# Factors associated with anxiety and depression symptoms among women with endometriosis: A cross-sectional study within the ComPaRe-Endometriosis cohort

Zélia Breton, Solène Gouesbet, Hélène Amazouz, Hélèna Schoefs, Viet-Thi Tran, Bruno Falissard, Emmanuelle Corruble, Marina Kvaskoff

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## To cite this version:

Zélia Breton, Solène Gouesbet, Hélène Amazouz, Hélèna Schoefs, Viet-Thi Tran, et al. Factors associated with anxiety and depression symptoms among women with endometriosis: A cross-sectional study within the ComPaRe-Endometriosis cohort. Journal of Psychosomatic Research, 2025, 196, pp.112329. 10.1016/j.jpsychores.2025.112329. hal-05373442

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# Factors associated with anxiety and depression symptoms among women with endometriosis: A cross-sectional study within the ComPaRe-Endometriosis cohort

Zélia Breton<sup>a,b</sup>, Solène Gouesbet<sup>a</sup>, Hélène Amazouz<sup>a</sup>, Hélèna Schoefs<sup>c,d,e</sup>, Viet-Thi Tran<sup>f,g</sup>, Bruno Falissard<sup>a,h</sup>, Emmanuelle Corruble<sup>i,j</sup>, Marina Kvaskoff<sup>a,*</sup>

## ARTICLE INFO

Keywords:

Anxiety

Endometriosis

Cross-sectional studies

Depression

Mental well-being

Mental health

Women's health

## ABSTRACT

**Context and objectives:** Women with endometriosis report higher anxiety and depression levels compared with the general population. While numerous studies focused on chronic pain, few have investigated broader potential correlates of mental well-being in patients with endometriosis. This cross-sectional study aimed to highlight the factors associated with higher anxiety and depression symptoms in women with endometriosis.

**Methods:** We conducted a cross-sectional analysis among 2394 participants of the ComPaRe-Endometriosis e-cohort. Symptoms of anxiety and depression were assessed via GAD-7 and PHQ-9 scales at baseline. We used polytomous logistic regression modeling to explore the factors associated with anxiety and depression symptoms severity after adjustment for age, body mass index (BMI), number of comorbidities, diagnostic delay, and age at first symptoms.

**Results:** Overall, 32 % and 45 % of participants had moderate-to-severe anxiety and depression symptoms respectively. Factors positively associated with higher anxiety/depression symptom severity included lower education, poor sleep quality, reduced quality of life, severity of pelvic/abdominal pain, number of comorbidities, higher BMI, number of medical consultations to diagnosis, and use of complementary medicine. In contrast, older age, a financial situation perceived as comfortable, lack of pain treatment or less frequent transvaginal ultrasound follow-ups were associated with lower anxiety and depression symptoms.

**Conclusion:** This study identified several sociodemographic and medical factors associated with higher severity of anxiety and depression symptoms in women with endometriosis. If confirmed in future studies, these results could guide preventive strategies, enhance healthcare provider training, and optimize treatments for improved patient-centered care.

<footnote><sup>a</sup> Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805 Villejuif, France</footnote>

<footnote><sup>b</sup> Lyv Healthcare, 44000 Nantes, France</footnote>

<footnote><sup>c</sup> Faculté de Psychologie, Logopédie et Sciences de l'Éducation, Université de Liège, 4020 Liège, Belgium</footnote>

<footnote><sup>d</sup> Laboratoire de Psychologie Sociale et Cognitive, LAPSCO, UMR UCA-CNRS 6024, Université Clermont Auvergne, 63000, Clermont-Ferrand, France</footnote>

<footnote><sup>e</sup> Union nationale des Associations de Défense des Familles et de l'Individu victimes de sectes, UNADFI, 78200 Buchelay, France</footnote>

<footnote><sup>f</sup> METHODS team, Inserm UMR1153/CRESS, Clinical Epidemiology Center, Hôtel-Dieu Hospital, AP-HP, 75004 Paris, France</footnote>

<footnote><sup>g</sup> Department of Epidemiology and Public Health, Hôtel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), 75004 Paris, France</footnote>

<footnote><sup>h</sup> AP-HP Paris-Saclay, Epidemiology and Public Health Department, 94270 Le Kremlin-Bicêtre, France</footnote>

<footnote><sup>i</sup> Université Paris-Saclay, Faculté de Pharmacie, Inserm UMR 1018, CESP, MOODS Team, 91400 Orsay, France</footnote>

<footnote><sup>j</sup> Department of Psychiatry, Bicêtre Hospital, APHP Paris Saclay, 94270 Le Kremlin-Bicêtre, France</footnote>

<footnote>* Corresponding author at: Inserm U1018, Centre for Research in Epidemiology and Population Health, "Exposome, Heredity, Cancer, and Health" Team, Paul Brousse Hospital, Bat. 15/16, 12 avenue Paul Vaillant Couturier, F-94805, Villejuif Cedex, France.</footnote>

<footnote>E-mail addresses: Zelia.breton@inserm.fr (Z. Breton), solene.gouesbet@gustaveroussy.fr (S. Gouesbet), helene.amazouz@inserm.fr (H. Amazouz), helena.schoefs@protonmail.com (H. Schoefs), thi.tran-viet@aphp.fr (V.-T. Tran), bruno.falissard@gmail.com (B. Falissard), emmanuelle.corruble@aphp.fr (E. Corruble), marina.kvaskoff@inserm.fr (M. Kvaskoff).</footnote>
# 1. Introduction

## 1.1. Background

Endometriosis is an inflammatory condition where endometrium-like tissue is found outside the uterus, affecting about 10% of women of reproductive age [1]. It is classified into four surgical stages according to the revised criteria of the American Fertility Society and the American Society of Reproductive Medicine: minimal (stage I) to severe (stage IV). The disease manifests in three pelvic forms: Superficial Peritoneal Endometriosis (SPE), Ovarian Endometriosis (OMA), and Deep Endometriosis (DE). Adenomyosis, or the presence of endometrium-like lesions within the myometrium, once considered a form of endometriosis, is now recognized as a separate condition, although both conditions often coexist [2]. While we refer to “women” in this study, it is essential to note that endometriosis can affect all people assigned female at birth.

Endometriosis is associated with debilitating symptoms (dysmenorrhea, dyspareunia, dysuria, dyschezia, chronic fatigue) [3] as well as infertility and a higher risk of other chronic conditions [4,5]. A 7- to 10-year average delay is often described between onset of symptoms and diagnosis [3,6]. Consequently, the disease has a profound impact on patients, affecting different areas of their lives (professional, social, economic, sexual, relationships, and quality of life (QoL)) [7,8].

Endometriosis is a chronic disease for which no definitive cure exists [9]. Treatment strategies consist in relieving painful symptoms through hormone therapy, analgesics, and surgery if indicated, with complementary non-drug therapies and physical activity being often proposed [10,11]. The potential severity of symptoms, long course of treatment, and lack of recognition of the difficulties experienced by patients potentially have a significant impact on their mental health, particularly with regards to anxiety and depression, as suggested by several studies [12-15].

Previous reviews reported that anxiety and depression levels among women with endometriosis or chronic pelvic pain were positively associated with pain severity, poor QoL or quality of sleep, intensity of fatigue or of gastro-intestinal symptoms, poor sexual function, presence of comorbidities, stigma, and diagnostic delay [7,12-14,16-20]. In contrast, factors that were inversely associated with anxiety and depression include coping strategies, multidisciplinary care, medical and surgical treatment, and being married.

However, published studies focusing on the mental well-being of women with endometriosis specifically aimed to mainly describe patients' anxiety and depression levels; few explored the factors associated with anxiety and depression symptoms, and those that did mainly focused on pain. Also, only one study was conducted in France [21], and most studies focused on surgically-diagnosed patients – thus potentially more severe cases given the current European guidelines recommending imaging as the first diagnostic approach [10,22]. Moreover, most studies were based on limited sample sizes (from *n* = 62 in Friedl et al., 2015 to *n* = 1039 in Guillemot et al., 2024), except for one retrospective matched-cohort study with *n* = 72,000 (Estes et al., 2021) that evaluated anxiety and depression diagnoses from electronic health records, but with limited covariate data available [21,23,24]. There is a need for a broader understanding of the factors associated with anxiety and depression levels in women with endometriosis, in order to identify potential avenues for intervention and inform public health policies.

## 1.2. Objectives

The aims of this cross-sectional study were to describe anxiety and depression symptom levels among women with endometriosis and to investigate their associated factors in a large sample of patients.

# 2. Material and methods

## 2.1. Study population

ComPaRe (Community of Patients for Research) is an ongoing prospective e-cohort of over 55,000 chronic disease patients volunteering to help advance research on chronic diseases [25]. Participants are French-speaking adults aged 18 or older reporting at least one chronic illness, defined as illness requiring care for at least 6 months. The participatory research platform was initiated in 2017. Patients register online (http://compare.aphp.fr) and provide electronic consent before participating in the e-cohort. The cohort was approved by the Institutional Review Board of the Hôtel-Dieu Hospital in Paris (IRB: 0008367) and the French National Commission for Data Protection and Privacy (CNIL: 916397). ComPaRe-Endometriosis, a sub-cohort of ComPaRe, consists of participants who self-reported endometriosis and/or adenomyosis. After the initial launch of ComPaRe-Endometriosis in 2018, about 7000 women were active participants of the cohort on the 22nd of June 2023 (date of data extraction for analysis).

## 2.2. Collected data

At inclusion, all ComPaRe participants reply to a baseline questionnaire on their health and socio-demographic factors. Subsequent questionnaires then collect information on various factors including employment status, lifestyle, comorbidities, reproductive factors among women, and several patient-reported outcome measurements (PROMs) and experience measurements (PREMs). ComPaRe-Endometriosis participants additionally reply to specific endometriosis-related questionnaires collecting information on medical path to diagnosis, self-reported stage and type of disease, surgical history, and symptom history, based on adapted versions of the WERF-EPHect clinical questionnaire [26]. An annual endometriosis follow-up questionnaire also updates information on pain symptoms and treatments.

### 2.2.1. Outcome data

ComPaRe participants receive an annual questionnaire asking about their mental well-being over the previous two weeks. Specifically, it includes two standardized scales for symptoms of anxiety and depression, respectively: the Generalized Anxiety Disorder questionnaire (GAD-7), which provides a score between 0 and 21 [27]; and the Patient Health Questionnaire (PHQ-9), which provides scores between 0 and 27 [28]. Scores <5 were considered “minimal”, 5-9 “mild”, and ≥ 10 “moderate-to-severe” symptoms on both scales.

Since few time points were available for analysis, we used a cross-sectional design and considered participants' responses to the GAD-7 and PHQ-9 questionnaires that occurred after the first annual endometriosis follow-up questionnaire (collecting current pain levels).

### 2.2.2. Data on factors of interest

QoL was assessed using two components in ComPaRe: the EQ-5D VAS, which scores participants' perceived health status from 0 (worst imaginable health) to 100 (best imaginable health); and the EQ-5D-5L, a measure of quality-adjusted life years (QALY) ranging from -0.52 (worst health status) to 1 (best health status). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), a standardized tool with scores ranging from 0 to 21, where higher scores indicate poorer sleep quality. The seven components of the PSQI were each rated from 0 (no difficulties) to 3 (severe difficulties).

The annual endometriosis follow-up questionnaire includes an evaluation of the worst pain levels measured using a numeric rating scale (NRS) from 0 (no pain) to 10 (worst imaginable pain), over the past 3 months for dysmenorrhea, dyschezia, dysuria, and pelvic or abdominal pain, and over the past 12 months for dyspareunia. NRS scores were categorized into the following ranges: 0-3, 4-5, 6-7, and 8-10. The annual follow-up also updates data on treatments, presence of 15 other
symptoms (decreased libido, decline in mood, right scapulalgia, cervical pain, pain in the right hypochondrium, sciatic pain, leg pain, back pain, muscular and articular pain, sitting pain, hypersomnia, insomnia, migraine, feeling of chest tightness, and severe fatigue), and anatomical location of dyspareunia.

Other endometriosis-specific questionnaires collected data on health-related QoL, evaluated using the EHP-5, a 5-item standardized questionnaire scored from 0 (best QoL) to 100 (worst QoL), and on fertility issues (unsuccessful attempts to conceive for 6–12 months). Finally, another questionnaire asked participants about their use of complementary and alternative medicine for their endometriosis symptoms.

From the 3718 participants who replied to the first mental health questionnaire, we only considered data from those who had already reported pain levels in the first annual endometriosis follow-up questionnaire (N = 2538). We excluded participants reporting no diagnosis (N = 20) or a diagnosis of adenomyosis only (N = 124) in order to focus on endometriosis-diagnosed patients. Our final dataset consisted of 2394 participants. For factors collected prospectively and repeatedly (sleep quality, QoL (EQ-5D), endometriosis symptoms and treatments), we considered participants' responses occurring before their response to the mental health questionnaire that was included in the analysis.

## 2.3. Statistical analysis

The outcomes of interest for this cross-sectional study were the GAD-7 and PHQ-9 scores. We analyzed them as categorical variables in order to identify factors associated with high levels of anxiety and depression symptoms. We categorized GAD-7 and PHQ-9 scores using established clinical thresholds to facilitate interpretation and to reflect meaningful symptom severity levels [27,28]. We used polytomous logistic regression models to estimate the odds ratios (ORs) and 95 % confidence intervals (CI) of the associations between various factors and severity of anxiety and depression symptoms (none-minimal – reference, mild, moderate-to-severe). Adjustment variables were selected based on univariate analyses and were theoretical confounding variables between most of the explored factors and our studied outcomes. Models were first adjusted for age (continuous – M1), then additionally adjusted for body mass index (BMI – continuous) and number of comorbidities (continuous – M2). A third model (M3) further adjusted for diagnostic delay and age at first symptoms (continuous). Model relevance was appreciated with the likelihood-ratio test and Akaike Information Criterion (AIC), which retained M3 as the best-fitting model; we thus presented all results based on M3. To control for collinearity, we checked that correlations between adjustment variables were not greater than |0.8|, and that the variance inflation factor (VIF) was under 4. Tests for linear trends were performed using an ordinal score across categories for each factor. Missing values in covariates were imputed to the modal category if occurring in <5 % of observations; otherwise, a “missing” modality was created. Analyses were performed using the SAS statistical software package (version 9.4).

