Endometriosis – The challenge for occupational life of diagnosed women: A review of quantitative studies

The aim of the article was to summarize the results offered in the research on occupational functioning of women with endome - triosis. We followed PRISMA guidelines. Database search was done in November 2017 using EBSCO. In the review were included the articles clearly referring to the relationships between endometriosis and work or any aspect of work (e.g., work productivity, work ability, absenteeism). Eight papers were included in the final review. Seven studies were cross-sectional, 1 retrospective. The majority of researchers used standardized research measures, such as Work Ability Index , Work Productivity and Activity Impair- ment Questionnaire or Health Related Productivity Questionnaire . Only in 2 studies the reference group was considered, one of them consisted of healthy women. The results clearly indicate that endometriosis is a disease that causes major disturbance in occupational functioning of the suffering women. In the future the researchers should search for individual and organizational correlates of the improvement of occupational functioning in this group of patients. The methodology of the existing studies has been evaluated and the methodological cues for future research has been given. Med Pr 2018;69(6):663–671 Key words: pain, quality of work life, sickness absence, work ability, women’s health, chronic disease Corresponding author: Aleksandra Andysz, Nofer Institute of Occupational Medicine, Department of Health and Work Psychology, św. Teresy 8, 91-348 Łódź, Poland, e-mail: [email protected] Received: January 2, 2018, accepted: March 27, 2018 Medycyna Pracy 2018;69(6):663–671 http://medpr.imp.lodz.pl/en ENDOMETRIOSIS – THE CHALLENGE FOR OCCUPATIONAL LIFE OF DIAGNOSED WOMEN: A REVIEW OF QUANTITATIVE STUDIES REVIEW PAPER

Endometriosis is an estrogen-related disorder of a still unknown etiology and it is reported to affect  10% of women of reproductive age [1]. The core pathology of this disease is the presence of endometrium cells out - side the uterus. Ectopic endometrial cells spread and form endometriosis foci mainly in the organs of pelvic (ovaries, uterosacral ligaments and intestines) but also outside the pelvis. These ectopic cells are affected by cyclic hormonal fluctuations similarly to endometrial cells in the uterus – they proliferate and slough off but are not expelled from the body during menstruation. This process causes chronic inflammation in the area of endometriosis foci, as well as pain, adhesions and ana - tomic distortion in pelvic. There is a considerable delay in the diagnosis of en - dometriosis [2–5]. Frequently do women seek advice from numerous doctors before anyone recognizes the symptoms correctly. The symptoms are commonly ne- glected or ignored by women themselves as well as their relatives or doctors. Sometimes even severe menstrual pain is considered as normal. Moreover, because some of the symptoms are considered embarrassing (e.g., pain- ful sexual intercourses or defecation) the suffering wom- en refrain from consulting their discomfort with