Evaluation of Quality Of Life in Endometriosis Patients Before and After Surgical Treatment Using the EHP30 Questionnaire

Evaluation of Quality Of Life in Endometriosis Patients Before and After Surgical Treatment Using the EHP30 Questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Quality Of Life in Endometriosis Patients Before and After Surgical Treatment Using the EHP30 Questionnaire Denise Tiringer, Alexandra Pedrini, Manuela Gstöttner, Heinrich Husslein, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1621018/v2 This work is licensed under a CC BY 4.0 License Status: Under Review Version 2 posted 10 You are reading this latest preprint version Show more versions Abstract Backround: Endometriosis is one of the most common gynaecological illnesses causing extensive psychological, physical and social impact on patient´s life and exerts negative effects on health-related quality of Life (HRQoL). However, the effects of surgery on the postoperative HRQoL in the different endometriosis subgroups have not been fully evaluated. Methods: We performed a comparative retrospective study between 2014 and 2018 at the Medical University of Vienna, including all patients with surgically confirmed endometriosis who had completed the standardized Endometriosis Health Profile - 30 (EHP-30) questionnaire one day after surgery (the questions refer to the four weeks preoperatively) and six to ten weeks postoperatively. Results: Compared to preoperative values, we found significant benefits, regarding postoperative conditions, in our study group (n=115) in all five categories, “pain” (HR 0.78, p<0.001); “self-determination” (HR 0,92, p<0.001); “emotional health” (HR 0,83, p<0.001);” social environment” (HR 0,67, p<0.001); and “self-image” (HR 0,47, p<0,001). Patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms and there were no significant changes in any of the categories. In the subgroups deep infiltrating endometriosis (DIE) and DIE + ovarian endometrioma, surgical intervention results in a significantly greater improvement in all categories of EHP 30 compared to ovarian endometrioma without DIE or peritoneal endometriosis. Conclusion: Our study shows, that especially women with DIE - with or without ovarian endometrioma - demonstrate a more pronounced benefit from surgical therapy compared to patients with peritoneal endometriosis or endometrioma without DIE. endometriosis quality of life EHP-30 questionnaire surgical therapy laparoscopic surgery Figures Figure 1 Figure 2 Figure 3 Backround Endometriosis, defined as the presence of endometrium-like tissue outside the uterine cavity, is a chronic disease affecting women in their reproductive age. ( 1 , 2 ) One of the main symptoms reported by patients is pain that can be expressed in a variety of symptoms, including dysmenorrhea, dyspareunia, and chronic pelvic pain ( 3 ). These symptoms have an adverse impact on social, mental and physical wellbeing. Additionally, the impairment of HRQoL can significantly affect professional and private relationships, sexuality, social contacts, family planning (due to infertility) or psychological well-being ( 4 – 6 ). Recent studies confirmed that women with endometriosis have a lower HRQoL compared to the general population. ( 2 , 7 , 8 ) Therapy of endometriosis comprises surgery, hormonal contraceptives or pain therapy. Still, little is known about the quantitative impact of surgery on the patients HRQoL. In the past few years, there has been increasing progress in the development and validation of psychometric questionnaires in order to asses HRQoL of endometriosis patients in clinical routine ( 9 , 10 ). Several studies on HRQoL in patients with endometriosis have been performed with conflicting results and using different questionnaires. In addition, only a few studies focused on HRQoL in relation to the different forms of endometriosis ( 11 – 13 ). The 30-item Endometriosis Health Profile (EHP-30) developed by Georgina Jones, is a specific HRQoL scale derived from interviews of patients with endometriosis ( 14 – 16 ). The EHP-30 is the best validated disease-specific questionnaire for the documentation of endometriosis related impact on patients´ life. This questionnaire is sensitive to changes and is thus a suitable tool to evaluate treatment effects on the health status of patients with endometriosis ( 17 ). Consequently, the question remains if our therapeutic interventions help to improve those impairments. Thus, the aim of this study was to determine if surgical therapy of endometriotic lesions results in an improvement of HRQoL in relation to the different forms of endometriosis. Methods Patients We included all consecutive patients operated due to suspected endometriosis at the Medical University of Vienna, Austria, between 2014 and 2018, who gave their written informed consent to participate in our study. Inclusion criteria comprised age 18–50 years, histological confirmation of endometriosis and ability to complete the EHP-30 questionnaire. Women with a current malignancy defined as < 10 years after breast cancer or < 5 years after other malignant tumors, were excluded. Additionally, excluded were patients with infections such as HIV, Hepatitis (A, B, C), tuberculosis, and systemic autoimmune diseases. The respective patient flow-chart is shown in Fig. 1 . The study protocol was approved by the local ethic committee (EK code 1145/2018). Classification of endometriosis Due to the surgical report, patients with histological confirmed endometriosis were categorized based on the rASRM and ENZIAN ( 18 – 20 ) classification, retrospectively. Patients were then divided into four groups; group 1. peritoneal endometriosis; group 2. ovarian endometrioma; group 3. deep infiltrating endometriosis (DIE); and group 4. DIE + ovarian endometrioma ( 21 ). Surgical intervention Laparoscopic surgery was performed at the general hospital of Vienna (AKH) in all participating patients. The intraoperative steps were decided individually, but the overall result was the excision of endometriosis lesions in the abdominal and pelvic cavity in each patient. EHP questionnaire