## 3. Results

Participants' characteristics are described in Table 1. While average symptom levels were mild (anxiety: mean = 7.5, SD = 5.0; depression: mean = 9.4, SD = 5.3), 32 % and 45 % of participants had moderate-to-severe anxiety and depression symptoms, respectively (Fig. 1; Supplementary Table 1).

In M3 models, several socioeconomic factors were positively associated with moderate-to-severe anxiety and depression symptoms, such as a low educational level (GAD-7: $p_{trend} = 0.0005$; PHQ-9: $p_{trend} < 0.0001$) and being unemployed (GAD-7: aOR = 1.68, CI = 1.15–2.45; PHQ-9: aOR = 1.78, CI = 1.17–2.70). Being single rather than in a relationship (aOR = 1.67, CI = 1.29–2.15) was associated with moderate-to-severe depression only (Table 2).

<caption>**Table 1**</caption>

Sociodemographic data and health characteristics of participants, ComPaRe-Endometriosis cohort (N = 2394).

<table><thead><tr><th></th><th>Mean (sd) / N (%)</th></tr></thead><tbody><tr><td><strong>Education level (years)</strong></td><td></td></tr><tr><td>≥ 15</td><td>1423 (59.44)</td></tr><tr><td>13–14</td><td>446 (18.63)</td></tr><tr><td>12</td><td>384 (16.04)</td></tr><tr><td>&lt; 12</td><td>141 (5.89)</td></tr><tr><td><strong>Employment status</strong></td><td></td></tr><tr><td>Employed</td><td>1758 (73.43)</td></tr><tr><td>Not active</td><td>414 (17.29)</td></tr><tr><td>Unemployed / inclusion income support</td><td>222 (9.27)</td></tr><tr><td><strong>Marital status</strong></td><td></td></tr><tr><td>In a relationship / Married</td><td>1619 (67.63)</td></tr><tr><td>Single / Divorced / Widowed</td><td>775 (32.37)</td></tr><tr><td><strong>Perception of financial position</strong></td><td></td></tr><tr><td>It is difficult</td><td>300 (12.53)</td></tr><tr><td>A bit tight, I have to be careful with my finances</td><td>774 (32.33)</td></tr><tr><td>At the equilibrium</td><td>689 (28.78)</td></tr><tr><td>Comfortable</td><td>631 (26.36)</td></tr><tr><td>Age at filling in the mental health questionnaire (years)</td><td>35.76 (7.72)</td></tr><tr><td>Perceived health status (0–100, 100 = best)</td><td>65.29 (20.29)</td></tr><tr><td>Quality of life (EQ-5D)</td><td>0.82 (0.19)</td></tr><tr><td>Quality of life (EHP-5)</td><td>48.39 (25.11)</td></tr><tr><td>Worst level of dysmenorrhea (NRS)</td><td>5.88 (2.37)</td></tr><tr><td>Worst level of dyspareunia (NRS)</td><td>6.07 (2.59)</td></tr><tr><td>Worst level of dyschezia (NRS)</td><td>6.22 (2.23)</td></tr><tr><td>Worst level of dysuria (NRS)</td><td>4.77 (2.27)</td></tr><tr><td>Worst level of pelvic and abdominal pain (NRS)</td><td>5.86 (2.30)</td></tr><tr><td><strong>Number of comorbidities</strong></td><td></td></tr><tr><td>0</td><td>1106 (46.20)</td></tr><tr><td>1</td><td>599 (25.02)</td></tr><tr><td>≥ 2</td><td>689 (28.78)</td></tr><tr><td>BMI (kg/m²)</td><td>23.55 (4.82)</td></tr><tr><td><strong>Parity</strong></td><td></td></tr><tr><td>Nulliparous</td><td>1769 (73.89)</td></tr><tr><td>Parous</td><td>625 (26.11)</td></tr><tr><td>Age at first symptoms (years)</td><td>18.17 (6.65)</td></tr><tr><td>Time since diagnosis (years)</td><td>8.53 (5.82)</td></tr><tr><td>Diagnostic delay (years)</td><td>10.30 (7.07)</td></tr><tr><td>Anxiety symptom level (GAD-7, 0–21)</td><td>7.52 (5.02)</td></tr><tr><td>Depression symptom level (PHQ-9, 0–27)</td><td>9.36 (5.27)</td></tr></tbody></table>

Anxiety and depression symptom levels were positively and strongly associated with each other ($p_{trend} < 0.0001$ for each) (Table 3). Several other health-related factors were positively associated with moderate-to-severe anxiety and depression levels, including a poor sleep quality (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$); a health status perceived as poor (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$); a low QoL (continuous - GAD-7: aOR = 1.04, CI = 1.04–1.05; PHQ-9: aOR = 1.06, CI = 1.05–1.06 for EHP-5); intensity of worst level of dysmenorrhea (GAD-7: $p_{trend} = 0.001$; PHQ-9: $p_{trend} < 0.0001$), dyspareunia (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$), and pelvic or abdominal pain at last annual follow-up (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$); number of symptoms other than pelvic or abdominal pain (continuous – GAD-7: aOR = 1.39, CI = 1.32–1.45; PHQ-9: aOR = 1.64, CI = 1.55–1.73); number of comorbidities (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$); and BMI (continuous – GAD-7: aOR = 1.02, CI = 1.00–1.05; PHQ-9: aOR = 1.04, CI = 1.01–1.06). The worst levels of dyschezia (continuous, aOR = 1.21, CI = 1.05–1.30) and dysuria (continuous, aOR = 1.19, CI = 1.05–1.34) were positively associated with moderate-to-severe anxiety only.

In terms of pre-diagnostic medical care pathway, moderate-to-severe anxiety and depression symptoms were associated with a high number of health professionals consulted before diagnosis (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$), a high number of different types of health professionals consulted before diagnosis (GAD-7: $p_{trend} < 0.0001$; PHQ-9: $p_{trend} < 0.0001$), and the use of complementary and alternative medicine (GAD-7: aOR = 1.64, CI = 1.20–2.25; PHQ-9: aOR = 2.21, CI = 1.58–3.09) (Table 4).
<figure><img src="image_3.png" /><figcaption>Fig. 1. Anxiety and depression symptom levels in the ComPaRe-Endometriosis cohort (N = 2394).</figcaption></figure>

In contrast, moderate-to-severe anxiety and depression levels were inversely associated with age (continuous – GAD-7: aOR = 0.97, CI = 0.96–0.99; PHQ-9: aOR = 0.95, CI = 0.93–0.97), a financial position perceived as comfortable (GAD-7: p<0.0001; PHQ-9: p<0.0001), dyspareunia at vagina entrance only (vs. multiple localizations; GAD-7: aOR = 0.51, CI = 0.29–0.91; PHQ-9: aOR = 0.39, CI = 0.22–0.68), a high level of QoL measured with EQ-5D (GAD-7: p<0.0001; PHQ-9: p<0.0001), having no treatment for pain (vs. multiple treatments – GAD-7: aOR = 0.60, CI = 0.43–0.84; PHQ-9: aOR = 0.46, CI = 0.33–0.64), and having no follow-up with vaginal ultrasound (vs. every 6 months or less – GAD-7: aOR = 0.65, CI = 0.45–0.95; PHQ-9: aOR = 0.61, CI = 0.40–0.93). Age at first symptoms (continuous, aOR = 0.97, CI = 0.95–0.99), and age at diagnosis (continuous, aOR = 0.97, CI = 0.95–0.99) were inversely associated with moderate-to-severe symptoms of anxiety only. Being diagnosed with OMA exclusively (vs. multiple types: aOR = 0.58, CI = 0.40–0.85; vs. DE only: aOR = 0.45, CI = 0.31–0.65) was inversely associated with moderate-to-severe symptoms of depression only.

However, parity, infertility, endometriosis stage, family history of endometriosis, adenomyosis, or chronic pelvic pain, time since diagnosis and diagnostic delay, person who suspected the disease, and number of surgeries for endometriosis were not associated with anxiety or depression symptom levels among women with endometriosis in our study.

## 4. Discussion

In this cross-sectional study, we investigated the prevalence and factors associated with anxiety and depression symptoms among women participating in the ComPaRe-Endometriosis cohort. Anxiety and depression symptom levels were mild on average, although significant proportions presented moderate-to-severe anxiety (32%) or depression (45%) symptoms. Anxiety and depression symptom levels among patients were positively associated with unfavorable socioeconomic characteristics, a health status perceived as low, higher pain levels, number of experienced symptoms, number of comorbidities, a long healthcare pathway before diagnosis, and complementary and alternative medicine use. However, they were inversely associated with age, age at first symptoms or at diagnosis, level of QoL, and level of treatment and of follow-up by imaging.

### 4.1. Strengths and limitations

Our study has several limitations that should be taken into account when interpreting our findings. Since the cohort was based on voluntary

participation online, it should be noted that participants have higher education and socioeconomic levels than the general population, which may suggest participation bias. Anxiety and depression symptom levels may be underestimated, given their association with unfavorable socioeconomic conditions. In addition, it should be noted that the anxiety/ depression symptom levels described in our study reflect participants' situation after the first annual endometriosis follow-up, and the cross-sectional design of the study did not allow to interpret the temporality of the associations – although we attempted to control this by selecting participants' reported pain levels and lifestyle in the follow-up preceding their response to the mental health questionnaire. Longitudinal analyses will be needed to explore potentially causal relationships. Another limitation is that data were self-reported in our study, including disease characteristics, and thus our findings involving macro-phenotype and stage of endometriosis should be interpreted with caution. Also, we chose to categorize GAD-7 and PHQ-9 scores into severity categories (none-minimal, mild, moderate-to-severe) to facilitate clinical interpretation and to align with validated thresholds [27,28], as done in previous studies [29]. However, we acknowledge that this approach may result in a loss of statistical power and granularity, while it allows to focus on patients with more severe anxiety/depression symptoms.

Nevertheless, our study has several strengths, including the large sample size, with more diverse diagnostic methods and sociodemographic/disease characteristics compared to clinical studies, and our ability to explore a wide panel of potentially associated factors. Beyond the factors typically associated with anxiety and depression levels in the general population (such as marital status, financial situation, pain level, comorbidities, quality of life, prolonged care pathways, and use of analgesics), this study brings new insights into some endometriosis-specific aspects, including infertility, BMI, disease stage, and number of surgeries. This helps address an existing gap in the literature by contributing to a wider understanding of factors associated with anxiety and depression symptoms in this population.

### 4.2. Comparison with Prior Work

#### 4.2.1. Anxiety and depression symptom levels

Women with endometriosis were shown to have higher rates of anxiety and depression symptoms than the general population. A systematic review reported high prevalent rates of anxiety and depression symptoms among endometriosis patients, ranging from 11.5% to 87.5% for anxiety and from 9.8% to 98.5% for depression, compared to 6.0% to 10.1% and 6.6% to 9.3% in control groups, respectively [20].

In our study, levels of anxiety and depression symptoms also appeared higher than in the general population. While we did not find
<table><caption>**Table 2**

