Body image concerns, disordered eating, and negative affect in women with and without gynecological conditions

Gynecological conditions such as polycystic ovarian syndrome (PCOS), endometriosis, pelvic inflammatory disease, and dysmenorrhea are prevalent among women. Prevalence estimates for PCOS and endometriosis vary but have been reported to range from 4-21%. 1 , 2 Rates of dysmenorrhea (i.e., intense menstruation-related abdominal pain), which can be either a primary diagnosis or secondary to another diagnosis (e.g., endometriosis), reach as high as 91% for women of reproductive age. 3 Additionally, over 2 million women in the United States have received a diagnosis of pelvic inflammatory disease. 4 Gynecological conditions are not just common, they are also impactful and impairing conditions, associated with lower quality of life. 5 – 8 In particular, body image distress, negative affect, disordered eating behaviors, and other disturbances have been associated with certain gynecological conditions (e.g., PCOS), 9 , 10 however little is known about their relationship with other gynecological conditions. Body image concerns in those with gynecological conditions are distressing, yet are rarely targets of clinical screening or treatment. 11 Current literature shows high rates of body image distress in populations with PCOS and endometriosis, which suggests gynecological symptoms may contribute to body dissatisfaction. 9 , 12 , 13 In particular, there may be specific aspects of gynecological conditions that contribute to body image concerns. For instance, PCOS carries appearance-related symptoms including hirsutism, hair loss, and acne which may contribute to body image concerns. 14 – 16 Additionally, symptoms of gynecological conditions may impact body-related beliefs even if they are not outwardly visible. For instance, in both PCOS (e.g., infertility), and endometriosis (e.g., intense abdominal pain), women can experience impaired physical functioning. Pain and reductions in body functionality have been associated with a feeling of betrayal and hopelessness in one’s body. 11 , 17 , 18 Despite the relevance of these concerns to gynecological populations more generally, body image remains an understudied area, especially outside of PCOS and endometriosis. Additional research is warranted in investigating body image concerns, particularly in samples that include gynecological conditions such as dysmenorrhea, uterine fibroids, and pelvic inflammatory disease, which may also present risks for negative feelings toward the body. Body image and disordered eating are often related, with studies finding that poorer perceptions of one’s body may predict disordered eating and unhealthy dieting behaviors in the future. 19 , 20 Indeed, body dissatisfaction has been found to be central to the development and maintenance of maladaptive eating attitudes and behaviors. 21 Since body image disturbances pose a risk for eating disorders in women in general, it stands to reason that disordered eating should be investigated in gynecological populations as well. Some work does show higher occurrences of disordered eating behaviors associated with PCOS. 22 In fact, women with PCOS were over 4.5 times more likely to have disordered eating compared to women without. 23 Some investigations of disordered eating in women with endometriosis have also found high levels in this context as well. 24 In fact, in one investigation, more than one third of study completers with endometriosis were found to screen positive for eating disorders. 25 Notably, one epidemiological research study found a genetic association between endometriosis and eating disorders, resulting in adjusted odds of an eating disorder that were 3.6 times higher for women with endometriosis. 26 Others have found that women with endometriosis that have moderate to severe pain associated with their diagnosis have greater disordered eating than those with less symptom impairment. 27 Negative affect, including depression, stress, and anxiety, has also been associated with body image distress and disordered eating more generally. 21 , 28 Moreover, research suggests that females are at greater risk for depression and disordered eating, 29 anxiety, 30 stress, 31 and body dissatisfaction. 32 Thus, it might be expected that depression, stress, and anxiety would be particularly elevated among women with gynecological conditions. Research generally supports this position, with studies finding a link between negative affective states and gynecological diagnoses. 9 , 33 , 34 Specific studies of women with PCOS have found that body dissatisfaction is associated with anxiety 16 and depression. 35 In a study of women with endometriosis, positive eating disorder screenings were also related to higher anxiety and depression. 25 However, there is a dearth of research examining correlations between depression, anxiety, stress, body image, and disordered eating in gynecological samples more generally. Additionally, comparisons of facets of negative affect (i.e., depression, anxiety, and stress) between women with and without understudied gynecological conditions are largely absent from the literature. Previous research has theorized that negative affect may be higher in women with certain gynecological conditions perhaps either as a result of appearance concerns, or because depression may negatively impact body image. 36 The interconnection between negative affect and physical characteristics in relation to attitudes about the body is consistent with cognitive behavioral theories of body image 37 and cognitive behavioral models of body image and health conditions, such as chronic pain 17 . Specifically, this theory-based understanding of body image posits that physical factors, including various aspects of the body, along with cognitive, cultural, and other factors, are thought to influence body image attitudes. 