The EHP-30 consists of a 30-item core questionnaire applicable to all women with endometriosis, categorized into five subscales – pain (11 items), control and powerlessness (6 items), emotions (6 items), social support (4 items) and self-image (3 items). In addition, the EHP-30 consists also of modular questions. As this modular part does not apply to all patients, we did not include it in our analysis. The first evaluation of the EHP-30 questionnaire was performed one day after surgery. The questions referred to the past four weeks before the surgery. Six to ten weeks postoperatively, patients filled in the questionnaire again to evaluate the postoperative patient’s condition. Statistics All EHP questionnaires were entered in SciCoMed, exported as an Excel table and then imported into IBM-SPSS. The data was evaluated anonymized. The data of the EHP-30 questionnaire were generated according to the algorithm developed by Jones et al. evaluated in 2001.( 14 ) Response categories are rated on a five-point scale (0–4). Raw scores (the sum of items in each subscale) are translated into a score (each raw score is first divided by the maximum possible raw score and multiplied by 100) ranging from 0 (best possible health status) to 100 (worst possible health status). The maximum value of 100 corresponds to that of the maximum load and 0 means no impairment. After testing for normal distribution using Shapiro Wilk, all demographic data were given a Q-Q plot (quantile-quantile plot) in a frequency table. Depending on the scaling, the clinical data and categorical variables were given with absolute and relative frequency or by mean and standard deviation (SD). Correlations between socio-demographic and clinical data (age, partnership status, BMI, menarche, menstrual cycle, bleeding intensity, bleeding duration) and the parameters of the EHP-30 were determined. P-values < 0.05 were considered statistically significant. All statistical analyses were performed with IBM SPSS software version (Vienna/Austria). Results Demographics Initially, 300 patients suspected of having endometriosis and a planned surgery at the Medical University of Vienna, were screened. Of these, 190 patients had histologically confirmed endometriosis and met the relevant inclusion and exclusion criteria and gave their consent to participate in our study. Due to missing postoperative data, 75 of these patients had to be excluded. Patient´s characteristics and localization of endometriosis are shown in Table 1 . Table 1 Patient characteristics and localization of endometriosis n (%) age diagnosis (years) (m ean +/-SD) 32 ± 7 BMI (m ean +/-SD) 23.2 ± 4.4 partnership single in a partnership 28 (24.3) 87 (75.7) pregnancies 0 1 2 > 2 71 (61.7) 28 (24.3) 9 (7.8) 7 (6.1) births 0 1 2 > 2 87 (75.7) 21 (18.3) 6 (5.2) 1 (0.9) smoker smoker non-smoker 27 (23.5) 88 (76.5) Common symptoms (mulptiple selections possible) dysmenorrhea dyspareunia dysuria abdominal pain chest pain 108 (93.9) 93 (80.9) 75 (65.2) 62 (53.9) 12 (10.4) Menarche (age) mean (+/-SD) 12.7 ± 1.7 8–10 years 11–14 years 15–17 years 7 (6.1) 94 (81.7) 14 (12.2) Bleeding duration (days) mean (+/-SD) 5.0 ± 2.5 1–4 days 5–8 days 9–14 days 51 (44.3) 57 (49.6) 7 (6.1) Bleeding intensity amenorrhea light middle strong 5 (4.3) 7 (6.1) 43 (37.4) 60 (52.2) Hormonal therapy in the last 3 months yes combined hormonal therapy progesterone only no not specified 27 (23.5) 9 (33.3) 18 (66.7) 83 (72.2) 5 (4.3) Period of time from the beginning of pain until diagnosis (years) mean (+/-SD) 4.8 ± 6.1 Present wish to have children yes no 41 (35.7) 74 (64.3) Peritoneal endometriosis 26 (22,6) Ovarian endometriosis 23 (20%) DIE 52 (45,2) DIE + ovarian endometriosis 14 (12,2) The table should be placed in the results part after the section Demographics . EHP-30 Out of the core and modular questionnaire all categories were analyzed in detail in the total population as well as in the 4 subgroups. Impact of patient characteristics on EHP-30 A lower BMI was positively associated with "emotional health" (rs = 0.251, p = 0.007) and "self-image" (rs = 0.245, p = 0.008). There was a significant negative correlation between partnership status and the emotional health category (rs = -0.191, p = 0.041). Patients in a partnership had less negative impact on emotional health status. No significant correlations between age and such as emotional health or pain sensitivity were recorded. Impact of Endometriosis on EHP-30 Additionally, the EHP-30 categories were compared between the four endometriosis subgroups. The highest pre-operative pain levels were observed in patients DIE and DIE + ovarian endometrioma (42,2, +/- 22,1). The most significant improvement in respect to EHP-30 was also seen in these categories (-27,8, +/- 6,8). Impact of surgery on the EHP-30 All of the five main categories show a positive change in the quality of life postoperatively (Fig. 2 ): pain (HR 0.78, p < 0.001); self-determination (HR 0,92, p < 0.001); emotional health (HR 0,83, p < 0.001); social environment (HR 0,67, p < 0.001); and self-image (HR 0,47, p < 0,001). Analyzing the five categories regarding the four endometriosis subgroups separately (Fig. 3 ), reveals the most significant improvement in the groups of DIE and DIE + ovarian endometrioma. In the group of ovarian endometrioma there was a significant improvement postoperatively in the categories “pain”, “self-determination” and “emotional health”. In the patients with peritoneal endometriosis, there were no significant changes in any of the five categories. Aim of this study was to evaluate the effect of surgery on the HRQoL of patients with endometriosis. Using the EHP-30 questionnaire in the whole study group, we determined that all of the five main categories show a positive change and thus improvement of quality of life after laparoscopic surgery. HRQoL changes were also calculated separately in the four subpopulations (peritoneal, ovarian, DIE and DIE + ovarian endometrioma). Significant improvements were seen in the categories "pain", "self-determination" and "emotional health" in all subgroups, except in the group of