# Promoting physical activity and limiting sedentary behaviors to manage pain in endometriosis: What are the psychosocial variables to take into account?

Tracy Milane, Ulysse Herbach, Marie-Anne Jean, Géraldine Escriva-Boulley

## ► To cite this version:

Tracy Milane, Ulysse Herbach, Marie-Anne Jean, Géraldine Escriva-Boulley. Promoting physical activity and limiting sedentary behaviors to manage pain in endometriosis: What are the psychosocial variables to take into account?. Women's Reproductive Health, 2025, pp.1-21. 10.1080/23293691.2025.2582496. hal-05373194

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Submitted on 27 Nov 2025

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# Promoting physical activity and limiting sedentary behaviors to manage pain in endometriosis: what are the psychosocial variables to take into account?

Tracy Milane ¹, ², *, Ulysse Herbach ³, Marie-Anne Jean ¹, Géraldine Escriva-Boulley ¹, ⁴

¹Université de Haute-Alsace, Université de Strasbourg, Université de Lorraine, LISEC UR 2310, F-68100, Mulhouse, France

²AGEIS, Université Grenoble Alpes, 38000 Grenoble, France

³Université de Lorraine, CNRS, Inria, IECL, F-54000 Nancy, France

⁴UNIV. NIMES, APSY-V, Nîmes, France

For correspondence: tracymilane@gmail.com

*Please cite as:* Milane, T., Herbach, U., Jean, M. A., & Escriva-Boulley, G. (2025). Promoting physical activity and limiting sedentary behaviors to manage pain in endometriosis: what are the variables to take into account?. *SportRxiv*.

## ABSTRACT

Endometriosis may reduce physical activity (PA) due to its symptoms and psychosocial barriers. This study compared PA, sedentary behavior (SED), and psychosocial variables in women with
and without endometriosis. Women with endometriosis reported lower specific SED, poorer quality of life (QoL), greater kinesiophobia, more health-related barriers, lower physical self-concept, and negative PA-related stereotypes (beliefs or perceptions). PA was most related to previous behavior (PA frequency over the past 3 months) and intention, and specifically in endometriosis, with self-efficacy, perceived control, physical self-concept, health barriers, and kinesiophobia. SED was linked to treatment-related stereotypes and, in endometriosis, to physical QoL. Findings highlight the importance of motivational and self-concept-related variables, which could be targeted to support engagement in PA for symptom management and improved QoL in women with endometriosis.

**Keywords:** Endometriosis; physical activity; sedentary behavior; quality of life; psychosocial factors

INTRODUCTION

Endometriosis is a chronic gynecological disease, characterized by the presence of endometrial-like tissue outside of the uterine cavity (Giudice & Kao, 2004). According to the world health organization, it is estimated that one out of 10 women (190 million) of reproductive age is affected by endometriosis worldwide (World Health Organization, 2023) and 1.5 million people in France. This condition is associated with chronic inflammation (Smolarz et al., 2021) which lead to a range of variables and nonspecific symptoms (Bonocher et al., 2014; Rodrigues et al., 2022). The burden of the disease intensifies as symptom severity increases (Soliman et al., 2020).

Among the symptoms associated with endometriosis, pain is the most frequent (Florentino et al., 2019), manifesting as chronic pelvic pain, dysmenorrhea, dyspareunia, pain while defecating and urinating, as well as painful ovulation (Horne & Missmer, 2022; Smolarz et al., 2021). These symptoms significantly impair psychosocial functioning of affected women (Szypłowska et al., 2023), negatively affecting physical, mental and social well-being (Kennedy et al., 2005), and interfering with daily activities and interpersonal relationships (Rodrigues et al., 2022). Several studies have consistently shown that women with endometriosis experience a lower overall quality of life (QoL) (Bień et al., 2020; Facchin et al., 2015; Gallagher et al., 2018; Rodrigues et al., 2022; Yela et al., 2020), compared to women with other gynecological disorders (Szypłowska et al., 2023) or those without the condition (Facchin et al., 2015; Gallagher et al., 2018). In particular, women with endometriosis report poorer physical and mental health, with lower scores across all domains of the SF-12 healthy survey (Olliges et al., 2021; Soliman et al., 2020). In sum, this disease is linked to pain, different aspect of QoL, and relationship.
Treatment options such as hormonal therapies and surgery have been used for the management of endometriosis' symptoms (Allaire et al., 2023). However, considering side effects of the treatments, non-pharmacological therapies could be complementarily proposed to control chronic pelvic pain (Wang et al., 2022). Notably, regular exercise appears to have a protective effect against inflammatory diseases, since it increases systemic levels of anti-inflammatory cytokines (Awad et al., 2017) and it has been shown that local inflammatory peritoneal reaction could be responsible for endometriosis' symptoms (Bonocher et al., 2014).

Although several studies have investigated the relationship between physical activity (PA) and endometriosis, findings remain inconclusive (Tennfjord et al., 2021). Most research has focused on its role in reducing the risk of developing endometriosis (Bonocher et al., 2014; Ricci et al., 2016), with limited evidence regarding its potential use for managing endometriosis' symptoms (Bonocher et al., 2014). Nevertheless, some studies have reported potential positive effects of PA or exercise on endometriosis' symptoms (Awad et al., 2017; Ensari et al., 2022; Gonçalves et al., 2017). Women with endometriosis participating in an 8-week yoga program reported significant reductions in daily pain compared to those who did not practice yoga (Gonçalves et al., 2017). Similarly, an 8-week exercise program led to a decrease in endometriosis' pelvic pain intensity (Awad et al., 2017). Indeed, those who exercised regularly, three times per week, experienced reduced pain symptoms the day after exercising (Ensari et al., 2022). Furthermore, engaging in regular PA can increase their self-concept, particularly changing their body perception and confidence (Coquinos et al., 2025). A recent systematic review concluded that PA and exercise can enhance QoL and mental health, alleviate pain intensity, and positively impact pelvic floor function and bone density of women with endometriosis (Xie et al., 2025).

Despite these benefits, women with endometriosis exhibited lower levels of PA compared to those without endometriosis (Sachs et al., 2023). Notably, they practiced less hours of sports per week and climbed fewer stairs per day (Sachs et al., 2023), possibly due to pain-related barriers, such as dysmenorrhea and chronic pain (Sachs et al., 2023). Additionally, fear, avoidance behaviors, fatigue, lack of social support can limit PA practice (Sachs et al., 2023). Women reported that they tend to limit PA as a coping strategy in order to manage severe pain and heavy bleeding related to endometriosis (Roomaney & Kagee, 2016). Besides endometriosis' symptoms, lack of time, limited access to appropriate or nearby facilities, low self-confidence or motivation may also play a role in reduced PA levels in individuals with chronic diseases (Institut national de la santé et de la recherche médicale, 2019). Otherwise, several studies have highlighted the interplay between PA and sedentary behaviors (SED), and the need to increase PA and decrease SED at the same time (Ekelund et al., 2019; Schneider et al., 2018; Stamatakis & Gill, 2019). In endometriosis context SED was rarely studied. However, results showed a positive link between endometriosis and sitting behaviors (Hemmert et al., 2019). This highlights the need to better
understand the motivations and barriers influencing PA in women with endometriosis, as much as
SED.

Previous research has shown that women with endometriosis differ from their counterparts without the conditions in several variables. Compared to those without endometriosis, they experience more severe menstrual symptoms, greater pelvic pain severity, interference and impact, widespread pain and fatigue (Bartley et al., 2024; Evans et al., 2021), as well as lower QoL across all domains (Baczek et al., 2024). Negative body image is also more prevalent among these women (Coquinos et al., 2025; Volker & Mills, 2022), with namely reduced appearance satisfaction and functionality appreciation (Volker & Mills, 2022). Additionally, they report higher levels of kinesiophobia, fear of movement (Silva de Barros et al., 2024), associated with increased disability and pain-related interference in daily activities, influenced by pain catastrophizing and low selfefficacy (Si et al., 2024). In women with endometriosis, physical and mental QoL was positively associated with greater self-efficacy (O’Hara et al., 2021). While previous reviews have highlighted the negative psychosocial impact of endometriosis (Culley et al., 2013), few studies have directly compared the specific effects of endometriosis compared to those experienced by other women. Understanding these differences is important to determine whether the psychosocial challenges are unique or shared with women without the condition.

