Observational study on the influence of an app-based self-management program on the quality of life of women with endometriosis.

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Nadine Rohloff, Markus Rothenhöfer, Teresa Götz, Sebastian Schäfer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2138010/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Endometriosis can significantly impair the quality of life of those affected. Multimodal self-help measures are recommended but often difficult to access. Smartphone apps have been shown to improve quality of life for other conditions with chronic pain. The aim of this study was to examine whether there is evidence of beneficial effects of the smartphone app “Endo-App®” and whether a multicenter randomized controlled trial should be planned to substantiate these effects. Methods: In a sample of N=106 women affected by endometriosis the present study determined the influence of the use of Endo-App ® on their quality of life. Among others, the validated questionnaire Endometriosis Health Profile from Oxford University was used for this purpose. Results: The use of Endo-App ® lead to a highly significant improvement in quality of life already after two weeks. A statistically significant change was found for nine out of ten measured variables of quality of life. A series of further analyses validated that the measured positive effects were not due to other confounding factors. Conclusion: In summary, the results indicate that the quality of life of women with endometriosis improved by the digital self-management tool Endo-App ®. More studies are needed to further explore the influence of the app on quality of life and as confirmatory evidence of beneficial effects. For this purpose, a randomized controlled trial should be conducted over a longer period of time. Trial registration: This trial is registered at clinicaltrials.gov under the registration number NCT05528601 on August 18, 2022. It was retrospectively registered. endometriosis app quality of life Take Home Message The quality of life of endometriosis patients improved by use of a digital self-management tool introduced in this study in patients with endometriosis. A prospective long-term multicenter randomized controlled trial is needed to further explore the effect of this patient-controlled health intervention. Introduction An estimated 1.7 million women in Germany suffer from endometriosis. Approximately 40,000 new diagnoses are made each year [ 1 ]. The disease severely limits the quality of life of those affected [ 2 ]. The leading symptoms include sterility, pain symptoms and accompanying functional complaints. Due to the long course of the disease, frequent recurrences even after surgery[ 3 ] and the lack of a curative therapy, the symptoms often become chronic [ 4 ]. Chronic pain has the strongest deteriorating impact on quality of life [ 5 ]. Experts from the German Pain Society agree that it is advisable to introduce patients with chronic pain of any etiology to measures with which they can help themselves [ 6 ]. Physical therapy, nutritional therapy, and informational approaches, as well as stress reduction and symptom diaries, are cited as universally applicable options [ 6 ]. The current S2k guideline on the treatment and diagnosis of endometriosis of German speaking countries also emphasizes this. It is stated that patients should be informed about self-help services. The guideline also recommends complementary therapies with the goal of promoting skills in disease coping and self-management, support in behavioral and lifestyle changes, and maintaining earning capacity [ 7 ]. A multimodal, interdisciplinary approach to endometriosis therapy as an adjunct to standard therapy is recommended as it aims to significantly improve patients' quality of life [ 8 – 11 ]. However, these measures are currently only accessible to a very limited proportion of patients and are rarely covered by health insurances. For 2017, the health report of the Robert Koch Institute reports only 811 patients diagnosed with endometriosis in rehabilitation clinics [ 12 ]. Researchers, treating physicians, and patients therefore demand an improvement in patient care with the central goal of improving quality of life [ 9 , 10 ]. Thus, in addition to causal therapy, supportive care and help for self-help are also necessary. Access to reliable and trustworthy information is currently limited as well [ 13 , 14 ]. Most of the complementary therapies and self-management strategies mentioned above have to be carried out by the patients themselves in everyday life. The positive effect of self-care counselling for women with endometriosis has already been shown in a few randomised trials [ 15 , 16 ]. For other conditions with chronic pain, it has already been shown that smartphone apps can support these self-care therapies at home, positively influencing pain, symptoms, and disease management [ 17 ]. Therefore, it can be expected that a mobile application via smartphone can be effective in improving quality of life in endometriosis as well. Nonetheless, studies in this regard are still missing. The Endo-App ® was developed as a medical device. The aim of this study was to investigate the app’s effect on quality of life. It was examined whether there is evidence of positive care effects and whether a multicenter randomized controlled trial is worthwhile. Materials And Methods Sample The sample consisted of 106 women. Inclusion criteria were a minimum age of 18 years, prior diagnosis of endometriosis and residency in Germany. Women were recruited over self-help groups, advertising in social media and posting in endometriosis-related groups. Women with endometriosis were invited to take part in the survey. Individuals who did not have endometriosis as a diagnosis or did not return both questionnaires were excluded from the study population. In the final sample womens age ranged from 20 to 51 years (mean: 33 years). Various occupational backgrounds were identified. Employees were most frequently represented (68 women), followed by students (14 women). Study design The study consisted of an initial survey and a follow-up survey. The surveys were conducted using online questionnaires. The follow-up survey took place two weeks after the initial survey. The results of both questionnaires could be merged using participant coding while maintaining anonymity. At the beginning of the questionnaire, all women were informed about the aims of the study, the anonymity of their data, and the contact details of the medical management for questions. Informed consent then was obtained. Initial survey At the beginning of the questionnaire, screening criteria were collected (gender, age, diseases). In the next part of the survey, the women were asked about their quality of life. For this purpose, the standardized and validated Endometriosis Health Profile (EHP) questionnaire from Oxford University [ 18 ] was used. The implementation in the online questionnaire was reviewed by an Oxford University expert and found to be correct. The questionnaire asked about the five EHP core domains of quality of life: Pain (11 questions), Control & powerlessness (6 questions), Emotional well-being (6 questions), Social support (4 questions) and Self-image (3 questions). In addition, two supplementary domains of the EHP were queried: Work life (5 questions) and Treatment (3 questions). Participants were then asked to indicate their satisfaction with their own lives on a scale of 0 to 10 (quality of life index). In the next section, women were asked to react to various statements concerning their endometriosis care. In addition, the women were asked about the impact of endometriosis on their work. The therapy used so far was also recorded. In the following section, the women were asked about their menstrual periods. They were asked about hormonal therapy and the date of the first day of the last menstrual period to rule out confounding due to overrepresentation of one cyclic phase. In the last section of the questionnaire, the Endo-App was introduced and the women received information about the possibility to use the Endo-App free of charge. Follow-up survey after two weeks Two weeks after the initial survey, women who had signed up for the mailing list were invited via email to complete the follow-up survey. At the beginning of the follow-up survey, the women were asked about their usage behavior and intensity of use of the Endo-App. If women indicated that they had not used the Endo-App, they could voluntarily provide reasons. The same domains of the EHP, quality of life index, and endometriosis care statements were queried for all women. Additionally, for participants who indicated they had used the Endo-App, a section followed in which the women could evaluate individual features of the app. Recruitment and evaluation Recruitment for this study was conducted online through various tools such as Facebook and Google. Online recruitment was deemed adequate to target women who are familiar with and actively use digital media. By clicking on the respective link, participants were then taken to the online questionnaire, which was based on the SoSci Survey tool. The questionnaire could be completed either on a desktop computer or on a mobile device. All women who participated in the first questionnaire could take part in a lottery for 10 € online vouchers, regardless if they entered their Email address for the second survey or not. Only women who participated in both the initial survey and the follow-up survey were included in the analysis. In the user group, the women who were evaluated (n = 64) were those who reported using the app. The women who participated both times, but indicated that they had not used the app (n = 42) were evaluated separately. These acted as a comparison group with which the user group could be compared in order to exclude an influence of general events, e.g. world events or weather, on the quality of life. Endometriosis Health Profile (EHP) Each item of the EHP consists of a statement about the impact of endometriosis on the life of the affected person. The validated German survey was used. Responses are scaled from 0 = Never to 4 = Always. A domain's EHP score is calculated from the average of the domain's responses, scaled from 0 to 100, with a score of 0 being the best possible quality of life and 100 being the worst possible quality of life. In addition to the EHP score per domain (corresponding to the mean of the items assigned to this domain), a summary "EHP-30 Summary Index" can also be formed. This is calculated as an equally weighted mean of the five core domains. The calculation procedure of the Summary Index was also applied to the "All Domains" evaluation, so that an overall index could be created. This