Impact of structured lifestyle interventions on clinical, metabolic, and reproductive outcomes in women with endometriosis

Background: Endometriosis is a chronic gynecological disorder associated with pelvic pain, infertility, metabolic disturbances, and impaired quality of life. Lifestyle factors such as diet, physical activity, obesity, and stress have been implicated in the progression and severity of endometriosis. Lifestyle modification may offer a cost-effective adjunctive approach in improving both metabolic and reproductive outcomes in affected women. Aim: To evaluate the effect of lifestyle modifications on metabolic a nd reproductive outcomes among women with endometriosis.

This prospective interventional study was conducted among 50 women aged 18 - 40 years diagnosed with endometriosis at a tertiary care center. Participants underwent a structured six-month lifestyle modification program including dietary counseling, physical activity, weight management, stress reduction, and behavioral counseling. Baseline and post -intervention assessments included anthropometric measurements, fasting blood glucose, lipid profile, insulin resistance, menstrual characteristics, pain severity using Visual Analogue Scale (VAS), and quality of life using Endometriosis Health Profile -30 (EHP-30). Statistical analysis was performed using paired ttest and chi-square test, with p<0.05 considered statistically significant.

Significant reductions were observed in body weight, body mass index, waist circumference, fasting blood glucose, triglyceride levels, and HOMA -IR scores following intervention ( p<0.05). Reproducti ve outcomes also improved significantly, including menstrual regularity, ovulatory cycles, dysmenorrhea, dyspareunia, and chronic pelvic pain. Mean dysmenorrhea VAS score decreased from 7.8±1.2tan4.3±1.5 (p<0.001). Quality of life scores improved significantly after lifestyle modification.

Lifestyle modification significantly improved metabolic health, reproductive outcomes, symptom severity, and quality of life among women with endometriosis. Incorporating structured lifestyle interventions may serve as an effective adjunct in endometriosis management.

Endometriosis, lifestyle modification, metabolic outcomes, reproductive health, dysmenorrhea, quality of life, insulin resistance, infertility

Endometriosis is a chronic estrogen-dependent inflammatory disorder characterized by the presence of endometrial -like tissue outside the uterine cavity, most commonly involving the ovaries, pelvic peritoneum, uterosacral ligaments, and pouch of Douglas. The disease is associated with dysmenorrhea, chronic pelvic pain, dyspareunia, infertility, menstrual irregularities, and reduced quality of life. Although the exact pathogenesis remains unclear, retrograde menstruation, immune dysfunction, genetic predisposition, oxidative stress, an d chronic inflammation are considered important contributing mechanisms. Endometriosis has a significant impact on physical, psychological, reproductive, and social well-being among affected women[1]. Globally, endometriosis affects approximately 10% of women of reproductive age and nearly 30- 50% of women presenting with infertility or chronic pelvic pain [2].The prevalence is believed to be underestimated due to delayed diagnosis, variable clinical presentation, and limited awareness. In India, increasing incidence has been reported among young women, particularly those with sedentary lifestyle patterns, obesity, dietary imbalance, and stressrelated disorders [3]. Emerging evidence suggests that endometriosis is not merely a localized gynecological disease but may also be associated with systemic metabolic alterations including insulin resistance, dyslipidemia, increased inflammatory markers, and altered body composition [4]. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com 154 Conventional treatment modalities for endometriosis include hormonal suppression, analgesics, and surgical management. However, recurrence of symptoms and persistent impairment in quality of life remain major concerns despite treatment. Recent research has focused on the role of modifiable lifestyle factors in the pathophysiology and management of endometriosis. Dietary habits rich in omega -3 fatty acids, antioxidants, fruits, and vegetables have been shown to reduce inflammator y responses, whereas high intake of red meat, trans fats, and processed foods may worsen disease severity [5]. Regular physical activity has also been associated with reduced estrogen levels, improved insulin sensitivity, weight reduction, and decreased pelvic pain [6]. Stress management and behavioral interventions may further contribute to symptomatic improvement and enhanced psychological well-being. Previous studies have demonstrated promising benefi ts of lifestyle interventions in women with endometriosis. Parazzini et al. reported that increased consumption of green vegetables and fruits was associated with a lower risk of endometriosis, while high red meat intake increased disease risk [7]. Bonocher et al . observed that physical exercise and antiinflammatory dietary modifications significantly reduced pain severity and improved quality of life in affected women [8]. Similarly, Rahman et al . highlighted the role of obesity and metabolic dysfunction in aggravating inflammatory pathways associated with endometriosis progression [9]. Despite growing evidence, there remains limited prospective data evaluating the combined impact of structured lifestyle modification on both metabolic and reproductive outcomes in women with endometriosis, particularly in the Indian population. Considering the chronic nature of the disease, the limitations of conventional therapies, and the increasing burden of metabolic abnormalities among reproductive -age women, evaluation of lifestyle modification as an adjunctive therapeutic approach is clinically relevant [10]. This study was therefore undertaken to assess the effe ct of lifestyle modifications on metabolic parameters, reproductive outcomes, symptom severity, and quality of life among women diagnosed with endometriosis. Aim and Objectives Aim To evaluate the effect of lifestyle modifications on metabolic and reprodu ctive outcomes among women diagnosed with endometriosis.

