Associations of health and lifestyle factors with multidimensional quality of life among women with endometriosis: a cross-sectional study

Introduction: Endometriosis is a chronic disease associated with pain, fertility difficulties, and reduced quality of life (QoL). Beyond clinical symptoms, health-related and lifestyle behaviors may influence the long-term impact of the disease. This study aimed to assess multiple QoL dimensions in women with endometriosis and examine their associations with disease-related symptoms, body mass index (BMI), and lifestyle characteristics.

A cross-sectional online survey was completed by 153 women aged ≥ 18 years with self-reported endometriosis. Data included sociodemographic characteristics, body weight, physical activity, diet, smoking, and digestive symptoms, including painful defecation. The Endometriosis Impact Questionnaire evaluated physical, psychological, social, sexual and intimate, fertility, educational, employment and financial, and lifestyle QoL across three recall periods. Non-parametric tests and multivariate linear regression models assessed group differences and factors associated with QoL dimensions and overall impact.

The greatest burden was observed in fertility, physical, and psychological dimensions, particularly during the previous 12 months. Body-weight change since symptom onset was associated with poorer outcomes across all QoL domains. BMI showed coding-dependent associations: continuous BMI predicted greater physical and psychological impact, whereas BMI ≥ 25.0 kg/m2 was linked to lower impact in physical (β=−0.42; p = 0.005), sexual and intimate (β=−0.31; p = 0.044), and employment and financial QoL (β=−0.31; p = 0.049). Painful defecation was associated with greater psychological and sexual and intimate impact and higher overall impact. Smoking was associated with greater lifestyle impact (β=0.38; p < 0.001) and higher overall impact (β=0.17; p = 0.042). Dietary supplement use was associated with lower fertility impact (β=−0.18; p = 0.049), whereas following a dietary regimen was associated with higher fertility impact (β=0.22; p = 0.014).

Endometriosis substantially affects multiple life domains, particularly fertility and physical and psychological well-being. Weight change, painful defecation, and smoking were linked to poorer QoL, while BMI demonstrated complex domain-specific associations. Integrated medical and lifestyle approaches may improve long-term disease impact. 1 Introduction Endometriosis is a chronic, estrogen-dependent, systemic, and inflammatory gynecological disease characterized by the presence of endometrial-like tissue outside the uterine cavity (1–5). It causes a wide range of symptoms, including chronic pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and infertility (6, 7), which may be widespread and persist despite treatment (2, 8, 9). The condition affects approximately 10%–15% of women of reproductive age worldwide (1). Despite its prevalence, endometriosis is often described as a “missed disease” due to its unclear etiology and frequent diagnostic delays (4), partly because up to 20%–25% of women with endometriosis present with nonspecific symptoms or remain asymptomatic (10). Moreover, no single treatment currently provides a complete cure (3). Given its complex nature, endometriosis significantly affects physical, psychological, and social functioning, ultimately reducing quality of life (QoL). The World Health Organization (WHO) defines QoL as an individual's perception of their position in life within the context of their culture, value systems, goals, expectations, and concerns (11). QoL encompasses multiple dimensions, including physical health, psychological state, functional independence, social relationships, belief systems, and environmental context (11). However, the impact of endometriosis extends beyond these categories (12–16). Research shows that the condition alters women's QoL across numerous dimensions, including physical, psychological, social, sexual and intimate functioning, fertility, work life, finances, education, and lifestyle (13, 17, 18). Recent evidence further emphasizes the importance of comprehensive, disease-specific QoL assessment tools capable of capturing these multidimensional effects and supporting patient-centered care (19). Women with endometriosis frequently report a markedly reduced QoL compared with the general population (20). QoL outcomes may also vary according to socio-demographic, clinical, and psychological factors, highlighting the importance of examining multiple determinants of disease burden (21). Symptoms can limit daily functioning, sexual activity, intimate relationships, and work performance, contributing to frustration, anxiety, and depression (7). Chronic pain is a predominant symptom, occurring particularly during menstruation, during or after sexual intercourse, and during urination or defecation (3). Pain during defecation, with or without constipation, may result from bowel involvement, inflammation, or adhesions, and can substantially interfere with daily activities (22–25). Dyspareunia negatively affects sexual function and intimate relationships, increasing relationship-related stress and psychological burden (13). Fertility difficulties may also lead to emotional distress and reduced psychological well-being (26). Overall, chronic pain, infertility, and psychological factors such as anxiety and depression are consistently identified as key predictors of reduced QoL in women with endometriosis (27). Although pain and reproductive difficulties are among the most extensively studied features of endometriosis, growing evidence indicates that factors such as body mass index (BMI), physical activity, dietary habits, and body image also influence health perceptions and overall QoL (28–33). A healthy lifestyle, incorporating regular physical activity, balanced nutrition, and effective stress management, is known to positively affect overall