Self-esteem, quality of life, and physical activity in women with diagnosed endometriosis: a pilot study in an Italian sample

Endometriosis is a pathological condition where endometrial tissue that normally grows inside the uter- us is also found outside the uterus, causing chronic pelvic pain [1]. Women with endometriosis tend to experience painful periods, chronic lower abdominal pain, infertility, and dyspareunia [2]. Since the diag - nosis of endometriosis is often based on reported symp- toms, as the occurrence of pain, its identification is characterized by a delay of almost 10 years [3], leaving women in a depressed or frustrated mood [4]. t here- fore, women with diagnosed endometriosis may expe- rience problems in their social, sexual, and emotional daily life. A meta-analysis performed by Jia et al. [5] reports a significant impairment of women’s health- related quality of life, finding a negative correlation with pelvic pain intensity. t he negative impact of this pathology on quality of life may turn into impairment of self-esteem since the symptoms experienced may limit women’s daily activity, with a sense of general dissatisfaction con - cerning the self, described as a collection of attitudes towards one’s personal characteristics and potentiali- ties [6]. Some studies described low self-esteem as a consequence of infertility and in relation to mother- hood [7], to dyspareunia, and to lack of sexual relation- ship [8]. Only one study relating self-esteem to the A. bianco et al., Health of women with endometriosis HUMAN MOVEMENT 94 Human Movement, Vol. 22, No 4, 2021 humanmovement.pl experience of pain was found [9], reporting a non-sig- nificant correlation. Finally, as presented by bonocher et al. [10], physi- cal activity has been used to reduce painful symptoms in diseases involving inflammatory processes. t here- fore, the authors reviewed the literature for assessing the relationship between physical exercise and the prevalence and/or improvement of the symptoms as - sociated with endometriosis. Unfortunately, owing to the small number of studies existing on endometriosis, these results were inconsistent. Conversely, stretching activities, as yoga, seem to have beneficial effects on quality of life and chronic pelvic pain [11]. Even though quality of life of women with diag - nosed endometriosis has been already investigated, there is a lack of studies on a general evaluation of self- esteem and endometriosis. the retrieved studies asso- ciated endometriosis with specific symptoms or con - ditions (pain, infertility, dyspareunia, distress), but since it can manifest differently from woman to wom- an, a general evaluation of self-esteem could be useful to understand if there is a common feature in women who are affected by this pathology. t hus, the current study aimed at evaluating self-esteem, quality of life, smoking and alcohol habits, and frequency of physical activity in a sample of women with diagnosed endo - metriosis. Specifically, we expected that women with diagnosed endometriosis would experience a lower quality of life and lower self-esteem than the Italian population.

Participants Data were collected at the gynaecologic unit of the ARNAS Civico of Palermo hospital. All women who received a diagnosis of endometriosis in the hospital unit underwent assessment at a medical visit. the sam- ple was composed of 36 women aged 19–53 years (mean age: 36.97, SD = 8.22). the information was collected during a face-to-face interview at the hospital unit. the Italian personal data protection code (DL196/2003) was applied. Measures Rosenberg Self-Esteem Scale Self-esteem was investigated with the Rosenberg Self-Esteem Scale [12], a questionnaire consisting of 10 items, each with a 4-point Likert scale (from 1 = ‘t otally disagree’ to 4 = ‘t otally agree’), for a maximum total score of 40 points. t he Italian standardization provides a good reliability of the measure and indicates normative data depending on gender, educational level, marital status, and occupation. For the purpose of the study, the normative data for Italian women derived from the standardization were used as a reference category. Short Form (36) Health Survey Health-related quality of life was measured with the Short Form (36) Health Survey (SF-36) [13], which consists of 36 questions divided into 8 scales relat - ing to: physical functioning (10 items), role limitation owing to physical health (4 items), role limitation ow- ing to emotional problems (3 items), vitality (4 items), emotional well-being (5 items), social functioning (2 items), bodily pain (2 items), and general health (5 items). t he Italian standardization of the question- naire was used, and the scores were calculated with the procedure suggested by Ware and Sherbourne [14]. Questionnaire on sociodemographic data, lifestyle, and habits A questionnaire concerning sociodemographic data, lifestyle aspects, and habits was administered. It con- sisted of a sociodemographic part regarding age, height, weight, educational level. the other part included ques- tions related to sleeping hours per night (‘How many hours do you sleep per night?’), smoking habits (‘Do you smoke?’ with possible answers: Yes/No; if yes, ‘How many cigarettes do you smoke per day?’), phys- ical activity (‘How many hours of physical activity do you practice weekly?’), and alcohol consumption (‘Do you drink alcohol?’; if yes, ‘How many glasses of alco- holic drinks do you consume weekly?’). Data analysis Descriptive statistics were calculated for all the variables involved in this study. One sample t -test was used to compare the scores detected through our measures with the normative data for the population [12, 13]. t he significance level was set at = 0.05. t he Statistica software (version 10 for Windows) was applied. Ethical approval t he research related to human use has complied with all the relevant national regulations and institu - A. bianco et al., Health of women with endometriosis HUMAN MOVEMENT 95Human Movement, Vol. 22, No 4, 2021 humanmovement.pl tional policies, has followed the tenets of the Decla - ration of Helsinki, and has been approved by the Sport and Exercise Science Research Unit of the University of Palermo. Informed consent Informed consent has been obtained from all indi- viduals included in this study.

