Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30

Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30 | 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 Article Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30 Arij Youssef, Amal Alimi, Abdeljalil Khelifi, Sassi Bouguizan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9929703/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Study question: What is the impact of different therapeutic strategies on health-related quality of life in women with endometriosis? Summary answer: Surgical management, particularly complete excision, is associated with the greatest improvement in health-related quality of life in women with endometriosis. What is known already: Endometriosis significantly impairs quality of life beyond pain, affecting psychological, sexual, and social domains. Patient-reported outcomes such as the EHP-30 are increasingly used to assess treatment effectiveness. Study design, size, duration: This was a monocentric cross-sectional analytical study including 80 women with endometriosis, conducted over a 53-month period from January 2020 to May 2024. Participants/materials, setting, methods: Women aged 18–50 years with symptomatic pelvic endometriosis confirmed by clinical, imaging, and/or histological findings were included at the Department of Gynecology and Obstetrics, Farhat Hached University Hospital (Sousse, Tunisia). Patients with adenomyosis, other causes of infertility, or incomplete data were excluded. Data collected included sociodemographic characteristics, clinical presentation, disease phenotype, and therapeutic strategies (medical, surgical, or combined). Health-related quality of life was assessed using the validated Endometriosis Health Profile-30 (EHP-30). Statistical analysis was performed using SPSS v29 with a significance threshold of p ≤ 0.05. Main results and the role of chance: The mean age was 36.9 ± 8.3 years. The median global EHP-30 score was 29.7 [20–49.8], indicating moderate impairment. Surgical treatment was associated with the most significant improvement in overall quality of life, particularly after complete excision. Medical treatment, especially progestins, improved specific domains, mainly sexual function. Combined strategies showed significant benefits in pain, emotional well-being, and social support. Infertility was significantly associated with poorer quality of life across all domains. Given the cross-sectional design, causal inference is limited. Limitations, reasons for caution: The monocentric design and relatively small sample size may limit generalizability. The use of a non-validated Arabic version of the EHP-30 and telephone-based data collection may introduce information bias. Wider implications of the findings: These findings support a multidimensional and individualized approach to endometriosis management, integrating both surgical and medical strategies. The systematic use of patient-reported outcomes is essential to optimize patient-centered care. Study funding/competing interest(s): No specific funding was received. The authors declare no competing interests. Trial registration number: Not applicable. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Endometriosis EHP-30 Quality of life Chronic pelvic pain Health-related quality of life Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Endometriosis is a chronic, inflammatory, and estrogen-dependent disease defined by the ectopic presence of functional endometrial tissue outside the uterine cavity (1,2). However, this histological definition does not fully reflect the clinical complexity of the disease, which is characterized by marked phenotypic heterogeneity, a frequent dissociation between anatomical lesions and symptomatology, and a major functional impact. With an estimated prevalence of approximately 10% among women of reproductive age and up to 50% among infertile patients, endometriosis represents a major global public health issue (3). Nevertheless, these data remain approximate due to diagnostic limitations and clinical polymorphism (4). The diagnostic delay, still estimated at 5 to 10 years, remains a key determinant of unfavorable disease progression (5). The pathophysiology of endometriosis is based on complex interactions involving hormonal factors, immune dysregulation, chronic inflammation, and genetic susceptibility. Emerging mechanisms, such as central sensitization and neuroangiogenesis, contribute to pain chronicization and anatomo-clinical discordance, thereby challenging a strictly lesion-based approach to the disease (6). From a therapeutic perspective, medical treatments mainly aim at hormonal suppression and symptomatic control, without curative effects on the lesions. Surgery, although potentially effective in improving pain and fertility, is associated with significant morbidity and a risk of recurrence, limiting its indication within a long-term management strategy (7,8). In this context, the evaluation of therapeutic efficacy can no longer rely solely on isolated anatomical or symptomatic criteria. Endometriosis is now recognized as a disease with a major multidimensional impact, profoundly affecting health-related quality of life (HRQoL), including physical, psychological, social, professional, and sexual dimensions. The integration of patient-reported outcomes (PROs) into clinical assessment has therefore become a standard, enabling a patient-centered approach. Among the validated instruments, the Endometriosis Health Profile-30 (EHP-30) questionnaire constitutes a specific, robust, and widely used tool for the standardized evaluation of quality of life in endometriosis. Therefore, a multidimensional and dynamic evaluation based on reliable, standardized, and appropriate tools for the comprehensive assessment of quality of life in patients with endometriosis, taking into account physical, psychological, and social parameters, is essential for the global management of endometriosis. Objective To evaluate the impact of therapeutic strategies on health-related quality of life in patients with Endometriosis through a multidimensional analysis integrating patient-reported outcomes, using the validated Endometriosis Health Profile-30 (EHP-30) questionnaire. Materials and Methods Type and Setting of the Study This was a monocentric analytical cross-sectional study conducted in the Department of Obstetrics and Gynecology at Farhat Hached University Hospital over a 53- months period (January 1, 2020 – May 30, 2024). Population Included patients were women aged 18 t o 50 years presenting with symptomatic pelvic endometriosis confirmed by medical history, clinical examination, ultrasound, and imaging (pelvic MRI) and/or intraoperative histological confirmation. Only patients who received medical or surgical treatment at the university hospital and were followed in outpatient consultations were included. Participation was voluntary and based on informed consent. Exclusion and non-inclusion criteria were: minors, menopausal women, patients under guardianship or curatorship, refusal to participate, infertility due to another cause, chronic pelvic disease unrelated to endometriosis, severe unstable psychotic disorders, or adenomyosis. Among the 112 identified patients, 32 cases of adenomyosis, 1 refusal to participate, and 4 incomplete files or cases without diagnostic confirmation were excluded. The final cohort included 80 patients. Standardized Assessment Endometriosis-specific quality of life was assessed using the validated Endometriosis Health Profile-30 (EHP-30) questionnaire. Recruitment and Data Collection Patients were identified during outpatient consultations or hospitalizations, or contacted by telephone (maximum of three attempts per patient). Telephone interviews were recorded to ensure data reliability. Collected data included: Sociodemographic characteristics and medical history. Symptomatology and lesion localization (imaging findings). Therapeutic modalities (medical or surgical), including second-line treatment and recurrences. Operative and postoperative data: procedures performed, complications, and fertility outcomes. Evolution of quality of life (EHP-30). Ethical Considerations The study was approved by the Institutional Review Board of the University of Medecine of Sousse under approval number (Ref CEFMD 243/2024 ). Participation was voluntary and anonymous, with no impact on medical management . Study funding/competing interest(s) : No specific funding was received. The authors declare no competing interests. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics with a significance threshold set at p ≤ 0.05. All methods were performed in accordance with the relevant guidelines and regulations, and in compliance with the Declaration of Helsinki. Results 1. Population Characteristics A total of 80 patients with symptomatic external endometriosis were included. The mean age was 36.93 ± 8.29 years (range: 18–50 years). Most patients were married (67.5%) , lived in urban areas (73.8%) , and had a high educational level ( 51.2%). A family history of endometriosis was reported in 17.5% of cases. Regarding reproductive characteristics, the median gravidity was 1 [0–3] and the median parity was 1 [0–2] , with 43.8% of patients being nulliparous. Infertility was found in 21.3% of patients, predominantly primary infertility, with a median duration of 36 months. Assisted reproductive technology was used in 76.5% of infertile patients (Table I). 2. Clinical Presentation and Diagnostic Pathway Clinical presentation was predominantly characterized by cyclic pelvic pain ( 96.3%) , followed by secondary dysmenorrhea (63.7%) and deep dyspareunia (50%) ( Fig. 1 ). The diagnostic pathway was marked by significant medical wandering, with a median of four physicians consulted before diagnosis. The median diagnostic delay was 6 months [3–12]. Diagnosis was based on the combination of clinical findings and imaging data. Histological confirmation was obtained in 90% of cases, while pelvic MRI contributed to the diagnostic assessment in 65% of patients ( Fig. 2 ). 3. Disease phenotype Superficial and ovarian forms were predominant (83.8%). Deep infiltrating endometriosis was observed in 16.3% of cases, often associated with other locations, reflecting the heterogeneity of disease involvement ( Table II ). 4. Therapeutic management 4.1. Overall therapeutic strategy Surgery represented the main treatment modality, performed in 95% of patients, while medical therapy was prescribed in 37.5% of cases. A purely surgical approach was adopted in 62.5% of patients, whereas 32.5% benefited from a combined medical and surgical strategy. A second-line therapeutic approach was required in 41.3% of cases, highlighting the chronic and recurrent nature of the disease ( Fig. 3 ) ( Fig. 4 ). 4.2. First-line therapeutic strategy 4.2.1. First-line medical treatment: First-line medical treatment was used in 18.8% of patients, with dienogest being the primary first-line option (8.8%). As a second-line option, progestins were prescribed in 6.3% of cases. ( Table III) 4.2.2. First-line surgical treatment : First-line surgical treatment was performed in 83% of patients. The reference surgical approach was laparoscopy, used in 67.7% of cases. The most frequently performed technique was simple percutaneous laparoscopic drainage or a three-step procedure, followed by intraperitoneal cystectomy with or without electrocautery. Complete excision was achieved in only 37.5% of cases. Preoperative medical treatment was administered in 29.2% of patients, essentially based on GnRH analogues (26.2%). Postoperative treatment was indicated in 46.2% of patients, mainly using dienogest in 29.2% of cases (Table IV). 4.3. Second-line therapeutic strategy Second-line treatment was required in 33 patients (41.3%) . 4.3.1.Second-line medical treatment Among women managed medically, dienogest was the predominant treatment (51.5%), followed by other medical therapies, whereas GnRH analogs were used in a minority of cases (3%). ( Table V) 4.3.2.Second- line surgical treatment Among patients requiring second-line surgery (51.5%), laparoscopy was the most frequently used approach (70.6%). Simple laparoscopic drainage or a three-stage procedure was the most common intervention (24.2%). Postoperative medical treatment was prescribed in 58.8% of cases, predominantly dienogest (47.1%). Complete excision was achieved in 23.1% of surgically treated patients. ( Table VI). 5. Surgical outcomes and recurrence Overall surgical morbidity was low, with 5.2% intraoperative complications and 7.8% postoperative complications (Table VII). . Despite appropriate management, recurrence remained frequent, with 25% of patients experiencing recurrent pain and 20% showing anatomical recurrence. The median time to recurrence was 21 months . 6. Quality of life Quality of life assessment using the EHP-30 questionnaire showed a median global score of 29.69 [20–49.83] , indicating moderate impairment. The most affected dimensions were sexual function and treatment perception (Table VIII). 7. Impact of therapeutic strategies on quality of life Analysis according to treatment modalities showed that medical treatment, particularly progestins, was associated with an overall improvement in quality of life, with a particularly marked benefit on sexual function (Table IX). However, the most significant improvements were observed after surgical treatment, particularly in cases of complete excision and laparoscopic adnexectomy. In contrast, drainage techniques were associated with less favorable outcomes (Table X). Ultrasound-guided aspiration showed benefits in specific domains, particularly sexuality, fertility, and the physician–patient relationship (Table XI). Combined approaches, particularly in second-line management, resulted in significant improvement in pain, emotional well-being, and social support, highlighting the value of a multimodal treatment strategy (Table XII). Overall, first-line surgical management was associated with the greatest overall improvement in quality of life, while combined strategies allowed targeted optimization of specific domains (Table XIII) . 8. Patient-related factors impacting quality of life Analysis according to patient profile revealed significant differences. Single patients had the most impaired scores, whereas married patients showed better outcomes (Table XIV). Higher socioeconomic and educational levels were associated with better quality of life, likely reflecting improved access to healthcare and better treatment adherence (Table XV, Table XVI). Conversely, infertility emerged as a major factor negatively impacting quality of life, affecting all assessed dimensions (Table XVII) . Discussion 1. Quality of life assessment: relevance of the EHP-30 Quality of life assessment in endometriosis relies on validated, disease-specific, and sensitive tools capable of detecting treatment-induced changes. In this context, the Endometriosis Health Profile-30 (EHP-30) , developed by Jones et al., is considered a reference instrument. Designed from interviews with women affected by endometriosis, it demonstrates greater sensitivity to clinical changes compared with generic tools such as the SF-36 (9,10). The EHP-30 consists of a 30-item core questionnaire covering five main dimensions (pain, control/helplessness, emotional well-being, social support, and self-image), supplemented by a 23-item modular section addressing specific aspects such as sexuality, fertility, healthcare relationship, and work life. The Likert scale allows standardized scoring, converted into values ranging from 0 to 100, reflecting the degree of quality-of-life impairment (10). Thus, the EHP-30 is particularly well suited for assessing the impact of therapeutic strategies in endometriosis, both in clinical practice and research settings. 