well-being (34, 35), yet the physical limitations and psychological burden associated with endometriosis may hinder the adoption or maintenance of such behaviors (36). Despite increased research interest, the relationships between lifestyle variables, BMI, physical activity, unhealthy habits, and different dimensions of QoL remain insufficiently explored. Few studies have examined how disease manifestations and lifestyle factors interact to affect physical, psychological, social, reproductive, and sexual functioning, as well as work productivity, education, and financial status (8, 9, 28). Furthermore, the long-term impact of specific symptoms, such as pain during defecation, on daily functioning and QoL has not been thoroughly investigated (22–25). Alongside lifestyle behaviors, the use of dietary supplements has received attention due to their anti-inflammatory, antioxidant, antiproliferative, and immunomodulatory properties (37), although evidence regarding their effectiveness in improving QoL remains limited. Although several validated instruments are available to assess health-related QoL in women with endometriosis, including the Endometriosis Health Profile-30 (EHP-30) (38) and its shorter version, the EHP-5 (39), the Endometriosis Impact Questionnaire (EIQ) was specifically developed to evaluate the long-term impact of endometriosis on women's lives (8). A distinctive feature of the EIQ is that it assesses disease impact across multiple recall periods, allowing a more comprehensive evaluation of the enduring burden of endometriosis over time. Given the multidimensional objectives of the present study, the EIQ was considered particularly suitable for capturing the wide-ranging effects of endometriosis on women's lives.For these reasons, it is essential to examine the associations between QoL in women with endometriosis and factors such as lifestyle behaviors, BMI, physical activity, dietary supplement use, and health-related symptoms including painful defecation. Understanding these relationships may clarify how such variables influence different QoL dimensions, including physical, psychological, social, and sexual functioning (8, 9, 28, 40). Based on the existing literature, we hypothesized that lifestyle behaviors, BMI, and specific disease-related symptoms are associated with QoL in women with endometriosis. Higher BMI and weight gain since symptom onset, together with lower levels of physical activity, were expected to be related to poorer QoL across multiple dimensions. Conversely, regular physical activity and dietary supplement use were expected to correlate with better general health perceptions and emotional well-being. Furthermore, more severe and persistent symptoms, particularly pain during defecation, which may reflect deeper pelvic involvement, were assumed to contribute to greater functional impairment and psychosocial distress. Thus, the primary aim of this study was to assess the physical, psychological, social, fertility-related, sexual and intimate, educational, employment and financial, as well as lifestyle dimensions of QoL among women with endometriosis. A further objective was to analyze the associations between these dimensions and perceived weight, disease-related symptoms, and lifestyle factors, and to identify the predictors most strongly associated with reduced overall QoL. 2 Materials and methods 2.1 Study participants This cross-sectional study was conducted from 10th February 2025 to 1st July 2025. A total of 174 women with a self-reported history of endometriosis voluntarily participated. Participants were recruited using a non-probability convenience sampling approach through endometriosis patient associations, dedicated Facebook groups (both open and closed), and dissemination of the survey link via email, WhatsApp, and other electronic communication platforms. A snowball sampling method was also applied, whereby respondents were encouraged to share the survey with other women with endometriosis. Inclusion criteria were age ≥ 18 years and self-reported history of endometriosis. This approach was adopted to maximize recruitment reach and inclusivity, as requiring diagnostic verification would have substantially restricted participation and potentially introduced selection bias. Exclusion criteria included male sex, absence of endometriosis, age < 18 years, and incomplete questionnaires. Three participants were excluded due to missing sociodemographic data, one due to missing height and weight information, and four because they did not indicate their country or region of residence. Participants living outside the Republic of Croatia (N = 13) were excluded from further analyses due to the small number and heterogeneity of this subgroup relative to the main sample. These excluded participants did not differ significantly from Croatian participants in sociodemographic characteristics, health-related variables, or main outcome measures. The final analytical sample consisted of 153 participants. 2.2 Ethical considerations The study received ethical approval from the Ethics Committee of the University of Zadar, Croatia (approval number: 114-06/24-01/16; approval date: March 28, 2024) and was conducted in accordance with the principles of the Declaration of Helsinki and its revisions. Participation was voluntary, and informed consent was obtained from all participants before completing the questionnaire. The survey was anonymous, and no personally identifiable information was collected to ensure confidentiality. 