1. To assess the changes in metabolic parameters (BMI, waist circumference, lipid profile, fasting blood glucose, and insulin resistance) following lifestyle modification among women with endometriosis. 2. To evaluate the effect of lifestyle modification on reproductive outcomes including menstrual regularity, pain severity, ovulatory function, and fertility status in women with endometriosis. 3. To determine the association between adherence to lifestyle interventions and improvement in quality of life and symptom severity among women with endometriosis.

Study Design This study was designed as a hospital -based prospective interventional study conducted to evaluate the effect of lifestyle modifications on metabolic and reproductive outcomes among women diagnosed with endometriosis. Study Setting The study was carried out in the Department of Obstetrics and Gynaecology at a tertiary care teaching hospital over a period of 12 mo nths after obtaining approval from the Institutional Ethics Committee. Study Population Women diagnosed with endometriosis attending the gynecology outpatient department and infertility clinic were included in the study. Inclusion Criteria  Women aged between 18 and 40 years  Diagnosed cases of endometriosis confirmed clinically, ultrasonographically, laparoscopically, or histopathologically  Women willing to participate and provide informed written consent  Patients willing to adhere to lifestyle modificatio n protocols and follow-up visits Exclusion Criteria  Pregnant women  Women with malignancy or severe systemic illness  Patients with endocrine disorders such as uncontrolled diabetes mellitus, thyroid disorders, Cushing syndrome, or polycystic ovarian syndrome  Women receiving hormonal therapy during the previous three months  Patients with psychiatric illness or inability to comply with follow-up Sample Size Calculation The sample size was calculated using the formula for comparison of means in interventional studies: 𝑛 = (𝑍𝛼/2 + 𝑍𝛽)2 × 2𝜎2 𝑑2 Where:  𝑛= required sample size  𝑍𝛼/2= 1.96 corresponding to 95% confidence interval  𝑍𝛽= 0.84 corresponding to 80% study power  𝜎= standard deviation of pain score from previous study  𝑑= expected mean difference after intervention Based on a previous study by Yela DA et al., the expected reduction in pain score following lifestyle intervention was 1.5 with a standard deviation of 2.5. Substituting the values 𝑛 = (1.96 + 0.84)2 × 2 × (2.5)2 (1.5)2 𝑛 = 7.84 × 12.5 2.25 𝑛 = 43.5 International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com 155 The minimum required sample size was calculated to be 44 participants. Considering a 10% attrition rate due to possible loss to follow -up, the final sample size was rounded to 50 participants. Sampling Technique Eligible participants fulfilling the inclusion criteria were recruited using consecutive sampling until the required sample size was achieved. Study Procedure After obtaining written informed consent, detailed demographic and clinical information was collected u sing a predesigned structured proforma. Baseline Assessment The following baseline parameters were recorded: 1. Sociodemographic Data  Age  Marital status  Educational status  Occupation  Socioeconomic status 2. Clinical Parameters  Duration of symptoms  Menstrual history  Dysmenorrhea severity  Dyspareunia  Chronic pelvic pain  Infertility history  Obstetric history  Family history of endometriosis 3. Anthropometric Measurements  Height  Weight  Body mass index (BMI)  Waist circumference  Hip circumference  Waist-hip ratio 4. Metabolic Assessment  Fasting blood glucose  Serum insulin  Lipid profile  Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) 5. Reproductive Assessment  Menstrual cycle regularity  Ovulatory status  Fertility status  Ultrasonographic findings  Severity of endometriosis-related symptoms 6. Pain Assessment Pain severity was assessed using the Visual Analogue Scale (VAS) for:  Dysmenorrhea  Chronic pelvic pain  Dyspareunia 7. Quality of Life Assessment Quality of life was evaluated using the Endometri osis Health Profile questionnaire (EHP-30). Lifestyle Modification Intervention All participants underwent a structured lifestyle modification program for six months, which included: Dietary Modification Participants received dietary counseling focusing on:  Increased intake of fruits, vegetables, whole grains, and omega-3-rich foods  Reduction in processed foods, red meat, refined sugars, and saturated fats  Adequate hydration and balanced calorie intake Physical Activity Participants were advised:  Moderate aerobic exercise for at least 150 minutes per week  Yoga and stretching exercises  Regular walking and strengthening exercises Stress Reduction Measures  Sleep hygiene counseling  Meditation and relaxation techniques  Stress management education Behavioral Counseling Periodic counseling sessions were conducted to improve adherence to healthy lifestyle practices. Follow-Up Participants were followed up monthly for six months. During each follow-up visit:  Compliance with lifestyle modification was assessed  Anthropometric measurements were repeated  Symptom severity and pain scores were recorded  Adverse events, if any, were documented At the end of six months, metabolic and reproductive parameters were reassessed and compared with baseline findings. Outcome Measures Primary Outcomes  Change in BMI and waist circumference  Change in fasting blood glucose and lipid profile  Reduction in pain scores Secondary Outcomes  Improvement in menstrual regularity  Improvement in fertility status  Improvement in quality of life scores  Reduction in symptom severity Statistical Analysis Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables were expressed as mean ± standard deviation, while catego rical variables were presented as frequency and percentage. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com 156  Paired t-test was used to compare pre - and post - intervention continuous variables.  Chi-square test was used for categorical variables.  Pearson correlation analysis was performed to assess associations between adherence and clinical improvement.  A p-value of less than 0.05 was considered statistically significant. Ethical Considerations Institutional Ethics Committee approval was obtained prior to commencement of the study. Written informed consent was obtained from all participants. Confidentiality of patient information was strictly maintained throughout the study.