a doc - tor, which defers the accurate diagnosis. The endometriosis treatment usually includes hor - mone therapy and surgery interventions. Yet, despite a great pharmacology and medical technology develop - ment, current therapies are still not fully effective and the disease tends to recur. Living with endometriosis Symptoms of endometriosis adversely affect patients’ ev- eryday lives, thus, the life of a  woman suffering from endometriosis could be described as “shaped by pain” [6]. The pain accompanies periods ( dysmenorrhea), sexual https://doi.org/10.13075/mp.5893.00737 Funding: prepared within a statutory project of the Nofer Institute of Occupational Medicine (project No. IMP 21.9 entitled “Is there a po- sitive aspect of living with endometriosis? Research on determinants of posttraumatic growth in diagnosed women, ” project manager: Aleksandra Andysz, M.A.). A. Andysz et al. 664 Nr 6 intercourses (dyspareunia), defecation (dyschezia), and urination ( dysuria) [7]. Patients often complain about nausea [8–10] and chronic fatigue [11,12]. Importantly, women with endometriosis report high levels of stress [13], depressive symptoms and anxiety [14]. Endometriosis is found to be one of the leading caus- es of infertility [15]. This, in turn, leads to subsequent psychological consequences that affect mental health of women with endometriosis more than those with other gynaecological problems [16]. Women suffering from endometriosis experience crises in their relationships and also their partners’ quality of life is affected by the illness [17]. Depending on the stage of the illness and the severity of pain, social functioning of women with endometriosis is significantly impaired as well [12,18]. Social costs of endometriosis Due to its social costs, it is postulated to consider endo- metriosis as a social disease [19]. The costs result mainly from the diagnostic delay, ineffective treatment, high in- dex of hospital admissions, surgery procedures and con- comitant health problems (infertility, mental health prob- lems). Endometriosis affects women of productive age, hence it influences women’s occupational functioning. In 2006, the World Endometriosis Research Founda- tion (WERF) [20] initiated the EndoCost Study to assess the direct and indirect costs of the disease born by soci- ety (including costs of productivity loss) and by the diag- nosed women themselves. Data was collected in 12 me- dical centers from 10 countries (N = 909). The average an- nual total cost was calculated to over EUR 9000 per wom- an and the costs of productivity loss (approx. EUR 6000 per woman) were twice as high as healthcare costs (sur- geries, monitoring tests, hospitalizations and physicians visits). The data showed that economic burden associ - ated with endometriosis was similar to the one tied to other serious chronic diseases such as diabetes, Crohn’s disease or rheumatoid arthritis [21]. Rationale and the aim of the article The purpose of our review was to find research and summarize what is already known on the impact of en- dometriosis on the occupational functioning of women since such summary has not been done yet.

