felt guilty taking a day off because of the pain, \nand 31% felt worried because of their inability to work \ndue to the pain. The wide range of difficulties included: \nstomachache related or unrelated to menstruation, pain \nat urination and defecation, irregular bleeding, consti -\npation or diarrhea. The studied women also reported to \nhave experienced nausea, vomiting, headache, fatigue \nand lack of energy, pain while standing, sitting and \nwalking. \nThe study of Hansen et al. [8] also revealed mental \nconsequences of the suffering, directly related to work. \nWomen experienced a sense of guilt and embarrass-  \nment and they worried about worse functioning at work. \nFigure 1. Flow diagram showing the process of studies selection \nfor the review\n167 of records  \nidentified through \ndatabase searching\n125 records excluded \nbased on the titles and \nabstract (14 duplicates)\n44 records screened\n11 full-text articles \nassessed for eligibility\n8 of studies included  \nfor the review\n3 of the full-text articles \nexcluded due to  \nmethodology\n33 records excluded\n2 records identified \nthrough other resources\n\nA. Andysz et al.\n666\nNr 6Table 1. Methodology of the reviewed studies on occupational functioning of women with endometriosis\nReferences Keywords\nWork-related \nmeasured \nvariables\nStudy design Method of data \ncollection Participants Diagnostic \ndelay measured\nStandardized \nquestionnaires  \nto measure  \nwork-related \nvariables\nLimitations\nFagervold \net al. 2009 [9] \nNorway\nwork ability, \nquality of \nwork life\nabsenteeism, \nchanges in \nwork due to \nendometriosis\nretrospective \ndescriptive \n(15 years \nfollow-up)\nhospitals N = 78 (age: unknown)\nwomen discharged from hospital \nwith the ICD-9 diagnosis and/or \nhistological verified endometriosis\ncontrol group: no\nno no small sample, recall  \nand reporting errors\nFourquet \net al. 2010 [10] \nSouth \nAmerica\nwork \nperformance\nlimitations in \nwork activity, \ndecrease in \nquality of \nwork, career \nconsequences\ncross sectional \nquantitative \nstudy\nquestionnaires \ndistributed via \nmail and e-mail\nN = 107 (age: M±SD =  \n34.5±6.6 years old)\nself-reported surgically diagnosed \nwomen\ncontrol group: no\nyes (M±SD = \n8.9±7.9)\nno results representative for \nthe women with severe \nendometriosis, sample \nconsisted of well-educated \nwomen (small differences in the \nlevel of education of women), \nrecall and reporting errors\nNnoaham \net al. 2011 [24] \nmultinational\nwork \nproductivity\nabsenteeism, \npresenteeism, \noverall \nproductivity loss\nmulticenter \ncross-sectional \nstudy with \nprospective \nrecruitment\n16 hospitals, \n10 countries\nN = 745 (age: M±SD = \n32.5±6.2 years old (18–45 years old))\npremenopausal women scheduled for \nlaparoscopy without previous surgical \ndiagnosis of endometriosis\ncontrol group: yes, symptomatic \ncontrol women without endometriosis \n(N = 587) and sterilization control \nwomen without endometriosis (N = 86)\nyes (M±SD = \n6.7±6.3)\nWPAI:GH variables were measured in the \nweeks leading to the scheduled \nsurgery, results may be affected \nby this fact and the symptoms \nthemselves\nFourquet \net al. 2011 [10] \nSouth \nAmerica\nwork \nproductivity\nabsenteeism, \npresenteeism, \nwork productivity, \ndecrease in \nquality of \nwork, career \nconsequences\ncross sectional \nquantitative \nstudy\nquestionnaires \ndistributed via \nmail and e-mail\nN = 193 (age: M = 33.2 years old \n(18–52 years old))\nself-reported surgically diagnosed \nwomen\ncontrol group: no\nmeasured but \nnot reported\nWPAI no data on severity of disease\nHansen \net al. 2013 [8] \nDenmark\nwork ability, \nquality of \nwork life\nabsenteeism, \nwork ability, \nimplications for \nwork life\ncross sectional \nstudy (even \nthough the \nauthors \nconsidered it \na cohort study)\nelectronic \nquestionnaire \ndistributed online\nN = 610 (age: < 19 years old,  \n> 50 years old)\nwomen with endometriosis diagnosed \nby laparoscopy or/and magnetic \nresonance (MR)\ncontrol group: yes, healthy women \n(N = 751)\nyes, percentages EHP-30, W AI \nshort\nrecall bias, no validation of \nendometriosis in medical \nrecords, respondents selected  \non the basis of their availability \nand interest\nCaserta \net al. 2013 [25] \nItaly\nwork \nproductivity\nwork