A total of 50 women diagnosed with endometriosis were included in the study and completed the six -month lifestyle modification program. The effects of lifestyle intervention on metabolic and reproductive outcomes were analyzed. Table 1: Baseline Sociodemographic and Clinical Characteristics of Study Participants (n = 50) Variable Frequency (n) Percentage (%) Age Group (years) 18-25 12 24.0 26-30 18 36.0 31-35 14 28.0 36-40 6 12.0 Marital Status Married 38 76.0 Unmarried 12 24.0 Body Mass Index Normal (18.5-24.9 kg/m2) 17 34.0 Overweight (25-29.9 kg/m2) 23 46.0 Obese (≥30 kg/m2) 10 20.0 Presenting Symptoms Dysmenorrhea 44 88.0 Chronic pelvic pain 32 64.0 Dyspareunia 21 42.0 Infertility 19 38.0 Menstrual irregularity 28 56.0 Table 2: Comparison of Anthropometric and Metabolic Parameters Before and After Lifestyle Modification (n = 50) Parameter BaselineMean ± SD Post-interventionMean ± SD MeanDifference p-value Body weight (kg) 69.4 ± 8.2 64.8 ± 7.5 4.6 <0.001 BMI (kg/m2) 28.1 ± 3.4 25.9 ± 3.1 2.2 <0.001 Waist circumference (cm) 91.6 ± 7.8 86.3 ± 6.9 5.3 <0.001 Fasting blood glucose (mg/dL) 102.4 ± 14.1 94.7 ± 10.3 7.7 0.002 Serum triglycerides (mg/dL) 168.5 ± 28.6 148.2 ± 24.1 20.3 <0.001 HOMA-IR 3.1 ± 0.8 2.4 ± 0.6 0.7 0.001 Table 3: Comparison of Reproductive Outcomes Before and After Lifestyle Modification (n = 50) Reproductive Parameter Baseline n (%) Post-intervention n (%) p-value Regular menstrual cycles 22 (44.0) 37 (74.0) 0.003 Ovulatory cycles 26 (52.0) 39 (78.0) 0.006 Infertility 19 (38.0) 12 (24.0) 0.041 Dysmenorrhea 44 (88.0) 23 (46.0) <0.001 Dyspareunia 21 (42.0) 11 (22.0) 0.028 Chronic pelvic pain 32 (64.0) 16 (32.0) 0.002 Table 4: Comparison of Pain Scores and Quality of Life Before and After Lifestyle Modification (n = 50) Parameter Baseline Mean ± SD Post-intervention Mean ± SD p-value Dysmenorrhea VAS score 7.8 ± 1.2 4.3 ± 1.5 <0.001 Pelvic pain VAS score 6.9 ± 1.4 3.8 ± 1.3 <0.001 Dyspareunia VAS score 5.8 ± 1.6 3.1 ± 1.2 <0.001 EHP-30 quality of life score 61.4 ± 9.7 38.6 ± 8.4 <0.001 Table 5: Association Between Adherence to Lifestyle Modification and Clinical Improvement (n = 50) Adherence Level Significant Symptom Improvement n (%) No Significant Improvement n (%) Total p-value Good adherence 24 (88.9) 3 (11.1) 27 0.001 Moderate adherence 11 (64.7) 6 (35.3) 17 Poor adherence 2 (33.3) 4 (66.7) 6

