Endometriosis, pelvic pain, and psychological functioning

Transcription

1 FERTILITY AND STERILITY Vol. 63. No.4. April 1995 Copyright 1995 American Society for Reproductive Medicine Printed on acid-free paper in U. s. A. Endometriosis, pelvic pain, and psychological functioning Kathleen G. Waller, M.B., B.Ch.* Robert W. Shaw, M.D.t Department of Obstetrics and Gynaecology, University of Wales College of Medicine, Cardiff, Wales, United Kingdom Objective: To investigate whether there are psychological differences between women with symptomatic as opposed to asymptomatic mild endometriosis. Design: Forty-nine women with minimal or mild endometriosis completed the Beck Depression Inventory, the Speilberger State-Trait analysis, and the Golombok Rust Inventory of Sexual Satisfaction. Women admitted for sterilization acted as normal controls and women complaining of pelvic pain with no organic pathology were studied also. Setting: Tertiary referral centers for endometriosis. Main Outcome Measures: Women with pelvic pain symptoms, whether they had mild endometriosis or a normal pelvis, had similar scores for the Beck Depression Inventory. These scores were significantly higher than those of women with asymptomatic disease and normal women admitted for sterilization. Conclusions: Women with mild endometriosis should not be included as a control group when studies on pelvic pain are planned. Fertil Steril 1995;63: Key Words: Endometriosis, psychology, depression Many patients with minimal or mild endometriosis present to the gynecologist complaining of pain symptoms such as dysmenorrhea, pelvic pain, and dyspareunia. However, other individuals with the same amount of disease do not complain of any pain symptoms and endometriosis is discovered as a result of infertility investigations. These women are said to have asymptomatic disease. Are there psychological differences between women with mild endometriosis who present with pain symptoms and women whose disease is asymptomatic? Previous investigators have found psychological differences between women with an apparent or- Received April 13, 1994; revised and accepted October 13, Present address: Department of Obstetrics and Gynaecology, Watford General Hospital, Vicarage Road, Hertsfordshire, WD18HB, United Kingdom. t Reprint requests: Robert W. Shaw, M.D., Department of Obstetrics and Gynaecology, University of Wales College of Medicine, Heath Park, Cardiff, CF4 4XN, Wales, United Kingdom. ganic cause for their pain and women with no identifiable pelvic pathology (1-6). In 1977, Beard et al. (1) reported 35 cases, of which 17 had abnormalities at laparoscopy (including 3 with endometriosis) and 18 had a normal pelvis. The women with no cause demonstrable for their pelvic pain tended to be more neurotic and were shown to have negative attitudes towards themselves and their partners. Similarly negative attitudes were noted in the sexual sphere. Women with a negative laparoscopy rated their relationship with their husband or partner as less good. Women with chronic pain and a normal pelvis also have been found to be significantly depressed when compared with a group with positive laparoscopy findings (2) and to have had a higher lifetime number of sexual partners and to have had experienced more psychosexual trauma than in age-matched pain-free controls (3). In 1991, Reiter et al. (4) compared two groups oflaparoscopically normal women: 47 had a probable somatic cause for pain of which the most common diagnosis was myofascial pain and 52 women had no identifiable somatic cause for pain. These woman had an 796 Waller and Shaw Endometriosis: psychological functioning Fertility and Sterility

2 earlier age at first intercourse, a higher lifetime numbers of partners, and a higher prevalence of sexual abuse before the age of 20. However, Rapkin et al. (5) in 1990 compared patients with chronic pelvic pain with women with chronic pain in other locations and normal controls. Within the pelvic pain group, 11 of 31 patients had identifiable pathology, although the nature of this pathology was not disclosed. The women in the pelvic pain group as a whole were more likely to have been physically although not sexually abused. Women with endometriosis in general have been included with the control group in these studies. However, Renaer and co-workers (6) used only patients with endometriosis in the pelvic pathology group. The authors were surprised to find that the psychological profile of women with endometriosis did not differ significantly from the profile of women with no organic cause for pain. Both groups differed significantly from controls in that there were inflated scores for hypochondriasis, depression, hysteria, psychasthenia, social inversion, and