Endometriosis is an inflammatory disease that occurs outside the uterus with endometrium-like tissue, which is estrogen-dependent and chronic.[1] It is mainly seen in women of reproductive age, and it is a significant burden on gynecologic and public health issues.[2] The World Health Organization (WHO) estimates that approximately 10% of women of reproductive age, equivalent to nearly 190 million women worldwide, are affected by endometriosis.[3] This disorder can be accompanied by dysmenorrhea, chronic pelvic pain, menstrual bleeding, dyspareunia, fatigue, gastrointestinal or urinary symptoms, and infertility.[4] However, diagnosis is often delayed, and access to proper care and management by relevant specialists is low, especially in low- and middle-income countries.[5]

Endometriosis affects not only the physical features, but also has a significant impact on women's health-related quality of life (HRQoL).[6] Recurrent pelvic pain, dysmenorrhea, fatigue, infertility, and painful sexual intercourse can impact daily functioning, work, social and interpersonal interactions, and participation.[7] Additionally, chronic and unpredictable symptoms can lead to psychological distress, anxiety, depression, decreased self-esteem, and feelings of loss of control.[8] The overall impact of endometriosis on physical, psychological, sexual, social and economic health can significantly affect well-being, WHO points out.[9]

Comparative and longitudinal studies show that women suffering from endometriosis have worse HRQoL than women without endometriosis.[10] A large national prospective cohort study of 3,728 women found that women with endometriosis had significantly poorer physical functioning, role functioning, bodily pain, general health, vitality, social functioning, emotional well-being, and mental health. The largest relative degree of impairment was in the domain of bodily pain, indicating that pain is a significant factor in the burden of the disease.[6] Likewise, according to a comparative study conducted with the Endometriosis Health Profile-30 (EHP-30), women suffering from endometriosis have significantly lower scores in quality of life than women who are not affected by the condition, showing that the effects of endometriosis are not only on gynecological symptoms.[11]

Assessment of HRQoL is thus increasingly recognised as a fundamental part of care of women with endometriosis.[12]  The EHP-30 is reliable and valid, and modern psychometric evidence is in favor of its original 5 domains that measure HRQoL specific to disease.[13] A systematic review also revealed the widespread application of EHP methods in endometriosis research, such as medical and surgical interventions, and observational disease burden assessment.[14]

It is now widely known that the impact of endometriosis on HRQoL is significant, but it is important to compare women with and without endometriosis directly to determine the size of the burden endometriosis places on women's lives. Furthermore, much of the evidence available has been on women with endometriosis or the effects of treatment, and far fewer studies have compared the overall change in HRQoL between women with and without endometriosis within the same groups. This comparison is especially relevant in the context of chronic pelvic pain and menstruation symptoms being normalised, which can result in a delay in diagnosis and reduce their impact on women's lives.

The current study was thus carried out to compare HRQoL between women with and without endometriosis, to gain a more accurate understanding of the multi-dimensional burden of endometriosis. The results could contribute to better patient-centered assessment, raise awareness of the wider impact of endometriosis earlier, and inform interventions to manage symptoms, but also to improve women's physical, psychological, and social health. The aim of this study was to compare health-related quality of life between women with endometriosis and women without endometriosis.

