Anxiety in Women with Endometriosis -A Cross-sectional Study

: Aim: The present study aims to assess the anxiety in endometriosis women. Background: Endometriosis is a disease with chronic pain due to the presence of endometrial-like tissue in other organs of the body. Pain and infertility can reduce the quality of mental health in women’s underlying endometriosis. Objectives: The present study wants to assess anxiety in endometriosis women and compare it with healthy women in Arak City in 2023. Methods: The current research was conducted using a cross-sectional method. Eighty-four records of women who were diagnosed and treated by laparoscopy in one of the referral hospitals were included. In the control group, women who were referred to health centers for an annual checkup without any history of endometriosis were recruited for the study. They were entered into the study by convenience sampling. Two groups filled out the demographic and Anxiety Beck Inventory in 15 minutes. Data was analyzed through descriptive and inferential statistics using chi-square and t-tests using STATA software. Results: The results showed that the mean age of patients in the case and control groups was 31.5 ± 5.7 and 31.1 ± 6.1, respectively (p=0.57). Findings revealed that there was a statistically significant difference in the mean scores of FSFI between the case and control, respectively (23.08 ± 6.1vs 24.47 ± 6.6; p=0.031). Conclusion: The present study showed that women with endometriosis still experience more anxiety after surgery than healthy women. Therefore, the reasons for women's anxiety should be identified during consultations, and drug and non-drug treatment methods should be used to reduce their anxiety.


INTRODUCTION
Endometriosis is a disease with chronic pain due to the presence of endometrial-like tissue in other organs of the body, including ovaries, fallopian tubes, and pelvic cavity.The prevalence of this disease in the world includes 10% of women of reproductive age [1].The most common clinical symptoms of this disease are dyspareunia, dysmenorrhea and infertility [2].Laparoscopy and hormonal treatments are common methods of treating endometriosis.Due to the fact that the drug treatments for this disease are long-term, many patients may stop the treatment.Frequent recurrent after stopping the treatment and pelvic pains decrease the mental health of these women.Fear of stigmatizing symptoms associated with menstruation, decreased sexual activity, decreased self-esteem, negative sexual thoughts about intercourse, avoidance of sexual activity, inability to conceive, or worry about future infertility can exacerbate psychological distress [3][4][5].Because this disease affects the marital relationship of couples, women's work and education, it can reduce the quality of life of women [6].Studies show that one-third of women with endometriosis suffer from psychological problems and need therapeutic inter-ventions [7].Depression is more common in women than men, and if women have chronic pain, the risk of depression will be higher [8,9].A study showed that women with chronic pelvic pain were 1.5 times more depressed than women in the control group [10].Also, studies show that infertile women suffer from mental illnesses, including anxiety and depression, more than other women [11,12].Twenty-eight articles reviewed in women with endometriosis showed a prevalence between 10% and 98% for depression symptoms, and 11% to 88% for anxiety.The quality of life in patients with endometriosis was significantly reduced [13].Many studies show that women who have not undergone endometriosis surgery suffer from psychological problems, including anxiety [14,15], but few studies show that mental health has improved after surgery [16].Since women with endometriosis have both symptoms of chronic pelvic pain and infertility, it is expected the a high level of mental problems, including anxiety.Therefore, this study was conducted to investigate the level of depression in 2 groups of healthy women and women with endometriosis under the treatment.

Study Design
This cross-sectional study was conducted in Arak, Iran.

Setting of the Study
The case group entered the study from Taleghani Maternity Hospital by census sampling in Arak, one of the cities in Markazi Province, Iran.The control was selected from 5 regions of Arak city health centers and then sampling was done from each of the selected clinics in proportion to the covered population.This sampling was done by convenience method.

Patients
Eighty-four records of women who were diagnosed and treated by laparoscopy in one of the referral hospitals in Arak City were recruited to study.Sampling was done from 2017 to 2020.
All patients had no history of chronic diseases.All patients reported characteristic symptoms of endometriosis, such as dysmenorrhea, pelvic pain, dyspareunia or dyschezia at the time of surgical treatment.Patients were invited to participate in the study through call number.Anxiety was measured at least 6 months after surgery.In the control group, women who were referred to health centers for annual checkups, without any history of endometriosis were recruited to the study.They were entered into the study by convenience sampling.

