Beyond pain: employment status affects endometriosis-associated quality of life – a cross-sectional study

Beyond pain: employment status affects endometriosis-associated quality of life – a cross-sectional study | 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 Beyond pain: employment status affects endometriosis-associated quality of life – a cross-sectional study Jonas Vibert, Inès Ben Jazia, Milena Alec, Giuseppe Benagiano, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6297830/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Endometriosis is a chronic condition that affects multiple aspects of women's lives, including physical health, emotional well-being, and socioeconomic stability. While pain is a well-recognized determinant of health-related quality of life (HR-QoL), the role of employment status on pain experience remains underexplored. Objective This study examines the association between employment status and HR-QoL, exploring its role as an independent variable beyond clinical symptoms and pain severity. Methods This cross-sectional study was conducted at the University Hospital of Geneva. Women with a confirmed diagnosis of endometriosis were included. Employment status was categorized as full-time employment (over 80%), part-time employment (80% or less), voluntary unemployment (not seeking employment), and involuntary unemployment (seeking employment). HR-QoL was measured using the Endometriosis Health Profile-30 (EHP-30), which includes components such as pain, control and powerlessness, emotional well-being, social support, and self-image. Statistical analyses included univariate and multivariable linear regression, adjusting for clinical, sociodemographic, and health-related variables. Results A total of 324 patients were included, with a mean age of 32 ± 7.2 years; 78.2% had deep infiltrating endometriosis. Prior surgery was reported in 34.5%. Regarding employment, 63.2% were employed (51.5% full-time, 11.7% part-time), while 36.7% were unemployed, including 26.2% by choice. Employment status was significantly associated with specific HR-QoL domains. Full-time and part-time employment were linked to lower EHP30 pain scores, with part-time employment showing a stronger association (B = -34.48, 95% CI: -58.00 to -10.88, p = 0.006) compared to full-time employment (B = -20.57, 95% CI: -40.70 to -0.43, p = 0.046). Conversely, unemployed women actively seeking work exhibited worse HR-QoL scores, particularly in social support (B = 34.95, 95% CI: 1.89 to 70.80, p = 0.048) and overall HR-QoL burden (B = 168.27, 95% CI: 30.60 to 205.91, p = 0.019). Self-image, control and powerlessness, and emotional well-being scores did not show statistically significant differences across employment groups (p > 0.05). Conclusion This study identifies employment status as an independent predictor of HR-QoL in women with endometriosis including pain and social support domain. Despite Switzerland’s comprehensive unemployment benefits, unemployed women still report poorer HR-QoL, underscoring the role of social integration, professional identity, and daily structure/routine as an independent variable for the evaluation of endometriosis burden. Future research should explore the impact of remote work, flexible employment arrangements, and workplace accommodations, which may improve workforce participation and well-being in women with endometriosis. Endometriosis employment status health-related quality of life chronic pain work disability socioeconomic determinants psychosocial impact Figures Figure 1 1. INTRODUCTION Endometriosis is a frequent, chronic inflammatory disease that affects women of reproductive age [ 1 ]. While the condition is primarily characterized by cardinal pelvic pain symptoms—dysmenorrhea, dyspareunia, and non-menstrual pelvic pain—as well as infertility, extensive evidence demonstrates its profound impact on various aspects of women's lives, including daily activities, personal and sexual relationships, social interactions, and psychological well-being. Multiple studies have highlighted the substantial burden of endometriosis on both physical and mental Health-Related Quality of Life (HR-QoL) [ 2 , 3 , 4 , 5 ]. Systematic profiling of HR-QoL to assess the personal, relational, and societal burden of the disease has been recommended by multiple society consensus statements and has been proposed as a core outcome in a recent consensus [ 3 ]. Although the relationship between pain and endometriosis HR-QoL appears to be linear [ 6 ], additional variables may influence the perceived burden of the disease, as well as patient satisfaction, treatment compliance, and responsiveness. In 2011, Fourquet et al. [ 7 ] sought to quantify the impact of endometriosis symptoms on HR-QoL and work productivity, concluding that affected women experience significant disability in both physical and mental health domains. Notably, they reported an average loss of approximately one working day per week during periods of severe symptoms. Socioeconomic, demographic, lifestyle factors, and allostatic load—the physiological cost of chronic stress [ 8 ]— have been reported to be associated with HR-QoL [ 9 ]. In 2018, the American College of Obstetricians and Gynecologists (ACOG) recommended assessing social and structural determinants of health that may impact patients' overall health and well-being [ 10 ]. Endometriosis Health Profile 30 Questionnaire (EHP30) has been widely used to assess QoL in endometriosis patients providing valuable insights into the disease burden [ 11 – 12 ]. Despite these recent advancements in understanding HR-QoL in endometriosis, the role of employment status remains largely unexplored, even though work instability and financial dependence are major stressors in chronic pain conditions [ 13 ]. Addressing this gap, we sought to assess whether employment status independently influences HR-QoL beyond pain severity. Employment status has significant potential as a predictor of HR-QoL in chronic pain conditions and is particularly relevant in assessing the burden of endometriosis on women’s health [ 14 ]. This is because endometriosis predominantly affects women in their late 20s and early 30s, a period when they have typically completed their education and entered the workforce. Consequently, the disease can significantly impact a woman's economic independence, as well as her individual and social empowerment. Supporting this, studies have reported that approximately 40% of women with endometriosis experience impaired career growth due to their condition, while nearly 50% report a decreased ability to work because of chronic pain symptoms [ 14 ]. However, the potential role of employment status and job stability in shaping HR-QoL—beyond the burden of pain—has largely been overlooked. This study aims to assess the association of employment status with health-related quality of life in patients with endometriosis, examining multiple dimensions beyond clinical symptoms to determine its independent impact on patient well-being. 2. METHODS 2.1. Subjects and setting This cross-sectional study was conducted at the Division of Gynecology, University Hospital of Geneva, Switzerland, between 2018 and 2020. Medical records from 460 consecutively referred or self-referred patients, aged 18 years or older, with a clinical and/or surgical diagnosis of endometriosis, were reviewed and included in the study. Informed consent was obtained from all participants. This project was approved by the Cantonal Research Ethics Commission (CCER), Geneva, Switzerland (protocol number: 09-193R). 2.2. Data collection The following information was collected for each participant: sociodemographic characteristics, anthropometric indices, health-related behaviors, endometriosis-attributable and associated pain symptoms with their treatments, and HR-QoL scoring. All variables were assessed by a gynecologist during a medical consultation, and patients completed the HR-QoL questionnaire on the same day as their medical evaluation. Sociodemographic characteristics These included age (years), marital status (or stable relationship), parity, current smoking status (yes/no), alcohol consumption (≤ 1 unit per week / >1 unit per week), and education level (≤ 10 years / >10 years, with the latter corresponding to a bachelor’s degree or higher). Employment status Employment status was evaluated according to a Swiss national categorization based on the percentage of working time. In Switzerland, a full-time position (100%) generally corresponds to a 42-hour workweek, as defined by national labor regulations and most collective agreements. Based on this standard, employment was classified into four categories: full-time employment (> 80%, i.e., more than 34 hours per week), part-time employment (≤ 80%, i.e., 34 hours or less per week), involuntary unemployment (job-seeking), and voluntary unemployment (not seeking an employment). Evaluation of endometriosis and its symptoms The presence or absence of endometriosis was determined based on imaging and/or surgical confirmation. The assessment of endometriosis-associated cardinal pain symptoms included superficial and deep dyspareunia, dysmenorrhea, painful bowel movements (dyschezia), painful urination, and non-menstrual pelvic pain. All pain symptoms were evaluated using a visual analogue scale (VAS, 0–10). The evaluation of endometriosis treatments included the ongoing use of hormonal therapy (combined estro-progestins or progestins) and a history of one or more prior surgeries for endometriosis Comorbidity status Comorbidities were assessed if present for at least six months prior to inclusion in the study. These also included non-gynecological conditions including chronic pain-associated diseases or syndromes, such as migraine, fibromyalgia, chronic back pain, osteoarthritis, irritable bowel syndrome (IBS), abdominal/pelvic pain myalgia, and bladder pain syndrome/interstitial cystitis (BPS/IC). Health-Related Quality of Life (HR-QoL) Scoring HR-QoL scoring was assessed using the Endometriosis Health Profile 30 (EHP-30) [ 15 ], a reliable and valid patient-reported instrument designed to measure HR-QoL in women with endometriosis. Since its development, the EHP-30 has been widely used in clinical trials and is considered apt for providing a more comprehensive assessment of HR-QoL in endometriosis patients compared to other generic HR-QoL questionnaires (e.g., SF-36 [ 16 ]). We used the core version of the EHP-30, which consists of 30 questions covering five subscales [ 17 ]: pain, control and powerlessness, emotional well-being, social support, and self-image. Each item is rated on a 5-point Likert scale ranging from "never" to "always" [ 18 ]. Subscale scores are then transformed into a 0–100 scale, where higher scores indicate worse HR-QoL. The recall period for the EHP-30 was the past four weeks. 