2. Quality of life according to therapeutic strategies 2.1. First-line medical treatment In our study, patients treated exclusively with medical therapy as first-line management showed an improvement in quality of life, particularly under progestins and combined oral contraceptives. These findings are consistent with international guidelines, including those of ESHRE and HAS , which recommend these treatments as first-line management for endometriosis-related pain (11–13). Literature data suggest that combined oral contraceptives can achieve a significant reduction in pain, up to 50%, especially when administered continuously (11). However, the lack of robust randomized controlled trials limits the level of evidence, as most available data are derived from observational studies. Progestins, particularly dienogest and desogestrel, have demonstrated significant efficacy on pain and quality of life, with meaningful improvements in EHP-30 scores (14). Several recent cohort studies confirm these findings, showing progressive and sustained improvement in quality of life, although certain domains such as self-image and perceived control may remain impaired. Nevertheless, in deep infiltrating forms, some studies report persistent impairment in quality of life, particularly in sexual, emotional, and social domains. Moreover, adverse effects may limit treatment adherence, negatively impacting long-term outcomes (15). 2.2. First-line surgical treatment In our series, first-line surgery—particularly complete excision and laparoscopic adnexectomy—was associated with the greatest overall improvement in quality of life. These results are consistent with multiple studies showing that surgery not only reduces pain but also significantly improves quality of life and sexual function (16). A recent systematic review confirms that various laparoscopic surgical techniques (excision, ablation, vaporization) lead to significant improvements in EHP-30 scores across most domains, particularly in deep infiltrating forms (17) (Table XVIII). However, the role of first-line surgery remains debated, particularly in deep infiltrating forms, where current guidelines tend to favor an initial medical approach (18,19). Some data suggest that postoperative improvement may decrease over time, whereas medical treatments induce a more gradual but sustained improvement in quality of life. 2.3. Alternative and combined approaches Ultrasound-guided aspiration, particularly when associated with sclerotherapy, appears to be an interesting alternative in selected cases, especially in patients with recurrent disease or a history of extensive surgery. This approach seems to be associated with improvement in specific domains of quality of life, particularly sexuality and fertility. In our study, combined strategies, especially in second-line management, were associated with the best overall outcomes, particularly in terms of pain experience and emotional well-being (self-image, control/helplessness, and social support). These findings suggest the value of a multimodal approach tailored to disease evolution and individual patient characteristics. 3. Factors influencing quality of life 3.1. Marital status and age Our results show more impaired quality of life among single patients, often younger. This finding is consistent with the literature, highlighting the major psychological burden of endometriosis in young women, particularly regarding sexuality, fertility, and social relationships (20). Chronic pain, diagnostic delay, and therapeutic burden contribute to significant emotional distress, further exacerbated by uncertainty regarding reproductive and professional future (21,22). 3.2. Socioeconomic status A higher socioeconomic level was associated with better quality of life, likely due to improved access to healthcare, better treatment adherence, and earlier management. Conversely, financial constraints may represent a major barrier to care access and investigations, exacerbating health inequalities (23). 3.3. Educational level Educational level also appears to be an important determinant of quality of life. Low educational level is associated with poorer understanding of the disease and reduced treatment adherence, contributing to more severe impairment in quality of life (24). However, this relationship remains complex and multifactorial, involving cognitive, cultural, and psychosocial dimensions. Adapting therapeutic education to patient profiles is therefore essential to optimize management (23,25). 3.4. Infertility status In our study, infertile patients exhibited significantly worse quality of life compared to fertile women, affecting all assessed dimensions. Infertility, particularly related to tubal and/or ovarian involvement, has a global impact on quality of life and often leads to the use of assisted reproductive technologies (ART). However, despite therapeutic hope, the diagnosis of infertility remains a major psychological trauma, sometimes intensified by the ART journey (25). Anxiety and depressive symptoms in these patients may reach levels comparable to those observed in certain severe chronic diseases (26). Affected women frequently report feelings of guilt, frustration, loss of control, and reduced self-esteem (27). Sociocultural pressure related to motherhood further weakens feminine identity, promoting social isolation and avoidance behaviors (28). Moreover, infertility significantly affects couple sexuality, with reduced spontaneity and a decrease in sexual frequency, which becomes goal-oriented and centered on conception rather than intimacy (29). Study limitations This study has several limitations. First, its single-center design and relatively limited sample size may restrict the generalizability of the findings to other populations and healthcare settings with different clinical practices. Second, some data were collected retrospectively, which may have introduced information bias. Furthermore, although the EHP-30 is a validated and widely used instrument for assessing quality of life in women with endometriosis, it was administered in French through oral translation and semi-structured interviews, potentially leading to interpretation bias. As no validated Arabic version of the EHP-30 was available at the time of the study, further multicenter studies are needed to validate its use in the Tunisian population and to confirm its reliability in evaluating therapeutic outcomes and quality of life before and after treatment. Conclusion Endometriosis is a chronic, complex, and multisystem disease with a major impact on patients’ physical, psychological, sexual, and social quality of life. Prolonged diagnostic delay, combined with sociocultural factors and variability in clinical practice, contributes to therapeutic delay and symptom worsening. Our results confirm that first-line surgical management significantly improves pain and quality of life regardless of lesion type; however, the choice of technique must be individualized based on multidisciplinary expertise and lesion mapping. Hormonal medical treatments remain essential, particularly as complementary therapy or for patients not eligible for surgery. Systematic integration of patient-reported outcomes using validated tools such as the EHP-30 is essential to evaluate real-world effectiveness and guide personalized care. Finally, strengthening specialized centers, validating local follow-up tools, and conducting large prospective studies are priorities to improve epidemiological understanding, optimize therapeutic strategies, and reduce the multidimensional burden of this disease. Declarations Data availability : The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request . Ethics Approval : The study was approved by the Institutional Review Board of the University of Medecine of Sousse under approval number (Ref CEFMD 243/2024 ). Participation was voluntary and anonymous, with no impact on medical management . Competing interests : The authors declare no competing interests. Funding : No specific funding was received. Author Contribution AY ET AA ont rédigé le texte et ont préparé les figures et les tableaux.AK ET SB ont corrigé la méthodologie et la discussion. References Pathophysiology of Endometriosis. EM-Consulte. Available from: https://www.em-consulte.com/article/178873 Borghese B, Santulli P, Marcellin L, Chapron C. Definition, description, anatomical and clinical forms, pathogenesis and natural history of endometriosis. CNGOF-HAS Endometriosis Guidelines. Gynecol Obstet Fertil Senol. 