Enriched Environments: a Multi-level Integrative Medicine Intervention for Endometriosis
Phase: NA
Conditions: Endometriosis-related Pain, Endometriosis, Pelvic Pain, Quality of Life, Inflammation Pelvic
Sponsor: Ponce Medical School Foundation, Inc.

ID: 1R21HD098481-01 
    
    
Official Title: Enriched Environments: a Multi-level Integrative Medicine Intervention for Endometriosis   
NCT#: NCT04179149 
Date of last revision: 11/15/2019 
 
R21 Environmental Enrichment Study Protocol 
 
Translation of the EE intervention: The environmental enrichment (EE) paradigm was translated by a 
multidisciplinary team composed of investigators with expertise in psychology, physiology, neuroscience, 
integrative mind-body disciplines, gynecology, and translational research, together with consultants in HPA axis 
research and stress management, met during a period of one year to design an intervention to be tested in 
patients. A pilot randomized clinical trial was designed to test the efficacy of reducing painful symptoms and 
improving QoL as an adjuvant to standard care. The adaptation followed the ORBIT Model proposed by 
Czajkowski et al. (2015) to develop behavioral interventions for chronic diseases [refs]. This model guides the 
early pre-efficacy stages of the development of a behavioral intervention using a four-phase approach (F1: 
design, F2: preliminary efficacy, F3: efficacy, F4: effectiveness (F2 to be tested in the current proposal). Guided 
by the model, we translated a basic neurobehavioral finding (stress control and EE reduces the growth of 
lesions in rats) into a clinical question (will an EE intervention be effective in reducing pain 
symptoms/inflammation and increasing QoL in women with endometriosis?). First, we conducted a systematic 
literature review to select the approaches for the adapted EE intervention, using the PRISMA-P 2015 protocol 
and the PRISMA evaluation checklist. The process of translating the environmental enrichment (EE) paradigm 
has been described in detail in Nieves-Vázquez et al. (2022) [41]. 
 
Recruitment: After IRB approval (Protocol #1901004205R003) a recruitment campaign was conducted using 
social media (Facebook, Instagram, Twitter) of the Fundación Puertorriqueña de Pacientes con Endometriosis 
(ENDOPR), the only patient support association in Puerto Rico established in 2015. Recruitment for session 
one took place from September 2019 to December 2021 and then from May to June 2021. Recruitment for 
session two took place from August 2021 to February 2022. Patients interested in participating will be first 
screened for inclusion/exclusion criteria by our research coordinator and verbally consented to before being 
randomized into the intervention and control groups described below.  
 
Inclusion Criteria: Participants were women with a surgical diagnosis of endometriosis, 18-50 years old, who 
are symptomatic and refractory to hormonal treatment, able to provide written informed consent, and can 
commit the time to participate in the environmental enrichment (EE) intervention for a period of 3 months.  
Exclusion Criteria: We excluded patients who present endometriosis symptoms but who have not been 
diagnosed by surgery by an OB-GYN specialist; pregnant women or those who plan to or become pregnant 
during the study period; women with endometriosis under hormonal treatment who report no symptoms as 
defined predominantly by pain; post-menopausal women; documented or visual cognitive or physical 
impairment that would interfere with participation or consent; currently under mental health treatment or using 

steroid medications; affected by other confounding conditions, including pain syndromes (e.g., fibromyalgia, 
chronic fatigue syndrome, arthritis).     
 
Study design of the pilot RCT: To evaluate the efficacy of a translated EE intervention for endometriosis 
patients, we conducted a RCT of parallel design with an intervention group (EE intervention) (n=29) and a wait 
list control group (n=27) from August 2021 to July 2022. Participants randomized to the intervention 
participated in six EE modules on alternate Saturday mornings. They could receive (or continue receiving) 
standard gynecological care (hormonal, analgesics, or surgeries) and psychological therapy as needed. 
Participants randomized to the wait-list control condition were invited to participate in an online seminar about 
endometriosis and could also receive standard of care for endometriosis and mental health. After providing 
informed consent, all subjects completed a set of validated surveys at baseline and end of the intervention to 
assess QoL, perceived stress, anxiety, depression, and pain symptoms, and provided saliva samples. 
Individuals in the intervention group were followed up 3-months after the study ended to assess possible long-
term effects of the intervention. Participants in the control group completed the same questionnaires and 
provided the saliva samples during house visits that took place within one week before and one week after the 
timeline of the intervention. Clinical and socio-demographic data, as well as pain catastrophizing scores were 
obtained with the Endometriosis Phenome Project (EPHect) questionnaire [42]. Participants in the intervention 
group used WhatsApp chats to continue their communications between meetings. Data regarding treatments 
and doctor’s visits during the study were obtained from all participants with a clinical history questionnaire 
administered twice during the study period. 
 
Study surveys: Participants in the EE condition completed the following surveys at baseline and end of the 
intervention, and at 3 months after the intervention was completed. Individuals in the control group completed 
the same questionnaires only at baseline and end of the study period: 
 
(1) Endometriosis Phenome Project Clinical Minimal Questionnaire (EPQ-M):  The validated Spanish version of 
the EPhect’s EPQ-M survey was used to collect cross-sectional, self-reported data. Developed by the World 
Endometriosis Research Foundation (WERF), this survey standardizes data collection from patients, including 
demographics, medical history, ob-gyn history, and lifestyle [42]. Different types of pelvic pain (dysmenorrhea, 
dyspareunia, chronic pelvic pain) are measured using a numerical rating scale from 1 (no pain) to 10 (worse 
pain) [43]. 
 