A comparative cross-sectional study was conducted in the Department of Obstetrics and Gynecology of Lady Reading Hospital, Peshawar, over a period of six months, from 1st January 2025 to 30th June 2025. OpenEpi version 3.01 was used to determine the sample size. The calculation was done based on the results of a prospective comparative study done by Poordast et al that used the Endometriosis Health Profile-30 (EHP-30) to measure the quality of life in women with endometriosis compared to healthy women.[11] In that study, we used a minimum mean difference of 5 points on the quality-of-life scores, a type-I error of 5%, a statistical power of 80%, and an expected response rate of 85%, which led to a sample size of about 113 patients per group.[11] Therefore, 226 participants were needed for the present study, including 113 women with endometriosis and 102 women without endometriosis. Non-probability consecutive sampling was used. All women who met the set criteria were approached consecutively and included in the study until the samples were full. The endometriosis group consisted of women with a clinical and/or documented diagnosis of endometriosis, and the comparison group consisted of women without a clinical or documented diagnosis of endometriosis. The recruitment of both groups from a single hospital population helped to reduce variation due to access to health services and demographic factors. Women aged 18–45 years were included in the study. Women with endometriosis included in the endometriosis group had a diagnosis of endometriosis confirmed by clinical, radiological, and/or histopathological evidence. Women without endometriosis were included in the comparison group if they had no previous diagnosis or clinical evidence suggestive of endometriosis. The participants had to be familiar with the study questionnaire and sign a written informed consent. Women who had previously had a malignancy, severe chronic systemic disease, severe psychiatric illness, cognitive impairment, or other factors that would significantly affect quality of life apart from endometriosis were excluded. Women who were pregnant when assessed, women who had had major gynecological surgery recently, and women with incomplete questionnaires were also excluded. Women who refused participation or withdrew at any point did not qualify for the final analysis. Demographic and clinical data were obtained after obtaining informed consent with a structured questionnaire. Information obtained consisted of age, marital status, educational level, occupation, body mass index, parity, socioeconomic status, menstrual characteristics, length of symptoms, status of infertility, and clinical history. Clinical records were also used to obtain information for women with endometriosis about duration of disease, presenting symptoms, the severity of pelvic pain, and documented characteristics of the disease. The Endometriosis Health Profile-30 (EHP-30) was used to assess health-related quality of life and was validated.[15] EHP-30 is a disease-specific instrument designed to assess the multidimensional effect of endometriosis on women's quality of life and contains the core domains of pain, control and powerlessness, emotional well-being, social support and self-image. It is divided into modules for evaluating other aspects, like work life, relationships, sexual intercourse, interactions with medical personnel, treatment, and infertility. The questionnaire was administered in the same way in a private environment, and the participants were asked to answer all questions based on their experiences over the indicated recall period. In participants with endometriosis, clinical information was obtained from medical records when available. The pain intensity was measured by a numerical or visual analogue pain scale, based on the question in the study questionnaire. All information collected was coded with a study ID number for confidentiality. Completed questionnaires were checked for completeness before data entry. The data collected were entered and analyzed with the help of IBM SPSS Statistics 26 software. Continuous variables were tested for normality by the Shapiro–Wilk test and were expressed as mean ± standard deviation (SD) or median (interquartile range). Categorical data were summarized by frequencies and percentages. Normally-distributed continuous variables between women with and without endometriosis were compared using the independent-samples t test, while non-normally-distributed continuous variables were compared using the Mann–Whitney U test. The chi-square test was used to compare categorical variables between the two groups. The mean EHP-30 domain scores and overall quality-of-life measures were compared between women with endometriosis and women without endometriosis. Demographic or clinical factors were correlated with HRQoL scores by Pearson or Spearman correlation, depending on the distribution of the data. Multiple linear regression was used to adjust for potential confounders and identify independent factors associated with lower HRQoL. A p-value <0.05 was regarded as statistically significant, and 95% confidence intervals were calculated.

A total of 226 women were included, comprising 113 women with endometriosis and 113 women without endometriosis. Women with endometriosis were significantly older than controls, had a more frequent history of infertility, and differences in marital status and occupation, whereas BMI, education, and socioeconomic status were comparable (Table 1).

Compared to women without endometriosis, women with endometriosis experienced significantly greater rates of irregular menstruation, heavy menstrual bleeding, dysmenorrhea, dyspareunia, chronic pelvic pain, and fatigue. Their median symptom duration and mean pain score were also significantly higher than for women who did not have endometriosis (Table 2).

Women with endometriosis had a significantly lower HRQoL for all five of the core EHP-30 domains. The most impaired domain was pain, followed by control/powerlessness and emotional well-being. The overall EHP-30 score was also significantly elevated for the endometriosis group, reflecting significantly lower QOL with endometriosis (Table 3).