2018;46(3):156–167 Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244–1256. Nisolle M, Donnez J. 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Supplementary Files tableau1.docx TableIII.docx tableau4.docx TAB5.docx tab6.docx TableVII.docx TableVIII.docx tab9.docx TableX.docx tab12.docx 13.docx 14.docx 15.docx 16.docx 17.docx TableauII.docx TableXI.docx TableauXIX.docx TableauXVIII.docx ListofFigures.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 26 Jun, 2026 Editor assigned by journal 26 Jun, 2026 Editor invited by journal 26 Jun, 2026 Submission checks completed at journal 25 Jun, 2026 First submitted to journal 25 Jun, 2026 You are reading this latest preprint version 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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10:13:31","extension":"docx","order_by":18,"title":"","display":"","copyAsset":false,"role":"supplement","size":91748,"visible":true,"origin":"","legend":"","description":"","filename":"TableauXVIII.docx","url":"https://assets-eu.researchsquare.com/files/rs-9929703/v1/53edb61043d5b3b477392909.docx"},{"id":113664660,"identity":"1ddfbd91-6ae9-40a0-af5c-69671964c141","added_by":"auto","created_at":"2026-07-02 09:57:49","extension":"docx","order_by":19,"title":"","display":"","copyAsset":false,"role":"supplement","size":19425,"visible":true,"origin":"","legend":"","description":"","filename":"ListofFigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-9929703/v1/32f9d7ac972998d132d66b97.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a chronic, inflammatory, and estrogen-dependent disease defined by the ectopic presence of functional endometrial tissue outside the uterine cavity (1,2). However, this histological definition does not fully reflect the clinical complexity of the disease, which is characterized by marked phenotypic heterogeneity, a frequent dissociation between anatomical lesions and symptomatology, and a major functional impact.\u003c/p\u003e \u003cp\u003eWith an estimated prevalence of approximately 10% among women of reproductive age and up to 50% among infertile patients, endometriosis represents a major global public health issue (3). Nevertheless, these data remain approximate due to diagnostic limitations and clinical polymorphism (4). The diagnostic delay, still estimated at 5 to 10 years, remains a key determinant of unfavorable disease progression (5).\u003c/p\u003e \u003cp\u003eThe pathophysiology of endometriosis is based on complex interactions involving hormonal factors, immune dysregulation, chronic inflammation, and genetic susceptibility. Emerging mechanisms, such as central sensitization and neuroangiogenesis, contribute to pain chronicization and anatomo-clinical discordance, thereby challenging a strictly lesion-based approach to the disease (6).\u003c/p\u003e \u003cp\u003eFrom a therapeutic perspective, medical treatments mainly aim at hormonal suppression and symptomatic control, without curative effects on the lesions. Surgery, although potentially effective in improving pain and fertility, is associated with significant morbidity and a risk of recurrence, limiting its indication within a long-term management strategy (7,8). In this context, the evaluation of therapeutic efficacy can no longer rely solely on isolated anatomical or symptomatic criteria.\u003c/p\u003e \u003cp\u003eEndometriosis is now recognized as a disease with a major multidimensional impact, profoundly affecting health-related quality of life (HRQoL), including physical, psychological, social, professional, and sexual dimensions. The integration of patient-reported outcomes (PROs) into clinical assessment has therefore become a standard, enabling a patient-centered approach.\u003c/p\u003e \u003cp\u003eAmong the validated instruments, the Endometriosis Health Profile-30 (EHP-30) questionnaire constitutes a specific, robust, and widely used tool for the standardized evaluation of quality of life in endometriosis.\u003c/p\u003e \u003cp\u003eTherefore, a multidimensional and dynamic evaluation based on reliable, standardized, and appropriate tools for the comprehensive assessment of quality of life in patients with endometriosis, taking into account physical, psychological, and social parameters, is essential for the global management of endometriosis.\u003c/p\u003e\n\u003ch3\u003eObjective\u003c/h3\u003e\n\u003cp\u003eTo evaluate the impact of therapeutic strategies on health-related quality of life in patients with Endometriosis through a multidimensional analysis integrating patient-reported outcomes, using the validated Endometriosis Health Profile-30 (EHP-30) questionnaire.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e \u003cb\u003eType and Setting of the Study\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis was a monocentric analytical cross-sectional study conducted in the Department of Obstetrics and Gynecology at Farhat Hached University Hospital over a \u003cb\u003e53-\u003c/b\u003emonths period (January 1, 2020 \u0026ndash; May 30, 2024).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePopulation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIncluded patients were women aged \u003cb\u003e18 t\u003c/b\u003eo \u003cb\u003e50\u003c/b\u003e years presenting with symptomatic pelvic endometriosis confirmed by medical history, clinical examination, ultrasound, and imaging (pelvic MRI) and/or intraoperative histological confirmation. Only patients who received medical or surgical treatment at the university hospital and were followed in outpatient consultations were included. Participation was voluntary and based on informed consent.\u003c/p\u003e \u003cp\u003eExclusion and non-inclusion criteria were: minors, menopausal women, patients under guardianship or curatorship, refusal to participate, infertility due to another cause, chronic pelvic disease unrelated to endometriosis, severe unstable psychotic disorders, or adenomyosis.\u003c/p\u003e \u003cp\u003eAmong the 112 identified patients, 32 cases of adenomyosis, 1 refusal to participate, and 4 incomplete files or cases without diagnostic confirmation were excluded. The final cohort included 80 patients.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStandardized Assessment\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEndometriosis-specific quality of life was assessed using the validated Endometriosis Health Profile-30 (EHP-30) questionnaire.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecruitment and Data Collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatients were identified during outpatient consultations or hospitalizations, or contacted by telephone (maximum of three attempts per patient). Telephone interviews were recorded to ensure data reliability.\u003c/p\u003e \u003cp\u003eCollected data included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSociodemographic characteristics and medical history.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSymptomatology and lesion localization (imaging findings).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTherapeutic modalities (medical or surgical), including second-line treatment and recurrences.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOperative and postoperative data: procedures performed, complications, and fertility outcomes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvolution of quality of life (EHP-30).