patients with peritoneal endometriosis. In the categories “social environment” and “self-image”, there was only a significant change in the groups of DIE and DIE + ovarian endometriosis. We observed, that patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms. Due to the more pronounced preoperative clinical symptoms particularly in DIE and DIE + ovarian endometrioma, surgical improvement seems to result in a greater change in the score and consecutively a greater improvement in the quality of life. Thus, the results of this study highlight, that especially patients with DIE and DIE + ovarian endometrioma benefit from a surgical intervention. A limitation of this study is the low patient number. Studies with larger subpopulations are thus required to validate our findings. Discussion In clinical practice, routine evaluation of HRQoL in women who suffer from endometriosis is essential, both, for the health-care provider and the patient ( 22 ). In this study, longitudinal data of quality of life was obtained from a total of 115 patients with endometriosis. The median age of the recruited patients was 33 years, comparable to similar studies reporting an average age of 34 years ( 23 – 25 ). Most of the included patients were in a partnership, a factor known to increase the probability of consulting a doctor because of painful intercourse or the desire to have children ( 13 ). There was no correlation between age and “emotional health” (rs = -0.154 p = 0.101). In contrast to another similar Austrian study, in which older age led to a deterioration in “emotional health” ( 13 ). A negative correlation between the BMI and “emotional health” or “self-image” was recorded, which means that a higher BMI led to a deterioration in emotional health and self-image. This finding has also been confirmed by another study ( 10 ). Our data is comparable to the study by Jones et al published in 2004, the greatest positive change in the total population was revealed in the aspect of "self-determination" ( 23 ). One of the strengths of our data is that only patients with histologically confirmed endometriosis were included. In another study by Khong et al., patients with only suspected endometriosis due to pelvic pain or infertility were included in an EHP-30 questionnaire study ( 16 ). Furthermore, one additional strength lies in the preoperative and postoperative collection of the data, which was not carried out in other studies ( 13 ). In addition, our collective is part of a prospective cohort design of well characterized endometriosis patients ( 26 ). However, due to the short follow-up period (6–10 weeks), no statement about the long-term effect can be given. In this regard, further studies are needed to assess the effectiveness of an operative treatment over a longer period. It should also be noted, that the questionnaires are always answered from a subjective perspective. Since the content validity of the EHP-30 is high, the results based on the questionnaire can be regarded as relevant despite the subjective answers. Nevertheless, it should be noted that many patients have been living with impairments in HRQoL such as pain for years and in some cases have learned to deal with its draw backs. Confirming previous data ( 17 , 23 , 27 ), our study highlights that the EHP-30 can be regarded as a reliable instrument that reacts sensitively to changes. The preoperative and postoperative values ​​can be used to determine the individual effect of surgical therapy regarding different types of endometriosis. Conclusion The EHP-30 questionnaire shows a good overall performance in measuring HRQoL. The present work underlines, that the surgical treatment of endometriosis has a positive effect on all well-being parameters measured by the EHP-30. Significant improvement of EHP-30 was achieved in all endometriosis groups, except peritoneal endometriosis. Especially women with DIE – with or without ovarian endometrioma -show a pronounced benefit from surgery compared to peritoneal and ovarian endometrioma without DIE. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Conflict of Interest The authors have no relevant financial or non-financial interests to disclose. Author Contribution All authors contributed to the study conception and design. All authors read and approved the final manuscript Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Medival University of Vienna (Date 2018-05-04 / No 1145) Consent to participate Informed consent was obtained from all individual participants included in the study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21(3):329–39. Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012;27(5):1292–9. Marinho MCP, Magalhaes TF, Fernandes LFC, Augusto KL, Brilhante AVM, Bezerra L. Quality of Life in Women with Endometriosis: An Integrative Review. J Womens Health (Larchmt). 2018;27(3):399–408. Moradi M, Parker M, Sneddon A, Lopez V, Ellwood D. Impact of endometriosis on women's lives: a qualitative study. BMC Womens Health. 2014;14:123. 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Cite Share Download PDF Status: Under Review Version 2 posted Editorial decision: Major revision 18 Aug, 2022 Reviews received at journal 22 May, 2022 Reviews received at journal 19 May, 2022 Reviewers agreed at journal 09 May, 2022 Reviewers agreed at journal 09 May, 2022 Reviewers invited by journal 09 May, 2022 Editor assigned by journal 09 May, 2022 Editor invited by journal 09 May, 2022 Submission checks completed at journal 09 May, 2022 First submitted to journal 07 May, 2022 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1621018","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2022-05-05 16:47:10","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":107554231,"identity":"4f6173c3-0bf3-4206-9ea7-26b1bb0f8e8b","order_by":0,"name":"Denise Tiringer","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":true,"prefix":"","firstName":"Denise","middleName":"","lastName":"Tiringer","suffix":""},{"id":107554232,"identity":"92fb8b6f-d195-4117-a438-bb561bd5c912","order_by":1,"name":"Alexandra