Assessment of treatment expectations in people with suspected endometriosis: A psychometric analysis

Ann-Katrin Meyrose; Lukas A. Basedow; Nina Hirsing; Olaf Buchweitz; Winfried Rief; Yvonne Nestoriuc

doi:10.12688/f1000research.145377.2

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Research Article

Revised

Assessment of treatment expectations in people with suspected endometriosis: A psychometric analysis

[version 2; peer review: 1 approved, 3 approved with reservations]

Ann-Katrin Meyrose ^1,2, Lukas A. Basedow³, Nina Hirsing², Olaf Buchweitz⁴, Winfried Rief³, Yvonne Nestoriuc^2,5

Ann-Katrin Meyrose ^1,2, Lukas A. Basedow³, [...] Nina Hirsing², Olaf Buchweitz⁴, Winfried Rief³, Yvonne Nestoriuc^2,5

PUBLISHED 09 Sep 2024

Author details Author details

¹ Clinical Psychology and Psychotherapy, Helmut-Schmidt-University / University of the Federal Armed Forces Hamburg, Hamburg, Germany
² Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany
³ Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-Universitat Marburg, Marburg, Germany
⁴ Frauenklinik an der Elbe, Center of Surgical Endoscopy and Endometriosis, Hamburg, Germany
⁵ Institute of Systems Neuroscience, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

Ann-Katrin Meyrose
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation

Lukas A. Basedow
Roles: Conceptualization, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation

Nina Hirsing
Roles: Conceptualization, Investigation, Validation, Visualization, Writing – Review & Editing

Olaf Buchweitz
Roles: Conceptualization, Investigation, Resources, Supervision, Writing – Review & Editing

Winfried Rief
Roles: Conceptualization, Resources, Supervision, Writing – Review & Editing

Yvonne Nestoriuc
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Endometriosis collection.

Abstract

Background

Treatment expectations influence clinical outcomes in various physical and psychological conditions; however, no studies have explored their role in endometriosis treatment. It is necessary to understand how these expectations can be measured to study treatment expectations and their effects in clinical practice. This study aimed to psychometrically analyze and compare different treatment expectation measurements and describe treatment expectations in women with suspected endometriosis.

Method

Analysis of cross-sectional baseline data of a mixed-method clinical observational study of N=699 patients undergoing laparoscopy in Germany. Descriptives, bivariate associations, convergent and discriminant validity of four expectation measurements (Treatment Expectation Questionnaire (TEX-Q); Generic rating scale for previous treatment experiences, treatment expectations, and treatment effects (GEEE); numerical rating scales (NRS) assessing improvement and worsening of endometriosis symptoms, expected Pain Disability Index (PDI); range: 0 to 10) were estimated. A cluster analysis was performed on the three GEEE items.

Results

Most participants expected high improvement (M=6.68 to 7.20, SD=1.90 to 2.09) and low worsening (M=1.09 to 2.52, SD=1.80 to 2.25) of disability from laparoscopy. Participants who expected greater worsening expected more side effects (r=.31 to .60, p<.001). Associations between the positive and negative expectation dimensions, including side effects, were small to non-significant (r =|.24| to .00, p<.001 to.978). Four distinct clusters, described as’positive’, ‘no pain, no gain’, ‘diminished’, and ‘uniform’ were found, with a total PVE of 62.2%.

Conclusions

Women with suspected endometriosis reported positive expectations concerning laparoscopy, but wide ranges indicated interindividual differences. Treatment expectations seem to be a multidimensional construct in this patient group. The investigated measurements did not correlate to the extent that they measured exactly the same construct. The selection of measurements should be carefully considered and adapted for the study purposes. Clusters provide initial indications for individualized interventions that target expectation manipulation.

Trial Registration Number

ID NCT05019612 (ClinicalTrials.gov)

Keywords

placebo, nocebo, expectancies, laparoscopy, G-EEE, TEX-Q

Corresponding author: Ann-Katrin Meyrose

Competing interests: No competing interests were disclosed.

Grant information: This work was funded by internal research funding (IFF2020, 27/05/2020; grant to Prof. Dr. Yvonne Nestoriuc and Dr. Ann-Katrin Meyrose) of the Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, and was supported by funds from the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG), CRC 289 Treatment Expectation, Project Number 422744262.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Meyrose AK et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Meyrose AK, Basedow LA, Hirsing N et al. Assessment of treatment expectations in people with suspected endometriosis: A psychometric analysis [version 2; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 13:174 (https://doi.org/10.12688/f1000research.145377.2) First published: 11 Mar 2024, 13:174 (https://doi.org/10.12688/f1000research.145377.1) Latest published: 09 Sep 2024, 13:174 (https://doi.org/10.12688/f1000research.145377.2)

Revised Amendments from Version 1

In the revised manuscript, we incorporated additional information, references, and statistics, and revised phrases based on the reviewer’s comments. The study aims were restructured for clarity and consistency. The first aim now focuses on describing treatment expectations (including cluster analysis), while the second aim compares expectation measures (including convergent and discriminant validity).
The introduction was supplemented by a sentence and references to describe the association between depression, pain catastrophizing and anxiety with persistent complaints after laparoscopy. We clarified that only pre-operative variables were considered. Where appropriate, the terms “people” and “participants” were used instead of “women” (also in the title) since some individuals identified themselves as non-binary.
The methods section now includes a table describing and comparing the four treatment expectation measures. Additionally, the following clinical data were added to the manuscript to describe the sample more thoroughly: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding.
Although the manuscript's primary focus is methodological, we acknowledged the readers’ interest in clinical implications by adding discussion points of what is known to shape expectations for other patient groups and recommendations for future studies (i.e., longitudinal studies to explore whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations or whether expectations do not have an impact on post-operative outcomes; qualitative interviews to deepen understanding of expectations in endometriosis patients more deeply).
Finally, the abstract was revised to align with these changes, reflecting the restructured aims, corresponding results, and conclusions.