38 It is also thought that body functionality, which includes observable and internal bodily processes and abilities, also impacts body image. 39 Perceptions of body functionality may be lower among women with gynecological concerns, given that symptoms can be painful and impairing. For example, qualitative work indicates that some women with endometriosis feel that their bodies have betrayed them or pose a barrier to valued behaviors. 40 Taken together, this suggests that women with gynecological conditions may be at greater risk for body dissatisfaction given the association between gynecological conditions and negative affect, the physical factors that may accompany gynecological conditions, and the limitations to body functionality that are associated with gynecological diagnoses. In sum, body image concerns, and related psychological factors, remain understudied in women with gynecological conditions. This is a gap need of remedy. Both theory and empirical evidence point toward the connection between body image and gynecological conditions. Symptoms of gynecological conditions pose particular risk for body image concerns, beyond the sociocultural pressures regarding appearance and body size faced by women more generally, 41 , 42 indicating they are a uniquely vulnerable group warranting increased research attention. Research in this area has the potential to increase understanding of gynecological conditions from a holistic perspective, including greater knowledge of the ways in which physical conditions may relate to psychological factors. As such, this may yield findings that could inform more comprehensive care across medical and mental health fields. It is also important to expand beyond investigations of single diagnoses such as PCOS to better understand the concerns of women with gynecological diagnoses that have been largely overlooked in previous research, and to account for women who may have comorbid conditions. Further, scant research exists to examine whether the perceived impact of one’s gynecological condition relates to the intensity of body image concerns, disordered eating, depression, stress, or anxiety. This is surprising, considering that women can have variable presentations of gynecological conditions which may have different relevance for psychological correlates such as body image. 43 Examining the impact of gynecological conditions, not just their presence or absence, represents a relatively novel contribution to the literature that would increase depth of understanding between the ways in which gynecological concerns relate to psychological factors. In order to fill these gaps, we aim to investigate the relationships between gynecological conditions and body image, disordered eating, and negative affect. We hypothesize positive associations between gynecological conditions and body image concerns, and between gynecological conditions and disordered eating. Regarding negative affect, we hypothesize there will be positive associations between gynecological conditions and 1) depression, 2) stress, and 3) anxiety. Additionally, we aim to understand whether differences in the presentation of gynecological diagnoses may relate to our psychological factors of interest, and hypothesize that greater impact from gynecological diagnoses will be related to greater body image concerns, higher disordered eating, and greater depression, stress, and anxiety.

This study was reviewed by The Office for Research Protections at Penn State University and deemed exempt from formal Institutional Review Board (IRB) review. Specifically, the study met the criteria for exempt research and was granted approval number STUDYPRAMS00034763 and STUDY00024518 under the exempt designation based on university policies and related federal regulations. The Office of Research Protections waived the requirement for written informed consent, as the research was classified as posing no more than minimal risk to participants under the exempt category. Participants received detailed information about the study and indicated their willingness to participate by clicking a button, consistent with IRB exemption procedures that require provision of study information and issue a waiver of written consent. We have followed the STROBE guidelines for cross-sectional studies. 44 Data were collected via a Qualtrics survey sent out to women ( N =235) from an undergraduate psychology subject pool and the research website, Prolific. We only recruited women given our interest in examining relationships with gynecological conditions. Other inclusion criteria include living in the United States, fluency in the English language, aging from 18 to 45, and not currently pregnant. We were specifically interested in recruiting reproductive-age women as this is when symptoms of gynecological concerns may be most notable. Initial recruitment efforts were broad and open to all women within the inclusion criteria; however, after these efforts did not yield a sufficient subsample of women with gynecological diagnoses, targeted recruitment of women with one or more gynecological conditions was employed through Prolific. Participants recruited from Prolific were required to meet the general inclusion criteria listed above and self-report at least one gynecological condition. The study was cross sectional, and it took approximately 20 minutes to complete the survey. The study procedures, such as participant recruitment and participation, spanned from August 2023-March 2024. Participants from the psychology subject pool received credit toward their research participation requirements, while participants recruited through Prolific received payment at the rate of approximately $3 per survey.

