Pain, Psychological Distress and Social Functioning in Dysmenorrhea: A Prospective Comparison in People With and Without a Diagnosis of Endometriosis

Pain, Psychological Distress and Social Functioning in Dysmenorrhea: A Prospective Comparison in People With and Without a Diagnosis of Endometriosis | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 5 November 2025 V1 Latest version Share on Pain, Psychological Distress and Social Functioning in Dysmenorrhea: A Prospective Comparison in People With and Without a Diagnosis of Endometriosis Authors : Danielle. Mosterd 0009-0007-7347-6906 [email protected] , David. Skvarc 0000-0002-3334-4980 , Antonina Mikocka-Walus , Leesa. Van Niekerk , and Subhadra Evans 0000-0002-1898-0030 Authors Info & Affiliations https://doi.org/10.22541/au.176231718.89100180/v1 271 views 174 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective Assess longitudinal biopsychosocial wellbeing in people with dysmenorrhea alone compared to people with dysmenorrhea and diagnosed endometriosis Design Longitudinal survey Setting Online Population or Sample The sample comprised of 405 women with dysmenorrhea alone and 276 with dysmenorrhea and diagnosed endometriosis (dysmenorrhea+). Methods Participants completed online surveys 12 and 24 months after the initial baseline survey was completed in 2019. Two cross-lagged panel models were used, one for each group. Main Outcome Measures Pain, psychological distress, and social functioning. Results The dysmenorrhea+ group presented significantly higher pain at all times points and higher psychological distress, and lower social functioning at Times 1 and 2, compared to the dysmenorrhea group. In the dysmenorrhea model, pain at Time 2 was significantly positively associated with psychological distress at Time 3 ( B = .168, p = .001) and negatively associated with social functioning at Time 3 ( B = -.188, p = .001), whilst social functioning was negatively associated with psychological distress at Time 3 ( B = -.144, p = .011). In the dysmenorrhea+ group model, only psychological distress was associated with social functioning at Time 2 ( B = -.133, p = .048). Conclusions Although participants with dysmenorrhea+ presented overall poorer functioning, pain in the dysmenorrhea group was predictive of future psychosocial distress. This suggests that people with dysmenorrhea need adequate pain treatment and validation, as well as interdisciplinary care, to reduce future psychosocial difficulties. Pain, Psychological Distress and Social Functioning in Dysmenorrhea: A Prospective Comparison in People With and Without a Diagnosis of Endometriosis Mosterd, Danielle. 1 , Skvarc, David. 1 , Mikocka-Walus, Antonina. 1,3 , Van Niekerk, Leesa. 2,3 and Evans, Subhadra. 1 1 School of Psychology, Deakin University, Burwood, 3125, VIC, Australia 2 School of Psychological Sciences, College of Health & Medicine, University of Tasmania, Hobart, 7000, TAS, Australia 3 National Endometriosis Clinical and Scientific Trials (NECST) Network, UNSW, Sydney, Australia Correspondence address: School of Psychology, Deakin University, 221 Burwood Highway, Burwood 3125 VIC. Email: [email protected] . Author ORCID’S, emails- Danielle Mosterd- https://orcid.org/0009-0007-7347-6906, [email protected] Dr David Skvarc- https://orcid.org/0000-0002-3334-4980, [email protected] Professor Antonina Mikocka-Walus- https://orcid.org/0000-0003-4864-3956, [email protected] Associate Professor Leesa Van Niekerk- https://orcid.org/0000-0002-6641-5888, [email protected] Associate Professor Subhadra Evans- https://orcid.org/0000-0002-1898-0030, [email protected] Abstract Objective Assess longitudinal biopsychosocial wellbeing in people with dysmenorrhea alone compared to people with dysmenorrhea and diagnosed endometriosis Design Longitudinal survey Setting Online Population or Sample The sample comprised of 405 women with dysmenorrhea alone and 276 with dysmenorrhea and diagnosed endometriosis (dysmenorrhea+). Methods Participants completed online surveys 12 and 24 months after the initial baseline survey was completed in 2019. Two cross-lagged panel models were used, one for each group. Main Outcome Measures Pain, psychological distress, and social functioning. Results The dysmenorrhea+ group presented significantly higher pain at all times points and higher psychological distress, and lower social functioning at Times 1 and 2, compared to the dysmenorrhea group. In the dysmenorrhea model, pain at Time 2 was significantly positively associated with psychological distress at Time 3 ( B = .168, p = .001) and negatively associated with social functioning at Time 3 ( B = -.188, p = .001), whilst social functioning was negatively associated with psychological distress at Time 3 ( B = -.144, p = .011). In the dysmenorrhea+ group model, only psychological distress was associated with social functioning at Time 2 ( B = -.133, p = .048). Conclusions Although participants with dysmenorrhea+ presented overall poorer functioning, pain in the dysmenorrhea group was predictive of future psychosocial distress. This suggests that people with dysmenorrhea need adequate pain treatment and validation, as well as interdisciplinary