Therefore, the aims of this study were: (1) to determine differences between women with and without endometriosis in PA, SED, and psychosocial variables which can be related to PA, (2) to identify psychosocial, behavioral, and health-related variables correlated to PA and SED in women with endometriosis.

# METHOD

## Study population and recruitment

The study was approved by Upper Alsace University ethic committee (CER/UHA/2021-01) and carried out between January and April 2022 in France. The inclusion criteria for the endometriosis group were: (1) being 18 years or older, (2) being diagnosed with endometriosis, (3) having French language competency to complete the questionnaire. The inclusion criteria for the no-endometriosis group were: (1) being 18 years or older, (2) no diagnosis of endometriosis, (3) having French language competency to complete the questionnaire. Participants were asked to sign a consent form to be able to participate in the study. A total of 1420 subjects received the surveys. The recruitment process was summarized in a flowchart (Figure 1).
<figure><img src="image_3.png" /><figcaption>**Figure 1.** Flowchart of the recruitment process</figcaption></figure>

## Assessments

Participants were invited to complete a self-administered questionnaire including sociodemographic data, gynecological data, physical and psychosocial variables.

**Pain.** The Numeric Rating Scale (NRS) was used to evaluate participants’ pain intensity using an 11-point scale, ranging from 0 (no pain) to 10 (worst imaginable pain) (Ferreira-Valente et al., 2011). Participants with endometriosis were asked to select the number that best represents their current pain intensity, their pain intensity over the last seven days, and their pain intensity due to
endometriosis (without treatment). Pain intensity scores were classified as mild (1-3), moderate (4-7) and severe (8-10) (Sheikh et al., 2021).

**Physical activity.** The International Physical Activity Questionnaire (IPAQ) short form measures three types of PA intensity: vigorous, moderate and walking. Participants were asked to report frequency (days per week) and duration (time per day) for each activity in the last seven days. Data collected was reported in categories (low activity levels, moderate activity levels or high activity levels). These categories were reported based on IPAQ guidelines (Bauman et al., 2009).

**Sedentary behavior.** The International Sedentary Assessment Tool (ISAT) was used to assess SED (Prince et al., 2017). Participants were asked about activities they carried out while sitting or lying down during the past week on a typical weekday/weekend. The questions referred to the time spent using screens, watching TV, using computers (including tablets, smart phones, and video games), time spent in transportation, time spent reading, time spent resting due to endometriosis symptoms, and total sitting time. Total sitting time was also calculated from the sum of the first three questions (screen use, transportation, and reading). Daily sitting time was categorized as follows: <4h, 4 to <6h, 6 to <8h, and ≥ 8h (Ekelund et al., 2016; Stamatakis et al., 2019).

**Quality of life.** The Short Form-12 Health Survey (SF-12) questionnaire is a validated short version of the SF-36 which assesses patients' perception of their general health status over the previous 4 weeks. It consists of 12 items combined into a physical component summary (PCS) and a mental component summary (MCS). Higher scores indicate better QoL (Gandek et al., 1998). A PCS score of 50 or less determines physical condition while an MCS score of 42 or less might indicate clinical depression (Soh et al., 2021).

**Theory of planned behavior (measurement tools adapted from (Vallance et al., 2011)).**

Intention was measured using three items on a 7-point Likert scale (e.g., "I strongly intend to participate in regular PA over the next month" (1=extremely false to 7=extremely true).

Attitude was measured using six questions on a 7-point Likert scale. Following the stem "For me, participating in regular PA over the next month would be", adjectives such as useless/useful, unpleasant/pleasant were used to assess attitude. A higher score suggests a more positive attitude toward participation in physical activities.

Injunctive norm was measured using three questions on a 7-point Likert scale (e.g., "Most people who are important to me would approve [my practice of PA] (1=extremely disapproving to 7=extremely approving).
Descriptive norm was measured using three questions on a 7-point Likert scale (e.g., “Most people who are important to me will themselves be...” (1=extremely inactive to 7=extremely active). A higher score indicates subjective norms that strongly support PA.

Perceived behavioral control was measured using eight questions on a 7-point Likert scale (e.g., “I believe that I am capable of engaging in regular PA over the next 4 weeks” (1=strongly disagree, 7=strongly agree). A higher score indicated a stronger behavioral control regarding participation in PA.

Previous behavior was measured by one item “how often have you practiced regular PA over the last 3 months” on a 7-point Likert scale ranging from 1 (never) to 7 (4 times per week).

**Motivation.** The Echelle de Motivation envers l'Activité Physique en contexte de Santé (EMAPS) is an 18-item questionnaire which evaluates the different types of motivation (Boiché et al., 2019). It consists of the following six subscales, 3-item each: intrinsic motivation, integrated regulation, identified regulation, introjected regulation, external regulation and amotivation. Participants answered each proposition on a Likert scale ranging from 1 (no match at all) to 7 (strong match) following the question “In general, why do you practice PA?”.

**Psychological needs.** The Psychological Needs Satisfaction and Frustration Scale (PNSS-S) was used to evaluate states of satisfaction and frustration of the participants across their three basic psychological needs for autonomy, competence, and relatedness (Bhavsar et al., 2020). It consists of 29 items, divided into six categories: autonomy satisfaction, autonomy frustration, competence satisfaction, competence frustration, relatedness satisfaction, relatedness frustration. Participants answered the propositions starting with the stem “In my sport, I...” on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).

**Self-efficacy.** The Exercise Self-Efficacy (ESE) is an 18-item scale developed by Bandura (Everett et al., 2009) that measured self-efficacy for regular exercise in participants with chronic disease. The Likert scale ranged from 0 (I cannot do this activity at all) to 10 (I am certain that I can do this activity successfully).

**Barriers to physical activity.** The Barriers to Physical Activity Questionnaire – Motivation and Intervention (BPAQ-MI) questionnaire measures perceived barriers to PA across intrapersonal (health, beliefs/attitudes), interpersonal (friends, family), organizational (fitness center-built environment, staff/program/policy) and community (community-built environment, community-built (Vasudevan et al., 2015). For the purposes of our study, the following six domains health, beliefs, friends, family, community-built environment and safety were examined. For each item in these domains, score ranged from 0 (not important) to 5 (important).
**Kinesiophobia.** The Tampa Scale of Kinesiophobia (TSK) assesses the fear of movement or (re)injury (Roelofs et al., 2004). Participants answered 17 items using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). TSK total score ranges from 17 to 68 with higher scores indicating higher degree of kinesiophobia (Van der Gucht et al., 2020). With a score > 37, participants were considered to suffer from kinesiophobia (Liu et al., 2021).

**Stereotypes.** The Cancer Exercise Stereotype Scale (CESS), initially developed to evaluate stereotypes related to physical exercise in cancer patients, was used to measure stereotypes in participants with endometriosis in this study. It consists of 19 items divided into five subscales describing stereotypes related to the lack of interest in exercise, the lack of physical abilities, role of side effects of treatment, risks of exercise, and benefits of exercise (Falzon et al., 2014). Participants answered a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).

**Social support.** The Social Support for Exercise Scale (SSES) was developed to measure social support for exercise (Sallis et al., 1987). It consists of a 5-point Likert scale ranging from 1 (never) to 5 (very often), in which participants reported the support for PA they had from their friends, their family and the person with whom they share their life during the past three months. 2.2.13.

**Physical self-concept.** The Physical Dimensions Self-Concept Questionnaire (PDSQ) (Guérin et al., 2003) was used to assess physical self-concept. It consists of 70 items divided into 11 subscales: health, coordination, endurance, sports competence, activity, body fat, global esteem, flexibility, strength, Global Physical Self-concept, appearance. For the purposes of this study, the following six subscales were examined: health, body fat, sports competence, global physical self-concept, appearance, and global esteem. It is a 6-point Likert scale ranging from 0 (false) to 5 (true).