anxiety as well as lower scores on ego strength using the Minnesota Multiphasic Personality Inventory (MMPI). The authors concluded that, as endometriosis is unlikely to occur in neurotic people, pain itself is likely to lead to neuroticism. This study aims to elucidate further the relationship between endometriosis and psychological functioning by comparing women whose endometriosis is symptomatic with women who have asymptomatic disease. Two groups of women are included in this study for comparison: women being sterilized who have a normal pelvis and women complaining of pelvic pain symptoms who have a normal pelvis at laparoscopy. If women with symptomatic endometriosis only are found to have abnormalities of psychological functioning, then these results would concur with those of Renaer and coworkers (6). However, if both groups of women with endometriosis have similar abnormalities on psychometric testing when compared with controls, this could mean that some women are psychologically more vulnerable to developing endometriosis. MATERIALS AND METHODS All participants in the study were recruited from October 1991 until March 1992 at the Royal Free Hospital, London and from April 1992 until June 1993 at the University of Wales College of Medicine. Women admitted for laparoscopy for pelvic pain symptoms, infertility, or sterilization were administered psychometric tests as well as an endometriosis symptom questionnaire. Patients known to have endometriosis were excluded, as were patients found to have anything other than a normal pelvis or minimal or mild endometriosis, according to The American Fertility Society classification of 1985 (7). Women presenting to the gynecologist with the dual complaints of endometriosis and pain also were excluded. Almost all questionnaires were administered on the day before surgery, so that the patient and doctor would be blind to the results of laparoscopy. Six questionnaires, however, were distributed on the day after laparoscopy; these patients included at least one from each group. Patients were divided into four groups according to the findings at surgery. The control group (n = 38) consisted of patients admitted for sterilization and found to have a normal pelvis. Group 2 (n = 31) consisted of patients complaining only of infertility who were found to have minimal or mild endometriosis. Group 3 (n = 18) consisted of patients found to have minimal or mild endometriosis complaining of one or more of the following: dysmenorrhea, dyspareunia, or pelvic pain. Group 4 (n = 30) consisted of patients with pelvic pain symptoms with no obvious pathology at laparoscopy. Each patient was administered the following tests: The Beck Depression Inventory (BDI) (8). The revised version of 1979 is a 21-item instrument that can be used to detect possible depression in normal populations. Two subscales are used for the BDI, the first 13 items create a cognitive affective subscale for estimating depression in persons whose vegetative and somatic symptoms might overestimate the severity of their depression. The last eight items create a subscale to measure somatic performance complaints. The Speilberger State-Trait Anxiety Inventory (9) assesses state and trait anxiety separately and was administered in addition to the Golombok Rust Inventory of Sexual Satisfaction (10). One patient who would have entered group 3 refused testing, and some women did not complete the Golombok Rust Inventory of Sexual Satisfaction but did complete the other tests. This either was because they did not have a partner (n = 4) or because they found it embarrassing (n = 5). The endometriosis symptom questionnaire rated dysmenorrhea and pelvic pain in terms of a multidimensional scoring system. This defined pain in terms of limitation of normal activities (0 = no interference, 1 = mild interference, 2 = noticeable interference, 3 = unable to function normally) and Vol. 63, No.4, April 1995 Waller and Shaw Endometriosis: psychological functioning 797

3 need for analgesics (1 = analgesics used occasionally, 2 = analgesics used often, 3 = analgesics essential). Women were asked specifically about the presence or absence of dyspareunia and whether it was deep inside or at the entrance to the vagina. Only symptoms of deep dyspareunia were included in the analysis (0 = no pain with intercourse; 1 = mild pain, able to tolerate; 2 = moderate pain, causes intercourse to be interrupted; 3 = severe pain, unable to have intercourse). Women also were asked about their lifetime number of sexual partners. The following scale was used: 1 = no partners, 2 = 1, 3 = 2 to 4, 4 = 5 to 9, 5 = 10 to 14, 6 = 15 to 20, 7 = >20,8 = >30 partners. Data were analyzed with Minitab version 7.2 (Minitab, Inc., State College, PA). Mann-Whitney