care, to reduce future psychosocial difficulties. Funding Australian Government Research Training Program Keywords dysmenorrhea, endometriosis, pain, psychological distress, mental health, social functioning, biopsychosocial, longitudinal Introduction Dysmenorrhea (painful menstruation) impacts between 45-95% of people who menstruate (1). Historically, dysmenorrhea has been minimised, normalised, and attributed to mental illness or weakness (2). This has contributed to shame and stigma associated with painful periods, barriers to seeking healthcare and undertreatment by medical professionals (3–5). The biopsychosocial model conceptualises the symptoms, impairments, and treatment recommendations associated with dysmenorrhea (6,7). This model incorporates the biological aspects of an illness (e.g., pain, physical symptoms), with the psychological (e.g., emotions, illness representation, psychological distress), and social aspects (e.g., social functioning, relationships) to provide a whole-person understanding of illness (6). Dysmenorrhea is most viewed as a symptom, rather than a specific diagnosable condition, resulting in many not receiving a diagnosis or adequate pain treatment. Dysmenorrhea is associated with higher levels of emotional distress (8) and also impacts social connectiveness, such as impaired social functioning, employability and educational attainment (9). Longitudinal studies of dysmenorrhea have found that poorer physical functioning was associated with greater perceived loneliness over time (10) and higher levels of psychological distress positively predict later functional pain disability (11), suggesting that pain, psychological distress, and social functioning may have a reciprocal, longitudinal relationship. Dysmenorrhea may be attributed to endometriosis, a condition where endometrial-like lesions are found outside of the uterus (1,12). Endometriosis is associated with a greater array of symptoms than severe dysmenorrhea alone, such as non-menstruation related pelvic pain, bowel and urinary symptoms, fatigue, and subfertility (11,12). Following endometriosis diagnosis, patients usually receive greater access to adequate pain treatment than prior to diagnosis (13,14). However, endometriosis has been associated with higher rates of psychological distress and diagnosed anxiety and depression (15,16), as well as significant negative impacts to social functioning (17,18). Whilst those with dysmenorrhea alone and dysmenorrhea with endometriosis experience some similar symptoms, the illness experiences and healthcare needs of each differ. For example, people with diagnosed endometriosis reported lower pain, psychological distress, and greater health related quality of life compared to those with suspected endometriosis without formal diagnosis (19), suggesting that diagnosis status may impact wellbeing, potentially due to a lack of validation and treatment prior to diagnosis (19). The current study intends to examine the longitudinal severity of and relationship between pain, psychological distress, and social functioning in people with dysmenorrhea alone (hereafter referred to as dysmenorrhea) compared to those with dysmenorrhea and diagnosed endometriosis (dysmenorrhea+), to increase understanding and healthcare for both conditions. Participants The sample comprised of 681 women aged 18 years or older with self-reported dysmenorrhea, who resided in Australia, with 276 of participants reporting a clinical, ultrasound or surgically confirmed diagnosis of endometriosis. The average age was 28.97 years ( SD = 7.47, range = 18 to 48 years). Participants were grouped in either the dysmenorrhea group (n = 405) or the dysmenorrhea+ group (n = 276). Measures Demographic and Health Information Demographic, health, and diagnostic information was collected including age, gender, country of birth and residence, relationship status, employment, number of children, ethnicity, and endometriosis diagnosis. Pain Period pain was assessed using a 10-point numerical rating scale response to the question “On a scale of 0 ( no pain ) to 10 ( worse pain possible ), what is your usual level of pain during your period (without any pain medicine)?”. Psychological Distress: DASS-21 The Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) is not diagnostic in nature but rather indicates a person’s level of depressive, anxiety, and stress symptoms over the last month, on a scale ranging from 0 ( did not apply to me at all ) to 3 ( very much or all the time ). Higher scores reflect a greater level of psychological distress. A composite total score was calculated to represent overall psychological distress (21,22). The DASS has shown good psychometric properties in chronic pain, clinical and general samples (23) Social Functioning: WHOQOL-BREF: Social Domain The WHOQOL-BREF is a measure of quality life, with the social domain specifically assessing social functioning via personal relationships, social support and sexual activity (24). The domain comprises of 3 questions, with a scale ranging from 1 ( very dissatisfied ) to 5 ( very satisfied ). Higher scores denote higher social functioning and the measure has shown good