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study was approved by the Institutional Review Board of the University of Medecine of Sousse under approval number \u003cb\u003e(Ref CEFMD 243/2024\u003c/b\u003e). Participation was voluntary and anonymous, with no impact on medical management .\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy funding/competing interest(s)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eNo specific funding was received. The authors declare no competing interests.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics with a significance threshold set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003e\u003cb\u003e All methods were performed in accordance with the relevant guidelines and regulations, and in compliance with the Declaration of Helsinki.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Population Characteristics\u003c/h3\u003e\n\u003cp\u003eA total of 80 patients with symptomatic external endometriosis were included. The mean age was \u003cb\u003e36.93\u0026thinsp;\u0026plusmn;\u0026thinsp;8.29\u003c/b\u003e years (range: 18\u0026ndash;50 years). Most patients were married \u003cb\u003e(67.5%)\u003c/b\u003e, lived in urban areas \u003cb\u003e(73.8%)\u003c/b\u003e, and had a high educational level (\u003cb\u003e51.2%).\u003c/b\u003e A family history of endometriosis was reported in \u003cb\u003e17.5%\u003c/b\u003e of cases.\u003c/p\u003e \u003cp\u003eRegarding reproductive characteristics, the median gravidity was \u003cb\u003e1 [0\u0026ndash;3]\u003c/b\u003e and the median parity was \u003cb\u003e1 [0\u0026ndash;2]\u003c/b\u003e, with \u003cb\u003e43.8%\u003c/b\u003e of patients being nulliparous. Infertility was found in \u003cb\u003e21.3%\u003c/b\u003e of patients, predominantly primary infertility, with a median duration of 36 months. Assisted reproductive technology was used in \u003cb\u003e76.5%\u003c/b\u003e of infertile patients \u003cb\u003e(Table I).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003e2. Clinical Presentation and Diagnostic Pathway\u003c/h3\u003e\n\u003cp\u003eClinical presentation was predominantly characterized by cyclic pelvic pain (\u003cb\u003e96.3%)\u003c/b\u003e, followed by secondary dysmenorrhea \u003cb\u003e(63.7%)\u003c/b\u003e and deep dyspareunia \u003cb\u003e(50%) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe diagnostic pathway was marked by significant medical wandering, with a median of four physicians consulted before diagnosis. The median diagnostic delay was \u003cb\u003e6 months [3\u0026ndash;12].\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDiagnosis was based on the combination of clinical findings and imaging data. Histological confirmation was obtained in 90% of cases, while pelvic MRI contributed to the diagnostic assessment in 65% of patients \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003e3. Disease phenotype\u003c/h3\u003e\n\u003cp\u003eSuperficial and ovarian forms were predominant \u003cb\u003e(83.8%).\u003c/b\u003e Deep infiltrating endometriosis was observed in \u003cb\u003e16.3%\u003c/b\u003e of cases, often associated with other locations, reflecting the heterogeneity of disease involvement \u003cb\u003e( Table II ).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003e4. Therapeutic management\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Overall therapeutic strategy\u003c/h2\u003e \u003cp\u003eSurgery represented the main treatment modality, performed in \u003cb\u003e95%\u003c/b\u003e of patients, while medical therapy was prescribed in \u003cb\u003e37.5%\u003c/b\u003e of cases. A purely surgical approach was adopted in \u003cb\u003e62.5%\u003c/b\u003e of patients, whereas \u003cb\u003e32.5%\u003c/b\u003e benefited from a combined medical and surgical strategy.\u003c/p\u003e \u003cp\u003eA second-line therapeutic approach was required in \u003cb\u003e41.3%\u003c/b\u003e of cases, highlighting the chronic and recurrent nature of the disease \u003cb\u003e(\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e) (\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.2. First-line therapeutic strategy\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e4.2.1. First-line medical treatment:\u003c/h2\u003e \u003cp\u003eFirst-line medical treatment was used in \u003cb\u003e18.8%\u003c/b\u003e of patients, with dienogest being the primary first-line option \u003cb\u003e(8.8%).\u003c/b\u003e As a second-line option, progestins were prescribed in 6.3% of cases. \u003cb\u003e( Table III)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e4.2.2. First-line surgical treatment :\u003c/h2\u003e \u003cp\u003eFirst-line surgical treatment was performed in \u003cb\u003e83%\u003c/b\u003e of patients. The reference surgical approach was laparoscopy, used in \u003cb\u003e67.7%\u003c/b\u003e of cases. The most frequently performed technique was simple percutaneous laparoscopic drainage or a three-step procedure, followed by intraperitoneal cystectomy with or without electrocautery. Complete excision was achieved in only \u003cb\u003e37.5%\u003c/b\u003e of cases.\u003c/p\u003e \u003cp\u003ePreoperative medical treatment was administered in \u003cb\u003e29.2%\u003c/b\u003e of patients, essentially based on GnRH analogues \u003cb\u003e(26.2%).\u003c/b\u003e Postoperative treatment was indicated in \u003cb\u003e46.2%\u003c/b\u003e of patients, mainly using dienogest in \u003cb\u003e29.2%\u003c/b\u003e of cases \u003cb\u003e(Table IV).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Second-line therapeutic strategy\u003c/h2\u003e \u003cp\u003eSecond-line treatment was required in \u003cb\u003e33\u003c/b\u003e patients \u003cb\u003e(41.3%)\u003c/b\u003e .\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e4.3.1.Second-line medical treatment\u003c/h2\u003e \u003cp\u003eAmong women managed medically, dienogest was the predominant treatment (51.5%), followed by other medical therapies, whereas GnRH analogs were used in a minority of cases (3%). \u003cb\u003e( Table V)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e4.3.2.Second- line surgical treatment\u003c/h2\u003e \u003cp\u003eAmong patients requiring second-line surgery (51.5%), laparoscopy was the most frequently used approach (70.6%). Simple laparoscopic drainage or a three-stage procedure was the most common intervention (24.2%). Postoperative medical treatment was prescribed in 58.8% of cases, predominantly dienogest (47.1%). Complete excision was achieved in 23.1% of surgically treated patients. \u003cb\u003e( Table VI).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e5. Surgical outcomes and recurrence\u003c/h3\u003e\n\u003cp\u003eOverall surgical morbidity was low, with \u003cb\u003e5.2%\u003c/b\u003e intraoperative complications and \u003cb\u003e7.8%\u003c/b\u003e postoperative complications \u003cb\u003e(Table VII).\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eDespite appropriate management, recurrence remained frequent, with \u003cb\u003e25%\u003c/b\u003e of patients experiencing recurrent pain and \u003cb\u003e20%\u003c/b\u003e showing anatomical recurrence. The median time to recurrence was \u003cb\u003e21 months\u003c/b\u003e .\u003c/p\u003e\n\u003ch3\u003e6. Quality of life\u003c/h3\u003e\n\u003cp\u003eQuality of life assessment using the \u003cb\u003eEHP-30 questionnaire\u003c/b\u003e showed a median global score of \u003cb\u003e29.69 [20\u0026ndash;49.83]\u003c/b\u003e, indicating moderate impairment.\u003c/p\u003e \u003cp\u003eThe most affected dimensions were sexual function and treatment perception \u003cb\u003e(Table VIII).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003e7. Impact of therapeutic strategies on quality of life\u003c/h3\u003e\n\u003cp\u003eAnalysis according to treatment modalities showed that medical treatment, particularly progestins, was associated with an overall improvement in quality of life, with a particularly marked benefit on sexual function \u003cb\u003e(Table IX).