Our sample ( N = 235) included women with ( n = 127; 54%) and without ( n = 108; 46%) self-reported gynecological conditions. Participants’ ages ranged from 18 to 45 ( M = 25.61, SD = 9.09). More than half (54.1%) of the sample identified as a member of a racial or ethnic minority group. The most commonly reported gynecological condition was PCOS (21.3%) followed by endometriosis (11.9%). A chi-square test indicated women of color were represented at a significantly higher level in the subsample of women with gynecological conditions ( X 2 (1, 233) = 7.80, p = .005). Women with gynecological conditions were also older than women without ( t (233) = - 15.80, p <.001). There were differences in age ( t (233) = - 23.28, p <.001) and race ( X 2 (1, 233) = 10.79, p = .001) based on recruitment site; however, analyses controlled for these variables. More demographic characteristics are presented in Table 1 . Table 1. Demographic information for participants ( N = 235). ​ n % Age  18-29 160 68.1  30-39 45 19.1  40-45 30 12.8 Race and ethnicity  African American 43 18.3  Native American/American Indian/Native Alaskan 1 0.4  Asian/Pacific Islander 45 19.1  Latina 19 8.1  Multiracial 11 4.7  White 108 45.9  Other 6 2.6  Not Provided 2 0.9 Presence Of Gynecological Condition  Yes 127 54  No 108 46 Gynecological Condition  Polycystic Ovarian Syndrome 50 21.3  Endometriosis 28 11.9  Dysmenorrhea 24 10.2  Pelvic Inflammatory Disease 1 0.4  Uterine Fibroids 1 0.4  More Than One 16 6.8  Other 3 1.3  Not Specified 4 1.7 Demographic information for participants ( N = 235). Descriptive information including means, standard deviations, and score ranges for body image, disordered eating, and negative affect in women with and without gynecological conditions is presented in Table 2 . According to the severity ranges established in the DASS-21 manual, 52 mean depression and stress scores for women without gynecological diagnoses fell within the normal range. For women with gynecological diagnoses though, depression and stress scores fell within in the mild severity range. Both women with and without gynecological diagnoses had anxiety scores that fell within the moderate severity range. Table 2. Descriptive information about body image, disordered eating, and negative affect in women with and without gynecological conditions. ​ Women without gynecological conditions ( n = 108) Women with gynecological conditions ( n = 127) M SD Range M SD Range Appearance Evaluation 1 3.38 .902 1-4.86 2.64 1.04 1-5 Appearance Orientation 1 3.76 .568 2.17-5 3.47 .790 1.25-4.92 Body Area Satisfaction 1 3.43 .745 1.89-5 2.74 .849 1-5 Overweight Preoccupation 1 2.62 1.00 1-5 3.05 1.13 1-5 Self-Classified Weight 1 3.17 .730 1-5 3.84 .942 1.5-5 Restraint 2 .991 1.43 0-6 2.30 2.05 0-6 Shape/Weight Overevaluation 2 1.72 1.95 0-6 3.51 2.06 0-6 Body Disatisfaction 2 2.14 2.00 0-6 3.74 2.03 0-6 Global Disordered Eating 2 1.60 1.56 0-6 3.19 1.74 0-6 Depression 3 8.91 8.57 0-38 15.30 12.96 0-42 Stress 3 13.35 9.18 0-42 17.07 11.07 0-42 Anxiety 3 10.98 8.49 0-40 11.62 10.03 0-40 1 Measured by a subscale of the Multidimensional Body-Self Relations Questionnaire (MBSRQ). 2 Measured by the 7-item version of the Eating Disorder Examination Questionnaire (EDE-Q7). 3 Measured by a subscale of the Depression, Anxiety and Stress Scale (DASS-21). Descriptive information about body image, disordered eating, and negative affect in women with and without gynecological conditions. 1 Measured by a subscale of the Multidimensional Body-Self Relations Questionnaire (MBSRQ). 2 Measured by the 7-item version of the Eating Disorder Examination Questionnaire (EDE-Q7). 3 Measured by a subscale of the Depression, Anxiety and Stress Scale (DASS-21). To evaluate our first three aims, we performed hierarchical linear regressions controlling for age and race/ethnicity (See Table 3 ). For our first aim, we found that gynecological diagnoses were associated with worse body image on several MBSRQ scales. Specifically, gynecological diagnoses related to lower Appearance Evaluation, lower Body Area Satisfaction, and greater Overweight Preoccupation. Cohen’s f 2 effect size values for the significant MBSRQ regression models were all in the small to moderate range. For our second aim, we found gynecological diagnoses were associated with greater disordered eating for the overall EDE-Q7 Global score, as well as across the Restraint, Shape/Weight Overevaluation, and Body