• Gabriella Márki, Attila Bokor, János Rigó, and Adrien Rigó.
• Doctoral School of Psychology, Eötvös Loránd University, Budapest 1064, Hungary.
• Hum. Reprod. 2017 Jul 1; 32 (7): 1432-1438.

Study QuestionTo what extent are pain symptoms, psychological variables (anxiety, depression and distress) and emotion regulation associated with women's health in endometriosis?Summary AnswerPhysical pain symptoms and emotion regulation difficulties via psychological stress negatively affect the health-related quality of life (HRQoL) of women living with endometriosis.What Is Known AlreadyThere are some missing links in the definitive treatment and recovery from endometriosis. Women with chronic pain report a decrease in HRQoL and an increase in the frequency of psychological problems, but little is known about the complex relationship between these variables in the context of endometriosis.Study Design, Size, DurationThis cross-sectional study was conducted between October 2014 and October 2015 on 193 women living with endometriosis.Participants/Materials, Setting, MethodsThe sample consisted of women with a medically confirmed diagnosis of endometriosis who received treatment at the participating clinic. All participants completed the Short Form Health Survey (SF-36), the Hospital Anxiety and Depression Scale, the Perceived Stress Scale and the Difficulties in Emotion Regulation Scale. Spearman's rank correlation was used to explore the associations between the measured variables, and structural equation modeling was used to test the proposed mediation models.Main Results And The Role Of ChanceThe response rate was 46%. In this study, 54.79% of the participants presented with anxiety and 20.3% with depressive symptoms. Pain symptoms, psychological variables and difficulties in emotion regulation were negatively associated with HRQoL. Mediation models revealed that physical pain, psychological stress and difficulties in emotion regulation explained 55% of the variance in the overall HRQoL, 41% of the variation in physical and 55% of the variation in mental HRQoL. Accordingly, severe physical pain (β = -0.39, P < 0.001) was directly, and difficulties in emotion regulation (β = -0.38, P < 0.001) was indirectly related to deterioration in overall HRQoL. Physical pain had a higher direct standardized effect (β = -0.51, P < 0.001) on physical HRQoL, and had no significant direct effect on mental HRQoL. Furthermore, both physical pain (β = -0.07, P < 0.001) and difficulties in emotion regulation (β = -0.46, P < 0.001) had a significant indirect effect on mental HRQoL.Limitations, Reasons For CautionThe data were heterogeneous with regard to the severity of endometriosis. The validity of this cross-sectional study is limited to correlations; therefore, further longitudinal studies using a more representative sample are needed to explore valid causal relationships.Wider Implications Of The FindingsThe results of this study indicate that HRQoL can be improved through pain management and emotion regulation strategies. The authors believe that HRQoL would increase with concomitant application of physical treatment and psychological care.Study Funding/Competing Interest(S)There were no external funding sources for this study, and the authors have no conflicts of interest to declare.Trial Registration NumberNot applicable.© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

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