2.3. Statistical analysis Descriptive statistics were used to summarize the data. Means, standard deviations, and ranges were calculated for continuous variables, while categorical variables were reported as frequencies and percentages. The frequency and severity of symptoms were analyzed accordingly. The normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data were analyzed using Student’s t-test, while non-normally distributed data were analyzed using the Mann-Whitney U test (for two groups) or the Kruskal-Wallis test (for more than two groups). Categorical variables were compared using the Chi-square test or Fisher’s exact test, as appropriate. Post-hoc pairwise comparisons between employment groups were conducted to evaluate differences in HR-QoL scores, with Bonferroni-adjusted p-values applied to correct for multiple comparisons. A multivariable linear regression analysis was conducted for each of the five domains of the EHP-30 questionnaire to determine whether employment status was an independent predictor of HR-QoL scores. The models were adjusted for relevant clinical, sociodemographic, and health-behavior variables, with voluntarily unemployed individuals serving as the reference group. Results were reported as regression coefficients with 95% confidence intervals. A p-value < 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics version 22. 3. RESULTS 3.1. Participants’ characteristics (Table 1 – 2 ) Table 1 Sociodemographic characteristics (mean ± SD or number (%)) by employment status Sociodemographic characteristics Voluntary jobless N = 34 Full time job N = 167 Part Time job N = 38 Involuntary jobless N = 85 P-value Age, y 28.9 (8.1) 34.9 (6.6) 32 (6.1) 34.6 (8.1) < 0.01 BMI 23.9 (5.7) 23.4 (4.4) 22.4 (3) 23.7 (5.2) 0.8 Gravidity 1.2 (1.96) 0.89 (1.2) 0.65 (1) 1.3 (1.5) 0.20 Parity 0.8 (1.1) 0.5 (0.85) 0.3 (0.67) 0.8 (1.1) 0.12 Stable relationship 28 (22.8) 74 (60.2) 11 (8.9) 10 (8.1) < 0.01 Bachelor degree or higher 18 (56.3) 11(34.4) 2(6.3) 1 (3.1) <0.01 Smoking 25 (22.5) 59 (53.2) 16 (14,4) 11 (9.9) <0.01 Alcohol drinking 33 (28.7) 63 (54.8) 13 (11.3) 6 (5.2) < 0.01 Anxio-depressive disease 8 (17) 21 (44.7) 7 (14.9) 11 (23.4) 0.34 Infertility 3 (5.2) 44 (75.9) 7 (121) 4 (6.9) < 0.01 Hormonal treatment 27 (30) 46 (51.1) 26 (11.9) 26 (11.9) < 0.01 Surgery for endometriosis 14 (28) 20 (40) 6 (12) 10 (20) < 0.05 Number of pain comorbidities 2 (1) 1(1) 3(1) 2(2) 0.2 Notes : - Data are expressed as mean ± standard deviation for continuous variables and as percentages for categorical variables. - Statistical comparisons were performed using the Chi-square for categorical variables and the Kruskal-Wallis test for continuous variables. - p-values < 0.05 were considered statistically significant. Table 2 Pain characteristics (VAS ± SD) of the study population by employment status Pain characteristics (VAS) Voluntary jobless Full time job Part Time job Involuntary jobless P-value Dysmenorrhea 6.4 (3.4) 5.8 (3.6) 6.4 (3.7) 6.3 (3.5) 0.61 Deep Dyspareunia 5.7 (3.3) 4.2 (3.6) 5.6 (3.3) 6.2 (2.5) < 0.01 Dysuria 0.5 (1.3) 0.7 (1.9) 1.2 (2.7) 1.5 (3.2) 0.67 Dyschesia 3.5 (3.6) 2.5 (3.3) 3.3 (3.6) 4.1 (3.4) < 0.05 Superficial Dyspareunia 1.7 (0.9) 1.26 (1.1) 1.6 (1) 1.7 (0.8) < 0.01 Chronic pelvic pain 4.2 (3.4) 4.1 (3.3) 4.7 (3.7) 5.2 (3.1) 0.27 Notes : - Data are expressed as mean ± standard deviation - Statistical comparisons were performed using the Kruskal-Wallis test - p-values < 0.05 were considered statistically significant. The study population initially consisted of 460 subjects. Patients without a confirmed surgical and/or imaging diagnosis of endometriosis, as well as those who did not fully complete the EHP30 questionnaire, were excluded. In the end, 324 patients met the study criteria and were included in the analysis. Participants had a mean age of 32 ± 7.2 years. Among them, 78.2% had a diagnosis of deep infiltrating endometriosis (DIE), 42.5% had also adenomyosis, and 34.5% had undergone one or more previous surgeries for endometriosis. Infertility was reported in 18.5% of patients, while 13.5% had a diagnosis of anxiety-depressive disorder. The mean EHP-30 scores (± SD) were 35.2 ± 26.7 for pain, 47.5 ± 30.6 for control and powerlessness, 40.4 ± 24.9 for emotional well-being, 37.8 ± 29.1 for social support, and 30.5 ± 28.6 for self-image. The results of the different subcategories of the EHP-30 according to employment status are presented in Fig. 1 . The study population was subdivided into four groups according to employment status. 205 participants (63.2%) were employed and 119 (36.7%) were unemployed. Among them, full-time employment accounted for 51.5% of the study population, part-time employment for 11.7%, voluntary unemployment for 26.2%, and involuntary unemployment for 10.5%. Sociodemographic characteristics were analyzed across the four employment status groups. Univariate analysis revealed statistically significant differences between the subgroups in terms of age (p < 0.0001), deep dyspareunia (p = 0.005), dyschezia (p = 0.024), superficial dyspareunia (p = 0.009), education level (bachelor’s degree or higher, p < 0.01), alcohol consumption (p < 0.05), infertility (p < 0.01), and history of endometriosis surgery (p < 0.05). No significant differences were observed between employment status subgroups for other sociodemographic characteristics, including parity, dysmenorrhea, chronic pelvic pain, marital status, and anxiety-depressive disorder. (Table 1 and Table 2 ) 3.2. Association between employment status and EHP30 subscale Univariate Linear Regression Analysis (Table 3 ) Table 3 Univariate and multivariable linear analysis of EHP30 score — decomposition into key health and well-being dimensions with comparison by employment status and adjusted for demographic, clinical, and lifestyle factors* EHP 30 Items Employment Status Univariate linear regression Multivariable linear regression* Unadjusted Coefficient (95% CI) P-value Adjusted Coefficient (95% CI) P-value Pain Involuntary Unemployed 13.68 (3.38–23.97) 0.009 17.91 (-6.70-42.60) 0.149 Part-Time -13.18 (-22.88- -3.49) 0.008 -34.48 (-58.00- -10.88) 0.006 Full-Time -9.57 (-16.57- -2.57) 0.008 -20.57 (-40.70- -0.43) 0.046 Control and powerlessness Involuntary Unemployed 12.41 (0.77–24.06) 0.037 9.73(-24.89-44.36) .570 Part-Time -11.64 (-22.60- -0.67) 0.038 -22.28(-55.36-10.80). .179. Full-Time -10.80 (-18.72- -2.88) 0.008 -7.21(-35.45-21.02) .605. Social support Involuntary Unemployed 9.12 (-2.22-20.45) 0.114 34.95 (1.89–70.80) 0.048 Part-Time -9.82 (-20.50-0.85) 0.071 -4.68 (-38.90-29.56) 0.782 Full-Time -9.79 (-17.50- -2.07) 0.013 5.92 (-23.30-35.15) 0.682 Emotional well-being Involuntary Unemployed 10.14 (0.75–19.53) 0.034 10.43 (-16.07-36.94) 0.427 Part-Time -9.40 (-18.25-0.56) 0.037 -19.49(-44.81-5.83) 0.126 Full-Time -5.07 (-11.46-1.32) 0.12 -7.24 (-28.85-14.38) 0.499 Self-image Involuntary Unemployed 6.98 (-4.71-18.67) 0.241 8.96 (-30.43-48.35) .466 Part-Time -2.49 (-13.50-8.52) 0.656 -5.35 (-42.98-32.28) .645 Full-Time -0.84 (-8.80-7.12) 0.835 11.60 (-20.52-43.71) .773 Overall EHP30 Score Involuntary Unemployed 58.91 (16.85-100.96) 0.006 168.27 (30.60-205.91) 0.019 Part-Time -57.53 (-97.13- -17.92) 0.005 -32.66 (-145.50-80.23) 0.554 Full-Time -32.62 (-61.25- -3.99) 0.026 14.41 (-81.50-110.38) 0.758 *adjusted for educational level, marital status, age, body mass index (BMI), parity, tobacco use, alcohol consumption history, use of hormonal treatment, number of comorbidities, dyspareunia, chronic pelvic pain, dysmenorrhea, infertility, and anxiety/depression. Univariate analysis demonstrated that employment status was significantly associated with various dimensions of HR-QoL, as measured by the EHP-30 questionnaire. Compared to voluntarily unemployed participants, full-time and part-time employed individuals reported significantly lower scores for pain, control and powerlessness, suggesting better HR-QoL outcomes in these domains. Specifically, full-time employment was associated with a lower pain score ( B = -9.57, 95% CI: -16.57, -2.57; p = 0.008), while part-time employment showed an even greater negative association ( B = -13.18, 95% CI: -22.88, -3.49; p = 0.008). Conversely, unemployed individuals actively seeking work had significantly higher pain scores ( B = 13.68, 95% CI: 3.38, 23.97; p = 0.009). Similarly, control and powerlessness scores were significantly lower in employed groups, with full-time employment associated with a reduction of -10.80 points ( B = -10.80, 95% CI: -18.72, -2.88; p = 0.008) and part-time employment showing a -11.64 point decrease ( B = -11.64, 95% CI: -22.60, -0.67; p = 0.038). In contrast, the job-seeking unemployed subgroup had significantly worse scores in this domain ( B = 12.41, 95% CI: 0.77, 24.06; p = 0.037). Regarding emotional well-being, part-time employment was associated with a significantly lower score (B = -9.40, 95% CI: -18.25, -0.56; p = 0.037), while those actively seeking employment had a significantly higher score, indicating worse well-being (B = 10.14, 95% CI: 0.75, 19.53; p = 0.034). For social support, full-time employment was significantly associated with better scores (B = -9.79, 95% CI: -17.50, -2.07; p = 0.013), whereas unemployed individuals actively seeking work did not show significant differences in this domain ( p = 0.114). No statistically significant differences were observed between employment groups in self-image scores, with p -values ranging from 0.241 to 0.835. Multivariable Linear Regression Analysis (Table 3 ) After adjusting for age, BMI, parity, infertility, anxiety/depression, alcohol and tobacco use, use of hormonal treatments, dyspareunia, chronic pelvic pain, dysmenorrhea, marital status, and education level, employment status remained an independent predictor of several HR-QoL dimensions. Active employment was positively associated with higher QoL domains. Full-time employment was significantly associated with lower EHP30 pain score ( B = -20.57, 95% CI: -40.70, -0.43; p = 0.046). Part-time employment had an even stronger association with pain EHP30 domain ( B = -34.48, 95% CI: -58.00, -10.88; p = 0.006). For overall EHP30 scores, job-seeking individuals had the highest burden, with a significant increase of 168.27 points compared to the reference group ( B = 168.27, 95% CI: 30.60, 205.91; p = 0.019), indicating substantially poorer quality of life. Although part-time employment was linked to lower EHP30 powerlessness scores in the univariate analysis, this association was no longer statistically significant after adjustment ( p = 0.179). Similarly, no significant associations were found for self-image across employment groups ( p > 0.05). 4. DISCUSSION Our findings demonstrate that employment status is an independent predictor of HR-QoL in women with endometriosis. Specifically, employment, whether full-time or part-time, is associated with lower EHP30 pain scores, while unemployed individuals actively seeking a job significantly worse HR-QoL independently of pain symptoms and main psychosocial variables. For women with endometriosis, maintaining stable employment can be challenging due to chronic pelvic pain, fatigue, and fluctuating symptom severity. Many patients experience absenteeism, reduced work productivity, and career stagnation, which may exacerbate the emotional and economic burden of the disease [ 19 ]. The relationship between employment status and HR-QoL is particularly relevant in chronic conditions, where socioeconomic stability can influence treatment adherence, psychological resilience, and overall well-being [ 2 , 3 , 4 , 5 ]. Having a stable job may help mitigate the burden of endometriosis-related symptoms through multiple mechanisms, as shown in other chronic pain conditions [ 20 ]. Financial stability ensures access to healthcare, specialized consultations, and treatments, while in Switzerland, where health insurance is mandatory, it can influence access to supplementary coverage and out-of-pocket medical expenses. However, financial security alone may not fully explain these differences, as unemployment in Switzerland is mitigated by a robust compensation system, providing 70–80% of the average salary from the last six months [ 21 ]. Additionally, patients unable to work receive a special pension called disability insurance ( Assurance Invalidité , AI), a social security system that offers comfortable financial support to individuals whose health condition significantly limits their ability to work [ 22 ]. Despite those financial supports, unemployed individuals—particularly those actively seeking work—still reported significantly lower HR-QoL scores, including pain domain, suggesting that factors beyond income stability play a crucial role in well-being. Beyond financial security, employment provides psychological and emotional benefits, giving a sense of purpose, self-worth, and social integration, which may reduce stress and feelings of helplessness. Work can also serve as a cognitive distraction from pain and improve social support through workplace interactions. A structured daily routine associated with employment may positively impact sleep, diet, and physical activity, all of which influence symptom severity. Additionally, lower allostatic load—reducing chronic stress linked to financial and social insecurity—may help modulate neuroendocrine and inflammatory responses involved in endometriosis. Moreover, part-time employment showed a trend toward better EHP-30 scores in our study, suggesting that a more flexible work schedule may provide more time to manage endometriosis symptoms, reduce stress, and improve work-life balance. Furthermore, deep dyspareunia, superficial dyspareunia, and dyschezia were significantly different across employment groups, raising the question of whether employment influences pain perception or whether more symptomatic patients have lower employment stability due to their disease burden. While employment may provide psychosocial benefits that modulate pain perception, it is also plausible that women with more severe pain are unable to sustain employment, leading to a reverse causality effect. However, in our multivariable analysis, we adjusted for different dimensions of pain, and the association between employment status and HR-QoL remained significant, suggesting that factors beyond pain perception—such as social integration, self-efficacy, and workplace accommodations—may contribute to the observed differences. These findings highlight the need to better understand the bidirectional relationship between endometriosis symptom burden and employment stability. Limitations Several limitations and potential biases must be acknowledged when interpreting these findings. First, the study was conducted in a tertiary referral center, meaning that participants were likely self-referred or referred by specialists. This may have excluded women with milder symptoms, who are more commonly managed by general practitioners or private practice gynecologists. A volunteer bias may also be present, as 51.5% of the study population were employed full-time, which is higher than expected for a population suffering from a chronic and often debilitating disease. A statistically significant difference in age was observed across employment subgroups, which may reflect natural employment trends rather than a direct effect of endometriosis. Younger patients are more likely to be actively job-seeking, while older patients or those with children may opt for part-time work or voluntarily withdraw from the workforce. This age-related employment distribution constitutes a confounding bias, as it could partly explain differences in HR-QoL independent of disease severity. To conclude, that data were collected between 2018 and 2020, potentially missing changes in employment policies, remote work, healthcare access, and endometriosis awareness. However, given the chronic nature of the disease and persistent employment challenges, the relationship between employment status and HR-QoL likely remains relevant. The rise of flexible work post-COVID-19 warrants further investigation. Conclusion Our study provides strong evidence that employment status is an independent predictor of HR-QoL in women with endometriosis. While these findings highlight the importance of socioeconomic determinants in endometriosis management, they also raise critical questions about causality—does employment actively protect against worsening QoL, or does severe endometriosis prevent workforce participation? Addressing this uncertainty requires longitudinal studies to further explore these relationships and inform holistic, patient-centered management strategies that integrate both clinical and socioeconomic considerations. Moreover, these results should prompt physicians to carefully reassess the implications of prolonged sick leave in women with endometriosis. While intended to alleviate burden, extended absence from work may unintentionally transfer an even greater one—the psychological weight of unemployment. Further research should adopt a longitudinal design to clarify the directionality of the relationship between employment and HR-QoL and should also explore the impact of remote work, flexible employment arrangements, and workplace accommodations, which may influence workforce participation and well-being in women with endometriosis. Declarations Ethics approval and consent to participate Informed consent was obtained from all participants involved in this study. The study followed institutional and national ethical standards, in line with the 1964 Helsinki Declaration and its amendments. This project was approved by the Cantonal Research Ethics Commission (CCER), Geneva, Switzerland (protocol number: 09-193R). Consent for publication All authors consent to the publication of this manuscript. Availability of data and materials The data that support the findings of this study are available from N.P., upon request. Competing interests The authors declare no conflicts of interest related to this work. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions N.P. conceived and designed the study. N.P. analysed the data. J.V. drafted the manuscript. G.B. and N.P. critically revised the manuscript. All authors approved the final version of the report. References McGonagle, A. K., Chosewood, L. C., Hartley, T. A., Newman, L. S., Ray, T., & Rosemberg, M. A. 