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 suitable 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.

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.

EHP-30

Out of the core and modular 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). 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.  

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 (Figures 4-6) (Table 2).