The most impaired domains of the EHP-30 were the women with endometriosis in the domain of infertility, sexual intercourse, and work life. These results indicated that the effect of endometriosis did not stop at physical pain but also affected reproductive aspects, work and interpersonal relationships, as well as the healthcare aspects of everyday life (Table 4).

With correlation analysis, higher EHP-30 scores were significantly correlated with higher severity of pain, longer symptom duration, chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. Age and educational level showed weak inverse correlations with HRQoL scores, whereas BMI was not significantly associated with overall HRQoL (Table 5).

In multivariable linear regression, pain severity, symptom duration, chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility continued to be independent predictors of poorer HRQoL. Higher educational attainment was independently associated with better HRQoL, while BMI and socioeconomic status were not significant predictors. As for the regression model, the overall EHP-30 scores accounted for 58% of the variability (Table 6).

Table 1. Comparison of demographic characteristics between women with and without endometriosis

Table 2. Menstrual and clinical characteristics of study participants

Table 3. Comparison of EHP-30 core quality-of-life domains between study groups

Table 4. EHP-30 modular domains among women with endometriosis

Table 5. Correlation of demographic and clinical factors with EHP-30 overall score among women with endometriosis

Table 6. Multiple linear regression analysis of factors independently associated with poorer HRQoL