2.3 Questionnaire Sociodemographic data, medical history, lifestyle habits, and the perceived impact of endometriosis on QoL were collected through a self-administered online questionnaire. The questionnaire combined two original instruments: the Questionnaire on Health and Lifestyle Habits among Women with Endometriosis (41) and the EIQ (8). Written permission to use both questionnaires for research purposes was obtained from the respective authors. An expanded version of the validated Questionnaire on Health and Lifestyle Habits among Women with Endometriosis (41) was developed. Compared to the original version, the questionnaire was extended and included items related to participants' education in fields potentially influencing baseline knowledge (e.g., health sciences, psychology, nutrition, physical activity), based on the assumption that formal training in these areas may shape relevant behaviors. Participants self-reported their body weight and height, frequency and duration of physical activity, number and timing of daily meals, and information on their use of dietary supplements and additives. Dietary habits were assessed through fruit, vegetable, and fluid intake, in accordance with the original instrument, and supplemented with questions on predominant dietary patterns (e.g., traditional, Mediterranean, vegan). Participants additionally reported their consumption of caffeine, alcohol, and tobacco products, as well as perceived endometriosis-related weight changes, adherence to specific dietary regimens, and awareness of the relationship between nutrition and symptom severity. Health-related questions also addressed digestive function, including stool frequency and consistency, pain during defecation, and perceptions of diet-related effects on digestive disturbances (41). The EIQ was used to assess the long-term impact of endometriosis across eight QoL dimensions: physical, psychological, social, sexual and intimate, fertility, employment and financial, educational, and lifestyle, the latter assessing lifestyle-related coping behaviors, specifically the use of alcohol, tobacco, or other illicit substances to cope with endometriosis symptoms or their emotional impact (8). Each dimension was evaluated over three recall periods: the past 12 months, one to five years ago, and more than five years ago. Responses were rated on a 0–4 scale (0 = not at all, 1 = a little, 2 = somewhat, 3 = quite a lot, 4 = very much), with an additional option of 9 = not applicable, which was excluded from score calculations. For each domain and recall period, scores were calculated as the sum of all applicable item responses divided by the maximum possible score (number of items × 4), then rescaled to a 0–100 scale, where 0 represents minimal and 100 maximal impact of endometriosis. Because higher EIQ scores indicate greater disease impact, positive regression coefficients reflect worse QoL (greater impact), whereas negative coefficients indicate lower perceived impact. The total score for each dimension was calculated as the mean across the three recall periods. If a participant did not provide responses for a specific dimension or recall period, a score for that part could not be generated. Both dimension-specific scores and the overall EIQ score were included in the final analysis (8). 2.4 Statistical analysis The final sample comprised 153 women with endometriosis residing in Croatia. The Kolmogorov–Smirnov test was used to assess the normality of data distribution. Categorical variables were presented as absolute numbers and percentages, while numerical variables were summarized using the mean (M) or median (Mdn) and standard deviation (SD) or interquartile range (IQR), depending on their distribution. Differences in recall scores across the three time periods within each QoL dimension were examined using the Friedman test. The Mann–Whitney U test was applied to numerical variables to explore between-group differences. Multivariate linear regression analyses were performed to examine associations between variables. Several multivariable linear regression models were constructed for each QoL dimension (physical, psychological, social, sexual and intimate, fertility, employment and financial, educational, and lifestyle) and for the overall EIQ score. Predictor variables included age, education level, marital status, BMI, body weight changes, perceived body weight category, physical activity, following a dietary regimen, dietary supplement use, fluid intake, smoking, coffee and alcohol consumption, bowel problems, painful defecation, and constipation. BMI was analyzed both as a continuous variable (kg/m2) and as a dichotomous variable using a cut-off of 25.0 kg/m2 (<25.0 vs. ≥ 25.0 kg/m2), consistent with the WHO classification of overweight. The same set of predictor variables was entered simultaneously into each model, allowing assessment of the independent association of each predictor with the respective outcome while controlling for all other variables included in the model. In observational studies examining QoL in women with endometriosis, multivariable models consistently show that clinical, psychosocial, and behavioral predictors explain a moderate proportion of variance in QoL outcomes. Studies identifying predictors of QoL in this population report meaningful standardized regression effects across symptom burden, emotional well-being, and health-related behaviors, corresponding to medium effect sizes within the Cohen framework (10, 42, 43). Therefore, a medium effect size (f2 = 0.15) was considered an appropriate and conservative estimate for the power calculation. An a priori power analysis was performed using the G*Power software (Heinrich Heine University Düsseldorf, Düsseldorf, Germany) to determine whether the planned sample size would provide adequate statistical power for a multiple linear regression model with 17 predictors. Assuming a medium effect size (f2 = 0.15), a significance level of α = 0.05, and a desired statistical power of 0.80, the analysis indicated that a minimum of 146 participants was required. After data collection, a post hoc power analysis was carried out for the final sample of 153 participants with 17 predictors, confirming that the achieved power was sufficient (1-β = 0.82). Statistical analyses were conducted using SPSS Statistics version 21.0 (IBM, Armonk, NY, USA). A p-value < 0.05 was considered statistically significant. 