overall index including the additional domains has not been validated in the Oxford EHP-30. However, before calculating the overall index, the corresponding Cronbach's alpha value was calculated to check the reliability of the scale and thus the feasibility of the index. Inferential statistics To examine the change after two weeks of Endo-App use, statistical tests were performed with the variables described above. First, an F-test was used to see if a T-test could be applied with equal variance. Then, if possible, a two-tailed paired T test was performed for each variable and significance was calculated. Furthermore, the effect size was calculated via Cohen's d. As a between-group comparison, pairwise group comparisons were performed for the Summary Index Change score using nonparametric two-sided Mann-Whitney U tests for unrelated samples. Just as described in the EHP manual, this study also found a sufficiently large Cronbach's alpha for the Summary Index (0.81) to consider it a summary index of the integrated individual domains. A two-tailed, unpaired Mann-Whitney U test was used to compare the effects on the change scores of the Summary Index of user group with non-user group. Results Demographics Table 1 shows a summary of the demographic characteristics of the participants. All participants were female and reported being diagnosed with endometriosis. The age ranged from 20 to 51 years. Table 1 demographic characteristics of the participants. users non-users total sex female 64 42 106 male 0 0 0 diverse 0 0 0 age mean 33 32 33 minimum 20 22 20 maximum 51 46 51 occupation high school student 0 0 0 apprentice 2 3 5 university student 9 5 14 employee 42 26 68 public official 1 2 3 self-employed 0 3 3 unemployed 3 1 4 other 7 2 9 diagnoses endometriosis 64 42 106 breast cancer 0 0 0 History of infection with chlamydia trachomatis 2 2 4 ovarian cancer 0 0 0 fibroids 10 4 14 smartphone Android 43 43 Apple iOS 21 21 Of the 106 participants, 64 self-reported using the Endo-App (user group). In contrast, 42 indicated that they had not used the Endo-App (non-user group). N = 15 women gave a reason for not using the app. Reasons fell into the categories of technical problems and little time for cell phone use. Changes In The User Group An inferential statistical analysis was performed for the user group. This involved comparing the change in variables from initial to follow-up surveys. The results of the analysis are shown in Table 2 . Table 2 comparison of variables before and during use of the Endo-App in the user group (n = number; M = median; SD = standard deviation; T Stat = ; p = probability; EHP = Endometriosis Health Profile; QoL = quality of life; ** = change statistically significant) initial survey follow up change variable n M SD M SD M T Stat p Cohen's d EHP Pain 64 52,66 17,95 43,43 21,39 -9,23 -5,80 0,0000 ** -0,73 Control & powerlessness 64 70,51 22,37 55,92 23,54 -14,58 -6,15 0,0000 ** -0,77 Emotional well-being 64 60,48 17,86 52,86 21,30 -7,62 -4,07 0,0001 ** -0,51 Social support 64 64,75 23,92 54,69 29,53 -10,06 -3,81 0,0003 ** -0,48 Self-image 64 55,86 27,08 51,30 29,96 -4,56 -1,66 0,1027 -0,21 Work life 46 43,37 25,51 33,43 24,34 -9,93 -3,05 0,0038 ** -0,45 Treatment 45 58,33 26,01 49,83 25,06 -8,51 -3,30 0,0019 ** -0,49 All Domains 64 58,43 18,44 49,24 20,47 -9,18 -5,50 0,0000 ** -0,69 Summary Index 64 60,85 17,72 51,64 21,02 -9,21 -5,38 0,0000 ** -0,67 QoL (one-item) 64 4,94 1,97 5,63 1,55 0,69 3,80 0,0003 ** 0,48 With regard to the EHP, an improvement was observed in all domains except self-image . The improvement of all variables except self-image was statistically highly significant. In the core domains pain, control & powerlessness, emotional well-being, social support and self-image all data sets were complete. In the work life and treatment modular questionnaires, 18 and 19 women, respectively, selected the "not applicable" response option offered in the modular questionnaire. All other questionnaires were complete. For the variables pain, control & powerlessness, emotional well-being, all domains and summary index a strong effect could be found according to Cohen’s d (|d| >0,5). Since all domains is not an externally validated index, the Cronbach alpha value was calculated. This was α = 0,832, so the index could be included. Changes in the non-user group The same inferential statistical analysis was performed for the non-user group. The results are shown in Table 3 . There was a statistically significant change (improvement) in pain for the non-user group. There were no other significant results. Table 3 comparison of variables in the non-user group (n = number; M = median; SD = standard deviation; T Stat = ; p = probability; EHP = Endometriosis Health Profile; QoL = quality of life; ** = change statistically significant) initial survey follow up change variable n M SD M SD M T Stat p Cohen's d EHP Pain 42 42,80 22,55 37,12 22,39 -5,68 -3,38 0,0016 ** -0,52 Control & powerlessness 42 54,66 24,83 52,28 24,59 -2,38 -0,83 0,4097 -0,13 Emotional well-being 42 49,50 22,97 47,72 23,05 -1,79 -0,70 0,4861 -0,11 Social support 42 48,66 26,32 50,30 24,69 1,64 0,43 0,6668 0,07 Self-image 42 39,48 28,64 38,69 26,08 -0,79 -0,30 0,7657 -0,05 Work life 33 29,86 24,65 28,71 26,91 -1,15 -1,40 0,1704 -0,24 Treatment 29 44,29 25,94 44,89 29,40 0,61 -0,08 0,9380 -0,01 All Domains 42 44,54 19,56 43,16 20,61 -1,38 -1,01 0,3200 -0,16 Summary Index 42 47,02 20,74 45,22 21,00 -1,80 -0,88 0,3864 -0,14 QoL (one-item) 42 6,10 1,46 6,31 1,63 0,21 1,32 0,1927 0,20 Comparison Of User Group And Non-user Group Table 4 compares the results of user group and non-user group. ∆ M represents the average change in the variables between the initial and follow-up surveys (see "change" columns in Table 2 and Table 3 ). A direct comparison is not calculated in the table. Table 4 comparison of results between user group and non-user group (n = number; ∆ M = change of median; p = probability; EHP = Endometriosis Health Profile; QoL = quality of life; ** = change statistically significant). user Group non-User group variable n ∆ M p n ∆ M p EHP Pain 64 -9,23 0,0000 ** 42 -5,68 0,0016 ** Control & powerlessness 64 -14,58 0,0000 ** 42 -2,38 0,4097 Emotional well-being 64 -7,62 0,0001 ** 42 -1,79 0,4861 Social support 64 -10,06 0,0003 ** 42 1,64 0,6668 Self-image 64 -4,56 0,1027 42 -0,79 0,7657 Work life 46 -9,46 0,0038 ** 33 -3,79 0,1704 Treatment 45 -9,81 0,0019 ** 29 -0,29 0,9380 All Domains 64 -9,06 0,0000 ** 42 -1,98 0,3200 Summary Index 64 -9,21 0,0000 ** 42 -1,80 0,3864 QoL (one-item) 64 0,69 0,0003 ** 42 0,21 0,1927 To test whether the difference between user group and non-user group for the summary index was significant, a two-sided Mann-Whitney U test was calculated for the summary index. This was highly significant with p-value = 0.006477. Days Since The Beginning Of The Last Menstrual Period Table 5 provides an overview of the phase of the menstrual period at the time of the initial survey. The purpose of analyzing the menstrual periods was to exclude confounding. For this purpose, the time span between the first day of the last menstrual period and the date of participation in the survey was calculated. The cycle-point was then grouped into weeks. Participants in the long-term cycle were recorded separately, as no meaningful date of the last menstrual period could be determined for them. Table 5 days since last menstrual period (n = number) users non-users days since last period n proportion n proportion 0–7 9 13% 7 13% 8–14 10 14% 10 19% 14–21 9 13% 3 6% 22–28 9 13% 3 6% > 28 9 13% 8 15% long cycle 25 35% 22 42% Discussion In this study already after two weeks of use, a statistically significant improvement of quality of life was observed among Endo-App users both according to EHP and the quality of life index. Quality of life according to summary index improved by -9.21 points. This coincided with the improvement according to the quality of life scale of 0.69 points. It is noteworthy that the Endo-App did not have an equal impact on all domains of the EHP quality of life. After two weeks of use, the impact of endometriosis on work life was reduced by an average of -9.93 points. Likewise, the variable for control & helplessness improved by -14.58 points. There was also an improvement of -9.23 points in the pain domain. Only the domain self-image resulted in merely a small improvement of -4.56 points, which was not statistically significant. To exclude bias in quality of life scores due to increased symptoms during the menstrual period, the timing of the menstrual cycle was determined at the time of the initial survey. An accumulation of the same menstrual cycle phase, for example day 1–7 at the time of the initial survey, could theoretically lead to an over- or underestimation of the effect. There was no significant clustering of menstrual cycle phases among participants during the initial or follow-up surveys and an even distribution across all menstrual cycle phases and women on long-cycle hormone therapy (see Table 5 ). Consequently, it can be assumed that there was no significant bias in the results due to specific menstrual phases. Analogous to a bias due to the menstrual phase, it would be possible for the results to be positively influenced by external influences. Such influences could be, for example, changes in the seasons or societal changes such as changes in corona measures. To test this, the results of women who used the Endo-App were compared with those who did not use the Endo-App. Because of the observational design, the study did not meet the requirements for a control group in an interventional study. For example, no randomization was performed. Nevertheless, the participants, who according to their own statements did not use the Endo-App, offered themselves as a point of comparison. The comparison was shown in the results section in Table 4 . In the user group, nine out of ten variables were improved in a highly significant manner. In the summary index, the observed changes after two weeks regarding user group and non-user group differed by -7.41. The comparison of changes between the user group and the non-user group on the summary index was validated with a Mann-Whitney U test. The result of the test was highly significant (p-value = 0.006477). This confirms the hypothesis that a corresponding improvement in quality of life was triggered by the Endo-App. Overall, the comparison with the non-user group supports the hypothesis that the Endo-App itself is responsible for the improvement in quality of life and that this is not due to external influences. It would also be theoretically possible that the non-user group did not use the Endo-App because of substantial deterioration in their quality of life. In this case, the quality of life scores between groups would be biased by systematic self-selection. To exclude this possibility, reasons for non-use were recorded and subjected to careful scrutiny in the analysis. The reason for non-use was recorded via free text at the follow-up survey. 