internal consistency and acceptable psychometric properties in Australian samples (25) Procedure Ethical approval for the current study was granted by the Deakin University ethics committee (HEAG-H 10_2019). Participation in the study was voluntary as stated in the Plain Language Statement, with informed consent given before beginning the survey. Baseline data was collected at Time 1 in May 2019, with participants being contacted by email or phone at two additional time points if consent was given, June 2020 (Time 2) and June 2021 (Time 3). Initial recruitment occurred via advertisement flyers shared via university forums, social media and women’s gyms between May and July 2019. Analysis Group mean pain, psychological distress and social functioning were compared between the dysmenorrhea and dysmenorrhea+ groups using independent samples t-tests, Supplementary Table 2. The assumption of homogeneity of variance was violated for the pain scale, but not for the psychological distress and social functioning scales. The sample only included participants with fully completed baseline surveys. Participants were retained if at least one follow-up measurement was recorded, and scores were estimated using maximum likelihood estimation through AMOS. A random-intercepts stable-trait cross-lagged panel model was attempted but failed to converge, and so a three-wave cross-lagged panel longitudinal model (CLPM) was used to assess auto regressive and cross panel relationships between pain, psychological distress and social functioning over time in the dysmenorrhea and dysmenorrhea+ groups. Relevant covariates (relationship, employment and children) were assessed but did not significantly impact the model, so were removed for parsimony. Model fit was assessed using Tucker-Lewis Fit Index (TLI), Comparative Fit Index (CFI; acceptable fit indicated by scores greater than .950) and Root Mean Square Error of Approximation (RMSEA, <.05). Both specified models achieved excellent fit: Dysmenorrhea model: TLI = 1, CFI = 1, RMSEA = .000; Dysmenorrhea+ model: TLI = 1, CFI = 1, RMSEA = .000. Each model estimated 48 parameters and retained 6 degrees of freedom (Dysmenorrhea: X 2 = 4.864, p = .561. Dysmenorrhea+: X 2 = 3.874, p = .694). Figure 1 presents the model with all proposed pathways. INSERT FIGURE 1 HERE Results Descriptives A majority of the sample were born in Australia (90.16%), were in a relationship (50.5%), employed (67.1%) and did not have children (74.9%), with 3.5% of the sample being of Aboriginal or Torres Strait Islander descent. The two groups were similar demographically in terms of ethnicity and children, the mean age of the dysmenorrhea group was 28.15, whereas the mean age was 30.18 in the dysmenorrhea+ group. The dysmenorrhea+ group had higher rates of employment (77%) and being in a relationship (60%), compared to the dysmenorrhea group (60.2% employed, 44% in relationship). Overall, the dysmenorrhea+ group presented statistically significantly higher mean pain at all time points and higher psychological distress and lower social functioning at Times 1 and 2 than the dysmenorrhea group, as seen in Table 1. Supplementary Table 1 presents the bivariate correlations between the study variables for the entire sample. INSERT TABLE 1 HERE Main Analyses The regression parameters for each model are reported in Tables 3 and 4. In both the dysmenorrhea and dysmenorrhea+ models, the pain, psychological distress and social functioning variables showed significant positive autoregressive pathways (i.e., variables were associated with their future selves). As seen in Figure 2, in the dysmenorrhea model, pain at Time 2 was significantly positively related to psychological distress a Time 3 (Table 2). Pain at Time 2 was also significantly negatively associated with social functioning at Time 3. This suggests that increased pain at Time 2 is associated with increased psychological distress and decreased social functioning at Time 3. Social functioning at Time 2 was negatively associated with psychological distress at Time 3, suggesting that as social functioning decreases, psychological distress increases. Comparatively, the dysmenorrhea + model only showed one significant cross panel correlation (Table 3). Psychological distress at Time 1 was negatively associated with social functioning at Time 2, suggesting that as psychological distress increases, social functioning decreases. In both models, there was contemporaneous correlations between pain, psychological distress and social functioning at Time 1, and contemporaneous correlations between psychological distress and social functioning at Time 2 as well as Time 3. INSERT FIGURE 2, TABLE 2 AND TABLE 3 HERE Discussion Main Findings This novel study examined the biopsychosocial wellbeing of people with dysmenorrhea compared to those with dysmenorrhea+ over 24 months. The dysmenorrhea+ group largely presented overall poorer biopsychosocial wellbeing compared to the dysmenorrhea group. However, pain predicted future psychological distress and declines in social functioning in the dysmenorrhea model only, suggesting dysmenorrhea alone impacts future wellbeing more than dysmenorrhea+. Interpretation