Descriptive statistics are presented in t able 1. t he participants belonged to normal weight category of body mass index (mean: 23.7, SD = 3.66) and had low to medium education degree (only 2 individuals had university graduation). t he average number of sleeping hours was 6.68 hours/night ( SD = 1.54). Only 4 women (11.1%) declared to dedicate some time to physical activity, with an average of 5.33 hours per week (SD = 3.21). Out of the 36 patients, 16 (44.4%) regularly smoked cigarettes, with an average of 10.6 cigarettes per day ( SD = 6.07). Concerning alcohol consumption, 31 women (86.1%) declared not to con- sume alcohol regularly, while 5 women (13.9%) reported that they drank 1 glass of alcoholic beverages per week. t he comparison with the normative scores for the population returned non-significant differences con - cerning the following SF-36 scales: role limitations owing to physical health, bodily pain, general health, social functioning, role limitation owing to emotional problems, and emotional well-being. Significant dif - ferences were found with reference to vitality, where the women obtained lower scores compared with the normative data for the population (t = –3.24, p = 0.003), and physical functioning (t = 3.64, p < 0.001). Self-es- teem levels were higher in our sample than the results for the general population of women with low-to-me- dium educational level (t = 5.65, p < 0.001). Although the scores did not reach the significance, it should be noted that women reported lower general health. t able 1. Descriptive statistics of the sample and comparison with normative data Demographic characteristics Mean (SD) Age (years) 36.97 (8.22) Height (cm) 164.70 (6.47) Weight (kg) 64.29 (11.27) Sleeping hours/night 6.68 (1.54) Education Frequency Percentage Elementary school 5 13.9% Middle school (10–13 years) 16 44.4% High school 13 36.1% University 2 5.6% Lifestyle habits Frequency Percentage Smoking (yes) 16 44.4% Alcohol consumption (yes) 5 13.9% Sport practice (yes) 4 11.1% SF-36 scales Sample mean (SD) Normative data mean (SD) Mean difference t p Physical functioning 91.67 (11.89) 84.46 (23.18) 7.21 3.64 < 0.001** Role limitation owing to physical health 84.29 (35.92) 78.21 (35.93) 6.08 1.00 Non-significant Role limitation owing to emotional problems 84.31 (35.99) 76.16 (37.25) 8.35 1.32 Non-significant Vitality (energy/fatigue) 52.22 (17.90) 61.89 (20.69) –9.67 –3.24 0.003* Emotional well-being 60.56 (20.06) 66.59 (20.89) –6.03 –1.80 Non-significant Social functioning 84.02 (27.81) 77.43 (23.34) 6.60 1.42 Non-significant bodily pain 73.89 (24.11) 73.67 (27.65) 0.22 0.05 Non-significant General health 59.71 (30.92) 65.22 (22.18) –5.51 –1.05 Non-significant Self-esteem 25.86 (5.20) 30.89 (not reported) 4.97 5.65 < 0.001** * p < 0.05, ** p < 0.001 A. bianco et al., Health of women with endometriosis HUMAN MOVEMENT 96 Human Movement, Vol. 22, No 4, 2021 humanmovement.pl

t he current study aimed to compare self-esteem and quality of life dimensions of women with diag - nosed endometriosis with normative data obtained for the general population. Moreover, we wanted to detect the patients’ lifestyle characteristics, particularly referring to physical activity. Our sample consisted of 36 women treated in the gynaecologic unit of the Civico Hospital, one of the main hospitals in Palermo. t he results contradicted our main hypothesis of lower self-esteem in women with diagnosed endome- triosis, and partially contradicted also the one related to a lower quality of life. In fact, our sample presented high levels of self-esteem and a normal quality of life, except for the scale of vitality, where the results turned out lower than the normative scores. Also, women re- ported lower general health compared with the gen - eral population, even if this difference did not reach statistical significance. As for the patients’ habits, the group was characterized by a high presence of smokers, with an average of more than 10 cigarettes per day; only a few individuals practised sports. With regard to self-esteem, a few studies treating self-esteem as a predictor or consequence of specific endometriosis symptoms have been retrieved [7–9, 15]. Conversely, we aimed to obtain a general evaluation of self-esteem in women affected by endometriosis, independently from the experienced symptoms. Our study found a high self-esteem level among the 36 women with endometriosis. Moreover, the severity of the symptoms should also impact on women’s quality of life [1, 4]. In our study, we observed a lack of energy in women with diagnosed endometriosis, but they re- ported normal levels, sometimes higher, in the other dimensions of quality of life. t hese results should be interpreted under a cul - tural light: data were collected in a hospital situated in a poor area of the city, were people present a low so- cioeconomic status and low education level (21 partici- pants went to school until the age of 13 years, while 13 gained a high school diploma). Since these indi - viduals were characterized by scarce communicating skills, it is very likely that our results could have been biased for this cultural issue. Even if some women experienced pain or felt to be less capable than the others, the tendency was to suppress these thoughts and to rate oneself as better than the others. t he aim of the current research was to gain infor - mation useful for planning a future study about women with diagnosed endometriosis, their self-esteem, quali- ty of life, and physical activity. For this reason, some

