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.