3 Results 3.1 Sociodemographic, health-related, and lifestyle characteristics of women with endometriosis The average age of participants was 34.8 years (SD = 5.9), with more than half (53.6%) between 26 and 35 years. Most participants were married or in a civil partnership (74.5%) and had a university-level education (75.8%) (Supplementary Table 1). A change in body weight since the onset of endometriosis symptoms was reported by 66.0% of participants. Of these, 32.7% reported weight gain, 5.9% reported weight loss, and 27.4% reported fluctuating weight (Table 1). Nearly half of participants (48.4%) perceived themselves as overweight, and 22.9% reported following a dietary regimen. Bowel-related symptoms (including diarrhea, constipation, or mixed bowel habits) were present in 41.2% of participants, while pain during defecation was reported by more than half (58.2%) (Table 1). Table 1 | Variable | Value | |---|---| | Body height (m), Mdn (IQR) | 168.0 (8.0) | | Body weight (kg), Mdn (IQR) | 65.0 (14.0) | | BMI, Mdn (IQR) | 22.5 (5.7) | | BMI category, N (%) | | | < 18.5 kg/m2 (underweight) | 8 (5.2) | | 18.5–24.9 kg/m2 (normal weight) | 96 (62.7) | | 25.0–29.9 kg/m2 (overweight) | 45 (29.4) | | ≥ 30.0 kg/m2 (obesity) | 4 (2.6) | | Perceived weight change since symptom onset, N (%) | | | Weight gain | 50 (32.7) | | Weight loss | 9 (5.9) | | Weight fluctuation | 42 (27.4) | | No change | 52 (34.0) | | Perceived body weight, N (%) | | | Underweight | 12 (7.8) | | Normal weight | 67 (43.8) | | Overweight | 74 (48.4) | | Following a dietary regimen, N (%) | | | No | 118 (77.1) | | Yes | 35 (22.9) | | Bowel-related symptoms, N (%) | | | Yes | 63 (41.2) | | No | 90 (58.8) | | Pain during defecation, N (%) | | | Yes | 89 (58.2) | | No | 64 (41.8) | Health-related characteristics of the study group (N = 153). Mdn, median; IQR, interquartile range; BMI, body mass index; N, number of participants. The largest proportion of participants reported engaging in 1–3 h of physical activity per week (44.4%) (Table 2). Regarding dietary habits, 52.9% indicated partial adherence to a healthy diet, and the same proportion (52.9%) consumed fewer than three meals per day. The most commonly reported dietary patterns were the traditional diet (32.7%) and the Mediterranean diet (22.2%). A total of 77.1% of participants used dietary supplements, while 84.6% reported a daily fluid intake below 2000mL. Water was the predominant beverage choice (96.1%). Regarding substance use, 63.4% of participants were active smokers, 81.0% consumed coffee, and 50.3% reported occasional alcohol intake (Table 2). Table 2 | Variable | Value | |---|---| | Physical activity, N (%) | | | Less than 1 h per week | 44 (28.8) | | 1–3 h per week | 68 (44.4) | | 3–5 h per week | 28 (18.3) | | More than 5 h per week | 13 (8.5) | | Adherence to healthy eating habits, N (%) | | | No | 17 (11.1) | | Yes | 55 (35.9) | | Partially | 81 (52.9) | | Number of meals per day, N (%) | | | < 3 meals | 81 (52.9) | | ≥ 3 meals | 72 (47.1) | | Predominant dietary pattern, N (%) | | | Traditional diet | 50 (32.7) | | Mediterranean diet | 34 (22.2) | | Vegetarian and vegan | 9 (5.9) | | Gluten-free, lactose-free, and LCHF diet | 10 (6.5) | | Other/combinations | 27 (17.6) | | No particular attention to diet | 23 (15.0) | | Use of dietary supplements, N (%) | | | Yes | 118 (77.1) | | No | 35 (22.9) | | Daily fluid intake, N (%) | | | 2,000 mL | 24 (15.4) | | Most frequently consumed type of beverage, N (%) | | | Water | 147 (96.1) | | Juices | 6 (3.9) | | Smoking, N (%) | | | Yes | 97 (63.4) | | No | 56 (36.6) | | Coffee consumption, N (%) | | | Yes | 124 (81.0) | | No | 29 (19.0) | | Alcohol consumption, N (%) | | | Sometimes | 77 (50.3) | | Never | 76 (49.7) | Lifestyle characteristics of the study group (N = 153). N, number of participants; LCHF, low-carbohydrate, high-fat. 3.2 Differences between quality-of-life dimensions related to endometriosis Significant differences between recall periods were observed across all QoL dimensions except the educational dimension, with the strongest impact reported for the past 12 months (Table 3). When examining each period separately, as well as when combining scores across periods, the highest EIQ scores were observed in the fertility domain (Mdn = 66.6, IQR = 74.7), followed by the physical (Mdn = 61.6, IQR = 27.8), psychological (Mdn = 59.1, IQR = 42.0), and social dimensions (Mdn = 43.8, IQR = 46.4). The lifestyle dimension was the least affected (Mdn = 9.7, IQR = 33.3). The Mdn overall EIQ score was 36.2 (IQR = 27.8) (Table 3). Table 3 | Quality-of-life dimension | Recall period | pa | Overall score | || |---|---|---|---|---|---| | Last 12 months | 1 to 5 years ago | More than 5 years ago | ||| | Biopsychosocial dimension, Mdn (IQR) | ||||| | Physical dimension | 64.4 (46.3) | 62.5 (34.6) | 55.8 (32.7) | < 0.001 | 61.6 (27.8) | | Psychological dimension | 71.1 (54.3) | 67.2 (40.2) | 54.7 (54.3) | < 0.001 | 59.1 (42.0) | | Social dimension | 50.0 (60.9) | 43.8 (54.7) | 40.6 (62.5) | < 0.001 | 43.8 (46.4) | | Sexual and intimate relationships, Mdn (IQR) | 35.7 (39.3) | 33.9 (46.4) | 30.4 (67.9) | < 0.001 | 32.1 (34.5) | | Fertility dimension, Mdn (IQR) | 75.0 (87.5) | 75.0 (70.8) | 50.0 (100.0) | 0.004 | 66.6 (74.7) | | Employment and financial dimension, Mdn (IQR) | 27.3 (31.8) | 19.3 (34.1) | 14.8 (42.6) | < 0.001 | 22.0 (33.0) | | Educational dimension, Mdn (IQR) | 0.0 (29.2) | 0.0 (37.5) | 14.6 (58.3) | 0.439 | 9.7 (40.6) | | Lifestyle dimension, Mdn (IQR) | 0.0 (25.0) | 4.2 (33.3) | 0.0 (39.6) | 0.010 | 9.7 (33.3) | | Overall for all dimensions, Mdn (IQR) | 36.2 (27.8) | Impact of endometriosis on quality-of-life dimensions across three recall periods (N = 153). Friedman test. Mdn, median; IQR, interquartile range; EIQ, Endometriosis Impact Questionnaire. Among women who reported a change in body weight since the onset of endometriosis symptoms, a significant impact was observed across all QoL dimensions. The total mean rank was 87.2 (p < 