The dysmenorrhea+ group had statistically significantly higher pain at all time points and higher psychological distress and lower social functioning at Times 1 and 2, compared to the dysmenorrhea only group. This may occur due to the chronic nature of endometriosis, meaning symptoms can occur for longer periods of time than solely during and around the menstrual cycle (12). Pain at Time 2 in the dysmenorrhea model was positively associated with psychological distress and negatively associated with social functioning at Time 3. The normalisation of dysmenorrhea by health care providers often results in less pain management and support being given to patients with dysmenorrhea who are not diagnosed with a condition, such as endometriosis (3,13). This may explain why pain at Time 2 is associated with psychological distress and social functioning in the dysmenorrhea group but not the dysmenorrhea+ group, given that those with endometriosis are more likely to receive adequate pain management following diagnosis (13,14). Importantly, dysmenorrhea alone was associated with future psychological distress and poorer social functioning, suggesting unmanaged pain may have negative impacts on future psychosocial wellbeing. This finding aligns with those of McCurry et al. (2025), where physical functioning was negatively correlated with loneliness over time. In the dysmenorrhea+ model, psychological distress at Time 1 was a significant negative predictor of social functioning at Time 2. This finding aligns with a review of 42 studies by Culley et al., (2013) who suggested emotional distress may increase social isolation and loneliness in endometriosis. However, past research often frames the relationship in the reverse direction, where the need to withdraw from social or sexual interactions due to endometriosis symptoms leads to depressive symptoms or psychological distress (27). Cumulatively, this may suggest a bi-directional relationship between psychological distress and social functioning or a potential feed forward relationship, where psychological distress leads to poor social functioning which leads to distress and so on. This highlights the vicious cycle of depression and anxiety where withdrawal from social activities can act as a perpetuating factor long term, rather than alleviating symptoms (28). Social functioning at Time 2 was negatively associated with psychological distress at Time 3 in the dysmenorrhea model, suggesting that declines in social functioning are associated with prospective increases to psychological distress. This also supports a potential feed forward relationship. Furthermore, this finding aligns with the cross sectional results of Abbas et al. (2025) who found that social support predicted positive psychological wellbeing. The need to conceal dysmenorrhea as part of ‘menstrual etiquette’ means that people are less likely to discuss menstruation and seek external validation from peers and more often withdraw from social situations due to pain (29). As discussed, people with dysmenorrhea often miss social activities (3), meaning they may not experience the positive psychological benefits of social interactions (9), potentially explaining the present negative correlation. This finding may represent an artefact of COVID-19 social distancing measures during Time 2 data collection (2020), where decreased social interaction may have impacted psychological distress the following year. However, this appears unlikely given that the dysmenorrhea groups mean social functioning score increased in 2020, compared to Time 1. In both models, contemporaneous correlations (intercorrelations at the same time points) for pain were no longer significant after Time 1, suggesting that cross-panel correlations (correlations with future time points) were more relevant. This may represent an issue with the time periods specified during measurement, where participants were asked about ‘usual levels’ of period pain, whereas psychological distress and social functioning were assessed specifically over the last week and two weeks, respectively. Participants may have interpreted this to mean a range of time periods, including since menarche, rather than only recently. Regarding demographics, a higher number of participants in the dysmenorrhea+ group were in a relationship and/or employed, suggesting they have greater opportunities for social connection than the dysmenorrhea group. This is interesting given that relationship status and employment were not significant covariates to either model, and that the dysmenorrhea+ group has lower social functioning than those in the dysmenorrhea group. When comparing the two models, the dysmenorrhea model is better able to predict future psychological distress and social functioning based on past pain, than the dysmenorrhea+ model. This may be due to people with diagnosed endometriosis having better access to treatment and validation of their symptoms (13,14), as well as potential increased hope for future treatment and greater social connectiveness via employment and relationships, meaning their current levels of pain do not impact future psychosocial wellbeing. This suggests to medical