YSM researchers explored the psychiatric comorbidities associated with endometriosis

Courtesy of Dora Caller

Endometriosis is a disease that affects approximately 10 percent of women worldwide, according to the World Health Organization.

Symptoms of endometriosis – a Illness Where tissue similar to the endometrium grows outside the uterus – it goes beyond gynecology and affects the entire body and mind. Researchers in the Department of Psychiatry at Yale University School of Medicine investigated mental illnesses as possible comorbidities of endometriosis, and found that the disease has epidemiological and genetic associations with depression, anxiety, and eating disorders.

Despite the prominence of endometriosis and its often well-known symptoms such as chronic menstrual pain and digestive problems, the disease is not widely diagnosed. Dora Koller, a postdoctoral fellow in the Department of Psychiatry and first author of the study, explained that this is due to ignoring women’s concerns and the broader societal stigma surrounding menstruation.

“It [the underdiagnosis of endometriosis] “Because of medical misogyny,” Kohler said. “Women aren’t taken seriously, you know something is wrong with your body – you know it’s not normal how you feel, but nobody takes it seriously. Not society, or medical professionals. In my opinion, it’s not that hard.” Very thoughtful about someone having endometriosis when they have all the symptoms.”

Most often, the disease is diagnosed after women decide they want to become pregnant, Koehler said, since infertility is another prominent symptom of endometriosis. Koller explained that this has historical roots, as for a long time a woman’s job in society was seen as merely reproduction, and so people only start to care when that job breaks down.

Koller and Gita Pathak, a postdoctoral fellow in the Department of Psychiatry and second author on the study, explain that the underdiagnosis of endometriosis is exacerbated by the limited discussion of periods. This limited discussion makes defining “normal” when it comes to menstrual pain difficult. Koller explained that women may think it’s normal to not be able to stand for two days because of the debilitating pain.

“It’s often misclassified as period pain for most women, like it’s a common thing you have to put up with during your periods,” said Pathak. “But then someone has to tell you that it’s not normal, to go to the doctor and not just brush it off as a woman’s thing, something you have to put up with.”

This study is the first to consider both epidemiological and genetic data in an analysis of the mental health comorbidities of endometriosis, and the first to identify eating disorders as one of these comorbidities. The study began by investigating the phenotypic associations between endometriosis and depression, anxiety, and eating disorders.

When looking at data from the UK Biobank on 270,000 women, the study found that this association was very high, outweighing the comorbid mental illness that comes with chronic pain from any illness.

“Our findings highlight that the association of endometriosis with depression, anxiety, and eating disorders is independent of chronic pain,” Renato Pullimante, assistant professor of psychiatry at the College of Medicine and senior author of the study, wrote to the news. “This is a very important finding, as it suggests that the mechanisms responsible for comorbidities are more complex than previously expected.”

To verify this finding, the researchers conducted a genome-wide association study and found high genetic associations between depression, anxiety, and eating disorders with endometriosis. Using multi-way analysis to find genes common to depression and endometriosis, the researchers also identified a gene, DGKB, that is highly expressed in female reproductive tissues as well as many different brain regions.

Furthermore, based on this genetic analysis, Koehler and her colleagues found that depression and anxiety are actually triggers of endometriosis, rather than the other way around, which was previously expected. Polimante explained that identifying genetic associations also indicates pathogenesis of co-morbidity.

This work was personal to Koller, as she had endometriosis and wanted to apply her training in psychiatry to investigating the disease.

“For me, it was a personal trigger,” Kohler said. “I have endometriosis and it hasn’t been diagnosed for fifteen years… We do research on mental disorders in general, Gita and I, and I really wanted to know if there was anything between endometriosis and psychiatry.”

Koller hopes that general practitioners and gynecologists will use this study to better understand the endometrial system.

When treating patients with endometriosis, Bulimante emphasized, mental health should be considered.

“Unfortunately, although endometriosis is a common disorder with a significant impact on women’s health, it is still very much under investigation,” Polimante wrote to The News. Accordingly, we need more attention from scientists and funding agencies to support research that can untangle the complexity of endometriosis and lead to more effective treatments.

Based on their findings on genetic associations, Koller discussed the potential of precision medicine, one that is tailored to individual patients. Genetic analysis can be used as a tool to predict the likelihood of developing psychiatric comorbidity in individuals with endometriosis.

The Department of Psychiatry at Yale University School of Medicine was established in 1930.

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