Odds ratios and 95 % confidence intervals of logistic regression models evaluating associations between socio-demographic characteristics and anxiety and depression symptom levels, ComPaRe-Endometriosis cohort (N = 2394 - Model 3).</caption><thead><tr><th rowspan="3"></th><th colspan="4">Anxiety (GAD-7)<br/>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br/>Reference = None-minimal</th></tr><tr><th colspan="2">None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th><th colspan="2">None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th></tr><tr><th>% /<br/>mean (sd)</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>% /<br/>mean (sd)</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th></tr></thead><tbody><tr><td><strong>Education level (years)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>≥ 15</td><td>61.56</td><td>62.56</td><td>Reference</td><td></td><td>53.85</td><td>Reference</td><td>67.57</td><td>63.64</td><td>Reference</td><td></td><td>52.48</td><td>Reference</td><td></td></tr><tr><td>13-14</td><td>19.41</td><td>18.60</td><td>0.94<br/>(0.72-1.23)</td><td>0.6491</td><td>17.86</td><td>1.05<br/>(0.80-1.39)</td><td>16.95</td><td>18.77</td><td>1.25<br/>(0.92-1.71)</td><td>0.1587</td><td>19.27</td><td>1.55<br/>(1.14-2.12)</td><td>0.0051</td></tr><tr><td>12</td><td>13.79</td><td>13.98</td><td>0.91<br/>(0.68-1.23)</td><td>0.5408</td><td>20.60</td><td>1.44<br/>(1.07-1.92)</td><td>12.13</td><td>12.87</td><td>1.10<br/>(0.77-1.58)</td><td>0.6125</td><td>20.30</td><td>1.79<br/>(1.28-2.52)</td><td>0.0008</td></tr><tr><td>&lt; 12</td><td>5.24</td><td>4.86</td><td>0.88<br/>(0.56-1.40)</td><td>0.5981</td><td>7.69</td><td>1.53<br/>(0.99-2.38)</td><td>0.0569</td><td>4.72</td><td>1.60<br/>(0.86-2.97)</td><td>0.1356</td><td>7.95</td><td>3.06<br/>(1.71-5.49)</td><td>0.0002</td></tr><tr><td>Ptrend</td><td colspan="2">0.0005</td><td></td><td></td><td></td><td></td><td colspan="2">&lt;0.0001</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Employment status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Employed</td><td>79.18</td><td>73.34</td><td>Reference</td><td></td><td>67.67</td><td>Reference</td><td>82.43</td><td>76.98</td><td>Reference</td><td></td><td>66.60</td><td>Reference</td><td></td></tr><tr><td>Not active</td><td>13.92</td><td>16.59</td><td>1.19<br/>(0.89-1.59)</td><td>0.2522</td><td>21.51</td><td>1.36<br/>(1.02-1.82)</td><td>10.46</td><td>15.35</td><td>1.41<br/>(0.97-2.04)</td><td>0.0690</td><td>21.89</td><td>1.85<br/>(1.30-2.64)</td><td>0.0007</td></tr><tr><td>Unemployed / inclusion income<br/>support</td><td>6.90</td><td>10.07</td><td>1.53<br/>(1.06-2.22)</td><td>0.0244</td><td>10.82</td><td>1.68<br/>(1.15-2.45)</td><td>0.0069</td><td>7.11</td><td>1.08<br/>(0.69-1.69)</td><td>0.7401</td><td>11.51</td><td>1.78<br/>(1.17-2.70)</td><td>0.0070</td></tr><tr><td><strong>Marital status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>In a relationship / Married</td><td>69.73</td><td>68.01</td><td>Reference</td><td></td><td>65.06</td><td>Reference</td><td>75.31</td><td>71.07</td><td>Reference</td><td></td><td>61.46</td><td>Reference</td><td></td></tr><tr><td>Single / Divorced / Widowed</td><td>30.27</td><td>31.99</td><td>1.02<br/>(0.82-1.27)</td><td>0.8611</td><td>34.94</td><td>1.07<br/>(0.86-1.34)</td><td>0.5511</td><td>24.69</td><td>1.14<br/>(0.88-1.49)</td><td>0.3243</td><td>38.54</td><td>1.67<br/>(1.29-2.15)</td><td>&lt;0.0001</td></tr><tr><td><strong>Perception of financial position</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>It is difficult</td><td>6.51</td><td>12.68</td><td>Reference</td><td></td><td>18.51</td><td>Reference</td><td>3.56</td><td>9.21</td><td>Reference</td><td></td><td>19.18</td><td>Reference</td><td></td></tr><tr><td>A bit tight, I have to be careful with<br/>my finances</td><td>30.01</td><td>30.09</td><td>0.56<br/>(0.38-0.82)</td><td>0.0031</td><td>37.16</td><td>0.50<br/>(0.34-0.72)</td><td>0.0003</td><td>26.15</td><td>0.46<br/>(0.25-0.82)</td><td>0.0085</td><td>37.23</td><td>0.32<br/>(0.18-0.56)</td><td>&lt;0.0001</td></tr><tr><td>At the equilibrium</td><td>30.40</td><td>29.38</td><td>0.54<br/>(0.36-0.80)</td><td>0.0019</td><td>26.47</td><td>0.36<br/>(0.25-0.53)</td><td>&lt;0.0001</td><td>32.43</td><td>0.37<br/>(0.21-0.66)</td><td>0.0007</td><td>26.01</td><td>0.18<br/>(0.11-0.32)</td><td>&lt;0.0001</td></tr><tr><td>Comfortable</td><td>33.08</td><td>27.84</td><td>0.48<br/>(0.32-0.71)</td><td>0.0003</td><td>17.86</td><td>0.25<br/>(0.17-0.37)</td><td>&lt;0.0001</td><td>37.87</td><td>0.34<br/>(0.19-0.60)</td><td>0.0002</td><td>17.59</td><td>0.12<br/>(0.07-0.21)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="2">&lt;0.0001</td><td></td><td></td><td></td><td></td><td colspan="2">&lt;0.0001</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Age at mental health<br/>questionnaire response<br/>(years)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>36.66<br/>(7.91)</td><td>35.59<br/>(7.33)</td><td>0.98<br/>(0.96-1.00)</td><td>0.0262</td><td>35.02<br/>(7.87)</td><td>0.97<br/>(0.96-0.99)</td><td>0.0050</td><td>37.29<br/>(7.86)</td><td>0.98<br/>(0.96-1.00)</td><td>0.0181</td><td>34.96<br/>(7.76)</td><td>0.95<br/>(0.93-0.97)</td><td>&lt;0.0001</td></tr><tr><td>&lt; 30</td><td>16.73</td><td>19.31</td><td>Reference</td><td></td><td>26.08</td><td>Reference</td><td></td><td>14.23</td><td>19.36</td><td>Reference</td><td></td><td>24.51</td><td>Reference</td><td></td></tr><tr><td>30-39</td><td>51.21</td><td>52.37</td><td>0.91<br/>(0.67-1.23)</td><td>0.5286</td><td>47.72</td><td>0.66<br/>(0.49-0.89)</td><td>0.0063</td><td>51.26</td><td>50.65</td><td>0.72<br/>(0.50-1.04)</td><td>0.0805</td><td>50.05</td><td>0.60<br/>(0.43-0.86)</td><td>0.0051</td></tr><tr><td>≥ 40</td><td>32.06</td><td>28.32</td><td>0.76<br/>(0.52-1.11)</td><td>0.1595</td><td>26.21</td><td>0.53<br/>(0.36-0.78)</td><td>0.0012</td><td>34.52</td><td>29.99</td><td>0.63<br/>(0.40-0.99)</td><td>0.0427</td><td>25.44</td><td>0.39<br/>(0.25-0.61)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="2">0.0063</td><td></td><td></td><td></td><td></td><td colspan="2">&lt;0.0001</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

Model 3 was adjusted for age, BMI, number of comorbidities, diagnostic delay, and age at first symptoms.
<caption>**Table 3**</caption>

Odds ratios and 95 % confidence intervals of logistic regression models evaluating associations between health-related factors and anxiety and depression symptom levels, ComPaRe-Endometriosis cohort (N = 2394 - Model 3).

<table><thead><tr><th rowspan="3"></th><th colspan="4">Anxiety (GAD-7)<br/>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br/>Reference = None-minimal</th></tr><tr><th colspan="2">None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th><th colspan="2">None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th></tr><tr><th>% /<br/>mean (sd)</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br/>mean (sd)</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br/>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th></tr></thead><tbody><tr><td><strong>Anxiety symptom<br/>level (GAD-7)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous (0-21)</td><td>2.37<br/>(1.43)</td><td>6.60<br/>(1.35)</td><td>-</td><td>&lt;0.0001</td><td>13.78<br/>(2.70)</td><td>-</td><td>&lt;0.0001</td><td>2.85<br/>(2.50)</td><td>6.14<br/>(3.61)</td><td>1.49<br/>(1.41-1.58)</td><td>&lt;0.0001</td><td>10.69<br/>(4.69)</td><td>1.90 (1.79-2.01)</td><td>&lt;0.0001</td></tr><tr><td>Minimal (0-4)</td><td>100.00</td><td>0.00</td><td>Reference</td><td></td><td>0.00</td><td>Reference</td><td></td><td>78.87</td><td>35.66</td><td>Reference</td><td></td><td>9.73</td><td>Reference</td><td></td></tr><tr><td>Mild (5-9)</td><td>0.00</td><td>100.00</td><td>-</td><td>0.0120</td><td>0.00</td><td>-</td><td>0.3007</td><td>19.25</td><td>46.99</td><td>5.33<br/>(4.02-7.08)</td><td>&lt;0.0001</td><td>33.12</td><td>13.75<br/>(9.89-19.12)</td><td>&lt;0.0001</td></tr><tr><td>Moderate - severe<br/>(10-21)</td><td>0.00</td><td>0.00</td><td>-</td><td>0.3247</td><td>100.00</td><td>-</td><td>0.0191</td><td>1.88</td><td>17.36</td><td>21.17<br/>(10.21-43.90)</td><td>&lt;0.0001</td><td>57.16</td><td>246.94<br/>(118.45-514.82)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td><strong>Depression symptom<br/>level (PHQ-9)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous (0-27)</td><td>5.31<br/>(3.53)</td><td>9.13<br/>(3.92)</td><td>1.31<br/>(1.27-1.36)</td><td>&lt;0.0001</td><td>13.74<br/>(4.59)</td><td>1.66 (1.59-1.72)</td><td>&lt;0.0001</td><td>2.56<br/>(1.24)</td><td>7.04<br/>(1.34)</td><td>-</td><td>&lt;0.0001</td><td>14.23<br/>(3.37)</td><td>-</td><td>&lt;0.0001</td></tr><tr><td>None-minimal (0-4)</td><td>48.15</td><td>10.90</td><td>Reference</td><td></td><td>1.17</td><td>Reference</td><td></td><td>100.00</td><td>0.00</td><td>Reference</td><td></td><td>0.00</td><td>Reference</td><td></td></tr><tr><td>Mild (5-9)</td><td>38.57</td><td>47.16</td><td>5.35<br/>(4.03-7.10)</td><td>&lt;0.0001</td><td>19.17</td><td>21.01<br/>(10.13-43.58)</td><td>&lt;0.0001</td><td>0.00</td><td>100.00</td><td>-</td><td>0.1914</td><td>0.00</td><td>-</td><td>0.4477</td></tr><tr><td>Moderate - severe<br/>(10-27)</td><td>13.28</td><td>41.94</td><td>13.83<br/>(9.94-19.23)</td><td>&lt;0.0001</td><td>79.66</td><td>246<br/>(118.01-512.81)</td><td>&lt;0.0001</td><td>0.00</td><td>0.00</td><td>-</td><td>0.4721</td><td>100.00</td><td>-</td><td>0.1447</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td><strong>Sleep quality (PSQI) -<br/>0 = best</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>6.46<br/>(2.65)</td><td>7.74<br/>(2.74)</td><td>1.19<br/>(1.14-1.24)</td><td>&lt;0.0001</td><td>9.11<br/>(3.00)</td><td>1.38 (1.32-1.44)</td><td>&lt;0.0001</td><td>5.70<br/>(2.26)</td><td>7.17<br/>(2.56)</td><td>1.28<br/>(1.20-1.35)</td><td>&lt;0.0001</td><td>9.12<br/>(2.92)</td><td>1.62 (1.53-1.72)</td><td>&lt;0.0001</td></tr><tr><td>1st quartile: &lt; 6</td><td>51.09</td><td>33.65</td><td>Reference</td><td></td><td>26.21</td><td>Reference</td><td></td><td>58.16</td><td>40.02</td><td>Reference</td><td></td><td>25.07</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 6-7</td><td>23.50</td><td>21.80</td><td>1.44<br/>(1.11-1.88)</td><td>0.0062</td><td>16.82</td><td>1.39 (1.04-1.86)</td><td>0.0263</td><td>24.48</td><td>24.56</td><td>1.44<br/>(1.08-1.91)</td><td>0.0134</td><td>16.09</td><td>1.48 (1.09-2.00)</td><td>0.0109</td></tr><tr><td>3rd quartile: 8-10</td><td>18.52</td><td>31.64</td><td>2.59<br/>(2.00-3.36)</td><td>&lt;0.0001</td><td>29.86</td><td>3.05 (2.31-4.02)</td><td>&lt;0.0001</td><td>15.69</td><td>26.45</td><td>2.41<br/>(1.76-3.31)</td><td>&lt;0.0001</td><td>31.99</td><td>4.56 (3.33-6.25)</td><td>&lt;0.0001</td></tr><tr><td>4th quartile: ≥ 11</td><td>6.90</td><td>12.91</td><td>2.64<br/>(1.82-3.83)</td><td>&lt;0.0001</td><td>27.12</td><td>6.56 (4.59-9.36)</td><td>&lt;0.0001</td><td>1.67</td><td>8.97</td><td>7.19<br/>(3.39-15.23)</td><td>&lt;0.0001</td><td>26.85</td><td>30.72<br/>(14.80-63.78)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td><strong>Perceived health<br/>status (0-100, 100<br/>= best)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>72.19<br/>(18.73)</td><td>65.75<br/>(18.90)</td><td>0.98<br/>(0.98-0.99)</td><td>&lt;0.0001</td><td>57.00<br/>(20.55)</td><td>0.96 (0.96-0.97)</td><td>&lt;0.0001</td><td>76.98<br/>(15.69)</td><td>68.45<br/>(17.56)</td><td>0.97<br/>(0.96-0.98)</td><td>&lt;0.0001</td><td>57.03<br/>(20.76)</td><td>0.94 (0.94-0.95)</td><td>&lt;0.0001</td></tr><tr><td>75-100</td><td>40.10</td><td>27.49</td><td>Reference</td><td></td><td>14.73</td><td>Reference</td><td></td><td>50.42</td><td>29.99</td><td>Reference</td><td></td><td>15.34</td><td>Reference</td><td></td></tr><tr><td>50-74</td><td>29.63</td><td>36.14</td><td>1.73<br/>(1.35-2.23)</td><td>&lt;0.0001</td><td>35.72</td><td>3.04 (2.28-4.05)</td><td>&lt;0.0001</td><td>26.57</td><td>33.65</td><td>2.03<br/>(1.53-2.70)</td><td>&lt;0.0001</td><td>37.32</td><td>4.13 (3.08-5.56)</td><td>&lt;0.0001</td></tr><tr><td>25-49</td><td>5.87</td><td>9.24</td><td>2.30<br/>(1.52-3.48)</td><td>&lt;0.0001</td><td>14.73</td><td>5.99 (3.93-9.14)</td><td>&lt;0.0001</td><td>2.72</td><td>7.20</td><td>4.04<br/>(2.15-7.58)</td><td>&lt;0.0001</td><td>15.25</td><td>14.97<br/>(8.13-27.56)</td><td>&lt;0.0001</td></tr><tr><td>0-24</td><td>24.39</td><td>27.13</td><td>1.50<br/>(1.15-1.96)</td><td>0.0029</td><td>34.81</td><td>3.38 (2.51-4.53)</td><td>&lt;0.0001</td><td>20.29</td><td>29.16</td><td>2.29<br/>(1.69-3.11)</td><td>&lt;0.0001</td><td>32.09</td><td>4.51 (3.29-6.18)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td><strong>Quality of life (EQ-5D)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

