Cognitive Behavioral Therapy in Endometriosis, Psychological Based Intervention: A Systematic Review

Donatti, Lilian; Malvezzi, Helena; Azevedo, Bruna Cestari de; Baracat, Edmund Chada; Podgaec, Sergio

doi:10.1055/s-0042-1742406

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Revista Brasileira de Ginecologia e Obstetrícia

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Review Article • Rev. Bras. Ginecol. Obstet. 44 (3) • Mar 2022 • https://doi.org/10.1055/s-0042-1742406 copy

Cognitive Behavioral Therapy in Endometriosis, Psychological Based Intervention: A Systematic Review

Intervenção psicológica baseada na terapia cognitivocomportamental na endometriose: Uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Endometriosis is an inflammatory disease that affects women of reproductive age, causing pain and the possibility of infertility. Endometriosis was associated to low life quality and research shows the impact of endometriosis in several areas of life, justifying how these patients are more likely to develop depression, anxiety, and stress.

Objective

The aim of the present systematic review was to explore the field of psychology in endometriosis, identifying studies that used the cognitive behavioral therapy technique as a treatment for endometriosis and chronic pelvic pain.

Methods

The keywords used were Endometriosis and Behavioral Therapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy; Mental Health; Psychological Techniques; Psychology; Psychotherapy; Mental Health Services; and the search was performed in the following databases: PubMed/Medline, Scielo, Lilacs, and Capes. The study followed the PRISMA guidelines and all studies whose intervention strategy used was related to cognitive-behavioral therapy were considered.

Results

Of the 129 articles found, only 5 were selected, and it was possible to identify that the psychological intervention whose approach brought cognitive-behavioral therapy techniques promoted a decrease in the sensation of pain, improvements in the scores of depression and stress, and significant changes in aspects of quality of life such as vitality, physical and social functioning, emotional well-being, control, and autonomy.

Conclusion

Cognitive-behavioral therapy can be very promising to take care of the emotional side of those who have endometriosis However, the present systematic review highlights the need to develop more structured studies with consistent, clear and replicablemethods to reach a psychological intervention protocol for patients who live with this gynecological-physical-emotional condition.

Keywords:
endometriosis; cognitive behavioral therapy; psychological intervention; chronic pelvic pain; quality of life; systematic reviews

Scientific databases	Search period	Search terms
PubMed/MedlineScieloLilacsCapes	June 20, 2019, until July 30, 2020	EndometriosisBehaviorTherapyBehavioralDisciplinesandActivitiesCognitiveBehavioralTherapyMentalHealthPsychologicalTechniquesPsychology, PsychotherapyMental Health Services

Source	N treatment	N control	Age (years old)	Study Design	Inclusion criteria	Exclusion criteria	Instrument used	Other intervention strategy applied in addition to psychology	Intervention period and organization	JOURNAL	Limitation
Lorençatto et al. (2007)⁹9 Lorençatto C, Vieira MJ, Marques A, Benetti-Pinto CL, Petta CA. Avaliação de dor e depressão em mulheres com endometriose após intervenção multiprofissional em grupo. Rev Assoc Med Bras (1992). 2007;53(05):433-438. Doi: 10.1590/S0104-42302007000500020 https://doi.org/10.1590/S0104-4230200700... Brazil	64	64	median 34,7	Randomized clinical trial	Surgical diagnosis of endometriosis, symptons of chronic pelvic pain at the beginning of the group evaluation, having participated in at least seven meetings, having completely completed the clinical and psychological assessments and having completed the daily pain record	Those who had already participated in other psicological intervation	Sociodemographic questionnaire, clinical condition of endometriosis and pain symptom; Beck Depression Inventory (BDI); Visual Analogue Scale (VAS); daily pain record	1 hour of physiotherapy before psychology sessions	10 sessions in groups of 12 patients	Rev Assoc Med Bras	No protocol application specification session by session
Meissner et al. (2016)¹⁶16 Meissner K, Schweizer-Arau A, Limmer A, Preibisch C, Popovici RM, Lange I, et al. Psychotherapy with somatosensory stimulation for endometriosis-associated pain. Obstet Gynecol. 2016;128 (05):1134-1142. Doi: 10.1097/AOG.0000000000001691 https://doi.org/10.1097/AOG.000000000000... Germany	35	32	18 to 40	Randomized clinical trial	Adult women aged between 18 and 40 years old with a history of histologically verified endometriosis and chronic pelvic pain	Hormonal treatment during the month prior to enrollment, use of drugs or alcohol, pregnancy, insufficient knowledge of the German language and contraindications for MRI (as a result of the primary outcome)	Magnetic resonance imaging; numerical scale from “0” (“without pain”) to “10” (“worst possible pain”); quality of life (scores of the physical and psychological sum of the German version 12 Item: Short-Form Health Survey); functional well-being, depression, and anxiety and measurement for acute pain	Hypnotherapy and acupuncture	Individual sessions of 30 to 60 minutes. 3 months application and follow-up after 6 and 24 months	Obstetrics & gynecology	No protocol application specification session by session
Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69... Denmark	10	0	14 to 37	Qualitative study. Prospective, observational, pilot study	Endometriosis diagnosis and severe pain	not mentioned	SF36 and EHP-30	No	10 sessions (5 in group and 5 individually: total of 15 hours) and 6 and 12 months of follow-up	Nordic psychology	No control group
Hansen et al. (2016)¹⁸18 Hansen KE, Kesmodel US, Kold M, Forman A. Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: a six-year follow-up on a pilot study. Nordic Psychol. 2017;69(02):100-109. Doi: 10.1080/19012276.2016.1181562 https://doi.org/10.1080/19012276.2016.11... Denamark	10	0		Longitudinal study	Patients who had participated in the 2012 intervention and had committed themselves to applying the techniques at home in their daily lives	Patients who failed to commit to practicing mental techniques at home	EHP-30 and SF-36	No	10 weeks, follow-up up after 6 years	Nordic psychology	No control group
Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72... Brazil	26	0	median 32,2	Observational, prospective	Endometriosis diagnosis by visual identification during laparoscopy or laparotomy plus biopsy; and with chronic pelvic pain	Patients who abandoned treatment for some reason or who did not have a frequency of at least 75% during sessions	Visual Analog Pain Scale (VAS), Perceived Stress Questionnaire (PSQ), SF36, Cortisol levels in saliva.	During the 1st hour: physical therapy, lumbar repositioning, body awareness, breathing exercises (focusing on rhythm, frequency, depth, volume of air inhalation and respiratory rehabilitation),stretching, exercises aiming the pelvic region, perineal muscle strengthtening, massage, self-massage, transcutaneous electrical nerve stimulation, relaxation and instructions related to activities of daily life	10 sessions, once a week (2h30m)	Journal of Psychosomatic Obstetrics & Gynecology	No control group