See the authors' detailed response to the review by Claire E Lunde
See the authors' detailed response to the review by Michel Canis

Introduction

Treatment expectations are important for clinical outcomes in various physical and psychological conditions,¹ such as acute and chronic pain,²^,³ surgeries,⁴^,⁵ breast cancer,⁶ and psychiatric disorders.⁷ For pain and depression effects were large: Up to 70% of treatments effects can be attributed to expectations. For analgesic treatments, up to 50% of treatment effect can be attributed to placebo effects.⁸^,⁹ Auer et al. (2016) found low to moderate associations between presurgery patients’ expectations and postsurgery quality of life. Despite the high prevalence of endometriosis (4.4% in the general population¹⁰) and enormous individual burden,¹¹ no study has focused on treatment expectations in people with suspected endometriosis. Endometriosis is a chronic inflammatory disease in women of procreative age and is characterized by endometrium-like tissues outside the uterus.¹² The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.¹³ The German S2k-treatment guideline for endometriosis recommends a laparoscopy, a minimally invasive surgery under general anesthesia, when endocrine therapy has failed.¹⁴ Laparoscopy is associated with short-term symptom improvement,¹⁵ but 20–30% of patients do not respond satisfactorily.¹⁶^,¹⁷ Depressive symptoms, anxiety, and pain catastrophization seem to be associated with persistent symptoms.¹⁸^–²⁰ In summary, current treatment options are inadequate for many patients.²¹ A deeper understanding of the role of treatment expectations might help a) clarify why complaints persist and b) develop new intervention avenues to foster positive expectations and prevent nocebo effects.²²

Measurement of expectations

To properly implement and study treatment expectations and their effects in clinical practice, it is necessary to have a good understanding of how these expectations can be measured. This is not as easy as it seems, since treatment expectations can and should be considered multidimensional constructs that differ across specific contexts and time intervals.²³ Specifically, expectations can be positive (e.g., improvement of symptoms) or negative (e.g., worsening of symptoms or side effects),²⁴ related to treatment processes or outcomes,²⁵ rated based on valence (more or less important) or probability of occurrence,²⁶ treatment-specific or related to general symptoms,²⁷ or different in terms of being real, that is, plausible or ideal expectations.²³^,²⁵ This complexity of the ‘treatment expectation’ construct leads to pronounced heterogeneity in available instruments.²⁸^–³⁰ While single-item measures have been the most popular historically,²⁶^,²⁹^,³¹ recent advances have led to the development of multidimensional treatment-expectation questionnaires.²⁸^,³² Although this development circumvents several issues in the assessment of treatment expectations,²³ an ideal method of expectation measurement has not been developed. Several issues remain understudied and are fruitful targets for continued psychometric research, such as the contrast between context specific and general expectations.

Aims and hypotheses

The first aim of this study was to describe and exploratively cluster pre-operative treatment expectations in this burdened and understudied patient group. The second aim was to psychometrically analyze and compare different treatment expectation measurements in this large sample of N=699 people with suspected endometriosis. Referring to our second aim, we hypothesise that:

i) Treatment expectations are a multidimensional construct; that is, intercorrelations of different scales and dimensions of the Treatment Expectation Questionnaire (TEX-Q)²⁸ and the three expectation items of the Generic rating scale for previous treatment experiences, treatment expectations, and treatment effects (GEEE³²) will be heterogeneous.
ii) Treatment expectation measurements correlate higher with each other in terms of convergent validity compared to other psychological measurements assessed (i.e., disability, severity of symptoms, depressive symptoms, anxiety, and catastrophizing pain) in terms of discriminant validity.

Methods

This study used pre-operative data from the baseline assessment of a mixed-method clinical observational study³³ that focused on patients undergoing laparoscopy for suspected endometriosis. People with endometriosis reported their endometriosis-related disability, complaints, and a priori specified predictors once before and eight times after laparoscopy, covering trajectories over a 12-month period. This observational study was registered at ClinicalTrials.gov (ID NCT05019612), but baseline analyses were not described.

Participants

The target population included people with endometriosis-related complaints with or without an unmet wish to have children aged 18 and older. Further inclusion criteria were sufficient German language skills, female sex, informed consent for study participation, and indications for laparoscopy. For these analyses, N=699 patients were included, irrespective of the actual surgery or clinical diagnosis after laparoscopy.

Recruitment and procedure

People with an appointment for laparoscopy in a specialized center for surgical endoscopy and endometriosis (Frauenklinik an der Elbe, Germany) were informed about the study by phone. If interested, the people were referred to the baseline online survey. The online survey included written information about the study and checked the inclusion criteria. Written informed consent for the online survey, storage and processing of data was obtained online from all participants, and baseline assessment was initiated. An individualized study code was used to store the data. Patients completed the survey between 25^th of August 2021 to 27^th of June 2023 until the required sample size of longitudinally participating patients with diagnosed endometriosis was reached. Interested patients were sent email reminders to encourage their participation. Detailed information on the study design, postoperative assessments, and further efforts to address potential bias are described in the study protocol.³³

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. All procedures involving patients were approved by the Psychotherapeutenkammer Hamburg, Germany (ROXWELL-2021-HH, 25^th of June 2021).

Measurements

Treatment expectations about laparoscopy were assessed by four self-reported measurements (Treatment Expectation Questionnaire; three items assessing treatment expectations of the Generic rating scale for previous treatment experiences, treatment expectations, and treatment effects; self-constructed numerical rating scales; and expected Pain Disability Index). Table 1 gives an overview of expectation measurements. The Treatment Expectation Questionnaire (TEX-Q)²⁸^,³⁴ comprises 15 items of six dimensions with 11 response options each. The mean score ranged from 0 to 10. Higher scores indicated more positive treatment expectations for the total score and dimensions of ‘treatment benefit’, ‘positive impact’, ‘process’, and ‘behavioral control’. Higher scores indicate more negative treatment expectations for the ‘adverse events’ and ‘negative impact” dimensions. In this study, Cronbach’s α of the total score was.82 and ranged between.72 and.91 for the dimensions in accordance with the validation sample.³⁴

Table 1. Overview of expectation measurements under analysis.