productivity cross-sectional questionnaires \ndistributed in \nhospital during \noutpatient medical \nexamination\nN = 222 (age: M±SD =  \n37.9±6.5 years old)\nwomen with surgically diagnosed \nendometriosis\ncontrol group: no\nno WPAI not mentioned\nDe Graaf et al. \n2013 [22] \nmultinational\nnot related to \nwork\nnegative effect on \nendometriosis \nwork\ncross-sectional questionnaires \ndistributed \nvia mail to \nparticipants after \npositive answer  \nto the invitation\nN = 931 (age: M±SD = 36.1±6.8 years \nold (14–67 years old))\nwomen with laparoscopic and/or \nhistological diagnosis of \nendometriosis\ncontrol group: no\nyes\nyears of patient \ndelay*: M±SD = \n2.1±4 (0–32)\ndoctor delay**: \nM±SD = \n3.4±5.3 (0–38)\ntotal delay: \nM±SD = \n5.5±6.6 (0–38)\nGSWH possible over representation \nof women with moderate \nand severe endometriosis, \nlow response rate to the mail \ninvitation (29%)\nSoliman et al. \n2017 [23] \nUSA\nwork \nproductivity\nabsenteeism, \npresenteeism, \noverall \nproductivity loss\ncross-sectional web based survey N = 1 318 (age: M±SD = 34.6±0.3 \nyears old (18–49 years old))  \nwomen with symptomatic \nendometriosis, currently being  \ntreated or having hysterectomy\ncontrol group: no\nno HRPQ participation of women who \nhad access to the internet \nonly, recall bias, the type of \ntreatment was not controlled\n* Patient delay – interval between onset of symptoms to first visit.\n** Doctor delay – interval between first doctor visit and diagnosis.\nWPAI:GH – Work Productivity and Activity Impairment: General Health V2.2 , WPAI – Work Productivity and Activity Impairment , EHP-30 – Endometriosis Health Questionnaire 30 , WAI – Work Ability Index , \nGSWH – Global Study of Women’s Health Questionnaire , HRPQ – Health Related Productivity Questionnaire .\n\nEndometriosis – The challenge for occupational life\n667\nNr 6\nTable 1. Methodology of the reviewed studies on occupational functioning of women with endometriosis\nReferences Keywords\nWork-related \nmeasured \nvariables\nStudy design Method of data \ncollection Participants Diagnostic \ndelay measured\nStandardized \nquestionnaires  \nto measure  \nwork-related \nvariables\nLimitations\nFagervold \net al. 2009 [9] \nNorway\nwork ability, \nquality of \nwork life\nabsenteeism, \nchanges in \nwork due to \nendometriosis\nretrospective \ndescriptive \n(15 years \nfollow-up)\nhospitals N = 78 (age: unknown)\nwomen discharged from hospital \nwith the ICD-9 diagnosis and/or \nhistological verified endometriosis\ncontrol group: no\nno no small sample, recall  \nand reporting errors\nFourquet \net al. 2010 [10] \nSouth \nAmerica\nwork \nperformance\nlimitations in \nwork activity, \ndecrease in \nquality of \nwork, career \nconsequences\ncross sectional \nquantitative \nstudy\nquestionnaires \ndistributed via \nmail and e-mail\nN = 107 (age: M±SD =  \n34.5±6.6 years old)\nself-reported surgically diagnosed \nwomen\ncontrol group: no\nyes (M±SD = \n8.9±7.9)\nno results representative for \nthe women with severe \nendometriosis, sample \nconsisted of well-educated \nwomen (small differences in the \nlevel of education of women), \nrecall and reporting errors\nNnoaham \net al. 2011 [24] \nmultinational\nwork \nproductivity\nabsenteeism, \npresenteeism, \noverall \nproductivity loss\nmulticenter \ncross-sectional \nstudy with \nprospective \nrecruitment\n16 hospitals, \n10 countries\nN = 745 (age: M±SD = \n32.5±6.2 years old (18–45 years old))\npremenopausal women scheduled for \nlaparoscopy without previous surgical \ndiagnosis of endometriosis\ncontrol group: yes, symptomatic \ncontrol women without endometriosis \n(N = 587) and sterilization control \nwomen without endometriosis (N = 86)\nyes (M±SD = \n6.7±6.3)\nWPAI:GH variables were measured in the \nweeks leading to the scheduled \nsurgery, results may be affected \nby this fact and the symptoms \nthemselves\nFourquet \net al. 2011 [10] \nSouth \nAmerica\nwork \nproductivity\nabsenteeism, \npresenteeism, \nwork productivity, \ndecrease in \nquality of \nwork, career \nconsequences\ncross sectional \nquantitative \nstudy\nquestionnaires \ndistributed via \nmail and e-mail\nN = 193 (age: M = 33.2 years old \n(18–52 years old))\nself-reported surgically diagnosed \nwomen\ncontrol group: no\nmeasured but \nnot reported\nWPAI no