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G., Marschall, H., Forman, A., & Kesmodel, U. S. (2021). Health-related quality of life in women with endometriosis: psychometric validation of the Endometriosis Health Profile 30 questionnaire using confirmatory factor analysis. Human reproduction open , 2022 (1), hoab042. https://doi.org/10.1093/hropen/hoab042 Jones, G. L., Budds, K., Taylor, F., Musson, D., Raymer, J., Churchman, D., Kennedy, S. H., & Jenkinson, C. (2024). A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis. Human reproduction update , 30 (2), 186–214. https://doi.org/10.1093/humupd/dmad029 Yildiz, B., Schuring, M., Knoef, M. G., & Burdorf, A. (2020). Chronic diseases and multimorbidity among unemployed and employed persons in the Netherlands: a register-based cross-sectional study. BMJ open , 10 (7), e035037. https://doi.org/10.1136/bmjopen-2019-035037 Sperschneider, M. L., Hengartner, M. P., Kohl-Schwartz, A., Geraedts, K., Rauchfuss, M., Woelfler, M. M., Haeberlin, F., von Orelli, S., Eberhard, M., Maurer, F., Imthurn, B., Imesch, P., & Leeners, B. (2019). Does endometriosis affect professional life? A matched case-control study in Switzerland, Germany and Austria. BMJ open , 9 (1), e019570. https://doi.org/10.1136/bmjopen-2017-019570 Jones, G., Kennedy, S., Barnard, A., Wong, J., & Jenkinson, C. (2001). Development of an endometriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstetrics and gynecology , 98 (2), 258–264. https://doi.org/10.1016/s0029-7844(01)01433-8 Lins, L., & Carvalho, F. M. (2016). SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE open medicine , 4 , 2050312116671725. https://doi.org/10.1177/2050312116671725 Jones, G., Jenkinson, C., & Kennedy, S. (2004). Evaluating the responsiveness of the Endometriosis Health Profile Questionnaire: the EHP-30. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation , 13 (3), 705–713. https://doi.org/10.1023/B:QURE.0000021316.79349.af Hansen, K. E., Lambek, R., Røssaak, K., Egekvist, A. G., Marschall, H., Forman, A., & Kesmodel, U. S. (2021). Health-related quality of life in women with endometriosis: psychometric validation of the Endometriosis Health Profile 30 questionnaire using confirmatory factor analysis. Human reproduction open , 2022 (1), hoab042. https://doi.org/10.1093/hropen/hoab042 Soliman, A. M., Coyne, K. S., Gries, K. S., Castelli-Haley, J., Snabes, M. C., & Surrey, E. S. (2017). The Effect of Endometriosis Symptoms on Absenteeism and Presenteeism in the Workplace and at Home. Journal of managed care & specialty pharmacy , 23 (7), 745–754. https://doi.org/10.18553/jmcp.2017.23.7.745 Tsuji, T., Matsudaira, K., Sato, H., Vietri, J., & Jaffe, D. H. (2018). Association between presenteeism and health-related quality of life among Japanese adults with chronic lower back pain: a retrospective observational study. BMJ open , 8 (6), e021160. https://doi.org/10.1136/bmjopen-2017-021160 State Secretariat for Economic Affairs (SECO). (n.d.). Unemployment benefits – FAQs. Arbeit.swiss. Retrieved February 15, 2025, from https://www.arbeit.swiss/secoalv/en/home/menue/stellensuchende/arbeitslos-was-tun-/faq_arbeitslosenentschaedigung.html Swiss Confederation. (2025). Disability insurance (DI/IV/AI) in Switzerland. Retrieved February 15, 2025, from https://www.ch.ch/en/insurance/disability-insurance--di/iv/ai-/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-6297830","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":441619435,"identity":"260eb20b-2336-4c87-b7eb-47ec527ac53f","order_by":0,"name":"Jonas Vibert","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYBACxgYIzWMAIj8wHABRbERrYWycQYwWOABpaeYhRgtze+/Bjz8YDsuYs/c+f2xTcydxwwHmZw/wOqznXLI0D8NhHsue44bNOceeAbWwmRvg1TIjx0CagSGNx+BGGmNzbsPhxJkNPGwSBLQY//wB0nL/GWOzJZFazCR4GGyAtrAxNjMCtfQzENLSc8bMmsfABuiXNMaZPccOG/czs5nh1WLY3mN880eFhL05+zGGDz9qDsu2sTc/w6+lAUSihBAzPvVAIE9AfhSMglEwCkYBAwMAirpEyK/n8mEAAAAASUVORK5CYII=","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Jonas","middleName":"","lastName":"Vibert","suffix":""},{"id":441619436,"identity":"e0b807df-e2a4-45af-9ff0-5e6e5caec968","order_by":1,"name":"Inès Ben Jazia","email":"","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Inès","middleName":"Ben","lastName":"Jazia","suffix":""},{"id":441619437,"identity":"aed165ba-d342-470b-bff7-cee36a461f4a","order_by":2,"name":"Milena Alec","email":"","orcid":"","institution":"University Hospital of Geneva","correspondingAuthor":false,"prefix":"","firstName":"Milena","middleName":"","lastName":"Alec","suffix":""},{"id":441619438,"identity":"177843c0-6576-4455-8ceb-d96a2f85f643","order_by":3,"name":"Giuseppe Benagiano","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Benagiano","suffix":""},{"id":441619439,"identity":"ff821857-f26f-4be0-a677-cf7c89f54081","order_by":4,"name":"Nicola Pluchino","email":"","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Nicola","middleName":"","lastName":"Pluchino","suffix":""}],"badges":[],"createdAt":"2025-03-24 18:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6297830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6297830/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82071674,"identity":"b2194897-e669-4432-a33a-b5750017089f","added_by":"auto","created_at":"2025-05-06 13:22:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63891,"visible":true,"origin":"","legend":"\u003cp\u003eEHP30 scores by employment status category\u003c/p\u003e\n\u003cp\u003enote: Independent Kruskal-Wallis test with Bonferroni correction was used to assess differences between groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e* p-value \u0026lt;0.05\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e** p-value \u0026lt;0.01\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e** p-value \u0026lt;0.001\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6297830/v1/02d416b54765db5f38329649.png"},{"id":82074223,"identity":"e6abdc42-3c8a-4e28-af19-9c88ebe6e60c","added_by":"auto","created_at":"2025-05-06 13:38:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1062500,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6297830/v1/9f188205-11f6-4b43-ad95-5eff8cfe200d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond pain: employment status affects endometriosis-associated quality of life – a cross-sectional study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eEndometriosis is a frequent, chronic inflammatory disease that affects women of reproductive age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While the condition is primarily characterized by cardinal pelvic pain symptoms\u0026mdash;dysmenorrhea, dyspareunia, and non-menstrual pelvic pain\u0026mdash;as well as infertility, extensive evidence demonstrates its profound impact on various aspects of women's lives, including daily activities, personal and sexual relationships, social interactions, and psychological well-being. Multiple studies have highlighted the substantial burden of endometriosis on both physical and mental Health-Related Quality of Life (HR-QoL) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSystematic profiling of HR-QoL to assess the personal, relational, and societal burden of the disease has been recommended by multiple society consensus statements and has been proposed as a core outcome in a recent consensus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the relationship between pain and endometriosis HR-QoL appears to be linear [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], additional variables may influence the perceived burden of the disease, as well as patient satisfaction, treatment compliance, and responsiveness. In 2011, Fourquet et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] sought to quantify the impact of endometriosis symptoms on HR-QoL and work productivity, concluding that affected women experience significant disability in both physical and mental health domains. Notably, they reported an average loss of approximately one working day per week during periods of severe symptoms.\u003c/p\u003e \u003cp\u003eSocioeconomic, demographic, lifestyle factors, and allostatic load\u0026mdash;the physiological cost of chronic stress [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u0026mdash; have been reported to be associated with HR-QoL [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In 2018, the American College of Obstetricians and Gynecologists (ACOG) recommended assessing social and structural determinants of health that may impact patients' overall health and well-being [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEndometriosis Health Profile 30 Questionnaire (EHP30) has been widely used to assess QoL in endometriosis patients providing valuable insights into the disease burden [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite these recent advancements in understanding HR-QoL in endometriosis, the role of employment status remains largely unexplored, even though work instability and financial dependence are major stressors in chronic pain conditions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Addressing this gap, we sought to assess whether employment status independently influences HR-QoL beyond pain severity.