Expectation measurement	Treatment expectation questionnaire	Generic rating scale for treatment expectations^a	Numerical rating scales	Expected pain disability index
Abbreviation	TEX-Q	GEEE	NRS	Expected PDI
Reference	²⁸^,³⁴	³²	Self-constructed	Adapted PDI by study team³⁵^,³⁶
Number of items	15	3	10	7
Response options	11 (range: 0-10)	11 (range: 0-10)	11 (range: 0-10)	11 (range: 0-10)
Dimensions	1. treatment benefit 2. positive impact 3. adverse events 4. negative impact 5. process 6. behavioral control + Total score	expected improvement of disability expected worsening of disability expected side effects from laparoscopy	expected improvement and worsening of dysmenorrhea, pelvic/abdominal pain, dyspareunia, dyschezia, dysuria	expected disabilities after laparoscopy

a Three items assessed to measure treatment expectations of the Generic rating scale for previous treatment experiences, treatment expectations, and treatment effects.

Three items assessing treatment expectations of the Generic rating scale for previous treatment experiences, treatment expectations, and treatment effects (GEEE)³² were used, focusing on expected improvement of disability, worsening of disability, and side effects from laparoscopy with 11 response options (0=no improvement/impairment to 10=greatest improvement/worsening imaginable; 0=no complaints to 10=greatest complaints imaginable). No sum or mean scores were obtained.

Ten self-constructed numerical rating scales (NRS) with 11 response options were used to assess the expected improvement and worsening of the five most prevalent endometriosis symptoms (dysmenorrhea, pelvic/abdominal pain, dyspareunia, dyschezia, and dysuria). The wording of items and response options (0=no improvement/impairment to 10=greatest improvement/worsening imaginable) were derived from the GEEE in accordance with the recommendations for the assessment of pain. No sum or mean scores were obtained.

Expected endometriosis-related pain disability was assessed using the German version of the Pain Disability Index³⁵^,³⁶ adapted to expected disabilities after laparoscopy (expected PDI). The expected PDI covers seven items with 11 response options (0=no disability to 10=total disability). The sum (range: 0-70) and mean scores (0-10) were calculated. Higher scores indicate higher expected disability. The mean scores were mainly used because of their better comparability to the other expectation measurements in this study. The Cronbach’s α was.93 in this study. The expected change in disability by laparoscopy was defined as the difference between endometriosis-related disability before laparoscopy and expected endometriosis-related disability after laparoscopy (ΔPDI score=PDI – expected PDI; theoretically ranging from -70 to 70 for the sum and -10 to 10 for the mean score). Positive scores indicate a positive change in disability by laparoscopy, that is, improvement, whereas negative scores indicate a negative change in disability, that is, worsening.

Further, self-reported psychological measurements were used to describe the sample and estimate discriminant validity. Endometriosis-related disability was assessed using the PDI³⁵^,³⁶ covering seven items with 11 response options (0=no to 10=total disability). The introductory text was adapted to endometriosis-related disability. The sum (range: 0-70) and mean scores (0-10) were calculated. Higher scores indicate higher disability. Cronbach’s α was .85 in this study. Disability will be compared to women of the German general population.³⁷

The severity of endometriosis-related symptoms was assessed by five NRS referring to the five most prevalent endometriosis symptoms (dysmenorrhea, pelvic/abdominal pain, dyspareunia, dyschezia, and dysuria) with 11 response options (0=no pain to 10=worst pain imaginable). To summarize symptoms, the maximum severity of symptoms score was calculated using the stated maximum severity of symptoms within the five NRS, for example, if someone selected response options between 2 and 8 for the five endometriosis symptoms, the maximum severity of symptoms score was 8.

Depressive symptoms and anxiety were assessed using the Patient Health Questionnaire (PHQ-4)³⁸ which covers four items with four response options (0=not at all, 1=several days, 2=more than half the days, 3=nearly every day). Sum scores for the depressive symptoms and anxiety subscales ranged from 0 to 6. Higher scores indicate more depressive symptoms and anxiety, respectively. Cronbach’s α was .77 for depressive symptoms and.76 for anxiety in this study. A cutoff score of 3 or greater indicates good sensitivity and specificity for detecting major depression³⁹ and anxiety disorders.⁴⁰

Pain catastrophizing was assessed by the subscale catastrophizing of the Coping Strategies Questionnaire (CSQ)⁴¹ which covers six items with seven response options each (0=never do that to 6=always do that). The sum score ranges from 0 to 36, with higher scores indicating a higher level of catastrophizing pain. The Cronbach’s α was .88 in this study.

Further, following self-reported medical characteristics were used to describe the sample: reason for laparoscopy, duration of endometriosis symptoms (in months), previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints depend on menstrual bleeding (before, during, after, independent).