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHowever, the most significant improvements were observed after surgical treatment, particularly in cases of complete excision and laparoscopic adnexectomy. In contrast, drainage techniques were associated with less favorable outcomes \u003cb\u003e(Table X).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUltrasound-guided aspiration showed benefits in specific domains, particularly sexuality, fertility, and the physician\u0026ndash;patient relationship \u003cb\u003e(Table XI).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCombined approaches, particularly in second-line management, resulted in significant improvement in pain, emotional well-being, and social support, highlighting the value of a multimodal treatment strategy \u003cb\u003e(Table XII).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOverall, first-line surgical management was associated with the greatest overall improvement in quality of life, while combined strategies allowed targeted optimization of specific domains \u003cb\u003e(Table XIII)\u003c/b\u003e.\u003c/p\u003e\n\u003ch3\u003e8. Patient-related factors impacting quality of life\u003c/h3\u003e\n\u003cp\u003eAnalysis according to patient profile revealed significant differences. Single patients had the most impaired scores, whereas married patients showed better outcomes \u003cb\u003e(Table XIV).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHigher socioeconomic and educational levels were associated with better quality of life, likely reflecting improved access to healthcare and better treatment adherence \u003cb\u003e(Table XV, Table XVI).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eConversely, infertility emerged as a major factor negatively impacting quality of life, affecting all assessed dimensions \u003cb\u003e(Table XVII)\u003c/b\u003e.\u003c/p\u003e "},{"header":"Discussion","content":"\u003ch3\u003e1. Quality of life assessment: relevance of the EHP-30\u003c/h3\u003e\n\u003cp\u003eQuality of life assessment in endometriosis relies on validated, disease-specific, and sensitive tools capable of detecting treatment-induced changes. In this context, the \u003cb\u003eEndometriosis Health Profile-30 (EHP-30)\u003c/b\u003e, developed by Jones et al., is considered a reference instrument. Designed from interviews with women affected by endometriosis, it demonstrates greater sensitivity to clinical changes compared with generic tools such as the SF-36 (9,10).\u003c/p\u003e \u003cp\u003eThe EHP-30 consists of a 30-item core questionnaire covering five main dimensions (pain, control/helplessness, emotional well-being, social support, and self-image), supplemented by a 23-item modular section addressing specific aspects such as sexuality, fertility, healthcare relationship, and work life. The Likert scale allows standardized scoring, converted into values ranging from 0 to 100, reflecting the degree of quality-of-life impairment (10).\u003c/p\u003e \u003cp\u003eThus, the EHP-30 is particularly well suited for assessing the impact of therapeutic strategies in endometriosis, both in clinical practice and research settings.\u003c/p\u003e\n\u003ch3\u003e2. Quality of life according to therapeutic strategies\u003c/h3\u003e\n\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e2.1. First-line medical treatment\u003c/h2\u003e \u003cp\u003eIn our study, patients treated exclusively with medical therapy as first-line management showed an improvement in quality of life, particularly under progestins and combined oral contraceptives. These findings are consistent with international guidelines, including those of \u003cb\u003eESHRE and HAS\u003c/b\u003e, which recommend these treatments as first-line management for endometriosis-related pain (11\u0026ndash;13).\u003c/p\u003e \u003cp\u003eLiterature data suggest that combined oral contraceptives can achieve a significant reduction in pain, up to 50%, especially when administered continuously (11). However, the lack of robust randomized controlled trials limits the level of evidence, as most available data are derived from observational studies.\u003c/p\u003e \u003cp\u003eProgestins, particularly dienogest and desogestrel, have demonstrated significant efficacy on pain and quality of life, with meaningful improvements in EHP-30 scores (14). Several recent cohort studies confirm these findings, showing progressive and sustained improvement in quality of life, although certain domains such as self-image and perceived control may remain impaired.\u003c/p\u003e \u003cp\u003eNevertheless, in deep infiltrating forms, some studies report persistent impairment in quality of life, particularly in sexual, emotional, and social domains. Moreover, adverse effects may limit treatment adherence, negatively impacting long-term outcomes (15).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e2.2. First-line surgical treatment\u003c/h2\u003e \u003cp\u003eIn our series, first-line surgery\u0026mdash;particularly complete excision and laparoscopic adnexectomy\u0026mdash;was associated with the greatest overall improvement in quality of life. These results are consistent with multiple studies showing that surgery not only reduces pain but also significantly improves quality of life and sexual function (16).\u003c/p\u003e \u003cp\u003eA recent systematic review confirms that various laparoscopic surgical techniques (excision, ablation, vaporization) lead to significant improvements in EHP-30 scores across most domains, particularly in deep infiltrating forms (17) \u003cb\u003e(Table XVIII).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e However, the role of first-line surgery remains debated, particularly in deep infiltrating forms, where current guidelines tend to favor an initial medical approach (18,19). Some data suggest that postoperative improvement may decrease over time, whereas medical treatments induce a more gradual but sustained improvement in quality of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Alternative and combined approaches\u003c/h2\u003e \u003cp\u003eUltrasound-guided aspiration, particularly when associated with sclerotherapy, appears to be an interesting alternative in selected cases, especially in patients with recurrent disease or a history of extensive surgery. This approach seems to be associated with improvement in specific domains of quality of life, particularly sexuality and fertility.\u003c/p\u003e \u003cp\u003eIn our study, combined strategies, especially in second-line management, were associated with the best overall outcomes, particularly in terms of pain experience and emotional well-being (self-image, control/helplessness, and social support). These findings suggest the value of a multimodal approach tailored to disease evolution and individual patient characteristics.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e3. Factors influencing quality of life\u003c/h3\u003e\n\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Marital status and age\u003c/h2\u003e \u003cp\u003eOur results show more impaired quality of life among single patients, often younger. This finding is consistent with the literature, highlighting the major psychological burden of endometriosis in young women, particularly regarding sexuality, fertility, and social relationships (20).\u003c/p\u003e \u003cp\u003eChronic pain, diagnostic delay, and therapeutic burden contribute to significant emotional distress, further exacerbated by uncertainty regarding reproductive and professional future (21,22).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Socioeconomic status\u003c/h2\u003e \u003cp\u003eA higher socioeconomic level was associated with better quality of life, likely due to improved access to healthcare, better treatment adherence, and earlier management. Conversely, financial constraints may represent a major barrier to care access and investigations, exacerbating health inequalities (23).