The current study showed that women with endometriosis had significantly lower HRQoL than women without endometriosis. Endometriosis patients reported significantly higher EHP-30 scores and scores for all five EHP-30 domains (pain, control and powerlessness, emotional well-being, social support and self-image). These results were consistent with the multidimensionality of the morbidity associated with endometriosis and suggested that the disease impacts not just physical, but psychological, interpersonal, and social functioning. The results obtained were similar to those of Poordast et al. (2022), who prospectively compared women with endometriosis, infertile women, and healthy women with the EHP-30. They found a significant difference between women with endometriosis and infertile women, compared to healthy women, in the quality of life and its associated factors (p<0.001). Their finding of an inverse association between age and EHP-30 is similar to the present results, as is the inverse association between education and EHP-30.[11] Tiringer et al. (2022) found a marked impairment in the pain domain, which was also confirmed in our study. The authors analyzed the results of a retrospective study conducted in 115 women who had surgery to confirm the diagnosis of endometriosis; all 5 EHP-30 domains showed significant improvements after surgery, especially domains related to pain, emotional health, social environment, and self-image. Their results confirm the importance of pain in the overall assessment of HRQoL and showed that women with higher pain scores had significantly poorer HRQoL, as we had observed.[16] Additionally, the validity of our use of the EHP-30 was supported by Ramin-Wright et al. (2022) when they conducted an evaluation of the psychometric properties of the instrument, which confirmed its five-domain structure, reliability, and appropriateness for measuring the specific impact of endometriosis on HRQoL. Their results support the understanding of our significantly higher EHP-30 scores as clinical impairment instead of just differences in generic health status.[17] In a similar study, Darici et al. (2023) translated and validated the Turkish version of the EHP-30, and statistically significant differences were found between women with endometriosis and healthy women on all subscales. The high test-retest reliability and agreement with EQ-5D-3L also illustrated the capacity of EHP-30 to measure impairment in quality of life due to the disease. This is very similar to our results, which showed that females with endometriosis achieved significantly lower scores in all five core domains.[18] In our study, the relationship between clinical symptoms and lower HRQoL was more apparent for pain, dysmenorrhea, chronic pelvic pain, dyspareunia, and duration of symptoms. This was very similar to the findings of Pontoppidan et al. (2023), who assessed 476 women with endometriosis and reported an overall low quality of life with a mean score of 45.9 on the EHP-30. They found that mental health issues, opioid use, increased primary-care visits before specialist referral, younger age of symptom onset, and decreased patient-centeredness were independent factors that explained decreased quality of life in their multivariable analysis. Their findings highlight the importance of the combined impact of symptoms, psychological aspects, and health care experiences on the burden of endometriosis, rather than the impact of its diagnosis.[19] The correlation between HRQoL and infertility was also similar to that of Poordast et al. (2022), who concluded that there was a strong association between HRQoL and infertility with the lowest scores being obtained in the infertile group. In our study, the overall EHP-30 score was significantly correlated with infertility, and this remained an independent predictor of HRQoL in the multivariable analysis. This could be due to the combined psychological, reproductive, interpersonal, and social impacts of the problem of conception among women who are already suffering from chronic pain and menstrual symptoms.[11] The significant deficit seen in the sexual intercourse and infertility domains in our study was corroborated by Sassanie et al. (2024), who found that patients with moderate-to-severe endometriosis-associated pain had evidence of significant deficits in sexual intercourse and infertility. Their analysis revealed that clinically significant decreases in dyspareunia were associated with substantial improvements in all EHP-30 domains (pain, emotional well-being, social support, self-image, control and powerlessness, sexual intercourse). This confirms our results showing that dyspareunia was an independent factor of the lower HRQoL.[20] Our results also corroborated those of Guo et al. (2025) who assessed women with endometriosis before and after laparoscopic surgery using EHP-30. Overall EHP-30 scores were significantly lower, and improvement was observed after surgery in domains of pain, emotional well-being, social support, self-image, work life, sexual intercourse, and infertility-related domains. Their findings confirm that there are broad improvements in multiple dimensions of quality of life that can follow the improvements in pain and disease-related symptoms, indicating the clinical relevance of the impairments we identified in our study.[21] A pilot study in 2024 in Pakistan found that women suffering from endometriosis also experienced significant impairment in their quality of life, conducted at Peoples Medical College Hospital, Nawabshah. Severe pelvic pain was recorded in 58.3% of the respondents, and significant pain, emotional distress, and social dysfunction were reported significantly, and advanced disease was strongly associated by the respondents with the inference of infertility. The results of these investigations are important for the present study as both studies were carried out in Pakistan's health care setting, and it is clear that endometriosis has a significant reproductive and psychosocial burden on Pakistani women.[22] The association between HRQoL and psychological and interpersonal factors was also seen in a 2024 BMC Women's Health study on 627 women with endometriosis. The study looked at HRQoL in combination with psychological well-being and HRQoL associated with the experience of infertility and relationship quality, highlighting the close relationship between HRQoL of people with endometriosis and psychological and reproductive experiences. This is consistent with our finding that emotional state, social support, self-image, sexual intercourse, and infertility were among the key contributors to the overall disease burden.[23] Recent data from 2026 further underscores the crucial role of health education and psychosocial support. In a cross-sectional study of 203 women with endometriosis, the mean EHP-30 score was 49.3 ± 17.9, with higher scores being significantly correlated with higher scores on the self-image and social-life subscales. Our findings are in line with these studies, which indicate that treatment for endometriosis needs to focus on more than just drugs or surgery; it should also involve patient education and strategies for enhancing the psychological and social health of the patient.[24] Overall, the results were largely comparable with the current international and Pakistani evidence. Endometriosis was consistently linked to reduced quality of life, including pain, emotional, social, sexual and fertility problems across various populations and study designs. The current results support a patient-centered, multi-disciplinary approach that should include patient-reported HRQoL as a treatment target in addition to symptom control and fertility preservation. Limitations There were several limitations in the study. The cross-sectional design did not allow for assessing temporal and causal relationships between symptoms of endometriosis and quality of life. The findings of this study may be limited to the particular hospital, as non-probability consecutive sampling was used to select study participants. Assessments of HRQoL and symptom severity were self-reported, potentially affecting the recall or response bias. The disease status, treatment history, and length of endometriosis may have also affected the quality-of-life scores. In addition, there were no standardized instruments used to measure potentially important psychosocial factors such as anxiety, depression, and relationship-related stressors.

Health-related quality of life was significantly lower among women with endometriosis than women without endometriosis and was impaired in pain, emotional well-being, social support, self-image and perceived control. Poorer quality of life was independently associated with greater pain severity, longer symptom duration, chronic pelvic pain, dysmenorrhea, dyspareunia, or infertility. The results of this study demonstrate the need for a holistic and patient-focused approach to the management of endometriosis, spanning beyond the physical realm and incorporating psychological, sexual, reproductive, and social dimensions.

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