Statistical analysis

Frequencies and descriptive statistics (mean, standard deviation, median, range, skewness, and kurtosis) were calculated to describe the sample. Missing data are also reported. Distributions of treatment expectation measurements are displayed by raincloud plots using the R packages ggplot2, ggdist, ggforce, gghalves, haven, RcolorBrewer. Bivariate associations were estimated using Pearson correlation coefficients and displayed as a correlation matrix heatmap using the R package ggcorrplot.⁴² Convergent validity was determined by bivariate associations of all treatment expectation measurements, discriminant validity by bivariate associations of treatment expectation measurements, and psychological constructs. According to Cohen,⁴³ Pearson’s r=.1–.3 is interpreted as small, r=.3–.5 as medium, and r≥.5 as large. The two-sided level of significance was set at α=.05. The optimal number of clusters was determined by visual inspection of elbow and silhouette plots. The resulting optimal number of clusters was used for the k-means clustering of the three G-EEE items using the cluster package.⁴⁴ SPSS version 27 and R version 2022.12.0+353 were used for statistical analyses. The data that support the findings of this study are openly available.⁴⁵

Results

Descriptive characteristics

Overall, n=2,361 people clicked the survey link, n=1,145 began the online survey, n=1,098 met the inclusion criteria, n=1,082 gave informed consent, and n=699 completed the online survey. More details on the flow of participants are displayed in Figure 1.

Figure 1. Flow chart of study participation.

The ages of the 699 participants with suspected endometriosis ranged from 18 to 51 years (M=29.90, SD=6.45). About one-fifth had a migrant background, i.e. participants or one or both parents were not born in Germany, and 39.2% had acquired a higher entrance certificate (German ‘Abitur’) and 33.2% had a university degree. The reason for laparoscopy was endometriosis-related complaints with (21.5%) or without (77.5%) an unmet wish to have children. Overall, participants were enormously burdened by endometriosis-related symptoms before laparoscopy (PDI sum score: M=30.52, SD=13.66) compared with women in the general population in Germany (M=6.9, SD=11.1, N=1,368³⁷; d=3.14). On average, the maximum severity within the five endometriosis-related symptom scales (NRS) was M=7.18 (SD=1.81, potential range: 0-10). More than half (54.8%) showed signs of major depression (41.6%, M=2.56, SD=1.40) and/or anxiety disorder (42.6%, M=2.44, SD=1.63) according to the PHQ-4. Approximately one-fifth had previous experience with laparoscopy (21.3%) and one-fifth was currently treated with endocrine therapy (20.3%). Table 2 presents more information on the characteristics of the sample under analysis and the descriptive statistics of all the treatment expectation measurements.

Table 2. Descriptive characteristics of the sample under analysis (N=699).

	n (%)	M	SD	Md	Observed range	Potential range	Skew	Kurt
Gender
Female	686 (98.1)
Non-binary	13 (1.9)
Age in years	699	29.90	6.45	29.50	18-51	≥18	0.47	-0.21
Migrant background
Yes	129 (22.5)
No	445 (77.5)
Educational level
No school degree	2 (0.4)
In school	8 (1.1)
Lower secondary school	13 (1.9)
Secondary school	170 (24.3)
Higher entrance certificate	274 (39.2)
University degree	232 (33.2)
Able to work despite endometriosis-related complaints
Yes	623 (89.1)
No	76 (10.9)
Reason for laparoscopy
Complaints	549 (77.5)
Complaints with an unmet wish to have children	150 (21.5)
Duration of symptoms in months	684 (97.9)	77.48	78.39	48.00	2-468	>0	1.42	1.61
Previous experience with laparoscopy
Yes	149 (21.3)
No	550 (78.7)
Current endocrine therapy
Yes	142 (20.3)
No	557 (79.7)
Dependency of complaints on menstrual bleeding
Before	107 (15.3)
During	298 (42.6)
After	20 (2.9)
Independent	274 (39.2)
Severity of symptoms (NRS)
Dysmenorrhoea^a	624 (89.3)	6.85	1.95	7.00	0-10	0-10	-0.80	0.51
Abdomen	699	5.72	2.27	6.00	0-10	0-10	-0.50	-0.32
Sexual intercourse^b	476 (68.1)	3.61	2.72	3.50	0-10	0-10	0.31	-0.85
Dysuria	699	1.43	2.10	0.00	0-10	0-10	1.50	1.48
Dyschezia	699	2.52	2.60	2.00	0-10	0-10	0.76	-0.44
Max. severity of symptoms	699	7.18	1.81	8.00	1-10	0-10	-0.82	0.55
Disability (PDI)
Total sum score	699	30.52	13.66	31.00	0-70	0-70	0.01	-0.31
Total mean score	699	4.36	1.95	4.43	0-10	0-10	0.01	-0.31
Depressive symptoms (PHQ-4)	699	2.56	1.40	2.00	0-6	0-6	0.53	-0.03
Anxiety (PHQ-4)	699	2.44	1.63	2.00	0-6	0-6	0.43	-0.53
Catastrophizing pain (CSQ)	699	18.26	6.91	18.00	6-35	0.36	0.25	-0.62
TREATMENT EXPECTATIONS
TEX-Q
Total score	699	6.73	1.28	6.73	2.40-10	0-10	-0.19	0.03
Treatment benefit	699	7.15	1.90	7.33	0-10	0-10	-0.67	0.20
Positive impact	699	6.68	2.35	7.00	0-10	0-10	-0.64	-0.17
Adverse events	699	3.67	1.93	3.33	0-9.67	0-10	0.34	-0.34
Negative impact	699	2.52	2.25	2.00	0-10	0-10	0.80	-0.08
Process	699	6.89	1.92	7.00	0-10	0-10	-0.30	-0.32
Behavioral control	699	5.87	2.44	6.00	0-10	0-10	-0.33	-0.52
Generic rating scales (GEEE)
Improvement	699	7.20	2.09	8.00	0-10	0-10	-0.84	0.67
Worsening	699	1.09	1.79	0.00	0-10	0-10	2.17	5.21
Side effects	699	3.72	2.33	3.00	0-10	0-10	0.30	-0.62
Expected severity of symptoms (NRS)
Dysmenorrhoea improvement^a	624 (89.3)	6.70	2.34	7.00	0-10	0-10	-0.73	0.19
Dysmenorrhoea worsening^a	624 (89.3)	0.0.92	1.79	0.00	0-10	0-10	2.68	8.10
Abdomen improvement	699	6.94	2.35	7.00	0-10	0-10	-0.86	0.51
Abdomen worsening	699	1.05	2.01	0.00	0-10	0-10	2.50	6.21
Sexual intercourse improvement^b	476 (68.1)	5.58	3.64	7.00	0-10	0-10	-0.38	-1.29
Sexual intercourse worsening^b	476 (68.1)	0.91	2.04	0.00	0-10	0-10	2.79	7.60
Dysuria improvement	699	3.73	4.04	2.00	0-10	0-10	0.41	-1.53
Dysuria worsening	699	0.60	1.62	0.00	0-10	0-10	3.45	12.58
Dyschezia improvement	699	4.67	3.87	5.00	0-10	0-10	0.00	-1.58
Dyschezia worsening	699	0.70	1.78	0.00	0-10	0-10	3.17	10.32
Expected disability (expected PDI)
Total sum score	699	15.41	13.77	12.00	0-66	0-70	1.07	0.52
ΔTotal sum score^c	699	15.10	14.12	14.00	-36-65	-70-70	0.16	0.34
Total mean score	699	2.20	1.97	1.71	0-9.43	0-10	1.07	0.52
ΔTotal mean score^c	699	2.16	2.02	2.00	-5.14-9.29	-10-10	0.16	0.34

