{"paper_id":"f437a65e-cd62-47ea-8d11-77bb58fb3e16","body_text":"HUMAN MOVEMENT (ISSN 1899-1955) \n93\nSELF-ESTEEM, QUALITY OF LIFE, AND PHYSICAL ACTIVITY  \nIN WOMEN WITH DIAGNOSED ENDOMETRIOSIS: A PILOT STUDY  \nIN AN ITALIAN SAMPLE\nANTONINO BIANCO1, AMBRA GENTILE1, MARZIA RUSSO1, ANTONIO MAIORANA2,  \nGIOACCHINO LAVANCO1, ARIANNA MELLINA2, ANTONIO PALMA1\n1 Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy\n2 Gynaecologic and Obstetric Unit, ARNAS Civico Di Cristina Fatebenefratelli, Palermo, Italy\nAbStRAC t\nPurpose. Endometriosis is a painful pathology impairing women’s daily life. Several studies have shown that patients report \nlow mental and physical quality of life, but no general evaluation of their self-esteem has been found. Studies concerning \nphysical activity frequency present inconsistent results. t herefore, the current paper aims to compare life quality and self-\nesteem in women with endometriosis with the Italian normative data of the measures used.\nMethods. Overall, 36 women with diagnosed endometriosis treated in hospital completed a questionnaire detecting physical \nactivity frequency, self-esteem, quality of life, and socioeconomic information. One sample t-test served to compare the data \nfrom this particular group with those of the general Italian population.\nResults. t he participants displayed higher self-esteem ( t = 5.65, p < 0.001) and a good quality of life (physical functioning: \nt = 3.64, p < 0.001), except for fatigue (t = –3.24, p = 0.003; significant difference); they declared feeling more fatigue than \nthe general population. Only 4 women (11%) reported regular physical activity, while 16 were smokers (44.4%, mean: 10.6 \ncigarettes/day).\nConclusions. Women with diagnosed endometriosis presented higher self-esteem and normal quality of life, even though \ntheir general health was lower and fatigue was higher than in the general Italian population. However, the sample involved \nfemales of low socioeconomic status and low education, characterized by poor communication skills and not open to externalize \ntheir feelings. t herefore, they might not have been honest in their answers. this potential bias, together with the small sample \nsize, will be addressed in future research.\nKey words: endometriosis, self-esteem, quality of life, dyspareunia, pain\noriginal paper\nDOI: https://doi.org/10.5114/hm.2021.103295\n2021; 22(4): 93–97\nCorrespondence address:  Antonino b ianco, University of Palermo, Via Pascoli, 6, 90144, Palermo, Italy,  \ne-mail: antonino.bianco@unipa.it\nReceived: June 9, 2020\nAccepted for publication: September 6, 2020\nCitation: bianco A, Gentile A, Russo M, Maiorana A, Lavanco G, Mellina A, Palma A. Self-esteem, quality of life, and physical \nactivity in women with diagnosed endometriosis: a pilot study in an Italian sample. Hum Mov. 2021;22(4):93–97; doi: \nhttps://doi.org/10.5114/hm.2021.103295.\n© University School of Physical Education in Wroclaw\nIntroduction\nEndometriosis is a pathological condition where \nendometrial tissue that normally grows inside the uter-\nus is also found outside the uterus, causing chronic \npelvic pain [1]. Women with endometriosis tend to \nexperience painful periods, chronic lower abdominal \npain, infertility, and dyspareunia [2]. Since the diag -\nnosis of endometriosis is often based on reported symp-\ntoms, as the occurrence of pain, its identification is \ncharacterized by a delay of almost 10 years [3], leaving \nwomen in a depressed or frustrated mood [4]. t here-\nfore, women with diagnosed endometriosis may expe-\nrience problems in their social, sexual, and emotional \ndaily life. A meta-analysis performed by Jia et al. [5] \nreports a significant impairment of women’s health-\nrelated quality of life, finding a negative correlation \nwith pelvic pain intensity.