Journal of Community Medicine & Health Education
Open Access

Endometriosis, defined as the presence of endometrium like tissue outside the uterine cavity, is a chronic disease affecting women in their reproductive age [1,2]. One of the main symptoms reported by patients is pain that can be expressed in a variety of symptoms, including dysmenorrhea, dyspareunia, and chronic pelvic pain [3]. These symptoms have an adverse impact on social, mental and physical wellbeing. Additionally, the impairment of HRQoL can significantly affect professional and private relationships, sexuality, social contacts, family planning (due to infertility) or psychological well-being [4-6]. Recent studies confirmed that women with endometriosis have a lower HRQoL compared to the general population [2,7,8].

Therapy of endometriosis comprises surgery, hormonal contraceptives or pain therapy. Still, little is known about the quantitative impact of surgery on the patients HRQoL. In the past few years, there has been increasing progress in the development and validation of psychometric questionnaires in order to asses HRQoL of endometriosis patients in clinical routine [9,10]. Several studies on HRQoL in patients with endometriosis have been performed with conflicting results and using different questionnaires. In addition, only a few studies focused on HRQoL in relation to the different forms of endometriosis [11-13]. The 30 item Endometriosis Health Profile (EHP-30) developed by Georgina Jones, is a specific HRQoL scale derived from interviews of patients with endometriosis [14- 16].

The EHP-30 is the best validated disease specific questionnaire for the documentation of endometriosis related impact on patients´ life. This questionnaire is sensitive to changes and is thus a suifigu tool to evaluate treatment effects on the health status of patients with endometriosis [17]. Consequently, the question remains if our therapeutic interventions help to improve those impairments.

Thus, the aim of this study was to determine if surgical therapy of endometriotic lesions results in an improvement of HRQoL in relation to the different forms of endometriosis.

Patients

We included all consecutive patients operated due to suspected endometriosis at the Medical University of Vienna, Austria, between 2014 and 2018, who gave their written informed consent to participate in our study. Inclusion criteria comprised age 18-50 years, histological confirmation of endometriosis and ability to complete the EHP-30 questionnaire. Women with a current malignancy defined as <10 years after breast cancer or <5 years after other malignant tumors, were excluded. Additionally, excluded were patients with infections such as HIV, Hepatitis (A, B, C), tuberculosis, and systemic autoimmune diseases. The respective patient flow chart is shown in Figure 1. The study protocol was approved by the local ethic committee (EK code 1145/2018).

Figure 1: Flow chart of patient’s inclusion.

Classification of endometriosis

Due to the surgical report, patients with histological confirmed endometriosis were categorized based on the rASRM and ENZIAN [18,19] classification, retrospectively. Patients were then divided into four groups; group 1. Peritoneal endometriosis; group 2. Ovarian endometrioma; group 3. Deep infiltrating endometriosis (DIE); and group 4. DIE+ovarian endometrioma [20].

EHP questionnaire

The EHP-30 consists of a 30 item core questionnaire applicable to all women with endometriosis, categorized into five subscales – pain (11 items), control and powerlessness (6 items), emotions (6 items), social support (4 items) and self-image (3 items). In addition, the EHP-30 consists also of modular questions. As this modular part does not apply to all patients, we did not include it in our analysis.

The first evaluation of the EHP-30 questionnaire was performed one day before surgery. The questions referred to the past four weeks before the surgery. Six to ten weeks postoperatively, patients filled in the questionnaire again to evaluate the postoperative patient’s condition.

Statistics

All EHP questionnaires were entered in SciCoMed, exported as an Excel table and then imported into IBM-SPSS. The data was evaluated anonymized. The data of the EHP-30 questionnaire were generated according to the algorithm developed by Jones et al. evaluated in 2001 [15]. Response categories are rated on a five point scale (0–4). Raw scores (the sum of items in each subscale) are translated into a score (each raw score is first divided by the maximum possible raw score and multiplied by 100) ranging from 0 (best possible health status) to 100 (worst possible health status). The maximum value of 100 corresponds to that of the maximum load and 0 means no impairment.

