Endometriosis and stress: impact on women’s health

Endometriosis is a chronic gynecological disorder, defined by the presence of endometrial tissue outside the uterine cavity, which undergoes the same cyclic changes of eutopic endometrium. The prevalence of the disease can reach about 10% of reproductive-age women, who present with chronic pelvic pain and/or infertility, leading to negative physical and psychological impact in patient’s lives. The pathogenesis involves several hormonal, inflammatory, immune, genetic, and epigenetic mechanisms, which may play a role in the establishment and progression of endometriotic lesions and their clinical manifestations. In the last years, a possible link between high levels of chronic stress and endometriosis has been hypothesized. Clinical evidence shows that patients with endometriosis report higher levels of perceived stress, anxiety, and depression than healthy women. Stress levels are positively correlated to the severity of the disease and pain intensity. Women with endometriosis, in fact, report impaired quality of life and they are more likely to be affected also by systemic and gynecological comorbidities, contributing to stress in a vicious circle. A high prevalence of immune, inflammatory, allergic and mental health diseases has been found and a strict link with adenomyosis has been shown. Moreover, experimental studies have shown that previous exposure to repeated and excessive stress accelerates the development and increases the severity of endometriosis in animal models and early life stressor contribute to the development of the disease in adult life. However, it is still debatable whether endometriosis is a cause and/or a consequence of stress and which mechanisms explain this relationship. An adequate management of endometriosis contribute to improve quality of life, reducing stress levels. It has been shown that among women surgically treated, those with worse quality of life had first surgery at a younger age, more symptoms recurrence and more reoperations. Thus, first endometriosis surgery at a later age is an independent predictor of better health condition. Furthermore, patients experiencing repetitive surgery for endometriosis recurrences have lower physical and mental scores than patients receiving a single surgical treatment. Women undergoing hormonal treatment both before and after surgery have a lower rate of recurrence and an improvement of clinical presentation, in terms of pain symptoms. Thus, hormonal treatments represent a valid cornerstone of endometriosis management and may be useful as a first-line therapeutic approach, in order to postpone surgery, and after surgery itself to reduce the risk of recurrence. The gold standard for modern endometriosis management is the individualized approach, aiming to reduce perceived stress, stress-related comorbidities and to improve quality of life.