Dissatisfaction subscales. Cohen’s f 2 values for the EDEQ-7 subscales were all in the moderate range. For our third aim, results indicated significant associations between gynecological diagnoses and depression and stress; Cohen’s f 2 values for both variables were in the small range for both analyses. However, no relationship was found for anxiety. Table 3. Hierarchical linear regression models evaluating relationships between gynecological diagnostic status (GYN Diagnosis) and body image, disordered eating, and negative affect, controlling for age and race/ethnicity. ​ F (df1, df2) p R 2 f 2 B β SE t p Outcome: MBSRQ 1 Appearance Evaluation Block 1: Age 9.30 (2,219) <.001 .08 .09 -.03 -.22 .01 -3.26 .001 Race/ethnicity ​ ​ ​ ​ .23 .11 .14 1.63 .10 Block 2: Age 11.13 (3, 218) <.001 .13 .15 .006 .05 .01 .49 .62 Race/ethnicity ​ ​ ​ ​ .27 .13 .14 1.94 .05 GYN Diagnosis 2 ​ ​ ​ ​ -.74 -.36 .20 -3.70 <.001 Outcome: MBSRQ 1 Appearance Orientation Block 1: Age 6.94 (2, 220) <.001 .06 .06 -.02 -.23 .01 -3.32 .001 Race/ethnicity ​ ​ ​ ​ .06 .04 .10 .56 .58 Block 2: Age 4.74 (3, 219) .003 .06 .06 -.01 -.18 .01 -2.03 .04 Race/ethnicity ​ ​ ​ ​ .06 .04 .10 .59 .56 GYN Diagnosis 2 ​ ​ ​ ​ -.09 -.06 .14 -.61 .55 Outcome: MBSRQ 1 Body Area Satisfaction Block 1: Age 13.47 (2,221) <.001 .11 .12 -.03 -.32 .01 -4.74 <.001 Race/ethnicity ​ ​ ​ ​ .06 .03 .12 .51 .61 Block 2: Age 14.04 (3,220) <.001 .16 .19 -.01 -.06 .01 -.63 .53 Race/ethnicity ​ ​ ​ ​ .09 .05 .11 .75 .45 GYN Diagnosis 2 ​ ​ ​ ​ -.60 -.34 .16 -3.69 <.001 Outcome: MBSRQ 1 Overweight Preoccupation Block 1: Age 1.57 (2,217) .21 .01 .01 .01 .12 .01 1.67 .10 Race/ethnicity ​ ​ ​ ​ .17 .08 .16 1.08 .28 Block 2: Age 3.80 (3,216) .01 .05 .05 -.01 .01 -.01 -.93 .36 Race/ethnicity ​ ​ ​ ​ .16 .15 .07 1.02 .31 GYN Diagnosis 2 ​ ​ ​ ​ .62 .28 .22 2.86 .005 Outcome: MBSRQ 1 Self Classified Weight Block 1: Age 26.99 (2,224) <.001 .19 .23 .04 .40 .01 6.32 <.001 Race/ethnicity ​ ​ ​ ​ -.18 -.10 .12 -1.51 .13 Block 2: Age 18.56 (3,223) <.001 .20 .25 .03 .32 .01 3.44 <.001 Race/ethnicity ​ ​ ​ ​ -.19 -.10 .12 -1.59 .11 GYN Diagnosis 2 ​ ​ ​ ​ .20 .11 .16 1.25 .21 Outcome: EDE-Q7 3 Restraint Block 1: Age 11.34 (2,226) <.001 .09 .10 .06 .30 .01 4.54 <.001 Race/ethnicity ​ ​ ​ ​ .01 .00 .26 .05 .96 Block 2: Age 10.59 (3,225) <.001 .12 .14 .02 .10 .02 1.00 .32 Race/ethnicity ​ ​ ​ ​ -.03 -.01 .25 -.14 .89 GYN Diagnosis 2 ​ ​ ​ ​ 1.04 .27 .36 2.89 .004 Outcome: EDE-Q7 3 Shape/Weight Overevaluation Block 1: Age 12.27 (2,222) <.001 .10 .11 .07 .31 .02 4.55 <.001 Race/ethnicity ​ ​ ​ ​ -.11 -.03 .30 -.37 .71 Block 2: Age 14.45 (3,221) <.001 .16 .19 .004 .02 .02 .16 .88 Race/ethnicity ​ ​ ​ ​ -.16 -.04 .29 -.58 .57 GYN Diagnosis 2 ​ ​ ​ ​ 1.68 .41 .38 4.13 <.001 Outcome: EDE-Q7 3 Body Dissatisfaction Block 1: Age 10.82 (2,222) <.001 .09 .10 .07 .29 .02 4.28 <.001 Race/ethnicity ​ ​ ​ ​ -.09 -.02 .29 -.31 .76 Block 2: Age 11.80 (3,221) <.001 .14 .16 .01 .04 .02 .37 .71 Race/ethnicity ​ ​ ​ ​ -.14 -.03 .29 -.48 .63 GYN Diagnosis 2 ​ ​ ​ ​ 1.45 .34 .41 3.55 <.001 Outcome: EDE-Q7 3 Global Block 1: Age 15.49 (2,227) <.001 .12 .13 .07 .34 .01 5.23 <.001 Race/ethnicity ​ ​ ​ ​ -.05 -.01 .24 -.21 .83 Block 2: Age 17.49 (3,226) <.001 .19 .23 .01 .05 .02 .54 .59 Race/ethnicity ​ ​ ​ ​ -.10 -.03 .23 -.43 .67 GYN Diagnosis 2 ​ ​ ​ ​ 1.43 .39 .33 4.36 <.001 Outcome: DASS21 4 Stress Block 1: Age .79 (2,227) .46 .007 .007 .06 .05 .08 .71 .48 Race/ethnicity ​ ​ ​ ​ -1.11 -.05 1.44 -.77 .44 Block 2: Age 3.26 (3,226) .02 .04 .04 -.18 -.16 .11 -1.57 .12 Race/ethnicity ​ ​ ​ ​ -1.34 -.07 1.42 -.94 .35 GYN Diagnosis 2 ​ ​ ​ ​ 5.70 .27 1.99 2.86 .005 Outcome: DASS21 4 Depression Block 1: Age 2.64 (2,227) .07 .02 .02 .20 .16 .09 2.29 .02 Race/ethnicity ​ ​ ​ ​ .81 .04 1.60 .51 .61 Block 2: Age 6.39 (3,226) <.001 .08 .09 -.13 -.11 .12 -1.04 .30 Race/ethnicity ​ ​ ​ ​ .48 .02 1.56 .31 .76 GYN Diagnosis 2 ​ ​ ​ ​ 8.04 .35 2.18 3.69 <.001 Outcome: DASS21 4 Anxiety Block 1: Age 1.27 (2,227) .28 .01 .01 -.06 -.06 .07 -.85 .40 Race/ethnicity ​ ​ ​ ​ -2.01 -.11 1.30 -1.54 .12 Block 2: Age 1.30 (3,226) .28 .02 .02 -.15 -.14 .10 -1.43 .15 Race/ethnicity ​ ​ ​ ​ -2.09 -.11 1.30 -1.61 .11 GYN Diagnosis 2 ​ ​ ​ ​ 2.13 .11 1.80 1.17 .24 1 Multidimensional Body-Self Relations Questionnaire; Cash, T. F. (1990). Multidimensional Body-Self Relations Questionnaire (MBSRQ) [Database record]. APA PsycTests. https://doi.org/10.1037/t08755-000 . 2 Note, GYN diagnosis reflected the presence of one or more gynecological conditions (coded as 1) or no gynecological conditions (coded as 0). 