{"paper_id":"fbc1e5e8-a6de-487d-a933-35a53629b8b3","body_text":"The Open Public Health Journal ISSN: 1874-9445\nDOI: 10.2174/0118749445308945240614110217, 2024, 17, e18749445308945 1\nRESEARCH ARTICLE OPEN ACCESS\nAnxiety in Women with Endometriosis -A Cross-\nsectional Study\n1\nObstetric Department, Arak University of Medical Sciences, Arak, Iran\n2\nMidwifery Department, Medical School, Traditional and Complementary Medicine Research Center (TCMRC), Arak\nUniversity of Medical Sciences, Arak, Iran\n3\nHealth Department, Arak University of Medical Sciences, Arak, Iran\n4\nMidwifery Department, Arak University of Medical Sciences, Arak, Iran\n5\nMidwifery Department, Islamic Azad University of Arak, Arak, Iran\nAbstract:\nAim: The present study aims to assess the anxiety in endometriosis women.\nBackground: Endometriosis is a disease with chronic pain due to the presence of endometrial-like tissue in other\norgans of the body. Pain and infertility can reduce the quality of mental health in women’s underlying endometriosis.\nObjectives: The present study wants to assess anxiety in endometriosis women and compare it with healthy women\nin Arak City in 2023.\nMethods: The current research was conducted using a cross-sectional method. Eighty-four records of women who\nwere diagnosed and treated by laparoscopy in one of the referral hospitals were included. In the control group,\nwomen  who  were  referred  to  health  centers  for  an  annual  checkup  without  any  history  of  endometriosis  were\nrecruited  for  the  study.  They  were  entered  into  the  study  by  convenience  sampling.  Two  groups  filled  out  the\ndemographic  and  Anxiety  Beck  Inventory  in  15  minutes.  Data  was  analyzed  through  descriptive  and  inferential\nstatistics using chi-square and t-tests using STATA software.\nResults: The results showed that the mean age of patients in the case and control groups was 31.5 ±5.7 and 31.1\n±6.1, respectively (p=0.57). Findings revealed that there was a statistically significant difference in the mean scores\nof FSFI between the case and control, respectively (23.08 ±6.1vs 24.47 ±6.6; p=0.031).\nConclusion: The present study showed that women with endometriosis still experience more anxiety after surgery\nthan healthy women. Therefore, the reasons for women's anxiety should be identified during consultations, and drug\nand non-drug treatment methods should be used to reduce their anxiety.\nKeywords: Reproductive health, Endometriosis, Anxiety, Mental health, Pain, Infertility.\n© 2024 The Author(s). Published by Bentham Open.\nThis is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public\nLicense (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license\npermits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are\ncredited.\n*Address correspondence to this author at the Midwifery Department, Medical School, Traditional and Complementary\nMedicine Research Center (TCMRC), Basij Square, Khalije Fars Street, Arak University of Medical Sciences, Arak, Iran;\nTel: 098-8634173505; E-mails: cattyv2002@yahoo.com and dr.kvakilian@arakmu,.ac.ir\nCite as: Najdi N, Vakilian K, Almasi-Hashiani A, Mirzaie F, Shokrpoor M, Karimi H. Anxiety in Women with Endometriosis\n-A Cross-sectional Study. Open Public Health J, 2024; 17: e18749445308945.\nhttp://dx.doi.org/10.2174/0118749445308945240614110217\nReceived: March 07, 2024\nRevised: May 28, 2024\nAccepted: June 06, 2024\nSend Orders for Reprints to\nreprints@benthamscience.net\nPublished: June 25, 2024\nNazila  Najdi\n1\n,  Katayon  Vakilian\n2,*\n,  Amir  Almasi-Hashiani\n3\n,  Fatemeh  Mirzaie\n4\n,  Maryam\nShokrpoor\n1\n and Hourieh Karimi\n5\n\n2   The Open Public Health Journal, 2024, Vol. 17 Najdi et al.\n1. INTRODUCTION\nEndometriosis is a disease with chronic pain due to the\npresence of endometrial-like tissue in other organs of the\nbody, including ovaries, fallopian tubes, and pelvic cavity.\nThe prevalence of this disease in the world includes 10% of\nwomen of reproductive age [ 1]. The most common clinical\nsymptoms  of  this  disease  are  dyspareunia,  dysmenorrhea\nand  infertility  [2].  