was used for nonparametric data and Student's t test for data with a normal distribution. Results were considered significant if the confidence interval did not include 0 and if P < Spearman rank correlation (r.) was used to assess the relationship between two different variables. RESULTS The mean ± SD age of women in each group was as follows: group 1, 35.0 ± 4.9 years; group 2, 31.0 ± 4.1 years; group 3, 30.9 ± 7.5 years; and group 4, 30.6 ± 7.6 years. Women undergoing sterilization (group 1) were slightly older; this represents unavoidable bias due to the selection of patients for the operation. Pelvic pain symptoms are reported in Figure 1. Women in group 2 suffered significantly more dys- Multidimensional ac:ore o DyamenorrhoN Dyspareunia Pelvic peln IOGroup 1 (n=38) IIIIIIGroup 2 ("=31) Ii:JGroup 3 ("=18) _Group 4 ("=30) I Figure 1 Pelvic pain symptoms according to patient group. Group 1, normal pelvis, asymptomatic (sterilization); group 2, minimal or mild endometriosis, asymptomatic; group 3, minimal or mild endometriosis, symptomatic; group 4, normal pelvis, symptomatic. menorrhea (P = 0.001) and pelvic pain (P = 0.02) than group 1 patients. However, group 3 women had significantly higher scores for dyspareunia (P = 0.004) and pelvic pain (P = 0.004) when compared to group 2 patients. There were no significant differences between the pain scores of groups 3 and 4. Group 4 patients with a normal pelvis reported the highest pain scores for all parameters. Table 1 shows that women in groups 3 and 4 had higher mean BDI scores than group 2 women (P = 0.01, confidence interval [CI] 1.0 to 8.0) and group 1 women (P = 0.002, CI 2.0 to 8.0). Group 3 and 4 women had significantly higher scores for the somatic performance items when compared with groups 1 and 2, but there was no difference when compared with group 2 for the cognitive-affective items. The cutoff point for diagnosing depression varies according to the population studied, but a cutoff point> 13 has been used to diagnose depression in medical patients (11). The proportions of patients with BDI scores> 13 are as follows: group 1,7.9%; group 2,13.0%; group 3, 23.5%; and group 4,30.0%. These differences are only significant for group 4 versus group 1 (CI 0.41 to 0.04). No significant differences between the groups were noted for the Speilberger State or Trait scales. The mean scores for all groups were similar to normative data for general medical and surgical patients (mean ± SD for state anxiety = 42.4 ± 13.7; mean ± SD for trait anxiety = 41.9 ± 12.7) (9). Table 2 analyzes sexual functioning of the four groups. The four groups were similar as regards age at coitarche, lifetime number of partners, and total Golombok Rust Inventory of Sexual Satisfaction score. When subscales of the Golombok Rust Inventory of Sexual Satisfaction were analyzed, women in groups 3 and 4 scored higher than those in groups 1 and 2 for infrequency of sexual intercourse (P ::::;; 0.05). Women in groups 3 and 4seemed to avoid intercourse significantly more than women in group 2 (P = 0.03) but did not avoid intercourse more than group 1 women. Women in group 4 scored higher for nonsensuality than women in both control groups (P::::;; 0.02), and group 4 women scored higher on the scale for vaginismus than women in group 1 (P = 0.02). These differences do not seem to be accounted for by the greater frequency of dyspareunia in groups 3 and 4. For group 3 there was no correlation between the dyspareunia score and the Golombok Rust Inventory of Sexual Satisfaction score (r. = 0.16) or dyspareunia and infrequency (r. = 0.02) or dyspareunia and avoid- 798 Waller and Shaw Endometriosis: psychological functioning Fertility and Sterility

4 Table 1 Beck Depression Inventory (BDI) and Speilberger* Group 1 (n = 38) Group 2 (n = 31) Group 3 (n = 17) Group 4 (n = 30) BD! Cognitive affective items Somatic performance items Total score Speilberger State anxiety Trait anxiety 2.69 ± ± ± ± ± ± ± ± ± ± ± 6.62t:1: ± 11.0 ± ± ± ± ± ± 7.63t:1: 42.1 ± ± 12.7 * Values are means ± SD. t p = 0.01 versus group 2 (ClI.O to 8.0). + p = versus group 1 (CI 2.0 to 8.0). p = versus groups 1 and 2 (ClI.O to 5.0). II P = versus groups 1 and 2 (ClI.O to 4.0). 