\nt he negative impact of this pathology on quality \nof life may turn into impairment of self-esteem since \nthe symptoms experienced may limit women’s daily \nactivity, with a sense of general dissatisfaction con -\ncerning the self, described as a collection of attitudes \ntowards one’s personal characteristics and potentiali-\nties [6]. Some studies described low self-esteem as \na consequence of infertility and in relation to mother-\nhood [7], to dyspareunia, and to lack of sexual relation-\nship [8]. Only one study relating self-esteem to the \n\nA. bianco et al., Health of women with endometriosis\nHUMAN MOVEMENT\n94 Human Movement, Vol. 22, No 4, 2021  \nhumanmovement.pl\nexperience of pain was found [9], reporting a non-sig-\nnificant correlation.\nFinally, as presented by bonocher et al. [10], physi-\ncal activity has been used to reduce painful symptoms \nin diseases involving inflammatory processes. t here-\nfore, the authors reviewed the literature for assessing \nthe relationship between physical exercise and the \nprevalence and/or improvement of the symptoms as -\nsociated with endometriosis. Unfortunately, owing to \nthe small number of studies existing on endometriosis, \nthese results were inconsistent. Conversely, stretching \nactivities, as yoga, seem to have beneficial effects on \nquality of life and chronic pelvic pain [11].\nEven though quality of life of women with diag -\nnosed endometriosis has been already investigated, \nthere is a lack of studies on a general evaluation of self-\nesteem and endometriosis. the retrieved studies asso-\nciated endometriosis with specific symptoms or con -\nditions (pain, infertility, dyspareunia, distress), but \nsince it can manifest differently from woman to wom-\nan, a general evaluation of self-esteem could be useful \nto understand if there is a common feature in women \nwho are affected by this pathology. t hus, the current \nstudy aimed at evaluating self-esteem, quality of life, \nsmoking and alcohol habits, and frequency of physical \nactivity in a sample of women with diagnosed endo -\nmetriosis. Specifically, we expected that women with \ndiagnosed endometriosis would experience a lower \nquality of life and lower self-esteem than the Italian \npopulation.\nMaterial and methods\nParticipants\nData were collected at the gynaecologic unit of the \nARNAS Civico of Palermo hospital. All women who \nreceived a diagnosis of endometriosis in the hospital \nunit underwent assessment at a medical visit. the sam-\nple was composed of 36 women aged 19–53 years (mean \nage: 36.97, SD = 8.22). the information was collected \nduring a face-to-face interview at the hospital unit. the \nItalian personal data protection code (DL196/2003) \nwas applied.\nMeasures\nRosenberg Self-Esteem Scale\nSelf-esteem was investigated with the Rosenberg \nSelf-Esteem Scale [12], a questionnaire consisting of \n10 items, each with a 4-point Likert scale (from 1 = \n‘t otally disagree’ to 4 = ‘t otally agree’), for a maximum \ntotal score of 40 points. t he Italian standardization \nprovides a good reliability of the measure and indicates \nnormative data depending on gender, educational level, \nmarital status, and occupation. For the purpose of the \nstudy, the normative data for Italian women derived \nfrom the standardization were used as a reference \ncategory.\nShort Form (36) Health Survey\nHealth-related quality of life was measured with the \nShort Form (36) Health Survey (SF-36) [13], which \nconsists of 36 questions divided into 8 scales relat -\ning to: physical functioning (10 items), role limitation \nowing to physical health (4 items), role limitation ow-\ning to emotional problems (3 items), vitality (4 items), \nemotional well-being (5 items), social functioning \n(2 items), bodily pain (2 items), and general health \n(5 items). t he Italian standardization of the question-\nnaire was used, and the scores were calculated with \nthe procedure suggested by Ware and Sherbourne [14].\nQuestionnaire on sociodemographic data,  \nlifestyle, and habits\nA questionnaire concerning sociodemographic data, \nlifestyle aspects, and habits was administered. It con-\nsisted of a sociodemographic part regarding age, height, \nweight, educational level. the other part included ques-\ntions related to sleeping hours per night (‘How many \nhours do you sleep per night?’), smoking habits (‘Do \nyou smoke?’ with possible answers: Yes/No; if yes, \n‘How many cigarettes do you smoke per day?’), phys-\nical activity (‘How many hours of physical activity do \nyou practice weekly?’), and alcohol consumption (‘Do \nyou drink alcohol?’; if yes, ‘How many glasses of alco-\nholic drinks do you consume weekly?’).\nData analysis\nDescriptive statistics were calculated for all the \nvariables involved in this study. One sample t -test \nwas used to compare the scores detected through our \nmeasures with the normative data for the population \n[12, 13]. t he significance level was set at \n = 0.05. \nt he Statistica software (version 10 for Windows) was \napplied.\nEthical approval\nt he research related to human use has complied \nwith all the relevant national regulations and institu -\n\nA. bianco et al., Health of women with endometriosis\nHUMAN MOVEMENT\n95Human Movement, Vol. 22, No 4, 2021 \nhumanmovement.pl\ntional policies, has followed the tenets of the Decla -\nration of Helsinki, and has been approved by the Sport \nand Exercise Science Research Unit of the University \nof Palermo.\nInformed consent\nInformed consent has been obtained from all indi-\nviduals included in this study.\nResults\nDescriptive statistics are presented in t able 1. \nt he participants belonged to normal weight category \nof body mass index (mean: 23.7, SD = 3.66) and had \nlow to medium education degree (only 2 individuals \nhad university graduation). t he average number of \nsleeping hours was 6.68 hours/night ( SD = 1.54). \nOnly 4 women (11.1%) declared to dedicate some time \nto physical activity, with an average of 5.33 hours per \nweek (SD = 3.21). Out of the 36 patients, 16 (44.4%) \nregularly smoked cigarettes, with an average of 10.6 \ncigarettes per day ( SD = 6.07). Concerning alcohol \nconsumption, 31 women (86.1%) declared not to con-\nsume alcohol regularly, while 5 women (13.9%) reported \nthat they drank 1 glass of alcoholic beverages per week.\nt he comparison with the normative scores for the \npopulation returned non-significant differences con -\ncerning the following SF-36 scales: role limitations \nowing to physical health, bodily pain, general health, \nsocial functioning, role limitation owing to emotional \nproblems, and emotional well-being. Significant dif -\nferences were found with reference to vitality, where \nthe women obtained lower scores compared with the \nnormative data for the population (t = –3.24, p = 0.003), \nand physical functioning (t = 3.64, p < 0.001). Self-es-\nteem levels were higher in our sample than the results \nfor the general population of women with low-to-me-\ndium educational level (t = 5.65, p < 0.001). Although \nthe scores did not reach the significance, it should be \nnoted that women reported lower general health.\nt able 1. Descriptive statistics of the sample and comparison with normative data\nDemographic characteristics Mean (SD)\nAge (years) 36.97 (8.22)\nHeight (cm) 164.70 (6.47)\nWeight (kg) 64.29 (11.27)\nSleeping hours/night 6.68 (1.54)\nEducation Frequency Percentage\nElementary school 5 13.9%\nMiddle school (10–13 years) 16 44.4%\nHigh school 13 36.1%\nUniversity 2 5.6%\nLifestyle habits Frequency Percentage\nSmoking (yes) 16 44.4%\nAlcohol consumption (yes) 5 13.9%\nSport practice (yes) 4 11.1%\nSF-36 scales Sample\nmean (SD)\nNormative data\nmean (SD)\nMean \ndifference t p\nPhysical functioning 91.67 (11.89) 84.46 (23.18) 7.21 3.64 < 0.001**\nRole limitation owing to physical health 84.29 (35.92) 78.21 (35.93) 6.08 1.00 Non-significant\nRole limitation owing to emotional problems 84.31 (35.99) 76.16 (37.25) 8.35 1.32 Non-significant\nVitality (energy/fatigue) 52.22 (17.90) 61.89 (20.69) –9.67 –3.24 0.003*\nEmotional well-being 60.56 (20.06) 66.59 (20.89) –6.03 –1.80 Non-significant\nSocial functioning 84.02 (27.81) 77.43 (23.34) 6.60 1.42 Non-significant\nbodily pain 73.89 (24.11) 73.67 (27.65) 0.22 0.05 Non-significant\nGeneral health 59.71 (30.92) 65.22 (22.18) –5.51 –1.05 Non-significant\nSelf-esteem 25.86 (5.20) 30.89  \n(not reported)\n4.97 5.65 < 0.001**\n* p < 0.05, ** p < 0.001\n\nA. bianco et al., Health of women with endometriosis\nHUMAN MOVEMENT\n96 Human Movement, Vol. 22, No 4, 2021  \nhumanmovement.pl\nDiscussion\nt he current study aimed to compare self-esteem \nand quality of life dimensions of women with diag -\nnosed endometriosis with normative data obtained \nfor the general population. Moreover, we wanted to \ndetect the patients’ lifestyle characteristics, particularly \nreferring to physical activity. Our sample consisted of \n36 women treated in the gynaecologic unit of the Civico \nHospital, one of the main hospitals in Palermo.