data on severity of disease\nHansen \net al. 2013 [8] \nDenmark\nwork ability, \nquality of \nwork life\nabsenteeism, \nwork ability, \nimplications for \nwork life\ncross sectional \nstudy (even \nthough the \nauthors \nconsidered it \na cohort study)\nelectronic \nquestionnaire \ndistributed online\nN = 610 (age: < 19 years old,  \n> 50 years old)\nwomen with endometriosis diagnosed \nby laparoscopy or/and magnetic \nresonance (MR)\ncontrol group: yes, healthy women \n(N = 751)\nyes, percentages EHP-30, W AI \nshort\nrecall bias, no validation of \nendometriosis in medical \nrecords, respondents selected  \non the basis of their availability \nand interest\nCaserta \net al. 2013 [25] \nItaly\nwork \nproductivity\nwork productivity cross-sectional questionnaires \ndistributed in \nhospital during \noutpatient medical \nexamination\nN = 222 (age: M±SD =  \n37.9±6.5 years old)\nwomen with surgically diagnosed \nendometriosis\ncontrol group: no\nno WPAI not mentioned\nDe Graaf et al. \n2013 [22] \nmultinational\nnot related to \nwork\nnegative effect on \nendometriosis \nwork\ncross-sectional questionnaires \ndistributed \nvia mail to \nparticipants after \npositive answer  \nto the invitation\nN = 931 (age: M±SD = 36.1±6.8 years \nold (14–67 years old))\nwomen with laparoscopic and/or \nhistological diagnosis of \nendometriosis\ncontrol group: no\nyes\nyears of patient \ndelay*: M±SD = \n2.1±4 (0–32)\ndoctor delay**: \nM±SD = \n3.4±5.3 (0–38)\ntotal delay: \nM±SD = \n5.5±6.6 (0–38)\nGSWH possible over representation \nof women with moderate \nand severe endometriosis, \nlow response rate to the mail \ninvitation (29%)\nSoliman et al. \n2017 [23] \nUSA\nwork \nproductivity\nabsenteeism, \npresenteeism, \noverall \nproductivity loss\ncross-sectional web based survey N = 1 318 (age: M±SD = 34.6±0.3 \nyears old (18–49 years old))  \nwomen with symptomatic \nendometriosis, currently being  \ntreated or having hysterectomy\ncontrol group: no\nno HRPQ participation of women who \nhad access to the internet \nonly, recall bias, the type of \ntreatment was not controlled\n* Patient delay – interval between onset of symptoms to first visit.\n** Doctor delay – interval between first doctor visit and diagnosis.\nWPAI:GH – Work Productivity and Activity Impairment: General Health V2.2 , WPAI – Work Productivity and Activity Impairment , EHP-30 – Endometriosis Health Questionnaire 30 , WAI – Work Ability Index , \nGSWH – Global Study of Women’s Health Questionnaire , HRPQ – Health Related Productivity Questionnaire .\n\nA. Andysz et al.\n668\nNr 6\nThey accomplished less than desired because of the \npain and they felt they could have been able to work \nlonger and more efficiently if they had not felt the pain. \nAdditionally, their ambitions would have been higher \nif they had been more concentrated, but it was the pain \nthat hindered their concentration.\nDeterioration of work ability, work performance \nand quality of work caused by endometriosis\nFagervold et al. [9] conducted a retrospective study il -\nlustrating 15-year-long experience of the life with en -\ndometriosis. The results showed significant negative \ncorrelations between the number of the endometriosis \nsymptoms in the past (pain, dysmenorrhea, pain at ovu-\nlation, dyspareunia, pain at defecation, constant pelvic \npain, menorrhagia, irregular menstrual cycles, uri -\nnary symptoms, flatulence/constipation, fatigue) and \nlater course of patients’ education and work. Nearly \na half of the respondents who participated in the fol -\nlow-up study (49%) experienced negative influence of \nendometriosis on their work ability. Five percent of the \nstudied women decreased their working hours (from \nfull-time to part-time) due to their disease and anoth -\ner 3% changed their place of employment. One woman \n(1%) became unable to work.\nThe study by De Graaf et al. [22] showed that among \nwomen who reported negative impact of endometriosis on \ntheir work, 11% lost their jobs and 7% changed their jobs.\nIn a study by Fourquet et al. [16], 84% of women re -\nported decrease in the quality of their work due to en -\ndometriosis and its symptoms made 20% of the studied \nwomen temporarily disabled. Furthermore, 66% of the \nrespondents reported that the work-related activities \nthey could perform were limited [10].