Discussion
The main purpose of this research was the effect of HRQoL on symptoms of Depression, Anxiety and Stress in women with Endometriosis, with Personality as a mediating factor. The results showed that the HRQoL significantly affects the symptoms of Stress and Anxiety, but not Depression. Worse HRQoL predicts increased symptoms of Stress and Anxiety but not Depression. Thus, the first research hypothesis is supported except for the symptoms of Depression.
This new finding presents new statistical data for the literature, since the importance of HRQoL in the symptoms of Stress is shown. This relationship may be explained by previous research that found that women with Endometriosis consider their disease to define their lives (12). Endometriosis diminishes HRQoL (16) and can reduce wellbeing (6), the predictive relationship found in this research is of great value, since it links the impact of the disease on the quality of life and the psychological well-being of women with Endometriosis. Also, the link found in this study emphasises the importance of psychological support in women with Endometriosis. As shown by the research of Farshi et al.21 counselling with self-care as its core can reduce anxiety symptoms. Thus, since the present research showed that health-related quality of life is linked to stress and anxiety levels, it is important in any psychological support given to women with Endometriosis to explore self-care. These research findings also support the theory of Facchin et al.8 where the daily life of women with Endometriosis is disrupted to a great extent, resulting in Stress and Anxiety. The lack of a significant effect of HRQoL on symptoms of Depressions could be due to the majority of the participants reporting low levels of depressive symptoms.
Another noteworthy result of this research was the significant effect of the subscale Pain on Stress. Research has previously shown that women with Endometriosis experience pain due to the disease on a daily basis (5). Therefore, the predictive relationship between the Pain subscale of HRQoL and Stress levels is a very important finding for the literature, as it emphasises the power pain has on mental wellbeing. Future research could investigate in more depth the levels of pain in Endometriosis and how they affect psychological wellbeing. Moreover, this research showed a significant effect of the subscale Control and Powerlessness on Stress levels. This finding supports the relationship between the Control and Powerlessness scale with subjective well-being shown by the research of Rush & Misajon15. The unpredictable nature of Endometriosis and the physical exhaustion it causes, leads to loss of control and total inability to do various activities, which increases Stress levels.
Furthermore, it was found that Neuroticism as a mediating factor between Stress symptoms and HRQoL showed moderate statistical significance. It was also found that Neuroticism as a mediating factor between HRQoL and Anxiety symptoms showed significant statistical significance with a large effect. Meaning, when HRQoL is low and Neuroticism levels are high, Anxiety and Stress symptoms are reduced. When HRQoL is worse, levels of Neuroticism are lower and Anxiety and Stress symptoms are increased. Research has shown that Endometriosis can be a ‘continuous battle’ as the disease makes it extremely difficult for women to maintain their everyday life (13). The ”sickness response” from a biopsychological point of view, involves behavioral changes (10). These studies can partially support this relationship. Despite this, the interesting relationship between Neuroticism and Stress and Anxiety symptoms do not support previous findings that found that high Neuroticism levels can predict high Anxiety and Stress levels in women with Endometriosis. The reason for this result in the present research may be due to the low levels of Anxiety and the high levels of Neuroticism presented by the participants. People with high levels of Neuroticism usually present negative feelings and constant worry (30) and this research presents findings which are very unpredictable. One theory that could possibly explain this predictive relationship is Bury’s18 adaptive theory. Although it is quite an antiquated theory, it may contribute. According to this theory women with Endometriosis have to adapt and modify their identity in order to cope with the unpredictability that follows with the start of their Endometriosis symptoms. Thus, the relation between high levels of Neuroticism and low levels of symptoms of anxiety and stress may be due to this adaptation in behavioural patterns to be able to survive the intense pain that may come with Endometriosis. Endometriosis is a disease that in the long term can change the sense of personal identity, since women have to adapt to be able to face the difficulties that the disease brings (19).
Overall, this research has introduced new information about Endometriosis and its link with mental health and personality characteristics. Although the effect of the mediating factor Neuroticism that was found was unpredictable it is still a noteworthy finding which can add to the literature. The main outcome of this study is that HRQoL can predict symptoms of Stress and Anxiety and Neuroticism levels can affect this relationship. Some of the limitations of this study may have affected the results. It has to be acknowledged that the sample of 47 women is quite small so the findings need to be generalised with caution. The many symptoms of Endometriosis could also have affected the results as the severity of the disease was not investigated in this study. Despite these limitations, this research is one of the first studies on mental health in Endometriosis in the Cypriot population.