Results	CBT techniques	Source
Decreased pain scores	Cognitive and behavioral techniques/psychoeducation	Lorençatto et al. (2007)⁹9 Lorençatto C, Vieira MJ, Marques A, Benetti-Pinto CL, Petta CA. Avaliação de dor e depressão em mulheres com endometriose após intervenção multiprofissional em grupo. Rev Assoc Med Bras (1992). 2007;53(05):433-438. Doi: 10.1590/S0104-42302007000500020 https://doi.org/10.1590/S0104-4230200700...
	Mindfulness/coping/psychoeducation	Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69...
	Mindfulness/coping/cognitive and behavioral techniques	Meissner et al. (2016)¹⁶16 Meissner K, Schweizer-Arau A, Limmer A, Preibisch C, Popovici RM, Lange I, et al. Psychotherapy with somatosensory stimulation for endometriosis-associated pain. Obstet Gynecol. 2016;128 (05):1134-1142. Doi: 10.1097/AOG.0000000000001691 https://doi.org/10.1097/AOG.000000000000...
Decreased depression score	Cognitive and behavioral techniques/psychoeducation	Lorençatto et al. (2007)⁹9 Lorençatto C, Vieira MJ, Marques A, Benetti-Pinto CL, Petta CA. Avaliação de dor e depressão em mulheres com endometriose após intervenção multiprofissional em grupo. Rev Assoc Med Bras (1992). 2007;53(05):433-438. Doi: 10.1590/S0104-42302007000500020 https://doi.org/10.1590/S0104-4230200700...
Reduction in the perception of stress	Psychoeducation/coping	Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...
Normalization of cortisol levels	Psychoeducation/coping	Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...
Increased vitality in everyday life	Psychoeducation/coping	Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...
Increased day-to-day functionality	Psychoeducation/coping	Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...
Increased day-to-day functionality	Mindfulness/psychoeducation	Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69...
Increased sense of well-being	Mindfulness/coping/psychoeducation	Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69...
Improvement in quality of life	Mindfulness	Hansen et al. (2016)¹⁸18 Hansen KE, Kesmodel US, Kold M, Forman A. Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: a six-year follow-up on a pilot study. Nordic Psychol. 2017;69(02):100-109. Doi: 10.1080/19012276.2016.1181562 https://doi.org/10.1080/19012276.2016.11...
Improvement in quality of life	Mindfulness/coping/cognitive and behavioral techniques	Meissner et al. (2016)¹⁶16 Meissner K, Schweizer-Arau A, Limmer A, Preibisch C, Popovici RM, Lange I, et al. Psychotherapy with somatosensory stimulation for endometriosis-associated pain. Obstet Gynecol. 2016;128 (05):1134-1142. Doi: 10.1097/AOG.0000000000001691 https://doi.org/10.1097/AOG.000000000000...