Pedrini","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Pedrini","suffix":""},{"id":107554233,"identity":"df1286d3-0725-4fa0-a056-4f0c2c9c1b94","order_by":2,"name":"Manuela Gstöttner","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Manuela","middleName":"","lastName":"Gstöttner","suffix":""},{"id":107554234,"identity":"fa81feb8-f849-4076-82c1-c5e2e1547fd7","order_by":3,"name":"Heinrich Husslein","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Heinrich","middleName":"","lastName":"Husslein","suffix":""},{"id":107554235,"identity":"4cec3aa2-9588-4d6a-8bd5-3db8a5bd711c","order_by":4,"name":"Lorenz Küssel","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Lorenz","middleName":"","lastName":"Küssel","suffix":""},{"id":107554236,"identity":"668a929d-5950-4f71-b33f-f29a81a2b0cf","order_by":5,"name":"Alexandra Perricos","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Perricos","suffix":""},{"id":107554237,"identity":"53f3d804-4d8c-4c1f-b2ed-a32716ec09c5","order_by":6,"name":"René Wenzl","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"René","middleName":"","lastName":"Wenzl","suffix":""}],"badges":[],"createdAt":"2022-05-04 06:29:18","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-1621018/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1621018/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":21778207,"identity":"12f65f07-e41b-4c43-963a-733fd8642903","added_by":"auto","created_at":"2022-05-23 14:22:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30438,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patients´ inclusion\u003c/p\u003e","description":"","filename":"OnlineFigureI.png","url":"https://assets-eu.researchsquare.com/files/rs-1621018/v2/ca243ceecc442e31e39e0286.png"},{"id":21778206,"identity":"87712217-a2b9-452f-a57d-5044f75552e5","added_by":"auto","created_at":"2022-05-23 14:22:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21579,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of pre- and postoperative Health related quality of Life (HRQoL) values in the four endometriosis groups. (1) patients with peritoneal endometriosis; (2) patients with ovarian endometriosis; (3) patients with deep infiltrating endometriosis; (4) patients with deep infiltrating endometriosis + ovarian endometrioma.\u003c/p\u003e","description":"","filename":"OnlineFigureII.png","url":"https://assets-eu.researchsquare.com/files/rs-1621018/v2/fbad2b31b784bfc64011f07f.png"},{"id":21779208,"identity":"c3fa76ff-4176-4662-822f-350026c15b39","added_by":"auto","created_at":"2022-05-23 14:27:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":315668,"visible":true,"origin":"","legend":"\u003cp\u003eChanges of EHP-30 scores in the four endometriosis groups during the study period. Values are mean + pos SD shown by vertical bars. EHP subdomains scores range from 0 to 100. Lower score indicates fewer negative symptoms.\u0026nbsp;(1) \u0026nbsp;patients with peritoneal endometriosis; (2) patients with ovarian endometriosis; (3) patients with deep infiltrating endometriosis; (4) patients with deep infiltrating endometriosis + ovarian endometrioma. (A) Pain scores. (B) Self-determination scores. (C) Emotional-health scores. (D) Social environment scores. (E) Self-image scores. EHP-30, endometriosis health profile-30.\u003c/p\u003e\u003cp\u003e* P\u0026lt;0,05\u003c/p\u003e","description":"","filename":"OnlineFigureIIIAbisEhochSW.png","url":"https://assets-eu.researchsquare.com/files/rs-1621018/v2/fb1f26d23b86fe7b3592108a.png"},{"id":21779209,"identity":"a8c454ca-bfd1-406e-ab5c-f744e7f1cb20","added_by":"auto","created_at":"2022-05-23 14:27:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":388830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1621018/v2/3abe01bf-8b5d-4739-a296-f38a47affb17.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Quality Of Life in Endometriosis Patients Before and After Surgical Treatment Using the EHP30 Questionnaire","fulltext":[{"header":"Backround","content":"\u003cp\u003eEndometriosis, defined as the presence of endometrium-like tissue outside the uterine cavity, is a chronic disease affecting women in their reproductive age. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) One of the main symptoms reported by patients is pain that can be expressed in a variety of symptoms, including dysmenorrhea, dyspareunia, and chronic pelvic pain (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These symptoms have an adverse impact on social, mental and physical wellbeing. Additionally, the impairment of HRQoL can significantly affect professional and private relationships, sexuality, social contacts, family planning (due to infertility) or psychological well-being (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Recent studies confirmed that women with endometriosis have a lower HRQoL compared to the general population. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTherapy of endometriosis comprises surgery, hormonal contraceptives or pain therapy. Still, little is known about the quantitative impact of surgery on the patients HRQoL. In the past few years, there has been increasing progress in the development and validation of psychometric questionnaires in order to asses HRQoL of endometriosis patients in clinical routine (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Several studies on HRQoL in patients with endometriosis have been performed with conflicting results and using different questionnaires. In addition, only a few studies focused on HRQoL in relation to the different forms of endometriosis (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 30-item Endometriosis Health Profile (EHP-30) developed by Georgina Jones, is a specific HRQoL scale derived from interviews of patients with endometriosis (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The EHP-30 is the best validated disease-specific questionnaire for the documentation of endometriosis related impact on patients\u0026acute; life. This questionnaire is sensitive to changes and is thus a suitable tool to evaluate treatment effects on the health status of patients with endometriosis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Consequently, the