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Educational level\u003c/h2\u003e \u003cp\u003eEducational level also appears to be an important determinant of quality of life. Low educational level is associated with poorer understanding of the disease and reduced treatment adherence, contributing to more severe impairment in quality of life (24).\u003c/p\u003e \u003cp\u003eHowever, this relationship remains complex and multifactorial, involving cognitive, cultural, and psychosocial dimensions. Adapting therapeutic education to patient profiles is therefore essential to optimize management (23,25).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Infertility status\u003c/h2\u003e \u003cp\u003eIn our study, infertile patients exhibited significantly worse quality of life compared to fertile women, affecting all assessed dimensions.\u003c/p\u003e \u003cp\u003eInfertility, particularly related to tubal and/or ovarian involvement, has a global impact on quality of life and often leads to the use of assisted reproductive technologies (ART). However, despite therapeutic hope, the diagnosis of infertility remains a major psychological trauma, sometimes intensified by the ART journey (25).\u003c/p\u003e \u003cp\u003eAnxiety and depressive symptoms in these patients may reach levels comparable to those observed in certain severe chronic diseases (26). Affected women frequently report feelings of guilt, frustration, loss of control, and reduced self-esteem (27). Sociocultural pressure related to motherhood further weakens feminine identity, promoting social isolation and avoidance behaviors (28).\u003c/p\u003e \u003cp\u003eMoreover, infertility significantly affects couple sexuality, with reduced spontaneity and a decrease in sexual frequency, which becomes goal-oriented and centered on conception rather than intimacy (29).\u003c/p\u003e "},{"header":"Study limitations","content":"\u003cp\u003eThis study has several limitations. First, its single-center design and relatively limited sample size may restrict the generalizability of the findings to other populations and healthcare settings with different clinical practices. Second, some data were collected retrospectively, which may have introduced information bias. Furthermore, although the EHP-30 is a validated and widely used instrument for assessing quality of life in women with endometriosis, it was administered in French through oral translation and semi-structured interviews, potentially leading to interpretation bias. As no validated Arabic version of the EHP-30 was available at the time of the study, further multicenter studies are needed to validate its use in the Tunisian population and to confirm its reliability in evaluating therapeutic outcomes and quality of life before and after treatment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEndometriosis is a chronic, complex, and multisystem disease with a major impact on patients\u0026rsquo; physical, psychological, sexual, and social quality of life. Prolonged diagnostic delay, combined with sociocultural factors and variability in clinical practice, contributes to therapeutic delay and symptom worsening.\u003c/p\u003e \u003cp\u003eOur results confirm that first-line surgical management significantly improves pain and quality of life regardless of lesion type; however, the choice of technique must be individualized based on multidisciplinary expertise and lesion mapping. Hormonal medical treatments remain essential, particularly as complementary therapy or for patients not eligible for surgery.\u003c/p\u003e \u003cp\u003eSystematic integration of patient-reported outcomes using validated tools such as the EHP-30 is essential to evaluate real-world effectiveness and guide personalized care.\u003c/p\u003e \u003cp\u003eFinally, strengthening specialized centers, validating local follow-up tools, and conducting large prospective studies are priorities to improve epidemiological understanding, optimize therapeutic strategies, and reduce the multidimensional burden of this disease.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of the University of Medecine of Sousse under approval number \u003cstrong\u003e(Ref CEFMD 243/2024\u003c/strong\u003e). Participation was voluntary and anonymous, with no impact on medical management .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAY ET AA ont r\u0026eacute;dig\u0026eacute; le texte et ont pr\u0026eacute;par\u0026eacute; les figures et les tableaux.AK ET SB ont corrig\u0026eacute; la m\u0026eacute;thodologie et la discussion.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePathophysiology of Endometriosis. EM-Consulte. Available from: https://www.em-consulte.com/article/178873\u003c/li\u003e\n\u003cli\u003eBorghese B, Santulli P, Marcellin L, Chapron C. Definition, description, anatomical and clinical forms, pathogenesis and natural history of endometriosis. CNGOF-HAS Endometriosis Guidelines. Gynecol Obstet Fertil Senol. 2018;46(3):156\u0026ndash;167 \u003c/li\u003e\n\u003cli\u003eZondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244\u0026ndash;1256.\u003c/li\u003e\n\u003cli\u003eNisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril 1997;68(4):585\u0026ndash;96. \u003c/li\u003e\n\u003cli\u003eMissmer SA, Hankinson SE, Spiegelman D, et al. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am J Epidemiol 2004 ;160(8):784-96. doi : 160/8/784 [pii] 10.1093 /aje/\u003c/li\u003e\n\u003cli\u003eVercellini P, Frontino G, Pietropaolo G, et al. Deep endometriosis: definition, pathogenesis, and clinical management. J Am Assoc Gynecol Laparosc. 2004;11:153\u0026ndash;161. \u003c/li\u003e\n\u003cli\u003eDarai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, et al. Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol. 2005;192:394\u0026ndash;400.\u003c/li\u003e\n\u003cli\u003eBecker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022(2).\u003c/li\u003e\n\u003cli\u003eJones G, Jenkinson C, Kennedy S. Evaluating the responsiveness of the Endometriosis Health Profile Questionnaire: the EHP-30.Qual Life Res Int J Qual Life Asp Treat Care Rehabil 2004;13:705\u0026ndash;13. doi:10.1023/B:QURE.0000021316.79349.af \u003c/li\u003e\n\u003cli\u003eSelvi Dogan F, Cottenet J, Douvier S, et al [Quality of life after deep pelvic endometriosis surgery: Evaluation of a French version of the EHP-30]. J Gynecol Obstet Biol Reprod (Paris) 2016 ;45 :249\u0026ndash;56. doi :10.1016/j.jgyn.2015.06.007 \u003c/li\u003e\n\u003cli\u003eFrench National Authority for Health (HAS). Management of Endometriosis: Clinical Practice Guidelines. 2017.\u003c/li\u003e\n\u003cli\u003eMedical treatment of painful endometriosis without infertility. CNGOF-HAS Endometriosis Guidelines. \u003c/li\u003e\n\u003cli\u003eVercellini P, Somigliana E, Vigan\u0026ograve; P et al. Endometriosis: current and future medical therapies. Best Pract Res Clin Obstet Gynaecol 2008;22:275\u0026ndash;306 \u003c/li\u003e\n\u003cli\u003eTechatraisak K, Hestiantoro A, Soon R, Banal-Silao MJ, Kim MR, Seong SJ, Hidayat ST, Cai L, Shin S, Lee BS (2022) Impact of Long-Term Dienogest Therapy on Quality of Life in Asian Women with Endometriosis: the Prospective Non-Interventional Study ENVISIOeN. Reprod Sci 29(4):1157\u0026ndash;1169. https://doi.org/10.1007/s43032-021-00787-w \u003c/li\u003e\n\u003cli\u003eA systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis- PubMed [Internet]. [cit\u0026eacute; 1 d\u0026eacute;c. 2024]. Disponible sur : https://pubmed.ncbi.nlm.nih.gov/38007607/ \u003c/li\u003e\n\u003cli\u003eVercellini P, Somigliana E, Buggio L, Barbara G, Frattaruolo MP, Fedele L. \u0026quot;I can\u0026apos;t get no satisfaction\u0026quot;: deep dyspareunia and sexual functioning in women with rectovaginal endometriosis. Fertil Steril 2012;98(6):1503\u0026ndash;11 [e1. Pub-Med PMID : 22910685]. \u003c/li\u003e\n\u003cli\u003eJones G, Budds K, Taylor F, Musson D, Raymer J, Churchman D, Kennedy S, Jenkinson C. A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis. Hum Reprod Update. 