3 The Brief Eating Disorder Examination Questionnaire; Grilo, C. M., Reas, D. L., Hopwood, C. J., & Crosby, R. D. (2015). Factor structure and construct validity of the Eating Disorder Examination-Questionnaire in college students: further support for a modified brief version. International Journal of Eating Disorders , 48 (3), 284–289. https://doi.org/10.1002/eat.22358 and Jenkins, P. E., & Davey, E. (2020). The brief (seven-item) eating disorder examination-questionnaire: Evaluation of a non-nested version in men and women. International Journal of Eating Disorders , 53 (11), 1809–1817. https://doi.org/10.1002/eat.23360 . 4 Depression Anxiety and Stress Scales; Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33 (3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U . Hierarchical linear regression models evaluating relationships between gynecological diagnostic status (GYN Diagnosis) and body image, disordered eating, and negative affect, controlling for age and race/ethnicity. 1 Multidimensional Body-Self Relations Questionnaire; Cash, T. F. (1990). Multidimensional Body-Self Relations Questionnaire (MBSRQ) [Database record]. APA PsycTests. https://doi.org/10.1037/t08755-000 . 2 Note, GYN diagnosis reflected the presence of one or more gynecological conditions (coded as 1) or no gynecological conditions (coded as 0). 3 The Brief Eating Disorder Examination Questionnaire; Grilo, C. M., Reas, D. L., Hopwood, C. J., & Crosby, R. D. (2015). Factor structure and construct validity of the Eating Disorder Examination-Questionnaire in college students: further support for a modified brief version. International Journal of Eating Disorders , 48 (3), 284–289. https://doi.org/10.1002/eat.22358 and Jenkins, P. E., & Davey, E. (2020). The brief (seven-item) eating disorder examination-questionnaire: Evaluation of a non-nested version in men and women. International Journal of Eating Disorders , 53 (11), 1809–1817. https://doi.org/10.1002/eat.23360 . 4 Depression Anxiety and Stress Scales; Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33 (3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U . For our fourth aim, a correlation matrix showed a range of significant, small to large associations, regarding the perceived impact of gynecological diagnoses on all body image, disordered eating, depression, stress, and anxiety (See Table 4 ). Table 4. Correlation between key study variables and impact of gynecological condition. ​ 1 2 3 4 5 6 7 8 9 10 11 12 ​ 1. Impact -- ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2. Appearance Evaluation 1 -.40*** -- ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3. Appearance Orientation 1 -.15* .07 -- ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 4. Body Area Satisfaction 1 -.48*** .83*** .04 -- ​ ​ ​ ​ ​ ​ ​ ​ ​ 5. Overweight Preoccupation 1 .31*** -.48*** .42*** -.54*** -- ​ ​ ​ ​ ​ ​ ​ ​ 6. Self-Classified Weight 1 .40*** -.57*** -.16* -.50*** .36*** -- ​ ​ ​ ​ ​ ​ ​ 7. Restraint 2 .42*** -.42*** .21** -.48*** .69*** .35*** -- ​ ​ ​ ​ ​ ​ 8. Shape/Weight Overevaluation 2 .46*** -.65*** .15* -.66*** .66*** .45*** .58*** -- ​ ​ ​ ​ ​ 9. Body Dissatisfaction 2 .45*** -.70*** .14* -.71*** .65*** .54*** .57*** .81*** -- ​ ​ ​ ​ 10. Global Disordered Eating 2 .51*** -.68*** .19** -.70*** .75*** .51*** .80*** .92*** .91*** -- ​ ​ ​ 11. Anxiety 3 .13* -.30*** .07 -.32*** .33*** .08 .28*** .31*** .33*** .35*** -- ​ ​ 12. Depression 3 .36*** -.51*** .004 -.53*** .42*** .21** .35*** .53*** .49*** .52*** .68*** -- ​ 13. Stress 3 .28*** -.39*** .10 -.44*** .40*** .15* .35*** .39*** .43*** .44*** .75*** .73*** -- * p <.05, ** p <.01 , *** p <.001 1 Measured by a subscale of the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Cash, 1990). 2 Measured by the 7-item version of the Eating Disorder Examination Questionnaire (EDE-Q7; Jenkins & Davey, 2020). 3 Measured by a subscale of the Depression, Anxiety and Stress Scale (DASS21; Lovibond & Lovibond, 1995). Correlation between key study variables and impact of gynecological condition. * p <.05, ** p <.01 , *** p <.001 1 Measured by a subscale of the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Cash, 1990). 2 Measured by the 7-item version of the Eating Disorder Examination Questionnaire (EDE-Q7; Jenkins & Davey, 2020). 3 Measured by a subscale of the Depression, Anxiety and Stress Scale (DASS21; Lovibond & Lovibond, 1995).