## Data analysis

Descriptive statistics were performed to analyze sociodemographic and gynecological characteristics of the participants. For categorical variables, the frequency (percentage) was determined, and for continuous variables, mean, standard deviation, median, interquartile range and confidence interval were calculated. From Likert-valued data, continuous variables were constructed by averaging items within each scale. These variables summarize the measured scales and are closer to being normally distributed than the raw data, although this is not the case strictly speaking. We point out that a finer approach would require a specific treatment of the ordinal nature of the data, for example using latent Gaussian variables (Liddell & Kruschke, 2018): this is
beyond the scope of this article but planned in future work (in preparation). The Mann-Whitney U
test was used to compare variables between women with and without endometriosis. The Chi-
square test was used to compare the distribution of yes/no responses regarding participation in
vigorous activity, moderate activity, and walking activity between women with and without
endometriosis. Statistical comparison and Chi-square analyses were conducted using IBM SPSS
Statistics (version 26). Finally, we used Pearson correlation coefficients to identify variables
correlated to PA and SED, taking health status (i.e., endometriosis or not) into account. The
correlation coefficients and related p-values were computed using the pearsonr function from
SciPy (version 1.15.2) with default parameters.

RESULTS

Sample description

The final sample consisted of 470 participants, with 221 participants diagnosed with endometriosis ($M_{age}$ = 33.9 years, $SD$ = 7.7 years) and 249 participants without endometriosis ($M_{age}$ = 28.5 years, $SD$ = 11.5 years). Patients' sociodemographic and gynecological characteristics were reported in Table 1. Participants with endometriosis were significantly older than participants without endometriosis. Most patients were married or in couples (74.5%), do not have children (66.7%), professionally active (77.7%), mainly employee (40.8%), had deep infiltrating endometriosis (55.6%), take treatment only when it hurts (53.2%), and do not take contraception (43.85%). As for women without endometriosis, most were married or in couple (59.1%), do not have children (71.1%), were students (62.1%), and do not take contraception (32.0%). Regarding pain, among the participants who suffer from endometriosis assessing the current pain level, 56.6% had mild pain, when assessing the pain over the last seven days, 51.6% had moderate pain and when assessing the pain due to endometriosis (crisis), 56.6% had severe pain.

Comparison between participants with and without endometriosis

PA and sedentary behaviors

No difference was found in participants regarding PA (Table 2). Women with endometriosis reported significantly less time spent watching TV or using electronic devices compared to women without endometriosis. They also spent less time sitting while driving or using public transport. Additionally, overall sitting time on weekdays and weekends was slightly lower in the
endometriosis group. No significant differences were observed for time spent reading and total sedentary time calculated (Table 3).

## QoL

Compared to participants without endometriosis, women with endometriosis had significantly lower scores of the PCS and MCS (Table 4).

<table><caption>**Table 1.** Characteristics of the study population</caption><thead><tr><th rowspan="2"></th><th rowspan="2">N total of answers</th><th colspan="2">With endometriosis (n=221)</th><th colspan="2">Without endometriosis (n=249)</th><th rowspan="2">p value</th></tr><tr><th>M ± SD or frequency (%)</th><th>Med, 95% CI</th><th>M ± SD or frequency (%)</th><th>Med, 95% CI</th></tr></thead><tbody><tr><td colspan="7"><strong>Sociodemographic characteristics</strong></td></tr><tr><td>Gender, F [n (%)]</td><td></td><td>221 (100%)</td><td></td><td>235 (94.4%)</td><td></td><td></td></tr><tr><td>Age, years</td><td></td><td>33.9 ± 7.7</td><td>34, 32.9-35.0</td><td>28.5 ± 11.5</td><td>22, 27.9-29.9</td><td>p &lt; .001</td></tr><tr><td>Menarche age, years</td><td></td><td>12.7 ± 1.6</td><td>13, 12.5-13</td><td>12.7 ± 1.5</td><td>13, 12.5-12.9</td><td>p = .792</td></tr><tr><td>Marital status</td><td>N=220<br>N=242</td><td></td><td></td><td></td><td></td><td>p &lt; .001</td></tr><tr><td>Married/ in couple</td><td></td><td>164 (74.5%)</td><td></td><td>143 (59.1%)</td><td></td><td></td></tr><tr><td>Separated/ divorced</td><td></td><td>4 (1.8%)</td><td></td><td>6 (2.5%)</td><td></td><td></td></tr><tr><td>Widow</td><td></td><td>3 (1.4%)</td><td></td><td>1 (0.4%)</td><td></td><td></td></tr><tr><td>Single</td><td></td><td>49 (22.3%)</td><td></td><td>92 (38%)</td><td></td><td></td></tr><tr><td>Children</td><td>N=219<br>N=246</td><td></td><td></td><td></td><td></td><td>p = .846</td></tr><tr><td>0</td><td></td><td>146 (66.7%)</td><td></td><td>175 (71.1%)</td><td></td><td></td></tr><tr><td>1</td><td></td><td>44 (20.1%)</td><td></td><td>19 (7.7%)</td><td></td><td></td></tr><tr><td>2</td><td></td><td>26 (11.9%)</td><td></td><td>39 (15.9%)</td><td></td><td></td></tr><tr><td>3</td><td></td><td>2 (0.9%)</td><td></td><td>11 (4.5%)</td><td></td><td></td></tr><tr><td>4</td><td></td><td>1 (0.5%)</td><td></td><td>2 (0.8%)</td><td></td><td></td></tr><tr><td>Education level</td><td>N=218<br>N=248</td><td></td><td></td><td></td><td></td><td>p = .952</td></tr><tr><td>Brevet des collèges</td><td></td><td>2 (0.9%)</td><td></td><td>0</td><td></td><td></td></tr><tr><td>BEP, CAP</td><td></td><td>6 (2.8%)</td><td></td><td>3 (1.2%)</td><td></td><td></td></tr><tr><td>Bac général /professionnel /technologique</td><td></td><td>24 (11.0%)</td><td></td><td>31 (12.5%)</td><td></td><td></td></tr><tr><td>Bac +1,+2,+3</td><td></td><td>91 (41.7%)</td><td></td><td>107 (43.1%)</td><td></td><td></td></tr><tr><td>Bac+4,+5 ou plus</td><td></td><td>93 (42.7%)</td><td></td><td>106 (42.7%)</td><td></td><td></td></tr><tr><td>Other</td><td></td><td>2 (0.9%)</td><td></td><td>1 (0.4%)</td><td></td><td></td></tr><tr><td>Current occupation</td><td>N=220<br>N=248</td><td></td><td></td><td></td><td></td><td>p &lt; .001</td></tr><tr><td>Active</td><td></td><td>171 (77.7%)</td><td></td><td>89 (35.9%)</td><td></td><td></td></tr><tr><td>Unemployed and looking for work</td><td></td><td>10 (4.5%)</td><td></td><td>2 (0.8%)</td><td></td><td></td></tr><tr><td>Student</td><td></td><td>24 (10.9%)</td><td></td><td>154 (62.1%)</td><td></td><td></td></tr><tr><td>Career transition</td><td></td><td>5 (2.3%)</td><td></td><td>0</td><td></td><td></td></tr><tr><td>Long-term leave</td><td></td><td>2 (0.9%)</td><td></td><td>0</td><td></td><td></td></tr><tr><td>Other</td><td></td><td>8 (3.6%)</td><td></td><td>3 (1.2%)</td><td></td><td></td></tr><tr><td>Type of Job</td><td>N=213</td><td></td><td></td><td></td><td></td><td>p &lt; .001</td></tr></tbody></table>
<table><tr><td>Farmer</td><td>N=184</td><td>2 (0.9%)</td><td>0</td></tr><tr><td>Artisan</td><td></td><td>28 (13.1%)</td><td>4 (2.2%)</td></tr><tr><td>Manager</td><td></td><td>61 (28.6%)</td><td>43 (23.4%)</td></tr><tr><td>Intermediate profession</td><td></td><td>18 (8.4%)</td><td>14 (7.6%)</td></tr><tr><td>Employee</td><td></td><td>87 (40.8%)</td><td>61 (33.1%)</td></tr><tr><td>Worker</td><td></td><td>1 (0.5%)</td><td>1 (0.5%)</td></tr><tr><td>Other</td><td></td><td>16 (7.5%)</td><td>61 (33.1%)</td></tr></table>

