Demystifying and Addressing The Familiar Pain: Endometriosis and Mental Health
By: Lauren Simmons
It is a Saturday morning, the sun is streaming through your blinds, and your clock reads 9:45 a.m. You slept in. In a panic, you quickly reach for your morning medication, but you know it is already too late. That familiar, barbed-wired feeling has already begun to make its way into your lower abdomen, cutting into your insides like a searing-hot knife. Your vision blurs as you tap out three ibuprofen tablets into your shaking palm and swallow them in a hurry. It is going to be a very long day.
For a person living with endometriosis, this scenario can be their daily reality. Endometriosis is a gynecological condition where uterine cells grow outside of the uterus, resulting in chronic pain episodes that usually occur in tandem with one’s period but can also happen at random. The erratic nature of endometrial pain can leave individuals compromised and unable to function for several hours when they least expect it. Because of this reality, individuals suffering from endometriosis live with the constant stress of possibly being rendered helpless and in pain at any time.
Within the past decade, researchers have been studying just how much endometriosis affects mental health and, subsequently, if the resulting psychological determinants have an effect on the level of chronic pain experienced.
In 2012, at the Ponce School of Medicine and Health Sciences in Puerto Rico, a team of researchers conducted a study on whether or not stress affects the severity of endometriosis symptoms (Cuevas, et al., 2012). Using female Sprague-Dawley rats as their model organism, they placed a sample of about ten rats in a confusing water maze every day for ten days with the intent of inducing high stress levels in the rats. After ten days, the rats in this “endo-stress” group underwent a surgical procedure where the connective tissue found at the intersection of the uterus and fallopian tubes was sutured to the intestines, thereby giving the rats endometriosis. After two months, by taking cellular samples of the lining of the rats’ abdomens, the researchers compared the endo-stress group to an endo-no stress group that underwent the same surgery without experiencing any stressors (Cuevas, et al., 2012).
The rats exposed to over a week of high-intensity stress developed 25% more extracellular vesicles than the no-stress group. 50% of these vesicles were much larger than the standard diameter found in the no-stress group (Cuevas, et al., 2012). Extracellular vesicles have historically been indicators of disease progression in many chronic conditions and have been assumed to act in a similar way in relation to endometriosis (Khalaj, et al., 2019). The endo-stress rats also had increased levels of inflammation and colon damage (Cuevas, et al., 2012). Additionally, most of the rats were surgically given endometriosis during the proestrus (pre-ovulation) stage of the menstrual cycle and therefore would then be expected to be in proestrus again two months later. However, it was observed that the majority of endo-stress rats had progressed into the estrus stage when they should have been in proestrus. This may suggest that high-stress levels may lead to shorter, or quicker, menstrual cycles. This change in menstrual timing was not observed in the no-stress rats. In conclusion, there is a statistically significant correlation between stress and the development and severity of endometriosis, as well as a correlation between stress and the timing of the menstrual cycle in general (Cuevas, et al., 2012).
While these findings provide important insight into how medical professionals can better examine and diagnose people with endometriosis, this study examines only one side of this double-edged sword. What about when the condition of living with endometriosis itself damages the patient’s mental health?
To find an answer, we must visit Milan, Italy where Dr. Facchin and her colleagues are asking the very same question. In 2014, this research team launched a study on how living with endometriosis affects the quality of one’s mental health and livelihood (Facchin, et al., 2015). Their experiment focused on psychological measures gathered through psychometric tests and their correspondence to the severity of the patient’s endometrial pain in the pelvic area. Three groups were studied: participants with endometriosis and painful symptoms, participants with endometriosis and no painful symptoms, and participants without endometriosis. All three groups were given two psychometric tests that measured the participant’s overall quality of life, any symptoms of depression, and any symptoms of anxiety (Facchin, et al., 2015). The hypotheses being tested in this study are as follows:
“…the ‘disease-focused hypothesis’, women’s quality of life and mental health will be negatively influenced by the fact of having a chronic inflammatory disease such as endometriosis… [and] the ‘pain-focused hypothesis’, women’s mental health and quality of life will be negatively affected only by the presence of pelvic pain associated with endometriosis” (Facchin, et al., 2015).
The study’s results rejected the disease-focused hypothesis and failed to reject the pain-focused hypothesis. It was found that the participants with endometriosis and painful symptoms had poorer self-reported quality of life and experienced more symptoms of depression and anxiety. There was no significant difference in psychometric results between the group with endometriosis and no painful symptoms and the healthy control group. These results were found to be statistically significant via MANCOVA mean comparison tests (Facchin, et al., 2015).
When analyzing these two studies, it is important to consider the demographics and size of the sample populations. Both studies used very small sample sizes, with n = 9-10 per group in Dr. Cuevas’ study and n = 171 for all three groups in Dr. Facchin’s study. Also, in Dr. Facchin’s study, all the participants were Italian, caucasian cis-gendered women. This sample population is not representative of the general population here in the United States or globally.
These studies on the relationship between mental health and endometriosis are two of only a handful of studies in this field. Therefore, it is crucial that we use their findings to construct and fund larger projects around the world that can be applied to many more populations. Without the continuation of important research like this, healthcare providers in obstetrics and gynecology will be missing out on integral insight into how to improve their care and understanding of patients living with endometriosis and pelvic pain.
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Cuevas, M., Flores, I., Thompson, K., et al. (2012, August). Stress exacerbates endometriosis manifestations and inflammatory parameters in an animal model. Retrieved March 24, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046310/
Facchin, F., Barbara, G., Saita, E., Mosconi, P., Roberto, A., Fidele, L., & Vercellini, P. (2015, August 27). Impact of endometriosis on quality of life and mental health: Pelvic pain makes the difference. Retrieved March 25, 2021, from https://www.tandfonline.com/doi/full/10.3109/0167482X.2015.1074173
Khalaj, K., Miller, J., Lingegowda, H., Fazleabas, A., Young, S., Lessey, B., . . . Tayade, C. (2019, September 19). Extracellular vesicles from endometriosis patients are characterized by a unique mirna-lncrna signature. Retrieved March 24, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795291/