\u003c/p\u003e \u003cp\u003eEmployment status has significant potential as a predictor of HR-QoL in chronic pain conditions and is particularly relevant in assessing the burden of endometriosis on women\u0026rsquo;s health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This is because endometriosis predominantly affects women in their late 20s and early 30s, a period when they have typically completed their education and entered the workforce. Consequently, the disease can significantly impact a woman's economic independence, as well as her individual and social empowerment. Supporting this, studies have reported that approximately 40% of women with endometriosis experience impaired career growth due to their condition, while nearly 50% report a decreased ability to work because of chronic pain symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the potential role of employment status and job stability in shaping HR-QoL\u0026mdash;beyond the burden of pain\u0026mdash;has largely been overlooked.\u003c/p\u003e \u003cp\u003eThis study aims to assess the association of employment status with health-related quality of life in patients with endometriosis, examining multiple dimensions beyond clinical symptoms to determine its independent impact on patient well-being.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Subjects and setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted at the Division of Gynecology, University Hospital of Geneva, Switzerland, between 2018 and 2020. Medical records from 460 consecutively referred or self-referred patients, aged 18 years or older, with a clinical and/or surgical diagnosis of endometriosis, were reviewed and included in the study. Informed consent was obtained from all participants. This project was approved by the Cantonal Research Ethics Commission (CCER), Geneva, Switzerland (protocol number: 09-193R).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data collection\u003c/h2\u003e \u003cp\u003eThe following information was collected for each participant: sociodemographic characteristics, anthropometric indices, health-related behaviors, endometriosis-attributable and associated pain symptoms with their treatments, and HR-QoL scoring.\u003c/p\u003e \u003cp\u003eAll variables were assessed by a gynecologist during a medical consultation, and patients completed the HR-QoL questionnaire on the same day as their medical evaluation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eSociodemographic characteristics\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThese included age (years), marital status (or stable relationship), parity, current smoking status (yes/no), alcohol consumption (\u0026le;\u0026thinsp;1 unit per week / \u0026gt;1 unit per week), and education level (\u0026le;\u0026thinsp;10 years / \u0026gt;10 years, with the latter corresponding to a bachelor\u0026rsquo;s degree or higher).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEmployment status\u003c/span\u003e \u003c/p\u003e \u003cp\u003eEmployment status was evaluated according to a Swiss national categorization based on the percentage of working time. In Switzerland, a full-time position (100%) generally corresponds to a 42-hour workweek, as defined by national labor regulations and most collective agreements. Based on this standard, employment was classified into four categories: full-time employment (\u0026gt;\u0026thinsp;80%, i.e., more than 34 hours per week), part-time employment (\u0026le;\u0026thinsp;80%, i.e., 34 hours or less per week), involuntary unemployment (job-seeking), and voluntary unemployment (not seeking an employment).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEvaluation of endometriosis and its symptoms\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe presence or absence of endometriosis was determined based on imaging and/or surgical confirmation. The assessment of endometriosis-associated cardinal pain symptoms included superficial and deep dyspareunia, dysmenorrhea, painful bowel movements (dyschezia), painful urination, and non-menstrual pelvic pain. All pain symptoms were evaluated using a visual analogue scale (VAS, 0\u0026ndash;10).\u003c/p\u003e \u003cp\u003eThe evaluation of endometriosis treatments included the ongoing use of hormonal therapy (combined estro-progestins or progestins) and a history of one or more prior surgeries for endometriosis\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eComorbidity status\u003c/span\u003e \u003c/p\u003e \u003cp\u003eComorbidities were assessed if present for at least six months prior to inclusion in the study. These also included non-gynecological conditions including chronic pain-associated diseases or syndromes, such as migraine, fibromyalgia, chronic back pain, osteoarthritis, irritable bowel syndrome (IBS), abdominal/pelvic pain myalgia, and bladder pain syndrome/interstitial cystitis (BPS/IC).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eHealth-Related Quality of Life (HR-QoL) Scoring\u003c/span\u003e \u003c/p\u003e \u003cp\u003eHR-QoL scoring was assessed using the Endometriosis Health Profile 30 (EHP-30) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], a reliable and valid patient-reported instrument designed to measure HR-QoL in women with endometriosis. Since its development, the EHP-30 has been widely used in clinical trials and is considered apt for providing a more comprehensive assessment of HR-QoL in endometriosis patients compared to other generic HR-QoL questionnaires (e.g., SF-36 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]).\u003c/p\u003e \u003cp\u003eWe used the core version of the EHP-30, which consists of 30 questions covering five subscales [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]: pain, control and powerlessness, emotional well-being, social support, and self-image. Each item is rated on a 5-point Likert scale ranging from \"never\" to \"always\" [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Subscale scores are then transformed into a 0\u0026ndash;100 scale, where higher scores indicate worse HR-QoL. The recall period for the EHP-30 was the past four weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the data. Means, standard deviations, and ranges were calculated for continuous variables, while categorical variables were reported as frequencies and percentages. The frequency and severity of symptoms were analyzed accordingly.\u003c/p\u003e \u003cp\u003eThe normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data were analyzed using Student\u0026rsquo;s t-test, while non-normally distributed data were analyzed using the Mann-Whitney U test (for two groups) or the Kruskal-Wallis test (for more than two groups). Categorical variables were compared using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate.\u003c/p\u003e \u003cp\u003ePost-hoc pairwise comparisons between employment groups were conducted to evaluate differences in HR-QoL scores, with Bonferroni-adjusted p-values applied to correct for multiple comparisons.\u003c/p\u003e \u003cp\u003eA multivariable linear regression analysis was conducted for each of the five domains of the EHP-30 questionnaire to determine whether employment status was an independent predictor of HR-QoL scores. The models were adjusted for relevant clinical, sociodemographic, and health-behavior variables, with voluntarily unemployed individuals serving as the reference group. Results were reported as regression coefficients with 95% confidence intervals.\u003c/p\u003e \u003cp\u003eA p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics version 22.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. \u003cb\u003eParticipants\u0026rsquo; characteristics\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/h2\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\u003eSociodemographic characteristics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or number (%)) by employment status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eVoluntary jobless\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull time job\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;167\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePart Time job\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;38\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInvoluntary jobless\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;85\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.9 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e34.9 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.6 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.9 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e23.4 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.4 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.7 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2 (1.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.89 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.65 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.3 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.20\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.5 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.8 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.12\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStable relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e74 (60.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e11 (8.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e10 (8.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor degree or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e11(34.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e2(6.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e1 (3.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e59 (53.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e16 (14,4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e11 (9.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlcohol drinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e63 (54.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e13 (11.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e6 (5.