Selection of articles – eligibility criteria and search Conducting the review search and analysis, we fol - lowed the PRISMA guidelines. To find relevant papers, we searched the following databases using the EBSCO: MEDLINE Complete, OAIster, MasterFILE Premier and JSTOR Journals with no limits as regards the ear - liest date of publication. The search was performed in November  2017. Exact duplicates were automatically excluded from the results. We searched only for arti - cles written in English and published in peer-reviewed journals. First, we used the following keywords: “endometri - osis” and “work;” “endometriosis” and “occupation*” (asterisk was used for retrieving variations of a searched word) in the title; “endometriosis” in the title and “work” in the abstract or keywords.

Study selection Forty-four records met the primary criteria and were screened for eligibility for further analysis. We exclud - ed: qualitative studies (N = 4), a review (N = 1), unpub - lished PhD thesis (N = 1), articles in which “work” did not refer to paid work (N = 6), articles in which “work” occurred in the abstract but was only a part of the in - troduction (N  =  8), papers considering the influence of work on the risk of endometriosis (N = 4), articles in which researchers studied the influence of different therapies, on, e.g., functioning at work (N  =  5), arti - cles in which the main topic was not endometriosis but endometriosis-related symptoms (N  =  2) and articles focused on estimating costs of endometriosis (N = 3). Next, 3 out of the 11 remaining papers were excluded due to their significant methodological shortcomings. Eventually, a total of 8 papers were included in the final review. The stages of study selection are presented in the flow diagram (Figure 1). Characteristics of selected studies Data collection In the reviewed studies, women were identified in patients’ registers and invited to the study by post or e-mail [8,10,16,22,23] or they were recruited from hos- pital wards [9,24,25]. Study samples With the exception of Nnoaham et al. study [24] that was conducted in 16 clinics in 10 European countries, North and South America and Asia, all the other studies referred to local societies: central America [10,16], Denmark [8], Italy [25], Norway [9] and USA [23]. The smallest study group included 78 women [9] and the largest – 1318 [23]. Endometriosis – The challenge for occupational life 665 Nr 6 The diagnosis of endometriosis was the inclusion criteri- on in all studies, but the accepted basis of the diagnosis varied between the reviewed studies (Table 1). Study designs All the reviewed studies were cross-sectional, only one was a 15-year-long retrospective study [9]. Two studies included control groups – 1 consisted of women from the general population [8], the other – of symptomatic (pelvic pain and subfertility) women without endome - triosis and women to be sterilized [24]. Measures Most authors used standardized tools to measure work- related variables: Work Productivity and Activity Im - pairment Questionnaire [16,24,25], a short version of Work Ability Index [8], Global Study of Women’s Health Questionnaire [24], work-related module of the Endo - metriosis Health Profile [8] or Health-Related Produc- tivity Questionnaire [23]. Two teams of researchers de- veloped their own surveys [9,16]. Research areas Having analyzed the content of the selected papers, we distinguished the following research areas: ■ impact of endometriosis-induced pain on occupa - tional functioning, ■ deterioration of work ability, work performance and quality of work caused by endometriosis, ■ productivity loss caused by endometriosis-related symptoms. The summary of the studies included in the review is presented in the Table 1. The impact of endometriosis-induced pain on occupational functioning Two publications by Fourquet et  al. [10,16] depict the situation of women suffering from endometriosis in South America. At least 66% of the studied women ex - perienced pain-related difficulties in work,  43% iden - tified these difficulties as severe [10]. For 60% of them (N = 64) the pain was the reason for missed working days [16]. In a study by Caserta et al. [25], nearly 30% of the studied women considered the impact of endometri - osis on work as extreme, 35% as moderate and 23% as minimal. Only 12% of them reported no impact of endo- metriosis on their work. The percentage of women who experienced extreme negative influence of endometriosis on work was even higher in Fourquet’s study – 43% [10]. In a  study by De Graaf et  al. [22]  51% of the partici - pants reported that endometriosis negatively affected their work. Hansen et al. [8] showed the range of pain intensity and pain-related consequences at work in the case of women with diagnosed endometriosis in comparison to a reference group of the general female population. Women with endometriosis took sick leaves due to their pain significantly more often than healthy wom - en from the reference group. Up to 59% of the respon - dents felt the endometriosis pain impaired their work efficiency. In the case of  53% it decreased concentra - tion, 30% felt guilty taking a day off because of the pain, and 31% felt worried because of their inability to work due to the pain. The wide range of difficulties included: stomachache related or unrelated to menstruation, pain at urination and defecation, irregular bleeding, consti - pation or diarrhea. The studied women also reported to have experienced nausea, vomiting, headache, fatigue and lack of energy, pain while standing, sitting and walking. The study of Hansen et al. [8] also revealed mental consequences of the suffering, directly related to work. Women experienced a sense of guilt and embarrass- ment and they worried about worse functioning at work. Figure 1. Flow diagram showing the process of studies selection for the review 167 of records identified through database searching 125 records excluded based on the titles and