Laparoscopy  and  hormonal  treatments\nare common methods of treating endometriosis. Due to the\nfact that the drug treatments for this disease are long-term,\nmany patients may stop the treatment. Frequent recurrent\nafter stopping the treatment and pelvic pains decrease the\nmental  health  of  these  women.  Fear  of  stigmatizing\nsymptoms associated with menstruation, decreased sexual\nactivity,  decreased  self-esteem,  negative  sexual  thoughts\nabout intercourse, avoidance of sexual activity, inability to\nconceive, or worry about future infertility can exacerbate\npsychological distress [3-5]. Because this disease affects the\nmarital  relationship  of  couples,  women's  work  and\neducation, it can reduce the quality of life of women [ 6].\nStudies show that one-third of women with endometriosis\nsuffer  from  psychological  problems  and  need  therapeutic\ninter- ventions [ 7]. Depression is more common in women\nthan  men,  and  if  women  have  chronic  pain,  the  risk  of\ndepression  will  be  higher  [ 8,  9].  A  study  showed  that\nwomen  with  chronic  pelvic  pain  were  1.5  times  more\ndepressed  than  women  in  the  control  group  [ 10].  Also,\nstudies  show  that  infertile  women  suffer  from  mental\nillnesses, including anxiety and depression, more than other\nwomen [ 11, 12]. Twenty-eight articles reviewed in women\nwith endometriosis showed a prevalence between 10% and\n98% for depression symptoms, and 11% to 88% for anxiety.\nThe  quality  of  life  in  patients  with  endometriosis  was\nsignificantly reduced [ 13]. Many studies show that women\nwho have not undergone endometriosis surgery suffer from\npsychological problems, including anxiety [ 14, 15], but few\nstudies show that mental health has improved after surgery\n[16]. Since women with endometriosis have both symptoms\nof  chronic  pelvic  pain  and  infertility,  it  is  expected  the  a\nhigh level of mental problems, including anxiety. Therefore,\nthis  study  was  conducted  to  investigate  the  level  of\ndepression in 2 groups of healthy women and women with\nendometriosis under the treatment.\n2. METHODS\n2.1. Study Design\nThis cross-sectional study was conducted in Arak, Iran.\n2.2. Setting of the Study\nThe  case  group  entered  the  study  from  Taleghani\nMaternity Hospital by census sampling in Arak, one of the\ncities in Markazi Province, Iran. The control was selected\nfrom  5  regions  of  Arak  city  health  centers  and  then\nsampling  was  done  from  each  of  the  selected  clinics  in\nproportion  to  the  covered  population.  This  sampling  was\ndone by convenience method.\n2.3. Patients\nEighty-four records of women who were diagnosed and\ntreated by laparoscopy in one of the referral hospitals in\nArak City were recruited to study. Sampling was done from\n2017 to 2020.\nAll  patients  had  no  history  of  chronic  diseases.  All\npatients  reported  characteristic  symptoms  of  endo-\nmetriosis, such as dysmenorrhea, pelvic pain, dyspareunia\nor  dyschezia  at  the  time  of  surgical  treatment.  Patients\nwere  invited  to  participate  in  the  study  through  call\nnumber.  Anxiety  was  measured  at  least  6  months  after\nsurgery. In the control group, women who were referred to\nhealth centers for annual checkups, without any history of\nendometriosis  were  recruited  to  the  study.  They  were\nentered  into  the  study  by  convenience  sampling.\n2.4. The Sampling Method\nOut of 110 patients, 84 cases met the inclusion criteria\nand  signed  a  written  consent  form  after  informing  the\nstudy's  goals  and  ethical  considerations.  Sixteen  patients\ndid not meet the inclusion criteria and 10 patients did not\nsign  the  informed  consent.  Finally,  84  patients  parti-\ncipated  in  this  study.  In  the  control  group,  convenient\nsampling  was  done  by  the  researchers.\n2.5. Inclusion Criteria\nThe  criteria  of  the  case  group  include  having  been\ndiagnosed  with  endometriosis  and  having  undergone\nlaparoscopy,  ages  between  20  and  40  years,  not  having\nany chronic or acute diseases under treatment, not having\nother  gynecological  diseases,  not  having  mental  illness\nand  being  treated,  and  not  having  addictions.  In  the\ncontrol group, all were confirmed except that they did not\nhave a history of endometriosis.\n2.6. Sample Size\nTwo-fold sample of case group was considered for the\ncontrol group. 