question remains if our therapeutic interventions help to improve those impairments. Thus, the aim of this study was to determine if surgical therapy of endometriotic lesions results in an improvement of HRQoL in relation to the different forms of endometriosis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe included all consecutive patients operated due to suspected endometriosis at the Medical University of Vienna, Austria, between 2014 and 2018, who gave their written informed consent to participate in our study. Inclusion criteria comprised age 18\u0026ndash;50 years, histological confirmation of endometriosis and ability to complete the EHP-30 questionnaire. Women with a current malignancy defined as \u0026lt;\u0026thinsp;10 years after breast cancer or \u0026lt;\u0026thinsp;5 years after other malignant tumors, were excluded. Additionally, excluded were patients with infections such as HIV, Hepatitis (A, B, C), tuberculosis, and systemic autoimmune diseases. The respective patient flow-chart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The study protocol was approved by the local ethic committee (EK code 1145/2018).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eClassification of endometriosis\u003c/h2\u003e \u003cp\u003eDue to the surgical report, patients with histological confirmed endometriosis were categorized based on the rASRM and ENZIAN (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) classification, retrospectively. Patients were then divided into four groups; group 1. peritoneal endometriosis; group 2. ovarian endometrioma; group 3. deep infiltrating endometriosis (DIE); and group 4. DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eSurgical intervention\u003c/h2\u003e \u003cp\u003eLaparoscopic surgery was performed at the general hospital of Vienna (AKH) in all participating patients. The intraoperative steps were decided individually, but the overall result was the excision of endometriosis lesions in the abdominal and pelvic cavity in each patient.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eEHP questionnaire\u003c/h2\u003e \u003cp\u003eThe EHP-30 consists of a 30-item core questionnaire applicable to all women with endometriosis, categorized into five subscales \u0026ndash; pain (11 items), control and powerlessness (6 items), emotions (6 items), social support (4 items) and self-image (3 items). In addition, the EHP-30 consists also of modular questions. As this modular part does not apply to all patients, we did not include it in our analysis.\u003c/p\u003e \u003cp\u003eThe first evaluation of the EHP-30 questionnaire was performed one day after surgery. The questions referred to the past four weeks before the surgery. Six to ten weeks postoperatively, patients filled in the questionnaire again to evaluate the postoperative patient\u0026rsquo;s condition.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eAll EHP questionnaires were entered in SciCoMed, exported as an Excel table and then imported into IBM-SPSS. The data was evaluated anonymized. The data of the EHP-30 questionnaire were generated according to the algorithm developed by Jones et al. evaluated in 2001.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Response categories are rated on a five-point scale (0\u0026ndash;4). Raw scores (the sum of items in each subscale) are translated into a score (each raw score is first divided by the maximum possible raw score and multiplied by 100) ranging from 0 (best possible health status) to 100 (worst possible health status). The maximum value of 100 corresponds to that of the maximum load and 0 means no impairment.\u003c/p\u003e \u003cp\u003eAfter testing for normal distribution using Shapiro Wilk, all demographic data were given a Q-Q plot (quantile-quantile plot) in a frequency table. Depending on the scaling, the clinical data and categorical variables were given with absolute and relative frequency or by mean and standard deviation (SD). Correlations between socio-demographic and clinical data (age, partnership status, BMI, menarche, menstrual cycle, bleeding intensity, bleeding duration) and the parameters of the EHP-30 were determined. P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. All statistical analyses were performed with IBM SPSS software version (Vienna/Austria).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eInitially, 300 patients suspected of having endometriosis and a planned surgery at the Medical University of Vienna, were screened. Of these, 190 patients had histologically confirmed endometriosis and met the relevant inclusion and exclusion criteria and gave their consent to participate in our study. Due to missing postoperative data, 75 of these patients had to be excluded. Patient\u0026acute;s characteristics and localization of endometriosis are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and localization of endometriosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eage diagnosis (years) (m\u003c/b\u003eean +/-SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (m\u003c/b\u003eean +/-SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epartnership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle\u003c/p\u003e \u003cp\u003ein a partnership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (24.3)\u003c/p\u003e \u003cp\u003e87 (75.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003epregnancies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (61.7)\u003c/p\u003e \u003cp\u003e28 (24.3)\u003c/p\u003e \u003cp\u003e9 (7.8)\u003c/p\u003e \u003cp\u003e7 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ebirths\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (75.7)\u003c/p\u003e \u003cp\u003e21 (18.3)\u003c/p\u003e \u003cp\u003e6 (5.2)\u003c/p\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esmoker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esmoker\u003c/p\u003e \u003cp\u003enon-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (23.5)\u003c/p\u003e \u003cp\u003e88 (76.