(14 duplicates) 44 records screened 11 full-text articles assessed for eligibility 8 of studies included for the review 3 of the full-text articles excluded due to methodology 33 records excluded 2 records identified through other resources A. Andysz et al. 666 Nr 6Table 1. Methodology of the reviewed studies on occupational functioning of women with endometriosis

Keywords Work-related measured variables Study design Method of data collection Participants Diagnostic delay measured Standardized questionnaires to measure work-related variables

Fagervold et al. 2009 [9] Norway work ability, quality of work life absenteeism, changes in work due to endometriosis retrospective descriptive (15 years follow-up) hospitals N = 78 (age: unknown) women discharged from hospital with the ICD-9 diagnosis and/or histological verified endometriosis control group: no no no small sample, recall and reporting errors Fourquet et al. 2010 [10] South America work performance

in work activity, decrease in quality of work, career consequences cross sectional quantitative study questionnaires distributed via mail and e-mail N = 107 (age: M±SD = 34.5±6.6 years old) self-reported surgically diagnosed women control group: no yes (M±SD = 8.9±7.9) no results representative for the women with severe endometriosis, sample consisted of well-educated women (small differences in the level of education of women), recall and reporting errors Nnoaham et al. 2011 [24] multinational work productivity absenteeism, presenteeism, overall productivity loss multicenter cross-sectional study with prospective recruitment 16 hospitals, 10 countries N = 745 (age: M±SD = 32.5±6.2 years old (18–45 years old)) premenopausal women scheduled for laparoscopy without previous surgical diagnosis of endometriosis control group: yes, symptomatic control women without endometriosis (N = 587) and sterilization control women without endometriosis (N = 86) yes (M±SD = 6.7±6.3) WPAI:GH variables were measured in the weeks leading to the scheduled surgery, results may be affected by this fact and the symptoms themselves Fourquet et al. 2011 [10] South America work productivity absenteeism, presenteeism, work productivity, decrease in quality of work, career consequences cross sectional quantitative study questionnaires distributed via mail and e-mail N = 193 (age: M = 33.2 years old (18–52 years old)) self-reported surgically diagnosed women control group: no measured but not reported WPAI no data on severity of disease Hansen et al. 2013 [8] Denmark work ability, quality of work life absenteeism, work ability, implications for work life cross sectional study (even though the authors considered it a cohort study) electronic questionnaire distributed online N = 610 (age:  50 years old) women with endometriosis diagnosed by laparoscopy or/and magnetic resonance (MR) control group: yes, healthy women (N = 751) yes, percentages EHP-30, W AI short recall bias, no validation of endometriosis in medical records, respondents selected on the basis of their availability and interest Caserta et al. 2013 [25] Italy work productivity work productivity cross-sectional questionnaires distributed in hospital during outpatient medical examination N = 222 (age: M±SD =  37.9±6.5 years old) women with surgically diagnosed endometriosis control group: no no WPAI not mentioned De Graaf et al. 2013 [22] multinational not related to work negative effect on endometriosis work cross-sectional questionnaires distributed via mail to participants after positive answer to the invitation N = 931 (age: M±SD = 36.1±6.8 years old (14–67 years old)) women with laparoscopic and/or histological diagnosis of endometriosis control group: no yes years of patient delay*: M±SD = 2.1±4 (0–32) doctor delay**: M±SD = 3.4±5.3 (0–38) total delay: M±SD = 5.5±6.6 (0–38) GSWH possible over representation of women with moderate and severe endometriosis, low response rate to the mail invitation (29%) Soliman et al. 2017 [23] USA work productivity absenteeism, presenteeism, overall productivity loss cross-sectional web based survey N = 1 318 (age: M±SD = 34.6±0.3 years old (18–49 years old)) women with symptomatic endometriosis, currently being treated or having hysterectomy control group: no no HRPQ participation of women who had access to the internet only, recall bias, the type of treatment was not controlled * Patient delay – interval between onset of symptoms to first visit. ** Doctor delay – interval between first doctor visit and diagnosis. WPAI:GH – Work Productivity and Activity Impairment: General Health V2.2 , WPAI – Work Productivity and Activity Impairment , EHP-30 – Endometriosis Health Questionnaire 30 , WAI – Work Ability Index , GSWH – Global Study of Women’s Health Questionnaire , HRPQ – Health Related Productivity Questionnaire . Endometriosis – The challenge for occupational life 667 Nr 6 Table 1. Methodology of the reviewed studies on occupational functioning of women with endometriosis

Keywords Work-related measured variables Study design Method of data collection Participants Diagnostic delay measured Standardized questionnaires to measure work-related variables

Fagervold et al. 2009 [9] Norway work ability, quality of work life absenteeism, changes in work due to endometriosis retrospective descriptive (15 years follow-up) hospitals N = 78 (age: unknown) women discharged from hospital with the ICD-9 diagnosis and/or histological verified endometriosis control group: no no no small sample, recall and reporting errors Fourquet et al. 2010 [10] South America work performance