## Gynecological characteristics

<table><tr><td>Type of endometriosis</td><td>N=221</td><td>NA</td></tr><tr><td>Superficial peritoneal endometriosis</td><td></td><td>21 (9.5%)</td></tr><tr><td>Ovarian endometrioma</td><td></td><td>24 (10.9%)</td></tr><tr><td>Deep infiltrating endometriosis</td><td></td><td>123 (55.6%)</td></tr><tr><td>Adenomyosis</td><td></td><td>7 (3.2%)</td></tr><tr><td>At least 2 types</td><td></td><td>19 (8.6%)</td></tr><tr><td>Don't know</td><td></td><td>25 (11.3%)</td></tr><tr><td>Digestive</td><td></td><td>2 (0.9%)</td></tr></table>

<table><tr><td>Age at first pain, years</td><td>N=216</td><td>18.4 ± 7.7</td><td>15, 17.4-19.5</td><td>NA</td></tr></table>

<table><tr><td>Age at first diagnosis, years</td><td>N=218</td><td>28.7 ± 6.7</td><td>28, 27.8-29.6</td></tr></table>

<table><tr><td>Diagnostic wandering, years</td><td>N=213</td><td>10.1 ± 7.4</td><td>9, 9.14-11.1</td></tr></table>

<table><tr><td>Time since diagnosis, years</td><td>N=218</td><td>5.2 ± 5.5</td><td>3, 4.50-5.98</td><td>NA</td></tr></table>

<table><tr><td>Medical treatment</td><td>N=221</td><td>NA</td></tr></table>

<table><tr><td>Yes</td><td>154 (69.7%)</td></tr></table>

<table><tr><td>No</td><td>67 (30.3%)</td></tr></table>

<table><tr><td>Frequency of treatment</td><td>N=154</td><td>NA</td></tr></table>

<table><tr><td>Daily</td><td>42 (27.3%)</td></tr></table>

<table><tr><td>Throughout period</td><td>6 (3.9%)</td></tr></table>

<table><tr><td>Only when it hurts</td><td>82 (53.2%)</td></tr></table>

<table><tr><td>Just before and one day during period</td><td>2 (1.3%)</td></tr></table>

<table><tr><td>Other</td><td>22 (14.3)</td></tr></table>

<table><tr><td>Contraception</td><td>N=219</td><td></td><td></td><td>p = .977</td></tr></table>

<table><tr><td>N=244</td><td></td></tr></table>

<table><tr><td>Pills</td><td>94 (42.9%)</td><td>72 (29.5%)</td></tr></table>

<table><tr><td>Intrauterine device</td><td>0</td><td>30 (12.3%)</td></tr></table>

<table><tr><td>Intrauterine system</td><td>10 (4.6%)</td><td>12 (4.9%)</td></tr></table>

<table><tr><td>Implants</td><td>5 (2.3%)</td><td>4 (1.6%)</td></tr></table>

<table><tr><td>Condom, diaphragm, spermicide</td><td>11 (5.0%)</td><td>33 (13.5%)</td></tr></table>

<table><tr><td>> 1</td><td>3 (1.4%)</td><td>15 (6.1%)</td></tr></table>

<table><tr><td>No</td><td>96 (43.85%)</td><td>78 (32.0%)</td></tr></table>

M: mean; SD: standard deviation; Med: median; CI: confidence intervals; NA: not applicable

## Theory of planned behavior regarding PA

Except for perceived behavioral control no difference was found between participants: participants
with endometriosis had lower scores of perceived behavioral control (Table 5).

Motivation for PA

Except for integrated regulation and identified regulation, no difference was found between participants: participants with endometriosis had higher scores of integrated regulation and identified regulation (Table 5).

<table><caption>**Table 2.** Comparison of physical activity types between participants with and without endometriosis</caption><thead><tr><th rowspan="2"></th><th colspan="2">With endometriosis</th><th colspan="2">Without endometriosis</th><th rowspan="2">p value</th></tr><tr><th>Median (Q1-Q3)</th><th>95%CI</th><th>Median (Q1-Q3)</th><th>95%CI</th></tr></thead><tbody><tr><td><strong>Vigorous activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes, n (%)</td><td>95 (43%)</td><td></td><td>118 (47%)</td><td></td><td></td></tr><tr><td>MET minutes/week</td><td>1920 (720-3840)</td><td>2128-3185</td><td>2160 (960-4800)</td><td>2714-3854</td><td>p = .113</td></tr><tr><td>Minutes/week</td><td>240 (90-480)</td><td>266-398</td><td>270 (120-600)</td><td>339-482</td><td>p = .113</td></tr><tr><td><strong>Moderate activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes, n (%)</td><td>145 (66%)</td><td></td><td>170 (68%)</td><td></td><td></td></tr><tr><td>MET minutes/week</td><td>960 (320-2160)</td><td>1179-1699</td><td>960 (480-1920)</td><td>1269-1824</td><td>p = .629</td></tr><tr><td>Minutes/week</td><td>240 (80-540)</td><td>295-425</td><td>240 (120-480)</td><td>317-456</td><td>p = .629</td></tr><tr><td><strong>Walking activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes, n (%)</td><td>203 (92%)</td><td></td><td>230 (92%)</td><td></td><td></td></tr><tr><td>Episodes, yes n (%)</td><td>109 (49%)</td><td></td><td>99 (40%)</td><td></td><td></td></tr><tr><td>MET minutes/week</td><td>297 (165-503)</td><td>337-480</td><td>264 (132-528)</td><td>304-453</td><td>p = .333</td></tr><tr><td>Minutes/week</td><td>90 (50-153)</td><td>103-149</td><td>80 (40-160)</td><td>92-137</td><td>p = .324</td></tr><tr><td><strong>Total activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>MET minutes/week</td><td>1450 (709-3660)</td><td>2157-2965</td><td>1680 (693-4833)</td><td>2601-3521</td><td>p = .299</td></tr><tr><td>Minutes/week</td><td>340 (130-713)</td><td>415-553</td><td>360 (140-840)</td><td>474-629</td><td>p = .475</td></tr></tbody></table>

<table><caption>**Table 3.** Comparison of sedentary behavior between participants with and without endometriosis</caption><thead><tr><th></th><th>With endometriosis</th><th>Without endometriosis</th><th>p value</th></tr></thead><tbody><tr><td>Watching TV or using a computer, tablet or smartphone (h/day)</td><td>3 (2-5.2)</td><td>4 (2-5.5)</td><td>p = .007</td></tr><tr><td>Sitting and driving in a car, bus, or train (h/day)</td><td>1.25 (0.5-2.75)</td><td>2 (0.75-4)</td><td>p = .023</td></tr><tr><td>Sitting reading a book or magazine (h/day)</td><td>1 (0.3-2)</td><td>1 (0-2)</td><td>p = .846</td></tr><tr><td>Lying down due to endometriosis symptoms (h/day)</td><td>0.5 (0-3)</td><td>NA</td><td></td></tr></tbody></table>
<table><tr><td>Total sedentary time (h/day) (calculated)</td><td>7 (4.5-11.5)</td><td>6.7 (3.6-10)</td><td>p = .092</td></tr><tr><td>Sitting on weekdays and weekends in general (h/day)</td><td>7 (4.6-10)</td><td>7.1 (5.7-10)</td><td>p = .009</td></tr></table>

Values are reported as median (Q1-Q3); NA: not applicable

<table><caption>**Table 4.** Comparison of PCS and MCS scores between participants with and without endometriosis</caption><thead><tr><th rowspan="2"></th><th colspan="2">With endometriosis</th><th colspan="2">Without endometriosis</th><th rowspan="2">p value</th><th rowspan="2">Cronbach's α</th></tr><tr><th>Mean (SD)</th><th>95%CI</th><th>Mean (SD)</th><th>95%CI</th></tr></thead><tbody><tr><td>PCS12</td><td>39.2 (8.6)</td><td>38.0-40.3</td><td>50.1 (8.8)</td><td>49.0-51.2</td><td>p < .001</td><td>0.876</td></tr><tr><td>MCS12</td><td>34.7 (8.8)</td><td>33.6-35.9</td><td>36.9 (10.1)</td><td>35.6-38.1</td><td>p = .023</td><td>0.826</td></tr></tbody></table>

## Psychological needs

Participants with endometriosis had lower scores of competence satisfaction (p = .021), and a higher score of competence frustration (p = .002), and relatedness frustration (p = .010). No difference was found for other psychological needs (Table 5).