15 of the 42 non-users surveyed gave a reason in the free text. In 14 cases, the reason was based on technical problems during installation. These technical difficulties can be explained by the fact that the app was made available via Apple Testflight and Android APK, which was unfamiliar to some users and thus represented a technical challenge. Since the occurrence of technical difficulties is in no way related to the quality of life or endometriosis symptoms of those affected, it can be assumed that the classification of the women into the non-user group did not result in any relevant distortions in terms of content. The time interval between initial interview and follow-up interview may already display short-term changes with the Endo-App. Based on the current literature, it can be expected that the effect would also be detectable after a longer period of time [ 14 , 19 , 20 ]. This needs to be the subject of future longitudinal studies with longer survey periods. It is also expected that some of the Endo-App content would reach its maximum effect over a longer period of use. For example, physiotherapy exercises, yoga, mindfulness exercises, or a healthier diet have short-term effects but also build up their effect over several weeks and months [ 21 , 22 ] and maintain this effect in the long term [ 23 ]. Hansen et al. were able to show that even six years after an intervention with mindfulness and acceptance and commitment therapy, the improvement achieved was still detectable [ 24 ]. It is noteworthy that the survey with the EHP always looks at the last four weeks in the women's lives, because the items of the questionnaire are designed for this period and, according to Oxford, may not be changed. This means that at the follow-up survey, two of the four weeks in the period under consideration were still prior to use of the Endo-App. This in turn suggests that even stronger effects or improvements would be observable in a follow-up survey that would take place longer after the initial survey. The results presented here allow initial conclusions to be drawn regarding a beneficial effect of the Endo-App. However, it must be pointed out that there are limitations in the study design. The analyses shown were not adjusted for multiple testing. Thus, across all hypotheses tested, there is a greater risk of alpha error than 5%. It should be noted, however, that changes in many domains and especially the summary index of the user group remain significant even after adjustment for multiple testing following the Bonferroni-Holm method. Another limitation is the rather small sample size. Although it was enough to achieve sufficient power for finding significant effects. However, small samples generally have to be assumed to have limited generalizability to the overall population. Testing the effects found here with a higher number of participants is therefore an important area for further studies on the topic. Although complete case analysis is often used in medical studies [ 25 ] it has its limits, especially when the reason for dropouts is not known [ 26 ]. For the necessary randomized trial measures to prevent dropouts like reminders and recruitment via medical personnel should be implemented as well as investigations concerning the dropout reason. Despite the limitations, the results found are an important starting point to plan a randomized controlled trial subsequently and to support the exploration of expected effects. The results also clearly point to the meaningfulness and usefulness of such a follow-up study due to the expected positive effects. Conclusion In this observational study, it could be shown that a significant improvement in the quality of life occurred in the surveyed users of the Endo-App already after two weeks. This included several relevant domains of quality of life and could not be explained by external or confounding variables. However, further research on the Endo-App requires a randomized controlled trial with sufficient power to provide confirmatory insights in the medium- and long-term effects. In summary, the results are very promising, so it is expected that women with endometriosis will benefit from the use of the Endo-App. Considering the substantial burden of endometriosis and the identified gaps in patient care, further investigation is of great interest. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Conflict of Interest Nadine Rohloff (founder and management), Markus Rothenhöfer (employment) and Teresa Götz (employment) are employees of Endo Health GmbH which developed the Endo App that was studied in this publication. Sebastian Daniel Schaefer declares the following potential conflicts of interests: Advisory Board of PlantTec Medical GmbH and Baxter Medical on adhesions, Advisory Boards of European Endometriosis League, German Working Group Gynecological Endoscopy, German Endometriosis Research Foundation, Early Career Board of World Endometriosis Society, Vice President German Working Group Endometriosis. Author contribution N Rohloff: protocol/project development, data collection and management, data analysis, manuscript writing/editing M Rothenhöfer: protocol/project development, data collection and management, data analysis, manuscript writing/editing T Götz: protocol/project development, data collection and management, data analysis, manuscript writing/editing S Schäfer: protocol/project development, data analysis, manuscript writing/editing Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Westfalian Wilhelms University Münster, Germany (17.08.2022 / 2021-338-f-S). Consent to participate Informed consent was obtained from all individual participants included in the study. References Janni W, Hancke K, Fehm T et al (eds) (2017) Facharztwissen Gynäkologie, 2. Auflage. Elsevier, München, Deutschland Fourquet J, Báez L, Figueroa M et al (2011) Quantification of the impact of endometriosis symptoms on health-related quality of life and work productivity. Fertil Steril 96:107–112. https://doi.org/10.1016/j.fertnstert.2011.04.095 Guo S-W (2009) Recurrence of endometriosis and its control. Hum Reprod Update 15:441–461. https://doi.org/10.1093/humupd/dmp007 Soliman AM, Du EX, Yang H et al (2017) Retreatment Rates Among Endometriosis Patients Undergoing Hysterectomy or Laparoscopy. J Womens Health (Larchmt) 26:644–654. https://doi.org/10.1089/jwh.2016.6043 Facchin F, Barbara G, Saita E et al (2015) Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference. J Psychosom Obstet Gynaecol 36:135–141. https://doi.org/10.3109/0167482X.2015.1074173 Arnold B, Brinkschmidt T, Casser H-R et al (2014) Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome. Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplinäre Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten. [Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society on treatment contents]. Schmerz 28:459–472. https://doi.org/10.1007/s00482-014-1471-x Burghaus S, Schäfer SD, Beckmann MW et al (2021) Diagnostik und Therapie der Endometriose. S2k-Leitlinie der DGGG, SGGG und OEGGG. [Diagnosis and Treatment of Endometriosis. S2k-Guideline of the DGGG, SGGG and OEGGG]. Geburtshilfe Frauenheilkd 81:422–446. https://doi.org/10.1055/a-1380-3693 Buggio L, Barbara G, Facchin F et al (2017) Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. Int J Womens Health 9:281–293. https://doi.org/10.2147/IJWH.S119724 Cooper H, Booth K, Fear S et al (2001) Chronic disease patient education: lessons from meta-analyses. Patient Educ Couns 44:107–117. https://doi.org/10.1016/s0738-3991(00)00182-8 Häuser W, Bock F, Hüppe M et al (2020) 2. Aktualisierung der S3 Leitlinie „Langzeitanwendungen von Opioiden bei chronischen nicht-tumorbedingten Schmerzen (LONTS 2020). [2. Update of the S3 guideline "Long-term opioid use in non-cancer pain"]. Der Schmerz 204–244. https://doi.org/10.1007/s00482-020-00472-y Mikolasek M, Berg J, Witt CM et al (2018) Effectiveness of Mindfulness- and Relaxation-Based eHealth Interventions for Patients with Medical Conditions: a Systematic Review and Synthesis. Int J Behav Med 25:1–16. https://doi.org/10.1007/s12529-017-9679-7 Robert K-I (2020) Gesundheitliche Lage der Frauen in Deutschland. Gesundheitsberichterstattung des Bundes: Gemeinsam getragen von RKI und Destatis. [Health situation of women in Germany. Federal health reporting]. . Accessed 12 Sep 2022 Hirsch M, Aggarwal S, Barker C et al (2017) Googling endometriosis: a systematic review of information available on the Internet. Am J Obstet Gynecol 216:451–458e1. https://doi.org/10.1016/j.ajog.2016.11.1007 Moseley L (2002) Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother 48:297–302. https://doi.org/10.1016/s0004-9514(14)60169-0 Farshi N, Hasanpour S, Mirghafourvand M et al (2020) Effect of self-care counselling on depression and anxiety in women with endometriosis: a randomized controlled trial. BMC Psychiatry 20:391. https://doi.org/10.1186/s12888-020-02795-7 Zhao L, Wu H, Zhou X et al (2012) Effects of progressive muscular relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy. Eur J Obstet Gynecol Reprod Biol 162:211–215. https://doi.org/10.1016/j.ejogrb.2012.02.029 Kristjánsdóttir OB, Fors EA, Eide E et al (2013) A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. J Med Internet Res 15:e5. https://doi.org/10.2196/jmir.2249 Jones G, Jenkinson C, Kennedy S (2004) Evaluating the responsiveness of the Endometriosis Health Profile Questionnaire: the EHP-30. Qual Life Res 13:705–713. https://doi.org/10.1023/B:QURE.0000021316.79349.af Gonçalves AV, Barros NF, Bahamondes L (2017) The Practice of Hatha Yoga for the Treatment of Pain Associated with Endometriosis. J Altern Complement Med 23:45–52. https://doi.org/10.1089/acm.2015.0343 Ryan CG, Gray HG, Newton M et al (2010) Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther 15:382–387. https://doi.org/10.1016/j.math.2010.03.003 Schmid AA, van Puymbroeck M, Fruhauf CA et al (2019) Yoga improves occupational performance, depression, and daily activities for people with chronic pain. Work 63:181–189. https://doi.org/10.3233/WOR-192919 Ott J, Nouri K, Hrebacka D et al (2012) Endometriosis and nutrition – recommending a mediterranean diet decreases endometriosis-associated pain: an experimental observa­tional study.J Aging Res Clin Practice:162–166 Santanam N, Kavtaradze N, Murphy A et al (2013) Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Transl Res 161:189–195. https://doi.org/10.1016/j.trsl.2012.05.001 Hansen KE, Kesmodel US, Kold M et al (2017) Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: A six-year follow-up on a pilot study. Nordic