(2) Endometriosis Health Profile-30 (EHP-30): This survey measures the endometriosis-related health status 
through 30 items covering five disease-related scales (core questionnaire): pain, control and helplessness, 
emotional wellbeing, social support, and self-image. EHP-30 has been shown to be sensitive to changes in 
patient outcomes, making it a useful tool in endometriosis clinical trials. Response categories are rated on a 
five-point Likert scale (0 to 4). The global QoL score is converted on a scale of 0 to 100, with the lower score 
representing a better quality of life [44, 45]. 

 
(3) Brief Pain Inventory (BPI): This questionnaire measures both pain intensity (minimum , maximum, average, 
current) using a numerical rating scale (NRS) of 0 to 10, with the highest number representing the worst 
imaginable pain. This instrument also measures the degree of pain impairment on function regarding general 
activity, mood, walking, work (including housework and paid work), relationships, sleep, and enjoyment of life. 
A global pain impact score can be calculated, with the higher score indicating worse impact [46].  
 
(4) Perceived Stress Scale (PSS-14): This self-assessment tool measures the level of perceived stress due to 
life situations over the past month. It assesses to what extent respondents feel in control of unpredictable or 
unexpected situations, or conversely, whether they feel out of control and experience stress that leads to 
discomfort. It consists of 14 items with a response format of a five-point scale (0=never, 1=almost never, 
2=occasionally, 3=often, 4=very often). A high total score corresponds to a high level of perceived stress [47]. 
 
(5) Anxiety (General Anxiety Disorder-7 (GAD-7): This self-administered questionnaire measures anxiety 
symptomatology through seven items which are scored from 0 to 3. The cut points of 5, 10, and 15 represent 
mild, moderate, and severe, respectively [48]. Patients reporting moderate-severe scores in GAD-7 were 
provided with a referral for psychological services. 
 
(6) Patient Health Questionnaire-8 (PHQ-8): This self-administered questionnaire measures depression 
symptomatology through eight items which are scored from zero to three. Scores of 5, 10, 15, and 20 
represent cut points for mild, moderate, moderately severe, and severe, respectively. [49]. Patients reporting 
moderate-severe scores in PHQ-8 were provided with a referral for psychological services. 
 
(7) Pain catastrophizing scale (PCS): This scale is part of the EPhect-Q Questionnaire that was completed at 
baseline. The PCS evaluates three dimensions of catastrophizing: helplessness, rumination, and magnification 
[50]. The scale has a total score of 52 with items scored from 0 (‘not at all’) to 4 (‘all the time’) [51]. A PCS 
score higher than 30 is considered clinically significant and identifies those with a higher risk of chronicity and 
disability due to pain [52].  
 
Saliva sampling and cortisol ELISA: Saliva samples for cortisol were collected at baseline, end of the 
intervention, and at the 3-month follow up for the experimental group. Saliva samples (approximately 1-3 mL) 
were obtained by passive drool into pre-labeled 15 mL tubes. These samples were obtained at the same time 
of the day (between 8:00-9:00am and at noon, before and after the intervention) to account for circadian 
variations in cortisol levels. For the control group, samples were collected one week before the start of the 
intervention and one week after during house visits. Control individuals were asked to collect saliva at the 
same time as the intervention group, on the same day, and store them at 4°C until collection during visits by 
the research team. Saliva samples were stored short-term on wet ice during transport to the research 
laboratory where they were processed and stored at -80°C until analysis. Once in the lab, the saliva samples 

were spun down to clear buccal cells, and aliquots stored at -80°C until analysis by ELISA. Cortisol analysis 
was done using the High Sensitivity Salivary Cortisol Enzyme Immunoassay kit (Salimetrics, State College, PA, 
cat #130025), validated for the quantitative measurement of salivary cortisol, following the manufacturer’s 
protocol. All samples were assayed undiluted in duplicate on the same assay plate. Cortisol concentrations 
were calculated based on standard curve, averaged, and reported in mg/dL.  
 
Statistical analysis:  The pilot trial’s acceptability and feasibility were determined by rates of Recruitment, 
Enrollment, Adherence, Survey completion and Module evaluations.Equivalence of baseline characteristics, as 
well as between-group differences in clinical-demographics variables and study outcomes were assessed 
using descriptive and univariate statistics, including T-test or Mann-Whitney test for continuous variables 
(depending on normality of distribution, as assessed by Shapiro-Wilk test), and Chi-square or Fisher’s exact 
test for categorical variables. Between group differences, as well as changes in the intervention group (from 
baseline) were evaluated for % improvement. Outcomes were evaluated using repeated two-way analysis of 
variance and assessed differences in intragroup (baseline vs. end of intervention) and intergroup (intervention 
vs. control). If findings were significant, we used a Tukey post-hoc test. Clinically meaningful changes in pain 
were considered when there was a change of three or more points (substantial difference), two to three points 
in the NRS (moderate difference) or 1 point (minimal difference) [43, 53]. A p value of 0.05 or less was 
considered statistically significant.