in work activity, decrease in quality of work, career consequences cross sectional quantitative study questionnaires distributed via mail and e-mail N = 107 (age: M±SD = 34.5±6.6 years old) self-reported surgically diagnosed women control group: no yes (M±SD = 8.9±7.9) no results representative for the women with severe endometriosis, sample consisted of well-educated women (small differences in the level of education of women), recall and reporting errors Nnoaham et al. 2011 [24] multinational work productivity absenteeism, presenteeism, overall productivity loss multicenter cross-sectional study with prospective recruitment 16 hospitals, 10 countries N = 745 (age: M±SD = 32.5±6.2 years old (18–45 years old)) premenopausal women scheduled for laparoscopy without previous surgical diagnosis of endometriosis control group: yes, symptomatic control women without endometriosis (N = 587) and sterilization control women without endometriosis (N = 86) yes (M±SD = 6.7±6.3) WPAI:GH variables were measured in the weeks leading to the scheduled surgery, results may be affected by this fact and the symptoms themselves Fourquet et al. 2011 [10] South America work productivity absenteeism, presenteeism, work productivity, decrease in quality of work, career consequences cross sectional quantitative study questionnaires distributed via mail and e-mail N = 193 (age: M = 33.2 years old (18–52 years old)) self-reported surgically diagnosed women control group: no measured but not reported WPAI no data on severity of disease Hansen et al. 2013 [8] Denmark work ability, quality of work life absenteeism, work ability, implications for work life cross sectional study (even though the authors considered it a cohort study) electronic questionnaire distributed online N = 610 (age:  50 years old) women with endometriosis diagnosed by laparoscopy or/and magnetic resonance (MR) control group: yes, healthy women (N = 751) yes, percentages EHP-30, W AI short recall bias, no validation of endometriosis in medical records, respondents selected on the basis of their availability and interest Caserta et al. 2013 [25] Italy work productivity work productivity cross-sectional questionnaires distributed in hospital during outpatient medical examination N = 222 (age: M±SD =  37.9±6.5 years old) women with surgically diagnosed endometriosis control group: no no WPAI not mentioned De Graaf et al. 2013 [22] multinational not related to work negative effect on endometriosis work cross-sectional questionnaires distributed via mail to participants after positive answer to the invitation N = 931 (age: M±SD = 36.1±6.8 years old (14–67 years old)) women with laparoscopic and/or histological diagnosis of endometriosis control group: no yes years of patient delay*: M±SD = 2.1±4 (0–32) doctor delay**: M±SD = 3.4±5.3 (0–38) total delay: M±SD = 5.5±6.6 (0–38) GSWH possible over representation of women with moderate and severe endometriosis, low response rate to the mail invitation (29%) Soliman et al. 2017 [23] USA work productivity absenteeism, presenteeism, overall productivity loss cross-sectional web based survey N = 1 318 (age: M±SD = 34.6±0.3 years old (18–49 years old)) women with symptomatic endometriosis, currently being treated or having hysterectomy control group: no no HRPQ participation of women who had access to the internet only, recall bias, the type of treatment was not controlled * Patient delay – interval between onset of symptoms to first visit. ** Doctor delay – interval between first doctor visit and diagnosis. WPAI:GH – Work Productivity and Activity Impairment: General Health V2.2 , WPAI – Work Productivity and Activity Impairment , EHP-30 – Endometriosis Health Questionnaire 30 , WAI – Work Ability Index , GSWH – Global Study of Women’s Health Questionnaire , HRPQ – Health Related Productivity Questionnaire . A. Andysz et al. 668 Nr 6 They accomplished less than desired because of the pain and they felt they could have been able to work longer and more efficiently if they had not felt the pain. Additionally, their ambitions would have been higher if they had been more concentrated, but it was the pain that hindered their concentration. Deterioration of work ability, work performance and quality of work caused by endometriosis Fagervold et al. [9] conducted a retrospective study il - lustrating 15-year-long experience of the life with en - dometriosis. The results showed significant negative correlations between the number of the endometriosis symptoms in the past (pain, dysmenorrhea, pain at ovu- lation, dyspareunia, pain at defecation, constant pelvic pain, menorrhagia, irregular menstrual cycles, uri - nary symptoms, flatulence/constipation, fatigue) and later course of patients’ education and work. Nearly a half of the respondents who participated in the fol - low-up study (49%) experienced negative influence of endometriosis on their work ability. Five percent of the studied women decreased their working hours (from full-time to part-time) due to their disease and anoth - er 3% changed their place of employment. One woman (1%) became unable to work. The study by De Graaf et al. [22] showed that among women who reported negative impact of endometriosis on their work, 11% lost their jobs and 7% changed their jobs. In a study by Fourquet et al. [16], 84% of women re - ported decrease in the quality of their work due to en - dometriosis and its symptoms made 20% of the studied women temporarily disabled. Furthermore, 66% of the respondents reported that the work-related activities they could perform were limited [10]. Hansen et  al. [8] revealed that the number of sick days, disturbances due to symptoms and work ability differed significantly between women suffering from endometriosis and healthy women. Poor work ability was reported by 14% of the women with endometriosis vs. 8% of healthy women from the reference group. Ex - cellent work ability was declared only by 12% of the suf- fering women in contrast to 38% of the women from the

