{"paper_id":"fdc7f9e5-07a1-4e0f-ac3d-32fe5547d137","body_text":"THESIS \n \nIMPACT OF ENDOMETRIOSIS ON QUALITY OF LIFE IN WOMEN \n \n                                              A Descriptive Literature Review \n \n \n \n \n \n \n \nABHAR IKRAM \nOLUWASEUN OLADEJI \n \nThesis \nBachelor of Health Care (Nursing) \nLapland University of Applied Sciences \n2024\n\n\n \nDegree programme in Nursing  \nBachelor of Health Care \n \n \n \nAbstract of Thesis \n \n   \n \nAuthors        Abhar Ikram         2024\n       Oluwaseun Oladeji   \nSupervisor Sirpa Orajärvi \nTitle  IMPACT OF ENDOMETRIOSIS ON QUALITY OF \n LIFE IN WOMEN – A Descriptive Literature Review \nNumber of pages  47 + 10 \n \n \nEndometriosis is a chronic, oestrogen-dependent inflammatory condition affect-\ning about 10% of women globally. It primarily affects pelvic tissues, including the \novaries, and significantly reduces quality of life by causing chronic pelvic pain, \nmenstrual irregularities, and psychological distress. \n \nThe purpose of this thesis was to examine impact of endometriosis on the quality \nof life in women. The aim was to identify the impact of endometriosis and its \nsymptoms on a woman's quality of life and thereby help healthcare personnel \nbetter understand and guide patients suffering from endometriosis. \n    \nThe thesis was carried out as a descriptive literature review, the material of which \nwas sought to respond to the theme: endometriosis and quality of Life. The re-\nsearch articles were retrieved from electronic databases. The report consisted of \ntwelve articles in English. The selected data were analyzed using deductive con-\ntent analysis. \n \nThe results of the thesis show that the impact of endometriosis on quality of life \nin women is multifaceted, and these impacts are interrelated. Endometriosis neg-\natively affects physical, psychosocial, emotional, social, educational and work life \naspects of women’s perceived quality of life. For women living with endometrio-\nsis, chronic pain is central limiting factor to their physical and psychological well-\nbeing. \n \nThe results of this thesis could serve as a valuable source of information for \nhealthcare professionals and nursing students, providing a deeper understanding \nof the effects of endometriosis on women's quality of life. Thereby contributing to \na better understanding of the disease and its treatment. \n \nKeywords                             Endometriosis, quality of life, Pain, Health.\n\n \nDegree Programme in Nursing \nSairaanhoitaja (AMK) \n \nOpinnäytetyön tiivistelmä  \n \n   \n \n \nTekijät  Abhar Khan   2024\n  Oluwaseun Oladeji  \nOhjaaja  Sirpa Orajärvi \nTyön nimi Endometrioosin vaikutus naisen elämänlaatuun - \n  kuvaileva kirjallisuuskatsastus. \nSivumäärä 47 + 10 \n \n \nEndometrioosi on krooninen, estrogeeniriippuvainen tulehdustila, joka vaikuttaa \nnoin 10 prosenttiin naisista maailmanlaajuisesti. Se vaikuttaa ensisijaisesti lan-\ntion kudoksiin, mukaan lukien munasarjat, ja heikentää merkittävästi elämänlaa-\ntua aiheuttamalla kroonista lantion kipua, kuukautisten epäsäännöllisyyttä ja psy-\nkologista ahdistusta. \n \nOpinnäytetyön tarkoituksena oli tutkia endometrioosin vaikutusta naisten elämän-\nlaatuun. Tavoitteena oli selvittää endometrioosin ja sen oireiden vaikutus naisen \nelämänlaatuun ja siten auttaa terveydenhuollon henkilöstöä ymmärtämään pa-\nremmin ja ohjaamaan en dometrioosista kärsiviä potilaita.  Tutkielma toteutettiin \nkuvailevana kirjallisuuskatsauksena, ja aineisto hankittiin vastaamaan teemaa: \nEndometrioosi ja elämänlaatu. Tutkimusartikkelit haettiin sähköisistä tietokan-\nnoista. Raportti koostui kahdentoista englanninkielisestä artikkelista. \nTutkimuksen tulokset osoittavat, että endometrioosin vaikutus naisten elämän-\nlaatuun on monitahoinen ja vaikutukset liittyvät toisiinsa. Endometrioosi vaikuttaa \nkielteisesti naisten fyysiseen, psykososiaaliseen, emotionaaliseen, sosiaaliseen, \nkoulutukselliseen ja työelämän laatuun. Naisilla, jotka elävät endometrioosin \nkanssa, krooninen kipu on keskeinen rajoittava tekijä heidän fyysiselle ja psyyk-\nkiselle hyvinvoinnilleen. \n  \nTämän opinnäytetyön tulokset voivat toimia arvokkaana tietolähteenä terveyden-\nhuollon ammattilaisille ja hoitotyön opiskelijoille ja tarjota syvempää ymmärrystä \nendometrioosin vaikutuksista naisten elämänlaatuun. Näin edistetään sairauden \nja sen hoidon parempaa ymmärtämistä. \n \nAvainsanat Endometrioosi, Elämänlaatu, Kipu, Terveys \n \n \n \n \n \n \n \n \n \n\n4 \n \n   \n \n \nCONTENTS \n1 INTRODUCTION ............................................................................................ 7 \n2 AIM AND RESEARCH QUESTIONS ............................................................ 10 \n2.1 PURPOSE AND AIM .......................................................................... 10 \n2.2 RESEARCH QUESTIONS .................................................................. 10 \n3 ENDOMETRIOSIS AND QUALITY OF LIFE ................................................ 11 \n3.1 Etiology of Endometriosis ................................................................... 11 \n3.2 Risk Factors of Endometriosis ............................................................ 11 \n3.3 Classification of Endometriosis ........................................................... 12 \n3.4 Diagnosis of Endometriosis ................................................................ 13 \n3.5 Quality of Life ...................................................................................... 15 \n3.5.1 Physical Quality of Life ................................................................ 16 \n3.5.2 Psychological and Emotional Quality of Life ................................ 17 \n3.5.3 Social Quality of Life .................................................................... 17 \n4 METHODOLOGICAL IMPLEMENTATION ................................................... 18 \n4.1 Creating Research Questions and Data Collection ............................ 18 \n4.2 Content Analysis ................................................................................. 24 \n5 RESULTS ..................................................................................................... 26 \n5.1 Endometriosis and Its Impact on Overall Quality of Life ..................... 26 \n5.2 Impact of Endometriosis on Physical Quality of life in Women ........... 27 \n5.3 Impact of Endometriosis on Psychological and Emotional Quality of Life \nin Women ...................................................................................................... 29 \n5.4 Impact of Endometriosis on Social Quality of Life and Sexual Health of \nWomen. ......................................................................................................... 32 \n5.5 Impact of Endometriosis on Work Life and Education of women ........ 34 \n6 THESIS ETHICS AND RELIABILITY ............................................................ 36 \n7 DISCUSSION ............................................................................................... 38 \nAPPENDICES ................................................................................................... 47 \n \n\n5 \n \n   \n \n \nFOREWORD \n  \nThis thesis would not have been possible without the invaluable support, guid-\nance, and encouragement of numerous individuals and institutions, to whom we \nowe our deepest gratitude. \nFirst and foremost, we wish to express our profound appreciation to our advisor, \nSirpa Orajärvi, as well as the esteemed faculty of Nursing, Lapland University of \nApplied Sciences. Your remarkable support, insightful guidance, and patient en-\ncouragement have been instrumental in shaping this work. The expertise and \ndedication you have shared throughout this journey have been truly invaluable. \nWe extend our heartfelt gratitude to Lapland University of Applied Sciences for \nproviding the resources, facilities, and academic environment necessary to un-\ndertake and complete this research. The institution's commitment to fostering in-\ntellectual growth has played a crucial role in our academic success. \nTo our families, we offer our deepest thanks for your unconditional love, stead-\nfast encouragement, and enduring belief in us. Your support, both emotional \nand practical, has been a pillar of strength throughout this endeavour. We are \nespecially grateful to our parents and siblings for their specific assistance and \nimmense presence during this journey. \nFinally, we wish to acknowledge the support of our friends and colleagues. Your \nkindness, understanding, and camaraderie have brought light to challenging \nmoments and enriched this experience. Your contributions, no matter how big \nor small, have left an indelible mark on this work. \nTo all who have walked alongside us on this journey, we extend our heartfelt \nthanks. This thesis is not only a reflection of our efforts but also a testament to \nyour invaluable contributions. \nThank you. \n \n\n6 \n \n   \n \nSYMBOLS AND ABBREVIATIONS USED \nMRI    Magnetic Resonance Imaging  \nSTDs    Sexually Transmitted Diseases \nDIE    Deep Infiltrating Endometriosis \nPCOS    polycystic ovarian syndrome \nWHO    World Health Organization   \nQOL   Quality of Life    \nHRQoL   Health-Related Quality of Life  \nHIV   Human Immunodeficiency Virus \nNMPP   Non-Menstrual Pelvic Pain  \nEAPP   Endometriosis-Associated Pelvic Pain  \nWHOQOL-BREF World Health Organization Quality of Life-BREF \nAYA   Adolescent and Young Adults  \nCPP   Chronic Pelvic Pain \nCBT   Cognitive Behavioral Therapy \n\n7 \n \n   \n \n1 INTRODUCTION \nEndometriosis is a chronic, systemic disorder that occurs when endometrial -like \ncells grow abnormally outside the uteru s. Endometriosis affects approximately \n190 million people globally and is found to be prevalent amongst approximately \n10% of women of reproductive age (Shafrir et al. 2018).  \nSeveral risk factors are robustly associated with endometriosis, including an early \nage at menarche, shorter menstrual cycle lengths, and a lean body size. Con-\nversely, factors such as greater parity appear to be protective. However, associ-\nations with other quality of life factors such as physical activity, dietary influences, \nand lactation remain inconsistent, largely due to methodological challenges re-\nquiring rigorous longitudinal data collection (Shafrir et al. 2018). \nAccurately measuring the prevalence and incidence of endometriosis presents \nsignificant challenges, primarily because the condition requires surgical visuali-\nzation for definitive diagnosis. This reliance on surgery introduces a diagnostic \nbias, as those wh o undergo surgical evaluation often represent a subset of pa-\ntients with severe symptoms. Reported prevalence estimates vary widely, from \nas low as 2% to as high as 43% in asymptomatic women undergoing elective \ntubal ligation, and between 5% and 50% in women experiencing infertility. Among \nwomen hospitalized for pelvic pain, prevalence ranges from 5% to 21%. These \nestimates highlight that endometriosis is both underdiagnosed in some popula-\ntions and overrepresented in clinical settings focused on infertility or chronic pain \n(Shafrir et al. 2018). \nEndometriosis, a chronic inflammatory condition characterized by the presence \nof endometrium-like tissue outside the uterine cavity, is a global health concern \naffecting approximately 10% of women of reproductive age (Wang et al. 2022). \nThis condition is a ssociated with a range of debilitating symptoms, including \nchronic pelvic pain, dysmenorrhea, dyspareunia, and infertility, significantly im-\npairing reproductive performance and quality of life. The socio-economic burden \nof endometriosis is substantial, as the disease frequently disrupts daily living and \npresents long-term health challenges, such as fibrosis, adhesions, and a potential \nrisk of malignant transformation (Wang et al. 2022). \n\n8 \n \n   \n \nEndometriosis manifests in various subtypes based on its location, including \novarian endometrioma, adenomyosis, deep infiltrating endometriosis, and super-\nficial endometriosis, which may occur alone or in combination. Among these, \novarian endometrioma is one of the most common phenotypes, with a prevalence \nranging from 17% to 55% . The primary goals of endometriosis management in-\nclude alleviating pain, restoring reproductive functionality, and preventing or de-\nlaying long-term sequelae. However, achieving these objectives is often compli-\ncated by the challenges associated with accurate diagnosis and effective treat-\nment strategies (Wang et al. 2022). \nEndometriosis is a complex and multifaceted disorder characterized by the \ngrowth of endometrial -like cells outside the uterus. It presents a wide range of \nmanifestations, associated clinical problems, and therapeutic challenges. Among \nits various forms, deep endometriosis, which infiltrates multiple pelvic organs, is \nconsidered the most severe. This form poses significant uncertainties in the man-\nagement of infertility and pelvic pain, both of which severely impact the quality of \nlife of affected individuals (Vercellini, 2015). \nRecent evidence challenges the traditional understanding of endometriosis as a \npurely gynecological condition. Contrary to earlier beliefs, its effects extend be-\nyond reproductive health, influencing pregnancy, delivery, and the postpartum \nperiod. The longstanding notion that pregnancy serves as a cure for endometrio-\nsis has been discredited, emphasizing the need for updated clinical approaches. \nFor instance, safe and effective treatments to minimize symptom recurrence and \nlesion regrowth after conservative s urgery are now available and should be of-\nfered to patients not immediately pursuing conception (Vercellini, 2015). \nWhile endometriosis is associated with a moderate increase in ovarian cancer \nrisk, current evidence does not support its classification as a pre-neoplastic con-\ndition. Consequently, routine screening for undiagnosed endometriosis in asymp-\ntomatic women is no t recommended. As endometriosis is not malignancy, shift \nfrom lesion -focused treatment to symptom -focused management is essential. \nThis patient -centered approach should address the primary clinical problems, \nalign with the patient's preferences and priorit ies, and incorporate transparent \n\n9 \n \n   \n \ncounseling about the potential benefits, risks, and costs of each therapeutic op-\ntion. Gynecologists play a crucial role in supporting patients during the shared \ndecision-making process by providing detailed explanations of all available treat-\nments, rather than limiting discussions to their personal preferences or expertise \n(Vercellini, 2015).       \nEndometriosis in women causes recurring strong pains presenting in the lower \nabdomen and pelvic area according to the menstrual cycle. Furthermore, there \nmay be long -term continuous pain, exacerbations of pain independent of the \nmenstrual cycle, and pain r elated to intercourse, defecation, or urination \n(Hamunen, Sipilä, Jernfors & Härkki 2022) and onset of symptoms frequently oc-\ncurs in adolescence, with two-thirds of adult diagnoses having their roots before \nthe age of 20. Despite this early manifestation, the diagnosis in young women is \noften delayed, with an average delay of 12 years reported in adolescents (Wüest \net al.2023).       \nEndometriosis tissue, believed to stem from retrograde menstruation implanting \nendometriotic tissue, remains incompletely understood. Despite symptom onset \noften occurring in adolescence and young adulthood, studies on this demo-\ngraphic are limited (Naoko et al. 2020) The condition profoundly affects the quality \nof life, contributing to school absenteeism and hindering daily activities. Recog-\nnizing and addressing endometriosis in its early stages, especially in the young \npopulation, holds potential for preventing chronic pain and mitigating its adverse \neffects on the quality of life in this demographic (Wüest et al. 2023). \nThe purpose of the thesis is to review literatures that examines the physical and \npsychological impact of endometriosis on the quality of life in women. The aim is \nto identify the unique challenges faced by endometriosis patients and understand \nhow these challenges affect their daily lives. \n \n \n\n10 \n \n   \n \n2  AIM AND RESEARCH QUESTIONS  \n2.1 PURPOSE AND AIM \nThe purpose of the thesis is to examine impact of endometriosis on the quality of \nlife in women. The aim is to identify the impact of endometriosis and its symptoms \non a woman's quality of life and thereby help healthcare personnel better under-\nstand and guide patients suffering from endometriosis.  \n2.2 RESEARCH QUESTIONS  \nHow does endometriosis affect the quality of life of women, and in what ways \ndoes it impact their overall physical, emotional, and psychological well-being? To \nwhat extent can the symptoms and challenges associated with endometriosis in-\nterfere with daily a ctivities, relationships, work, and mental health, and how do \nthese effects vary across different individuals? \n \n \n \n \n \n \n \n \n \n \n\n11 \n \n   \n \n3 ENDOMETRIOSIS AND QUALITY OF LIFE \n3.1 Etiology of Endometriosis \nEndometriosis is a complex clinical syndrome that has undergone significant ad-\nvancements in our understanding over the past two decades. Characterized by \nan estrogen-dependent chronic inflammatory process, it primarily affects pelvic \ntissues, including the  ovaries. This condition stands as the leading cause of \nchronic pelvic pain in women of reproductive age, intricately linked to persistent \nepisodes of ovulation, menstruation, and cycling steroid hormones. Its multifac-\ntorial origin and high prevalence align it with other chronic inflammatory disorders \nassociated with pain, such as inflammatory bowel disease and gastroesophageal \nreflux disorder. However, what sets endometriosis apart is its unique dependence \non estrogen as the primary biological driver of inflammation (Bulun et al. 2019.) \nEndometrioses occur when endometrial cells that reach the peritoneal cavity \nthrough the retrograde menstruation (this process occur in almost all women) are \nnot broken down and cleared. This is postulated to occur due to cellular adhesion \nand proliferation, inflammation, localized steroidogenesis, neurogenesis, somatic \nmutations and immune dysregulation. This endometrial-like cells implant outside \nthe uterus and respond to estrogenic stimulation from the ovaries and the cells \nthemselves, leading to inflammation and subsequent scarring and adhesions (Al-\nlaire, Bedaiwy & Yong 2023.) \n3.2 Risk Factors of Endometriosis  \nEndometriosis can be chronic and progressive in a subset of patients. The exact \ncause of endometriosis remains unknown . However, the most widely accepted \ntheory is Sampson’s theory (1927) that during menstruation endometrial cells re-\ngurgitate through the fallopian tubes and implant on the surrounding pelvic vis-\ncera. Other hypotheses suggest a multi-factorial etiology with immunological, an-\natomical, and genetic mechanisms leading to dysfunction in the ectopic endome-\ntrium and/or immune system. However various individual features (family history \nof endometriosis, early menarche, and exposure to circulating steroid hormones, \n\n12 \n \n   \n \nbody mass index during late childhood and early adolescence), lifestyle charac-\nteristics and environmental factors are likely related to the development of endo-\nmetriosis (Janssen, Rijkers, Hoppenbrouwers, Meuleman, & D'Hooghe 2013.) \nEarly life exposures, such as mode of delivery, parental smoking, and exposure \nto breastfeeding, may modify the hormonal and  immune status of the newborn, \nwhich could influence disease risk later in life . Among adolescents and young \nadults, data suggest exposures to breastfeeding in early life and secondhand \nsmoke during childhood may be associated with endometriosis risk , specifically, \nmaternal exposure to diethylstilbestrol, smoking during pregnancy, and lower \nbirthweight have been reported to be associated with greater risk of endometrio-\nsis diagnosed in adulthood. (Naoko et al. 2020.) \n3.3 Classification of Endometriosis \nPelvic endometriosis can be categorized into three  distinct subtypes each with \ndifferent symptom presentation and method of diagnosis (Figure 1). Endometrio-\nmas are cysts that develop in the ovary and contain dark, blood-stained fluid often \nreferred to as “ chocolate cysts”. Deep endometriosis ( formerly known as deep \ninfiltrating endometriosis) involves lesions that extend beyond the peritoneum. \nThese lesions are typically nodular and fibrotic and could invade nearby pelvic \norgans such as the rectosigmoid  colon, ureter or bladder. Superficial Peritoneal \nEndometriosis is the most common form, characterized by lesions of varying col-\nors on the peritoneal surface. These lesions are typically small and located on \nthe peritoneum. (Allaire etal. 2023.) \nSubtypes can overlap with some patients having more than one manifestation of \nthe disease at the same time. For example, endometriomas often co -occur with \ndeep endometriosis, and the discovery of an endometrioma on ultrasonography \nshould prompt further investigation, particularly if the patient reports severe pain. \nDeep endometriosis can lead to serious complica tions, including organ damage \nsuch as kidney failure (due to ureter obstruction) or bowel obstruction, making \nearly diagnosis and management critica l. Extra-pelvic endometriosis, which oc-\ncurs less frequently, can involve areas outside the pelvis, such as the diaphragm, \nthoracic cavity, or surgical scars  (Allaire etal. 2023.)  (Figure 1) shows imaging \nand laparoscopic appearance of endometriosis subtypes (Allaire etal. 2023). \n\n13 \n \n   \n \n \n \nFigure 1. Imaging and laparoscopic appearance of endometriosis subtypes  \n(Allaire etal. 2023). \n3.4 Diagnosis of Endometriosis \nThere are multiple pathways through which a person with endometriosis may be \ndiagnosed or mis/undiagnosed, some women are diagnosed due to pelvic pain, \nwhereas others are diagnosed at the time of an infertility evaluation or diagnosed \nincidentally for unrelated pelvic surgical procedures (such as appendectomy or \ntubal ligation). The wide variation in symptoms, surgically visualized presentation, \nand pathologic findings makes selection of an appropriate case definition for en-\ndometriosis both critical and challenging. Laparoscopy remains the gold standard \nfor diagnosing endometriosis. However, making a case definition for endometri-\nosis especially in adolescents is challenging, as only those with the most severe \nsymptoms will undergo surgery hence surgical diagnosis. (Shafrir et al. 2018.) \n\n\n14 \n \n   \n \nThe diagnostic process for endometriosis remains controversial, with laparos-\ncopy long regarded as the gold standard. Despite its utility in direct visualization \nand histological confirmation, laparoscopy poses certain risks, including vascular \nand visceral injuries and post-operative complications. Additionally, the absence \nof histological confirmation in some cases further complicates the diagnostic pro-\ncess. Non-invasive diagnostic tools, such as high -resolution vaginal ultrasound \nand magnetic resonance imaging, have advanced significantly, but limitations in \ntheir reproducibility and validation hinder their widespread application . (Wang et \nal. 2022.) \nThe pathophysiology of endometriosis also remains incompletely understood, de-\nspite the existence of various hypotheses and theories exploring genetic, epige-\nnetic, immunological, hormonal, and environmental factors. This uncertainty con-\ntributes to ongoing debates about the optimal timing, duration, and type of treat-\nment. For instance, there is no consensus on whether laparoscopy should pre-\ncede medical therapy, nor is there agreement on the best strategies for integrat-\ning surgical and medical treatments. Thes e uncertainties often lead to delays in \nboth diagnosis and therapeutic intervention, posing significant challenges to cli-\nnicians and patients alike. Advances in minimally invasive technologies and ther-\napeutic approaches have provided improved options for m anaging this complex \ncondition, but controversies in routine clinical practice persist. Addressing these \nchallenges is essential for developing patient -centered strategies that enhance \nthe quality of life for women affected by endometriosis (Wang et al. 2022). \nUltrasound examinations are most frequently used as the initial imaging tech-\nnique for endometriosis. This allows for a detailed exploration of the pelvis with \nthe ability to exclude pelvic masses or structural anomalies, although easily vis-\nualized endometriomas are less common in adolescents compared to adults \nhence magnetic resonance imaging (MRI) provides a better understanding of en-\ndometriosis compared to ultrasounds as this gives a more detailed imaging of the \npelvic compartment. Laparoscopy, however, compared to MRI give more endo-\nmetriosis finding and is more cost effective as an initial screening tool. Laboratory \nstudies such as complete blood count  or erythrocyte sedimentation rate which \n\n15 \n \n   \n \nreflects underlying inflammation process have low effectiveness in the identifica-\ntion of endometriosis. Currently there are no standardized blood tests or serum \nmarkers for the diagnosis of endometriosis however, pregnancy tests, urine anal-\nysis and sexually transmitted disease tests (STDs) should be used to rule out \nother potential causes. (Liakopoulou et al. 2022.) Therefore, many endometriosis \ncase definitions can be considered, including diagnosis based on symptoms, lap-\naroscopic confirmation due to pelvic pain, infertility or unrelated surgery, or visu-\nalization by using imaging techniques (Shafrir et al. 2018). \nEndometriosis is classified into various types, including ovarian endometriosis, \ndeep infiltrating endometriosis (DIE), and involvement of adjacent pelvic struc-\ntures, highlighting its diverse clinical presentations. Each type presents a unique \nset of characteristics, contributing to the complexity of effectively managing this \ncondition. (Dunselman et al. 2014). \n3.5  Quality of Life  \nThe World Health Organization (WHO) defines Quality of Life (QoL) as an indi-\nvidual's perception of their position in life, considering the cultural and value sys-\ntems in which they live and relative to their goals, expectations, standards, and \nconcerns (WHO, 2024.) QoL is a complex collection of interacting objective and \nsubjective domains and expresses the individual’s perspective and experiences \nwhich is likely to be mediated by cognitive factors.  Other components of a per-\nson’s perceived quality of life include their functional capacity in physical activi-\nties, the level and quality of social interaction, psychological well -being, somatic \nsensations, happiness, life situations, life satisfaction and need for satisfaction  \n(Megari ,2013). \n\n16 \n \n   \n \nChronic diseases are characterized by their slow progression, long duration and \nneed for medical treatment. They hold the potential to worsen the overall health \nof patients by limiting their ability to live a healthy life, limit the functional status, \nproductivity and health related quality of life ( HRQoL) and make significant con-\ntributions to the overall costs of healthcare . Among these diseases are cancer, \nheart diseases, stroke, diabetes, human immunodeficiency virus  (HIV), bowel \ndiseases, renal diseases and diseases of the central nervous system. There’s a \nnotable rise in the rate of chronic diseases and the need for more studies on the \nimpact of the disease symptoms and their treatment on the HRQoL of patients to \nimprove patient centered care. (Megari, 2013.) \n3.5.1 Physical Quality of Life \nThe presence of one or more chronic dis orders in women has been established \nto impact on perceived physical quality of life, decreased quality of life from weight \ngain, acne vulgaris, alopecia, mood disturbances and decreased sexual satisfac-\ntion because of polycystic ovarian syndrome (PCOS) a chronic endocrine disor-\nder has been well documented.  PCOS affects 5%–10% of women in the devel-\noped world and is the most common endocrine disorder of women in their repro-\nductive years. Women with PCOS often feel less sexually attractive and less sat-\nisfied with their sex life. (Brady, Mousa, & Mousa, 2009.) \nOne of the most significant impacts of PCOS on women's physical quality of life \nas reported in a study is Hirsutism, defined as the excessive hair growth in women \nthat follows a male distribution pattern.  The presence of facial hair causes dis-\ntress in women giving a “unfeminine”, “freakish\", \"weird” and “different” feeling. \nThis is also accompanied with other troubling problems as expressed by 30 in-\nterviewed women who described excess hair growth, irregular menses and infer-\ntility as their worst troubles from PCOS. (Brady, Mousa, & Mousa, 2009.) \n \n\n17 \n \n   \n \n3.5.2  Psychological and Emotional Quality of Life \nPresence of a chronic illness has significant impact on the self-assessed quality \nof life among women as seen in women with  polycystic ovarian syndrome  \n(PCOS), the disease showed a multifaceted impact on their well -being, particu-\nlarly in the sexual, psychological, and social spheres. While most women rate \ntheir overall quality of life as good or very good, a significant proportion report \nchallenges, with PCOS predominantly affecting their sexual relationships \n(79.2%), family life (61.9%), and social interac tions (50.6%). Emotional burdens \nare pronounced, with 79% experiencing sadness and 75% feeling out of control \ndue to the condition. Body image issues are prevalent, as only 40.5% accept their \nappearance, and 67.5% report low self -esteem. Although family support is gen-\nerally rated as moderate to good, the variability in support levels underscores the \nneed for stronger social and emotional backing. These findings align with broader \nchronic illness trends, where physical symptoms, mental health struggles, and \nsocial impacts collectively diminish quality of life. (Ligocka et al. 2024.)   \n3.5.3 Social Quality of Life  \nThe social impact of chronic PCOS is significant in the patient's family life.  and \nsocial life. More than half, 61.9% (family life) and 50.6% (social life), with fewer \nwomen noting an effect on their occupational life (24.4%). The condition appears \nto have a more significant impact on intimate relationships and social interactions \ncompared to work -related activities, possibly due to the emotional and psycho-\nlogical consequences of managing PCOS symptoms. (Ligocka et al. 2024). \n3.5.4 Nursing Care for Endometriosis Patients in Finland \nThe Finnish healthcare system, known for its patient-centered approach, offers a \nunique context for understanding nursing care for endometriosis patients (Finnish \nMinistry of Health and Social Affairs, 2022). Finnish nursing professionals are at \nthe forefront of patient care, providing essential support, education, and advo-\ncacy. Their role in managing the physical, emotional, and social aspects of endo-\nmetriosis is indispensable (Nursing Association of Finland, 2021.) \n \n\n18 \n \n   \n \n4 METHODOLOGICAL IMPLEMENTATION \nThis research methodology involves a descriptive literature review to explore the \nimpact of endometriosis on quality of life in women, descriptive literature review \nemploys a phenomenological method to comprehensively collect, describe, and \nsystematically examine previous information regarding a chosen research topic. \nThis method of literature review was chosen as it aligns with the purpose of the \nstudies to collect and analyze data from previous research on the impact of en-\ndometriosis using previously defined domains and present the process in stages \nto describe the special features as well as ethical and r eliability issues. The de-\nscriptive literature review is based on a research question and produces a de-\nscriptive, qualitative answer based on the selected material. Its steps are defined \nas 1) creating a research question, 2) choosing the material. 3) building the de-\nscription and examining the desired result. (Kangasniemi & Utriainen & Ahonen \n& Pietilä & Jääskeläinen 2013: 291–301.) \n4.1 Creating Research Questions and Data Collection \nThe descriptive literature review is based on research questions, and they are \nfollowed throughout the process, which is why it is important that the research \nquestions are sufficiently limited and precise. If the research questions are broad, \nthe matter being described can be examined from many different perspectives. \n(Kangasniemi et al., 2013: 291 -301). On this basis the research question which \nguided this work was: How does endometriosis affect the quality of life of women, \nand in what ways does it impact their overall physical, emotional, and psycholog-\nical well-being? To what extent can the symptoms and challenges associated \nwith endometriosis interfere with daily activities, relationships, work, and mental \nhealth, and how do these effects vary across different individuals? \nAfter the research questions have been formed, a selection of data was made \nwith the aim of finding the studies that answer the research questions as well as \npossible. The descriptive literature review includes a description of how the ma-\nterial was selected. The material selected for the review is retrieved from various \nscientific databases and scientific publications. Data selection is described as two \ndifferent processes: implicit and explicit data selection. In implicit data selection, \n\n19 \n \n   \n \nit is not separately stated how the data was searched, and which databases were \nused, but the report highlights the reliability and source criticality of the data and \nthat the choice is justified in relation to the research question. In explicit data \nselection, the selection process is described in detail, indicating which keywords \nand databases have been used, as well as exclusion and inclusion criteria. The \nselection method may, however, deviate from precise search terms, as well as \ntime and language rest rictions, if this is relevant to the research questions. For \nthis research an explicit data selection process was employed (Kangasniemi et \nal. 2013: 291–301.)  \nThis thesis was implemented as a descriptive literature review and the search for \noriginal research and articles was carried out systematically. In the initial phase \nof getting to know the topic, information was searched extensively from various \nreference databases in the health sector. The final information searches were \nconducted from international health sector reference databases  EBSCOhost \nCINAHL with full text , EBSCOhost Medline, PubMed, ScienceDirect and Wiley \nonline Library. \nThe keyword terms used in the article search were “endometriosis AND quality \nof life” on the database ScienceDirect and Wiley Online Library while in certain \ndatabases more specific terms were used to enhance the search result delibera-\ntely. Information retrieval from PubMed was done using the search terms “(endo-\nmetriosis [Title]) AND (quality of life [Title])”, while from EBSCOhost CINAHL and \nMedline the keywords were searched at the Title: endometriosis AND (quality of \nlife or wellbeing or well-being or health-related quality of life) \nAutomated filters for Full text articles, English language articles and articles from \n2014 till date was further applied. The purpose was to find relevant, recent and \ninternational studies on the topic. For the original studies selected for the litera-\nture review, admission criteria were defined before the selection, with the help of \nwhich an effort was made to narrow down the most relevant studies to be pro-\ncessed in the literature review. Inclusion and exclusion criteria are described in \nTable 1. \n \n\n20 \n \n   \n \n \nTable 1. Inclusion and exclusion criterion table. \nInclusion Criteria Exclusion Criteria \nAvailable articles to the search en-\ngine. Article in languages other than English. \nFree access articles Articles published prior to 2014 \nPDF articles with full texts \nArticles unrelated to endometriosis \n \nPresence of the keywords Articles that focus on medical aspect of en-\ndometriosis (e.g. laparoscopy) \nArticles published 2014-till date  Articles unrelated to the research ques-\ntions \nPeer reviewed articles Duplicate articles \nArticles in English language  \n \nThe selection of included and excluded studies for the literature review was done \nstep by step at the title, abstract and full text level, so that the studies found in \nthe searches are mirrored in the inclusion criteria. \nThe selection of the original studies selected for this literature review was deter-\nmined by the following inclusion criteria: the subject of the study is endometriosis, \nthe study has discussed the effects of endometriosis on a woman's life and quality \nof life (Keywords: Endometriosis AND Quality Of Life), the study is an original \nstudy, or an article written about it , peer reviewed articles, and the study can be \nread entirely electronically, free access and PDF articles with full texts . In addi-\ntion, the research is in English and published between 2014‒till date. \nIn the PubMed database search, the search term returned a total of 251 publica-\ntions, these were limited based on language (English language), Full text articles \nand year of publication (2014-2024), 106 articles remained, these were then exa-\nmined based on Title from which 31 articles were selected. From the EBSCOhost- \nCINAHL with Full Text  database using the search terms ( Title: endometriosis \nAND (quality of life or wellbeing or well-being or health-related quality of life) gave \n\n21 \n \n   \n \na total of 163 publications, these were limited based on language (English langu-\nage), Full text articles and year of publication (Past ten years), 45 articles remai-\nned from which 9 articles were selected based on Title.  \nA search was also conducted on EBSCOhost Medline database using the search \nterms (Title: endometriosis AND (quality of life or wellbeing or well -being or \nhealth-related quality of life) which returned a total of 264 results these were limi-\nted by language (English language), Full text articles and publication year (Past \n10 years), a total of 36 articles were remaining from which 6 articles were selected \nbased on Title.  \nScienceDirect database search using the search terms ( Endometriosis AND \nQuality of life) returned 11,141 results limited based on Year of publication: 2015–\n2025, Title: endometriosis AND Quality of life Open Access and Open archive,25 \narticles remained from which 4 articles were selected based on Title. \nAlso, from the database Wiley online library a search was conducted using the \nsearch terms (Endometriosis AND quality of life) which returned 10,738 publica-\ntions, application of the filters Publication year 2014–2024 (Title: Endometriosis \nAND quality of life), Open Access content returned 1 article which was a duplicate \nof another article from previous database search result. The information retrieval \nprocess from electronic databases is presented in Table 2. \nTable 2. Information Retrieved from Database search results. \nDatabase and \nsearch terms \nResults( \nn=) \n \nFilters  \nCho-\nsen \nafter \nfilter \nIn-\ncluded \nin re-\nview \nbased \non title  \nPubMed (endometri-\nosis [Title]) AND \n(quality of life [Title]) n=251 \nEnglish language, Full \ntext articles, 2014 till date n=106 n=31 \nEBSCOhost- CI-\nNAHL with Full Text: \nTitle: endometriosis \nAND (quality of life or \nn=163 English language, Full \ntext articles,  Past 10 \nyears. \nn=45 n=9 \n\n22 \n \n   \n \nDatabase and \nsearch terms \nResults( \nn=) \n \nFilters  \nCho-\nsen \nafter \nfilter \nIn-\ncluded \nin re-\nview \nbased \non title  \nwellbeing or well -be-\ning or health -related \nquality of life)  \nScienceDirect: endo-\nmetriosis AND Qual-\nity of life  \nn=11,141 \nYear: 2015-2025 \nTitle: endometriosis AND \nQuality of life \nOpen Access and Open \narchive \nn=25 \nn=4 \n \nEBSCOhost Medline: \nTitle: endometriosis \nAND (quality of life or \nwellbeing or well -be-\ning or health -related \nquality of life)  \nn=264 \nEnglish language, Full \ntext art icles, Past 10 \nyears. \nn=36 n=6 \nWiley online library: \nEndometriosis AND \nquality of life  \nn=10,738 Year 2014-2024 \nTitle: Endometriosis AND \nquality of life  \nOpen Access content \nn=1 n=0 \n \n \nThe studies found in the information search were further reviewed at the keyword \nand abstract level, and full text level for eligibility. For this literature review, re-\nsearch that focus on Endometriosis risk factors, diagnosis and prevention of en-\ndometriosis, endometriosis associated diseases/symptoms and show no clear \nassociation with quality of life in endometriosis were excluded from the search \nresult. In the selected articles, the effects of endometriosis on a woman's quality \nof life were discussed at a more general level. In addition, the studies had to meet \n\n23 \n \n   \n \nthe inclusion criteria mentioned above. In the end a total of 12 articles were inclu-\nded for the literature review. The final selected articles are shown in Appendix 1. \nThe research articles selection process is shown in Figure 2. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nFigure 2. Research articles selection process. \n \nIdentification of studies via databases and registers \nRecords identified from 5 data-\nbases \nPUBMED (n= 251) \nEBSCOhost- CINAHL with Full \nText (n=163) \nScienceDirect (n=11,141) \nEbscohost Medline (n=264) \nWiley online library (n = 10738) \nRecords removed before screen-\ning: \nDuplicate records removed (n \n=7 ) \nRecords marked as ineligible \nby automation tools (n =0) \nRecords removed for other \nreasons (n = 0) \nRecords screened using d ata-\nbase filters \n(n = 22,606) \nRecords excluded \n(n = 22,335) \nReports sought for retrieval \n(n = 215) \nReports not retrieved \n(n =165) \nFull-texts articles assessed for el-\nigibility \n(n = 50) \nArticles excluded with reasons (n=38) \nResearch focus on Endometriosis, risk \nfactor (n =10) \nResearch focuses on diagnosis and \nprevention of endometriosis (n =5) \nResearch focuses on endometriosis \nassociated diseases/symptoms \n(n=10) \nNo clear association with quality of life \nin endometriosis (n=13) \n \nStudies included in review \n(n =12) \n  \nIdentification \nScreening \n \nIncluded \n\n24 \n \n   \n \n4.2 Content Analysis \nContent analysis is a systematic and objective research method used to describe \nand quantify phenomena , in content analysis words are  grouped into a smaller \nset of categories that are relevant to the content. The assumption is that words, \nphrases, and other elements within the same category convey similar meanings. \ncontent analysis serves to make valid and replicable inferences from data to its \nbroader context, with the aim of generating new knowledge, offering fresh in-\nsights, presenting facts, and providing practical guidance for action. (Elo & Kyn-\ngäs, 2008. 107-115.) This analysis can be Inductive or Deductive. Inductive ana-\nlysis process includes open coding, creating categories and abstraction.  Open \ncoding means that notes and headings are written in the  text while reading it . \nDeductive content analysis is used to retest existing data in a new context, to do \nthis a categorization matrix is developed from previous literature, after this, all the \ndata are reviewed and coded for correspondence with or without exemplification \nof the identified categories. The results are therefore a described content of the \ncategories, i.e. the meanings of the categories. The content of the categories is  \ndescribed through subcategories. (Elo & Kyngäs, 2008. 