Participants were asked to complete demographic items. This included self-identification of age, and race/ethnicity. Body image was assessed using the Multidimensional Body-Self Relations Questionnaire, Appearance Scales (MBSRQ 45 ). The following subscales were included – Appearance Evaluation, Appearance Orientation, Body Area Satisfaction, Overweight Preoccupation, and Self Classified Weight. Appearance Evaluation assesses feelings of attractiveness, with higher scores indicating more positive feelings about one’s appearance and lower scores indicating feelings of unattractiveness. Appearance Orientation assesses the extent of investment in one’s appearance, with higher scores indicating more investment and appearance-focused behaviors. Body Area Satisfaction assesses contentment with discrete aspects of one’s physique, with higher scores indicating greater satisfaction with most areas of the body. Overweight Preoccupation assesses a construct reflecting weight vigilance and eating restraint, with higher scores indicating greater preoccupation with weight gain. Finally, Self-Classified Weight assesses how one perceives and labels one’s weight, with higher scores indicating heavier perceived body size. For all subscales, items are reported on a Likert scale ranging from 1 to 5 (5 = highest level of agreement), with scores being averaged. The Appearance Orientation and Appearance Evaluation subscales include some items that are reverse scored. Test-retest reliabilities in women were 0.91, 0.90, 0.74, 0.89, and 0.74 for Appearance Evaluation, Appearance Orientation, Body Areas Satisfaction, Overweight Preoccupation, and Self-Classified Weight, respectively. 46 Previous research samples of women have also demonstrated good internal consistency for the Appearance Evaluation and Appearance Orientation subscales, 47 and Body Area Satisfaction, and Overweight Preoccupation subscales. 46 Self-Classified Weight has also shown strong internal consistency (Cronbach alpha = 0.87) in a mixed gender sample. 48 Participants were asked to fill out the 7-item version of the Eating Disorder Examination Questionnaire (EDE-Q7 49 , 50 ) which assesses disordered eating. Items are reported as a Likert scale and scores are averaged ranging from 0 to 6. All subscales were included – Restraint, Shape/Weight Overevaluation, and Body Dissatisfaction – as well as the overall Global score. Restraint assesses endorsement of restrictive behaviors such as food avoidance, with higher scores indicating higher endorsement. Shape/Weight Overevaluation assesses assess degree of importance placed on shape and weight for defining self-worth, with higher scores indicating greater importance. Body Dissatisfaction assesses negative beliefs pertaining to weight or shape, with higher scores indicating greater dissatisfaction. Scores are averaged to produce a Global score, where a higher Global score indicates greater disordered eating overall. Internal consistency has been found to be good in all three subscales: Restraint (ω = 0.88), Shape/Weight Overevaluation (ω = 0.88) and Body Dissatisfaction (ω = 0.87). 50 Participants completed the Depression Anxiety Stress Scales (DASS-21 51 , 52 ). DASS-21 items are reported as a Likert scale ranging from 0 to 3 with scores being summed for the depression, anxiety, and stress subscales and multiplied by 2; higher scores indicate higher distress in each of the three categories. This measure has demonstrated good psychometrics including concurrent validity for the depression and anxiety subscales with similar measures such as the Beck Depression Inventory-II, and Beck Anxiety Inventory, respectively. 53 Previous research has found good internal consistency for the anxiety (α = 0.82), 54 depression (α = 0.92), 55 and stress (α = 0.88) 56 subscales. Participants self-reported the presence or absence of gynecological diagnoses. Participants who indicated they had one or more conditions were coded as yes (1) and those who indicated they did not have a gynecological condition were coded as no (0) for all analyses. Participants with gynecological conditions were asked to indicate which diagnoses were present by selecting from a list (e.g., endometriosis, dysmenorrhea, PCOS, pelvic inflammatory disease, uterine fibroids, cervical dysplasia, other, etc.) Participants who had one or more gynecological conditions were also asked to rate the impact of condition(s), “ Please rate the average impact of your gynecological condition(s) on your life ”, with scores ranging from 0 to 10. Higher scores indicated greater perceived impact. Data were analyzed using IBM SPSS Statistics (Version 29) and a power calculation was computed in G*Power 3.1. 57 Due to small cell sizes for some racial groups (e.g., Native American), a dichotomous variable was created representing women of color (1) and white women (0), respectively. Two participants who did not report race/ethnicity were omitted from this variable. Chi square analyses were used to determine differences in race/ethnicity based on gynecological group membership and based on recruitment source. Independent samples t-tests were used to evaluate differences in age between women with and without gynecological conditions, and between recruitment sources. Data were screened for missingness as a part of Little’s MCAR test. 58 Data were missing at a rate of 6% or less on dependent variables. There were no missing data on the gynecological condition variable. Little’s MCAR test determined that data were missing completely at random ( p = 1.0). Listwise deletion was chosen for handling missing data given the low rate of missingness, and since this method does not introduce bias for data that are MCAR. 59 In order to evaluate the relationships between gynecological conditions and body image, disordered eating, depression, stress, and anxiety, we performed separate hierarchical linear regressions using our full sample. Gynecological diagnosis (yes/no) was the independent variable for all regressions. Since age and race/ethnicity were significantly related to the presence of a gynecological condition, regression analyses controlled for these variables. It was determined that a minimum sample size of 77 participants would be required for 80% power to detect a medium effect in a hierarchical linear regression analysis with three independent variables. To identify associations between the impact of gynecological conditions and study variables of interest, we ran bivariate correlations.