2024 Mar 1;30(2):186-214. doi:10.1093/humupd/dmad029. \u003c/li\u003e\n\u003cli\u003eVercellini P, Pietropaolo G, De Giorgi O, Pasin R, Chiodini A, Crosignani PG. Treatment of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate.Fertil Steril. 2005 nov. ; 84(5) : 1375-87\u003c/li\u003e\n\u003cli\u003eCaruso S, Iraci M, Cianci S, Fava V, Casella E, Cianci A. Comparative, open-label prospective study on the quality of life and sexual function of women affected by endometriosis-associated pelvic pain on 2 mg dienogest/30 \u0026micro;g ethinyl estradiol continuous or 21/7 regimen oral contraceptive. J Endocrinol Invest. 2016 Mar 29; \u003c/li\u003e\n\u003cli\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? Fertil Steril 2010 ;94(5) :1928\u0026ndash;32 [PubMed PMID : 20189557]. \u003c/li\u003e\n\u003cli\u003eWomen\u0026apos;s expectations in endometriosis: what information should be provided? CNGOF-HAS Endometriosis Guidelines.\u003c/li\u003e\n\u003cli\u003eMoradi M, Parker M, Sneddon A, Lopez V, Ellwood D. Impact of endometriosis on women\u0026apos;s lives: a qualitative study . BMC Womens Health 2014 ; 14 [Internet ; consult\u0026eacute; le 11 janvier 2016 ; disponible sur : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287196/]\u003c/li\u003e\n\u003cli\u003eLombrali P, Pascal J. Social inequalities in health and access to healthcare. | Cairn.info [Internet]. [ \u003c/li\u003e\n\u003cli\u003eNielsen JO, Shrestha AD, Neupane D, Kallestrup P. Non-adherence to anti-hypertensive medication in low- and middle-income countries: a systematic review and meta-analysis of 92443 subjects. J Hum hypertens. 2017 ;31(1) :14-21.\u003c/li\u003e\n\u003cli\u003ePE Osamor, BE Owumi. Factors associated with treatment compliance in hypertension in southwest Nigeriaa. J Health Popul Nutr. 2011 d\u0026eacute;c;29(6):619-28. doi: 10.3329/jhpn.v29i6.9899- \u003c/li\u003e\n\u003cli\u003eKL Roony, AD Domar. The relationship between stress and infertility. Dialogues Clin Neurosci. Mars 2018 ; 20(1) : 41-47. \u003c/li\u003e\n\u003cli\u003eFE Omu, AE Omu. Emotional reaction to diagnosis of infertility in Kuwait and successful clients\u0026apos; perception of nurses\u0026apos; role during treatment | BMC Nursing | Disponible sur : https://bmcnurs.biomedcentral.com/articles/10.1186/1472-6955-9-5 .\u003c/li\u003e\n\u003cli\u003eCoussinau, A.M., Domar, A.D. Psychological impact of infertility . Best Pract Res Clin Obstet Gynaecol. 2007 ;21(2):293-308. doi : 10.1016/j.bpobgyn.2006.12.003 .\u003c/li\u003e\n\u003cli\u003eReder F, Fernandez A, Ohl J. [Does sexuality still have a place for couples treated with assisted reproductive techniques?]. J Gynecol Obstet Biol Reprod 2009;38(5):377\u0026ndash;88 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 19 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endometriosis, EHP-30, Quality of life, Chronic pelvic pain, Health-related quality of life","lastPublishedDoi":"10.21203/rs.3.rs-9929703/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9929703/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy question: \u003c/strong\u003eWhat is the impact of different therapeutic strategies on health-related quality of life in women with endometriosis?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSummary answer: \u003c/strong\u003eSurgical management, particularly complete excision, is associated with the greatest improvement in health-related quality of life in women with endometriosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is known already: \u003c/strong\u003eEndometriosis significantly impairs quality of life beyond pain, affecting psychological, sexual, and social domains. Patient-reported outcomes such as the EHP-30 are increasingly used to assess treatment effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design, size, duration: \u003c/strong\u003eThis was a monocentric cross-sectional analytical study including 80 women with endometriosis, conducted over a 53-month period from January 2020 to May 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants/materials, setting, methods: \u003c/strong\u003eWomen aged 18–50 years with symptomatic pelvic endometriosis confirmed by clinical, imaging, and/or histological findings were included at the Department of Gynecology and Obstetrics, Farhat Hached University Hospital (Sousse, Tunisia). Patients with adenomyosis, other causes of infertility, or incomplete data were excluded. Data collected included sociodemographic characteristics, clinical presentation, disease phenotype, and therapeutic strategies (medical, surgical, or combined). Health-related quality of life was assessed using the validated Endometriosis Health Profile-30 (EHP-30). Statistical analysis was performed using SPSS v29 with a significance threshold of p ≤ 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain results and the role of chance: \u003c/strong\u003eThe mean age was 36.9 ± 8.3 years. The median global EHP-30 score was 29.7 [20–49.8], indicating moderate impairment. Surgical treatment was associated with the most significant improvement in overall quality of life, particularly after complete excision. Medical treatment, especially progestins, improved specific domains, mainly sexual function. Combined strategies showed significant benefits in pain, emotional well-being, and social support. Infertility was significantly associated with poorer quality of life across all domains. Given the cross-sectional design, causal inference is limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations, reasons for caution: \u003c/strong\u003eThe monocentric design and relatively small sample size may limit generalizability. The use of a non-validated Arabic version of the EHP-30 and telephone-based data collection may introduce information bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWider implications of the findings: \u003c/strong\u003eThese findings support a multidimensional and individualized approach to endometriosis management, integrating both surgical and medical strategies. The systematic use of patient-reported outcomes is essential to optimize patient-centered care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy funding/competing interest(s): \u003c/strong\u003eNo specific funding was received. The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration number: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-07-02 09:12:14","doi":"10.21203/rs.3.rs-9929703/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-06-26T18:13:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-06-26T17:49:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-06-26T05:23:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-06-26T03:20:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-06-25T19:31:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8f85d364-5da4-45d3-858e-3f8383ca4be4","owner":[],"postedDate":"July 2nd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"6","date":"2026-06-26T18:13:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-06-26T17:49:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-06-26T05:23:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-06-26T03:20:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-06-25T19:31:24+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":71043329,"name":"Health sciences/Diseases"},{"id":71043330,"name":"Health sciences/Health care"},{"id":71043331,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-07-02T09:12:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-07-02 09:12:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9929703","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9929703","identity":"rs-9929703","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}