107-115.) \nDeductive content analysis is appropriate for this study as  we seek to apply the \nWorld Health Organization’s (WHO) definition of Quality of Life (QoL) and its di-\nmensions namely physical (this includes chronic pain, physical functionality, and \nthe impact of symptoms like fatigue or infertility on daily activities), psychological \n(this addresses emotional burdens, mental health challenges such as anxiety and \ndepression, and issues related to self -esteem and body image)  and social do-\nmains(which examines the impact of endometriosis on social relationships, family \ndynamics, and professional life) to the data collected from the literature on endo-\nmetriosis. The categorization matrix was developed using these predefined di-\nmensions to ensure a structured and comprehensive analysis. The focus on de-\nductive analysis allows the study to explore how existi ng theoretical frameworks \non QoL intersect with the lived experiences of women diagnosed with endometri-\nosis. This approach not only facilitates a deeper understanding of the phenome-\nnon but also ensures that findings are aligned with established QoL constructs \n(WHO, 2024; Elo & Kyngäs, 2008). \n\n25 \n \n   \n \nDuring the organizing phase the data was reviewed systematically and coded \nbased on its correspondence to the categories in the matrix. The pre -existing \nstructure allowed the analysis to focus on identifying patterns and variations in \nhow endometriosis affects each domain of QoL. For instance, statements or fin-\ndings about pain interfering with daily tasks were categorized under Physical \nQoL, while references to feelings of sadness or isolation were classified under \nPsychological QoL (Elo & Kyngäs, 2008). Example of categorization process is \nshown in Figure 3. In the reporting phase, the results are presented in alignment \nwith the predefined categories. This structured approach ensures clarity and co-\nherence in the findings, linking the data to the broader theoretical framework of \nQoL. (Elo & Kyngäs, 2008 .) Table detailing the categorization process is shown \nin Appendix 2. \n \nFigure 3. Example of categorization process. \n \n \n \n \nOriginal \nexpression\n•endometriosis-associated pelvic pain (EAPP), including dysmenorrhea, NMPP, and dyspareunia, contribute \nto a significant reduction in quality of life of women, and this effect increases with the severity of the pain.\nReduced \nexpression\n•Chronic pelvic pain is associated with poor quality of life.\nSub Category \n• Chronic pain\nGeneric \ncategory \n•Pain\nMain \nCategory \n•Impact of endometriosis on Physical Quality of life \n\n26 \n \n   \n \n5 RESULTS \nThe aim of this research was to identify the impact of endometriosis and its symp-\ntoms on a woman's quality of life and thereby help healthcare personnel better \nunderstand and guide patients suffering from endometriosis . This led to the re-\nsearch question, how does endometriosis affect the quality of life of women, and \nin what ways does it impact their overall physical, emotional, and psychological \nwell-being? To what extent can the symptoms and challenges associated with \nendometriosis interfere with daily a ctivities, relationships, work, and mental \nhealth, and how do these effects vary across different individuals? The result of \nthe research shows no doubt that endometriosis impacts the overall quality of life \nof women (this includes physical, mental wellbeing, social and sexual life and \nwork life) and these effects impact on the overall wellbeing and life course of \nwomen with endometriosis.  (Missmer et al. 2021.) \n5.1 Endometriosis and Its Impact on Overall Quality of Life \nEndometriosis affects the overall wellbeing of a person living with endometriosis, \nincluding social participation, physical and sexual functioning, and mental well -\nbeing, which collectively affect individuals’ educational, professional, and rela-\ntional fulfillment. Over time, these disruptions can lead to significant life course \nlimitations, restricting educational achievements, career progression, and stable \nrelationships. These limitations may manifest most acutely during formative peri-\nods from adolescence  to middle age, when significant, trajectory -defining deci-\nsions are made. Consequently, the effect of endometriosis induced symptoms \nand impairments is seen across the life -course of women and these effects are \ninterrelated. (Missmer et al., 2021) . (Figure 4) shows the interrelation between \nendometriosis-associated symptoms and quality of life impacts.  \n \n\n27 \n \n   \n \n \nFigure 4. Interrelation between endometriosis -associated symptoms and quality \nof life impacts.  \n5.2 Impact of Endometriosis on Physical Quality of life in Women \nTo explain the main category (impact of endometriosis on physical quality of life), \nOriginal expressions were reduced from the selected articles and (n=3) generic \ncategories were derived from (n=7) Subcategories. (Figure 5) shows the catego-\nrization process for Impact of endometriosis on Physical quality of life of women. \nEndometriosis as a chronic inflammatory condition characterized by the presence \nof endometrial-like tissues outside the uterus is strongly associated to and can  \nimpose significant personal, societal, and economic burdens, including poor \nhealth-related quality of life (HRQoL), loss of productivity, and direct healthcare \ncosts on women. In women, endometriosis is often accompanied by pelvic pain, \nthis includes a variety of chronic pelvic pain of which painful menstrual periods \n(Dysmenorrhea) are reported to be the most common, other pains include, non -\nmenstrual pelvic pain (NMPP) and painful intercourse (Dyspareunia). (As-Sanie, \nShafrir, Halvorson, Chawla, Hughes, & Merz, 2024.) \n\n\n28 \n \n   \n \nAccording to As-Sanie et al. (2024) endometriosis-associated pelvic pain (EAPP), \nincluding dysmenorrhea, NMPP, and dyspareunia , contribute to a significant re-\nduction in quality of life of women, and this effect increases with the severity of \nthe pain. In several studies that investigated the impact of EAPP on the HRQOL \nof women using indices such as the World Health Organization Quality of L ife-\nBREF (WHOQOL-BREF), adolescents and young adults (AYA) with endometrio-\nsis and dyspareunia showed significant fatigue, poor sleep quality, physical, men-\ntal, and bodily pain when compared to other AYA without endometriosis. \nWomen diagnosed with endometriosis have painful periods and pains that ad-\nversely affect their day-to-day functioning. In research by Kalfas, Chisari, & Wind-\ngassen, (2022) there were positive associations between endometriosis associ-\nated pain and depression, anxiety, stress, generalized worry  and somatization \n(defined as the tendency to experience psychological distress in the form of so-\nmatic symptoms). Consequently, there is critical need for heightened awareness \namong healthcare providers and patients, advocating for early intervention to mit-\nigate dysmenorrhea's long -term impacts on life trajectory and overall quality of \nlife (MacGregor, Allaire, Bedaiwy, Yong, & Bougie, 2023).  \nMuscle strength is vital for managing daily physical demands, but women with \nendometriosis show notable impairments according to a study by Álvarez-Sal-\nvago et al. (2020) where physical health domain between patients diagnosed with \nendometriosis in Spain were compared with women with no reported endometri-\nosis. Low back muscle strength in the endometriosis group studied was lower \nthan controls, accompanied by reduced spinal flexibility likely due to adhesions, \npain, and lumbar fascia thickening. These factors, along with diminished postural \nbalance and proprioception, hinder static and dynamic balance, affecting daily \nactivities. Functional capacity was also reduced in these women with higher en-\ndometriosis-related fatigue correlating with declines in strength,  flexibility, bal-\nance, and overall fitness, alongside poorer sleep and quality of life. (Álvarez-Sal-\nvago et al., 2020.)  \nEndometriosis has a profound impact on the overall well-being and quality of life \nof affected women. Research has demonstrated a significant negative associa-\ntion between endometriosis and sleep quality, as assessed through measures \n\n29 \n \n   \n \nsuch as sleep quality indices, sleep latency, and sleep disturbance scales. \nAmong women engaged in night-shift work, particularly those who perform night \nshifts for most of their work schedule, notable alterations in sleep patterns on \nnon-working days have been identified. These changes have been associated \nwith an increased risk of endometriosis. Furthermore, endometriosis has been \nlinked to heightened levels of daytime sle epiness, subthreshold insomnia, and \nmoderate clinical insomnia, underscoring the condition's pervasive impact on \nsleep health. (Youseflu, Sadatmahalleh, Roshanzadeh, Mottaghi, Kazemnejad, \n& Moini, 2020.) \n \n \nFigure 5. Categorization Process for Impact of Endometriosis on Physical quality \nof life in women. \n5.3  Impact of Endometriosis on Psychological and Emotional Quality of Life in \nWomen \nTo explain the main category (impact of endometriosis on psychological and emo-\ntional quality of life), original expressions were reduced from the selected articles \nand (n=2) generic categories were derived from (n=6) Subcategories. (Figure 6) \nshows the categorization process for Impact of endometriosis on psychological \nand emotional quality of life of women. \nSub \nCategory \n• (Chronic pelvic pain) (Painful Menstrual pain) (Painful \nintercourse)( Fatigue) (poor postural balance)  (Sleep pattern \nchange) (insomnia)\nGeneric \ncategory \n• (Pain) . (Sleep Quality) (Physical strength)  \nMain \nCategory \n• Impact of endometriosis on Physical Quality of life \n\n30 \n \n   \n \nThe psychological toll of endometriosis is profound, as emotional dysregulation \nand psychological distress are often reported among patients. with severe pain \nsymptoms experience higher rates of anxiety and depression, suggesting a bidi-\nrectional relationship between pain and psychological health. (Rodríguez-Lozano \net al. 2022) Emotional dysregulation is a phenomenon marked by difficulties in \nmanaging emotions, heightened sensitivity, and impaired stress response, which \nin turn exacerbates the overall impact on quality of life. The study by Rodríguez-\nLozano et al. (2022) explores the complex relationship between endometriosis \nand emotional dysregulation, offering insight into how the condition impacts men-\ntal health and emotional well -being. This study indicates that chronic pain and \nphysical limitations imposed by endometriosis can lead to elevated anxiety, de-\npression, and emotional instability, particularly among women who experience \nsevere symptoms. Emotional dysregulation, a ccording to this study, often mani-\nfests irritability, mood swings, and difficulty in emotional control, adding another \nlayer of challenge to daily life. Women with endometriosis may also face social \nand interpersonal issues, stemming from both the physical pain and the emotional \nturmoil caused by the condition. This emotional impact not only affects their men-\ntal health but also strains their relationships and social interactions, leading to \npotential isolation and reduced quality of life. (Rodríguez-Lozano et al., 2022.) \nIn a study by Mu haram etal. (2022) exploring the association between chronic \npelvic pain of endometriosis and psychiatric disorder in women,revealed that pain \nand \"control and powerlessness\" were the most significant components among \nwomen with endometriosis, with pain scores indicating severe levels and sug-\ngesting life control impairment due to the experienced pain. Emotional well-being \nalso scored high, reflecting notable emotional disturbances and psychiatric per-\nceptions. Depression and anxiety disorders were the most prevalent psychiatric \nconditions, with more than a quarter of participants experiencing depression. Hor-\nmonal changes in women are known to increase susceptibility to depression, and \nwomen with endometriosis face an elevated risk of generalized anxiety disorder, \ndepression, alcohol addiction, and ADHD. Previous research indicates a  slight \nhazard ratio for depression in women with endometriosis. ( Muharam etal. 2022.) \n\n31 \n \n   \n \nOne of the causes of infertility is endometriosis, this relationship between endo-\nmetriosis and infertility is significant, with around 40% of women with endometri-\nosis are infertile, and between 25% and 50% of infertile women have endometri-\nosis. Women deali ng with infertility sometimes because of endometriosis lose \ncontrol over reproductive decisions and experience feelings of guilt, sadness, \nshame, and social isolation which has shown to reduce quality of life and nega-\ntively affect their mental wellbeing. I n addition to infertility clinical symptoms of \nendometriosis such as menstrual irregularity, chronic pelvic pain (CPP), dysmen-\norrhea, and dyspareunia also emotionally affect patients. (Mori, Zaia, Montagna, \nVilarino, & Barbosa, 2024.) \nIntegrative therapeutic interventions aimed at addressing both physical symp-\ntoms and emotional dysregulation, with approaches like cognitive behavioral ther-\napy (CBT) and stress management techniques can help patients better navigate \nthe psychological chall enges of endometriosis. This approach may foster emo-\ntional resilience, allowing women to manage their symptoms more effectively and \nimprove their overall quality of life. (Rodríguez-Lozano et al., 2022.) \n \n \nFigure 6. Categorization process for Impact of endometriosis on psychological \nand emotional quality of life in women. \nSub \nCategories\n• (Depression) (Emotional dysregulation)( elevated \nanxiety) (infertility stress) (Feeling of sadness) (Guilt)\nGeneric \ncategory \n•(Pyschological stress) (Pyschiatric disorder) \nMain \nCategory \n•Impact of endometriosis on psychological and emotional \nquality of life \n\n32 \n \n   \n \n5.4 Impact of Endometriosis on Social Quality of Life and Sexual Health of \nWomen. \nTo explain the main category (impact of endometriosis on social quality of life and \nsexual health), Original expressions were reduced from the selected articles and \n(n=3) generic categories were derived from (n= 8) Subcategories. (Figure 7) \nshows the categorization process for Impact of endometriosis on social quality of \nlife and sexual health of women. \nEndometriosis significantly impacts social lives, with many women reporting re-\nstricted participation in social activities due to pain, dyspareunia, fatigue, and de-\npression. Nearly half of women in a long -term registry cited physical limitations \nas a direct cause of reduced social engagement, often leading to isolation. Symp-\ntoms like dysmenorrhea further exacerbate social withdrawal, as seen in a Swe-\ndish study where 60% of adolescents avoided social activities due to menstrual \npain. (Missmer et al.2021.)   \nNegative impact of endometriosis symptoms on daily activities amongst adoles-\ncents with endometriosis and dysmenorrhea have also been reported. This can \ninclude missing out on social events, school, or work, which contributes to social \nisolation and difficulties in maintaining social commitments. social relationships, \nincluding friendships, family dynamics, and romantic relationships. The condi-\ntion's chronic pain and unpredictability often make it difficult to engage in normal \nsocial activities, leading to s ocial isolation, withdrawal from social networks, di-\nminish in coping abilities and an increase in feelings of loneliness. (Liakopoulou \net al. 2022.)  In addition, Women with endometriosis often experience fatigue \nlinked to pain, reduced emotional well-being, and inadequate social support. De-\nlayed diagnosis and treatment due to insufficient healthcare support worsen the \nsocial and emotional burden, resembling challen ges seen in adolescents with \nother chronic pain conditions like fibromyalgia or migraines. (Missmer et al. 2021.) \nEndometriosis profoundly affects women's sexual health, emotional well -being, \nand relationships. Dyspareunia, chronic pelvic pain, and depression contribute to \nreduced sexual activity, satisfaction, and self -esteem, lowering overall quality of \nlife. Women with endometriosis face increased risks of depression and anxiety, \n\n33 \n \n   \n \nwhich, along with poor sleep quality, exacerbate pelvic pain and impair daily func-\ntioning, creating a vicious cycle. Social isolation and feelings of shame further \nstrain relationships, with many women reporting a lack of understanding and sup-\nport. While chronic pain is a key factor, the complex interplay between physical \nand psychological distress remains under investigation. Women with endometri-\nosis face significant reductions in both mental and physical quality of life (QoL), \nsurpassing those seen in con ditions that primarily affect physical health. Emo-\ntional and sexual challenges, alongside feelings of frustration, anger, guilt, and \nshame, further compound these effects. Promoting open communication about \nrelational and sexual issues can aid in coping an d improving overall well -be-\ning.(Della Corte et al., 2020.) \nEndometriosis significantly affects personal relationships, including social, family, \nand intimate connections, due to their physical and emotional burdens. Sexual \nhealth is particularly impacted, with studies showing high rates of sexual distress \nand dysfunction. In Austria and Germany, 78% of women with endometriosis re-\nported sexual distress, and 32% experienced sexual dysfun ction, often linked to \npain during intercourse. A Dutch study found women with endometriosis had \nmore dyspareunia and lower sexual functioning scores. Dyspareunia and depres-\nsion were strong predictors of sexual difficulties, with many fearing it would affect \ntheir relationships. (Missmer et al., 2021.) \n Endometriosis profoundly impacts sexual and relational dynamics. Women often \nexperience reduced sexual frequency, satisfaction, and self -esteem, leading to \nfeelings of inadequacy, guilt, and difficulty engaging with their partner. Fear of \npain further diminishes intimacy and affection, while male partners report frustra-\ntion, decreased libido, and relational challenges, including infidelity or reliance on \ndigital media. These issues exacerbate the emotional burden for women, wors-\nening their quality of life and fuelling guilt and shame tied to the condition. \n(Farenga et al., 2024.) \n\n34 \n \n   \n \n \nFigure 7. Categorization Process for Impact of Endometriosis on Social Quality \nof Life and Sexual Health in Women  \n \n5.5 Impact of Endometriosis on Work Life and Education of women  \nTo explain the main category (impact of endometriosis on work life and education \nof women ), Original expressions were reduced from the selected articles and \n(n=2) generic categories were derived from (n= 4) Subcategories. (Figure 8) \nshows the categorization process for Impact of endometriosis on work life and \neducation of women. \nThe educational impacts of endometriosis on women, highlighting the challenges \nthat symptoms, especially pain, impose on academic progression has been \nwidely. For instance, a qualitative study from Sweden involving women diag-\nnosed with endometriosis report ed that the condition had led to missed educa-\ntional and career opportunities, as cited by women receiving chronic pain treat-\nment in a clinical setting. Another study using self-reported questionnaires found \nthat about 23.2 % of 431 women with endometriosis indicated they had refrained \nfrom pursuing further education due to their condition. Notably, participants in this \nstudy generally had a higher education level than comparable populations, po-\ntentially due to care access bias where women with diagnosed end ometriosis \nSub \nCategory \n• (reduced social participation) (Social withdrawal) (Missing school) (Difficult \nfamily dynamics) (Difficulty in romantic Relationships) (increased feeling of \nloneliness)(Reduced quality of Sex) (Difficulty with partners)\nGeneric \ncategory \n•(Relationship) (Social life) (Sexual life)\nMain \nCategory \n•Impact of endometriosis on Social Quality of life and Sexual health\n\n35 \n \n   \n \nmay have more educational resources. Pain emerged as a critical factor in limiting \neducational opportunities. (Missmer et al., 2021.) \nA cross-sectional study involving both adolescents and adults with confirmed en-\ndometriosis found that around 60% reported moderate -to-extreme interference \nwith work or school from endometriosis-related pain. Similarly, a large web-based \nsurvey of Swedish a dolescent girls linked dysmenorrhea with school absences, \nsuggesting that even without an official endometriosis diagnosis, pain may signif-\nicantly disrupt schooling. Additionally, a French study on the adolescent history \nof women undergoing surgery for endometriosis (2021) found that those with \ndeep endometriosis experienced more frequent absenteeism during menstrua-\ntion than those with other types. These findings align with impacts observed in \nother chronic pain conditions, like adolescent fibromyalgia, which also correlates \nwith reduced educational attainment in young women. (Missmer et al., 2021.) \n \nFigure 8. Categorization process for the Impact of Endometriosis on work life and \neducation \n \n \n \n \nSub \nCategory \n• (missed education oppurtunities) (missed career \noppurtunities) (Interference with work) (School absence)\nGeneric \ncategory \n• (Work life ) (Education)\nMain \nCategory \n• Impact of endometriosis on work life and education \n\n36 \n \n   \n \n6 THESIS ETHICS AND RELIABILITY  \nAs a descriptive literature review, ethicality in every phase of the thesis is empha-\nsized due to methodological looseness. To do this, a clear description and trans-\nparency of the method is done to ensure the reliability and sufficiency of the re-\nview (Kangasniemi et al., 2013 291–301.) In the formulation of the research ques-\ntion, selection and processing of the data, ethics compliance is ensured by rec-\nognizing the bias caused by possible subjectivity, fairness, equality, and honesty \nof the data report. (Kangasniemi et al. 2013: 291–301.)   \nTo ensure reliability of the research, the research question is presented clearly \nand detailed theoretical justification for the questions are done . Also, the basis \nfor the materials selected is detailed to improve the reliability of the thesis. (Kan-\ngasniemi et al. 2013: 291 –301.) Proper citation and referencing were diligently \nemployed to ensure due credit to the original authors and prevent plagiarism. To \nensure trustworthiness, reliability and validity of the analysis, the study employed \ntransparent documentation of the coding process, consistent application of the \ncategorization matrix, and cross-referencing with source material. Authentic cita-\ntions were used to enhance trustworthiness, and care was taken to present find-\nings that reflect the nuances of the data while maintaining alignment with the pre-\ndefined framework (Elo & Kyngäs, 2008.) \nThis study delve d into the experiences and perspectives of adolescents in the \ncare of endometriosis patients. It comprehensively explores the impact of endo-\nmetriosis on various facets of patients’ lives, encompassing physical health, emo-\ntional well-being, social interactions, and daily activities. The research methodol-\nogy includes a meticulous review of existing literature on the topic. The method-\nology for this literature review-based research thesis emphasizes descriptive lit-\nerature review approach to identifying, evaluating, and synthesizing existing re-\nsearch on the impact of endometriosis-associated symptoms on the quality of life \nof women. By employing this methodology, the research aims to contribute to a \ncomprehensive understanding of the topic and its implications for women’s \nawareness and healthcare globally. (Kangasniemi et al. 2013: 291–301.) \n \n\n37 \n \n   \n \nWhile descriptive literature review is a helpful methodological approach to review \nscientific information in nursing and other health sciences, we acknowledge its \nreliability may be limited by 1) the fact that the studies analyzed may be too thinly \nconnected to the theoretical background 2) selective review of the analyzed result \n3) limitation to current situations and possible future. (Kangasniemi et al. 2013: \n291–301.) \n\n38 \n \n   \n \n7 DISCUSSION \nThe purpose of our thesis was to find out how the  physical and psychological \nquality of life of women living with endometriosis was affected by the symptoms \nof the disease and what extent can these symptoms and challenges associated \nwith endometriosis interfere with daily activities, relationships, work, and mental \nhealth, and how do these effects vary across different individuals . The findings \ndemonstrate the multifaceted impact of endometriosis on women's quality of life, \nsignificantly influencing physical, psychosocial, emotional, social, educational, \nand occupational domains. These interconnected effects substantially disrupt \nday-to-day functioning (Kalfas et al., 2022).  \nFrom the results, endometriosis is associated with pain, variety of chronic pelvic \npain of which painful menstrual periods (Dysmenorrhea) are reported to be the \nmost common, other pains include, non-menstrual pelvic pain (NMPP) and pain-\nful intercourse (Dys pareunia). Pain directly affected the living conditions of wo-\nmen living with endometriosis, this effect increases in tandem with the severity of \npain experienced, according to Bien et al. (2020) daily functioning of most women \nliving with endometriosis is significantly reduced due to pain. Furthermore, endo-\nmetriosis associated pain (EAP) is positively associated with the presence of \npsychological stress symptoms such as depression, anxiety, stress , worry and \nsomatization. (Kalfas etal. 2022.)  \nThe findings underscore that the physical symptoms of endometriosis, such as \ndysmenorrhea, chronic pelvic pain (CPP), and dyspareunia, severely impair daily \nfunctioning and health-related quality of life (HRQoL). The chronic inflammatory \nnature of endometriosis contributes to muscle fatigue, reduced strength, and di-\nminished flexibility, as noted by Álvarez -Salvago et al. (2020) According to As -\nSanie et al (2024) pain is a central symptom of endometriosis; individualized pain \nmanagement strategies must be im plemented. This includes pharmacological \ntreatments (e.g., NSAIDs, hormonal therapy) and non-pharmacological methods \n(e.g., heat therapy, exercise) to provide holistic relief . Limiting physical capacity \n\n39 \n \n   \n \nand further exacerbating fatigue and pain. Pain severity, particularly endo-\nmetriosis-associated pelvic pain (EAPP), is strongly correlated with poorer phy-\nsical health outcomes and increased healthcare costs (As-Sanie et al. 2024.)  \nAdditionally, the significant impact on sleep quality —manifesting in insomnia, \nsleep disturbances, and fatigue—further amplifies these physical limitations. Re-\nsearch by Youseflu et al. (2020) highlights the correlation between disrupted \nsleep patterns and heightened endometriosis risk, adding another dimension to \nits pervasive influence. Early interventions targeting pain and sleep quality may \nbe critical in m itigating these compounding effects on physical well -being (You-\nseflu et al. 2020). Tailoring the treatment approach to the specific needs of each \npatient can help mitigate pain's disruptive effects on daily activities and work \nproductivity (Macgregor et al. 2023.) \nEndometriosis exerts profound psychological and emotional tolls on affected wo-\nmen, as evidenced by heightened rates of anxiety, depression, and emotional \ndysregulation. Chronic pain and hormonal changes appear to exacerbate these \nmental health challenges, creating a bidirectional relationship where psychologi-\ncal distress worsens physical symptoms. This cycle can further manifest in social \nwithdrawal, irritability, and mood swings, as women struggle to manage their \nsymptoms alongside daily life demands (Rodríguez-Lozano et al. 2022.) \nGiven the multidimensional impact of endometriosis on both physical and \npsychosocial well-being as highlighted by Rodríguez-Lozano et al., (2022) treat-\nment plans should integrate medical, psychological, and social support. Along \nwith traditional pharmacological therapies for pain management, healthcare pro-\nviders should also consider psychosocial interventions, such as cognitive beha-\nvioural therapy and stress management techniques, to improve the mental health \nand overall well-being of patients (Rodríguez-Lozano et al. 2022) \nThe emotional burden is particularly pronounced among women facing infertility \ndue to endometriosis, which can lead to feelings of guilt, shame, and loss of con-\ntrol over reproductive decisions. The findings reinforce the need for integrative \n\n40 \n \n   \n \ntherapeutic approaches, such as cognitive -behavioral therapy (CBT), that ad-\ndress both physical symptoms and psychological distress to foster resilience and \nimprove mental well-being (Mori et al. 2024.) \nSocial isolation is a pervasive consequence of endometriosis, driven by physical \nlimitations, pain, and psychological distress. Women with endometriosis often ex-\nperience restricted participation in social activities, leading to feelings of loneli-\nness and d iminished coping abilities (Liakopoulou et al., 2022 .) The condition \nalso profoundly impacts sexual health, with dyspareunia and reduced sexual sat-\nisfaction contributing to lower self-esteem and relational challenges. As Farenga \net al. (2024) noted, the in terplay between chronic pain, psychological distress, \nand fear of intimacy creates a vicious cycle that negatively affects women and \ntheir partners, underscoring the need for open communication and tailored sup-\nport (Farenga et al. 2024.)  Theres a var iation in the factors that affect QoL in \nwomen with endometriosis, showing the need for a multidisciplinary, patient-cen-\ntered care approach. patient-oriented care, characterized by continuity, respect, \nand provision of information, may improve HRQoL in women with endometriosis  \n(Bień et al. 2020.) \nEducational interventions focusing on positive coping mechanisms, such as cog-\nnitive restructuring, can be beneficial in helping patients manage the emotional \ntoll of the disease. Healthcare professionals should encourage psychosocial sup-\nport and coping skills training as part of standard care for endometriosis patients. \nAdolescents with endometriosis are particularly vulnerable to emotional dis-tress, \nsocial isolation, and missed educational opportunities as reported by Missmer et \nal. (2020) Specialized care pathways for young women should incorporate age -\nappropriate counselling and peer support networks to address the unique chal-\nlenges they face, including difficulties in school and social settings. Collaboration \nwith schools, families, and community organizations can further help reduce \nstigma and provide holistic support for affected individuals (Missmer et al. 2020) \n \n\n41 \n \n   \n \nEmpowering patients with knowledge about their condition and equipping them \nwith coping strategies can drastically improve their experience with endometrio-\nsis. Educating both patients and healthcare providers about the psychological \nand social dimensions o f the disease will help reduce stigma and improve the \nholistic care provided. This is particularly significant for young women, who may \nfeel isolated due to the nature of their symptoms and the delayed diagnosis. Wo-\nmen with endometriosis often undergo unnecessary tests and treatments, raising \nhealthcare costs and risks of adverse effects. Including HRQoL measures in cli-\nnical assessments can enhance diagnostic accuracy, improve outcomes, and \nfoster self-efficacy while promoting public health. Early diagnosis and effective \nmanagement can help prevent or mitigate the negative outcomes on these critical \naspects of life. Additionally improving diagnostic accuracy and treatment efficacy \ncould have substantial benefits not  only for patient well -being but also for the \nwider economy. By addressing work productivity loss and minimizing disability, \nhealthcare systems could reduce the overall economic impact of the disease  \n(Missmer et al. 2020.) \nOne of the most notable findings is the impact of psychosocial interventions on \nquality of life. According to Rodríguez-Lozano et al. (2022.) integrating psycholo-\ngical care, such as counselling, stress management, and coping skills training, \ninto the treatment plan, healthcare providers can significantly improve the \npsychological well-being and overall QoL of endometriosis patients. These inter-\nventions can also prevent the escalation of emotiona l dysregulation and mental \nhealth disorders like anxiety and de pression, which are commonly associated \nwith chronic illness (Rodríguez-Lozano et al. 2022.) \nAs Nursing students, working on this thesis provided us with insights into the right \nprocess of systematic literature review, the data collection, analysis and reporting \nstages were all significant learning points, we also deepened out knowledge of \nthe effect of endometriosis as a chronic disease on women’s wellbeing, and fac-\ntors that contributes to these effects. This body of work highlights the life-long \nimpact of endometriosis, as it affects crucial areas such as education, career de-\nvelopment, relationships, and family formation , also provides information on the \neffects of endometriosis on the quality of life and overall wellbeing of women . \n\n42 \n \n   \n \nRecognizing the long-term implications of this disease can guide healthcare pro-\nviders in not only addressing the current symptoms but also in helping patients \nnavigate life decisions that are influenced by their condition. \nThere are plenty of medical studies and articles about endometriosis that focus \non surgical and medical treatments and their importance for quality of life cannot \nbe underestimated. These studies focused mainly on medical and surgical treat-\nments and aspects, with little emphasis on women's quality of life factors. In the \nfuture, there should be even more research into the effects of the disease on \nwomen's quality of life and how endometriosis patients could be better supported \nin both physical and psychosocial matters. Studies on the role of nursing care in \nimproving quality of life would also be useful for professionals.  