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxio-depressive disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e21 (44.7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e7 (14.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e11 (23.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.34\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfertility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e44 (75.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e7 (121)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e4 (6.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHormonal treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e46 (51.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e26 (11.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e26 (11.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery for endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e20 (40)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e6 (12)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e10 (20)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of pain comorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e1(1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e3(1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e2(2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNotes\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables and as percentages for categorical variables.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Statistical comparisons were performed using the Chi-square for categorical variables and the Kruskal-Wallis test for continuous variables.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e- p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePain characteristics (VAS\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) of the study population by employment status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePain characteristics (VAS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVoluntary jobless\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFull time job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePart Time job\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eInvoluntary jobless\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDysmenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.8 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0.61\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeep Dyspareunia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.7 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.6 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDysuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0.67\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDyschesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperficial Dyspareunia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.26 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.7 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronic pelvic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.7 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.2 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cem\u003e0.27\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNotes\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Statistical comparisons were performed using the Kruskal-Wallis test\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e- p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe study population initially consisted of 460 subjects. Patients without a confirmed surgical and/or imaging diagnosis of endometriosis, as well as those who did not fully complete the EHP30 questionnaire, were excluded. In the end, 324 patients met the study criteria and were included in the analysis.\u003c/p\u003e \u003cp\u003eParticipants had a mean age of 32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years. Among them, 78.2% had a diagnosis of deep infiltrating endometriosis (DIE), 42.5% had also adenomyosis, and 34.5% had undergone one or more previous surgeries for endometriosis. Infertility was reported in 18.5% of patients, while 13.5% had a diagnosis of anxiety-depressive disorder. The mean EHP-30 scores (\u0026plusmn;\u0026thinsp;SD) were 35.2\u0026thinsp;\u0026plusmn;\u0026thinsp;26.7 for pain, 47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;30.6 for control and powerlessness, 40.4\u0026thinsp;\u0026plusmn;\u0026thinsp;24.9 for emotional well-being, 37.8\u0026thinsp;\u0026plusmn;\u0026thinsp;29.1 for social support, and 30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;28.6 for self-image. The results of the different subcategories of the EHP-30 according to employment status are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe study population was subdivided into four groups according to employment status. 205 participants (63.2%) were employed and 119 (36.7%) were unemployed. Among them, full-time employment accounted for 51.5% of the study population, part-time employment for 11.7%, voluntary unemployment for 26.2%, and involuntary unemployment for 10.5%.\u003c/p\u003e \u003cp\u003eSociodemographic characteristics were analyzed across the four employment status groups. Univariate analysis revealed statistically significant differences between the subgroups in terms of age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), deep dyspareunia (p\u0026thinsp;=\u0026thinsp;0.005), dyschezia (p\u0026thinsp;=\u0026thinsp;0.024), superficial dyspareunia (p\u0026thinsp;=\u0026thinsp;0.009), education level (bachelor\u0026rsquo;s degree or higher, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), alcohol consumption (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), infertility (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and history of endometriosis surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant differences were observed between employment status subgroups for other sociodemographic characteristics, including parity, dysmenorrhea, chronic pelvic pain, marital status, and anxiety-depressive disorder. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Association between employment status and EHP30 subscale\u003c/h2\u003e \u003cp\u003e \u003cb\u003eUnivariate Linear Regression Analysis\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariable linear analysis of EHP30 score \u0026mdash; decomposition into key health and well-being dimensions with comparison by employment status and adjusted for demographic, clinical, and lifestyle factors*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEHP 30 Items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eUnivariate linear regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eMultivariable linear regression*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnadjusted Coefficient (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eP-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdjusted Coefficient (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eP-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.68 (3.38\u0026ndash;23.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.91 (-6.70-42.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.149\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-13.18 (-22.88- -3.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-34.48 (-58.00- -10.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.57 (-16.57- -2.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-20.57 (-40.70- -0.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl and powerlessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.41 (0.77\u0026ndash;24.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.73(-24.89-44.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.570\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-11.64 (-22.60- -0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-22.28(-55.36-10.80).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.179.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-10.80 (-18.72- -2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-7.21(-35.45-21.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.605.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.12 (-2.22-20.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.114\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.95 (1.89\u0026ndash;70.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.82 (-20.50-0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.071\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-4.68 (-38.90-29.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.782\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.79 (-17.50- -2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.92 (-23.30-35.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.682\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.14 (0.75\u0026ndash;19.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.034\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.43 (-16.07-36.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.40 (-18.25-0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-19.49(-44.81-5.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.07 (-11.46-1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.12\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-7.24 (-28.85-14.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.98 (-4.71-18.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.241\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.96 (-30.43-48.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.49 (-13.50-8.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.656\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-5.35 (-42.98-32.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.84 (-8.80-7.