The Sampling Method
Out of 110 patients, 84 cases met the inclusion criteria and signed a written consent form after informing the study's goals and ethical considerations.Sixteen patients did not meet the inclusion criteria and 10 patients did not sign the informed consent.Finally, 84 patients participated in this study.In the control group, convenient sampling was done by the researchers.

Inclusion Criteria
The criteria of the case group include having been diagnosed with endometriosis and having undergone laparoscopy, ages between 20 and 40 years, not having any chronic or acute diseases under treatment, not having other gynecological diseases, not having mental illness and being treated, and not having addictions.In the control group, all were confirmed except that they did not have a history of endometriosis.

Sample Size
Two-fold sample of case group was considered for the control group.160 samples were sampled, but 141 filled out the questionnaire completely.

Data Collection Tools
The questionnaire was composed of questions regarding demographic and obstetric history.Anxiety was measured by the Beck Anxiety Inventory (BAI).This scale contained a 21-question multiple-choice.Score of 0 -21 = low anxiety score of 22 -35 = moderate anxiety Score of 36 and above = potentially concerning levels of anxiety.Test-retest reliability, an internal consistency, in Iranian people were (r = 0.67) and (α =0.88), respectively [17].

Implementation
After obtaining the ethical code from the Arak University of Medical Sciences, the control group was selected from 5 health centers that were randomly selected from the north, south, east, center, and west of the city.From each center, between 25-35 women were recruited after signing informed consent by using the convenience sampling method.Sampling was collected from January 2017 to February 2020.The sampling was performed by one of the researchers, who was a midwife.Data gathering was performed by demographic and Beck Anxiety Inventory (BAI).In case group, sampling was done in a maternity hospital.They were invited to the hospital  to fill out the questionnaires.The main outcome was an assessment of anxiety.Two groups filled out the demographic and BAI questionnaires in 15 minutes.Data were analyzed through descriptive and inferential statistics by chi-square and t-test by STATA software.
The BAI scores revealed that 15.16 (10.52) of the women in case and 7.82 (7.48) in control presented anxiety, 16 (21.3) in endometriosis vs 5 (3.5) in healthy women had sever anxiety (Table 2).

DISCUSSION
This study showed that there was a significant association between endometriosis and anxiety.In the study including 91,530 women with endometriosis, the highest odds ratio of experiencing anxiety appeared in this group (OR = 2.719, 95% CI 2.481-2.979)[9].In a study, 81 women with pelvic pain were studied, of which 40 had endometriosis and 41 had non-endometriosis chronic pain.All patients filled the state-trait anxiety inventory [STAI].
Based on the results of the study, endometriosis patients showed higher anxiety than women with other patients with chronic pain [18].A systematic review study, resulting in 1,837 records, showed that endometriosis patients experienced significant anxiety compared with healthy controls, but no differences were found comparing endometriosis patients with other chronic pelvic pain patients for anxiety [19].In contrast to these studies, one study showed that the state of anxiety in women with endometriosis did not significantly differ with healthy women [20].Studies show that inflammatory reactions in endometriosis patients and chronic pain cause disturbances in the hypothalamus-pituitary-adrenal (HPA) axis, which leads to a decrease or increase in blood cortisol.Both decrease and increase of cortisol are a sign of disorder in this axis, and they are associated with different psychopathologies [21].Eriksen et al. could not find any correlation between pain and anxiety and depression symptoms as an emotional response to endometriosis, but women with chronic pain had increased anxiety and depression levels [22].
Anxiety plays an important role in reducing selfconfidence, self-worth and peace in women's marital relationships.Also, they experience a lot of anxiety during the diagnostic and treatment planning stages, which usually causes significant psychological effects on patients.The specific factors affecting anxiety levels are still not well understood, although diagnostic delay, disease symptoms such as chronic pain, uncertainty of treatment, and consequences such as infertility seem to play a decisive role [23].One study showed that creating a trustful relationship between health workers/specialists with women and providing them with the appropriate counseling methods could reduce baseline anxiety levels [23].

CONCLUSION
The present study showed that women with endometriosis still experience more anxiety after surgery than healthy women.Therefore, the reasons for women's anxiety should be identified during consultations, and drug and non-drug treatment methods should be used to reduce their anxiety.There are limitations in the study.We included more than 97% of marital women, which may be influenced by marital status, and all samples were selected from referral center, which influenced the study generali-zation.We recommend more studies in this field.

Table 1 . Demographic and obstetric variables in endometriosis and healthy women.
Note: *chi-square.