Beyond Pain Relief: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30

Technical Summary: Impact of Therapeutic Strategies on Health-Related Quality of Life in Endometriosis Using the EHP-30

Problem Statement
Endometriosis is a chronic, inflammatory, and estrogen-dependent condition affecting approximately 10% of reproductive-age women and up to 50% of infertile patients. Despite its high prevalence, the disease is characterized by significant diagnostic delays (estimated at 5–10 years) and a frequent dissociation between anatomical lesions and symptomatology. While traditional management focuses on pain relief and anatomical correction, endometriosis profoundly impacts health-related quality of life (HRQoL) across physical, psychological, social, professional, and sexual domains. Current therapeutic strategies—ranging from hormonal suppression to surgical excision—lack a comprehensive evaluation of their multidimensional impact on patient well-being. There is a critical need to move beyond isolated symptomatic criteria to assess treatment efficacy using standardized, patient-reported outcomes (PROs).

Methodology
The study employed a monocentric, analytical cross-sectional design conducted at the Department of Gynecology and Obstetrics, Farhat Hached University Hospital (Sousse, Tunisia), over a 53-month period (January 2020 – May 2024).

• Population: The final cohort consisted of 80 women aged 18–50 with symptomatic pelvic endometriosis confirmed by clinical, imaging, and/or histological findings. Patients with adenomyosis, other causes of infertility, or incomplete data were excluded.
• Data Collection: Sociodemographic data, clinical presentation, disease phenotype, and therapeutic strategies (medical, surgical, or combined) were collected. Data was gathered via outpatient consultations, hospitalizations, and telephone interviews (with up to three attempts per patient).
• Primary Instrument: HRQoL was assessed using the Endometriosis Health Profile-30 (EHP-30), a validated, disease-specific tool comprising a 30-item core questionnaire (covering pain, control/helplessness, emotional well-being, social support, and self-image) and a 23-item modular section (addressing sexuality, fertility, healthcare relationship, and work).
• Statistical Analysis: Data were analyzed using IBM SPSS Statistics v29. A significance threshold of p ≤ 0.05 was applied. The study utilized the French version of the EHP-30 administered via oral translation due to the lack of a validated Arabic version at the time of the study.

Key Contributions and Results
The study evaluated the impact of different therapeutic modalities on HRQoL, revealing the following key findings:

1. Overall HRQoL Status: The cohort exhibited a median global EHP-30 score of 29.7 [20–49.8], indicating moderate impairment. The most significantly affected dimensions were sexual function and treatment perception.
2. Impact of Surgical Management: Surgical intervention, particularly complete excision and laparoscopic adnexectomy, was associated with the most significant improvement in overall HRQoL. While 95% of patients underwent surgery, only 37.5% achieved complete excision in the first line. Drainage techniques were associated with less favorable outcomes compared to excision.
3. Impact of Medical Management: Medical treatment, specifically progestins (e.g., dienogest), showed overall improvement in HRQoL, with a marked benefit specifically in the domain of sexual function. However, medical therapy alone did not yield the same magnitude of global improvement as surgical excision.
4. Combined Strategies: Multimodal approaches, particularly in second-line management, resulted in significant improvements in pain, emotional well-being, and social support, suggesting that combining strategies optimizes specific HRQoL domains.
5. Patient-Related Factors:
   • Infertility: Infertility was identified as a major negative factor, significantly impairing HRQoL across all assessed domains.
   • Marital Status: Single patients exhibited more impaired scores compared to married patients.
   • Socioeconomic/Educational Level: Higher socioeconomic and educational levels correlated with better HRQoL, likely due to improved healthcare access and treatment adherence.
6. Recurrence: Despite management, recurrence was frequent (25% for pain, 20% for anatomical recurrence), with a median time to recurrence of 21 months.

Significance and Claims
The authors assert that their findings support a multidimensional and individualized approach to endometriosis management. The study claims that:

• Surgical superiority: Surgical management, specifically complete excision, provides the greatest improvement in global HRQoL, though it must be balanced against morbidity and recurrence risks.
• Role of PROs: The systematic integration of patient-reported outcomes, specifically via tools like the EHP-30, is essential for optimizing patient-centered care and evaluating the real-world effectiveness of treatments beyond simple pain scores.
• Multimodal Necessity: While surgery offers the most robust global improvement, combined medical and surgical strategies are valuable for targeting specific domains (e.g., emotional well-being, social support) and managing recurrent disease.

Limitations
The paper explicitly notes several limitations that temper the generalizability of its claims:

• Design: The monocentric, cross-sectional nature of the study limits causal inference and the ability to track longitudinal changes.
• Sample Size: The relatively small sample size (n=80) restricts the statistical power and external validity.
• Measurement Bias: The use of a non-validated Arabic version of the EHP-30 (administered via oral translation) and telephone-based data collection may have introduced information and interpretation biases.
• Recall Bias: Some data were collected retrospectively.

The authors conclude that while their results highlight the efficacy of surgical excision and the value of combined strategies, further multicenter, prospective studies with validated local tools are necessary to confirm these findings and refine therapeutic algorithms in the Tunisian context.