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommon symptoms\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(mulptiple selections possible)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edysmenorrhea\u003c/p\u003e \u003cp\u003edyspareunia\u003c/p\u003e \u003cp\u003edysuria\u003c/p\u003e \u003cp\u003eabdominal pain\u003c/p\u003e \u003cp\u003echest pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (93.9)\u003c/p\u003e \u003cp\u003e93 (80.9)\u003c/p\u003e \u003cp\u003e75 (65.2)\u003c/p\u003e \u003cp\u003e62 (53.9)\u003c/p\u003e \u003cp\u003e12 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMenarche (age)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean (+/-SD) 12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003cp\u003e8\u0026ndash;10 years\u003c/p\u003e \u003cp\u003e11\u0026ndash;14 years\u003c/p\u003e \u003cp\u003e15\u0026ndash;17 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (6.1)\u003c/p\u003e \u003cp\u003e94 (81.7)\u003c/p\u003e \u003cp\u003e14 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBleeding duration (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean (+/-SD) 5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003cp\u003e1\u0026ndash;4 days\u003c/p\u003e \u003cp\u003e5\u0026ndash;8 days\u003c/p\u003e \u003cp\u003e9\u0026ndash;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (44.3)\u003c/p\u003e \u003cp\u003e57 (49.6)\u003c/p\u003e \u003cp\u003e7 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBleeding intensity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eamenorrhea\u003c/p\u003e \u003cp\u003elight\u003c/p\u003e \u003cp\u003emiddle\u003c/p\u003e \u003cp\u003estrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003cp\u003e7 (6.1)\u003c/p\u003e \u003cp\u003e43 (37.4)\u003c/p\u003e \u003cp\u003e60 (52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHormonal therapy in the last 3 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003cp\u003ecombined hormonal therapy\u003c/p\u003e \u003cp\u003eprogesterone only\u003c/p\u003e \u003cp\u003eno\u003c/p\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (23.5)\u003c/p\u003e \u003cp\u003e9 (33.3)\u003c/p\u003e \u003cp\u003e18 (66.7)\u003c/p\u003e \u003cp\u003e83 (72.2)\u003c/p\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeriod of time from the beginning of pain until diagnosis (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean (+/-SD) 4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresent wish to have children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (35.7)\u003c/p\u003e \u003cp\u003e74 (64.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeritoneal endometriosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (22,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOvarian endometriosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDIE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (45,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDIE\u0026thinsp;+\u0026thinsp;ovarian endometriosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (12,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eThe table should be placed in the results part after the section \u003cspan refid=\"Sec9\" class=\"InternalRef\"\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/span\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEHP-30\u003c/h2\u003e \u003cp\u003eOut of the core and modular questionnaire all categories were analyzed in detail in the total population as well as in the 4 subgroups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImpact of patient characteristics on EHP-30\u003c/h2\u003e \u003cp\u003eA lower BMI was positively associated with \"emotional health\" (rs\u0026thinsp;=\u0026thinsp;0.251, p\u0026thinsp;=\u0026thinsp;0.007) and \"self-image\" (rs\u0026thinsp;=\u0026thinsp;0.245, p\u0026thinsp;=\u0026thinsp;0.008). There was a significant negative correlation between partnership status and the emotional health category (rs = -0.191, p\u0026thinsp;=\u0026thinsp;0.041). Patients in a partnership had less negative impact on emotional health status. No significant correlations between age and such as emotional health or pain sensitivity were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImpact of Endometriosis on EHP-30\u003c/h2\u003e \u003cp\u003eAdditionally, the EHP-30 categories were compared between the four endometriosis subgroups. The highest pre-operative pain levels were observed in patients DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma (42,2, +/- 22,1). The most significant improvement in respect to EHP-30 was also seen in these categories (-27,8, +/- 6,8).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImpact of surgery on the EHP-30\u003c/h2\u003e \u003cp\u003eAll of the five main categories show a positive change in the quality of life postoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): pain (HR 0.78, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); self-determination (HR 0,92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); emotional health (HR 0,83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); social environment (HR 0,67, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and self-image (HR 0,47, p\u0026thinsp;\u0026lt;\u0026thinsp;0,001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnalyzing the five categories regarding the four endometriosis subgroups separately (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), reveals the most significant improvement in the groups of DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma. In the group of ovarian endometrioma there was a significant improvement postoperatively in the categories \u0026ldquo;pain\u0026rdquo;, \u0026ldquo;self-determination\u0026rdquo; and \u0026ldquo;emotional health\u0026rdquo;. In the patients with peritoneal endometriosis, there were no significant changes in any of the five categories.