Psychol 69:100–109. https://doi.org/10.1080/19012276.2016.1181562 Hunt NB, Gardarsdottir H, Bazelier MT et al (2021) A systematic review of how missing data are handled and reported in multi-database pharmacoepidemiologic studies. Pharmacoepidemiol Drug Saf 30:819–826. https://doi.org/10.1002/pds.5245 Leyrat C, Carpenter JR, Bailly S et al (2021) Common Methods for Handling Missing Data in Marginal Structural Models: What Works and Why. Am J Epidemiol 190:663–672. https://doi.org/10.1093/aje/kwaa225 Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 01 Dec, 2022 Reviewers invited by journal 30 Oct, 2022 Editor invited by journal 09 Oct, 2022 Editor assigned by journal 08 Oct, 2022 First submitted to journal 06 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2138010","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":148069675,"identity":"cf5dd0f4-f40c-480a-b9c3-97a37e0a2613","order_by":0,"name":"Nadine Rohloff","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Nadine","middleName":"","lastName":"Rohloff","suffix":""},{"id":148069676,"identity":"debafebf-ff85-40fc-9da2-6b036c560edb","order_by":1,"name":"Markus Rothenhöfer","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Markus","middleName":"","lastName":"Rothenhöfer","suffix":""},{"id":148069677,"identity":"b90026ed-ff15-4270-9bb4-dda133aef6cb","order_by":2,"name":"Teresa Götz","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Götz","suffix":""},{"id":148069678,"identity":"0c64d54e-f660-45da-aa7e-24c792fab8ed","order_by":3,"name":"Sebastian Schäfer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie2QsWrDMBCGzwjk5R5AIbh+hRhDp9JnkSkkS7aOGeJicBcbrzIE8gqeSoeCVQLJ4gcQaHEXd+ngbA10aFwCXaqQsYO+UXcf//0CsFj+If46Jr0TA7gxOC3I38nw+CcTJSkbpiiBTE7Kz7ZZYZzCSaHscuXwfHuFbt4tsHmKivHje7t/Aa8wdRGc7PPmLkTcXWtUOipXTfAgOghLU4ziMHZSEtVsSjX2OqrU3EmOZ0aVPKssl5nf0ftBqdXsLfk6KvV5ZcORUUqGwyrGgwSGFFN99ZqO8nQXZDglo1WjQ6HmQZlJFgpDir9ONv0hXfjobp3+Y6u9Qsza/lPeeIWpvun/mWnfYrFYLBfwDQOLaNAHwS5LAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8010-1463","institution":"Universitatsklinikum Munster Klinik fur Frauenheilkunde und Geburtshilfe","correspondingAuthor":true,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Schäfer","suffix":""}],"badges":[],"createdAt":"2022-10-06 09:43:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2138010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2138010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28634397,"identity":"b6826bb8-2d20-46a6-8c1e-6a9e11f3af86","added_by":"auto","created_at":"2022-11-03 20:34:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":380285,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2138010/v1/929ec8ec-4523-4df9-b3cf-be8010d656c0.pdf"}],"financialInterests":"","formattedTitle":"Observational study on the influence of an app-based self-management program on the quality of life of women with endometriosis.","fulltext":[{"header":"Take Home Message","content":"\u003cp\u003eThe quality of life of endometriosis patients improved by use of a digital self-management tool introduced in this study in patients with endometriosis. A prospective long-term multicenter randomized controlled trial is needed to further explore the effect of this patient-controlled health intervention.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAn estimated 1.7\u0026nbsp;million women in Germany suffer from endometriosis. Approximately 40,000 new diagnoses are made each year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe disease severely limits the quality of life of those affected [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The leading symptoms include sterility, pain symptoms and accompanying functional complaints. Due to the long course of the disease, frequent recurrences even after surgery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and the lack of a curative therapy, the symptoms often become chronic [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Chronic pain has the strongest deteriorating impact on quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExperts from the German Pain Society agree that it is advisable to introduce patients with chronic pain of any etiology to measures with which they can help themselves [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Physical therapy, nutritional therapy, and informational approaches, as well as stress reduction and symptom diaries, are cited as universally applicable options [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The current S2k guideline on the treatment and diagnosis of endometriosis of German speaking countries also emphasizes this. It is stated that patients should be informed about self-help services. The guideline also recommends complementary therapies with the goal of promoting skills in disease coping and self-management, support in behavioral and lifestyle changes, and maintaining earning capacity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA multimodal, interdisciplinary approach to endometriosis therapy as an adjunct to standard therapy is recommended as it aims to significantly improve patients' quality of life [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, these measures are currently only accessible to a very limited proportion of patients and are rarely covered by health insurances.\u003c/p\u003e \u003cp\u003eFor 2017, the health report of the Robert Koch Institute reports only 811 patients diagnosed with endometriosis in rehabilitation clinics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Researchers, treating physicians, and patients therefore demand an improvement in patient care with the central goal of improving quality of life [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, in addition to causal therapy, supportive care and help for self-help are also necessary. Access to reliable and trustworthy information is currently limited as well [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost of the complementary therapies and self-management strategies mentioned above have to be carried out by the patients themselves in everyday life. The positive effect of self-care counselling for women with endometriosis has already been shown in a few randomised trials [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For other conditions with chronic pain, it has already been shown that smartphone apps can support these self-care therapies at home, positively influencing pain, symptoms, and disease management [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, it can be expected that a mobile application via smartphone can be effective in improving quality of life in endometriosis as well. Nonetheless, studies in this regard are still missing.\u003c/p\u003e \u003cp\u003eThe Endo-App \u0026reg; was developed as a medical device. The aim of this study was to investigate the app\u0026rsquo;s effect on quality of life. It was examined whether there is evidence of positive care effects and whether a multicenter randomized controlled trial is worthwhile.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eThe sample consisted of 106 women. Inclusion criteria were a minimum age of 18 years, prior diagnosis of endometriosis and residency in Germany. Women were recruited over self-help groups, advertising in social media and posting in endometriosis-related groups. Women with endometriosis were invited to take part in the survey. Individuals who did not have endometriosis as a diagnosis or did not return both questionnaires were excluded from the study population.\u003c/p\u003e \u003cp\u003eIn the final sample womens age ranged from 20 to 51 years (mean: 33 years). Various occupational backgrounds were identified. Employees were most frequently represented (68 women), followed by students (14 women).\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study consisted of an initial survey and a follow-up survey. The surveys were conducted using online questionnaires. The follow-up survey took place two weeks after the initial survey. The results of both questionnaires could be merged using participant coding while maintaining anonymity.\u003c/p\u003e \u003cp\u003eAt the beginning of the questionnaire, all women were informed about the aims of the study, the anonymity of their data, and the contact details of the medical management for questions. Informed consent then was obtained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eInitial survey\u003c/h2\u003e \u003cp\u003eAt the beginning of the questionnaire, screening criteria were collected (gender, age, diseases). In the next part of the survey, the women were asked about their quality of life. For this purpose, the standardized and validated Endometriosis Health Profile (EHP) questionnaire from Oxford University [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was used. The implementation in the online questionnaire was reviewed by an Oxford University expert and found to be correct. The questionnaire asked about the five EHP core domains of quality of life:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePain (11 questions),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eControl \u0026amp; powerlessness (6 questions),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEmotional well-being (6 questions),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSocial support (4 questions) and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSelf-image (3 questions).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIn addition, two supplementary domains of the EHP were queried:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWork life (5 questions) and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTreatment (3 questions).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants were then asked to indicate their satisfaction with their own lives on a scale of 0 to 10 (quality of life index).\u003c/p\u003e \u003cp\u003eIn the next section, women were asked to react to various statements concerning their endometriosis care. In addition, the women were asked about the impact of endometriosis on their work. The therapy used so far was also recorded.\u003c/p\u003e \u003cp\u003eIn the following section, the women were asked about their menstrual periods. They were asked about hormonal therapy and the date of the first day of the last menstrual period to rule out confounding due to overrepresentation of one cyclic phase.\u003c/p\u003e \u003cp\u003eIn the last section of the questionnaire, the Endo-App was introduced and the women received information about the possibility to use the Endo-App free of charge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eFollow-up survey after two weeks\u003c/h2\u003e \u003cp\u003eTwo weeks after the initial survey, women who had signed up for the mailing list were invited via email to complete the follow-up survey.