This study adds to the existing literature by examining a diverse group of women with a variety of gynecological conditions in a community sample context. These findings show that there are significant associations between gynecological conditions across body image, disordered eating, and negative affect. This study demonstrates that women experiencing greater impact from their diagnosis had higher symptomology across all mental health measures. These results contribute to the greater conversation on body image and the future of women’s health in diverse gynecological populations. Findings suggest that body image concerns may exist in gynecological populations as a whole rather than being specific to one type of condition. Further clarity on the underlying mechanisms and symptomology of diverse gynecological conditions could advance women’s healthcare.

Our hypotheses for this study were generally supported. With these data, we demonstrated that the presence of a gynecological diagnosis was linked to greater body image concerns, including lower evaluations of personal appearance, less satisfaction with specific body areas, and greater preoccupation with being overweight. Additionally, having a gynecological diagnosis was related to greater disordered eating (i.e., more dietary restraint, over-evaluation of shape and weight, and body dissatisfaction), as well as depression, and stress. Finally, we found positive associations between the impact of a gynecological diagnosis and the variables listed above. The findings from this study can be contextualized within a cognitive behavioral model of body image. 37 Broadly, our results support the interconnection between negative emotions and negative body image. More specifically, our findings are consistent with aspects of cognitive behavioral body image theory which suggest that physical characteristics are related to body image attitudes such as lower evaluations of appearance. The positive association between the impact of gynecological conditions and poorer body image observed in this study also aligns with theory specific to the construct of body functionality, underscoring the importance of functionality to body-related thoughts and emotions. 18 Empirically, our results were generally consistent with previous research that has explored body image concerns in specific gynecological populations. For instance, previous work specifically evaluating endometriosis found poorer body image in women with the diagnosis compared to those without, with endometriosis related pain in particular correlating with body image concerns. 60 Poorer body image was associated with gynecological conditions in this study, and the larger literature generally supports poorer body image among women with PCOS compared to those without. 9 , 13 This suggests that body image findings in specific diagnostic groups may be consistent in diverse gynecological presentations as well. Notably, comparisons with previous literature regarding body image as measured by the MBSRQ and samples with PCOS can be complex. Some previous work finds women with PCOS have body image concerns represented across all domains of the MBSRQ. 9 , 13 However, our findings are more consistent with others who did not find higher levels of Appearance Orientation 61 , 62 or Self-Classified Weight 62 in women with PCOS compared to those without. It is possible that our findings regarding Appearance Orientation and Self-Classified weight may not align with the findings of some previous work 9 , 13 since our sample was not solely comprised of women with PCOS, who may experience greater salience of weight and grooming behaviors compared to other gynecological populations. Regarding disordered eating, our results are also generally consistent with the previous literature regarding more specific gynecological samples; however, this study extends the previous literature since we included under-examined and comorbid diagnoses. Several previous research studies have found elevated risk for disordered eating behaviors and higher scores on eating disorder assessments in women with PCOS, 10 , 22 , 23 , 63 , 64 and endometriosis. 25 , 26 Yet, to our knowledge, few have investigated disordered eating more broadly in gynecological disorders. The associations found between gynecological conditions and disordered eating, and the comparatively higher levels of disordered eating in women with gynecological concerns in our sample, suggest this disordered eating is a noteworthy concern for gynecological samples beyond those covered in previous work. The results from the current study add an important piece to the literature, indicating that the overarching characteristics of gynecological conditions (e.g., pain, impairments in functioning) may connect to maladaptive eating behaviors. Previous literature 9 , 26 , 36 , 65 , 66 also supports the relationship between gynecological diagnoses, depression, stress, and anxiety, which is somewhat consistent with our findings. Specifically, we found having a gynecological diagnosis was positively related to depression and stress, but not anxiety. The lack of a significant relationship between the presence of a gynecological diagnosis and anxiety in this study could be attributable to several factors. First, we included of women with a variety of gynecological diagnoses which differs from studies with narrower gynecological populations. Second, the level of anxiety in both the women with and without gynecological diagnoses in this study was similar as both groups experienced moderate levels of symptoms. The greater than expected levels of anxiety in the subsample without gynecological conditions may have obscured a potential relationship between gynecological concerns and anxiety that would have otherwise been present. Nonetheless, the overall pattern of results underscores the importance of negative affect in women with gynecological conditions. Our analysis of the impact of one’s gynecological diagnosis