The present prospective interventional study evaluated the effect of lifestyle modifications on metabolic and reproductive outcomes among women with endometriosis. The study demonstrated significant improvement in anthropometric indices, metabolic p arameters, reproductive health, pain severity, and quality of life following a structured six -month lifestyle intervention program. In the present study, the majority of participants belonged to the age group of 26 -30 years, and dysmenorrhea was the most common presenting complaint, observed in 88% of cases. Similar findings were reported by Parazzini et al., who observed that endometriosis predominantly affects women in the reproductive age group and commonly presents with dysmenorrhea and chronic pelvic p ain[7]. The high prevalence of overweight and obesity among study participants further supports the association between metabolic dysfunction and endometriosis progression. Significant reductions in body weight, BMI, waist circumference, fasting blood glucose, triglyceride levels, and HOMA-IR scores were observed after lifestyle intervention in the current study. These findings are consistent with the International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com 157 observations of Rahman et al., who demonstrated that increased body adiposity a nd metabolic imbalance contribute to inflammatory activity and disease severity in endometriosis [9]. Similarly, Nirgianakis et al. reported that dietary modification and physical activity improved metabolic parameters and reduced systemic inflammation among women with endometriosis[5]. The reduction in insulin resistance observed in the present study may be attributed to regular physical activity, improved dietary habits, and weight reduction achieved during follow-up. The present study also showed significant improvement in reproductive outcomes, including menstrual regularity, ovulatory cycles, and reduction in infertility-related complaints. Comparable results were observed by Tennfjord et al ., who reported that regular exercise and healthy lifestyle practices positively influenced reproductive hormone regulation and menstrual function in women with endometriosis [6]. Improved ovulatory function may be related to decreased chronic inflammation and improved metabolic homeostasis following intervention. Pain reduction was one of the major findings of this study. Significant decreases in dysmenorrhea, dyspareunia, and chronic pelvic pain scores were noted after six months of lifestyle modification. These results are in agreement with Bonocher et al., who demonstrated that physical exercise and anti-inflammatory dietary interventions reduced pelvic pain intensity and improved symptom control in women with endometriosis[8]. Physical activity is believed to reduce circulating estrogen levels and inflammatory mediators, thereby contributing to symptom improvement. Quality of life scores also improved significantly in the present study following intervention. Similar findings were reported by Armour et al ., who observed that lifestyle -based selfmanagement strategies including exercise, dietary regulation, and stress reduction improved psychological well - being and overall quality of life among women with endometriosis[11]. The improvement in quality of life observed in the current study may be secondary to reduction in pain severity, better menstrual health, and enhanced physical fitness. An important observation in the present stu dy was the significant association between adherence to lifestyle modification and clinical improvement. Participants with better adherence demonstrated greater symptomatic relief and metabolic improvement compared to those with poor adherence. This finding highlights the importance of sustained behavioral changes and patient motivation in long-term disease management. Overall, the findings of the present study support the growing evidence that lifestyle modification serves as an effective adjunctive strate gy in the management of endometriosis. Structured interventions focusing on healthy diet, physical activity, weight management, and stress reduction may improve both metabolic and reproductive outcomes while reducing symptom burden and enhancing quality of life.

The study was limited by its relatively small sample size and short duration of follow -up, which may restrict generalization of the findings. Being a single-center study, regional variations in lifestyle and disease characteristics could not be assessed. In addition, adherence to lifestyle modifications was partially dependent on self -reporting, which may introduce reporting bias. Further multicentric studies with larger sample sizes and long-term follow-up are recommended to validate the findings.

The present study demonstrated that structured lifestyle modification significantly improved metabolic parameters, reproductive outcomes, pain severity, and quality of life among women with endometriosis. Reduction in body weight, i nsulin resistance, dysmenorrhea, chronic pelvic pain, and menstrual irregularities was observed following dietary regulation, physical activity, and stress management interventions. Lifestyle modification may therefore serve as an effective, low- cost, and non-pharmacological adjunct in the comprehensive management of endometriosis.

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