group. Decreased work ability was predicted by fatigue, lack of energy, pain frequency, higher daily level of pain, the higher number of sick days and feel - ing depressed at work. That study also showed the rela- tionship between work ability and the diagnostic delay. Almost a half of the women who had been diagnosed within 2 years from the occurrence of the first symp - toms (48%) assessed their ability to work as excellent and only 16% found it poor. Among women who were diagnosed within  7–8 years from the first symptoms, these percentages equaled 5% and 24%, respectively. Fourquet et  al. calculated that a  substantial num - ber of women believed that their symptoms extreme - ly affected their work productivity (N = 44, 48%) [10] and 84% of the studied women reported a decrease in the quality of their work due to endometriosis and its symptoms [16]. Many women reported that they ac - complished less than expected – 64% of them attribut - ed it to physical limitations, 63% to emotional problems resulting from the experienced symptoms. Most re - spondents (66%) felt that because of the endometriosis the range of work-related activities they could perform was limited  [10]. Almost  40% of the studied women faced professional consequences  – their professional development was inhibited due to high rates of absen - teeism and/or low performance (N = 15), they were not promoted (N = 8), did not receive merit or excellence bonuses (N = 3), missed professional seminars (N = 2), lost clients (N = 1), were “totally incapacitated” (N = 3), dismissed or they quit the job (N = 3) [16]. In the study of Nnoaham et al. [24] the productivity loss was higher among women with endometriosis than in the case of the symptomatic control group without en- dometriosis (11±12.2% vs. 8±10.2% of productivity loss). Productivity loss caused by endometriosis-related symptoms The reviewed studies referred to productivity loss as measured by absenteeism (missed working time) and presenteeism (reduced work effectiveness due to com - ing to work despite experiencing health problems and symptoms). Long sick leaves were more common among wom - en with endometriosis than among women of general population [8]. Over  20% of the suffering women and  8% of the healthy women reported sick leaves lasting 25–100 days. Sick leaves lasting 100–365 days were taken by 6% of the suffering and 3% of the healthy women [8]. In the paper by Fagervold et  al. [9],  44% women took  0.9±1.7 sick leaves due to endometriosis-related symptoms per month on average. Fourquet et  al. [16] showed that due to inability to perform physical activities, the suffering women missed 3 working days a month on average (±3.7), which yields over a month of absence a year. The authors also calculated the days of absence due to treatment, oper - ation and rehabilitation to 19 days a year (±19.3). It oc - curred that the absence of women with endometriosis Endometriosis – The challenge for occupational life 669 Nr 6 was longer than among people suffering from head - aches, arthritis or backache. At the same time, 69% of the respondents admitted that they continued working despite the experienced pain. In the other study of Fourquet et al. [10] the authors calculated that the average length of absence equaled less than 1 working day a week (7±9 h), which means near - ly 20% of the whole average working week. In contrast, the average number of missing working hours due to other reasons (e.g., holidays) equaled 4 h (±10 h). A study by Nnoaham et al. [24] showed significantly higher presenteeism (coming to work despite being ill) among women with endometriosis than in the case of the symptomatic control group without endometriosis (6±7.9 h/week vs. 5±6.7 h/week). Caserta et al. [25] showed that average absence due to endometriosis equaled 2±5.3 h within the week pre - ceding the study. The number of hours worked within the 7 days preceding the study amounted to 34±12.4 on average (in a 40-h working week). Soliman et al. [23] calculated that women lost 1.1 work h/week and 6.6 days/year on average because of absen - teeism; and 5.3 work h/week and 31.8 days per year due to unproductive days at work (presenteeism). Based on the results, it may be concluded that the ab- sence due to endometriosis amounted to approx. 1 work- ing day a week on average.