\u003c/p\u003e \u003cp\u003eAt the beginning of the follow-up survey, the women were asked about their usage behavior and intensity of use of the Endo-App. If women indicated that they had not used the Endo-App, they could voluntarily provide reasons.\u003c/p\u003e \u003cp\u003eThe same domains of the EHP, quality of life index, and endometriosis care statements were queried for all women.\u003c/p\u003e \u003cp\u003e Additionally, for participants who indicated they had used the Endo-App, a section followed in which the women could evaluate individual features of the app.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eRecruitment and evaluation\u003c/h2\u003e \u003cp\u003eRecruitment for this study was conducted online through various tools such as Facebook and Google. Online recruitment was deemed adequate to target women who are familiar with and actively use digital media.\u003c/p\u003e \u003cp\u003eBy clicking on the respective link, participants were then taken to the online questionnaire, which was based on the SoSci Survey tool. The questionnaire could be completed either on a desktop computer or on a mobile device.\u003c/p\u003e \u003cp\u003eAll women who participated in the first questionnaire could take part in a lottery for 10 \u0026euro; online vouchers, regardless if they entered their Email address for the second survey or not.\u003c/p\u003e \u003cp\u003eOnly women who participated in both the initial survey and the follow-up survey were included in the analysis.\u003c/p\u003e \u003cp\u003eIn the user group, the women who were evaluated (n\u0026thinsp;=\u0026thinsp;64) were those who reported using the app. The women who participated both times, but indicated that they had not used the app (n\u0026thinsp;=\u0026thinsp;42) were evaluated separately. These acted as a comparison group with which the user group could be compared in order to exclude an influence of general events, e.g. world events or weather, on the quality of life.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section4\"\u003e \u003ch2\u003eEndometriosis Health Profile (EHP)\u003c/h2\u003e \u003cp\u003eEach item of the EHP consists of a statement about the impact of endometriosis on the life of the affected person. The validated German survey was used. Responses are scaled from 0\u0026thinsp;=\u0026thinsp;Never to 4\u0026thinsp;=\u0026thinsp;Always. A domain's EHP score is calculated from the average of the domain's responses, scaled from 0 to 100, with a score of 0 being the best possible quality of life and 100 being the worst possible quality of life.\u003c/p\u003e \u003cp\u003eIn addition to the EHP score per domain (corresponding to the mean of the items assigned to this domain), a summary \"EHP-30 Summary Index\" can also be formed. This is calculated as an equally weighted mean of the five core domains. The calculation procedure of the Summary Index was also applied to the \"All Domains\" evaluation, so that an overall index could be created. This overall index including the additional domains has not been validated in the Oxford EHP-30. However, before calculating the overall index, the corresponding Cronbach's alpha value was calculated to check the reliability of the scale and thus the feasibility of the index.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section4\"\u003e \u003ch2\u003eInferential statistics\u003c/h2\u003e \u003cp\u003eTo examine the change after two weeks of Endo-App use, statistical tests were performed with the variables described above.\u003c/p\u003e \u003cp\u003eFirst, an F-test was used to see if a T-test could be applied with equal variance. Then, if possible, a two-tailed paired T test was performed for each variable and significance was calculated. Furthermore, the effect size was calculated via Cohen's d.\u003c/p\u003e \u003cp\u003eAs a between-group comparison, pairwise group comparisons were performed for the Summary Index Change score using nonparametric two-sided Mann-Whitney U tests for unrelated samples.\u003c/p\u003e \u003cp\u003eJust as described in the EHP manual, this study also found a sufficiently large Cronbach's alpha for the Summary Index (0.81) to consider it a summary index of the integrated individual domains.\u003c/p\u003e \u003cp\u003eA two-tailed, unpaired Mann-Whitney U test was used to compare the effects on the change scores of the Summary Index of user group with non-user group.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\n\u003ch3\u003eDemographics\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows a summary of the demographic characteristics of the participants. All participants were female and reported being diagnosed with endometriosis. The age ranged from 20 to 51 years.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edemographic characteristics of the participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eusers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-users\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ediverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eminimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eoccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehigh school student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eapprentice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003euniversity student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eemployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epublic official\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eself-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eunemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ediagnoses\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eendometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of infection with\u003c/p\u003e \u003cp\u003echlamydia trachomatis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eovarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efibroids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esmartphone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApple iOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 106 participants, 64 self-reported using the Endo-App (user group). In contrast, 42 indicated that they had not used the Endo-App (non-user group). N\u0026thinsp;=\u0026thinsp;15 women gave a reason for not using the app. Reasons fell into the categories of technical problems and little time for cell phone use.\u003c/p\u003e\n\u003ch3\u003eChanges In The User Group\u003c/h3\u003e\n\u003cp\u003eAn inferential statistical analysis was performed for the user group. This involved comparing the change in variables from initial to follow-up surveys. The results of the analysis are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ecomparison of variables before and during use of the Endo-App in the user group (n\u0026thinsp;=\u0026thinsp;number; M\u0026thinsp;=\u0026thinsp;median; SD\u0026thinsp;=\u0026thinsp;standard deviation; T Stat = ; p\u0026thinsp;=\u0026thinsp;probability; EHP\u0026thinsp;=\u0026thinsp;Endometriosis Health Profile; QoL\u0026thinsp;=\u0026thinsp;quality of life; ** = change statistically significant)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003einitial survey\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003efollow up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003echange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT Stat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEHP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17,95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43,43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21,39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9,23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-5,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl \u0026amp; powerlessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70,51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22,37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55,92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23,54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-14,58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-6,15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60,48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17,86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52,86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-7,62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-4,07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64,75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23,92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29,53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-10,06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3,81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55,86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27,08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29,96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-4,56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,1027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43,37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25,51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33,43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24,34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9,93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58,33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26,01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49,83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25,06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-8,51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAll Domains\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58,43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18,44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49,24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20,47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-5,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSummary Index\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60,85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17,72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51,64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21,02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9,21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-5,38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQoL (one-item)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5,63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1,55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0,48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith regard to the EHP, an improvement was observed in all domains except \u003cem\u003eself-image\u003c/em\u003e. The improvement of all variables except \u003cem\u003eself-image\u003c/em\u003e was statistically highly significant. In the core domains \u003cem\u003epain, control \u0026amp; powerlessness, emotional well-being, social support\u003c/em\u003e and \u003cem\u003eself-image\u003c/em\u003e all data sets were complete. In the \u003cem\u003ework life\u003c/em\u003e and \u003cem\u003etreatment\u003c/em\u003e modular questionnaires, 18 and 19 women, respectively, selected the \"not applicable\" response option offered in the modular questionnaire. All other questionnaires were complete.