## Self-efficacy

No difference was found for self-efficacy (Table 5).

## Barriers to PA

Participants with endometriosis had higher scores on health domain (p = .013) while they had lower score on safety domain (p = .042) than participants without endometriosis. No difference was found for other barriers (Table 5).

## Kinesiophobia

Participants with endometriosis had higher scores (p < .001) on TSK than participants without endometriosis even though both groups had scores < 37 (i.e., no kinesiophobia) (Table 5).

## Stereotypes
Participants with endometriosis had significantly higher scores on stereotypes related to physical exercise in endometriosis context regarding lack of interest in exercise (p = .005), lack of physical abilities (p < .001), role of side effects of treatment (p < .001) and benefits of exercises (p = .007) compared with participants without endometriosis. However, they had lower scores on risk of exercises (p = .004) (Table 5).

## Social support

No differences were found for social support (Table 5).

## Physical self-concept

Participants with endometriosis had significantly lower scores on three out of six domains: health (p = .012), global physical satisfaction (p < .001) and global esteem (p = .027) compared with participants without endometriosis (Table 5).

<table><caption>**Table 5.** Comparison of motivational variables, barriers to PA, kinesiophobia, stereotype, social support, self-concept between participants with and without endometriosis.</caption><thead><tr><th rowspan="2"></th><th colspan="2">With endometriosis</th><th colspan="2">Without endometriosis</th><th rowspan="2">p value</th><th rowspan="2">Cronbach's α</th></tr><tr><th>M (SD)</th><th>95% CI</th><th>M (SD)</th><th>95% CI</th></tr></thead><tbody><tr><td colspan="7"><strong>Theory of planned behavior</strong></td></tr><tr><td>Attitude</td><td>5.1 (1.4)</td><td>4.92-5.32</td><td>5.4 (1.3)</td><td>5.20-5.55</td><td>p = .082</td><td>0.763</td></tr><tr><td>Injunctive norm</td><td>6.4 (1.2)</td><td>6.19-6.49</td><td>6.3 (1.2)</td><td>6.11-6.39</td><td>p = .123</td><td>0.788</td></tr><tr><td>Descriptive norm</td><td>4.5 (1.5)</td><td>4.27-4.65</td><td>4.3 (1.4)</td><td>4.14-4.47</td><td>p = .145</td><td>0.888</td></tr><tr><td>Perceived behavioral control</td><td>4.6 (1.9)</td><td>4.41-4.88</td><td>5.1 (1.8)</td><td>4.90-5.28</td><td>p = .012</td><td>0.931</td></tr><tr><td>Intention</td><td>5.1 (1.8)</td><td>4.86-5.36</td><td>4.9 (1.8)</td><td>4.65-5.14</td><td>p = .164</td><td>0.948</td></tr><tr><td>Previous behavior</td><td>4.1 (1.7)</td><td>3.92-4.39</td><td>4.3 (1.8)</td><td>4.11-4.60</td><td>p = .213</td><td>-</td></tr><tr><td>Total</td><td>4.9 (1.1)</td><td>4.74-5.05</td><td>5.0 (1.3)</td><td>4.85-5.16</td><td>p = .289</td><td>0.918</td></tr><tr><td colspan="7"><strong>Motivation</strong></td></tr><tr><td>Intrinsic motivation</td><td>4.9 (1.9)</td><td>4.64-5.11</td><td>4.6 (1.9)</td><td>4.32-4.79</td><td>p = .072</td><td>0.870</td></tr><tr><td>Integrated regulation</td><td>4.2 (2.2)</td><td>3.92-4.47</td><td>3.8 (2.2)</td><td>3.55-4.06</td><td>p = .043</td><td>0.887</td></tr><tr><td>Identified regulation</td><td>5.6 (1.6)</td><td>5.40-5.81</td><td>5.3 (1.7)</td><td>5.12-5.54</td><td>p = .051</td><td>0.880</td></tr><tr><td>Introjected regulation</td><td>4.3 (2.1)</td><td>4.06-4.53</td><td>4.1 (2.1)</td><td>3.88-4.34</td><td>p = .238</td><td>0.784</td></tr><tr><td>External regulation</td><td>1.5 (1.1)</td><td>1.38-1.62</td><td>1.6 (1.3)</td><td>1.51-1.78</td><td>p = .107</td><td>0.724</td></tr><tr><td>Amotivation</td><td>1.4 (0.9)</td><td>1.30-1.55</td><td>1.6 (1.2)</td><td>1.43-1.71</td><td>p = .091</td><td>0.844</td></tr><tr><td colspan="7"><strong>Psychological needs</strong></td></tr><tr><td>Autonomy satisfaction</td><td>5.1 (1.9)</td><td>4.91-5.33</td><td>5.2 (1.8)</td><td>5.06-5.42</td><td>p = .545</td><td>0.821</td></tr><tr><td>Competence satisfaction</td><td>4.3 (1.9)</td><td>4.08-4.52</td><td>4.6 (1.8)</td><td>4.43-4.85</td><td>p = .021</td><td>0.908</td></tr></tbody></table>
<table><tbody><tr><td>Relatedness satisfaction</td><td>4.3 (2.1)</td><td>4.06-4.46</td><td>4.3 (2.1)</td><td>4.13-4.52</td><td>p = .517</td><td>0.776</td></tr><tr><td>Autonomy frustration</td><td>1.8 (1.4)</td><td>1.67-1.94</td><td>1.9 (1.5)</td><td>1.74-2.02</td><td>p = .489</td><td>0.727</td></tr><tr><td>Competence frustration</td><td>2.2 (1.7)</td><td>2.02-2.43</td><td>1.8 (1.5)</td><td>1.62-1.98</td><td>p = .002</td><td>0.885</td></tr><tr><td>Relatedness frustration</td><td>1.8 (1.5)</td><td>1.64-1.97</td><td>1.6 (1.3)</td><td>1.44-1.73</td><td>p = .010</td><td>0.878</td></tr><tr><td><strong>Self-efficacy</strong></td><td>5.6 (1.9)</td><td>5.30-5.84</td><td>5.5 (1.9)</td><td>5.21-5.74</td><td>p = .839</td><td>0.919</td></tr><tr><td><strong>Barriers to physical activity</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Health</td><td>2.6 (1.1)</td><td>2.47-2.80</td><td>2.4 (1.0)</td><td>2.22-2.49</td><td>p = .013</td><td>0.729</td></tr><tr><td>Beliefs/ attitudes towards PA</td><td>1.4 (1.0)</td><td>1.23-1.54</td><td>1.4 (1.0)</td><td>1.29-1.59</td><td>p = .557</td><td>0.787</td></tr><tr><td>Friends</td><td>1.1 (1.2)</td><td>0.94-1.30</td><td>1.1 (1.2)</td><td>0.94-1.28</td><td>p = .882</td><td>0.855</td></tr><tr><td>Family</td><td>1.1 (1.3)</td><td>0.89-1.27</td><td>1.1 (1.2)</td><td>0.92-1.27</td><td>p = .541</td><td>0.857</td></tr><tr><td>Community built environment</td><td>1.0 (1.2)</td><td>0.85-1.23</td><td>1.1 (1.1)</td><td>0.95-1.28</td><td>p = .244</td><td>0.919</td></tr><tr><td>Safety</td><td>1.2 (1.3)</td><td>1.04-1.45</td><td>1.5 (1.4)</td><td>1.30-1.70</td><td>p = .042</td><td>0.867</td></tr><tr><td><strong>Kinesiophobia</strong></td><td>32.2 (7.6)</td><td>31.0-33.4</td><td>22.8 (11.8)</td><td>22.8-26.2</td><td>p &lt; .001</td><td>0.804</td></tr><tr><td><strong>Stereotypes</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lack of interest</td><td>2.8 (1.8)</td><td>2.56-3.05</td><td>2.3 (1.6)</td><td>2.04-2.51</td><td>p = .005</td><td>0.789</td></tr><tr><td>Lack of physical abilities</td><td>4.2 (1.8)</td><td>3.91-4.36</td><td>3.5 (1.8)</td><td>3.28-3.77</td><td>p &lt; .001</td><td>0.824</td></tr><tr><td>Side effects of treatment</td><td>5.1 (1.8)</td><td>4.93-5.29</td><td>4.5 (1.7)</td><td>4.33-4.71</td><td>p &lt; .001</td><td>0.686</td></tr><tr><td>Risks of exercise</td><td>2.8 (1.7)</td><td>2.63-2.99</td><td>3.2 (1.5)</td><td>2.97-3.40</td><td>p = .004</td><td>0.680</td></tr><tr><td>Benefits of exercise</td><td>5.6 (1.6)</td><td>5.42-5.76</td><td>5.3 (1.5)</td><td>5.04-5.45</td><td>p = .007</td><td>0.777</td></tr><tr><td><strong>Social support</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Friends</td><td>1.9 (0.8)</td><td>1.74-1.99</td><td>2.0 (0.7)</td><td>1.87-2.10</td><td>p = .083</td><td>0.842</td></tr><tr><td>Family</td><td>1.8 (0.7)</td><td>1.69-1.92</td><td>1.85 (0.7)</td><td>1.73-1.97</td><td>p = .635</td><td>0.842</td></tr><tr><td>Lover</td><td>2.2 (0.9)</td><td>2.06-2.39</td><td>2.3 (0.8)</td><td>2.12-2.46</td><td>p = .534</td><td>0.858</td></tr><tr><td><strong>Physical self-concept</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Health</td><td>3.7 (1.2)</td><td>3.52-3.91</td><td>4.6 (1.1)</td><td>4.39-4.72</td><td>p = .012</td><td>0.889</td></tr><tr><td>Body fat</td><td>3.4 (1.8)</td><td>3.14-3.70</td><td>3.7 (1.6)</td><td>3.49-3.98</td><td>p = .077</td><td>0.952</td></tr><tr><td>Sports competence</td><td>2.8 (1.4)</td><td>2.63-3.06</td><td>3.1 (1.4)</td><td>2.88-3.31</td><td>p = .089</td><td>0.947</td></tr><tr><td>Global physical satisfaction</td><td>2.8 (1.3)</td><td>2.59-3.00</td><td>3.4 (1.3)</td><td>3.16-3.59</td><td>p &lt; .001</td><td>0.947</td></tr><tr><td>Physical appearance</td><td>3.6 (1.2)</td><td>3.44-3.81</td><td>3.7 (1.1)</td><td>3.56-3.92</td><td>p = .365</td><td>0.907</td></tr><tr><td>Global esteem</td><td>4.4 (1.0)</td><td>4.26-4.56</td><td>4.6 (1.0)</td><td>4.47-4.77</td><td>p = .027</td><td>0.898</td></tr></tbody></table>