0.001) for body weight change and 89.7 (p = 0.028) for perceived overweight (Table 4). Among smokers, endometriosis had a significant impact on the employment and financial dimension (mean rank = 76.7; p = 0.043) and on the lifestyle dimension (mean rank = 79.7; p < 0.001). In women who used dietary supplements, significant effects were found in the fertility (mean rank = 67.2; p = 0.038), employment and financial (mean rank = 75.9; p = 0.020), and lifestyle dimensions (mean rank = 70.5; p = 0.022). Painful defecation was associated with overall QoL dimensions, with a total mean rank of 83.4 (p = 0.034) (Table 4). Table 4 | QoL dimension | Overall QoL | ||||||||| |---|---|---|---|---|---|---|---|---|---|---| | Variable | Category / p-value | Physical | Psychological | Social | Sexual and Intimate | Fertility | Employment and Financial | Educational | Lifestyle | | | Body weight change since symptom onset | yes | 83.5 | 86.2 | 87.4 | 81.5 | 71.4 | 79.1 | 51.0 | 72.0 | 87.2 | | no | 64.5 | 59.1 | 56.8 | 55.8 | 48.3 | 56.6 | 34.3 | 56.5 | 57.1 | | | pa | 0.012 | < 0.001 | < 0.001 | 0.001 | 0.001 | 0.002 | 0.003 | 0.021 | < 0.001 | | | Perceived overweight | yes | 88.5 | 91.3 | 90.8 | 79.3 | 72.7 | 84.0 | 55.1 | 72.6 | 89.7 | | no | 72.6 | 71.5 | 71.8 | 70.7 | 60.1 | 66.6 | 41.3 | 64.3 | 72.2 | | | pa | 0.048 | 0.014 | 0.018 | 0.276 | 0.084 | 0.023 | 0.023 | 0.261 | 0.028 | | | Smoking | yes | 81.7 | 81.0 | 82.3 | 71.9 | 62.6 | 76.7 | 46.9 | 79.7 | 82.7 | | no | 68.8 | 70.1 | 67.8 | 75.1 | 65.2 | 62.2 | 41.8 | 40.2 | 67.5 | | | pa | 0.083 | 0.141 | 0.051 | 0.659 | 0.709 | 0.043 | 0.366 | < 0.001 | 0.045 | | | Physical activity less than 3 h per week | yes | 81.8 | 80.3 | 81.2 | 72.3 | 62.4 | 72.7 | 45.2 | 66.8 | 79.3 | | no | 65.1 | 68.9 | 66.7 | 74.8 | 66.8 | 68.5 | 44.5 | 65.6 | 71.3 | | | pa | 0.035 | 0.153 | 0.067 | 0.752 | 0.547 | 0.583 | 0.905 | 0.866 | 0.312 | | | Following a dietary regimen | yes | 80.4 | 81.5 | 83.0 | 74.3 | 81.8 | 78.3 | 50.5 | 80.5 | 89.5 | | no | 76.0 | 75.7 | 75.2 | 72.6 | 58.3 | 69.5 | 43.6 | 62.2 | 73.3 | | | pa | 0.608 | 0.491 | 0.359 | 0.835 | 0.002 | 0.285 | 0.303 | 0.017 | 0.057 | | | Dietary supplement use | yes | 76.9 | 80.1 | 79.5 | 71.7 | 67.2 | 75.9 | 44.7 | 70.5 | 79.6 | | no | 77.5 | 66.5 | 68.5 | 77.5 | 51.3 | 56.9 | 46.0 | 52.8 | 68.1 | | | pa | 0.939 | 0.110 | 0.198 | 0.487 | 0.038 | 0.020 | 0.854 | 0.022 | 0.175 | | | Pain during defecation | yes | 83.1 | 83.7 | 81.1 | 82.5 | 68.5 | 72.7 | 50.8 | 67.6 | 83.4 | | no | 68.6 | 67.6 | 71.4 | 60.3 | 56.4 | 69.8 | 36.8 | 65.0 | 68.0 | | | pa | 0.046 | 0.027 | 0.182 | 0.002 | 0.065 | 0.683 | 0.010 | 0.699 | 0.034 | | | Stool type | normal | 71.8 | 72.1 | 71.8 | 68.8 | 60.9 | 67.5 | 44.6 | 65.7 | 73.9 | | diarrhea | 107.0 | 97.1 | 102.6 | 96.6 | 66.7 | 105.1 | 54.3 | 69.0 | 94.1 | | | constipation | 84.3 | 92.5 | 88.7 | 65.7 | 65.7 | 73.3 | 30.5 | 78.2 | 81.0 | | | mixed | 77.4 | 77.3 | 77.5 | 77.1 | 68.3 | 69.1 | 49.7 | 64.3 | 77.7 | | | pb | 0.070 | 0.169 | 0.108 | 0.152 | 0.793 | 0.030 | 0.257 | 0.778 | 0.504 | Differences in the impact of endometriosis according to health-related and lifestyle characteristics (N = 153). Values are presented as mean rank values calculated for the compared groups; . Mann–Whitney U test; . Kruskal Wallis test. p, p-value. 3.3 Associations of health and lifestyle factors with the impact of endometriosis on quality-of-life dimensions Strong positive correlations were observed among the QoL dimensions in women with endometriosis. The strongest association was between the psychological and social dimensions (Rs = 0.77; p < 0.001), with a similarly strong correlation between the social and employment and financial dimensions (Rs = 0.77; p < 0.001). A strong correlation was also observed between the physical and psychological dimensions (Rs = 0.72; p < 0.001) (Supplementary Table 2). Linear regression analyses confirmed associations between body weight change since symptom onset and all QoL dimensions, with an overall impact score of β = 0.30 (p = 0.001), indicating greater perceived impact among women reporting weight change. BMI was positively associated with the physical (β = 0.53, p = 0.001) and psychological dimensions (β = 0.33, p = 0.033), suggesting that higher BMI values were related to greater disease impact in these dimensions. In contrast, BMI ≥ 25.0 kg/m2 was negatively associated with the physical (β = −0.42, p = 0.005), sexual and intimate (β = −0.31, p = 0.044), and employment and financial dimensions (β = −0.31, p = 0.049), indicating lower impact scores within this categorical comparison. Fertility was positively associated with following a dietary regimen (β = 0.22, p = 0.014) and negatively associated with dietary supplement use (β = −0.18, p = 0.049), suggesting higher perceived fertility-related impact among women following dietary regimens and lower impact among dietary supplement users. Smoking was positively associated with the lifestyle dimension (β = 0.38, p < 0.001) and with the overall impact of endometriosis on QoL (β = 0.17, p = 0.042), indicating greater lifestyle-related impact and poorer overall QoL among smokers. Painful defecation was linked to the psychological (β = 0.19, p = 0.023) and sexual and intimate dimensions (β = 0.30, p = 0.001), as well as to the overall impact score (β = 0.19, p = 0.024), reflecting higher perceived burden in these dimensions (Table 5). Table 5 | QoL dimension | |||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | Variable | Physical | Psychological | Social | Sexual and Intimate | Fertility | Employment and Financial | Educational | Lifestyle | Overall QoL | ||||||||| | β | p | β | p | β | p | β | p | β | p | β | p | β | p | β | p | β | p | | | Age | 0.07 | 0.394 | −0.08 | 0.297 | 0.05 | 0.533 | 0.03 | 0.672 | 0.00 | 0.999 | 0.10 | 0.229 | 0.06 | 0.606 | 0.08 | 0.323 | −0.01 | 0.946 | | University degree | 0.04 | 0.604 | 0.02 | 0.851 | −0.04 | 0.631 | −0.09 | 0.285 | 0.12 | 0.196 | −0.10 | 0.255 | −0.22 | 0.053 | −0.06 | 