professionals that people presenting with dysmenorrhea are likely to have future psychological distress and decreases in social functioning, meaning they require adequate pain management and validation to prevent future difficulties. These findings suggest that interdisciplinary care, which considers the biological, psychological, and social impacts of pain, is needed to improve the overall wellbeing of people with dysmenorrhea and dysmenorrhea plus endometriosis (30). People with dysmenorrhea, regardless of whether they have endometriosis or not, require increased access to adequate treatment and validation from health care providers to improve long term biopsychosocial functioning. Strengths and Limitations and Future Research The present research presents strengths in its use of longitudinal analysis to understand the prospective relationships between biopsychosocial factors in people with dysmenorrhea. It is important to note that endometriosis can occur without dysmenorrhea (31), and as such this study is not representative of every person with endometriosis as only those with dysmenorrhea were eligible to participate. Additionally, participants in the dysmenorrhea group may have undiagnosed endometriosis or another pelvic pain condition which was not assessed. The inclusion/exclusion criteria of the present study only referred to cisgender women, meaning trans or gender diverse people who experience dysmenorrhea and do not identify as women were ineligible to participate, reducing the representativeness and generalisability of the findings. Future research of biopsychosocial wellbeing of people with dysmenorrhea with longer time frames would be of interest to assess the life course of dysmenorrhea, such as that being conducted by the Longitudinal Study of Australian Children (32) or National Endometriosis Clinical and Scientific Trials Registry (33). Additionally, assessing participants with dysmenorrhea and various pelvic pain conditions would also be insightful. Conclusion In summary, participants with dysmenorrhea plus endometriosis reported higher pain, greater psychological distress, and poorer social functioning, compared to those with dysmenorrhea only. Pain was a significant positive prospective predictor of psychological distress and negatively associated with social functioning in the dysmenorrhea only model. Decreases in social functioning were significantly associated with prospective increases in psychological distress in the dysmenorrhea group. In the dysmenorrhea plus endometriosis group, psychological distress was negatively associated with prospective social functioning. These findings suggest that pain, psychological distress and social functioning have a reciprocal effect in both dysmenorrhea and dysmenorrhea with endometriosis, indicating biopsychosocial, interdisciplinary care is needed. Author Roles: Conceptualisation- all authors; Formal analysis- DM, DS; Methodology – all authors; Supervision- SE, AMW, LVN; Visualisation- DM; Writing original draft- DM; Writing review and editing- all authors. Data Availability: The data underlying this article will be shared on reasonable request to the senior author, Subhadra Evans ( [email protected] ). Acknowledgements: The authors would like to thank the participants for their time and the organisations who helped to recruit for this study. Funding: The current study is supported by the Australian Government Research Training Program Conflicts of Interest: The authors have no conflicts of interest to declare References 1. Christensen K. Dysmenorrhea. Australian Journal of General Practice [Internet]. 2024 [cited 2025 Jul 25];53(1–2). Available from: https://www1.racgp.org.au/ajgp/2024/january-february/dysmenorrhea2. Krebs E, Schoenbauer KV. 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Available from: https://www.unsw.edu.au/research/necstnetwork/registry Supplementary Material File (p4 figures and tables.docx) Download 326.13 KB Information & Authors Information Version history V1 Version 1 05 November 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords endometriosis: basic science general gynaecology pelvic pain Authors Affiliations Danielle. Mosterd 0009-0007-7347-6906 [email protected] Deakin University School of Psychology View all articles by this author David. Skvarc 0000-0002-3334-4980 Deakin University School of Psychology View all articles by this author Antonina Mikocka-Walus Deakin University School of Psychology View all articles by this author Leesa. Van Niekerk University of New South Wales View all articles by this author Subhadra Evans 0000-0002-1898-0030 Deakin University School of Psychology View all articles by this author Metrics & Citations Metrics Article Usage 271 views 174 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Danielle. Mosterd, David. Skvarc, Antonina Mikocka-Walus, et al. Pain, Psychological Distress and Social Functioning in Dysmenorrhea: A Prospective Comparison in People With and Without a Diagnosis of Endometriosis. Authorea . 05 November 2025. DOI: https://doi.org/10.22541/au.176231718.89100180/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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