Future research \nshould focus on understanding the long-term psychological effects of endometri-\nosis, particularly its impact on life -course potential. Studies should explore how \ndifferent coping strategies and psychosocial interventions influence the trajectory \nof the disease and the long-term outcomes in terms of career, relationships, and \nfamily building. Moreover, research into pain mechanisms and how they relate to \ndisease severity could improve the clinical understanding of endometriosis and \ninform more effective treatments. \n \n \n \n \n \n \n \n \n \n \n\n43 \n \n   \n \nBIBLIOGRAPHY \nA.L. Shafrir, L.V. Farland, D.K. Shah, H.R. Harris, M. 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Imboden,Pain Levels of Women Diagnosed with \nEndometriosis: Is There a Difference in Younger Women?,Journal of Pediatric \nand Adolescent GynecologyVolume 36, Issue 2,2023,Pages 140-147,ISSN \n1083-3188, \nhttps://doi.org/10.1016/j.jpag.2022.10.011.(https://www.sciencedirect.com/scien\nce/article/pii/S1083318822003345) Accessed on 15th November 2024. \nYouseflu, S., Jahanian Sadatmahalleh, S., Roshanzadeh, G., Mottaghi, A., \nKazemnejad, A., & Moini, A. (2020). Effects of endometriosis on sleep quality of \nwomen: Does life style factor make a difference? BMC Women’s Health, 20(1), \n1–7. https://doi.org/10.1186/s12905-020-01036-z. Accessed on November 10, \n2024. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n\n47 \n \n   \n \n \nAPPENDICES \nAppendix 1.  Table of articles chosen for the review \nAppendix 2.  Categorization Table \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n\n48 \n \n   \n \nNumber Article Author,year and title \n1 Bień A, Rzońca E, Zarajczyk M, Wilkosz K, Wdowiak A, Iwanowicz-Palus G. 2020 \nQuality of life in women with endometriosis: a cross-sectional survey. Qual Life Res.  \n2 Mori, L. P., Zaia, V., Montagna, E., Vilarino, F. L., & Barbosa, C. P. (2024).  \nEndometriosis in infertile women: An observational and comparative study of quality of life, anxiety, and depression. \nThis study accessed and compared the levels of depression, anxiety, and quality of life in infertile women with and without \nendometriosis. \n3 Liakopoulou, M.-K., Tsarna, E., Eleftheriades, A., Arapaki, A., Toutoudaki, K., & Christopoulos, P. (2022). \n Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of Literature. \nStudy aims to work on Medical and Behavioral Aspects of Adolescent Endometriosis \n\n49 \n \n   \n \n4 Missmer, S. A., Tu, F. F., Agarwal, S. K., Chapron, C., Soliman, A. M., Chiuve, S., Eichner, S., Flores-Caldera, I., Horne, A. \nW., Kimball, A. B., Laufer, M. R., Leyland, N., Singh, S. S., Taylor, H. S., & As-Sanie, S. (2021). \n5 Kalfas, M., Chisari, C., & Windgassen, S. (2022). Psychosocial factors associated with pain and health-related quality of life \nin Endometriosis. \nThe systematic review aims to explore the association of psychosocial factors with pain intensity/severity and HRQoL in \nwomen with Endometriosis. \n6 Youseflu, S., Jahanian Sadatmahalleh, S., Roshanzadeh, G., Mottaghi, A., Kazemnejad, A., & Moini, A. (2020).  \nEffects of endometriosis on sleep quality of women: Does lifestyle factor make a difference?  \nStudy aimed to compare the lifestyle factors and SQ between women with and without endometriosis. \n7 MacGregor, B., Allaire, C., Bedaiwy, M. A., Yong, P. J., & Bougie, O. (2023). \nDisease Burden of Dysmenorrhea: Impact on Life Course Potential  \nStudy aimed to check disease Burden of Dysmenorrhea: Impact on Life Course Potential \n8 Álvarez-Salvago, F., Lara-Ramos, A., Cantarero-Villanueva, I., Mazheika, M., Mundo-López, A., Galiano-Castillo, N., \nFernández-Lao, C., Arroyo-Morales, M., Ocón-Hernández, O., & Artacho-Cordón, F. (2020). \nChronic Fatigue, Physical Impairments and Quality of Life in Women with Endometriosis,  \nThe aim of the study was to examine Chronic Fatigue, Physical Impairments and Quality of Life in Women with \nEndometriosis \n\n50 \n \n   \n \n9 Mińko, A., Turoń-Skrzypińska, A., Rył, A., Bargiel, P., Hilicka, Z., Michalczyk, K., Łukowska, P., Rotter, I., & Cymbaluk-\nPłoska, A. (2021). \nEndometriosis-A Multifaceted Problem of a Modern Woman. \nExamine Endometriosis as a multifaceted problem of a modern woman  \n10 Muharam, R., Amalia, T., Pratama, G., Harzif, A. K., Agiananda, F., Maidarti, M., Azyati, M., Sumapraja, K., Winarto, H., Wi-\nweko, B., Hestiantoro, A., Suarthana, E., & Tulandi, T. (2022).  \nChronic Pelvic Pain in Women with Endometriosis is Associated with Psychiatric Disorder and Quality of Life Deterioration \nTo examine the association of Chronic Pelvic Pain in Women with Endometriosis with Psychiatric Disorder and Quality of Life \nDeterioration \n11 Della Corte, L., Di Filippo, C., Gabrielli, O., Reppuccia, S., La Rosa, V. L., Ragusa, R., Fichera, M., Commodari, E., Bifulco, \nG., & Giampaolino, P. (2020).  \nThe Burden of Endometriosis on Women’s Lifespan: A Narrative Overview on Quality of Life and Psychosocial Wellbeing.  \nThe aim is to summarize impact of endometriosis on quality of life in all its aspects including sexual life, work, and social \nrelationships \n12 Farenga, E., Bulfon, M., Dalla Zonca, C., Tersar, C., Ricci, G., Di Lorenzo, G., & Clarici, A. (2024). \n A Psychological Point of View on Endometriosis and Quality of Life: A Narrative Review.  \nThe publication explores the pathology of endometriosis, review its impact on quality of life and psycho-social effects, and \ndiscuss the experience of pain within the mind-brain-body relationship. \n \n \n\n51 \n \n   \n \nAppendix 2.  Categorization process table \n \nMainCategory Generic Category Sub Category Reduced Expression Original Expression \n     \nImpact on Quality of Life Life Course Effects Overall Well-being Disrupts education, ca-\nreer, and relationships. \nEndometriosis affects so-\ncial participation, physi-\ncal and sexual function-\ning, and mental well -be-\ning, influencing educa-\ntion, career, and relation-\nships across the life \ncourse, particularly during \nformative years. \n\n52 \n \n   \n \n  Life Course Limitations Long-term life limitations \ndue to symptoms. \nSymptoms restrict key de-\ncisions and achieve-\nments, with compounded \neffects across social and \nprofessional domains, \nmanifesting strongly dur-\ning adolescence to middle \nage. \nImpact on Physical Qual-\nity of life \nPain, sleep quality and \nphysical strenght  \n \nChronic pelvic pain) (Painful \nMenstrual pain) (Painful in-\ntercourse) (Fatigue) (poor \npostural balance) ( Sleep \npattern change) (insomnia) \nChronic pelvic pain re-\nduces quality of life. \nEndometriosis-associ-\nated pelvic pain (EAPP), \nincluding dysmenorrhea, \nnon-menstrual pelvic pain \n(NMPP), and dyspareunia, \nsignificantly reduces \nquality of life, with severity \nincreasing impacts. \n\n53 \n \n   \n \n   \n \nEndometriosis disrupts \nsleep patterns and qual-\nity. \nPoor sleep quality, sub -\nthreshold insomnia, and \nchanges in sleep patterns, \nespecially for night -shift \nworkers, are linked to en-\ndometriosis. \n  Comorbid Psychological \nDistress \nPain linked to mental \nhealth challenges. \nPain is associated with in-\ncreased rates of depres-\nsion, anxiety, and stress, \nnecessitating early inter-\nvention to mitigate long -\nterm impacts on quality of \nlife. \n. Impact of endometriosis \non psychological and \nemotional quality of life of \nwom-en. \n• Pyschological \nstress)  \n• (Pyschiatric disor-\nder)  \n \n• Depression) (Emo-\ntional dysregula-\ntion)( elevated anx-\niety) (infertility \nPain heightens emotional \ninstability. \nChronic pain exacerbates \nemotional instability, \nleading to irritability, \nmood swings, and difficul-\nties in emotional control, \n\n54 \n \n   \n \nstress) (Feeling of \nsadness) (Guilt \n \nwhich compound the \nchallenges of endometrio-\nsis. \n  Anxiety and Depression Severe symptoms linked \nto anxiety and depression. \nWomen with severe symp-\ntoms face higher rates of \nanxiety and depression, \nimpacting both mental \nhealth and interpersonal \nrelationships. \n  Infertility-Related Distress Infertility impacts mental \nhealth and quality of life. \nEndometriosis-associ-\nated infertility causes \nguilt, sadness, and isola-\ntion, reducing quality of \nlife and mental well-being. \n  Integrated Therapies CBT and stress manage-\nment aid emotional well -\nbeing. \nApproaches like CBT and \nstress management foster \n\n55 \n \n   \n \nresilience and help man-\nage the psychological toll \nof endometriosis. \nImpact of endometriosis \non Social Quality of life \nand Sexual health \n• (Relationship) (So-\ncial life) (Sexual life \n \n• reduced social \nparticipation) (So-\ncial withdrawal) \n(Missing school) \n(Difficult family dy-\nnamics) (Difficulty \nin romantic Rela-\ntionships) (in-\ncreased feeling of \nloneliness) \n(R8educed quality \nof Sex) (Difficulty \nwith partners) \n \nSymptoms lead to re-\nduced social interactions. \nPain, fatigue, and emo-\ntional turmoil often lead to \nwithdrawal from social in-\nteractions, diminished \ncoping abilities, and lone-\nliness. \n\n56 \n \n   \n \n  Relationship Challenges Strains personal and ro-\nmantic relationships. \nPhysical pain and emo-\ntional distress strain per-\nsonal and intimate rela-\ntionships, with many fear-\ning its impact on maintain-\ning partnerships. \n  Sexual Dysfunction Dyspareunia affects sex-\nual health and relation-\nships. \nHigh rates of dyspareunia \nand sexual distress signif-\nicantly impact sexual \nhealth, with pain predict-\ning sexual difficulties. \nImpact on Work and Edu-\ncation \nProductivity and Educa-\ntion \nEducational Challenges Pain disrupts education \nand schooling. \nPain and fatigue cause \nschool absences, re-\nduced academic perfor-\nmance, and missed edu-\ncational opportunities, \nespecially for adoles-\ncents. \n\n57 \n \n   \n \n  Career Limitations Pain restricts career op-\nportunities. \nSymptoms, particularly \nduring menstruation, lead \nto absenteeism and re-\nstricted career progres-\nsion, impacting long -term \nprofessional fulfillment. \n  Societal and Economic \nBurdens \nProductivity and eco-\nnomic losses due to \nsymptoms. \nLoss of productivity and \nhigh healthcare costs \ncontribute to the broader \nburden of endometriosis.","source_license":"CC0","license_restricted":false}