Endometriosis and mental health: a population-based cohort study

Peter S Thiel, Olga Bougie, Jessica Pudwell, Jonas Shellenberger, Maria P Velez, Ally Murji
American journal of obstetrics and gynecology · 2024 · vol. 230(6) , pp. 649.e1–649.e19 · doi:10.1016/j.ajog.2024.01.023 · PMID:38307469
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Endometriosis, diagnosed medically or surgically, is associated with a marginally increased risk for mental health conditions, particularly in the year following diagnosis.

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This population-based cohort study examined the association between endometriosis and subsequent mental health outcomes using administrative health data, following women in Ontario and identifying mental health diagnoses and related service use patterns over time. The authors reported that endometriosis was associated with increased risks of certain mental health conditions compared with those without endometriosis, based on their cohort analyses. A key limitation acknowledged in the design is reliance on administrative diagnostic coding, which can misclassify exposures and outcomes and may not capture symptom severity. This paper is centrally about endometriosis — specifically, its relationship with mental health outcomes.

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Abstract

BACKGROUND: Endometriosis is a chronic gynecologic disorder that leads to considerable pain and a reduced quality of life. Although its physiological manifestations have been explored, its impact on mental health is less well defined. Existing studies of endometriosis and mental health were conducted within diverse healthcare landscapes with varying access to care and with a primary focus on surgically diagnosed endometriosis. A single-payer healthcare system offers a unique environment to investigate this association with fewer barriers to access care while considering the mode of endometriosis diagnosis. OBJECTIVE: Our objective was to assess the association between endometriosis and the risk for mental health conditions and to evaluate differences between patients diagnosed medically and those diagnosed surgically. STUDY DESIGN: A matched, population-based retrospective cohort study was conducted in Ontario and included patients aged 18 to 50 years with a first-time endometriosis diagnosis between January 1, 2010, and July 1, 2020. Endometriosis exposure was determined through either medical or surgical diagnostic criteria. A medical diagnosis was defined by the use of the corresponding International Classification of Disease diagnostic codes from outpatient and in-hospital visits, whereas a surgical diagnosis was identified through inpatient or same-day surgeries. Individuals with endometriosis were matched 1:2 on age, sex, and geography to unexposed individuals without a history of endometriosis. The primary outcome was the first occurrence of any mental health condition after an endometriosis diagnosis. Individuals with a mental health diagnosis in the 2 years before study entry were excluded. Cox regression models were used to generate hazard ratios with adjustment for hysterectomy, salpingo-oophorectomy, infertility, pregnancy history, qualifying surgery for study inclusion, immigration status, history of asthma, abnormal uterine bleeding, diabetes, fibroids, hypertension, irritable bowel disorder, migraines, and nulliparity. RESULTS: A total of 107,832 individuals were included, 35,944 with a diagnosis of endometriosis (29.5% medically diagnosed, 60.5% surgically diagnosed, and 10.0% medically diagnosed with surgical confirmation) and 71,888 unexposed individuals. Over the study period, the incidence rate was 105.3 mental health events per 1000 person-years in the endometriosis group and 66.5 mental health events per 1000 person-year among unexposed individuals. Relative to the unexposed individuals, the adjusted hazard ratio for a mental health diagnosis was 1.28 (95% confidence interval, 1.24-1.33) among patients with medically diagnosed endometriosis, 1.33 (95% confidence interval, 1.16-1.52) among surgically diagnosed patients, and 1.36 (95% confidence interval, 1.2-1.6) among those diagnosed medically with subsequent surgical confirmation. The risk for receiving a mental health diagnosis was highest in the first year after an endometriosis diagnosis and declined in subsequent years. The cumulative incidence of a severe mental health condition requiring hospital visits was 7.0% among patients with endometriosis and 4.6% among unexposed individuals (hazard ratio, 1.56; 95% confidence interval, 1.53-1.59). CONCLUSION: Endometriosis, regardless of mode of diagnosis, is associated with a marginally increased risk for mental health conditions. The elevated risk, particularly evident in the years immediately following the diagnosis, underscores the need for proactive mental health screening among those newly diagnosed with endometriosis. Future research should investigate the potential benefits of mental health interventions for people with endometriosis with the aim of enhancing their overall quality of life.
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Endometriosis and mental health: a population-based cohort study Affiliations & Notes aDepartment of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada bDepartment of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada cDepartment of Obstetrics and Gynecology, Queen’s University, Kingston Health Sciences Center, Kingston, Ontario, Canada dInstitute for Clinical Evaluative Sciences, Toronto, Ontario, Canada eHealth Services and Policy Research Institute, Queen’s University, Kingston, Ontario, Canada Article Info Publication History: Received November 2, 2023; Revised January 23, 2024; Accepted January 24, 2024; Published online January 31, 2024 Footnotes: A.M. reports serving on the advisory board and speaker bureau for AbbVie, Bayer, and Pfizer. O.B. reports serving on the advisory board and speaker bureau for AbbVie, Bayer, and Pfizer. The remaining authors report no conflict of interest. The project was supported by funds from the 2023 Matthew Morton Research Award from the Department of Obstetrics and Gynaecology at Sinai Health, Toronto, Ontario, Canada. The funder had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. In addition, this study was supported by the Institute for Clinical Evaluative Sciences, which was funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care. This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which was based on data licensed from the Canada Post Corporation, and/or data adapted from the Ontario MOH Postal Code Conversion File, which contained data copied under license from the Canada Post Corporation and Statistics Canada. Parts of the material are based on data and/or information compiled and provided by the Canadian Institute for Health Information and the Ontario MOH. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts or all of this study are based on data and/or information compiled and provided by Immigration, Refugees and Citizenship Canada Permanent Residents (IRCC-PR) current to May 2017. However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors and not necessarily those of the IRCC. Parts of this study are based on data and information provided by Ontario Health (OH). The opinions, results, views, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of OH. No endorsement by OH is intended or should be inferred. Cite this article as: Thiel PS, Bougie O, Pudwell J, et al. Endometriosis and mental health: a population-based cohort study. Am J Obstet Gynecol 2024;230:649.e1-19. DOI: 10.1016/j.ajog.2024.01.023 External LinkAlso available on ScienceDirect External Link Copyright: © 2024 Elsevier Inc. All rights reserved. Linked Articles Download started OkKey words References 1. Shafrir, A.L. ∙ Farland, L.V. ∙ Shah, D.K. ... Risk for and consequences of endometriosis: a critical epidemiologic review Best Pract Res Clin Obstet Gynaecol. 2018; 51:1-15 2. Zondervan, K.T. ∙ Becker, C.M. ∙ Missmer, S.A. Endometriosis. N Engl J Med. 2020; 382:1244-1256 3. Estes, S.J. ∙ Huisingh, C.E. ∙ Chiuve, S.E. ... Depression, anxiety, and self-directed violence in women with endometriosis: a retrospective matched cohort study Am J Epidemiol. 2020; 190:843-852 4. Wang, Y. ∙ Li, B. ∙ Zhou, Y. ... Does endometriosis disturb mental health and quality of life? 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endometriosisinfertility

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Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

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