a Menstrual bleeding was not applicable for n=75.

b Sexual intercourse was not applicable for n=223.

c n=74 (10.6%) had negative values, that is, expected worsening of disability; n=22 (3.1%) had a value of zero, that is, expected no change in disability.

In general, participants with suspected endometriosis had rather positive treatment expectations concerning laparoscopy. However, the wide ranges of all measurements, mostly covering the total potential range, indicate pronounced interindividual differences. Positive dimensions (TEX-Q; treatment benefit, positive impact) and items (GEEE, NRS), such as expected improvement, were rated with higher values (M=6.68 to 7.20, SD=1.90 to 2.35) and were distributed slightly left-skewed (skewness: -0.84 to -0.64). Negative dimensions (TEX-Q; adverse events, negative impact) and items (GEEE, NRS) such as expected worsening (M=0.92 to 1.09, SD=1.79) or side effects (M=3.67 and 3.72, SD=1.93 and 2.33) were rated with lower values and distributed clearly right-skewed (0.30 to 3.45). Expected disability (PDI total mean score) after laparoscopy ranged from 0 to 9.43 (M=2.20, SD=1.97) and was right-skewed (1.07). Expected change of disability (Δtotal mean score) ranged from -5.14 (medium worsening) to 9.29 (high improvement). Scores tended to be normally distributed based on graphical examination and skewness and kurtosis parameters, whereas the Kolmogorov-Smirnov test was significant (D(699)=.05, p< 0.001). The distributions of some exemplary expectation measurements are shown in Figure 2.

Figure 2. Distributions of treatment expectation measurements using raincloud plots.

Note. A: TEX-Q subscales: positive impact, negative impact, and adverse events. B: GEEE scale improvement, worsening, and side effects.

Cluster of treatment expectations

Figure 3 shows the resulting elbow and silhouette plots for potential clustering of the three GEEE items (symptom improvement, symptom worsening, and side effects). Both plots suggest k=4 is the optimal number of clusters. K-means clustering with k=4 resulted in a proportion of explained variance of 62.2%. The details of these clusters are listed in Table 3. Descriptively, the clusters can be described as ‘positive’ (high improvement expectation), ‘no pain, no gain’ (high improvement and side effect expectation), ‘diminished’ (rather low expectations on every dimension), ‘uniform’ (equally high expectations in every direction) (see Figure 4).

Figure 3. Silhouette and elbow plots for the exploration of possible factors.

Note. A: Silhouette plot showing the average silhouette score in relation to the number of clusters. B: Elbow plot showing the total within-cluster sum of squares for the number of potential clusters.

Table 3. Characteristics of the four identified clusters.

	Cluster ‘positive’ (n=260)	Cluster ‘no pain, no gain’ (n=204)	Cluster ‘diminished’ (n=137)	Cluster ‘uniform’ (n=98)
Cluster centroids
Generic rating scales (GEEE) M (SD)
Improvement	8.46 (1.14)	7.85 (1.35)	4.30 (1.67)	6.55 (1.67)
Worsening	0.53 (0.88)	0.47 (0.75)	0.48 (0.81)	4.71 (1.87)
Side effects	1.76 (1.15)	5.84 (1.41)	2.82 (1.45)	5.77 (1.75)
Demographics per cluster
Mean age in years (SD)	29.9 (6.6)	30.5 (6.6)	29.2 (6.5)	29.6 (5.7)
N gender (%)
Female	255 (98.1)	202 (99.0)	132 (96.4)	97 (99.0)
Non-binary	5 (1.9)	2 (1.0)	5 (3.6)	1 (1.0)
N unable to work because of endometriosis-related complaints (%)	21 (8.1)	16 (7.8)	16 (11.7)	23 (23.5)
Migrant background N (%)
Yes	53 (25.5)	29 (16.8)	19 (17.0)	28 (34.6)
No	155 (74.5)	144 (83.2)	93 (83.0)	53 (65.4)
Educational level N (%)
No school degree	2 (0.8)	0	0	0
In school	3 (1.2)	3 (1.5)	1 (0.7)	1 (1.0)
Lower secondary school	10 (3.8)	1 (0.5)	2 (1.5)	0
Secondary school	73 (28.1)	48 (23.5)	16 (11.7)	33 (33.7)
Higher entrance certificate	88 (33.9)	79 (38.7)	63 (46.0)	44 (34.9)
University degree	84 (32.3)	73 (35.8)	55 (40.1)	20 (20.4)
Reason for Laparoscopy N (%)
Complaints	201 (77.3)	156 (76.5)	111 (81.0)	81 (82.7)
Complaints with an unmet wish to have children	59 (22.7)	48 (23.5)	26 (19.0)	17 (17.3)
Previous experience with laparoscopy N (%)
Yes	63 (24.2)	38 (18.6)	21 (15.3)	27 (27.6)
No	197 (75.8)	166 (81.4)	116 (84.7)	71 (72.4)
Disability (PDI)
Total mean score (SD)	4.3 (1.8)	4.3 (2.0)	4.0 (2.0)	5.1 (2.0)
Depressive symptoms (PHQ-4)
Total mean score (SD)	2.5 (1.4)	2.5 (1.3)	2.5 (1.5)	2.9 (1.4)
Anxiety (PHQ-4)
Total mean score (SD)	2.4 (1.7)	2.2 (1.5)	2.5 (1.8)	2.9 (1.6)
Catastrophizing pain (CSQ)
Total mean score (SD)	17.3 (7.6)	17.1 (7.7)	16.2 (8.2)	19.8 (7.7)