(continued on next page)
<table><caption>Table 3 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="4">Anxiety (GAD-7)<br/>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br/>Reference = None-minimal</th></tr><tr><th>None-minimal</th><th>Mild</th><th></th><th></th><th>None-minimal</th><th>Mild</th><th></th><th>Moderate - Severe</th></tr></thead><tbody><tr><td>Continuous</td><td>0.89<br/>(0.15)</td><td>0.83<br/>(0.17)</td><td>0.07<br/>(0.03-0.18)</td><td>&lt;0.0001</td><td>0.73<br/>(0.22)</td><td>0.01 (0.00-0.02)</td><td>&lt;0.0001</td><td>0.93<br/>(0.09)</td><td>0.85<br/>(0.16)</td><td>0.00<br/>(0.00-0.00)</td><td>&lt;0.0001</td><td>0.74<br/>(0.22)</td><td>0.00 (0.00-0.00)</td><td>&lt;0.0001</td></tr><tr><td>1st quartile: &lt; 0,73</td><td>32.69</td><td>41.71</td><td>Reference</td><td></td><td>59.45</td><td>Reference</td><td></td><td>23.64</td><td>41.32</td><td>Reference</td><td></td><td>56.22</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 0,73 - 0,89</td><td>11.88</td><td>18.60</td><td>1.27<br/>(0.93-1.72)</td><td>0.1347</td><td>19.17</td><td>0.90 (0.66-1.23)</td><td>0.5156</td><td>10.04</td><td>14.64</td><td>0.82<br/>(0.55-1.23)</td><td>0.3350</td><td>21.05</td><td>0.87 (0.59-1.28)</td><td>0.4760</td></tr><tr><td>3rd quartile: 0,90 - 0,94</td><td>18.14</td><td>20.97</td><td>0.93<br/>(0.71-1.24)</td><td>0.6374</td><td>14.99</td><td>0.51 (0.38-0.68)</td><td>&lt;0.0001</td><td>17.78</td><td>22.79</td><td>0.72<br/>(0.51-1.01)</td><td>0.0594</td><td>14.59</td><td>0.38 (0.27-0.53)</td><td>&lt;0.0001</td></tr><tr><td>4th quartile: ≥ 0,95</td><td>37.29</td><td>18.72</td><td>0.43<br/>(0.33-0.56)</td><td>&lt;0.0001</td><td>6.39</td><td>0.11 (0.08-0.16)</td><td>&lt;0.0001</td><td>48.54</td><td>21.25</td><td>0.26<br/>(0.20-0.36)</td><td>&lt;0.0001</td><td>8.14</td><td>0.08 (0.06-0.12)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="4"></td></tr><tr><td>Quality of life (EHP-5)<br/>(a)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>37.13<br/>(24.47)</td><td>48.96<br/>(23.05)</td><td>1.02<br/>(1.01-1.02)</td><td>&lt;0.0001</td><td>60.11<br/>(22.45)</td><td>1.04 (1.04-1.05)</td><td>&lt;0.0001</td><td>30.55<br/>(22.62)</td><td>44.68<br/>(23.05)</td><td>1.03<br/>(1.02-1.03)</td><td>&lt;0.0001</td><td>59.76<br/>(21.74)</td><td>1.06 (1.05-1.06)</td><td>&lt;0.0001</td><td></td></tr><tr><td>Worst level of<br/>dysmenorrhea</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>5.43<br/>(2.42)</td><td>5.84<br/>(2.35)</td><td>1.06<br/>(1.01-1.12)</td><td>0.0276</td><td>6.32<br/>(2.28)</td><td>1.13 (1.07-1.20)</td><td>&lt;0.0001</td><td>4.95<br/>(2.57)</td><td>5.66<br/>(2.27)</td><td>1.10<br/>(1.04-1.18)</td><td>0.0025</td><td>6.39<br/>(2.24)</td><td>1.24 (1.16-1.32)</td><td>&lt;0.0001</td></tr><tr><td>0-3 No or mild pain</td><td>14.43</td><td>11.85</td><td>Reference</td><td></td><td>8.87</td><td>Reference</td><td></td><td>19.25</td><td>12.04</td><td>Reference</td><td></td><td>8.14</td><td>Reference</td><td></td></tr><tr><td>4-5 Moderate pain</td><td>14.18</td><td>14.93</td><td>1.26<br/>(0.86-1.84)</td><td>0.2423</td><td>16.17</td><td>1.79 (1.20-2.68)</td><td>0.0052</td><td>11.92</td><td>17.36</td><td>2.25<br/>(1.47-3.47)</td><td>0.0002</td><td>14.69</td><td>2.81 (1.81-4.37)</td><td>&lt;0.0001</td></tr><tr><td>6-7 Sharp pain</td><td>19.03</td><td>19.79</td><td>1.19<br/>(0.83-1.70)</td><td>0.3550</td><td>22.82</td><td>1.71 (1.17-2.52)</td><td>0.0061</td><td>16.11</td><td>19.95</td><td>1.86<br/>(1.24-2.80)</td><td>0.0028</td><td>22.92</td><td>2.93 (1.94-4.42)</td><td>&lt;0.0001</td></tr><tr><td>8-10 Unbearable pain</td><td>13.03</td><td>18.01</td><td>1.54<br/>(1.06-2.26)</td><td>0.0251</td><td>24.38</td><td>2.40 (1.61-3.57)</td><td>&lt;0.0001</td><td>11.30</td><td>14.99</td><td>1.85<br/>(1.20-2.87)</td><td>0.0057</td><td>24.32</td><td>3.83 (2.48-5.90)</td><td>&lt;0.0001</td></tr><tr><td>Not concerned</td><td>39.34</td><td>35.43</td><td>1.06<br/>(0.76-1.46)</td><td>0.7423</td><td>27.77</td><td>1.04 (0.73-1.49)</td><td>0.8231</td><td>41.42</td><td>35.66</td><td>1.31<br/>(0.92-1.85)</td><td>0.1296</td><td>29.93</td><td>1.57 (1.09-2.25)</td><td>0.0145</td></tr><tr><td>Ptrend</td><td colspan="4">0.0011</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="4"></td></tr><tr><td>Worst level of<br/>dyspareunia</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>5.45<br/>(2.63)</td><td>6.02<br/>(2.63)</td><td>1.07<br/>(1.01-1.13)</td><td>0.0149</td><td>6.73<br/>(2.34)</td><td>1.17 (1.10-1.24)</td><td>&lt;0.0001</td><td>4.97<br/>(2.67)</td><td>5.77<br/>(2.56)</td><td>1.10<br/>(1.04-1.17)</td><td>0.0024</td><td>6.80<br/>(2.35)</td><td>1.27 (1.19-1.36)</td><td>&lt;0.0001</td></tr><tr><td>0-3 No or mild pain</td><td>12.52</td><td>10.31</td><td>Reference</td><td></td><td>6.65</td><td>Reference</td><td></td><td>17.15</td><td>10.39</td><td>Reference</td><td></td><td>6.17</td><td>Reference</td><td></td></tr><tr><td>4-5 Moderate pain</td><td>9.32</td><td>7.11</td><td>0.84<br/>(0.52-1.34)</td><td>0.4571</td><td>5.61</td><td>0.93 (0.55-1.57)</td><td>0.7830</td><td>9.62</td><td>8.38</td><td>1.30<br/>(0.79-2.14)</td><td>0.3052</td><td>5.52</td><td>1.24 (0.73-2.11)</td><td>0.4177</td></tr><tr><td>6-7 Sharp pain</td><td>15.33</td><td>16.00</td><td>1.19<br/>(0.80-1.77)</td><td>0.3882</td><td>17.21</td><td>1.73 (1.12-2.67)</td><td>0.0136</td><td>14.44</td><td>17.36</td><td>1.79<br/>(1.16-2.76)</td><td>0.0089</td><td>16.00</td><td>2.33 (1.49-3.64)</td><td>0.0002</td></tr><tr><td>8-10 Unbearable pain</td><td>12.90</td><td>18.84</td><td>1.64<br/>(1.10-2.45)</td><td>0.0155</td><td>21.77</td><td>2.40 (1.55-3.72)</td><td>&lt;0.0001</td><td>10.67</td><td>14.76</td><td>2.08<br/>(1.31-3.31)</td><td>0.0020</td><td>23.48</td><td>4.49 (2.82-7.14)</td><td>&lt;0.0001</td></tr><tr><td>Not concerned</td><td>49.94</td><td>47.75</td><td>1.15<br/>(0.81-1.61)</td><td>0.4305</td><td>48.76</td><td>1.55 (1.06-2.27)</td><td>0.0247</td><td>48.12</td><td>49.11</td><td>1.72<br/>(1.20-2.47)</td><td>0.0034</td><td>48.83</td><td>2.35 (1.61-3.44)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="4"></td></tr><tr><td>Worst level of<br/>dyschezia</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>5.58<br/>(2.30)</td><td>6.13<br/>(2.15)</td><td>1.09<br/>(0.95-1.26)</td><td>0.2370</td><td>6.64<br/>(2.19)</td><td>1.21 (1.05-1.30)</td><td>0.0076</td><td>5.71<br/>(2.55)</td><td>5.75<br/>(2.11)</td><td>0.97<br/>(0.80-1.16)</td><td>0.7191</td><td>6.54<br/>(2.18)</td><td>1.14 (0.96-1.36)</td><td>0.1317</td></tr><tr><td>0-3 No or mild pain</td><td>1.79</td><td>1.54</td><td>Reference</td><td></td><td>1.43</td><td>Reference</td><td></td><td>1.46</td><td>1.53</td><td>Reference</td><td></td><td>1.68</td><td>Reference</td><td></td></tr><tr><td>4-5 Moderate pain</td><td>3.07</td><td>3.08</td><td>1.17<br/>(0.50-3.03)</td><td>0.7445</td><td>4.04</td><td>1.63 (0.62-4.34)</td><td>0.3246</td><td>2.09</td><td>3.42</td><td>1.72<br/>(0.52-5.66)</td><td>0.3746</td><td>3.93</td><td>1.75 (0.55-5.55)</td><td>0.3450</td></tr><tr><td>6-7 Sharp pain</td><td>2.04</td><td>4.38</td><td>2.57<br/>(0.98-6.74)</td><td>0.0544</td><td>5.22</td><td>3.19 (1.18-8.65)</td><td>0.0225</td><td>1.88</td><td>2.95</td><td>1.57<br/>(0.47-5.20)</td><td>0.4643</td><td>5.52</td><td>2.69 (0.86-8.46)</td><td>0.0901</td></tr></tbody></table>

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<table><caption>Table 3 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="4">Anxiety (GAD-7)<br/>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br/>Reference = None-minimal</th></tr><tr><th>None-minimal</th><th>Mild</th><th>Moderate - Severe</th><th>None-minimal</th><th>Mild</th><th>Moderate - Severe</th><th></th><th></th></tr></thead><tbody><tr><td>8-10 Unbearable pain</td><td>2.17</td><td>3.67</td><td>1.76<br/>(0.67-4.63)</td><td>0.2516</td><td>6.65</td><td>3.16 (1.19-8.40)</td><td>0.0211</td><td>1.88</td><td>2.48</td><td>1.11<br/>(0.33-3.73)</td><td>0.8714</td><td>6.45</td><td>2.40 (0.77-7.49)</td><td>0.1320</td></tr><tr><td>Not concerned</td><td>90.93</td><td>87.32</td><td>1.15<br/>(0.53-2.50)</td><td>0.7209</td><td>82.66</td><td>1.23 (0.55-2.76)</td><td>0.6186</td><td>92.68</td><td>89.61</td><td>1.01<br/>(0.40-2.56)</td><td>0.9852</td><td>82.41</td><td>0.87 (0.35-2.14)</td><td>0.7607</td></tr><tr><td>Ptrend</td><td colspan="4">0.0402</td><td colspan="4">0.0235</td><td colspan="4"></td></tr><tr><td><strong>Worst level of dysuria</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>4.07<br/>(2.10)</td><td>4.84<br/>(2.32)</td><td>1.14<br/>(1.01-1.29)</td><td>0.0411</td><td>5.10<br/>(2.24)</td><td>1.19 (1.05-1.34)</td><td>0.0063</td><td>4.22<br/>(2.18)</td><td>4.50<br/>(2.28)</td><td>1.04<br/>(0.89-1.21)</td><td>0.6352</td><td>5.03<br/>(2.25)</td><td>1.13 (0.97-1.30)</td><td>0.1083</td></tr><tr><td>0-3 No or mild pain</td><td>5.75</td><td>6.16</td><td>Reference</td><td></td><td>6.00</td><td>Reference</td><td></td><td>5.23</td><td>5.79</td><td>Reference</td><td></td><td>6.45</td><td>Reference</td><td></td></tr><tr><td>4-5 Moderate pain</td><td>3.19</td><td>4.50</td><td>1.23<br/>(0.64-2.37)</td><td>0.5303</td><td>6.78</td><td>1.65 (0.86-3.14)</td><td>0.1321</td><td>2.30</td><td>3.90</td><td>1.40<br/>(0.60-3.27)</td><td>0.4348</td><td>6.64</td><td>1.88 (0.84-4.19)</td><td>0.1254</td></tr><tr><td>6-7 Sharp pain</td><td>2.68</td><td>3.20</td><td>1.12<br/>(0.55-2.28)</td><td>0.7501</td><td>6.00</td><td>1.97 (1.00-3.9)</td><td>0.0499</td><td>3.14</td><td>2.60</td><td>0.76<br/>(0.33-1.76)</td><td>0.5220</td><td>5.33</td><td>1.25 (0.58-2.67)</td><td>0.5733</td></tr><tr><td>8-10 Unbearable pain</td><td>0.77</td><td>2.73</td><td>3.03<br/>(1.13-8.15)</td><td>0.0283</td><td>3.65</td><td>3.34 (1.24-9.01)</td><td>0.0171</td><td>0.84</td><td>1.77</td><td>1.69<br/>(0.50-5.67)</td><td>0.3992</td><td>3.55</td><td>2.38 (0.75-7.53)</td><td>0.1409</td></tr><tr><td>Not concerned</td><td>87.61</td><td>83.41</td><td>0.89<br/>(0.58-1.36)</td><td>0.5898</td><td>77.57</td><td>0.83 (0.54-1.28)</td><td>0.4024</td><td>88.49</td><td>85.95</td><td>0.92<br/>(0.55-1.53)</td><td>0.7363</td><td>78.02</td><td>0.70 (0.43-1.15)</td><td>0.1573</td></tr><tr><td>Ptrend</td><td colspan="4">0.0264</td><td colspan="4">0.1759</td><td colspan="4"></td></tr><tr><td><strong>Worst level of pelvic<br/>and abdominal pain</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>5.39<br/>(2.28)</td><td>5.79<br/>(2.23)</td><td>1.06<br/>(1.00-1.11)</td><td>0.0462</td><td>6.34<br/>(2.30)</td><td>1.16 (1.10-1.23)</td><td>&lt;0.0001</td><td>4.94<br/>(2.29)</td><td>5.65<br/>(2.24)</td><td>1.11<br/>(1.04-1.19)</td><td>0.0015</td><td>6.29<br/>(2.24)</td><td>1.24 (1.16-1.32)</td><td>&lt;0.0001</td></tr><tr><td>0-3 No or mild pain</td><td>15.33</td><td>12.56</td><td>Reference</td><td></td><td>10.30</td><td>Reference</td><td></td><td>17.99</td><td>13.34</td><td>Reference</td><td></td><td>9.92</td><td>Reference</td><td></td></tr><tr><td>4-5 Moderate pain</td><td>19.41</td><td>20.85</td><td>1.23<br/>(0.86-1.74)</td><td>0.2569</td><td>16.04</td><td>1.14 (0.78-1.67)</td><td>0.5037</td><td>16.32</td><td>20.19</td><td>1.37<br/>(0.91-2.04)</td><td>0.1281</td><td>18.90</td><td>1.61 (1.07-2.41)</td><td>0.0216</td></tr><tr><td>6-7 Sharp pain</td><td>18.77</td><td>20.97</td><td>1.24<br/>(0.87-1.76)</td><td>0.2375</td><td>23.47</td><td>1.57 (1.08-2.29)</td><td>0.0174</td><td>12.97</td><td>21.72</td><td>1.86<br/>(1.23-2.83)</td><td>0.0036</td><td>24.13</td><td>2.45 (1.62-3.73)</td><td>&lt;0.0001</td></tr><tr><td>8-10 Unbearable pain</td><td>13.28</td><td>18.01</td><td>1.45<br/>(1.00-2.10)</td><td>0.0515</td><td>28.42</td><td>2.58 (1.76-3.78)</td><td>&lt;0.0001</td><td>8.79</td><td>16.41</td><td>2.03<br/>(1.28-3.21)</td><td>0.0024</td><td>27.41</td><td>4.00 (2.55-6.25)</td><td>&lt;0.0001</td></tr><tr><td>Not concerned</td><td>33.21</td><td>27.61</td><td>0.99<br/>(0.71-1.37)</td><td>0.9279</td><td>21.77</td><td>1 (0.70-1.44)</td><td>0.9818</td><td>43.93</td><td>28.34</td><td>0.77<br/>(0.54-1.10)</td><td>0.1465</td><td>19.64</td><td>0.74 (0.51-1.06)</td><td>0.0975</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td></tr><tr><td><strong>Number of other<br/>symptoms</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>5.04<br/>(2.66)</td><td>6.34<br/>(2.58)</td><td>1.20<br/>(1.15-1.25)</td><td>&lt;0.0001</td><td>7.35<br/>(2.36)</td><td>1.39 (1.32-1.45)</td><td>&lt;0.0001</td><td>4.17<br/>(2.46)</td><td>5.97<br/>(2.44)</td><td>1.32<br/>(1.25-1.39)</td><td>&lt;0.0001</td><td>7.37<br/>(2.39)</td><td>1.64 (1.55-1.73)</td><td>&lt;0.0001</td></tr><tr><td><strong>Number of<br/>comorbidities</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>2.03<br/>(1.70)</td><td>2.23<br/>(1.92)</td><td>1.07<br/>(1.01-1.14)</td><td>0.0197</td><td>2.70<br/>(2.65)</td><td>1.18 (1.11-1.25)</td><td>&lt;0.0001</td><td>1.84<br/>(1.37)</td><td>2.14<br/>(2.00)</td><td>1.16<br/>(1.07-1.26)</td><td>0.0005</td><td>2.67<br/>(2.45)</td><td>1.30 (1.20-1.41)</td><td>&lt;0.0001</td></tr><tr><td>0</td><td>53.26</td><td>45.85</td><td>Reference</td><td></td><td>39.37</td><td>Reference</td><td></td><td>54.60</td><td>47.34</td><td>Reference</td><td></td><td>41.53</td><td>Reference</td><td></td></tr><tr><td>1</td><td>24.01</td><td>25.00</td><td>1.19<br/>(0.93-1.52)</td><td>0.1715</td><td>26.08</td><td>1.46 (1.13-1.88)</td><td>0.0039</td><td>26.99</td><td>27.04</td><td>1.09<br/>(0.83-1.44)</td><td>0.5213</td><td>22.54</td><td>1.07 (0.81-1.41)</td><td>0.6295</td></tr><tr><td>≥ 2</td><td>22.73</td><td>29.15</td><td>1.44<br/>(1.12-1.84)</td><td>0.0039</td><td>34.55</td><td>2.03 (1.58-2.61)</td><td>&lt;0.0001</td><td>18.41</td><td>25.62</td><td>1.59<br/>(1.17-2.15)</td><td>0.0029</td><td>35.92</td><td>2.50 (1.87-3.34)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td></tr><tr><td><strong>BMI (kg/m<sup>2</sup>)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>23.24<br/>(4.34)</td><td>23.63<br/>(5.06)</td><td>1.02<br/>(1.00-1.04)</td><td>0.0747</td><td>23.78<br/>(5.00)</td><td>1.02 (1.00-1.05)</td><td>0.0431</td><td>23.25<br/>(4.20)</td><td>23.09<br/>(4.54)</td><td>0.99<br/>(0.97-1.02)</td><td>0.6550</td><td>24.04<br/>(5.23)</td><td>1.04 (1.01-1.06)</td><td>0.0035</td></tr><tr><td>&lt; 18.5 (underweight)</td><td>10.34</td><td>13.98</td><td>1.72<br/>(1.17-2.52)</td><td>0.0055</td><td>11.60</td><td>1.59 (1.07-2.37)</td><td>0.0215</td><td>11.51</td><td>14.05</td><td>1.91<br/>(1.20-3.03)</td><td>0.0061</td><td>10.66</td><td>1.49 (0.93-2.38)</td><td>0.0954</td></tr></tbody></table>

