**4. Psychological background to the co-existence of endometriosis and gastrointestinal symptoms**

tively for 4 months. The occurrence of a severe, sustained life stress during the previous 6 months significantly predicted increased heartburn symptoms during the following 4 months. Anxiety showed the strongest correlation to impaired quality of life and depression to heartburn medication use. Similar to other chronic conditions such as irritable bowel syn‐ drome, heartburn severity appears to be most responsive to major life events. Both heartburn and irritable bowel syndrome may be related to gastrointestinal motility disorders[20]. In the upper gastrointestinal tract oesophageal acid exposure due to inhibition of gastric emptying of acid may lead to heartburn. Alternatively motility disorders affecting the lower intestinal

Functional Gastrointestinal Symptoms in Women with Pelvic Endometriosis

http://dx.doi.org/10.5772/56611

173

On further investigation of gynaecological complaints, once the diagnosis of endometriosis is established, the phobia of infertility may set in, further compounding the psychological profile. If infertility does occur in these women, then depressive symptoms are more likely to appear. Self-reported depression was more common in subfertile women (n = 1,031), with endome‐

triosis (O.R. 5.43, C.I. 4.01-7.36) compared with fertile women (n = 4,905) [21].

**5. Neuro-endocrine imbalance in association with Gastrointestinal**

The majority of women suffering from endometriosis are well versed in their condition. With easy access to medical literature, besides subfertility, the risk of inflammatory bowel disease and ovarian cancer has now become universally known to most women suffering from endometriosis [21]. All these factors exacerbate the tenuous emotional status of these women

In response to high levels of perceived stress, neuroendocrine-immune imbalance has been alluded to as a reaction to the symptoms of endometriosis. Serum prolactin levels were significantly higher in infertile women with stage III-IV endometriosis (28.9 +/- 2.1 ng/mL) than in healthy controls (13.2 +/- 2.1 ng/mL)[22]. Elevated serum cortisol levels were noted in infertile women with stage III-IV endometriosis (20.1 +/- 1.3 ng/mL) compared to controls (10.5 +/- 1.4 ng/mL) [22]. Perception of stress has been noted to trigger or intensify the incidence or exacerbation of diseases such as inflammatory bowel disease, immunological cutaneous conditions, or pregnancy complications such as spontaneous miscarriage and pre-eclampsia. The effect on the immunity of the intestinal mucosa by stress has been implicated as a potential mechanism leading to irritable bowel syndrome. This is thought to be mediated through altered function of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Both of these systems can modulate mucosal immune function. A study by Chang et al indicated that basal adrenocorticotropin hormone levels were significantly blunted (P < 0.05), while basal and stimulated plasma cortisol levels were higher in patients with irritable bowel syndrome. Patients with irritable bowel syndrome presenting with diarrhoea had significantly decreased mRNA expression of mucosal cytokines [interleukin (IL)-2, IL-6] in the

tract lead to irritable bowel syndrome.

**symptoms and Endometriosis**

sigmoid colon versus controls (P < 0.05) [24].

(Figure 2.)

Emotional and mood disorders in women have been significantly detected in women suffering from endometriosis. These disorders were found more commonly in women with endome‐ triosis (11/23 p < 0.03), admitting regular administration of anxiolytic and/or anti depressant therapy for symptoms related to significant anxiety or depression [5].

In a prospective study by [16], out of 104 women diagnosed with pelvic endometriosis 87.5% of women complained of anxiety. This anxiety state was mild in 24% and severe in 63.5% of the subjects studied. Correlations between pain intensity and anxiety symptoms, were also obtained using the State-Trait Anxiety Inventory (STAI) (state, P=0.009; trait, P=0.048) and the Hamilton Rating Scale for Anxiety (HAMA) (P=0.0001). Moreover anxiolytic treatment with benzodiazepines such as clonazepam has been used in women with endometriosis. A number of these subjects also required prolonged treatment with serotonin selective serotonin reuptake inhibitors (SSRI's) [16].

Depression has also been noted to be prevalent in women with pelvic endometriosis, a high proportion of which require anti-depressant therapy. Depressive symptoms were observed in 86.5% of patients with pelvic endometriosis (mild in 22.1%, moderate in 31.7%, and severe in 32.7%) [16]. In a similar percentage (86%) of women, depression was detected in the women with endometriosis complaining of chronic pelvic pain [17]. Work inhibition, dissatisfaction, and sadness, were observed at a significantly higher rates in the group with abdominal pain [17]

The above mentioned psychological profile of these women may have been moulded from a very young age. The cyclical experience of the symptoms of severe dysmenorrhoea and menstrual disorders from puberty, may have conditioned these women to acquire certain personality traits as a reaction to the cyclical physical and subsequent psychological suffering they sustained [16]. Lower quality of life indices correlated with high pain scores. Lower quality of life status in psychological and environmental perspectives resulted in an inverse relationship between pain scores and the psychological dimension of quality of life (r = -0.310, P =.02)[18].