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAim of this study was to evaluate the effect of surgery on the HRQoL of patients with endometriosis. Using the EHP-30 questionnaire in the whole study group, we determined that all of the five main categories show a positive change and thus improvement of quality of life after laparoscopic surgery. HRQoL changes were also calculated separately in the four subpopulations (peritoneal, ovarian, DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma). Significant improvements were seen in the categories \"pain\", \"self-determination\" and \"emotional health\" in all subgroups, except in the group of patients with peritoneal endometriosis.\u003c/p\u003e \u003cp\u003eIn the categories \u0026ldquo;social environment\u0026rdquo; and \u0026ldquo;self-image\u0026rdquo;, there was only a significant change in the groups of DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometriosis. We observed, that patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms. Due to the more pronounced preoperative clinical symptoms particularly in DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma, surgical improvement seems to result in a greater change in the score and consecutively a greater improvement in the quality of life. Thus, the results of this study highlight, that especially patients with DIE and DIE\u0026thinsp;+\u0026thinsp;ovarian endometrioma benefit from a surgical intervention. A limitation of this study is the low patient number. Studies with larger subpopulations are thus required to validate our findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn clinical practice, routine evaluation of HRQoL in women who suffer from endometriosis is essential, both, for the health-care provider and the patient (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In this study, longitudinal data of quality of life was obtained from a total of 115 patients with endometriosis. The median age of the recruited patients was 33 years, comparable to similar studies reporting an average age of 34 years (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Most of the included patients were in a partnership, a factor known to increase the probability of consulting a doctor because of painful intercourse or the desire to have children (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). There was no correlation between age and \u0026ldquo;emotional health\u0026rdquo; (rs = -0.154 p\u0026thinsp;=\u0026thinsp;0.101). In contrast to another similar Austrian study, in which older age led to a deterioration in \u0026ldquo;emotional health\u0026rdquo; (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A negative correlation between the BMI and \u0026ldquo;emotional health\u0026rdquo; or \u0026ldquo;self-image\u0026rdquo; was recorded, which means that a higher BMI led to a deterioration in emotional health and self-image. This finding has also been confirmed by another study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur data is comparable to the study by Jones et al published in 2004, the greatest positive change in the total population was revealed in the aspect of \"self-determination\" (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the strengths of our data is that only patients with histologically confirmed endometriosis were included. In another study by Khong et al., patients with only suspected endometriosis due to pelvic pain or infertility were included in an EHP-30 questionnaire study (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Furthermore, one additional strength lies in the preoperative and postoperative collection of the data, which was not carried out in other studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, our collective is part of a prospective cohort design of well characterized endometriosis patients (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, due to the short follow-up period (6\u0026ndash;10 weeks), no statement about the long-term effect can be given. In this regard, further studies are needed to assess the effectiveness of an operative treatment over a longer period. It should also be noted, that the questionnaires are always answered from a subjective perspective. Since the content validity of the EHP-30 is high, the results based on the questionnaire can be regarded as relevant despite the subjective answers. Nevertheless, it should be noted that many patients have been living with impairments in HRQoL such as pain for years and in some cases have learned to deal with its draw backs.\u003c/p\u003e \u003cp\u003eConfirming previous data (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), our study highlights that the EHP-30 can be regarded as a reliable instrument that reacts sensitively to changes. The preoperative and postoperative values ​​can be used to determine the individual effect of surgical therapy regarding different types of endometriosis.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cdiv id=\"Sec15\" type=\"Conclusion\" class=\"Section2\"\u003e \u003cp\u003eThe EHP-30 questionnaire shows a good overall performance in measuring HRQoL. The present work underlines, that the surgical treatment of endometriosis has a positive effect on all well-being parameters measured by the EHP-30. Significant improvement of EHP-30 was achieved in all endometriosis groups, except peritoneal endometriosis. Especially women with DIE \u0026ndash; with or without ovarian endometrioma -show a pronounced benefit from surgery compared to peritoneal and ovarian endometrioma without DIE.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contribution\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Medival University of Vienna (Date 2018-05-04 / No 1145)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbr\u0026atilde;o MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. 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Arch Gynecol Obstet. 2015;292(6):1393\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones G, Kennedy S, Barnard A, Wong J, Jenkinson C. Development of an endometriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstet Gynecol. 2001;98(2):258\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenkinson C, Kennedy S, Jones G. Evaluation of the American version of the 30-item Endometriosis Health Profile (EHP-30). Qual Life Res. 2008;17(9):1147\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhong SY, Lam A, Luscombe G. Is the 30-item Endometriosis Health Profile (EHP-30) suitable as a self-report health status instrument for clinical trials? Fertility and sterility. 