160 samples were sampled, but 141 filled\nout the questionnaire completely.\n2.7. Data Collection Tools\nThe  questionnaire  was  composed  of  questions\nregarding demographic and obstetric history. Anxiety was\nmeasured by the Beck Anxiety Inventory (BAI). This scale\ncontained a 21-question multiple-choice. Score of 0 – 21 =\nlow anxiety score of 22 – 35 = moderate anxiety Score of\n36 and above = potentially concerning levels of anxiety.\nTest-retest reliability, an internal consistency, in Iranian\npeople were (r = 0.67) and (α =0.88), respectively [17].\n2.8. Implementation\nAfter  obtaining  the  ethical  code  from  the  Arak\nUniversity  of  Medical  Sciences,  the  control  group  was\nselected  from  5  health  centers  that  were  randomly\nselected from the north, south, east, center, and west of\nthe city. From each center, between 25-35 women were\nrecruited  after  signing  informed  consent  by  using  the\nconvenience  sampling  method.  Sampling  was  collected\nfrom January 2017 to February 2020. The sampling was\nperformed by one of the researchers, who was a midwife.\nData gathering was performed by demographic and Beck\nAnxiety Inventory (BAI). In case group, sampling was done\nin a maternity hospital. They were invited to the hospital\n\nAnxiety in Women with Endometriosis 3\nTable 1. Demographic and obstetric variables in endometriosis and healthy women.\nVariables Healthy Group\n(n=141)\nEndometriosis Group\n(n=84) *P Value OR\n(95%CI)\nAge Mean (SD) 31.1 (6.1) 31.5 (5.7) 0.579 1.01 (0.96-1.06)\nBMI Mean (SD) 25.5 (3.9) 23.7 (3.1) 0.001 0.87 (0.80-0.95)\nEducation\nUnder diploma\nDiploma\nAcademic\n45 (31.9)\n63 (44.7)\n33 (23.4)\n12 (14.5)\n19 (22.9)\n52 (62.6)\n0.001\n1\n1.13 (0.49-2.56)\n5.9 (2.7-12.7)\nMarital status Single\nMarried\n0\n140 (100)\n6 (7.2)\n77 (92.8) 0.001 -\n-\nJob Housewife\nEmployed\n124 (87.9)\n17 (12.1)\n58 (73.4)\n21 (26.6) 0.007 1\n2.6 (1.3-5.4)\nPregnancy Yes\nNo\n126 (89.4)\n15 (10.6)\n33 (40.2)\n49 (59.8) 0.001 1\n2.4 (1.8-3.2)\nAbortion Yes\nNo\n46 (32.6)\n95 (67.4)\n18 (21.9)\n64 (78.1) 0.085 1\n1.7 (0.9-3.2)\nGravida Mean (SD) 1.82 (1.08) 0.63 (0.90) 0.001 0.31 (0.22-0.44)\nPara Mean (SD) 1.49 (0.8) 0.4 (0.68) 0.001 0.15 (0.1-0.25)\nLive Child Mean (SD) 1.48 (0.8) 0.47 (0.66) 0.001 0.17 (0.10-0.3)\nFamily Endometriosis Yes\nNo\n0\n141 (100)\n15 (18.5)\n66 (81.5) 0.001 -\n-\nNote: *chi-square.\nTable 2. BAI in endometriosis and healthy women.\nVariables Endometriosis Group\n(n=141)\nHealthy Group\n(n=84) *P Value\nBAI score Mean (SD) 7.82 (7.48) 15.16 (10.52) 0.001\nBAI categories\nLow\nMild\nModerate\nSever\n81 (57.4)\n33 (23.4)\n22 (15.6)\n5 (3.5)\n24 (32.0)\n18 (24.0)\n17 (22.7)\n16 (21.3)\n0.001\nNote: *-T-test.\nto fill out the questionnaires. The main outcome was an\nassessment  of  anxiety.  Two  groups  filled  out  the\ndemographic and BAI questionnaires in 15 minutes. Data\nwere  analyzed  through  descriptive  and  inferential\nstatistics  by  chi-square  and  t-test  by  STATA  software.\n3. RESULTS\nThe demographic evaluation revealed that in the case\nand  control  groups,  it  was  31.5  ±5.7  and  31.1  ±6.1,\nrespectively  (p=0.57).  Thirty-three  (40.2)  cases  vs 126\n(89.4) controls had experienced the pregnancy (Table 1).\nThe  BAI  scores  revealed  that  15.16  (10.52)  of  the\nwomen  in  case  and  7.82  (7.48)  in  control  presented\nanxiety, 16 (21.3) in endometriosis vs 5 (3.5) in healthy\nwomen had sever anxiety (Table 2).\n4. DISCUSSION\nThis  study  showed  that  there  was  a  significant\nassociation between endometriosis and anxiety. In the study\nincluding  91,530  women  with  endometriosis,  the  highest\nodds ratio of experiencing anxiety appeared in this group\n(OR  =  2.719,  95%  CI  2.481–2.979)  [ 9].  In  a  study,  81\nwomen  with  pelvic  pain  were  studied,  of  which  40  had\nendometriosis and 41 had non-endometriosis chronic pain.\nAll patients filled the state-trait anxiety inventory [STAI].