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<table><caption>Table 3 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="3">Anxiety (GAD-7)<br>Reference = None-minimal</th><th colspan="3">Depression (PHQ-9)<br>Reference = None-minimal</th></tr><tr><th>None-minimal</th><th>Mild</th><th>Moderate - Severe</th><th>None-minimal</th><th>Mild</th><th>Moderate - Severe</th></tr></thead><tbody><tr><td>18.5-24 (normal weight)</td><td>65.26</td><td>57.35</td><td>Reference</td><td>57.76</td><td>Reference</td><td>65.48</td><td>61.39</td><td>Reference</td><td>56.59</td><td>Reference</td></tr><tr><td>25-29 (overweight)</td><td>15.84</td><td>17.77</td><td>1.29<br>(0.99-1.70)</td><td>0.0637</td><td>19.04</td><td>1.36 (1.03-1.79)</td><td>0.0325</td><td>14.85</td><td>16.53</td><td>1.21<br>(0.88-1.67)</td><td>0.2490</td><td>19.55</td><td>1.58 (1.16-2.16)</td><td>0.0039</td></tr><tr><td>≥ 30 (obesity)</td><td>8.56</td><td>10.90</td><td>1.44<br>(1.02-2.04)</td><td>0.0391</td><td>11.60</td><td>1.44 (1.01-2.06)</td><td>0.0436</td><td>8.16</td><td>8.03</td><td>1.04<br>(0.68-1.59)</td><td>0.8700</td><td>13.19</td><td>1.83 (1.23-2.73)</td><td>0.0028</td></tr><tr><td>Ptrend</td><td colspan="3">0.4272</td><td colspan="3">&lt;0.0001</td><td colspan="3"></td><td colspan="3"></td></tr><tr><td><strong>Description of pain during sexual intercourse</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Multiple pain location</td><td>25.29</td><td>31.64</td><td>Reference</td><td>40.03</td><td>Reference</td><td>21.55</td><td>28.93</td><td>Reference</td><td>39.66</td><td>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>At vagina entrance only</td><td>4.73</td><td>5.81</td><td>1.14<br>(0.70-1.86)</td><td>0.5940</td><td>3.26</td><td>0.51 (0.29-0.91)</td><td>0.0217</td><td>5.86</td><td>5.43</td><td>0.75<br>(0.43-1.29)</td><td>0.2929</td><td>3.46</td><td>0.39 (0.22-0.68)</td><td>0.0010</td></tr><tr><td>Deep in the vagina only</td><td>14.69</td><td>11.02</td><td>0.65<br>(0.46-0.91)</td><td>0.0116</td><td>14.99</td><td>0.76 (0.55-1.06)</td><td>0.1038</td><td>12.34</td><td>14.40</td><td>1.01<br>(0.67-1.50)</td><td>0.9792</td><td>13.28</td><td>0.78 (0.53-1.15)</td><td>0.2022</td></tr><tr><td>Not concerned</td><td>55.30</td><td>51.54</td><td>0.78<br>(0.61-0.98)</td><td>0.0361</td><td>41.72</td><td>0.53 (0.42-0.68)</td><td>&lt;0.0001</td><td>60.25</td><td>51.24</td><td>0.71<br>(0.53-0.94)</td><td>0.0176</td><td>43.59</td><td>0.48 (0.37-0.63)</td><td>&lt;0.0001</td></tr><tr><td><strong>Parity</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Nulliparous</td><td>72.16</td><td>75.47</td><td>Reference</td><td>73.92</td><td>Reference</td><td>69.87</td><td>73.79</td><td>Reference</td><td>75.77</td><td>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>Parous</td><td>27.84</td><td>24.53</td><td>0.94<br>(0.73-1.20)</td><td>0.6164</td><td>26.08</td><td>1.14 (0.88-1.46)</td><td>0.3205</td><td>30.13</td><td>26.21</td><td>0.96<br>(0.73-1.27)</td><td>0.7777</td><td>24.23</td><td>0.98 (0.75-1.29)</td><td>0.8903</td></tr><tr><td><strong>Fertility problems (a)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>15.71</td><td>16.00</td><td>Reference</td><td>16.17</td><td>Reference</td><td>15.90</td><td>15.35</td><td>Reference</td><td>16.46</td><td>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>39.85</td><td>40.64</td><td>1.08<br>(0.80-1.46)</td><td>0.6331</td><td>32.33</td><td>0.84 (0.61-1.15)</td><td>0.2790</td><td>44.56</td><td>39.43</td><td>1.00<br>(0.71-1.42)</td><td>0.9936</td><td>33.30</td><td>0.81 (0.58-1.14)</td><td>0.2339</td></tr><tr><td>Not concerned</td><td>24.39</td><td>21.21</td><td>0.72<br>(0.52-1.00)</td><td>0.0513</td><td>25.95</td><td>0.84 (0.60-1.17)</td><td>0.3060</td><td>21.55</td><td>20.31</td><td>0.82<br>(0.55-1.21)</td><td>0.3051</td><td>27.50</td><td>0.95 (0.65-1.37)</td><td>0.7671</td></tr><tr><td>Missing</td><td>20.05</td><td>22.16</td><td>1.03<br>(0.74-1.44)</td><td>0.8697</td><td>25.55</td><td>1.19 (0.84-1.67)</td><td>0.3244</td><td>17.99</td><td>24.91</td><td>1.43<br>(0.96-2.13)</td><td>0.0751</td><td>22.73</td><td>1.23 (0.84-1.81)</td><td>0.2923</td></tr></tbody></table>

(a) these variables could be assessed among 1854 participants who replied to a questionnaire on quality of life and fertility problems.
Model 3 was adjusted for age, BMI, number of comorbidities, diagnostic delay, and age at first symptoms.
<caption>**Table 4**</caption>

Odds ratios and 95 % confidence intervals of logistic regression models evaluating associations between circumstances of diagnosis, pre-diagnostic medical care pathway, family history of the disease, and anxiety and depression symptom levels, ComPaRe-Endometriosis cohort (N = 2394 - Model 3).

