Introduction
Endometriosis is a chronic disease in which the endometrial cells that cover the body of the uterus, which show secretory activity, are outside the uterus(1). The cells react to the hormonal changes that occur during the menstrual cycle, which leads to chronic inflammation(2). Symptoms of Endometriosis include severe pain during menstruation (dysmenorrhoea) and during intercourse (dyspareunia), dysuria, dyschesia, chronic fatigue, and possible infertility. Infertility is related to the negative impact on the physical, mental, sexual, and social well-being of the affected women (3). Negative effects of Endometriosis include increased emotional and psychological distress, decreased emotional well-being and sleep quality, and higher risk and severity of depression and anxiety symptoms (4,5). Women with Endometriosis may also experience fluctuations in stress levels, increased stress perception andstress levels (6). Infertility is the second most researched factor hypothesized to contribute to depression or anxiety in women with Endometriosis (7). Facchin et al.8 in their qualitative study on how Endometriosis affects mental health explain that the disruption of everyday life due to the symptoms of the disease, create intense anxiety and stress in the patients (9). A biopsychological research has shown that peripheral immune changes caused by Endometriosis may stimulate the central nervous system to cause the so-called ”sickness response”, which includes behavioral changes, depression-like behavior, fatigue, irregular appetite, sleep, anhedonia, and sadness (10). These behaviour changes can negatively affect social interactions and relationship intimacy, which in turn affect the mental wellbeing of women with Endometriosis (11).
Furthermore, Endometriosis-related pain is perceived as uncontrollable and unpredictable, with many women believing that it determines the rhythm of their life (12). A study (13) showed that women with Endometriosis report that since the symptom initiation, their life has been a ‘continuous battle’ between trying to maintain their personal and professional life while dealing with long-term pain. Health-related quality of life (HRQoL) is a multidimensional term that takes into consideration aspects such as somatic, emotional and social functioning (14). Using the Endometriosis Health Profile (EHP-30) a study (15) showed reduced HRQoL especially in the area of social well-being, infertility and sexual intercourse (16). In addition to this, a very recent literature review showed that Endometriosis can disrupt mental health (especially symptoms of depression and anxiety) and reduce both the mental and physical quality of life of women with Endometriosis (17). However, not many studies explore the effect of Endometriosis on HRQoL specifically, which as shown above is a majorly disrupted area in women with Endometriosis.
The long-term conditions of Endometriosis can change one’s sense of personal identity (18). The daily life of women with Endometriosis is greatly disrupted and thus an adjustment in behavioral patterns is required. Studies have shown that women experience disruptions in personal identity as a result of living with Endometriosis (19). Furthermore, intense and unpredictable pelvic pain puts pressure on them to suppress their negative emotions and proceed to ’self-silencing’ (20) and end up ’losing themselves’. A recent study showed that counselling based on self-care significantly reduced stress levels and significantly improved the quality of life of women with Endometriosis (21).
Concerning personality traits a recent study showed that high Neuroticism on the NEO-FFI is associated with severe depressive symptoms in women with Endometriosis (22). Moreover, a study showed that patients with high Neuroticism are more prone to develop chronic pain, which can contribute to the development of symptomatic Endometriosis (23).
The majority of the literature around Endometriosis explores the association between the disease and the development of symptoms of depression, anxiety and stress. However, information is lacking in regard to the relationship between health-related quality of life in Endometriosis and personality traits and their mediating role in the symptoms of depression, anxiety and stress. Therefore, the aim of this study is to investigate the association between HRQoL and the symptoms of depression, anxiety and stress and how personality traits, especially Neuroticism acts as a mediator between them.