Endometriosis and Mental Health: Disentangling Pain and Inflammation

Mental Health Risks in Endometriosis Arise From Both Symptoms and Underlying Biology

Key Points

Highlights:

• Endometriosis appears to affect mental health through both chronic pain and underlying inflammatory disease mechanisms, emphasizing the need to view it as a complex systemic condition.

Importance:

• Individuals experiencing pelvic pain without a confirmed diagnosis of endometriosis may be at particularly high risk for depression and anxiety, underscoring the psychological burden of diagnostic uncertainty.

What’s done here?

• A population-based retrospective cohort study from Vancouver identified 3,640 pathology-confirmed cases of endometriosis and linked them to administrative health records to evaluate coincident depression and/or anxiety.
• Three groups were compared: symptomatic endometriosis, pelvic pain without endometriosis, and asymptomatic endometriosis.
• Mental health outcomes were assessed using diagnostic codes for depression/anxiety and antidepressant prescription data.

Key results:

• Patients with pelvic pain but no pathologic evidence of endometriosis (Symp No Endo) had a 23% higher risk of depression/anxiety compared with those with symptomatic, pathology-confirmed endometriosis.
• Mental health risks were similar between symptomatic and asymptomatic endometriosis, suggesting that the disease itself may confer psychological vulnerability independent of pain.
• In sensitivity analyses, individuals with infertility but no pain had a 26% lower risk of depression/anxiety than the symptomatic group, reinforcing the central role of pain in mental health outcomes.

Strengths and Limitations:

• Inclusion of a pathologically confirmed cohort and the rare ability to study asymptomatic endometriosis, providing clearer insight into disease-specific versus symptom-driven mental health risks are the strengths of the study.
• However, .reliance on combined diagnostic codes for depression and anxiety, absence of a healthy control group, and lack of direct patient-reported pain measures.

From the Editor-in-Chief – EndoNews

"Understanding the mental health burden of endometriosis requires moving beyond the traditional assumption that depression and anxiety are simply downstream consequences of chronic pelvic pain. This population-based study provides important nuance by showing that mental health risk is shaped by two distinct but interacting mechanisms: the experience of unresolved pain and the systemic biology of endometriosis itself.

One of the most compelling findings is that individuals who experience pelvic pain without pathological evidence of endometriosis have the highest risk of depression and anxiety. This underscores the profound psychological impact of unrelieved, unexplained pain—an experience that often carries diagnostic uncertainty, delayed validation, and substantial functional impairment. The result is an underappreciated form of distress that warrants dedicated clinical attention.

Equally significant is the observation that patients with endometriosis show similar mental health risk regardless of whether they report pain. This finding supports a growing body of literature suggesting that endometriosis behaves as a systemic inflammatory and neuroendocrine condition, with effects that extend beyond the pelvis. The biological processes that drive lesion formation—immune dysregulation, cytokine signaling, oxidative stress, and altered hormonal environments—are the same pathways implicated in mood and anxiety disorders. The data therefore reinforce that mental health challenges in endometriosis are not merely psychological reactions to symptoms but may reflect disease-mediated physiologic mechanisms.

Methodologically, the study benefits from a rare, pathology-confirmed cohort and the inclusion of an asymptomatic group—allowing clearer separation of pain-driven versus disease-driven effects. These design strengths position the findings as an important contribution to a field historically limited by small samples and unverified diagnoses. Yet the inherent limitations of administrative data—particularly combined diagnostic codes for depression and anxiety and the absence of patient-reported pain metrics—highlight the need for future work with more granular phenotyping.

Clinically, the implications are profound. Pain management remains essential, but this study signals that focusing solely on pain risks missing a substantial component of disease burden. Mental health support should be considered a core element of endometriosis care, not an optional adjunct, and should be extended even to patients who do not present with severe pain. Screening for depression and anxiety across the full spectrum of disease presentations may enable earlier intervention, reduce morbidity, and improve overall quality of life.

Ultimately, this research advances a more integrated understanding of endometriosis—one that acknowledges its systemic biology, its neuroimmune effects, and its complex psychosocial dimensions. Such a framework is crucial for developing comprehensive, mechanistically informed strategies that address both the physical and emotional consequences of this chronic disease."

Lay Summary

Endometriosis is increasingly recognized as a condition that affects the body far beyond the pelvis, influencing immune function, inflammation, and even emotional wellbeing. Many patients experience symptoms such as chronic pelvic pain, fatigue, and hormonal changes, but the relationship between endometriosis and mental health has remained a subject of debate. Are depression and anxiety primarily a consequence of severe, unrelenting pain, or does the disease itself—through its systemic inflammatory effects—contribute to emotional distress?

To explore this question, Goodwin et al., a research team from Canada, conducted a large population-based retrospective study published in BMC Women’s Health. Using pathology-confirmed records from Vancouver, the investigators examined 3,640 individuals with endometriosis and compared three groups: those with symptomatic endometriosis, those with pelvic pain but no endometriosis, and those with endometriosis who reported no pain.

The findings were revealing. Individuals who had pelvic pain without a confirmed diagnosis of endometriosis faced the highest risk of depression or anxiety, suggesting that unexplained and unresolved pain carries a unique psychological burden. At the same time, people with endometriosis showed similar mental health risks whether they were symptomatic or asymptomatic, indicating that the disease may influence mental health through systemic biological mechanisms, independent of pain.

These insights reinforce the understanding that endometriosis is not merely a gynecologic disorder but a whole-body condition. Effective care should therefore include not only pain management but also proactive mental-health assessment and support—even for patients who do not report severe pain.

As the authors conclude, “Future work should aim to better understand each of these mechanisms independently and in combination, in order to optimize treatment options for patients.”

Research Source: https://pubmed.ncbi.nlm.nih.gov/41063111/