<table><thead><tr><th rowspan="3"></th><th colspan="4">Anxiety (GAD-7)<br>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br>Reference = None-minimal</th></tr><tr><th colspan="2">None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th><th colspan="2">None-minimal</th><th colspan="2">Mild</th></tr><tr><th>% /<br>mean (sd)</th><th>% /<br>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br>mean (sd)</th><th>aOR (95 % CI)</th><th>% /<br>mean (sd)</th><th>% /<br>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th><th>% /<br>mean (sd)</th><th>aOR (95 % CI)</th><th>p</th></tr></thead><tbody><tr><td colspan="15"><strong>Number of health professionals consulted before diagnosis</strong></td></tr><tr><td>Continuous</td><td>6.78<br>(5.61)</td><td>7.87<br>(6.43)</td><td>1.03<br>(1.01-1.05)</td><td>0.0019</td><td>9.72<br>(7.73)</td><td>1.06<br>(1.04-1.08)</td><td>&lt;0.0001</td><td>6.09<br>(5.19)</td><td>7.32<br>(5.87)</td><td>1.04<br>(1.01-1.07)</td><td>0.0021</td><td>9.64<br>(7.60)</td><td>1.09<br>(1.07-1.12)</td><td>&lt;0.0001</td></tr><tr><td>1st quartile: &lt; 5</td><td>42.91</td><td>33.53</td><td>Reference</td><td></td><td>24.64</td><td>Reference</td><td></td><td>46.86</td><td>36.48</td><td>Reference</td><td></td><td>25.72</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 5-6</td><td>18.90</td><td>18.25</td><td>1.26<br>(0.94-1.68)</td><td>0.1167</td><td>17.21</td><td>1.58<br>(1.16-2.14)</td><td>0.0037</td><td>19.46</td><td>18.89</td><td>1.13<br>(0.82-1.55)</td><td>0.4688</td><td>16.93</td><td>1.46<br>(1.06-2.02)</td><td>0.0210</td></tr><tr><td>3rd quartile: 7-10</td><td>21.33</td><td>23.82</td><td>1.38<br>(1.05-1.81)</td><td>0.0225</td><td>25.03</td><td>1.83<br>(1.37-2.45)</td><td>&lt;0.0001</td><td>19.04</td><td>25.86</td><td>1.58<br>(1.15-2.17)</td><td>0.0045</td><td>23.39</td><td>1.90<br>(1.38-2.61)</td><td>&lt;0.0001</td></tr><tr><td>4th quartile: ≥ 11</td><td>16.86</td><td>24.41</td><td>1.80<br>(1.35-2.41)</td><td>&lt;0.0001</td><td>33.12</td><td>2.98<br>(2.21-4.02)</td><td>&lt;0.0001</td><td>14.64</td><td>18.77</td><td>1.50<br>(1.05-2.14)</td><td>0.0247</td><td>33.96</td><td>3.59<br>(2.55-5.05)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td colspan="15"><strong>Number of types of health professionals consulted before diagnosis</strong></td></tr><tr><td>Continuous</td><td>3.16<br>(1.49)</td><td>3.41<br>(1.61)</td><td>1.10<br>(1.03-1.18)</td><td>0.0042</td><td>3.69<br>(1.61)</td><td>1.21<br>(1.13-1.29)</td><td>&lt;0.0001</td><td>2.98<br>(1.45)</td><td>3.32<br>(1.51)</td><td>1.11<br>(1.03-1.21)</td><td>0.0084</td><td>3.69<br>(1.64)</td><td>1.28<br>(1.18-1.38)</td><td>&lt;0.0001</td></tr><tr><td>1st quartile: &lt; 3</td><td>34.74</td><td>30.45</td><td>Reference</td><td></td><td>23.99</td><td>Reference</td><td></td><td>39.75</td><td>31.17</td><td>Reference</td><td></td><td>24.23</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 3</td><td>27.33</td><td>25.36</td><td>1.03<br>(0.79-1.34)</td><td>0.8380</td><td>23.86</td><td>1.20<br>(0.90-1.59)</td><td>0.2112</td><td>26.57</td><td>26.33</td><td>1.09<br>(0.81-1.47)</td><td>0.5779</td><td>24.42</td><td>1.19<br>(0.88-1.61)</td><td>0.2543</td></tr><tr><td>3rd quartile: 4</td><td>20.82</td><td>19.67</td><td>1.09<br>(0.82-1.45)</td><td>0.5682</td><td>23.99</td><td>1.57<br>(1.17-2.11)</td><td>0.0027</td><td>20.08</td><td>21.02</td><td>1.20<br>(0.87-1.65)</td><td>0.2773</td><td>22.36</td><td>1.54<br>(1.11-2.12)</td><td>0.0088</td></tr><tr><td>4th quartile: ≥ 5</td><td>17.11</td><td>24.53</td><td>1.53<br>(1.15-2.05)</td><td>0.0037</td><td>28.16</td><td>2.05<br>(1.52-2.77)</td><td>&lt;0.0001</td><td>13.60</td><td>21.49</td><td>1.73<br>(1.21-2.46)</td><td>0.0024</td><td>29.00</td><td>2.75<br>(1.95-3.88)</td><td>&lt;0.0001</td></tr><tr><td>Ptrend</td><td colspan="4">&lt;0.0001</td><td colspan="4"></td><td colspan="4">&lt;0.0001</td><td colspan="2"></td></tr><tr><td colspan="15"><strong>Ever used complementary and alternative medicine (b)</strong></td></tr><tr><td>No</td><td>19.92</td><td>10.78</td><td>Reference</td><td></td><td>12.26</td><td>Reference</td><td></td><td>22.18</td><td>13.70</td><td>Reference</td><td></td><td>11.13</td><td>Reference</td><td></td></tr><tr><td>Yes</td><td>40.36</td><td>46.68</td><td>2.21<br>(1.61-3.02)</td><td>&lt;0.0001</td><td>42.89</td><td>1.64<br>(1.20-2.25)</td><td>0.0019</td><td>38.70</td><td>44.27</td><td>1.77<br>(1.27-2.47)</td><td>0.0008</td><td>44.81</td><td>2.21<br>(1.58-3.09)</td><td>&lt;0.0001</td></tr><tr><td>Missing</td><td>39.72</td><td>42.54</td><td>2.02<br>(1.47-2.77)</td><td>&lt;0.0001</td><td>44.85</td><td>1.76<br>(1.29-2.41)</td><td>0.0004</td><td>39.12</td><td>42.03</td><td>1.69<br>(1.21-2.36)</td><td>0.0022</td><td>44.06</td><td>2.22<br>(1.58-3.10)</td><td>&lt;0.0001</td></tr><tr><td colspan="15"><strong>Treatments for pain</strong></td></tr><tr><td>Multiple treatment types</td><td>67.18</td><td>75.00</td><td>Reference</td><td></td><td>76.14</td><td>Reference</td><td></td><td>61.72</td><td>74.03</td><td>Reference</td><td></td><td>76.80</td><td>Reference</td><td></td></tr><tr><td>Intrauterine device exclusively</td><td>1.53</td><td>1.42</td><td>0.90<br>(0.40-2.03)</td><td>0.7937</td><td>1.56</td><td>0.95<br>(0.41-2.19)</td><td>0.8962</td><td>2.72</td><td>1.30</td><td>0.46<br>(0.20-1.06)</td><td>0.0693</td><td>1.12</td><td>0.42<br>(0.18-0.96)</td><td>0.0390</td></tr><tr><td>GnRH exclusively</td><td>0.26</td><td>0.12</td><td>0.43<br>(0.04-4.80)</td><td>0.4933</td><td>0.26</td><td>1.05<br>(0.14-7.72)</td><td>0.9618</td><td>0.21</td><td>0.00</td><td>-</td><td>0.9584</td><td>0.37</td><td>1.80<br>(0.19-17.10)</td><td>0.6102</td></tr><tr><td>Osteopathy exclusively</td><td>0.38</td><td>0.12</td><td>0.34<br>(0.04-3.29)</td><td>0.3507</td><td>0.78</td><td>2.36<br>(0.56-9.97)</td><td>0.2443</td><td>0.21</td><td>0.24</td><td>1.12<br>(0.10-12.41)</td><td>0.9297</td><td>0.65</td><td>3.70<br>(0.44-31.46)</td><td>0.2307</td></tr><tr><td>Surgical operation exclusively</td><td>0.38</td><td>0.36</td><td>1.41<br>(0.23-8.54)</td><td>0.7123</td><td>0.13</td><td>0.59<br>(0.05-6.66)</td><td>0.6686</td><td>0.42</td><td>0.47</td><td>2.27<br>(0.25-20.60)</td><td>0.4656</td><td>0.09</td><td>0.50<br>(0.03-8.18)</td><td>0.6261</td></tr><tr><td>Kinesitherapy exclusively</td><td>0.13</td><td>0.36</td><td>2.90<br>(0.30-28.37)</td><td>0.3592</td><td>0.13</td><td>1.02<br>(0.06-16.76)</td><td>0.9912</td><td>0.21</td><td>0.24</td><td>0.90<br>(0.08-10.20)</td><td>0.9335</td><td>0.19</td><td>0.79<br>(0.07-9.32)</td><td>0.8539</td></tr><tr><td>Painkillers exclusively</td><td>7.28</td><td>5.92</td><td>0.74<br>(0.48-1.12)</td><td>0.1527</td><td>6.52</td><td>0.85<br>(0.56-1.28)</td><td>0.4297</td><td>7.53</td><td>5.90</td><td>0.68<br>(0.42-1.10)</td><td>0.1129</td><td>6.64</td><td>0.75<br>(0.47-1.18)</td><td>0.2072</td></tr></tbody></table>

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<table><caption>Table 4 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="4">Anxiety (GAD-7)<br/>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br/>Reference = None-minimal</th></tr><tr><th>None-minimal</th><th>Mild</th><th></th><th>Moderate - Severe</th><th>None-minimal</th><th>Mild</th><th></th><th>Moderate - Severe</th></tr></thead><tbody><tr><td>Progestins exclusively</td><td>5.24</td><td>4.15</td><td>0.81<br/>(0.50-1.31)</td><td>0.3973</td><td>4.04<br/>(0.48-1.31)</td><td>0.3581</td><td>5.86</td><td>4.25<br/>(0.37-1.07)</td><td>0.0888<br/>(0.38-1.07)</td><td>0.0873</td></tr><tr><td>Yoga, meditation, sophrology<br/>exclusively</td><td>0.51</td><td>0.36</td><td>0.68<br/>(0.11-4.17)</td><td>0.6793</td><td>0.52<br/>(0.38-8.30)</td><td>0.4633</td><td>0.63</td><td>0.24<br/>(0.02-1.92)</td><td>0.1615<br/>(0.23-4.45)</td><td>0.9996</td></tr><tr><td>No treatment</td><td>16.09</td><td>10.90</td><td>0.70<br/>(0.52-0.95)</td><td>0.0237</td><td>9.00<br/>(0.43-0.84)</td><td>0.0030</td><td>19.25</td><td>12.28<br/>(0.44-0.86)</td><td>0.0041<br/>(0.33-0.64)</td><td>&lt;0.0001</td></tr><tr><td>Other exclusively</td><td>1.02</td><td>1.30</td><td>1.18<br/>(0.44-3.16)</td><td>0.7372</td><td>0.91<br/>(0.23-2.19)</td><td>0.5579</td><td>1.26</td><td>1.06<br/>(0.28-2.59)</td><td>0.7793<br/>(0.19-1.84)</td><td>0.3645</td></tr><tr><td colspan="11"><strong>Frequency of medical follow-up<br/>for endometriosis (c)</strong></td></tr><tr><td>Every 6 months or less</td><td>8.30</td><td>11.14</td><td>Reference</td><td></td><td>11.47<br/>Reference</td><td></td><td>8.16</td><td>9.56<br/>Reference</td><td></td><td>11.88<br/>Reference</td></tr><tr><td>Once a year</td><td>22.99</td><td>23.82</td><td>0.82<br/>(0.56-1.20)</td><td>0.3125</td><td>23.60<br/>(0.56-1.22)</td><td>0.3292</td><td>26.15</td><td>23.02<br/>(0.53-1.31)</td><td>0.4263</td><td>0.67<br/>(0.43-1.04)</td><td>0.0709</td></tr><tr><td>Every two years or more</td><td>7.79</td><td>7.94</td><td>0.88<br/>(0.54-1.43)</td><td>0.6020</td><td>6.91<br/>(0.47-1.29)</td><td>0.3243</td><td>6.90</td><td>8.50<br/>(0.64-2.04)</td><td>0.6408</td><td>0.86<br/>(0.49-1.52)</td><td>0.6090</td></tr><tr><td>Too irregular to answer</td><td>9.96</td><td>9.24</td><td>0.73<br/>(0.46-1.16)</td><td>0.1806</td><td>8.21<br/>(0.37-0.97)</td><td>0.0355</td><td>8.37</td><td>9.09<br/>(0.58-1.76)</td><td>0.9791</td><td>0.84<br/>(0.49-1.44)</td><td>0.5165</td></tr><tr><td>No follow-up with vaginal<br/>ultrasound</td><td>34.48</td><td>31.16</td><td>0.70<br/>(0.48-1.01)</td><td>0.0541</td><td>29.07<br/>(0.45-0.95)</td><td>0.0257</td><td>36.19</td><td>29.28<br/>(0.47-1.14)</td><td>0.1697</td><td>0.61<br/>(0.40-0.93)</td><td>0.0225</td></tr><tr><td>Missing</td><td>16.48</td><td>16.71</td><td>0.79<br/>(0.53-1.19)</td><td>0.2598</td><td>20.73<br/>(0.68-1.54)</td><td>0.9267</td><td>14.23</td><td>20.54<br/>(0.87-2.33)</td><td>0.1552</td><td>1.05<br/>(0.65-1.69)</td><td>0.8461</td></tr><tr><td>Ptrend</td><td colspan="4">0.0292</td><td colspan="4">0.2226</td><td colspan="4"></td></tr><tr><td colspan="11"><strong>Age at first symptoms (years)</strong></td></tr><tr><td>Continuous</td><td>19.21<br/>(7.14)</td><td>18.00<br/>(6.57)</td><td>0.99<br/>(0.97-1.01)</td><td>0.3525</td><td>17.29<br/>(6.06)</td><td>0.97<br/>(0.95-0.99)</td><td>0.0144</td><td>19.29<br/>(7.15)</td><td>18.54<br/>(6.72)</td><td>1.00<br/>(0.97-1.02)</td><td>0.7058</td><td>17.37<br/>(6.25)</td><td>0.98<br/>(0.95-1.00)</td><td>0.0786</td></tr><tr><td>&lt; 15</td><td>44.96</td><td>52.25</td><td>Reference</td><td></td><td>55.41<br/>Reference</td><td></td><td>44.14</td><td>47.93<br/>Reference</td><td></td><td>56.22<br/>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>15-19</td><td>23.37</td><td>22.99</td><td>0.90<br/>(0.69-1.18)</td><td>0.4460</td><td>22.43<br/>(0.60-1.05)</td><td>0.1027</td><td>24.48</td><td>24.09<br/>(0.64-1.19)</td><td>0.3897</td><td>21.33<br/>(0.49-0.91)</td><td>0.67<br/>(0.49-1.15)</td><td>0.0114</td><td></td><td></td></tr><tr><td>20-24</td><td>11.88</td><td>10.55</td><td>0.87<br/>(0.59-1.29)</td><td>0.4887</td><td>11.99<br/>(0.62-1.35)</td><td>0.6552</td><td>12.34</td><td>12.04<br/>(0.59-1.42)</td><td>0.6822</td><td>10.57<br/>(0.48-1.15)</td><td>0.74<br/>(0.48-1.15)</td><td>0.1785</td><td></td><td></td></tr><tr><td>≥ 25</td><td>19.80</td><td>14.22</td><td>0.78<br/>(0.51-1.18)</td><td>0.2325</td><td>10.17<br/>(0.33-0.80)</td><td>0.0033</td><td>19.04</td><td>15.94<br/>(0.54-1.39)</td><td>0.5416</td><td>11.88<br/>(0.41-1.04)</td><td>0.65<br/>(0.41-1.04)</td><td>0.0735</td><td></td><td></td></tr><tr><td>Ptrend</td><td colspan="4">0.0432</td><td colspan="4">0.1280</td><td colspan="4"></td><td></td><td></td></tr><tr><td colspan="11"><strong>Age at diagnosis (years)</strong></td></tr><tr><td>Continuous</td><td>29.16<br/>(6.20)</td><td>28.64<br/>(6.57)</td><td>0.99<br/>(0.97-1.01)</td><td>0.3525</td><td>28.01<br/>(6.53)</td><td>0.97<br/>(0.95-0.99)</td><td>0.0144</td><td>29.48<br/>(5.95)</td><td>28.78<br/>(5.86)</td><td>1.00<br/>(0.97-1.02)</td><td>0.7058</td><td>28.08<br/>(6.54)</td><td>0.98<br/>(0.95-1.00)</td><td>0.0786</td></tr><tr><td>&lt; 25</td><td>28.61</td><td>30.81</td><td>Reference</td><td></td><td>36.25<br/>Reference</td><td></td><td>26.15</td><td>30.11<br/>Reference</td><td></td><td>35.73<br/>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>25-29</td><td>33.97</td><td>36.97</td><td>0.99<br/>(0.68-1.43)</td><td>0.9476</td><td>32.59<br/>(0.73-1.55)</td><td>0.7601</td><td>37.24</td><td>35.89<br/>(0.62-1.44)</td><td>0.8024</td><td>32.37<br/>(0.72-1.66)</td><td>1.09<br/>(0.72-1.66)</td><td>0.6713</td><td></td><td></td></tr><tr><td>30-34</td><td>23.12</td><td>20.38</td><td>0.78<br/>(0.44-1.37)</td><td>0.3854</td><td>18.90<br/>(0.63-2.03)</td><td>0.6863</td><td>20.92</td><td>22.20<br/>(0.56-2.07)</td><td>0.8211</td><td>19.64<br/>(0.88-3.19)</td><td>1.68<br/>(0.88-3.19)</td><td>0.1158</td><td></td><td></td></tr><tr><td>≥ 35</td><td>14.30</td><td>11.85</td><td>0.69<br/>(0.29-1.64)</td><td>0.3977</td><td>12.26<br/>(0.64-3.71)</td><td>0.3421</td><td>15.69</td><td>11.81<br/>(0.30-2.23)</td><td>0.6985</td><td>12.25<br/>(0.80-5.60)</td><td>2.12<br/>(0.80-5.60)</td><td>0.1303</td><td></td><td></td></tr><tr><td>Ptrend</td><td colspan="4">0.2117</td><td colspan="4">0.0616</td><td colspan="4"></td><td></td><td></td></tr><tr><td colspan="11"><strong>Disease type (c)</strong></td></tr><tr><td>Multiple types</td><td>53.13</td><td>53.91</td><td>Reference</td><td></td><td>55.41<br/>Reference</td><td></td><td>53.14</td><td>51.00<br/>Reference</td><td></td><td>57.06<br/>Reference</td><td></td><td></td><td></td><td></td></tr><tr><td>Deep endometriosis exclusively</td><td>15.45</td><td>15.52</td><td>0.97<br/>(0.73-1.30)</td><td>0.8495</td><td>16.43<br/>(0.77-1.39)</td><td>0.8255</td><td>14.23</td><td>14.76<br/>(0.79-1.56)</td><td>0.5528</td><td>17.31<br/>(0.88-1.68)</td><td>1.21<br/>(0.88-1.68)</td><td>0.2458</td><td></td><td></td></tr><tr><td>Ovarian endometriosis exclusively</td><td>11.62</td><td>12.09</td><td>1.02<br/>(0.73-1.42)</td><td>0.9079</td><td>9.13<br/>(0.58-1.20)</td><td>0.3253</td><td>14.02</td><td>13.58<br/>(0.76-1.55)</td><td>0.6544</td><td>7.58<br/>(0.40-0.85)</td><td>0.58<br/>(0.40-0.85)</td><td>0.0053</td><td></td><td></td></tr><tr><td>Superficial endometriosis<br/>exclusively</td><td>5.87</td><td>6.28</td><td>1.00<br/>(0.65-1.53)</td><td>0.9854</td><td>6.26<br/>(0.59-1.42)</td><td>0.6756</td><td>5.23</td><td>6.97<br/>(0.80-2.19)</td><td>0.2832</td><td>5.89<br/>(0.53-1.48)</td><td>0.89<br/>(0.53-1.48)</td><td>0.6470</td><td></td><td></td></tr></tbody></table>