Figure 4. Distribution of the GEEE values for each cluster.

Note. A: Average GEEE improvement expectation scores for each of the four clusters. B: Average GEEE worsening expectation scores for each of the four clusters. C: Average GEEE side effect expectation scores for each of the four clusters.

Convergent validity: Bivariate associations of all treatment expectation measurements

All associations of the treatment expectation measurements are presented in Figure 5, with the underlying statistics in Table 4. The dimensions of ‘treatment benefit’ and ‘positive impact’ of the TEX-Q were largely associated with each other (r=.75, p<.001), the total score (r=.76, p<.001 and r=.73, p<.001), and with a medium effect size with the expected process (r=.49, p<.001 and r=.42, p<.001, respectively). Negative dimensions (‘adverse events’ and ‘negative impact’) were largely associated with each other (r=.60, p<.001) and the total score (r= -.51 to r=-40, p<.001), but correlations with positive dimensions were non-significant to small. The correlations of the GEEE items were non-significant to small. Participants who expected more worsening from laparoscopy also expected more side effects (r=.31, p<.001) and less improvement (r=-.09, p=.016), but the effect sizes were small. The expected improvement and side effects of laparoscopy were not associated (r=-.07, p=.061). Correlations of expected worsening and improvement of each endometriosis-related symptom (NRS) were non-significant to small (r=.15 to .24, p<.001), whereas some expected changes in specific endometriosis-related symptoms were highly associated with the same expected change of other symptoms, for example, improvement of dysmenorrhea and abdominal pain, worsening of dysuria, and dyschezia (r=.69 to.73, p<.001). The correlation between expected disability (expected PDI) and change in disability (Δtotal score) was high (r=-.52, p<.001); participants who expected more disability after laparoscopy also expected worsening or a smaller reduction in disability.

Figure 5. Heatmap representing pearson correlation coefficients between treatment expectation measurements and further psychological constructs.

Note. Red indicates positive correlations, and blue indicates negative correlations. Non-significant correlations are white. The box highlights the correlations between the treatment expectation measurements (convergent validity). More information on each measurement is provided in the Methods section Measurements. The underlying statistics are presented in Table 4.

TEX-Q, Treatment Expectation Questionnaire; GEEE, Generic Rating Scale for Treatment Expectations; eNRS, expected numerical rating scales; ePDI, expected Pain Disability Index; Δ, difference score; NRS, numerical rating scales; PDI, Pain Disability Index; PHQ-4, Patient Health Questionnaire, 4-item version; CSQ, Coping Strategies Questionnaire.

Table 4. Correlation matrix including all treatment expectation measurements and further psychological constructs under analysis (N=699).