Comparison between participants with and without endometriosis regarding correlates of PA and sedentary behaviors

We then calculated Pearson correlation coefficients between PA, SED, and other psychosocial variables while distinguishing participants with and without endometriosis (Table 6).
## Similar Correlates

Regarding motivational variables (from theory of planned behaviors, self-determination theory, and self-efficacy questionnaires), all were similar between groups except norms and identified regulation (positively correlated with PA in participants without endometriosis only), amotivation (negatively correlated with PA in participants without endometriosis only), and competence frustration (negatively correlated with PA in participants with endometriosis only). In both groups, previous behaviors, intention, and perceived behavioral control showed the strongest correlations with PA ($r > 0.33$).

In both groups, sports competence (from physical self-concept questionnaire) was positively correlated with PA, while beliefs toward PA (from barriers to PA questionnaire) were negatively correlated with PA and positively with SED.

## Different Correlates

Among participants with endometriosis, variables negatively correlated with PA included SED, barriers to PA related to poor health, family, safety and community-built environment, kinesiophobia, and stereotypes related to risk of exercise.

Conversely, among participants with endometriosis, variables positively correlated with PA included social support from friends and family, body fat perception, global physical satisfaction, global self-esteem, and PCS.

Among participants with endometriosis, variables negatively correlated with SED included variables from theory of planned behaviors (except both norms), motivational variables (except amotivation and external regulation), autonomy satisfaction, self-efficacy, global physical satisfaction, sport competence, and PCS.

In contrast, among participants with endometriosis, variables positively correlated with SED included all barriers to PA except safety, kinesiophobia, and stereotypes related to treatment side effects and risks of exercise.

Finally, among participants without endometriosis, social support from a partner was positively correlated with PA, and external regulation was positively correlated with SED. Other correlations were not significant.

## DISCUSSION

PA could be a solution for managing the symptoms of endometriosis as a complement to, or instead of, the proposed medical treatments. It therefore seems necessary to understand the variables specific to this population concerning PA but also SED and to identify the variables linked to these behaviors in order to promote or limit them, respectively. The aims of this study were first to determine differences between participants with and without endometriosis for variables related to PA and second to identify variables correlated to PA and SED in women with
endometriosis. Although differences were expected across all the variables, this was not the case. No prior hypotheses were formulated regarding variables correlated to PA and SED in the context of endometriosis.

## The differences between women with and without endometriosis

In the context of endometriosis, studies have focused mainly on PA, not on SED, although it is recognized that these two behaviors are not the opposite of each other, and need to be studied in parallel. Unlike previous studies, which have shown that women suffering from endometriosis were less physically active than those without endometriosis (Sachs et al., 2023), the present study showed no difference. The importance of PA in the context of endometriosis is increasing, and PA could be proposed as part of usual care protocols (e.g., medication, physical and mental care) (Becker et al., 2022). Furthermore, a guideline has recently been published describing physical practices and adapted PA (APA) to be implemented in the context of endometriosis (Pôle Santé CREPS Vichy, 2025). PA is increasingly recognized as a potential method for managing the symptoms of endometriosis. It is possible that women with endometriosis in our sample had already benefited from APA programs specifically designed for endometriosis, prescribed by their doctors and offered in their health centers -and continue to practice- or were aware of the benefits of PA to manage their symptoms. This was reflected in the results concerning stereotypes (i.e., women with endometriosis perceived the benefits of PA) and the type of motivation (i.e., women with endometriosis reported an integrated regulation for PA, which means that PA is part of their core values). These findings could explain why, in our sample, women with endometriosis did not practice less than women without endometriosis. However, the results also suggested that women with endometriosis may perceive that others with the condition show little interest or motivation to engage in PA. Therefore, it is important to develop meaningful and tailored strategies to encourage adherence to PA in the short, medium, and long term.

