Contents lists available at ScienceDirect Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores Review article Psychological and mind-body interventions for endometriosis: A systematic review Subhadra Evans a, ⁎ , Stephanie Fernandez a , Lisa Olive a , Laura A. Payne b , Antonina Mikocka-Walus a a School of Psychology, Deakin University, Geelong, Australia b Pediatric Pain and Palliative Care Program, David Geffen School of Medicine at UCLA, Los Angeles, USA ARTICLEINFO Keywords: Endometriosis Psychological intervention Mind-body Pain ABSTRACT Endometriosis is a common gynecological condition associated with debilitaing pain and poor mental health. This review examines the evidence for psychological and mind-body (PMB) interventions to improve en- dometriosis pain, psychological distress, sleep and fatigue. Electronic databases searched included PsychINFO, MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus, and PubMed. Inclusion criteria were women with endometriosis, and interventions that used psychological or mind-body interventions; there were no exclusion criteria regarding study design. Studies were identifed and coded using standard criteria, and risk of bias was assessed with established tools relevant to the study design. A total of 12 publications relating to 9 separate studies were identifed:- 3 randomized controlled trials, 1 controlled trial, 2 single-arm studies, 1 retrospective cohort study, and 2 case series. Interventions included yoga, mindfulness, relaxation training, cognitive beha- vioural therapy combined with physical therapy, Chinese medicine combined with psychotherapy, and bio- feedback. Results indicate that no studies have yet used gold-standard methodology and, thus, defnitive con- clusions cannot be ofered about PMB efcacy. However, the results of these pilot studies suggest that PMB interventions show promise in alleviating pain, anxiety, depression, stress and fatigue in women with en- dometriosis, and future well-designed RCTs including active control groups are warranted. 1. Introduction Endometriosis is a gynecological disorder resulting from tissue that normally lines the uterus to grow outside the uterus, leading to chronic pain and infertility [1]. The condition afects as many as 5–10% of the general population of reproductive-age women [2]. In addition to its personal burden, endometriosis has been estimated to cost the US $78 billion annually in direct and indirect costs, including lost productivity and use of healthcare resources [3]. Endometriosis has often been un- derrecognized and insufciently treated [4], perhaps due to the non- specifc nature of symptoms and the difculty in procuring a diagnosis, which is typically made via surgically removing tissue [3]. Diagnosis is often delayed, with many women enduring symptoms of debilitating pain and infertility without efective treatment or acknowledgement for 10 years or more [5]. Experiencing chronic pain along with delayed treatment can impair functioning and result in psychological distress in women. Although the precise biochemical processes involved in en- dometriosis are not entirely understood, psychological factors are implicated. The condition appears to involve infammation, with en- dometrial tissue producing pro-infammatory agents that worsen pain [6,7]. Given the link between elevated stress and exacerbation of in- fammatory conditions including endometriosis [7], psychological and mind-body interventions such as mindfulness - which are known to reduce stress [8,9] - may help to alleviate women's symptoms. As with other chronic pain conditions, psychological factors are likely to be important in modifying endometriosis pain perception. Improving coping and reducing alarm and avoidance may help to dampen pain networks and support women's engagement in life tasks. In a recent systematic review of psychological disorders associated with en- dometriosis, over half of women with endometriosis met criteria for a psychological comorbidity such as anxiety and depression, signifcantly higher than rates in women without endometriosis [10]. Endometriosis is a complex condition, with symptoms varying be- tween women. Objective markers of the condition do not always cor- respond to symptoms. Some women report minimal pain despite having physical pathology indicative of advanced endometriosis, while others have less pathology, but report elevated pain [11]. Women's experience https://doi.org/10.1016/j.jpsychores.2019.109756 Received 30 March 2019; Received in revised form 24 June 2019; Accepted 26 June 2019 ⁎ Corresponding author. E-mail address: subhadra.evans@deakin.edu.au (S. Evans). Journal of Psychosomatic Research 124 (2019) 109756 0022-3999/ © 2019 Elsevier Inc. All rights reserved. T