\nHansen et  al. [8] revealed that the number of sick \ndays, disturbances due to symptoms and work ability \ndiffered significantly between women suffering from \nendometriosis and healthy women. Poor work ability \nwas reported by 14% of the women with endometriosis \nvs. 8% of healthy women from the reference group. Ex -\ncellent work ability was declared only by 12% of the suf-\nfering women in contrast to 38% of the women from the \nreference group. Decreased work ability was predicted \nby fatigue, lack of energy, pain frequency, higher daily \nlevel of pain, the higher number of sick days and feel -\ning depressed at work. That study also showed the rela-\ntionship between work ability and the diagnostic delay. \nAlmost a half of the women who had been diagnosed \nwithin 2 years from the occurrence of the first symp -\ntoms (48%) assessed their ability to work as excellent \nand only 16% found it poor. Among women who were \ndiagnosed within  7–8 years from the first symptoms, \nthese percentages equaled 5% and 24%, respectively. \nFourquet et  al. calculated that a  substantial num -\nber of women believed that their symptoms extreme -\nly affected their work productivity (N = 44, 48%) [10] \nand 84% of the studied women reported a decrease in \nthe quality of their work due to endometriosis and its \nsymptoms [16]. Many women reported that they ac -\ncomplished less than expected – 64% of them attribut -\ned it to physical limitations, 63% to emotional problems \nresulting from the experienced symptoms. Most re -\nspondents (66%) felt that because of the endometriosis \nthe range of work-related activities they could perform \nwas limited  [10]. Almost  40% of the studied women \nfaced professional consequences  – their professional \ndevelopment was inhibited due to high rates of absen -\nteeism and/or low performance (N = 15), they were not \npromoted (N = 8), did not receive merit or excellence \nbonuses (N = 3), missed professional seminars (N = 2), \nlost clients (N = 1), were “totally incapacitated” (N = 3), \ndismissed or they quit the job (N = 3) [16]. \nIn the study of Nnoaham et al. [24] the productivity \nloss was higher among women with endometriosis than \nin the case of the symptomatic control group without en-\ndometriosis (11±12.2% vs. 8±10.2% of productivity loss). \nProductivity loss caused  \nby endometriosis-related symptoms\nThe reviewed studies referred to productivity loss as \nmeasured by absenteeism (missed working time) and \npresenteeism (reduced work effectiveness due to com -\ning to work despite experiencing health problems and \nsymptoms).\nLong sick leaves were more common among wom -\nen with endometriosis than among women of general \npopulation [8]. Over  20% of the suffering women and   \n8% of the healthy women reported sick leaves lasting \n25–100 days. Sick leaves lasting 100–365 days were taken \nby 6% of the suffering and 3% of the healthy women [8].\nIn the paper by Fagervold et  al. [9],  44% women \ntook  0.9±1.7 sick leaves due to endometriosis-related \nsymptoms per month on average.\nFourquet et  al. [16] showed that due to inability \nto perform physical activities, the suffering women \nmissed 3 working days a month on average (±3.7), which \nyields over a month of absence a year. The authors also \ncalculated the days of absence due to treatment, oper -\nation and rehabilitation to 19 days a year (±19.3). It oc -\ncurred that the absence of women with endometriosis \n\nEndometriosis – The challenge for occupational life\n669\nNr 6\nwas longer than among people suffering from head -\naches, arthritis or backache. At the same time, 69% of \nthe respondents admitted that they continued working \ndespite the experienced pain.\n In the other study of Fourquet et al. [10] the authors \ncalculated that the average length of absence equaled less \nthan 1 working day a week (7±9 h), which means near -\nly 20% of the whole average working week. In contrast, \nthe average number of missing working hours due to \nother reasons (e.g., holidays) equaled 4 h (±10 h).\nA study by Nnoaham et al. [24] showed significantly \nhigher presenteeism (coming to work despite being ill) \namong women with endometriosis than in the case of \nthe symptomatic control group without endometriosis \n(6±7.9 h/week vs. 5±6.7 h/week). \nCaserta et al. [25] showed that average absence due \nto endometriosis equaled 2±5.3 h within the week pre -\nceding the study. The number of hours worked within \nthe 7 days preceding the study amounted to 34±12.4 on \naverage (in a 40-h working week).