The present results revealed differences between groups in SED, with women with endometriosis adopting these behaviors less frequently. A previous study showed that time spent sitting was a risk factor for endometriosis (Hemmert et al., 2019). The present study went further by looking at different aspects of SED and showed that women with endometriosis were less likely to adopt SED, such as watching television or commuting. Pain associated with endometriosis may have contributed to these patterns, as prior study has highlighted difficulties in carrying out daily tasks (Cunnington et al., 2024). Moreover, pain can occur even when sitting or commuting, and such situations may exacerbate discomfort (Hvala & Hammarberg, 2025). In other words, it seems that SED can also aggravate pelvic pain (Tang et al., 2025), which could explain the reduced adoption of SED in our study. Although resting is one of the strategies often used to manage endometriosis symptoms (O'Hara et al., 2019; Roomaney & Kagee, 2016), our results indicated
that lying down due to endometriosis symptoms was the least adopted SED. Further studies are needed to clarify the relationship between endometriosis and SED.

Regarding psychological variables, consistent with previous studies, the results showed that women with endometriosis reported poorer QoL than those without the disease, underscoring the role of symptoms in this evaluation and the importance of both symptom management and addressing illness perception (Facchin et al., 2015; Marinho et al., 2018; Spinoni et al., 2025). It is worth noting that in both groups, MCS scores were low, with women with endometriosis having a lower score. The study was conducted less than two years after the first COVID 19 wave and two months after the 5th wave, a context in which physical and mental health were widely impacted, (Salari et al., 2020), which may partly explain these findings. Additionally, it is possible that the participants who were not diagnosed for endometriosis (i.e., namely women without endometriosis in our sample) also experienced symptoms such as pain during the menstrual cycle, which could have negatively affected their QoL.

Previous study has shown that pelvic pain influences the representation of the disease (i.e., negative view of endometriosis), and that the latter is associated with maladaptive behavior (Spinoni et al., 2025). In addition, previous research has reported that women with endometriosis may perceive a loss of control due to the disease and feel less able to carry out everyday tasks (R. A. Davenport et al., 2024), may experience reduced physical capacity (Silva et al., 2024), and have a negative body image (Cunnington et al., 2024; Sullivan-Myers et al., 2023; Volker & Mills, 2022) particularly with regard to their appearance and body functions (Coquinos et al., 2025). These factors could foster the fear that their symptoms will get worse (Pickup et al., 2024), potentially leading to avoidance behaviors. In line with the previous findings, the results of this study also showed that the differences highlighted are linked to the direct and indirect impacts of the disease. In terms of direct impact, the two groups differed in barriers to PA related to bad health, kinesiophobia, stereotypes linked to treatment side effects, and the self-concept linked to health (i.e., perceive oneself having good (bad) health). Women with endometriosis perceived their health as limiting PA opportunities. This result is confirmed by the study of the correlates, which showed that health-related barriers, and kinesiophobia are correlated negatively to PA and positively to SED, in women with endometriosis. In terms of indirect impact, this disease also affects perceived behavioral control and body image. The groups differed in terms of perceived behavioral control over PA, stereotypes related to physical ability, physical satisfaction, and overall self-esteem.

Although few studies have examined the effects of PA on endometriosis symptoms, evidence from other chronic conditions suggests that PA can be beneficial for symptom management, particularly for pain (Institut national de la santé et de la recherche médicale, 2019). The present study suggests that by considering the consequences of the disease (e.g., symptoms, current state
of fitness, capacities), it is possible to propose APA and demonstrate that engaging in PA is feasible despite the disease when the PA program is adapted. Such programs would enable individuals, such as women with endometriosis, to reappropriate their bodies, better accept the disease and improve their QoL (Pontoppidan et al., 2023; Zhang et al., 2025). Nevertheless, considering what women with endometriosis are capable of in APA is not enough. They should also feel heard and included, rather than overlooked or ignored. This was reflected in our findings, as women with endometriosis not only reported lower satisfaction and higher frustration of their needs for competence but also higher frustration of their needs for social relationships. Promoting PA, also requires showing its benefits and addressing beliefs linked to potential risks due to PA, for both women with and without endometriosis. Indeed, results showed that, when asked to what extent they think that PA could represent a risk, women with endometriosis perceived lower risk of practicing PA. This belief is particularly relevant, as correlation analyses showed that stereotypes linked to perceived risk of PA were negatively correlated to PA only in women with endometriosis.

The present study revealed two surprising results: no differences were found in self-efficacy and perceived social support from family, friends and life partners. Regarding the former variable, the items did not all relate to illness or health conditions, but focused on the obstacles commonly encountered to PA, which could have been experienced in both groups. In terms of social support, it has shown its importance in coping with endometriosis, particularly for emotional issues or accompaniment to medical appointments. In this context, social support for PA may have been perceived as less important than other domains where social support is needed, which could explain the lack of difference between groups. Nevertheless, social support remains linked to PA, as discussed in the following section.

## Different correlates between PA and SED

The correlation analyses provided additional information about the variables associated with PA and SED, in women with endometriosis, and the weight of these relations. Results showed that the correlations coefficients were similar for both groups regarding the correlations between dimensions of the theory of planned behavior, the self-determination theory and self-efficacy, on one hand, and PA, on the other hand. These variables are part of the core group of determinants of health behaviors (Hagger, 2025). It is interesting that these variables remain linked to PA with or without endometriosis. Given these results it could be assumed that intervention grounded on these theories could improve PA in endometriosis context as much as other health contexts (Hagger & Chatzisarantis, 2009; Sheeran et al., 2020; Steinmetz et al., 2016). It is worth noting that these variables were also correlated with SED, only in women with endometriosis. In the present study SED and PA are correlated but only in the latter sample of participants, showing the need to consider both behaviors but also to identify variables correlated to those. Our results showed that
theory-based interventions should explicitly target the increase of PA as much as the decrease of SED, in endometriosis context.

Several variables were correlated with both PA and SED in women with endometriosis. These included variables linked to physical health (i.e., barriers related to health, kinesiophobia, risks of exercise, global physical satisfaction, sports competence and PCS). Endometriosis and its symptoms have a substantial physical impact (Moradi et al., 2014), which can not only represent a barrier to PA but also shape beliefs about one's physical capacities (Moradi et al., 2014) and engender fear that PA may increase symptoms. To help modify these beliefs, educational programs promoting and explaining the benefits of PA and the deleterious effects of SED could be implemented. These programs should complement adapted PA interventions tailored to participants' abilities, skills, and fitness state, accounting for the effects of endometriosis symptoms or treatment side effects. Programs should also be progressive in terms of difficulty and intensity, to allow the participants to experience pleasure and success during PA sessions. This approach may allow participants to regain self-confidence and increase their engagement in PA. This could help them start modifying their self-concepts and thus enhancing body image and self-esteem (Babic et al., 2014; Sullivan-Myers et al., 2023), two other variables linked to PA, in the present study and affected by endometriosis (Sullivan-Myers et al., 2023; Volker & Mills, 2022).

The results also highlighted the importance of participants' environments. Regarding the social environment, although previous analyses from this study showed no differences between groups regarding social support, correlation analysis showed that support from family and friends, but not from life partner, were correlated to PA in women with endometriosis. Endometriosis can affect couples' relationship (Norinho et al., 2020), and relational satisfaction in women with endometriosis may depend on their partner being informed about the condition, showing interest in their health and accompanying them to medical appointments (Facchin et al., 2021). Consequently, support from life partners for PA may have been perceived as less relevant in our sample, whereas encouragement from friends and family remained important, consistent with previous studies (Eyler et al., 1999; Lindsay Smith et al., 2017; Treiber et al., 1991). Regarding local environment, results showed that unsafe environment and community-built environment that do not facilitate PA (e.g., no access to fitness center, sidewalks and streets in poor condition) are related negatively to PA and positively to SED (for community-built environment). In accordance with previous results, the present study highlighted the importance of PA-related policy in promoting PA (Gelius et al., 2020).