\nBased on the results of the study, endometriosis patients\nshowed higher anxiety than women with other patients with\nchronic pain [ 18]. A systematic review study, resulting in\n1,837  records,  showed  that  endometriosis  patients\nexperienced  significant  anxiety  compared  with  healthy\ncontrols,  but  no  differences  were  found  comparing\nendometriosis  patients  with  other  chronic  pelvic  pain\npatients for anxiety [ 19]. In contrast to these studies, one\nstudy  showed  that  the  state  of  anxiety  in  women  with\nendometriosis  did  not  significantly  differ  with  healthy\nwomen [ 20]. Studies show that inflammatory reactions in\nendometriosis patients and chronic pain cause disturbances\nin  the  hypothalamus-pituitary-adrenal  (HPA)  axis,  which\nleads  to  a  decrease  or  increase  in  blood  cortisol.  Both\ndecrease and increase of cortisol are a sign of disorder in\nthis  axis,  and  they  are  associated  with  different\npsychopathologies  [21].  Eriksen  et  al.  could  not  find  any\ncorrelation  between  pain  and  anxiety  and  depression\nsymptoms as an emotional response to endometriosis, but\nwomen  with  chronic  pain  had  increased  anxiety  and\ndepression  levels  [22].\nAnxiety  plays  an  important  role  in  reducing  self-\nconfidence,  self-worth  and  peace  in  women's  marital\nrelationships. Also, they experience a lot of anxiety during\nthe diagnostic and treatment planning stages, which usually\ncauses  significant  psychological  effects  on  patients.  The\n\n4   The Open Public Health Journal, 2024, Vol. 17 Najdi et al.\nspecific  factors  affecting  anxiety  levels  are  still  not  well\nunderstood,  although  diagnostic  delay,  disease  symptoms\nsuch  as  chronic  pain,  uncertainty  of  treatment,  and\nconsequences such as infertility seem to play a decisive role\n[23]. One study showed that creating a trustful relationship\nbetween  health  workers/specialists  with  women  and\nproviding  them  with  the  appropriate  counseling  methods\ncould reduce baseline anxiety levels [23].\nCONCLUSION\nThe  present  study  showed  that  women  with  endo-\nmetriosis still experience more anxiety after surgery than\nhealthy women. Therefore, the reasons for women's anxiety\nshould  be  identified  during  consultations,  and  drug  and\nnon-drug treatment methods should be used to reduce their\nanxiety.  There  are  limitations  in  the  study.  We  included\nmore than 97% of marital women, which may be influenced\nby  marital  status,  and  all  samples  were  selected  from\nreferral center, which influenced the study generali- zation.\nWe recommend more studies in this field.\nAUTHORS’ CONTRIBUTION\nIt  is  hereby  acknowledged  that  all  authors  have\naccepted  responsibility  for  the  manuscript's  content  and\nconsented  to  its  submission.  They  have  meticulously\nreviewed  all  results  and  unanimously  approved  the  final\nversion of the manuscript.\nABBREVIATION\nHPA = Hypothalamus-pituitary-adrenal\nETHICS  APPROVAL  AND  CONSENT  TO\nPARTICIPATE\nThe  study  was  approved  with  the  ethical  code  no.\nIR.ARAKMU.REC.1398.253  was  also  received  from  Arak\nUniversity of Medical Sciences.\nHUMAN AND ANIMAL RIGHTS\nAll procedures performed in studies involving human\nparticipants were in accordance with the ethical standards\nof  institutional  and/or  research  committee  and  with  the\n1975 Declaration of Helsinki, as revised in 2013.\nCONSENT FOR PUBLICATION\nThe  participants  in  this  study  signed  the  written\ninformed consent forms. Moreover, women had the right\nto participate or leave the study.\nSTANDARDS OF REPORTING\nSTROBE guidelines have been followed.\nAVAILABILITY OF DATA AND MATERIALS\nThe  data  that  support  the  findings  of  this  study  are\navailable  from  Arak  University  of  Medical  Sciences  but\nrestrictions apply to the availability of these data, which\nwere used under license for the current study, and so are\nnot publicly available. Data are, however available from\nthe authors upon reasonable request and with permission\nof Arak University of Medical Sciences.\nFUNDING\nThis study was funded by Arak University of Medical\nSciences under the code: 6001.\nCONFLICT OF INTEREST\nThe authors declare no conflict of interest, financial or\notherwise.\nACKNOWLEDGEMENTS\nDeclared none.\nREFERENCES\nGambadauro  P,  Carli  V,  Hadlaczky  G.  Depressive  symptoms[1]\namong women with endometriosis: A systematic review and meta-\nanalysis. 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