demonstrates an important contribution to the literature, as few prior studies have examined the relationship of the perceived impact of gynecological concerns to our dependent variables. We found that the greater the perceived impact of a gynecological diagnosis the greater the body image concerns, disordered eating, depression, anxiety, and stress. This set of findings highlights the importance of addressing different manifestations of gynecological diagnoses, taking careful consideration that gynecological disorders differ in their physical and mental hardships. That is, these results illustrate that in future gynecological research, and women’s health research more broadly, it is important not just to assess the impact of women’s diagnoses categorically (i.e., based on their presence or absence), but also dimensionally (i.e., based on the impairment they cause). It may be that consistent reminders of a diagnosis, such as pain, may ultimately contribute to worse mental health, and increased susceptibility to poor body image and disordered eating. However, different research designs (e.g., longitudinal study) would be needed to investigate potential causal mechanisms. Our use of a diverse sample of gynecological conditions suggests concerns pertaining to body image, disordered eating, and negative affect extend to more than only populations with PCOS, which has long been the focus of research in these areas. The results of our study suggest women with a variety of gynecological conditions tend to have concerns across an array of mental health domains and gynecological patients may be candidates for increased clinical attention. Specifically, these results suggest optimized women’s health care could include an increase in mental health screenings, as a survey indicated that less than half of gynecologists currently screen for issues such as disordered eating and body image concerns. 67 Further, since the same survey of gynecologists found that close to 90% describe their training in assessment for disordered eating as “barely adequate”, 67 implementation of greater screening may take coordinated efforts across medical training systems and interdisciplinary teams. For instance, integration of mental healthcare with gynecological healthcare would allow for “warm handoffs” between providers, a model which has been previously shown to be beneficial for patient engagement. 68 Our study included several strengths. First, our study included gynecological conditions beyond PCOS, such as Pelvic Inflammatory Disease and Dysmenorrhea, which are under-represented in the literature. Likewise, our sample displays racial and ethnic diversity, with more than half of our sample identifying as not white. Another important strength of our study is our use of a community sample, which may be a better representation of women with gynecological diagnoses as a whole as opposed to only including those who are actively seeking treatment. Finally, we were able to add significant contributions to the literature through our novel analysis of the perceived impact of gynecological diagnosis in relation to body image, disordered eating, and negative affect measures. This study also includes limitations. For instance, although we were able to achieve breadth across gynecological diagnoses represented, the composition of our sample and its size limited our ability to perform sub-group analyses within specific diagnostic groups which were infrequent in our dataset. Future research may be better equipped to manage both breadth and depth in a comprehensive analysis of gynecological diagnoses. It is possible some gynecological conditions were not captured or under-represented in our sample, which could limit generalizability. Future research may benefit from targeted recruitment of underexplored conditions to ensure sufficient power to compare across diagnoses. Likewise, women with more than one gynecological condition were grouped together, limiting further analysis regarding specific combinations of conditions in relation to the dependent variables, and the ability to understand unique relationships among specific diagnostic presentations. Our questionnaire to assess gynecological diagnoses focused on the presence or absence of a condition. Although we intended to capture primary dysmenorrhea in our sample by including it as a separate diagnosis, it is possible that because we did not require participants to indicate whether dysmenorrhea was a primary diagnosis or secondary to another condition (e.g., endometriosis) there may have been individual differences in how participants responded to this item. Future research may benefit from utilizing a more detailed approach to assessing. Our analysis of body image was limited to the domains of the MBSRQ measure. Future research should consider more expansive efforts to assess a broader range of body image dimensions, including aspects of positive body image such as body appreciation. We did not assess treatment for gynecological concerns and the impact it may have on psychological factors, which could be a target of future research. Specifically, it may be helpful to evaluate whether successful treatment of gynecological disorders reduces body image concerns and disordered eating behaviors, and if so, what factors are responsible for these shifts. This study was also cross sectional, limiting our understanding of how the results impact individuals long term. Finally, investigations of causal mechanisms regarding the relationships between gynecological conditions and our variables of interest were outside the scope of this study design. Additional research is needed to understand the connection between body image, disordered eating, and negative affect variables and how they relate to one another within the context of gynecological concerns. Other factors such as medication use, social support, and specific symptoms of different gynecological conditions should also be considered in future research.