2010;94:1928\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan de Burgt TJ, Kluivers KB, Hendriks JC. Responsiveness of the Dutch Endometriosis Health Profile-30 (EHP-30) questionnaire. Eur J Obstet Gynecol Reprod Biol. 2013;168(1):92\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, et al. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod. 2017;32(2):315\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, et al. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod. 2017;32(2):315\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaas D, Shebl O, Shamiyeh A, Oppelt P. The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Acta Obstet Gynecol Scand. 2013;92(1):3\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMabrouk M, Montanari G, Guerrini M, Villa G, Solfrini S, Vicenzi C, et al. Does laparoscopic management of deep infiltrating endometriosis improve quality of life? A prospective study. Health Qual Life Outcomes. 2011;9:98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginson IJ, Carr AJ. Measuring quality of life: Using quality of life measures in the clinical setting. Bmj. 2001;322(7297):1297\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones G, Jenkinson C, Kennedy S. Development of the Short Form Endometriosis Health Profile Questionnaire: the EHP-5. Qual Life Res. 2004;13(3):695\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoliman AM, Coyne KS, Zaiser E, Castelli-Haley J, Fuldeore MJ. The burden of endometriosis symptoms on health-related quality of life in women in the United States: a cross-sectional study. J Psychosom Obstet Gynaecol. 2017;38(4):238\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerricos A, Wenzl R, Husslein H, Eiwegger T, Gstoettner M, Weinhaeusel A, et al. Does the Use of the \"Proseek((R)) Multiplex Oncology I Panel\" on Peritoneal Fluid Allow a Better Insight in the Pathophysiology of Endometriosis, and in Particular Deep-Infiltrating Endometriosis? J Clin Med. 2020;9(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNogueira-Silva C, Costa P, Martins C, Barata S, Alho C, Calhaz-Jorge C, et al. Validation of the Portuguese Version of EHP-30 (The Endometriosis Health Profile-30). Acta Med Port. 2015;28(3):347\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"endometriosis, quality of life, EHP-30 questionnaire, surgical therapy, laparoscopic surgery","lastPublishedDoi":"10.21203/rs.3.rs-1621018/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1621018/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackround: \u003c/em\u003eEndometriosis is one of the most common gynaecological illnesses causing extensive psychological, physical and social impact on patient´s life and exerts negative effects on health-related quality of Life (HRQoL).\u0026nbsp;However, the effects of surgery on the postoperative HRQoL in the different endometriosis subgroups have not been fully evaluated.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMethods: \u003c/em\u003eWe performed a comparative retrospective study between 2014 and 2018 at the Medical University of Vienna, including all patients with surgically confirmed endometriosis who had completed the standardized Endometriosis Health Profile - 30 (EHP-30) questionnaire one day after surgery (the questions refer to the four weeks preoperatively) and six to ten weeks postoperatively. \u003c/p\u003e\u003cp\u003e\u003cem\u003eResults: \u003c/em\u003eCompared to preoperative values, we found significant benefits, regarding\u0026nbsp;postoperative conditions, in our study group (n=115) in all five categories, “pain” (HR\u0026nbsp;0.78, p\u0026lt;0.001); “self-determination” (HR 0,92, p\u0026lt;0.001); “emotional health” (HR 0,83, p\u0026lt;0.001);” social environment” (HR 0,67, p\u0026lt;0.001); and “self-image” (HR 0,47, p\u0026lt;0,001). Patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms and there were no significant changes in any of the categories. In the subgroups deep infiltrating endometriosis (DIE) and DIE + ovarian endometrioma, surgical intervention results in a significantly greater improvement in all categories of EHP 30 compared to ovarian endometrioma without DIE or peritoneal endometriosis.\u003c/p\u003e\u003cp\u003e\u003cem\u003eConclusion: \u003c/em\u003eOur study shows, that especially women with DIE - with or without ovarian endometrioma - demonstrate a more pronounced benefit from surgical therapy compared to patients with peritoneal endometriosis or endometrioma without DIE.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Evaluation of Quality Of Life in Endometriosis Patients Before and After Surgical Treatment Using the EHP30 Questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2022-05-23 14:21:59","doi":"10.21203/rs.3.rs-1621018/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-18T12:57:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-05-22T08:22:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-05-19T20:38:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cc343385-6c8c-4fc6-8c8c-d13d37c767fe","date":"2022-05-09T22:39:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81e20e0d-e0f8-4c26-889d-b6237d19553f","date":"2022-05-09T21:24:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-09T20:44:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-09T14:38:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-09T09:49:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-09T09:47:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2022-05-07T11:44:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36675b6a-d742-42d6-818b-07b661208d6d","owner":[],"postedDate":"May 23rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-12-05T07:14:28+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-23 14:21:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-1621018","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1621018","identity":"rs-1621018","version":["v2"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}