\u003c/p\u003e \u003cp\u003eFor the variables \u003cem\u003epain, control \u0026amp; powerlessness, emotional well-being, all domains\u003c/em\u003e and summary index a strong effect could be found according to Cohen\u0026rsquo;s d (|d| \u0026gt;0,5). Since \u003cem\u003eall domains\u003c/em\u003e is not an externally validated index, the Cronbach alpha value was calculated. This was α\u0026thinsp;=\u0026thinsp;0,832, so the index could be included.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eChanges in the non-user group\u003c/h2\u003e \u003cp\u003eThe same inferential statistical analysis was performed for the non-user group. The results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There was a statistically significant change (improvement) in \u003cem\u003epain\u003c/em\u003e for the non-user group. There were no other significant results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ecomparison of variables in the non-user group (n\u0026thinsp;=\u0026thinsp;number; M\u0026thinsp;=\u0026thinsp;median; SD\u0026thinsp;=\u0026thinsp;standard deviation; T Stat = ; p\u0026thinsp;=\u0026thinsp;probability; EHP\u0026thinsp;=\u0026thinsp;Endometriosis Health Profile; QoL\u0026thinsp;=\u0026thinsp;quality of life; ** = change statistically significant)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003einitial survey\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003efollow up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003echange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT Stat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEHP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22,55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37,12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22,39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-5,68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3,38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,0016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl \u0026amp; powerlessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24,83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52,28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24,59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2,38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0,83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,4097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22,97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47,72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0,70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,4861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26,32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1,64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,6668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0,07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39,48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28,64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26,08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0,79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,7657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29,86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24,65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28,71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26,91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1,40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,1704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44,29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25,94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44,89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29,40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0,08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,9380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAll Domains\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44,54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19,56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43,16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20,61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1,01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,3200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSummary Index\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47,02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20,74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45,22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0,88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,3864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0,14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQoL (one-item)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1,63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1,32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,1927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0,20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparison Of User Group And Non-user Group\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the results of user group and non-user group. ∆ M represents the average change in the variables between the initial and follow-up surveys (see \"change\" columns in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A direct comparison is not calculated in the table.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ecomparison of results between user group and non-user group (n\u0026thinsp;=\u0026thinsp;number; ∆ M\u0026thinsp;=\u0026thinsp;change of median; p\u0026thinsp;=\u0026thinsp;probability; EHP\u0026thinsp;=\u0026thinsp;Endometriosis Health Profile; QoL\u0026thinsp;=\u0026thinsp;quality of life; ** = change statistically significant).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003euser Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003enon-User group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e∆ M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e∆ M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEHP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9,23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-5,68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,0016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl \u0026amp; powerlessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-14,58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2,38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,4097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-7,62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,4861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-10,06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1,64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,6668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-4,56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,1027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0,79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,7657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9,46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-3,79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,1704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9,81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0,29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,9380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll Domains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9,06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,3200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSummary Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9,21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,3864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQoL (one-item)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,1927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo test whether the difference between user group and non-user group for the summary index was significant, a two-sided Mann-Whitney U test was calculated for the summary index. This was highly significant with p-value\u0026thinsp;=\u0026thinsp;0.006477.\u003c/p\u003e\n\u003ch3\u003eDays Since The Beginning Of The Last Menstrual Period\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e provides an overview of the phase of the menstrual period at the time of the initial survey. The purpose of analyzing the menstrual periods was to exclude confounding. For this purpose, the time span between the first day of the last menstrual period and the date of participation in the survey was calculated. The cycle-point was then grouped into weeks. Participants in the long-term cycle were recorded separately, as no meaningful date of the last menstrual period could be determined for them.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edays since last menstrual period (n\u0026thinsp;=\u0026thinsp;number)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eusers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003enon-users\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edays since last period\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eproportion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eproportion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u0026ndash;14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14\u0026ndash;21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e22\u0026ndash;28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003elong cycle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study already after two weeks of use, a statistically significant improvement of quality of life was observed among Endo-App users both according to EHP and the quality of life index.\u003c/p\u003e \u003cp\u003eQuality of life according to summary index improved by -9.21 points. This coincided with the improvement according to the quality of life scale of 0.69 points.\u003c/p\u003e \u003cp\u003eIt is noteworthy that the Endo-App did not have an equal impact on all domains of the EHP quality of life.\u003c/p\u003e \u003cp\u003eAfter two weeks of use, the impact of endometriosis on work life was reduced by an average of -9.93 points. Likewise, the variable for control \u0026amp; helplessness improved by -14.58 points. There was also an improvement of -9.23 points in the pain domain. Only the domain self-image resulted in merely a small improvement of -4.56 points, which was not statistically significant.