\nSoliman et al. [23] calculated that women lost 1.1 work \nh/week and 6.6 days/year on average because of absen -\nteeism; and 5.3 work h/week and 31.8 days per year due \nto unproductive days at work (presenteeism). \nBased on the results, it may be concluded that the ab-\nsence due to endometriosis amounted to approx. 1 work- \ning day a week on average.\nCONCLUSIONS\nSummary of the evidence\nThe presented review shows that the research direct -\nly referring to the impact of endometriosis on work is \nsurprisingly scarce, given the negative consequences of \nendometriosis on occupational functioning and their \nfinancial costs. The previous research on the impact \nof endometriosis on professional life of the suffering \nwomen lacks the established methodology and the dif -\nferences in the design of these studies make it difficult \nto compare the findings. At the moment, there are too \nfew studies to do a  meta-analysis. Despite little em -\npirical material so far, we believe the existing studies \nprovide valuable conclusions and cues for researchers \nwilling to undertake that issue in the future studies.\nTo summarize, Hansen’s et al. study [8] indicated \npain and diagnostic delay as predictors of poor ability to \nwork and sense of guilt as a  mental consequence of in -\nability to work. These authors also recognized long-term \nconsequences of the diagnostic delay – 1 in 4 women  \nwho assessed their work ability as poor got their  \ndiagnosis  7–8  years after the occurrence of the first \nsymptoms. Long diagnostic delay makes the disease \ndevelop and produce more symptoms and more irre -\nversible changes. Thus, we believe that the diagnostic \ndelay should become an issue of quantitative studies to \ndetermine the contribution of patients’ behavior (“bit-\ning the bullet” attitude, self-treatment with easily ac -\ncessible painkillers, postponing the decision to see the \ndoctor, etc.) and the contribution of the attitude of doc-\ntors (ignoring patients’ symptoms, postponing the di -\nagnostic procedures possibly due to economic reasons).\nAlarmingly, Fourquet et  al. [16] recognized little \nawareness of endometriosis  –  65% of the studied pa -\ntients had never heard of the disease before the surgery \nand had never suspected that they had had endometri -\nosis. The awareness of endometriosis, both among pa -\ntients and their families, is crucial to avoid many phe -\nnomena related to this disease, e.g., the diagnostic de -\nlay, but also to improve social life of the suffering wom-\nen. For many women describing the pain and proving \nits onerousness is difficult. This makes other people \nunaware of their suffering. Greater social awareness of \nendometriosis would help these women to be more open \nand feel more comfortable to talk about the disease and \nits symptoms. Thus, others would have more under -\nstanding for the suffering women, be less ignorant or \nless willing to suspect that they simulate or exaggerate \ntheir pain. Feeling more compassion from other peo -\nple, women would be more courageous to participate in \nsocial life despite their symptoms.\nThe reviewed studies also draw attention to some \nmethodological difficulties in studying the relation -\nships between endometriosis (or any other chronic dis-\nease) and its impact on professional life. First, Nnoa -\nham et al. [24] noted that work productivity loss and \nother variables related to occupational functioning \nwere measured shortly before the operation (weeks be-\nfore), which could significantly influence the responses. \nMoreover, the declared number of days of absence at \nwork might have resulted from the perceived symptoms \nat that moment of the study. The fact that women were \nwaiting for the operation might suggest severe stages \nof the disease, which could significantly confound the \nmeasuring outcomes. On the other hand, this situation \nmight have caused these women to suffer less, because \nthey had already received the diagnosis and expected \na relief after the operation. \nWe believe that research on mental consequenc -\nes of living with endometriosis needs to consider the \nspecificity of the situation and life circumstances of \n\nA. Andysz et al.