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.835\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.60 (-20.52-43.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOverall EHP30\u003c/p\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvoluntary Unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.91 (16.85-100.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e168.27 (30.60-205.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-57.53 (-97.13- -17.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-32.66 (-145.50-80.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.554\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-32.62 (-61.25- -3.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.41 (-81.50-110.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.758\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003e*adjusted for educational level, marital status, age, body mass index (BMI), parity, tobacco use, alcohol consumption history, use of hormonal treatment, number of comorbidities, dyspareunia, chronic pelvic pain, dysmenorrhea, infertility, and anxiety/depression.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUnivariate analysis demonstrated that employment status was significantly associated with various dimensions of HR-QoL, as measured by the EHP-30 questionnaire. Compared to voluntarily unemployed participants, full-time and part-time employed individuals reported significantly lower scores for pain, control and powerlessness, suggesting better HR-QoL outcomes in these domains. Specifically, full-time employment was associated with a lower pain score (\u003cem\u003eB\u003c/em\u003e = -9.57, 95% CI: -16.57, -2.57; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008), while part-time employment showed an even greater negative association (\u003cem\u003eB\u003c/em\u003e = -13.18, 95% CI: -22.88, -3.49; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008). Conversely, unemployed individuals actively seeking work had significantly higher pain scores (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.68, 95% CI: 3.38, 23.97; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003eSimilarly, control and powerlessness scores were significantly lower in employed groups, with full-time employment associated with a reduction of -10.80 points (\u003cem\u003eB\u003c/em\u003e = -10.80, 95% CI: -18.72, -2.88; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) and part-time employment showing a -11.64 point decrease (\u003cem\u003eB\u003c/em\u003e = -11.64, 95% CI: -22.60, -0.67; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038). In contrast, the job-seeking unemployed subgroup had significantly worse scores in this domain (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.41, 95% CI: 0.77, 24.06; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037).\u003c/p\u003e \u003cp\u003eRegarding emotional well-being, part-time employment was associated with a significantly lower score (B = -9.40, 95% CI: -18.25, -0.56; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037), while those actively seeking employment had a significantly higher score, indicating worse well-being (B\u0026thinsp;=\u0026thinsp;10.14, 95% CI: 0.75, 19.53; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034).\u003c/p\u003e \u003cp\u003eFor social support, full-time employment was significantly associated with better scores (B = -9.79, 95% CI: -17.50, -2.07; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), whereas unemployed individuals actively seeking work did not show significant differences in this domain (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.114).\u003c/p\u003e \u003cp\u003eNo statistically significant differences were observed between employment groups in self-image scores, with \u003cem\u003ep\u003c/em\u003e-values ranging from 0.241 to 0.835.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMultivariable Linear Regression Analysis\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAfter adjusting for age, BMI, parity, infertility, anxiety/depression, alcohol and tobacco use, use of hormonal treatments, dyspareunia, chronic pelvic pain, dysmenorrhea, marital status, and education level, employment status remained an independent predictor of several HR-QoL dimensions.\u003c/p\u003e \u003cp\u003eActive employment was positively associated with higher QoL domains. Full-time employment was significantly associated with lower EHP30 pain score (\u003cem\u003eB\u003c/em\u003e = -20.57, 95% CI: -40.70, -0.43; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046). Part-time employment had an even stronger association with pain EHP30 domain (\u003cem\u003eB\u003c/em\u003e = -34.48, 95% CI: -58.00, -10.88; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003eFor overall EHP30 scores, job-seeking individuals had the highest burden, with a significant increase of 168.27 points compared to the reference group (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;168.27, 95% CI: 30.60, 205.91; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019), indicating substantially poorer quality of life.\u003c/p\u003e \u003cp\u003eAlthough part-time employment was linked to lower EHP30 powerlessness scores in the univariate analysis, this association was no longer statistically significant after adjustment (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.179). Similarly, no significant associations were found for self-image across employment groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eOur findings demonstrate that employment status is an independent predictor of HR-QoL in women with endometriosis. Specifically, employment, whether full-time or part-time, is associated with lower EHP30 pain scores, while unemployed individuals actively seeking a job significantly worse HR-QoL independently of pain symptoms and main psychosocial variables.\u003c/p\u003e \u003cp\u003eFor women with endometriosis, maintaining stable employment can be challenging due to chronic pelvic pain, fatigue, and fluctuating symptom severity. Many patients experience absenteeism, reduced work productivity, and career stagnation, which may exacerbate the emotional and economic burden of the disease [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The relationship between employment status and HR-QoL is particularly relevant in chronic conditions, where socioeconomic stability can influence treatment adherence, psychological resilience, and overall well-being [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHaving a stable job may help mitigate the burden of endometriosis-related symptoms through multiple mechanisms, as shown in other chronic pain conditions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Financial stability ensures access to healthcare, specialized consultations, and treatments, while in Switzerland, where health insurance is mandatory, it can influence access to supplementary coverage and out-of-pocket medical expenses. However, financial security alone may not fully explain these differences, as unemployment in Switzerland is mitigated by a robust compensation system, providing 70–80% of the average salary from the last six months [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, patients unable to work receive a special pension called disability insurance (\u003cem\u003eAssurance Invalidité\u003c/em\u003e, AI), a social security system that offers comfortable financial support to individuals whose health condition significantly limits their ability to work [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite those financial supports, unemployed individuals—particularly those actively seeking work—still reported significantly lower HR-QoL scores, including pain domain, suggesting that factors beyond income stability play a crucial role in well-being.\u003c/p\u003e \u003cp\u003eBeyond financial security, employment provides psychological and emotional benefits, giving a sense of purpose, self-worth, and social integration, which may reduce stress and feelings of helplessness. Work can also serve as a cognitive distraction from pain and improve social support through workplace interactions. A structured daily routine associated with employment may positively impact sleep, diet, and physical activity, all of which influence symptom severity. Additionally, lower allostatic load—reducing chronic stress linked to financial and social insecurity—may help modulate neuroendocrine and inflammatory responses involved in endometriosis. Moreover, part-time employment showed a trend toward better EHP-30 scores in our study, suggesting that a more flexible work schedule may provide more time to manage endometriosis symptoms, reduce stress, and improve work-life balance.