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<table><caption>Table 4 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="4">Anxiety (GAD-7)<br>Reference = None-minimal</th><th colspan="4">Depression (PHQ-9)<br>Reference = None-minimal</th></tr><tr><th>None-minimal</th><th>Mild</th><th></th><th></th><th>None-minimal</th><th>Mild</th><th></th><th></th></tr></thead><tbody><tr><td>Adenomyosis exclusively</td><td>1.40</td><td>0.59</td><td>0.40<br>(0.14-1.18)</td><td>0.0961</td><td>1.56</td><td>0.83<br>(0.34-2.03)</td><td>0.6776</td><td>1.05</td><td>1.18</td><td>1.11<br>(0.37-3.30)</td><td>0.8568</td><td>1.22</td><td>0.84<br>(0.28-2.53)</td><td>0.7518</td></tr><tr><td>Do not know</td><td>12.52</td><td>11.61</td><td>0.99<br>(0.71-1.36)</td><td>0.9264</td><td>11.21</td><td>1.01<br>(0.72-1.40)</td><td>0.9765</td><td>12.34</td><td>12.51</td><td>1.20<br>(0.82-1.74)</td><td>0.3423</td><td>10.94</td><td>0.98<br>(0.67-1.42)</td><td>0.8966</td></tr><tr><td><strong>Disease type combination (c)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>DE</td><td>24.39</td><td>23.82</td><td>Reference</td><td></td><td>27.25</td><td>Reference</td><td></td><td>22.38</td><td>23.73</td><td>Reference</td><td></td><td>27.41</td><td>Reference</td><td></td></tr><tr><td>OMA</td><td>15.45</td><td>15.64</td><td>1.04<br>(0.74-1.44)</td><td>0.8362</td><td>11.86</td><td>0.74<br>(0.52-1.06)</td><td>0.0985</td><td>19.67</td><td>16.17</td><td>0.78<br>(0.54-1.13)</td><td>0.1905</td><td>10.57</td><td>0.45<br>(0.31-0.65)</td><td>&lt;0.0001</td></tr><tr><td>OMADE</td><td>20.18</td><td>19.91</td><td>1.12<br>(0.82-1.51)</td><td>0.4792</td><td>18.51</td><td>0.94<br>(0.69-1.28)</td><td>0.6967</td><td>20.08</td><td>19.95</td><td>0.97<br>(0.68-1.39)</td><td>0.8763</td><td>18.99</td><td>0.84<br>(0.59-1.18)</td><td>0.3067</td></tr><tr><td>OMASPE</td><td>5.49</td><td>5.69</td><td>1.04<br>(0.65-1.67)</td><td>0.8657</td><td>4.82</td><td>0.67<br>(0.40-1.11)</td><td>0.1202</td><td>5.65</td><td>4.37</td><td>0.68<br>(0.38-1.20)</td><td>0.1814</td><td>5.99</td><td>0.70<br>(0.41-1.20)</td><td>0.1979</td></tr><tr><td>OMASPEDE</td><td>5.36</td><td>6.40</td><td>1.24<br>(0.79-1.96)</td><td>0.3545</td><td>8.34</td><td>1.33<br>(0.85-2.09)</td><td>0.2133</td><td>5.86</td><td>5.08</td><td>0.80<br>(0.47-1.38)</td><td>0.4278</td><td>8.33</td><td>1.06<br>(0.64-1.74)</td><td>0.8252</td></tr><tr><td>SPE</td><td>9.07</td><td>10.19</td><td>1.11<br>(0.76-1.63)</td><td>0.5880</td><td>9.39</td><td>0.84<br>(0.56-1.24)</td><td>0.3724</td><td>7.74</td><td>10.39</td><td>1.13<br>(0.71-1.79)</td><td>0.6105</td><td>9.73</td><td>0.82<br>(0.52-1.29)</td><td>0.3786</td></tr><tr><td>SPEDE</td><td>6.13</td><td>6.16</td><td>0.93<br>(0.59-1.45)</td><td>0.7437</td><td>7.04</td><td>0.90<br>(0.58-1.41)</td><td>0.6526</td><td>5.23</td><td>6.61</td><td>1.03<br>(0.60-1.76)</td><td>0.9105</td><td>6.83</td><td>0.81<br>(0.48-1.37)</td><td>0.4306</td></tr><tr><td>Do not know</td><td>13.92</td><td>12.20</td><td>0.97<br>(0.69-1.38)</td><td>0.8741</td><td>12.78</td><td>0.92<br>(0.65-1.31)</td><td>0.6557</td><td>13.39</td><td>13.70</td><td>1.05<br>(0.70-1.57)</td><td>0.8283</td><td>12.16</td><td>0.79<br>(0.53-1.18)</td><td>0.2476</td></tr><tr><td><strong>Stage of endometriosis (c)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>I or II</td><td>7.54</td><td>9.12</td><td>Reference</td><td></td><td>9.26</td><td>Reference</td><td></td><td>7.95</td><td>9.45</td><td>Reference</td><td></td><td>8.33</td><td>Reference</td><td></td></tr><tr><td>III or IV</td><td>24.14</td><td>26.42</td><td>0.98<br>(0.65-1.47)</td><td>0.9039</td><td>27.25</td><td>1.04<br>(0.68-1.57)</td><td>0.8646</td><td>23.85</td><td>25.74</td><td>1.06<br>(0.66-1.68)</td><td>0.8183</td><td>27.03</td><td>1.43<br>(0.90-2.27)</td><td>0.1267</td></tr><tr><td>Never had surgery for<br>endometriosis</td><td>26.18</td><td>27.01</td><td>0.82<br>(0.55-1.23)</td><td>0.3404</td><td>28.16</td><td>0.83<br>(0.55-1.25)</td><td>0.3776</td><td>26.15</td><td>26.56</td><td>0.85<br>(0.54-1.34)</td><td>0.4902</td><td>27.97</td><td>0.95<br>(0.61-1.50)</td><td>0.8308</td></tr><tr><td>Missing</td><td>42.15</td><td>37.44</td><td>0.81<br>(0.55-1.19)</td><td>0.2746</td><td>35.33</td><td>0.75<br>(0.50-1.11)</td><td>0.1509</td><td>42.05</td><td>38.25</td><td>0.92<br>(0.59-1.43)</td><td>0.7065</td><td>36.67</td><td>1.06<br>(0.69-1.65)</td><td>0.7858</td></tr><tr><td><strong>Family history of endometriosis,<br>adenomyosis<br>or chronic pelvic pain</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or do not know</td><td>44.44</td><td>38.98</td><td>Reference</td><td></td><td>38.33</td><td>Reference</td><td></td><td>43.10</td><td>41.20</td><td>Reference</td><td></td><td>38.91</td><td>Reference</td><td></td></tr><tr><td>Yes</td><td>55.56</td><td>61.02</td><td>1.25<br>(1.02-1.54)</td><td>0.0348</td><td>61.67</td><td>1.19<br>(0.96-1.47)</td><td>0.1091</td><td>56.90</td><td>58.80</td><td>1.08<br>(0.85-1.37)</td><td>0.5249</td><td>61.09</td><td>1.11<br>(0.88-1.40)</td><td>0.3751</td></tr><tr><td><strong>Time since diagnosis (years)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>8.83<br>(5.96)</td><td>8.37<br>(5.52)</td><td>1.02<br>(0.93-1.12)</td><td>0.6781</td><td>8.40<br>(6.00)</td><td>1.01<br>(0.92-1.11)</td><td>0.8698</td><td>9.13<br>(6.10)</td><td>8.55<br>(5.76)</td><td>1.02<br>(0.92-1.13)</td><td>0.7202</td><td>8.24<br>(5.72)</td><td>0.98<br>(0.88-1.09)</td><td>0.6875</td></tr><tr><td>1st quartile: &lt; 5</td><td>17.24</td><td>21.21</td><td>Reference</td><td></td><td>24.12</td><td>Reference</td><td></td><td>17.24</td><td>21.21</td><td>Reference</td><td></td><td>24.12</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 5-6</td><td>29.25</td><td>30.45</td><td>0.87<br>(0.65-1.17)</td><td>0.3640</td><td>29.34</td><td>0.73<br>(0.54-0.99)</td><td>0.0416</td><td>29.25</td><td>30.45</td><td>0.70<br>(0.49-0.99)</td><td>0.0471</td><td>29.34</td><td>0.70<br>(0.50-0.99)</td><td>0.0472</td></tr><tr><td>3rd quartile: 7-9</td><td>22.73</td><td>19.19</td><td>0.74<br>(0.53-1.04)</td><td>0.0841</td><td>18.51</td><td>0.61<br>(0.44-0.86)</td><td>0.0052</td><td>22.73</td><td>19.19</td><td>0.69<br>(0.47-1.03)</td><td>0.0690</td><td>18.51</td><td>0.68<br>(0.46-1.01)</td><td>0.0533</td></tr><tr><td>4th quartile: ≥ 10</td><td>30.78</td><td>29.15</td><td>0.92<br>(0.59-1.44)</td><td>0.7236</td><td>28.03</td><td>0.67<br>(0.43-1.05)</td><td>0.0833</td><td>30.78</td><td>29.15</td><td>0.80<br>(0.48-1.34)</td><td>0.3986</td><td>28.03</td><td>0.70<br>(0.42-1.16)</td><td>0.1693</td></tr><tr><td>Ptrend</td><td>0.0578</td><td></td><td></td><td></td><td></td><td></td><td></td><td>0.1122</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Diagnostic delay (years)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>9.69<br>(7.05)</td><td>10.47<br>(7.02)</td><td>1.01<br>(0.99-1.04)</td><td>0.2719</td><td>10.71<br>(7.12)</td><td>1.01<br>(0.98-1.03)</td><td>0.6034</td><td>9.88<br>(6.98)</td><td>10.11<br>(7.03)</td><td>1.01<br>(0.98-1.03)</td><td>0.6118</td><td>1063<br>(7.13)</td><td>1.01<br>(0.98-1.04)</td><td>0.4697</td></tr><tr><td>1st quartile: 0-5</td><td>37.80</td><td>32.23</td><td>Reference</td><td></td><td>29.20</td><td>Reference</td><td></td><td>37.66</td><td>33.88</td><td>Reference</td><td></td><td>30.40</td><td>Reference</td><td></td></tr><tr><td>2nd quartile: 6-9</td><td>17.24</td><td>16.59</td><td>1.05<br>(0.77-1.43)</td><td>0.7537</td><td>19.56</td><td>1.25<br>(0.91-1.71)</td><td>0.1658</td><td>16.53</td><td>17.00</td><td>1.12<br>(0.79-1.59)</td><td>0.5296</td><td>18.90</td><td>1.22<br>(0.87-1.73)</td><td>0.2519</td></tr></tbody></table>