should be considered for the next phases. First of all, a bigger sample will be recruited by con - tacting participants from different Italian cities. It is more likely that employing a bigger sample, with het- erogeneous characteristics concerning age and edu - cation, could lead to different results. Additionally, more information about the diagnosis of endometrio- sis should be collected, e.g. when it was detected, when the symptoms started, and what diagnostic methodol- ogy was used. Moreover, we plan to obtain more de - tailed information on pain intensity and pain locali - zation, as well as to establish if this pain relates to an impairment in physical tasks. A section with more specific questions on physical activity will be included. Furthermore, as previously said, to overcome the cul- tural bias, the sample should be representative in terms of education and socioeconomic status, thus we intend to control these characteristics.

Women with diagnosed endometriosis were charac- terized by high self-esteem and normal quality of life. However, their general health was lower and fatigue was higher than in the general Italian population. Disclosure statement No author has any financial interest or received any financial benefit from this research. Conflict of interest t he authors state no conflict of interest.

1. Lövkvist L, b oström P, Edlund M, Olovsson M. Age-re- lated differences in quality of life in Swedish women with endometriosis. J Womens Health. 2016;25(6): 646–653; doi: 10.1089/jwh.2015.5403. 2. Fauconnier A, Fritel X, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications [in French]. Gynecol Obstet Fertil. 2009;37(1):57–69; doi: 10.1016/j.gyobfe.2008.08.016. 3. Hadfield R, Mardon H, b arlow D, Kennedy S. Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod. 1996;11(4): 878–880; doi: 10.1093/oxfordjournals.humrep.a019270. 4. Sepulcri RdP, do Amaral VF. Depressive symptoms, anxiety, and quality of life in women with pelvic endo- metriosis. Eur J Obstet Gynecol Reprod b iol. 2009; 142(1):53–56; doi: 10.1016/j.ejogrb.2008.09.003. 5. Jia S-Z, Leng J-H, Shi J-H, Sun P-R, Lang J-H. Health- related quality of life in women with endometriosis: a systematic review. J Ovarian Res. 2012;5(1):29; doi: 10.1186/1757-2215-5-29. A. bianco et al., Health of women with endometriosis HUMAN MOVEMENT 97Human Movement, Vol. 22, No 4, 2021 humanmovement.pl 6. Juth V, Smyth JM, Santuzzi AM. How do you feel? Self- esteem predicts affect, stress, social interaction, and symptom severity during daily life in patients with chronic illness. J Health Psychol. 2008;13(7):884– 894; doi: 10.1177/1359105308095062. 7. Facchin F, buggio L, Dridi D, Vercellini P. A woman’s worth: the psychological impact of beliefs about moth- erhood, female identity, and infertility on childless women with endometriosis. J Health Psychol. 2019; 1359105319863093; doi: 10.1177/1359105319863093. 8. Denny E, Mann CH. Endometriosis-associated dys - pareunia: the impact on women’s lives. J Fam Plann Re- prod Health Care. 2007;33(3):189–193; doi: 10.1783/ 147118907781004831. 9. Christian A. t he relationship between women’s symp- toms of endometriosis and self-esteem. J Obstet Gynecol Neonatal Nurs. 1993;22(4):370–376; doi: 10.1111/ j.1552-6909.1993.tb01817.x. 10. bonocher CM, Montenegro ML, Silva JCRE, Ferriani RA, Meola J. Endometriosis and physical exercises: a sys - tematic review. Reprod b iol Endocrinol. 2014;12(1):4; doi: 10.1186/1477-7827-12-4. 11. Gonçalves AV, barros NF, bahamondes L. t he practice of hatha yoga for the treatment of pain associated with endometriosis. J Altern Complement Med. 2017;23(1): 45–52; doi: 10.1089/acm.2015.0343. 12. Prezza M, t rombaccia FR, Armento L. t he Rosenberg Self-Esteem Scale: Italian translation and validation [in Italian]. Giunti Organizzazioni Speciali. 1997;223: 35–44. 13. Apolone G, Mosconi P. the Italian SF-36 health survey: translation, validation and norming. J Clin Epidemiol. 1998;51(11):1025–1036; doi: 10.1016/s0895-4356(98) 00094-8. 14. Ware JE Jr, Sherbourne CD. t he MOS 36-item short- form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30(6):473–483. 15. Facchin F, barbara G, Dridi D, Alberico D, b uggio L, Somigliana E, et al. Mental health in women with en- dometriosis: searching for predictors of psychological distress. Hum Reprod. 2017;32(9):1855–1861; doi: 10.1093/humrep/dex249.