	r/p
Measurement	1.	2.	3.	4.	5.	6.	7.	8.	9.	10.	11.	12.	13.	14.	15.	16.	17.	18.	19.	20.	21.	22.	23.	24.	25.	26.	27.	28.	29.	30.	31.
1. TEX-Q Total score	1
2. TEX-Q Treatment benefit	.762 <.001	1
3. TEX-Q Positive impact	.731 <.001	.748 <.001	1
4. TEX-Q Adverse events	-.509 <.001	-.077 .042	-.001 .978	1
5. TEX-Q Negative impact	-.401 <.001	-.022 .566	.070 .065	-.601 .<.001	1
6. TEX-Q Process	.706 <.001	.491 <.001	.419 <.001	-.288 <.001	-.168 <.001	1
7. TEX-Q Behavioral control	.448 <.001	.243 <.001	.284 <.001	.060 .113	.117 .002	.308 <.001	1
8. GEEE Improvement	.657 <.001	.771 <.001	.625 <.001	-.109 .004	-.043 .255	.507 <.001	.205 <.001	1
9. GEEE Worsening	-.164 <.001	-.057 .134	.063 .096	.338 <.001	.340 <.001	-.092 .015	.118 <.002	-.091 .016	1
10. GEEE Side effects	.354 <.001	-.068 .073	-.054 .151	.544 <.001	.449 <.001	-.239 <.001	.014 .702	-.071 .061	.309 <.001	1
11. eNRS Dysmenorrhoea improvement	.505 <.001	.663 <.001	.586 <.001	.016 .685	.054 .181	.352 <.001	-.145 <.001	.626 <.001	.013 .744	.003 .942	1
12. eNRS Dysmenorrhoea worsening	-.064 .109	.001 .974	.135 <.001	.246 <.001	.251 <.001	-.025 .527	.095 .018	.011 .775	.544 <.001	.167 <.001	.065 .106	1
13. eNRS Abdomen improvement	.534 <.001	.666 <.001	.549 <.001	-.043 .255	-.016 .668	.369 <.001	.168 <.001	.643 <.001	-.033 .379	-.016 .666	.691 <.001	.043 .279	1
14. eNRS Abdomen worsening	-.081 .031	-.016 .670	.045 .231	.163 <.001	.207 <.001	-.034 .369	.045 .237	-.030 .431	.465 <.001	.137 <.001	.021 .597	.575 <.001	.014 .710	1
15. eNRS Sexual intercourse improvement	.332 <.001	383 <.001	.381 <.001	.013 .775	.042 .366	.243 <.001	.144 .002	.365 <.001	.030 .519	-.002 .972	.324 <.001	.094 .051	.418 <.001	.099 .031	1
16. eNRS Sexual intercourse worsening	-.063 .169	.013 .772	.053 .253	.157 <.001	.174 <.001	-.054 .239	.048 .294	-.006 .904	.393 <.001	.081 .076	.019 .690	.509 <.001	-.006 .890	.647 <.001	.150 .001	1
17. eNRS Dysuria improvement	.232 <.001	.270 <.001	.381 <.001	.099 .009	.112 .003	.182 <.001	.120 .001	.255 <.001	.120 .001	.069 .070	.295 <.001	.157 <.001	.294 <.001	.122 .001	.442 <.001	.147 .001	1
18. eNRS Dysuria worsening	-0.64 .093	.006 .883	.081 .032	.180 <.001	.198 <.001	-.003 .936	.025 .514	.022 .565	.435 <.001	.094 .013	.056 .163	.519 <.001	.015 .701	.522 <.001	.087 .058	.605 <.001	.244 <.001	1
19. eNRS Dyschezia improvement	.259 <.001	.327 <.001	.362 <.001	.079 .037	.110 .003	.206 <.001	.145 <.001	.290 <.001	.124 <.001	.029 .447	.316 <.001	.166 <.001	.321 <.001	.066 .084	.399 <.001	.119 .009	.671 <.001	.206 <.001	1
20. eNRS Dyschezia worsening	-.095 .012	.008 .840	.066 .081	.245 <.001	.254 <.001	-.032 .392	.071 .060	.000 .996	.452 <.001	.110 .004	.051 .205	.470 <.001	.003 .945	.495 <.001	.076 .097	.628 <.001	.170 <.001	.732 <.001	.183 <.001	1
21. ePDI Total mean score	-.140 <.001	-.142 <.001	.027 .468	.172 <.001	.245 <.001	-.087 .022	.076 .044	-.161 <.0001	.238 <.001	.093 .013	-.095 .017	.249 <.001	-.126 <.001	.236 <.001	-.052 .255	.236 <.001	.032 .405	.231 <.001	.007 .850	.237 <.001	1
22. ePDI ΔTotal mean score	.169 <.001	.173 <.001	.222 <.001	.016 .668	-.073 .053	.070 .065	.038 .320	.195 <.001	-.088 .019	.040 .297	.182 <.001	-.083 .038	.188 <.001	-.162 <.001	.181 <.001	-.188 <.001	.115 .002	-.095 .012	.119 .002	-.115 .002	-.520 <.001	1
23. NRS Dysmenorrhoea	.088 .027	.090 .025	.191 <.001	.084 .036	.031 .442	.007 .856	.088 .028	.061 .127	.064 .112	.045 .265	.171 <.001	.133 <.001	.051 .199	.110 .006	.023 .637	.021 .657	.071 .078	.056 .160	.060 .137	.069 .085	.248 <.001	.119 .003	1
24. NRS Abdomen	.137 <.001	.140 <.001	.236 <.001	.077 .042	.090 .018	.094 .013	.134 <.001	.112 .003	.089 .019	.057 .133	.130 .001	.160 <.001	.131 <.001	.145 <.001	.130 .004	.144 .002	.155 <.001	.117 .002	.160 <.001	.106 .005	.283 <.001	.120 .001	.482 <.001	1
25. NRS Sexual intercourse	.024 .609	.031 .497	.080 .081	.068 .139	.093 .044	.038 .402	.073 .113	.036 .428	.077 .092	.057 .216	-.004 .928	.143 .003	.071 .124	.149 .001	.502 <.001	.217 <.001	.227 <.001	.185 <.001	.191 <.001	.124 .007	.221 <.001	.031 .504	.180 <.001	.335 <.001	1
26. NRS Dysuria	.030 .429	-035 .357	.161 <.001	.121 .001	.174 <.001	.030 .425	.124 .001	.067 .075	.145 <.001	.084 .026	.073 .070	.194 <.001	.084 .026	.107 .005	.171 <.001	.095 .039	.473 <.001	.245 <.001	.319 <.001	.160 <.001	.218 <.001	.050 .189	.202 <.001	.332 <.001	.343 <.001	1
27. NRS Dyschezia	.010 .801	.022 .568	.086 .023	.114 .003	.119 .002	.010 .794	.124 <.001	.042 .267	.106 .005	.074 .049	.068 .092	.132 <.001	.036 .345	.034 .373	.118 .010	.079 .084	.297 <.001	.143 <.001	.527 <.001	.175 <.001	.189 <.001	.062 .099	.221 <.001	.334 <.001	.219 <.001	.507 <.001	1
28. PDI total mean score	.034 .372	.035 .352	.257 <.001	.190 <.001	.171 <.001	-.015 .687	.116 .002	.039 .304	.149 <.001	.135 <.001	.090 .024	.168 <.001	.067 .077	.070 .063	.140 .002	.039 .395	.151 <.001	.134 <.001	.130 <.001	.121 .001	.471 <.001	.509 <.001	.374 <.001	.409 <.001	.258 <.001	.271 <.001	.255 <.001	1
29. Depressive symptoms (PHQ-4)	-.041 .274	.012 .748	.117 .002	.175 <.001	.107 .005	-.056 .138	.005 .900	.006 .884	.128 <.001	.099 .009	.032 .428	.158 <.001	.010 .801	.100 .008	.084 .067	.032 .479	.153 <.001	.096 .011	.133 <.001	.074 .050	.237 <.001	.190 <.001	.187 <.001	.178 <.001	.252 <.001	.194 <.001	.210 <.001	.435 <.001	1
30. Anxiety (PHQ-4)	-.117 .002	-.058 .123	.023 .548	.178 <.001	.081 .033	-.153 <.001	-.018 .637	-.061 .107	.091 .016	.064 .094	-.026 .514	.152 <.001	-.063 .096	.047 .212	.001 .987	.018 .702	.103 .006	.078 .039	.085 .025	.041 .280	.186 <.001	.099 .009	.101 .011	.093 .014	.144 .002	.136 <.001	.181 <.001	.290 <.001	.637 <.001	1
31. Catastrophizing pain (CSQ)	.030 .426	.049 .193	.193 <.001	.161 <.001	.067 .077	-.019 .614	.050 .185	.052 .171	.111 .003	.076 .045	.103 .010	.143 <.001	.030 .433	.069 .069	.075 .104	.032 .485	.094 .013	.067 .076	.092 .015	.051 .176	.236 <.001	.273 <.001	.417 <.001	.297 <.001	.219 <.001	.232 <.001	.227 <.001	.520 <.001	.454 <.001	.402 <.001	1