\nt he results contradicted our main hypothesis of \nlower self-esteem in women with diagnosed endome-\ntriosis, and partially contradicted also the one related \nto a lower quality of life. In fact, our sample presented \nhigh levels of self-esteem and a normal quality of life, \nexcept for the scale of vitality, where the results turned \nout lower than the normative scores. Also, women re-\nported lower general health compared with the gen -\neral population, even if this difference did not reach \nstatistical significance. As for the patients’ habits, the \ngroup was characterized by a high presence of smokers, \nwith an average of more than 10 cigarettes per day; \nonly a few individuals practised sports.\nWith regard to self-esteem, a few studies treating \nself-esteem as a predictor or consequence of specific \nendometriosis symptoms have been retrieved [7–9, 15]. \nConversely, we aimed to obtain a general evaluation \nof self-esteem in women affected by endometriosis, \nindependently from the experienced symptoms. Our \nstudy found a high self-esteem level among the 36 \nwomen with endometriosis. Moreover, the severity of \nthe symptoms should also impact on women’s quality \nof life [1, 4]. In our study, we observed a lack of energy \nin women with diagnosed endometriosis, but they re-\nported normal levels, sometimes higher, in the other \ndimensions of quality of life.\nt hese results should be interpreted under a cul -\ntural light: data were collected in a hospital situated \nin a poor area of the city, were people present a low so-\ncioeconomic status and low education level (21 partici-\npants went to school until the age of 13 years, while \n13 gained a high school diploma). Since these indi -\nviduals were characterized by scarce communicating \nskills, it is very likely that our results could have been \nbiased for this cultural issue. Even if some women \nexperienced pain or felt to be less capable than the \nothers, the tendency was to suppress these thoughts \nand to rate oneself as better than the others.\nt he aim of the current research was to gain infor -\nmation useful for planning a future study about women \nwith diagnosed endometriosis, their self-esteem, quali-\nty of life, and physical activity. For this reason, some \nlimitations should be considered for the next phases. \nFirst of all, a bigger sample will be recruited by con -\ntacting participants from different Italian cities. It is \nmore likely that employing a bigger sample, with het-\nerogeneous characteristics concerning age and edu -\ncation, could lead to different results. Additionally, \nmore information about the diagnosis of endometrio-\nsis should be collected, e.g. when it was detected, when \nthe symptoms started, and what diagnostic methodol-\nogy was used. Moreover, we plan to obtain more de -\ntailed information on pain intensity and pain locali -\nzation, as well as to establish if this pain relates to an \nimpairment in physical tasks. A section with more \nspecific questions on physical activity will be included. \nFurthermore, as previously said, to overcome the cul-\ntural bias, the sample should be representative in terms \nof education and socioeconomic status, thus we intend \nto control these characteristics.\nConclusions\nWomen with diagnosed endometriosis were charac-\nterized by high self-esteem and normal quality of life. \nHowever, their general health was lower and fatigue \nwas higher than in the general Italian population.\nDisclosure statement\nNo author has any financial interest or received any \nfinancial benefit from this research.\nConflict of interest\nt he authors state no conflict of interest.\nReferences\n1. Lövkvist L, b oström P, Edlund M, Olovsson M. 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