0.459 | 0.01 | 0.890 | | Living with a partner | −0.05 | 0.555 | 0.04 | 0.630 | 0.00 | 0.966 | 0.06 | 0.496 | 0.02 | 0.853 | 0.04 | 0.682 | 0.07 | 0.552 | 0.02 | 0.804 | 0.06 | 0.460 | | BMI | 0.53 | 0.001 | 0.33 | 0.033 | 0.15 | 0.339 | 0.26 | 0.093 | 0.04 | 0.773 | 0.27 | 0.098 | −0.07 | 0.745 | 0.18 | 0.303 | 0.26 | 0.089 | | BMI ≥ 25.0 kg/m2 | −0.42 | 0.005 | −0.24 | 0.111 | −0.14 | 0.353 | −0.31 | 0.044 | −0.03 | 0.858 | −0.31 | 0.049 | 0.06 | 0.799 | −0.23 | 0.168 | −0.28 | 0.056 | | Body weight change since symptom onset | 0.13 | 0.145 | 0.24 | 0.009 | 0.30 | 0.001 | 0.29 | 0.002 | 0.28 | 0.004 | 0.19 | 0.050 | 0.27 | 0.030 | 0.20 | 0.031 | 0.30 | 0.001 | | Perceived overweight | 0.02 | 0.860 | 0.02 | 0.807 | 0.02 | 0.861 | −0.01 | 0.928 | −0.03 | 0.803 | 0.05 | 0.646 | 0.11 | 0.444 | −0.03 | 0.729 | 0.01 | 0.945 | | Physical activity less than 3 h/week | 0.12 | 0.135 | 0.07 | 0.401 | 0.10 | 0.203 | −0.04 | 0.649 | −0.08 | 0.374 | −0.02 | 0.814 | −0.04 | 0.705 | −0.11 | 0.199 | 0.02 | 0.808 | | Following a dietary regimen | −0.03 | 0.748 | −0.03 | 0.684 | 0.00 | 0.975 | −0.01 | 0.950 | 0.22 | 0.014 | 0.03 | 0.764 | 0.05 | 0.670 | 0.13 | 0.137 | 0.06 | 0.435 | | Use of dietary supplements | 0.05 | 0.509 | −0.13 | 0.114 | −0.09 | 0.275 | 0.04 | 0.638 | −0.18 | 0.049 | −0.12 | 0.179 | −0.08 | 0.468 | −0.14 | 0.096 | −0.11 | 0.165 | | Daily fluid intake | −0.07 | 0.377 | −0.01 | 0.889 | −0.02 | 0.794 | 0.06 | 0.487 | −0.01 | 0.933 | −0.03 | 0.706 | −0.06 | 0.578 | −0.10 | 0.230 | −0.03 | 0.707 | | Smoking | 0.12 | 0.157 | 0.09 | 0.273 | 0.12 | 0.175 | −0.01 | 0.935 | −0.08 | 0.403 | 0.12 | 0.193 | 0.08 | 0.451 | 0.38 | <0.001 | 0.17 | 0.042 | | No coffee | 0.00 | 0.974 | 0.02 | 0.807 | 0.04 | 0.608 | −0.02 | 0.847 | −0.14 | 0.116 | 0.01 | 0.951 | −0.05 | 0.665 | −0.01 | 0.934 | −0.06 | 0.459 | | No alcohol | 0.08 | 0.354 | 0.04 | 0.637 | 0.00 | 0.955 | 0.13 | 0.119 | −0.03 | 0.755 | 0.13 | 0.150 | −0.17 | 0.147 | −0.02 | 0.787 | 0.06 | 0.501 | | Bowel problems | 0.11 | 0.222 | 0.05 | 0.598 | 0.06 | 0.540 | −0.01 | 0.877 | −0.06 | 0.532 | 0.12 | 0.205 | −0.07 | 0.564 | −0.03 | 0.782 | −0.04 | 0.634 | | Painful defecation | 0.15 | 0.088 | 0.19 | 0.023 | 0.10 | 0.262 | 0.30 | 0.001 | 0.17 | 0.072 | 0.01 | 0.876 | 0.20 | 0.104 | 0.08 | 0.347 | 0.19 | 0.024 | | Constipation | −0.07 | 0.399 | −0.02 | 0.856 | 0.02 | 0.846 | 0.05 | 0.572 | 0.11 | 0.243 | −0.04 | 0.661 | 0.02 | 0.893 | −0.01 | 0.910 | 0.03 | 0.684 | The associations between sociodemographic, health-related, and lifestyle characteristics and the impact of endometriosis on quality-of-life dimensions using multivariable linear regression models. QoL, quality-of-life; β, beta coefficient; p, p value; BMI, body mass index. Multivariable linear regression models were performed for each QoL dimension (one model per dimension), with all listed predictors included simultaneously in each model. 4 Discussion This study provides a multidimensional assessment of QoL among women with endometriosis and identifies potentially modifiable health and lifestyle factors associated with disease burden. By examining physical, psychological, social, sexual and intimate, fertility, educational, employment and financial, and lifestyle dimensions across three recall periods, the findings extend existing literature beyond symptom severity and highlight the broader societal and functional impact of endometriosis. From a public health perspective, the results emphasize the need to integrate lifestyle-oriented and psychosocial components into routine endometriosis care. Changes in body weight following symptom onset were associated with multiple QoL dimensions, indicating that body weight changes may represent an important indicator of disease burden. Most participants reporting body weight changes described weight gain or fluctuating weight, whereas relatively few reported weight loss. This pattern is noteworthy given that several previous studies have reported lower BMI among women with endometriosis compared with women without the disease (44, 45). However, BMI measured at a single time point and self-reported weight changes since symptom onset represent different constructs and should not be interpreted as directly comparable. Moreover, several factors, including chronic symptoms, treatment-related effects, and lifestyle modifications, may contribute to changes in body weight among women with endometriosis, although these factors were not assessed in the present study. Evidence suggests that body weight changes can affect physical functioning and psychological well-being (27), potentially exacerbating pain perception, fatigue, depressive symptoms, and social withdrawal (30, 31). Because the present study was cross-sectional and relied on retrospective self-report, the temporal relationship between endometriosis and body weight changes cannot be established, and these findings should therefore be interpreted with caution. These findings have implications for preventive and supportive care strategies, particularly in the context of the growing global prevalence of overweight and obesity. Structured weight management counseling, nutritional guidance, and psychological support could be incorporated into multidisciplinary care models to help women manage disease-related changes in body weight and their potential impact on QoL. At a systems level, this underscores the importance of embedding lifestyle counseling within gynecological and primary care services rather than treating it as an ancillary component. BMI ≥ 25.0 kg/m2 was negatively associated with the physical, sexual and intimate, and employment and financial impact scores. Although the relationship between BMI and endometriosis remains inconsistent in the literature (33, 45), the present findings suggest that body weight may be related to differences in functional and social experiences, with associations varying depending on BMI coding. Higher BMI has been linked to reduced sexual activity and desire in longitudinal