\n670\nNr 6\nwomen at the moment of the study (e.g., exacerbation \nof symptoms, waiting for the operation, or infertility \ntreatment).\nA reliable estimation of work absence or costs of \ntreatment of endometriosis poses another methodolog-\nical challenge. Such variables as sick leaves, the date \nof diagnosis, the number and types of medical proce -\ndures, money spent on medications are burdened with \na  recall bias. Thus, the researchers should attempt to \nhave the access to medical records.\nThe time since diagnosis has been included only \nin  1  of the reviewed studies [22]. Since diagnostic  \ndelay plays a critical role in the progression of the dis -\nease, time that has passed since the occurrence of the \nfirst symptoms and the date of diagnosis should be \ncontrolled in the studies on endometriosis. On the one \nhand, the longer one lives with the diagnosis of chron -\nic disease, the longer they live with the burden of the \ndisease. On the other hand, it is the time given to adapt \nto the disease and its consequences. We consider the \ninfluence of years of living with endometriosis on men-\ntal health and social functioning as a field for further \nscientific exploration.\nConsidering the previous studies on women suf -\nfering from endometriosis, we believe that further re -\nsearch in this group of patients should also focus on \npredictors of adaptive functioning or post-traumatic \ngrowth. We believe that post-traumatic growth in this \ngroup of patients is possible and finding any possible \npositive consequences of living with this difficult dis -\nease would be beneficial.\nLimitations\nThe above review has also its limitations. We searched \nonly for papers written in English. Probably, some local \nresearchers also undertake the issue of the impact en -\ndometriosis on occupational functioning but the results \nmight not be published in English or in peer-reviewed \njournals. Moreover, the inclusion criteria used in this \nsystematic review were relatively strict – we were look -\ning specifically for papers describing quantitative studies \non the impact of endometriosis at paid work. Probably, \nother papers (for instance based on qualitative studies) \ncould also enhance the discussion on the issue.\nSummary\nWe recommend further studies on the impact of en -\ndometriosis on occupational functioning. Yet, we be -\nlieve researchers should no longer ask whether endo -\nmetriosis has an adverse impact on the work life of the  \nsuffering women because it has already been unambig-\nuously confirmed. More urgently, they should search \nfor individual and organizational correlates of the opti-\nmal occupational functioning despite the illness. Espe -\ncially, studies on the attitude and awareness of the peo-\nple surrounding women with endometriosis constitute \nan important future research direction.\nIndicating the range of productivity loss or work ab-\nsence in this group and its relation to economic costs \nfor national budgets is another important issue be -\ncause nothing is that persuasive as money. Unlike in \nsome other countries [23], such calculations have not \nbeen done in Poland yet. We believe that the arguments \nbased on exact figures would be the most convincing \nfor stakeholders (politicians, insurers, healthcare pro -\nfessionals and employers) to undertake preventive and \ncorrective measures such as improving the diagnostic \nprocesses or increasing the social awareness of the en -\ndometriosis.\nREFERENCES\n1. Viganò P , Parazzini F , Somigliana E, Vercellini P . Endome-\ntriosis: Epidemiology and aetiological factors. 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Caserta D, Bordi G, Ralli E, Mateucci E, Moscarini F . \nImpact of endometriosis in work productivity and quali-\nty of life: A  survey from Italy. Int J  Manage Sci Business \nRes. 2013;2(4):43–9.\nThis work is available in Open Access model and licensed under a Creative Commons Attribution-NonCommercial 3.0 Poland License – http://creative -\ncommons.org/licenses/by-nc/3.0/pl/deed.en.\nPublisher: Nofer Institute of Occupational Medicine, Łódź, Poland","source_license":"CC0","license_restricted":false}