(continued on next page)
<table><caption>Table 4 (continued)</caption><thead><tr><th rowspan="2"></th><th colspan="2">Anxiety (GAD-7)<br>Reference = None-minimal</th><th colspan="2">Mild</th><th colspan="2">Depression (PHQ-9)<br>Reference = None-minimal</th><th colspan="2">Mild</th><th colspan="2">Moderate - Severe</th></tr><tr><th>None-minimal</th><th>Moderate - Severe</th><th>None-minimal</th><th>Moderate - Severe</th><th>None-minimal</th><th>Moderate - Severe</th><th>None-minimal</th><th>Moderate - Severe</th><th>None-minimal</th><th>Moderate - Severe</th></tr></thead><tbody><tr><td>3rd quartile: 10-14</td><td>20.56</td><td>22.39</td><td>1.19<br>(0.87-1.62)</td><td>0.2875</td><td>22.56</td><td>1.17<br>(0.84-1.62)</td><td>0.3486</td><td>21.76</td><td>22.79</td><td>1.19<br>(0.84-1.70)</td><td>0.3288</td><td>21.14</td><td>1.04<br>(0.73-1.47)</td><td>0.8492</td></tr><tr><td>4th quartile: 15-40</td><td>24.39</td><td>28.79</td><td>1.38<br>(0.97-1.95)</td><td>0.0740</td><td>28.68</td><td>1.31<br>(0.91-1.88)</td><td>0.1526</td><td>24.06</td><td>26.33</td><td>1.42<br>(0.95-2.11)</td><td>0.0879</td><td>29.56</td><td>1.48<br>(1.00-2.20)</td><td>0.0492</td></tr><tr><td>Prend<br>Person who suspected the disease</td><td>0.1703</td><td></td><td></td><td></td><td></td><td></td><td>0.1896</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Health professional</td><td>58.49</td><td>57.94</td><td>Reference</td><td></td><td>53.06</td><td>Reference</td><td></td><td>60.04</td><td>59.62</td><td>Reference</td><td></td><td>52.57</td><td>Reference</td><td></td></tr><tr><td>A relative</td><td>10.98</td><td>11.85</td><td>0.99<br>(0.71-1.37)</td><td>0.9492</td><td>15.51</td><td>1.30<br>(0.94-1.81)</td><td>0.1109</td><td>10.04</td><td>10.86</td><td>0.97<br>(0.66-1.45)</td><td>0.8968</td><td>15.43</td><td>1.42<br>(0.98-2.07)</td><td>0.0656</td></tr><tr><td>Self</td><td>30.52</td><td>30.21</td><td>0.90<br>(0.71-1.14)</td><td>0.3732</td><td>31.42</td><td>0.93<br>(0.73-1.19)</td><td>0.5545</td><td>29.92</td><td>29.52</td><td>0.83<br>(0.63-1.09)</td><td>0.1693</td><td>31.99</td><td>0.9<br>(0.69-1.18)</td><td>0.4605</td></tr><tr><td>Number of surgeries for<br>endometriosis (c)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuous</td><td>1.23<br>(1.49)</td><td>1.17<br>(1.52)</td><td>1.01<br>(0.93-1.09)</td><td>0.8726</td><td>1.22<br>(1.76)</td><td>1.02<br>(0.94-1.11)</td><td>0.6238</td><td>1.25<br>(1.49)</td><td>1.16<br>(1.53)</td><td>1.00<br>(0.91-1.10)</td><td>0.9859</td><td>1.22<br>(1.67)</td><td>1.06<br>(0.97-1.16)</td><td>0.2101</td></tr></tbody></table>

Model 3 was adjusted for age, BMI, number of comorbidities, diagnostic delay, and age at first symptoms.

(b) this variable could be assessed among 1380 participants who replied to a questionnaire on complementary and alternative medicine.

(c) these variables could be assessed among 1907 participants who replied to a questionnaire on surgery and imagery history.

any data on anxiety and depression levels measured through GAD-7 and PHQ-9 among the French general population, compared with German population data, the mean GAD-7 score in German women under 60 ranged between 3.9 and 4.6, while in our patient sample, this score was 7.5 [30,31]. Similarly, the PHQ-9 score in German women ranged between 2.5 and 3.3 but was 9.4 in our sample [31]. Additionally, the rate of moderate-to-severe anxiety (32%) and depression (45%) symptoms in our sample greatly exceeded the corresponding rates in the general German population (7.4% and 5.4%, respectively).

A recent Canadian retrospective cohort study involving 3815 endometriosis patients reported that 16% were found to have anxiety and/or depression, based on diagnostic codes in their medical and hospital records [32]. A Chinese study of 321 endometriosis hospital patients with reproductive intention assessed their post-surgical anxiety and depression levels based on the self-rating anxiety scale (SAS) and self-rating depression scale (SDS), respectively [33]. The study reports that 19% met the diagnostic criteria for anxiety (among whom 1.6% had moderate-to-severe anxiety), and 69% for depression (among whom 27.5% had moderate-to-severe depression), thus lower rates of moderate-to-severe anxiety and depression than in our study.

### 4.2.2. Factors positively associated with moderate-to-severe anxiety and depression symptom levels

Several studies reported on the factors associated with anxiety and depression levels among women with endometriosis. Our observation of a positive association with sociodemographic factors, such as low educational attainment and being out of the workforce, is supported by other studies. Social isolation and diminished self-worth, particularly among students and individuals not actively employed, were indeed suggested to contribute to worsening mental well-being [23,34,35], although these studies explored presence or absence of anxiety and depression rather than anxiety and depression levels. While a review suggested that being in a relationship was generally inversely associated with depression symptoms among endometriosis patients [14], as observed in our study, a study conducted among patients with reproductive intentions showed higher depression symptom levels among those in a relationship, most probably due to dealing with infertility [33]. However, anxiety and depression symptom levels were not associated with infertility in our study, as discussed further below.

Previous research has shown that symptom levels of anxiety and depression in women with endometriosis were strongly tied to their overall health status, with mental health issues often correlating with each other [14]. Consistently with our findings, factors such as poor sleep quality, fatigue [36,37], and reduced QoL [38-40] have indeed been linked to altered mental well-being. Importantly, anxiety and depression have been closely associated with the presence and severity of various endometriosis symptoms, notably pain [17,24,40-44], particularly chronic [45-47] and daily pain [21]. The association with pain could be a two-way relation: endometriosis symptoms may create a vicious cycle involving anxiety, depression, pain, and diminished QoL [7,14], which disrupts daily living [48]; and anxiety and depression symptoms may contribute to heightened pain perception and catastrophizing [13,40,43]. The use of complementary and alternative medicine appears to be particularly prevalent among patients with chronic pain [49]. The strong association observed between high levels of anxiety and depression and the use of complementary and alternative medicine may be in part due to the relationship between pain and mental health.

Pertinent to our findings on pain and the healthcare pathway, Goodwin et al. showed that compared with women with no anxiety or depression, those with one or the other were more likely to have had a clinical history of pain and pain as an indication for surgery, to have had a previous endometriosis-related surgery, to have been prescribed hormonal treatment or NSAIDs/opioids before their index surgery or after, to visit a physician for pelvic pain, and to have reoperations [32]. A recent integrative review of systematic reviews indeed suggested that
the long and complex diagnostic process, limited treatment efficacy, and persistence of symptoms significantly contributed to emotional distress in endometriosis patients [40].

Although sexual dysfunction is linked to mental health in endometriosis [14,16,19,50], we lacked data on this aspect in our cohort.

Comorbidities have been linked to higher levels of anxiety and depression in women with endometriosis, likely exacerbating the accumulation of symptoms and challenges along patients' healthcare journeys [51]. A US retrospective matched-cohort study using administrative health claims among 72,677 women over a period of over 18 years reported that painful comorbidities (such as chronic headaches, chronic low back pain, fibromyalgia, interstitial cystitis, or irritable bowel syndrome) were associated with a higher risk of mental health conditions, including anxiety and depression [24]. Also, depression is a comorbidity for many chronic diseases [52]. From another perspective, mental health conditions themselves can be considered comorbidities, which may further explain the link between number of comorbidities and elevated anxiety and depression symptom levels [53]. Additionally, BMI outside the normal range has been linked to anxiety and depression, which could be attributed to the social stigma faced by endometriosis patients [18,54] and those with a higher BMI [55,56]. While earlier research identified a clear association with obesity but not underweight status [57], the broader connection between BMI, stigma, and mental health remains meaningful.

In line with the existing literature, we found that longer healthcare pathways were associated with elevated anxiety and depression symptom levels in endometriosis patients [13,48]. However, the relationship with diagnostic delay was not statistically significant in our study (except for depression among women in the top quartile of diagnostic delay), contrasting with a qualitative study from Italy that reported diagnostic delay as an important factor associated with anxiety and depression [48].

### 4.2.3. Factors inversely associated with moderate-to-severe anxiety and depression symptom levels

As expected, endometriosis patients with more privileged socioeconomic characteristics were less likely to have high anxiety and depression levels. Also, age was inversely associated with anxiety and depression levels, in line with the results of an Austrian study suggesting that older patients may integrate their illness into their everyday life and feel less stressed [23].

In terms of health status, a low number of painful symptoms was also associated with less moderate-to-severe anxiety and depression symptoms. For instance, having only intromission or deep dyspareunia was associated with lower anxiety and depression symptoms than when reporting both dyspareunia localizations. Also, our observation that a higher QoL was associated with lower anxiety and depression levels was expected, since mental well-being is an item composing QoL scores, and this observation is well-known in the literature [38,39].

In our study, women who reported no treatment or imaging follow-up at their first annual assessment were less likely to experience moderate-to-severe anxiety and depression. This is in line with the results from Goodwin et al. linking anxiety and depression among endometriosis patients with more extensive healthcare use before and after surgery [32], and may suggest that, as expected, fewer painful symptoms are associated with better mental well-being [17]. Moreover, the absence of regular transvaginal ultrasound consultations could indicate milder symptoms and, thus potentially lower anxiety and depression levels. Later symptom onset was linked to shorter diagnostic delay [58], suggesting faster care may improve mental well-being.

Finally, diagnosis of OMA only (vs. DE only or multiple endometriosis types) was inversely associated with moderate-to-severe depression symptoms in our study, and this study was the first to examine associations between macro-phenotype of endometriosis and anxiety or depression symptom level. Of note, the healthcare pathway with OMA is usually more direct than with DE, since diagnosis is more

straightforward. Nevertheless, OMA is associated with an alteration in fertility [59] and could have been linked to higher anxiety and depression symptoms, although we did not observe this association in our data.

### 4.2.4. Factors not associated with anxiety or depression symptoms

Although infertility might be expected to influence anxiety and depression, we did not observe such an association. This finding aligns with a recent systematic review [20] but contrasts with some cross-sectional studies [44,50], consistently with the findings from Wu et al. [33]. This could be due to the definition of infertility in our study (i.e. unsuccessful attempts to conceive for 6–12 months). Regardless of fertility issues, pain appears to play a more substantial role in affecting mental well-being among patients [60].

Similarly, there was no link between endometriosis stage and anxiety or depression symptom levels in our study, consistent with earlier literature [12], as stage is not directly correlated with symptom severity [1], which limits its impact on patients' daily experiences.

Time since diagnosis was not associated with anxiety or depression symptoms, which could suggest that symptom management matters more than diagnosis timing. However, time since diagnosis was associated with higher anxiety levels in a cross-sectional study of 210 patients [61]. We also found no association between number of surgeries for endometriosis and anxiety or depression symptom levels, reinforcing the idea that chronic pain, rather than surgical interventions or diagnosis timing, is more strongly tied to mental well-being.

## 4.3. Conclusion

This cross-sectional study identified several socio-demographic and medical factors associated with levels of anxiety and depression symptom among women with endometriosis. Endometriosis affects all spheres of life, including mental health and well-being. These findings may help inform the development of hypotheses and identify patients who may benefit from targeted support. Promoting timely diagnosis, and a multimodal approach in the healthcare pathway, including psychological care and pain management, is essential among women living with the disease, particularly in the presence of chronic pain, poorer socioeconomic conditions, or a high number of symptoms and comorbidities.

## Funding

The authors are grateful to the associations ENDo mind, EndoFrance, EndoAction, Les Joyeux boulomanes Farledois, La Belle & l'Endo, and Les Chroniques Endométriques for their financial support of the ComPaRe-Endometriosis cohort. The ComPaRe cohort was funded by the Assistance Publique - Hôpitaux de Paris (APHP) and the Université Paris Cité. ZB's PhD was partly funded by the (ANRT) and by Lyv Healthcare. ZB was also supported by the EndoFrance association. None of these funding sources had any role in the design of the study, collection and analysis of data, or decision to publish.

## CRediT authorship contribution statement

**Zélia Breton:** Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Formal analysis, Data curation, Conceptualization. **Solène Gouesbet:** Writing – review & editing, Validation. **Hélène Amazouz:** Writing – review & editing, Validation. **Hélena Schoefs:** Writing – review & editing, Validation. **Viet-Thi Tran:** Writing – review & editing, Validation, Conceptualization. **Bruno Falissard:** Writing – review & editing, Validation. **Emmanuelle Corruble:** Writing – review & editing, Validation. **Marina Kvaskoff:** Writing – review & editing, Validation, Supervision, Project administration, Methodology, Funding acquisition, Conceptualization.
Declaration of competing interest

The authors declare the following financial interests/personal re-
lationships which may be considered as potential competing interests
(Zelia Breton reports financial support was provided by EndoFrance
association. Zelia Breton reports financial support was provided by
French National Association for Research and Technology. Zelia Breton
reports financial support was provided by LvY Healthcare. Zelia Breton
reports a relationship with LvY Healthcare that includes: employment. If
there are other authors, they declare that they have no known
competing financial interests or personal relationships that could have
appeared to influence the work reported in this paper.)

Acknowledgements

We are grateful to all participants of the ComPaRe-Endometriosis
cohort for their invaluable time and dedication to research. We also
thank the members of the ComPaRe-Endometriosis Scientific Commit-
tee: AFLAK Nizar, BORGHESE Bruno, GABILLET Marie, GAUTIER Juli-
ette, INDERSIE Émilie, LHUILLERY Delphine, MILLEPIED Anne-
Charlotte, NEVE DE MEVERGNIES Margaux, PETIT Erick, PLOTEAU
Stéphane, POULAIN Myriam, ROMAN Horace, ROMERIO Alice, SAU-
VANET Éric, TASSY Sylvain; all the patient societies involved (Endo-
France, who funded this study, ENDOmind, EndoAction); members of
the ComPaRe team; and Exposome and Heredity Team members at
Inserm U1018/CESP, particularly Fanny ARTAUD and Pauline FRENOY,
for their methodological advice.

**Appendix A. Supplementary data**

Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychores.2025.112329.

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## Glossary

**BMI:** Body Mass Index

**CI:** Confidence Intervals

**ComPaRe:** Community of Patients for Research

**DE:** Deep Endometriosis

**GAD-7:** Generalized Anxiety Disorder questionnaire

**NRS:** Numeric Rating Scale

**OMA:** Ovarian Endometriosis or endometrioma

**OR:** odds ratio

**PHQ-9:** Patient Health Questionnaire

**QoL:** Quality of life

**SPE:** Superficial Peritoneal Endometriosis

**VAS:** Visual Analogue Scale