After testing for normal distribution using Shapiro Wilk, all demographic data were given a Q-Q plot (quantile-quantile plot) in a frequency table. Depending on the scaling, the clinical data and categorical variables were given with absolute and relative frequency or by mean and standard deviation (SD). Correlations between socio-demographic and clinical data (age, partnership status, BMI, menarche, menstrual cycle, bleeding intensity, bleeding duration) and the parameters of the EHP- 30 were determined. P<0.05 were considered statistically significant. All statistical analyses were performed with IBM SPSS software version (Vienna/ Austria).

Demographics

Initially, 300 patients suspected of having endometriosis and a planned surgery at the Medical University of Vienna, were screened. Of these, 190 patients had histologically confirmed endometriosis and met the relevant inclusion and exclusion criteria and gave their consent to participate in our study. Due to missing postoperative data, 75 of these patients had to be excluded.

Patient´s characteristics and localization of endometriosis are shown in Table 1.

Table 1: Patient characteristics and localization of endometriosis

EHP-30: Out of the core part of the questionnaire, all categories were analyzed in detail in the total population as well as in the 4 subgroups.

Impact of patient characteristics on EHP-30

A lower BMI was positively associated with "emotional health" (rs=0.251, p=0.007) and "self-image" (rs=0.245, p=0.008). There was a significant negative correlation between partnership status and the emotional health category (rs=-0.191, p=0.041). Patients in a partnership had less negative impact on emotional health status. No significant correlations between age and such as emotional health or pain sensitivity were recorded.

Impact of endometriosis on EHP-30

Additionally, the EHP-30 categories were compared between the four endometriosis subgroups. The highest pre-operative pain levels were observed in patients DIE and DIE+ovarian endometrioma (42,2, ± 22,1). The most significant improvement in respect to EHP-30 was also seen in these categories (-27,8, ± 6,8).

Impact of surgery on the EHP-30

All of the five main categories show a positive change in the quality of life postoperatively (Figure 2): pain (HR 0.78, p<0.001); self-determination (HR 0, 92, p<0.001); emotional health (HR 0, 83, p<0.001); social environment (HR 0, 67, p<0.001); and self-image (HR 0, 47, p<0,001).

Figure 2: Comparison of pre- and postoperative Health related quality of Life (HRQoL) values in the four endometriosis groups. (1) Patients with peritoneal endometriosis; (2) patients with ovarian endometriosis; (3) patients with deep infiltrating endometriosis; (4) patients with deep infiltrating endometriosis + ovarian endometrioma.

Analyzing the five categories regarding the four endometriosis subgroups separately (Figure 3), reveals the most significant improvement in the groups of DIE and DIE+ovarian endometrioma. In the group of ovarian endometrioma there was a significant improvement postoperatively in the categories “pain”, “self-determination” and “emotional health”. In the patients with peritoneal endometriosis, there were no significant changes in any of the five categories.

Figure 3: Changes of EHP-30 scores in the four endometriosis groups during the study period. Values are mean + pos SD shown by vertical bars. EHP subdomains scores range from 0 to 100. Lower score indicates fewer negative symptoms. (1) Patients with peritoneal endometriosis; (2) patients with ovarian endometriosis; (3) patients with deep infiltrating endometriosis; (4) patients with deep infiltrating endometriosis + ovarian endometrioma. (A) Pain scores. (B) Self-determination scores. (C) Emotional-health scores. (D) Social environment scores. (E) Self-image scores. EHP-30, endometriosis health profile-30.

Aim of this study was to evaluate the effect of surgery on the HRQoL of patients with endometriosis. Using the EHP-30 questionnaire in the whole study group, we determined that all of the five main categories show a positive change and thus improvement of quality of life after laparoscopic surgery.

HRQoL changes were also calculated separately in the four subpopulations (peritoneal, ovarian, DIE and DIE+ovarian endometrioma). Significant improvements were seen in the categories "pain", "self-determination" and "emotional health" in all subgroups, except in the group of patients with peritoneal endometriosis.

In the categories “social environment” and “self-image”, there was only a significant change in the groups of DIE and DIE+ovarian endometriosis. We observed, that patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms. Due to the more pronounced preoperative clinical symptoms particularly in DIE and DIE+ovarian endometrioma, surgical improvement seems to result in a greater change in the score and consecutively a greater improvement in the quality of life. Thus, the results of this study highlight that especially patients with DIE and DIE+ovarian endometrioma benefit from a surgical intervention. A limitation of this study is the low patient number. Studies with larger subpopulations are thus required to validate our findings.