\u003c/p\u003e \u003cp\u003eFurthermore, deep dyspareunia, superficial dyspareunia, and dyschezia were significantly different across employment groups, raising the question of whether employment influences pain perception or whether more symptomatic patients have lower employment stability due to their disease burden. While employment may provide psychosocial benefits that modulate pain perception, it is also plausible that women with more severe pain are unable to sustain employment, leading to a reverse causality effect. However, in our multivariable analysis, we adjusted for different dimensions of pain, and the association between employment status and HR-QoL remained significant, suggesting that factors beyond pain perception—such as social integration, self-efficacy, and workplace accommodations—may contribute to the observed differences. These findings highlight the need to better understand the bidirectional relationship between endometriosis symptom burden and employment stability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral limitations and potential biases must be acknowledged when interpreting these findings. First, the study was conducted in a tertiary referral center, meaning that participants were likely self-referred or referred by specialists. This may have excluded women with milder symptoms, who are more commonly managed by general practitioners or private practice gynecologists. A volunteer bias may also be present, as 51.5% of the study population were employed full-time, which is higher than expected for a population suffering from a chronic and often debilitating disease. A statistically significant difference in age was observed across employment subgroups, which may reflect natural employment trends rather than a direct effect of endometriosis. Younger patients are more likely to be actively job-seeking, while older patients or those with children may opt for part-time work or voluntarily withdraw from the workforce. This age-related employment distribution constitutes a confounding bias, as it could partly explain differences in HR-QoL independent of disease severity. To conclude, that data were collected between 2018 and 2020, potentially missing changes in employment policies, remote work, healthcare access, and endometriosis awareness. However, given the chronic nature of the disease and persistent employment challenges, the relationship between employment status and HR-QoL likely remains relevant. The rise of flexible work post-COVID-19 warrants further investigation.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eOur study provides strong evidence that employment status is an independent predictor of HR-QoL in women with endometriosis.\u003c/p\u003e\u003cp\u003eWhile these findings highlight the importance of socioeconomic determinants in endometriosis management, they also raise critical questions about causality—does employment actively protect against worsening QoL, or does severe endometriosis prevent workforce participation? Addressing this uncertainty requires longitudinal studies to further explore these relationships and inform holistic, patient-centered management strategies that integrate both clinical and socioeconomic considerations. Moreover, these results should prompt physicians to carefully reassess the implications of prolonged sick leave in women with endometriosis. While intended to alleviate burden, extended absence from work may unintentionally transfer an even greater one—the psychological weight of unemployment.\u003c/p\u003e\u003cp\u003eFurther research should adopt a longitudinal design to clarify the directionality of the relationship between employment and HR-QoL and should also explore the impact of remote work, flexible employment arrangements, and workplace accommodations, which may influence workforce participation and well-being in women with endometriosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants involved in this study.\u0026nbsp;The study followed institutional and national ethical standards, in line with the 1964 Helsinki Declaration and its amendments. This project was approved by the Cantonal Research Ethics Commission (CCER), Geneva, Switzerland (protocol number: 09-193R).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent to the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from N.P., upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.P. conceived and designed the study. N.P. analysed the data. J.V. drafted the manuscript. G.B. and N.P. critically revised the manuscript. All authors approved the final version of the report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcGonagle, A. K., Chosewood, L. C., Hartley, T. A., Newman, L. S., Ray, T., \u0026amp; Rosemberg, M. A. (2024). Chronic Health Conditions in the Workplace: Work Stressors and Supportive Supervision, Work Design, and Programs. \u003cem\u003eOccupational health science\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(2), 233\u0026ndash;241. https://doi.org/10.1007/s41542-024-00192-0\u003c/li\u003e\n\u003cli\u003eCulley, L., Law, C., Hudson, N., Denny, E., Mitchell, H., Baumgarten, M., \u0026amp; Raine-Fenning, N. (2013). 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The Effect of Endometriosis Symptoms on Absenteeism and Presenteeism in the Workplace and at Home. \u003cem\u003eJournal of managed care \u0026amp; specialty pharmacy\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(7), 745\u0026ndash;754. https://doi.org/10.18553/jmcp.2017.23.7.745\u003c/li\u003e\n\u003cli\u003eTsuji, T., Matsudaira, K., Sato, H., Vietri, J., \u0026amp; Jaffe, D. H. (2018). Association between presenteeism and health-related quality of life among Japanese adults with chronic lower back pain: a retrospective observational study. \u003cem\u003eBMJ open\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(6), e021160. https://doi.org/10.1136/bmjopen-2017-021160\u003c/li\u003e\n\u003cli\u003eState Secretariat for Economic Affairs (SECO). (n.d.). \u003cem\u003eUnemployment benefits \u0026ndash; FAQs.\u003c/em\u003e Arbeit.swiss. Retrieved February 15, 2025, from https://www.arbeit.swiss/secoalv/en/home/menue/stellensuchende/arbeitslos-was-tun-/faq_arbeitslosenentschaedigung.html\u003c/li\u003e\n\u003cli\u003eSwiss Confederation. (2025). Disability insurance (DI/IV/AI) in Switzerland. Retrieved February 15, 2025, from https://www.ch.ch/en/insurance/disability-insurance--di/iv/ai-/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"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},"keywords":"Endometriosis, employment status, health-related quality of life, chronic pain, work disability, socioeconomic determinants, psychosocial impact","lastPublishedDoi":"10.21203/rs.3.rs-6297830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6297830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEndometriosis is a chronic condition that affects multiple aspects of women's lives, including physical health, emotional well-being, and socioeconomic stability. While pain is a well-recognized determinant of health-related quality of life (HR-QoL), the role of employment status on pain experience remains underexplored.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study examines the association between employment status and HR-QoL, exploring its role as an independent variable beyond clinical symptoms and pain severity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis cross-sectional study was conducted at the University Hospital of Geneva. Women with a confirmed diagnosis of endometriosis were included. Employment status was categorized as full-time employment (over 80%), part-time employment (80% or less), voluntary unemployment (not seeking employment), and involuntary unemployment (seeking employment). HR-QoL was measured using the Endometriosis Health Profile-30 (EHP-30), which includes components such as pain, control and powerlessness, emotional well-being, social support, and self-image. Statistical analyses included univariate and multivariable linear regression, adjusting for clinical, sociodemographic, and health-related variables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 324 patients were included, with a mean age of 32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years; 78.2% had deep infiltrating endometriosis. Prior surgery was reported in 34.5%. Regarding employment, 63.2% were employed (51.5% full-time, 11.7% part-time), while 36.7% were unemployed, including 26.2% by choice. Employment status was significantly associated with specific HR-QoL domains. Full-time and part-time employment were linked to lower EHP30 pain scores, with part-time employment showing a stronger association (B = -34.48, 95% CI: -58.00 to -10.88, p\u0026thinsp;=\u0026thinsp;0.006) compared to full-time employment (B = -20.57, 95% CI: -40.70 to -0.43, p\u0026thinsp;=\u0026thinsp;0.046). Conversely, unemployed women actively seeking work exhibited worse HR-QoL scores, particularly in social support (B\u0026thinsp;=\u0026thinsp;34.95, 95% CI: 1.89 to 70.80, p\u0026thinsp;=\u0026thinsp;0.048) and overall HR-QoL burden (B\u0026thinsp;=\u0026thinsp;168.27, 95% CI: 30.60 to 205.91, p\u0026thinsp;=\u0026thinsp;0.019). Self-image, control and powerlessness, and emotional well-being scores did not show statistically significant differences across employment groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study identifies employment status as an independent predictor of HR-QoL in women with endometriosis including pain and social support domain. Despite Switzerland\u0026rsquo;s comprehensive unemployment benefits, unemployed women still report poorer HR-QoL, underscoring the role of social integration, professional identity, and daily structure/routine as an independent variable for the evaluation of endometriosis burden. Future research should explore the impact of remote work, flexible employment arrangements, and workplace accommodations, which may improve workforce participation and well-being in women with endometriosis.\u003c/p\u003e","manuscriptTitle":"Beyond pain: employment status affects endometriosis-associated quality of life – a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 13:22:10","doi":"10.21203/rs.3.rs-6297830/v1","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}}],"origin":"","ownerIdentity":"4ad9da32-3dbd-4529-b32a-a5dd9339996b","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-06T13:22:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 13:22:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6297830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6297830","identity":"rs-6297830","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}