research (46, 47), while body image concerns may further affect intimate relationships (48). In our models, continuous BMI values were positively associated with greater physical and psychological impact, highlighting the complexity of these associations and the importance of nuanced interpretation. From a policy standpoint, addressing weight-related stigma, promoting healthy behaviors, and ensuring equitable access to lifestyle interventions may represent important components of comprehensive women's health strategies. Painful defecation (dyschezia) was significantly associated with poorer psychological and sexual and intimate QoL. This finding reinforces the need to recognize gastrointestinal symptoms as central—not peripheral—to the lived experience of endometriosis. Prior research indicates that dyschezia and dyspareunia contribute to anxiety, stress, reduced perceived control, and impaired daily functioning (49–54). The present results further highlight the importance of actively engaging women in symptom management and care decisions, as patient engagement has been associated with improved coping, self-management, and QoL outcomes among individuals living with chronic pain conditions, including endometriosis (55). Sexual dysfunction is also frequently reported in women facing infertility, highlighting the interplay between reproductive concerns, physical discomfort, and intimate relationships (56). These symptoms may limit physical activity and occupational performance, thereby increasing indirect societal costs through reduced productivity. Improved screening for gastrointestinal symptoms within gynecological services and timely referral pathways may therefore have broader benefits for mental health, sexual well-being, and work participation. The associations between dietary supplement use, dietary regimens, and the fertility dimension highlight the complex interplay between reproductive concerns and self-directed health behaviors. While supplement use was negatively associated with fertility impact scores, possibly reflecting lower perceived burden, following a dietary regimen was positively associated with fertility impact, suggesting that women experiencing greater reproductive difficulties may be more likely to seek dietary solutions. Nutritional interventions may influence oxidative stress, inflammation, and hormonal regulation (57), and dietary patterns may modulate estrogen levels and symptom expression (58). Additionally, engagement in dietary strategies may enhance perceived control and reduce stress related to fertility concerns (59). However, the cross-sectional design precludes causal conclusions. From a public health perspective, these findings support the development of evidence-based nutritional guidance tailored to women with endometriosis to prevent reliance on unverified or potentially ineffective interventions. Psychological distress is prevalent among women with endometriosis and may impair emotional well-being, social functioning, and intimate relationships (60). The observed associations between body weight, symptoms, and multiple QoL dimensions further illustrate the interdependence of physical and mental health. Symptoms such as chronic pain, fatigue, and reduced concentration may adversely affect academic and occupational performance, increasing psychosocial stress and potentially contributing to financial strain (26). Consistent with the BMI-related findings discussed earlier, employment and financial experiences may be influenced by complex interactions between physical health, body perception, and social functioning. Collectively, these findings support the inclusion of mental health screening and counseling within standard endometriosis management protocols, as recommended in integrated care frameworks (16, 61, 62). In the present study, 63.4% of participants reported active smoking, a prevalence substantially higher than that reported among women in the Croatian general population (21.7%) (63). Although the reasons for this finding cannot be determined from the present data, chronic pain, psychological distress, and disease-related stress are highly prevalent among women with endometriosis and may influence health-related behaviors, including smoking. However, because determinants of smoking behavior were not assessed in the present study, these explanations remain speculative and should be interpreted with caution. Smoking emerged as a significant lifestyle factor associated with poorer lifestyle-related QoL and higher overall impact scores. Consistent with previous studies, smokers report worse outcomes across multiple QoL dimensions (64). Biologically, smoking may exacerbate endometriosis through increased oxidative stress, endocrine disruption, and chronic inflammation (65, 66). Smoking also negatively affects ovarian function and fertility by disrupting the hypothalamic–pituitary–ovarian axis and accelerating follicular atresia (67, 68), compounding reproductive challenges (69, 70). These findings reinforce smoking cessation as a priority in women's reproductive health strategies. Integrating targeted smoking cessation programs into gynecological and reproductive health services may yield benefits for both symptom management and long-term health outcomes. This study has several limitations. The cross-sectional design limits causal inference, and reliance on self-reported endometriosis diagnosis and online data collection may introduce selection and recall bias. Information regarding the method of diagnosis (e.g., laparoscopic confirmation, imaging-based diagnosis, or clinical diagnosis) was not collected. Consequently, diagnostic heterogeneity cannot be excluded, which may affect the generalizability of the findings. Nevertheless, the use of self-reported diagnosis is common in large-scale survey-based studies of endometriosis, particularly when recruiting participants through patient associations and online communities. Additionally, the absence of detailed