Summary of the evidence The presented review shows that the research direct - ly referring to the impact of endometriosis on work is surprisingly scarce, given the negative consequences of endometriosis on occupational functioning and their financial costs. The previous research on the impact of endometriosis on professional life of the suffering women lacks the established methodology and the dif - ferences in the design of these studies make it difficult to compare the findings. At the moment, there are too few studies to do a  meta-analysis. Despite little em - pirical material so far, we believe the existing studies provide valuable conclusions and cues for researchers willing to undertake that issue in the future studies. To summarize, Hansen’s et al. study [8] indicated pain and diagnostic delay as predictors of poor ability to work and sense of guilt as a  mental consequence of in - ability to work. These authors also recognized long-term consequences of the diagnostic delay – 1 in 4 women who assessed their work ability as poor got their diagnosis  7–8  years after the occurrence of the first symptoms. Long diagnostic delay makes the disease develop and produce more symptoms and more irre - versible changes. Thus, we believe that the diagnostic delay should become an issue of quantitative studies to determine the contribution of patients’ behavior (“bit- ing the bullet” attitude, self-treatment with easily ac - cessible painkillers, postponing the decision to see the doctor, etc.) and the contribution of the attitude of doc- tors (ignoring patients’ symptoms, postponing the di - agnostic procedures possibly due to economic reasons). Alarmingly, Fourquet et  al. [16] recognized little awareness of endometriosis  –  65% of the studied pa - tients had never heard of the disease before the surgery and had never suspected that they had had endometri - osis. The awareness of endometriosis, both among pa - tients and their families, is crucial to avoid many phe - nomena related to this disease, e.g., the diagnostic de - lay, but also to improve social life of the suffering wom- en. For many women describing the pain and proving its onerousness is difficult. This makes other people unaware of their suffering. Greater social awareness of endometriosis would help these women to be more open and feel more comfortable to talk about the disease and its symptoms. Thus, others would have more under - standing for the suffering women, be less ignorant or less willing to suspect that they simulate or exaggerate their pain. Feeling more compassion from other peo - ple, women would be more courageous to participate in social life despite their symptoms. The reviewed studies also draw attention to some methodological difficulties in studying the relation - ships between endometriosis (or any other chronic dis- ease) and its impact on professional life. First, Nnoa - ham et al. [24] noted that work productivity loss and other variables related to occupational functioning were measured shortly before the operation (weeks be- fore), which could significantly influence the responses. Moreover, the declared number of days of absence at work might have resulted from the perceived symptoms at that moment of the study. The fact that women were waiting for the operation might suggest severe stages of the disease, which could significantly confound the measuring outcomes. On the other hand, this situation might have caused these women to suffer less, because they had already received the diagnosis and expected a relief after the operation. We believe that research on mental consequenc - es of living with endometriosis needs to consider the specificity of the situation and life circumstances of A. Andysz et al. 670 Nr 6 women at the moment of the study (e.g., exacerbation of symptoms, waiting for the operation, or infertility treatment). A reliable estimation of work absence or costs of treatment of endometriosis poses another methodolog- ical challenge. Such variables as sick leaves, the date of diagnosis, the number and types of medical proce - dures, money spent on medications are burdened with a  recall bias. Thus, the researchers should attempt to have the access to medical records. The time since diagnosis has been included only in  1  of the reviewed studies [22]. Since diagnostic delay plays a critical role in the progression of the dis - ease, time that has passed since the occurrence of the first symptoms and the date of diagnosis should be controlled in the studies on endometriosis. On the one hand, the longer one lives with the diagnosis of chron - ic disease, the longer they live with the burden of the disease. On the other hand, it is the time given to adapt to the disease and its consequences. We consider the influence of years of living with endometriosis on men- tal health and social functioning as a field for further scientific exploration. Considering the previous studies on women suf - fering from endometriosis, we believe that further re - search in this group of patients should also focus on predictors of adaptive functioning or post-traumatic growth. We believe that post-traumatic growth in this group of patients is possible and finding any possible positive consequences of living with this difficult dis - ease would be beneficial.

The above review has also its limitations. We searched only for papers written in English. Probably, some local researchers also undertake the issue of the impact en - dometriosis on occupational functioning but the results might not be published in English or in peer-reviewed journals. Moreover, the inclusion criteria used in this systematic review were relatively strict – we were look - ing specifically for papers describing quantitative studies on the impact of endometriosis at paid work. Probably, other papers (for instance based on qualitative studies) could also enhance the discussion on the issue. Summary We recommend further studies on the impact of en - dometriosis on occupational functioning. Yet, we be - lieve researchers should no longer ask whether endo - metriosis has an adverse impact on the work life of the suffering women because it has already been unambig- uously confirmed. More urgently, they should search for individual and organizational correlates of the opti- mal occupational functioning despite the illness. Espe - cially, studies on the attitude and awareness of the peo- ple surrounding women with endometriosis constitute an important future research direction. Indicating the range of productivity loss or work ab- sence in this group and its relation to economic costs for national budgets is another important issue be - cause nothing is that persuasive as money. Unlike in some other countries [23], such calculations have not been done in Poland yet. We believe that the arguments based on exact figures would be the most convincing for stakeholders (politicians, insurers, healthcare pro - fessionals and employers) to undertake preventive and corrective measures such as improving the diagnostic processes or increasing the social awareness of the en - dometriosis.

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