11 P = versus group 1. ance (r. = 0.28). Similarly for group 4 there was no correlation between the amount of dyspareunia and the Golombok Rust Inventory of Sexual Satisfaction score (r. = 0.38), infrequency (r. = -0.14), avoidance (r. = -0.55), nonsensuality (r. = -0.13), and vaginismus (r. = 0.35). A score of 5 or more for the main scale or subscales of the Golombok Rust Inventory of Sexual Satisfaction indicates probable abnormal functioning. DISCUSSION Women with endometriosis complaining only of infertility did have significantly more dysmenorrhea and pelvic pain than normal women being sterilized. However, women with symptomatic endometriosis had higher scores for dyspareunia and pelvic pain than their infertile counterparts with the same amount of disease. Women with a normal pelvis reporting pain symptoms had the highest pain scores of all. Women in both pain groups had higher mean BDI scores than both control groups. There was no difference, however, between the four groups regarding both the state and the trait Speilberger scales. The results for both scales were normal for all groups. Renaer and co-workers (6) also found that women with symptomatic endometriosis and women with pelvic pain and no pathology had simi- 1arly inflated scores for depression using the MMPI. However, anxiety scores also were elevated in both pain groups compared with the pain-free control group, in contrast to the results obtained in this study. Although some differences were found between the groups as regards sexual functioning, the groups were similar in many respects. Other studies (4, 5) have found a higher frequency of anorgasmia, a lower age at coitarche, and a higher number of sexual partners in women with pelvic pain and a normal pelvis. Women with symptomatic mild endometriosis were found to exhibit depressive symptoms and Table 2 Golombok-Rust Inventory of Sexual Satisfaction* (GRISS)* Group 1 (n = 38) Group 2 Group 3 (n = 31) (n = 17) Group 4 (n = 30) GRISS total Infrequency Noncommunication Dissatisfaction Avoidance N onsensuality Vaginismus Anorgasmia Lifetime partners Coitarche (y) 2.51 ± ± ± ± ± ± ± ± ± ± ± ± ± ± 1.50t 4.50 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 2.47 * Values are means ± SD. t P = ;5;0.05 versus groups 1 and 2. + P = ;5;0.04 versus groups 1 and 2. P = ;5;0.03 versus group 2. II P = ;5;0.02 versus groups 1 and P = 0.02 versus group 1. Vol. 63, No.4, April 1995 Waller and Shaw Endometriosis: psychological functioning 799

5 mild disorders of sexual functioning. However, women with asymptomatic disease did not show any kind of psychological abnormality, despite complaining of infertility. It does not therefore appear that certain psychological features make some women more vulnerable to developing endometriosis. It is more likely that women in chronic pain have substantial distress that leads to abnormalities of psychological functioning. Women with asymptomatic disease did in fact have significantly more dysmenorrhea and pelvic pain than women being sterilized but whether differences in psychological characteristics alter perception and reporting of pain is not clear. Women with mild endometriosis should not be included as a control group when studies on pelvic pain are planned. Psychological difficulties may be compounded by the fact that medication used to treat endometriosis can itself cause mood changes in some women. Depression is a well-known side effect when gonadotropin-releasing hormone agonists and danazol are used to treat endometriosis, although the proportion of patients reported with this side effect varies considerably with different clinical trials (12). It is important to be aware that mild depression may coexist with pain symptoms in women with endometriosis. A psychologist working with the gynecologist may be helpful in the management of some cases, and a supportive attitude on the part of the gynecologist is especially important. REFERENCES 1. Beard RW, Belsey EM, Lieberman BA, Wilkinson JCM. Pelvic pain in women. Am J Obstet Gynecol 1977;128: Magni G, Salmi A, DeLeo D, Ceola A. Chronic pelvic pain and depression. Psychopathology 1984;17: Reiter RC, Gambone JC. Demographic and historical variables in women with idiopathic pelvic pain. Obstet Gynecol 1990;75: Reiter RC, Shakerin LR, Gambone JC, Milburn AK. Correlation between sexual abuse and non somatic chronic pelvic pain. Am J Obstet Gynecol 1991;165: Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 1990;76: Renaer M, Vertommen H, Nijs P, Wage mans L Van Hemelrijck T. Psychological aspects of chronic pelvic pain in women. Am J Obstet Gynecol 1979;134: The American Fertility Society. Revised American Fertility Society classification of endometriosis: Fertil Steril 1985;43: Beck AT, Steer RA. Beck Depression Inventory manual. San Antonio, TX: The Psychological Corporation, Harcourt Brace Jovanovich, Inc., Speilberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, Inc., Rust J, Golombok S. The Golombok Rust inventory of sexual satisfaction. Windsor, United Kingdom: Nfer-Nelson, Nielsen AC, Williams TA. Depression in ambulatory medical patients. Arch Gen Psychiatry 1980;37: Shaw RW. Treatment of endometriosis. Lancet 1992; 340: Waller and Shaw Endometriosis: psychological functioning Fertility and Sterility