clinical indicators—such as disease stage, pain severity, comorbidities, medication use, and time since diagnosis—restricts clinical interpretation. Future longitudinal studies with clinically confirmed diagnoses and objective biomarkers are needed to clarify causal pathways and inform targeted interventions. Despite these limitations, this study contributes to the growing recognition of endometriosis as a condition with substantial multidimensional and societal impact. By identifying modifiable lifestyle and health-related correlates of QoL, the findings support the development of integrated, multidisciplinary care models that combine medical treatment with lifestyle counseling, psychological support, and sexual health services. This approach is further supported by evidence indicating that more positive perceptions of quality of care are associated with better QoL outcomes among women with endometriosis, underscoring the importance of patient-centered and coordinated care pathways in endometriosis management (71). At the policy level, increased awareness, earlier diagnosis, and improved coordination between primary care, gynecology, mental health, and public health services may reduce long-term burden and improve quality of life for women with endometriosis (16, 61, 62). The results underscore that endometriosis management should extend beyond symptom control to address behavioral, psychosocial, and reproductive dimensions. Strengthening preventive and supportive care strategies within women's health systems may help reduce disease-related inequities and enhance overall well-being. 5 Conclusion This study demonstrates that endometriosis is associated with substantial multidimensional burden, particularly in the fertility, physical, and psychological dimensions of QoL. Painful defecation, body weight changes following symptom onset, and smoking were associated with poorer outcomes across several QoL dimensions, while BMI ≥ 25.0 kg/m2 was associated with lower impact scores in selected QoL dimensions, reflecting the complex and context-dependent nature of BMI-related findings. Dietary supplement use and following a dietary regimen were also associated with perceived fertility-related impact, underscoring the complex interplay between reproductive concerns and self-directed health strategies. These findings reinforce the need to move beyond a symptom-focused model of care toward integrated, multidisciplinary approaches that address physical symptoms, mental health, sexual well-being, and lifestyle behaviors. Incorporating weight management support, smoking cessation interventions, nutritional counseling, and psychological assessment into routine gynecological care may contribute to improved long-term outcomes for women with endometriosis. Given the cross-sectional design and reliance on self-reported data, causal inferences cannot be drawn. Future longitudinal research using clinically confirmed diagnoses and objective indicators of disease severity is needed to better understand causal pathways and to inform evidence-based clinical and public health strategies aimed at reducing the overall burden of endometriosis and improving women's QoL. Statements Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Ethics statement The study received ethical approval from the Ethics Committee of the University of Zadar, Croatia (approval number: 114-06/24-01/16; approval date: March 28, 2024) and was conducted in accordance with the principles of the Declaration of Helsinki and its revisions. Informed consent was obtained from all participants before completing the questionnaire. Author contributions MMS: Conceptualization, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. ML: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. TS: Methodology, Writing – original draft, Writing – review & editing. AS: Methodology, Writing – original draft, Writing – review & editing. EM: Investigation, Writing – review & editing. SAM: Methodology, Writing – review & editing. MČ: Methodology, Supervision, Writing – review & editing. Funding The author(s) declared that financial support was received for this work and/or its publication. The study received no external funding. The APC was in part funded by the European Union -NextGenerationEU, and in part by the Institute for Anthropological Research, Zagreb, Croatia. Acknowledgments The authors wish to express their appreciation to the authors of the questionnaires used in this study for granting permission for their use, Ms. Zorica Martić, President of the “Ja sam 1 od 10” Association, for her support in data collection, and all participants who participated in the study. Conflict of interest The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Generative AI statement The author(s) declared that generative AI was not used in the creation of this manuscript. Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fgwh.2026.1837763/full#supplementary-material

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body mass index, dietary supplements, dyschezia, fertility impairment, patient-reported outcome measures, tobacco use Citation Matek Sarić M, Ljubičić M, Sorić T, Sarić A, Marušić E, Abdi Mahmoud S and Čoklo M (2026) Associations of health and lifestyle factors with multidimensional quality of life among women with endometriosis: a cross-sectional study. Front. Glob. Women’s Health 7:1837763. doi: 10.3389/fgwh.2026.1837763 Received 24 March 2026 Revised 18 June 2026 Accepted 30 June 2026 Published 22 July 2026 Volume 7 - 2026 Edited by Karin Meissner, Hochschule Coburg, Germany Reviewed by Cristy Brooks, Western Sydney University, Australia Mario Muselli, University of L'Aquila, Italy Updates Copyright © 2026 Matek Sarić, Ljubičić, Sorić, Sarić, Marušić, Abdi Mahmoud and Čoklo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Tamara Sorić [email protected] † These authors have contributed equally to this work Disclaimer All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.