In clinical practice, routine evaluation of HRQoL in women who suffer from endometriosis is essential, both, for the health care provider and the patient [21]. In this study, longitudinal data of quality of life was obtained from a total of 115 patients with endometriosis. The median age of the recruited patients was 33 years, comparable to similar studies reporting an average age of 34 years [9,22,23]. Most of the included patients were in a partnership, a factor known to increase the probability of consulting a doctor because of painful intercourse or the desire to have children [15]. There was no correlation between age and “emotional health” (rs=-0.154 p=0.101). In contrast to another similar Austrian study in which older age led to deterioration in emotional health [15]. A negative correlation between the BMI and “emotional health” or “self-image” was recorded, which means that a higher BMI led to a deterioration in emotional health and self-image. This finding has also been confirmed by another study [10].

Our data is comparable to the study by Jones et al published in 2004, the greatest positive change in the total population was revealed in the aspect of "self-determination" [9].

One of the strengths of our data is that only patients with histologically confirmed endometriosis were included. In another study by Khong et al., patients with only suspected endometriosis due to pelvic pain or infertility were included in an EHP-30 questionnaire study [16]. Furthermore, one additional strength lies in the preoperative and postoperative collection of the data, which was not carried out in other studies [12]. In addition, our collective is part of a prospective cohort design of well characterized endometriosis patients [24].

However, due to the short follow up period (6-10 weeks), no statement about the long term effect can be given. In this regard, further studies are needed to assess the effectiveness of an operative treatment over a longer period. It should also be noted, that the questionnaires are always answered from a subjective perspective. Since the content validity of the EHP-30 is high, the results based on the questionnaire can be regarded as relevant despite the subjective answers. Nevertheless, it should be noted that many patients have been living with impairments in HRQoL such as pain for years and in some cases have learned to deal with its draw backs.

Confirming previous data our study highlights that the EHP-30 can be regarded as a reliable instrument that reacts sensitively to changes. The preoperative and postoperative values can be used to determine the individual effect of surgical therapy regarding different types of endometriosis [9,17,25].

Endometriosis is one of the most common gynecological illnesses causing extensive psychological, physical and social impact on patient´s life and exerts negative effects on health related Quality of Life (HRQoL). The effects of surgery on the postoperative HRQoL in the different endometriosis subgroups have not been fully evaluated.

A comparative retrospective study between 2014 and 2018 was performed at the Medical University of Vienna.

A total of 115 patients with surgically confirmed endometriosis had completed the standardized Endometriosis Health Profile 30 (EHP-30) questionnaire preoperative (the questions refer to the four weeks preoperatively) and six to ten weeks postoperatively. All five categories regarding postoperative conditions showed significant benefits compared to preoperative values: “pain” (HR 0.78, p<0.001); “self-determination” (HR 0,92, p<0.001); “emotional health” (HR 0,83, p<0.001);” social environment” (HR 0,67, p<0.001); and “self-image” (HR 0,47, p<0,001). In patients with only peritoneal endometriosis were no significant changes in any of the categories. In the subgroups deep infiltrating endometriosis (DIE) and DIE+ovarian endometrioma, surgical intervention results in a significantly greater improvement in all categories of EHP-30 compared to ovarian endometrioma without DIE or peritoneal endometriosis. Long term effects are not reported due to the chosen postoperative time (six to ten weeks). Questionnaires only show the subjective view of the patient’s pain, however the EHP-30 questionnaire has high content validity. As a disease specific questionnaire, the EHP-30 provides an important tool to evaluate the benefits of surgical therapy in endometriosis patients.

D Tiringer, AS Pedrini, R Wenzl

AS Pedrini, M Gstottner

AS Pedrini, R Wenzl, D Tiringer, M Gstottner

D Tiringer, R Wenzl, H Husslein, L Kussel, AS Pedrini.

D Tiringer, R Wenzl, H Husslein, L Kussel, AS Pedrini.

None of the authors have a conflict of interest.