Mood disorders in adult women with endometriosis are associated with co-morbidities such as pain syndromes including irritable bowel syndrome, vulvodynia, fibromyalgia and asthma have been noted with in adult women with endometriosis. These co-morbidities appear to have their conception early in reproductive life in adolescents and young women. A study by Smorgick et al (2013) reviewing 138 adolescents/young women (younger than 24 years) demonstrated a prevalence of comorbid pain syndromes 56% women, mood conditions in 66 (48%) women, and asthma in 31 (26%) women [19].

Exacerbations of gastrointestinal motility disorders such as gastro-oesophageal reflux and irritable bowel syndrome are associated with the emergence of psychosocial stressors. Naliboff et al [20] assessed 60 subjects with current heartburn symptoms and correlated for the occurrence of stressful life events retrospectively over the preceding 6 months and prospec‐ tively for 4 months. The occurrence of a severe, sustained life stress during the previous 6 months significantly predicted increased heartburn symptoms during the following 4 months. Anxiety showed the strongest correlation to impaired quality of life and depression to heartburn medication use. Similar to other chronic conditions such as irritable bowel syn‐ drome, heartburn severity appears to be most responsive to major life events. Both heartburn and irritable bowel syndrome may be related to gastrointestinal motility disorders[20]. In the upper gastrointestinal tract oesophageal acid exposure due to inhibition of gastric emptying of acid may lead to heartburn. Alternatively motility disorders affecting the lower intestinal tract lead to irritable bowel syndrome.

**4. Psychological background to the co-existence of endometriosis and**

therapy for symptoms related to significant anxiety or depression [5].

Emotional and mood disorders in women have been significantly detected in women suffering from endometriosis. These disorders were found more commonly in women with endome‐ triosis (11/23 p < 0.03), admitting regular administration of anxiolytic and/or anti depressant

In a prospective study by [16], out of 104 women diagnosed with pelvic endometriosis 87.5% of women complained of anxiety. This anxiety state was mild in 24% and severe in 63.5% of the subjects studied. Correlations between pain intensity and anxiety symptoms, were also obtained using the State-Trait Anxiety Inventory (STAI) (state, P=0.009; trait, P=0.048) and the Hamilton Rating Scale for Anxiety (HAMA) (P=0.0001). Moreover anxiolytic treatment with benzodiazepines such as clonazepam has been used in women with endometriosis. A number of these subjects also required prolonged treatment with serotonin selective serotonin re-

Depression has also been noted to be prevalent in women with pelvic endometriosis, a high proportion of which require anti-depressant therapy. Depressive symptoms were observed in 86.5% of patients with pelvic endometriosis (mild in 22.1%, moderate in 31.7%, and severe in 32.7%) [16]. In a similar percentage (86%) of women, depression was detected in the women with endometriosis complaining of chronic pelvic pain [17]. Work inhibition, dissatisfaction, and sadness, were observed at a significantly higher rates in the group with abdominal pain

The above mentioned psychological profile of these women may have been moulded from a very young age. The cyclical experience of the symptoms of severe dysmenorrhoea and menstrual disorders from puberty, may have conditioned these women to acquire certain personality traits as a reaction to the cyclical physical and subsequent psychological suffering they sustained [16]. Lower quality of life indices correlated with high pain scores. Lower quality of life status in psychological and environmental perspectives resulted in an inverse relationship between pain scores and the psychological dimension of quality of life (r = -0.310,

Mood disorders in adult women with endometriosis are associated with co-morbidities such as pain syndromes including irritable bowel syndrome, vulvodynia, fibromyalgia and asthma have been noted with in adult women with endometriosis. These co-morbidities appear to have their conception early in reproductive life in adolescents and young women. A study by Smorgick et al (2013) reviewing 138 adolescents/young women (younger than 24 years) demonstrated a prevalence of comorbid pain syndromes 56% women, mood conditions in 66

Exacerbations of gastrointestinal motility disorders such as gastro-oesophageal reflux and irritable bowel syndrome are associated with the emergence of psychosocial stressors. Naliboff et al [20] assessed 60 subjects with current heartburn symptoms and correlated for the occurrence of stressful life events retrospectively over the preceding 6 months and prospec‐

(48%) women, and asthma in 31 (26%) women [19].

**gastrointestinal symptoms**

172 Dyspepsia - Advances in Understanding and Management

uptake inhibitors (SSRI's) [16].

[17]

P =.02)[18].

On further investigation of gynaecological complaints, once the diagnosis of endometriosis is established, the phobia of infertility may set in, further compounding the psychological profile. If infertility does occur in these women, then depressive symptoms are more likely to appear. Self-reported depression was more common in subfertile women (n = 1,031), with endome‐ triosis (O.R. 5.43, C.I. 4.01-7.36) compared with fertile women (n = 4,905) [21].