Source	What improved
	Depression	Stress	Pain
	Depression	Stress	Pelvic pain	Dyschezia
Lorençatto et al. (2007)⁹9 Lorençatto C, Vieira MJ, Marques A, Benetti-Pinto CL, Petta CA. Avaliação de dor e depressão em mulheres com endometriose após intervenção multiprofissional em grupo. Rev Assoc Med Bras (1992). 2007;53(05):433-438. Doi: 10.1590/S0104-42302007000500020 https://doi.org/10.1590/S0104-4230200700...	22.8 ± 10.2 versus 17.0 ± 10.2 (p < 0.0001).	X	4.2 ± 3.3 versus 6.6 ± 2.4 (p = 0.0002) general	X
Meissner et al. (2016)¹⁶16 Meissner K, Schweizer-Arau A, Limmer A, Preibisch C, Popovici RM, Lange I, et al. Psychotherapy with somatosensory stimulation for endometriosis-associated pain. Obstet Gynecol. 2016;128 (05):1134-1142. Doi: 10.1097/AOG.0000000000001691 https://doi.org/10.1097/AOG.000000000000...	X	X	(-1.4. 95%CI: 2.7–- 0.1; p = 0.036) pelvic	(-3 .5. 95% CI: - 5.8–-1.3; p =.003)
Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69...	X	X	52.53 ± 12.52 versus 33.18 ± 15.46; p > 0.005	X
Hansen et al. (2016)¹⁸18 Hansen KE, Kesmodel US, Kold M, Forman A. Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: a six-year follow-up on a pilot study. Nordic Psychol. 2017;69(02):100-109. Doi: 10.1080/19012276.2016.1181562 https://doi.org/10.1080/19012276.2016.11...	X	X	- 10.83 versus - 18.1; p = 0.583	X
Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...	X	Acknowledge stress: 0.62 ± 0.02 versus 0.56 ± 0.02; p < 0.05	X	X

Source	What improved
Source	Vitality	Physical functioning domains	Control and incapacity	Emotional well-being	Social support	Corporal pain	Physical and emotional role
Lorençatto et al. (2007)⁹9 Lorençatto C, Vieira MJ, Marques A, Benetti-Pinto CL, Petta CA. Avaliação de dor e depressão em mulheres com endometriose após intervenção multiprofissional em grupo. Rev Assoc Med Bras (1992). 2007;53(05):433-438. Doi: 10.1590/S0104-42302007000500020 https://doi.org/10.1590/S0104-4230200700...	X	X	X	X	X	X	X
Meissner et al. (2016)¹⁶16 Meissner K, Schweizer-Arau A, Limmer A, Preibisch C, Popovici RM, Lange I, et al. Psychotherapy with somatosensory stimulation for endometriosis-associated pain. Obstet Gynecol. 2016;128 (05):1134-1142. Doi: 10.1097/AOG.0000000000001691 https://doi.org/10.1097/AOG.000000000000...	X	3.8; 95%CI: 0.5–7.1; p = 0.026	X	5.9, 95%CI: 0.6–11.3; p = 0.031	X	- 2.5; 95%CI: - 3.5– -1.4; p < .001	X
Kold et al. (2012)¹⁷17 Kold M, Hansen T, Vedsted-Hansen H, Forman A. Mindfulness-based psychological intervention for coping with pain in endometriosis. Nordic Psychol. 2012;64(01):2-16. Doi: 10.1080/19012276.2012.693727 https://doi.org/10.1080/19012276.2012.69...	X	69.34 ± 14.62 versus 77.00 ± 18.14; p > 0.05	65.28 ± 18.98 versus 37.50 ± 10.58; p > 0.005	52.08 ± 16.23 versus 34.17 ± 15.06; p > 0.008	52.50 ± 25.89 versus 31.25 ± 15.59; p>0.005	23.00 ± 27.51 versus 61.00 ± 8.76; p > 0002;	23.33 ± 35.31 versus 76.67 ± 35.31; p > 0.05;
Hansen et al. (2016)¹⁸18 Hansen KE, Kesmodel US, Kold M, Forman A. Long-term effects of mindfulness-based psychological intervention for coping with pain in endometriosis: a six-year follow-up on a pilot study. Nordic Psychol. 2017;69(02):100-109. Doi: 10.1080/19012276.2016.1181562 https://doi.org/10.1080/19012276.2016.11...	- 23.28 versus -10.28; p = 0.404	- 12.07 versus -20.01; p = 0.587	- 12,24 versus -19.74; p = 0.609	- 18.08 versus -6.08; p = 0.290	−26.00 versus (-1.50) p = 0.032	- 22.82 versus - 20.22; p = 0.894	- 65.28 versus -11.95; p = 0.153
Friggi Sebe Petrelluzzi et al. (2012)¹⁹19 Friggi Sebe PetrelluzziK,GarciaMC, Petta CA, et al. Physical therapyand psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. J Psychosom Obstet Gynaecol. 2012;33(04):191-198. Doi: 10.3109/0167482X.2012.729625 https://doi.org/10.3109/0167482X.2012.72...	30 ± 3.9 versus 39 ± 4.6; p < 0.05	26 ± 6.5 versus 38 ± 7.5; p < 0.05	X	X	X	X	X

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[1] Address for correspondence
Lilian Donatti, Mestre, Av. Dr Enéas de Carvalho Aguiar, 255, 05403-010, São Paulo, SP, Brazil (e-mail: lilian.donatti@usp.br).