<table><caption>**Table 6.** Pearson correlations between psychological and psychosocial variables and PA and sedentary behaviors regarding endometriosis.</caption><thead><tr><th colspan="2">Physical activity</th><th colspan="2">Sedentary behaviors</th></tr></thead><tbody><tr><td>With endometriosis</td><td>Without endometriosis</td><td>With endometriosis</td><td>Without endometriosis</td></tr></tbody></table>
<table><tbody><tr><td><strong>Sedentary behaviors</strong></td><td>-.29*</td><td>-.06</td><td></td><td></td></tr><tr><td><strong>Theory of planned behavior</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Attitude</td><td>.17*</td><td>.21*</td><td>-.19*</td><td>-.04</td></tr><tr><td>Injunctive norm</td><td>.13</td><td>.18*</td><td>-.14</td><td>.03</td></tr><tr><td>Descriptive norm</td><td>.04</td><td>.20*</td><td>.04</td><td>-.11</td></tr><tr><td>Perceived behavioral control</td><td>.35*</td><td>.33*</td><td>-.19*</td><td>.05</td></tr><tr><td>Intention</td><td>.35*</td><td>.34*</td><td>-.27*</td><td>-.06</td></tr><tr><td>Previous behavior</td><td>.43*</td><td>.45*</td><td>-.18*</td><td>-.07</td></tr><tr><td><strong>Motivation</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Intrinsic motivation</td><td>.20*</td><td>.25*</td><td>-.23*</td><td>.00</td></tr><tr><td>Integrated regulation</td><td>.28*</td><td>.28*</td><td>-.24*</td><td>-.04</td></tr><tr><td>Identified regulation</td><td>.13</td><td>.21*</td><td>-.24*</td><td>.03</td></tr><tr><td>introjected regulation</td><td>.29*</td><td>.23*</td><td>-.23*</td><td>.12</td></tr><tr><td>External regulation</td><td>-.13</td><td>-.05</td><td>.06</td><td>.17*</td></tr><tr><td>Amotivation</td><td>-.10</td><td>-.23*</td><td>.13</td><td>.09</td></tr><tr><td><strong>Psychological needs</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Autonomy satisfaction</td><td>.20*</td><td>.22*</td><td>-.19*</td><td>-.04</td></tr><tr><td>Competence satisfaction</td><td>.30*</td><td>.20*</td><td>-.14</td><td>-.03</td></tr><tr><td>Relatedness satisfaction</td><td>.21*</td><td>.19*</td><td>-.14</td><td>-.02</td></tr><tr><td>Autonomy frustration</td><td>-.08</td><td>.01</td><td>.09</td><td>-.06</td></tr><tr><td>Competence frustration</td><td>-.20*</td><td>-.09</td><td>.14</td><td>.07</td></tr><tr><td>Relatedness frustration</td><td>-.10</td><td>-.05</td><td>.08</td><td>-.03</td></tr><tr><td><strong>Self-efficacy</strong></td><td>.38*</td><td>.27*</td><td>-.16*</td><td>-.08</td></tr><tr><td><strong>Barriers to physical activity</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Health</td><td>-.26*</td><td>.03</td><td>.26*</td><td>.08</td></tr><tr><td>Beliefs/ attitudes towards PA</td><td>-.19*</td><td>-.26*</td><td>.20*</td><td>.17*</td></tr><tr><td>Friends</td><td>-.09</td><td>-.10</td><td>.21*</td><td>.13</td></tr><tr><td>Family</td><td>-.18*</td><td>-.12</td><td>.21*</td><td>.02</td></tr><tr><td>Community built environment</td><td>-.20*</td><td>-.01</td><td>.22*</td><td>-.02</td></tr><tr><td>Safety</td><td>-.20*</td><td>.03</td><td>.16</td><td>.08</td></tr><tr><td><strong>Kinesiophobia</strong></td><td>-.27*</td><td>-.07</td><td>.27*</td><td>.08</td></tr><tr><td><strong>Stereotypes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Lack of interest</td><td>.17</td><td>-.08</td><td>.14</td><td>.05</td></tr><tr><td>Lack of physical abilities</td><td>-.03</td><td>-.02</td><td>.13</td><td>.11</td></tr><tr><td>Side effects of treatment</td><td>-.14</td><td>-.02</td><td>.33*</td><td>.18</td></tr><tr><td>Risks of exercise</td><td>-.18*</td><td>-.03</td><td>.21*</td><td>.01</td></tr><tr><td>Benefits of exercise</td><td>.16</td><td>.05</td><td>-.17</td><td>.12</td></tr><tr><td><strong>Social support</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Friends</td><td>.21*</td><td>.14</td><td>-.18</td><td>-.06</td></tr><tr><td>Family</td><td>.21*</td><td>.16</td><td>.01</td><td>-.05</td></tr><tr><td>Lover</td><td>.19</td><td>.40*</td><td>.07</td><td>.00</td></tr><tr><td><strong>Physical self-concept</strong></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><tbody><tr><td>Health</td><td>.04</td><td>-.01</td><td>-.15</td><td>-.09</td></tr><tr><td>Body fat</td><td>.22*</td><td>.09</td><td>-.06</td><td>-.01</td></tr><tr><td>Sports competence</td><td>.34*</td><td>.21*</td><td>-.20*</td><td>.04</td></tr><tr><td>Global physical satisfaction</td><td>.33*</td><td>.12</td><td>-.20*</td><td>-.05</td></tr><tr><td>Physical appearance</td><td>.17</td><td>.10</td><td>-.10</td><td>-.02</td></tr><tr><td>Global esteem</td><td>.18*</td><td>-.01</td><td>-.07</td><td>-.07</td></tr><tr><td><strong>QoL</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>PCS</td><td>.20*</td><td>.02</td><td>-.28*</td><td>-.02</td></tr><tr><td>MCS</td><td>.10</td><td>.05</td><td>-.11</td><td>-.04</td></tr><tr><td><strong>Pain</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Current pain</td><td>-.01</td><td></td><td>.20</td><td></td></tr><tr><td>Pain last week</td><td>.05</td><td></td><td>.14</td><td></td></tr><tr><td>Pain during crisis</td><td>-.12</td><td></td><td>.20</td><td></td></tr><tr><td><strong>Menarche</strong></td><td>.05</td><td>-.01</td><td>-.09</td><td>-.03</td></tr><tr><td><strong>Age</strong></td><td>-.07</td><td>-.01</td><td>-.02</td><td>-.08</td></tr></tbody></table>

Notes. * p < .05

## LIMITATIONS

This study is the first to compare samples of women with and without endometriosis, taking into account variables relating to PA and SED, physical and mental QoL, and motivational, psychological and psychosocial variables. Nevertheless, this study has several limitations. Firstly, it is not possible to establish a causal link between the variables given the cross-sectional design of the study. It is also possible that some of these variables are related to each other and that mediating relationships exist. Future studies could adopt a randomized controlled trial and propose exploratory structural equations to better understand the different relationships between these variables. Secondly, certain questions were only asked of the group suffering from endometriosis. However, some undiagnosed people could have had similar symptoms. Thirdly, this study uses only quantitative data. Qualitative data from semi-structured interviews or open-ended questions could clarify the results obtained. In the same vein, life partners were not interviewed. However, their point of view could also provide additional information.

## CONCLUSION

In conclusion, this study showed that there were differences in variables relating to PA and SED between women with and without endometriosis. It underlined the importance of taking these two behaviors into account and highlighted the role of the disease (its perception, its
consequences). Finally, the results highlighted the importance of motivational variables and variables linked to self-concept.

**Contributions**

Contributed to conception and design: GEB

Contributed to acquisition of data: TM, MAJ, GEB

Contributed to analysis and interpretation of data: TM, UH, GEB

Drafted and/or revised the article: TM, UH, MAJ, GEB

Approved the submitted version for publication: TM, UH, MAJ, GEB

**Acknowledgements**

The authors would like to thank Lionel Lenôtre, Charles-André Philip, Emilie Faller, Sophie Warembourg, and Patricia Branche for their valuable contributions and support to this study, as well as Sporactio for their assistance.

**Funding information**

This research was funded by the association EndoFrance, the French National Research Agency [Agence Nationale de la Recherche (ANR)], and the Foundation for Research on Endometriosis [Fondation pour la Recherche sur l'Endométriose (FRE)].

**Conflict of interest**

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

**Data and Supplementary Material Accessibility**

The data that supports the findings of this study are available from the corresponding author (T.M.), upon request.
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