\u003c/p\u003e \u003cp\u003eTo exclude bias in quality of life scores due to increased symptoms during the menstrual period, the timing of the menstrual cycle was determined at the time of the initial survey. An accumulation of the same menstrual cycle phase, for example day 1\u0026ndash;7 at the time of the initial survey, could theoretically lead to an over- or underestimation of the effect. There was no significant clustering of menstrual cycle phases among participants during the initial or follow-up surveys and an even distribution across all menstrual cycle phases and women on long-cycle hormone therapy (see Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Consequently, it can be assumed that there was no significant bias in the results due to specific menstrual phases.\u003c/p\u003e \u003cp\u003eAnalogous to a bias due to the menstrual phase, it would be possible for the results to be positively influenced by external influences. Such influences could be, for example, changes in the seasons or societal changes such as changes in corona measures. To test this, the results of women who used the Endo-App were compared with those who did not use the Endo-App. Because of the observational design, the study did not meet the requirements for a control group in an interventional study. For example, no randomization was performed. Nevertheless, the participants, who according to their own statements did not use the Endo-App, offered themselves as a point of comparison. The comparison was shown in the \u003cspan refid=\"Sec10\" class=\"InternalRef\"\u003eresults\u003c/span\u003e section in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn the user group, nine out of ten variables were improved in a highly significant manner.\u003c/p\u003e \u003cp\u003eIn the summary index, the observed changes after two weeks regarding user group and non-user group differed by -7.41. The comparison of changes between the user group and the non-user group on the summary index was validated with a Mann-Whitney U test. The result of the test was highly significant (p-value\u0026thinsp;=\u0026thinsp;0.006477). This confirms the hypothesis that a corresponding improvement in quality of life was triggered by the Endo-App.\u003c/p\u003e \u003cp\u003eOverall, the comparison with the non-user group supports the hypothesis that the Endo-App itself is responsible for the improvement in quality of life and that this is not due to external influences.\u003c/p\u003e \u003cp\u003eIt would also be theoretically possible that the non-user group did not use the Endo-App because of substantial deterioration in their quality of life. In this case, the quality of life scores between groups would be biased by systematic self-selection. To exclude this possibility, reasons for non-use were recorded and subjected to careful scrutiny in the analysis. The reason for non-use was recorded via free text at the follow-up survey. 15 of the 42 non-users surveyed gave a reason in the free text. In 14 cases, the reason was based on technical problems during installation. These technical difficulties can be explained by the fact that the app was made available via Apple Testflight and Android APK, which was unfamiliar to some users and thus represented a technical challenge. Since the occurrence of technical difficulties is in no way related to the quality of life or endometriosis symptoms of those affected, it can be assumed that the classification of the women into the non-user group did not result in any relevant distortions in terms of content.\u003c/p\u003e \u003cp\u003eThe time interval between initial interview and follow-up interview may already display short-term changes with the Endo-App. Based on the current literature, it can be expected that the effect would also be detectable after a longer period of time [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This needs to be the subject of future longitudinal studies with longer survey periods.\u003c/p\u003e \u003cp\u003eIt is also expected that some of the Endo-App content would reach its maximum effect over a longer period of use. For example, physiotherapy exercises, yoga, mindfulness exercises, or a healthier diet have short-term effects but also build up their effect over several weeks and months [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and maintain this effect in the long term [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Hansen et al. were able to show that even six years after an intervention with mindfulness and acceptance and commitment therapy, the improvement achieved was still detectable [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is noteworthy that the survey with the EHP always looks at the last four weeks in the women's lives, because the items of the questionnaire are designed for this period and, according to Oxford, may not be changed. This means that at the follow-up survey, two of the four weeks in the period under consideration were still prior to use of the Endo-App. This in turn suggests that even stronger effects or improvements would be observable in a follow-up survey that would take place longer after the initial survey.\u003c/p\u003e \u003cp\u003eThe results presented here allow initial conclusions to be drawn regarding a beneficial effect of the Endo-App. However, it must be pointed out that there are limitations in the study design.\u003c/p\u003e \u003cp\u003eThe analyses shown were not adjusted for multiple testing. Thus, across all hypotheses tested, there is a greater risk of alpha error than 5%. It should be noted, however, that changes in many domains and especially the summary index of the user group remain significant even after adjustment for multiple testing following the Bonferroni-Holm method.\u003c/p\u003e \u003cp\u003eAnother limitation is the rather small sample size. Although it was enough to achieve sufficient power for finding significant effects. However, small samples generally have to be assumed to have limited generalizability to the overall population. Testing the effects found here with a higher number of participants is therefore an important area for further studies on the topic.\u003c/p\u003e \u003cp\u003eAlthough complete case analysis is often used in medical studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] it has its limits, especially when the reason for dropouts is not known [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For the necessary randomized trial measures to prevent dropouts like reminders and recruitment via medical personnel should be implemented as well as investigations concerning the dropout reason.\u003c/p\u003e \u003cp\u003eDespite the limitations, the results found are an important starting point to plan a randomized controlled trial subsequently and to support the exploration of expected effects. The results also clearly point to the meaningfulness and usefulness of such a follow-up study due to the expected positive effects.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this observational study, it could be shown that a significant improvement in the quality of life occurred in the surveyed users of the Endo-App already after two weeks. This included several relevant domains of quality of life and could not be explained by external or confounding variables.\u003c/p\u003e \u003cp\u003eHowever, further research on the Endo-App requires a randomized controlled trial with sufficient power to provide confirmatory insights in the medium- and long-term effects.\u003c/p\u003e \u003cp\u003eIn summary, the results are very promising, so it is expected that women with endometriosis will benefit from the use of the Endo-App. Considering the substantial burden of endometriosis and the identified gaps in patient care, further investigation is of great interest.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNadine Rohloff (founder and management), Markus Rothenh\u0026ouml;fer (employment) and Teresa G\u0026ouml;tz (employment) are employees of Endo Health GmbH which developed the Endo App that was studied in this publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSebastian Daniel Schaefer declares the following potential conflicts of interests: Advisory Board of PlantTec Medical GmbH and Baxter Medical on adhesions, Advisory Boards of European Endometriosis League, German Working Group Gynecological Endoscopy, German Endometriosis Research Foundation, Early Career Board of World Endometriosis Society, Vice President German Working Group Endometriosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN Rohloff: protocol/project development, data collection and management, data analysis, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eM Rothenh\u0026ouml;fer: protocol/project development, data collection and management, data analysis, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eT G\u0026ouml;tz: protocol/project development, data collection and management, data analysis, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eS Sch\u0026auml;fer: protocol/project development, data analysis, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Westfalian Wilhelms University M\u0026uuml;nster, Germany (17.08.2022 / 2021-338-f-S).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJanni W, Hancke K, Fehm T et al (eds) (2017) Facharztwissen Gyn\u0026auml;kologie, 2. Auflage. Elsevier, M\u0026uuml;nchen, Deutschland\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFourquet J, B\u0026aacute;ez L, Figueroa M et al (2011) Quantification of the impact of endometriosis symptoms on health-related quality of life and work productivity. Fertil Steril 96:107\u0026ndash;112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert.2011.04.095\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2011.04.095\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo S-W (2009) Recurrence of endometriosis and its control. Hum Reprod Update 15:441\u0026ndash;461. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/humupd/dmp007\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dmp007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoliman AM, Du EX, Yang H et al (2017) Retreatment Rates Among Endometriosis Patients Undergoing Hysterectomy or Laparoscopy. J Womens Health (Larchmt) 26:644\u0026ndash;654. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/jwh.2016.6043\u003c/span\u003e\u003cspan address=\"10.1089/jwh.2016.6043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFacchin F, Barbara G, Saita E et al (2015) Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference. J Psychosom Obstet Gynaecol 36:135\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/0167482X.2015.1074173\u003c/span\u003e\u003cspan address=\"10.3109/0167482X.2015.1074173\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnold B, Brinkschmidt T, Casser H-R et al (2014) Multimodale Schmerztherapie f\u0026uuml;r die Behandlung chronischer Schmerzsyndrome. Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplin\u0026auml;re Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten. [Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society on treatment contents]. Schmerz 28:459\u0026ndash;472. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00482-014-1471-x\u003c/span\u003e\u003cspan address=\"10.1007/s00482-014-1471-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurghaus S, Sch\u0026auml;fer SD, Beckmann MW et al (2021) Diagnostik und Therapie der Endometriose. S2k-Leitlinie der DGGG, SGGG und OEGGG. [Diagnosis and Treatment of Endometriosis. S2k-Guideline of the DGGG, SGGG and OEGGG]. Geburtshilfe Frauenheilkd 81:422\u0026ndash;446. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-1380-3693\u003c/span\u003e\u003cspan address=\"10.1055/a-1380-3693\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuggio L, Barbara G, Facchin F et al (2017) Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. Int J Womens Health 9:281\u0026ndash;293. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/IJWH.S119724\u003c/span\u003e\u003cspan address=\"10.2147/IJWH.S119724\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper H, Booth K, Fear S et al (2001) Chronic disease patient education: lessons from meta-analyses. Patient Educ Couns 44:107\u0026ndash;117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0738-3991(00)00182-8\u003c/span\u003e\u003cspan address=\"10.1016/s0738-3991(00)00182-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026auml;user W, Bock F, H\u0026uuml;ppe M et al (2020) 2. Aktualisierung der S3 Leitlinie \u0026bdquo;Langzeitanwendungen von Opioiden bei chronischen nicht-tumorbedingten Schmerzen (LONTS 2020). [2. Update of the S3 guideline \"Long-term opioid use in non-cancer pain\"]. Der Schmerz 204\u0026ndash;244. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00482-020-00472-y\u003c/span\u003e\u003cspan address=\"10.1007/s00482-020-00472-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikolasek M, Berg J, Witt CM et al (2018) Effectiveness of Mindfulness- and Relaxation-Based eHealth Interventions for Patients with Medical Conditions: a Systematic Review and Synthesis. Int J Behav Med 25:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12529-017-9679-7\u003c/span\u003e\u003cspan address=\"10.1007/s12529-017-9679-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobert K-I (2020) Gesundheitliche Lage der Frauen in Deutschland. Gesundheitsberichterstattung des Bundes: Gemeinsam getragen von RKI und Destatis. [Health situation of women in Germany. Federal health reporting]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.rki.de/frauengesundheitsbericht\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 12 Sep 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirsch M, Aggarwal S, Barker C et al (2017) Googling endometriosis: a systematic review of information available on the Internet. Am J Obstet Gynecol 216:451\u0026ndash;458e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajog.2016.11.1007\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2016.11.1007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoseley L (2002) Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother 48:297\u0026ndash;302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0004-9514(14)60169-0\u003c/span\u003e\u003cspan address=\"10.1016/s0004-9514(14)60169-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarshi N, Hasanpour S, Mirghafourvand M et al (2020) Effect of self-care counselling on depression and anxiety in women with endometriosis: a randomized controlled trial. BMC Psychiatry 20:391. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-020-02795-7\u003c/span\u003e\u003cspan address=\"10.1186/s12888-020-02795-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao L, Wu H, Zhou X et al (2012) Effects of progressive muscular relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy. Eur J Obstet Gynecol Reprod Biol 162:211\u0026ndash;215. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejogrb.2012.02.029\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2012.02.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKristj\u0026aacute;nsd\u0026oacute;ttir OB, Fors EA, Eide E et al (2013) A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. J Med Internet Res 15:e5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/jmir.2249\u003c/span\u003e\u003cspan address=\"10.2196/jmir.2249\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones G, Jenkinson C, Kennedy S (2004) Evaluating the responsiveness of the Endometriosis Health Profile Questionnaire: the EHP-30. Qual Life Res 13:705\u0026ndash;713. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1023/B:QURE.0000021316.79349.af\u003c/span\u003e\u003cspan address=\"10.1023/B:QURE.0000021316.79349.af\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves AV, Barros NF, Bahamondes L (2017) The Practice of Hatha Yoga for the Treatment of Pain Associated with Endometriosis. J Altern Complement Med 23:45\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/acm.2015.0343\u003c/span\u003e\u003cspan address=\"10.1089/acm.2015.0343\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan CG, Gray HG, Newton M et al (2010) Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther 15:382\u0026ndash;387. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.math.2010.03.003\u003c/span\u003e\u003cspan address=\"10.1016/j.math.2010.03.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmid AA, van Puymbroeck M, Fruhauf CA et al (2019) Yoga improves occupational performance, depression, and daily activities for people with chronic pain. Work 63:181\u0026ndash;189. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3233/WOR-192919\u003c/span\u003e\u003cspan address=\"10.3233/WOR-192919\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOtt J, Nouri K, Hrebacka D et al (2012) Endometriosis and nutrition \u0026ndash; recommending a mediterranean diet decreases endometriosis-associated pain: an experimental observa\u0026shy;tional study.J Aging Res Clin Practice:162\u0026ndash;166\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantanam N, Kavtaradze N, Murphy A et al (2013) Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Transl Res 161:189\u0026ndash;195. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.trsl.2012.05.001\u003c/span\u003e\u003cspan address=\"10.1016/j.trsl.2012.05.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen KE, Kesmodel US, Kold M et al (2017) Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: A six-year follow-up on a pilot study. Nordic Psychol 69:100\u0026ndash;109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/19012276.2016.1181562\u003c/span\u003e\u003cspan address=\"10.1080/19012276.2016.1181562\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunt NB, Gardarsdottir H, Bazelier MT et al (2021) A systematic review of how missing data are handled and reported in multi-database pharmacoepidemiologic studies. Pharmacoepidemiol Drug Saf 30:819\u0026ndash;826. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/pds.5245\u003c/span\u003e\u003cspan address=\"10.1002/pds.5245\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeyrat C, Carpenter JR, Bailly S et al (2021) Common Methods for Handling Missing Data in Marginal Structural Models: What Works and Why. Am J Epidemiol 190:663\u0026ndash;672. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/aje/kwaa225\u003c/span\u003e\u003cspan address=\"10.1093/aje/kwaa225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"endometriosis, app, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-2138010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2138010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eEndometriosis can significantly impair the quality of life of those affected. Multimodal self-help measures are recommended but often difficult to access. Smartphone apps have been shown to improve quality of life for other conditions with chronic pain. The aim of this study was to examine whether there is evidence of beneficial effects of the smartphone app “Endo-App®” and whether a multicenter randomized controlled trial should be planned to substantiate these effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In a sample of N=106 women affected by endometriosis the present study determined the influence of the use of Endo-App ® on their quality of life. Among others, the validated questionnaire \u003cem\u003eEndometriosis Health Profile \u003c/em\u003efrom Oxford University was used for this purpose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The use of Endo-App ® lead to a highly significant improvement in quality of life already after two weeks. A statistically significant change was found for nine out of ten measured variables of quality of life. A series of further analyses validated that the measured positive effects were not due to other confounding factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In summary, the results indicate that the quality of life of women with endometriosis improved by the digital self-management tool Endo-App ®. More studies are needed to further explore the influence of the app on quality of life and as confirmatory evidence of beneficial effects. For this purpose, a randomized controlled trial should be conducted over a longer period of time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis trial is registered at clinicaltrials.gov under the registration number NCT05528601 on August 18, 2022. It was retrospectively registered.\u003c/p\u003e","manuscriptTitle":"Observational study on the influence of an app-based self-management program on the quality of life of women with endometriosis.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-03 20:34:04","doi":"10.21203/rs.3.rs-2138010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2022-12-01T12:58:55+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-10-30T21:17:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2022-10-09T19:47:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-08T12:53:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2022-10-06T13:13:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f27adea2-0ad7-454d-8558-2d09d554bc2f","owner":[],"postedDate":"November 3rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-03-12T08:33:07+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-03 20:34:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2138010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2138010","identity":"rs-2138010","version":["v1"]},"buildId":"0SHbDDIpRTBOrFPTvp6pu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}