The positive dimensions of treatment expectations regarding laparoscopy, the expected process, and the total score of the TEX-Q were highly and positively correlated with the expected improvement in disability as measured by the GEEE (r=.51 to .77, p<.001). Medium-sized positive correlations were found between the negative dimensions of the TEX-Q and expected worsening (r=.34, p<.001 and r=.34, p<.001) and expected side effects (r=.45 to.55, p<.001), as measured by the GEEE.

Considering the expected improvement and worsening of the severity of endometriosis-related symptoms (NRS), participants who expected more treatment benefit, positive impact from the laparoscopy, and had more positive overall treatment expectations measured by the TEX-Q, also reported more improvement in the severity of symptoms, especially dysmenorrhea (r=.51 to .66, p<.001) and abdominal pain (r=.53 to .67, p<.001). Negative dimensions of the TEX-Q were significantly correlated with the expected worsening of symptom severity, but the effect sizes were small (r=.16 to.25, p <.001). Additionally, the expected improvement and worsening of disability measured by the GEEE were positively correlated with the expected improvement and worsening of the severity of endometriosis-related symptoms (NRS), respectively, ranging from rather high correlations for dysmenorrhea (improvement: r=.63 and worsening: r=.54, p<.001) and abdominal pain (r=.64 and .47, p<.001) to rather medium correlations for pain during sexual intercourse (r=.37 and .39, p<.001), dysuria (r=.26 and .44, p<.001), and dyschezia (r=.29 and.45, p<.001).

Considering the expected disability after laparoscopy measured using the expected PDI, all correlations with other treatment expectation measurements were small. Participants who expected lower disability after laparoscopy had more positive treatment expectations overall (r=-.14, p<.001) and expected fewer adverse events and negative impact measured by the TEX-Q (r=.17 and.26, p<.001). Participants who expected a higher positive change in disability (Δtotal score) by laparoscopy (i.e., improvement of disability) also expected more benefit from treatment, more positive impact, and more positive treatment expectations overall (r=.17 to.22, p<.001). No associations were found with the other TEX-Q dimensions. Additionally, the correlations between the expected improvement and worsening of disability measured by the GEEE and expected disability after laparoscopy (r=-.16, p<.001 and r=.24, p<.001) and expected changes in disability (r=.20, p<.001 and r=-.09, p=.02) measured by the PDI were small, although both measurements explicitly referred to endometriosis-related disability. Similarly, almost the same associations regarding direction and effect size were found between expected disability and change in disability measured by the expected PDI and expected improvement and worsening of almost all endometriosis-related symptoms (NRS).

Discriminant validity: Bivariate associations of treatment expectation measurements and further psychological constructs

Overall, correlations between all treatment expectation measurements and investigated further psychological constructs, that is, preoperative disability, severity of the five most prevalent endometriosis-related symptoms, depressive symptoms, anxiety, and catastrophizing pain, were non-significant to small, with a few exceptions of medium-sized associations. Correlations between treatment expectations measured by the TEX-Q and all psychological constructs were non-significant to small. The most notable correlations were as follows: participants who experienced more preoperative disability and a higher severity of abdominal pain expected a higher positive impact from laparoscopy (r=.26 and .24, p<.001). Participants who reported more depressive symptoms and anxiety expected more adverse events (r=.18 and.18, p<.001).

The expected improvement, worsening, and side effects measured by the GEEE were not correlated with any of the psychological constructs to a relevant extent (r<.13). Correlations between expected improvement and worsening of the severity of the five most prevalent endometriosis-related symptoms and all further psychological constructs were non-significant to small, despite a few exceptions. Participants who experienced higher pain during sexual intercourse, more severe dysuria, and more severe dyschezia expected considerably more improvement in these specific complaints (r=.47 to .53, p<.001). Expected disability after laparoscopy and expected change in disability measured by PDI were highly correlated with preoperative disability. Participants who experienced more preoperative disability expected a higher disability after laparoscopy (r=.47, p<.001) and a higher change, that is, improvement of disability by laparoscopy (r=.51, p<.001). Additionally, participants who reported more severe endometriosis-related symptoms, more depressive symptoms, and more anxiety expected a higher disability after laparoscopy (r=.19 to .29, p<.001). Participants with a stronger tendency to catastrophize pain expected both a higher disability after laparoscopy and a higher chance, that is, improvement of disability from laparoscopy (r=.24 and .27, p<.001).

Discussion

Summary

People with suspected endometriosis reported rather positive pre-operative treatment expectations concerning laparoscopy, but wide ranges emphasize differences between participants. The negative dimensions indicate major floor effects. As hypothesized, low correlations between the dimensions of treatment expectation measurements indicate that treatment expectation also seems to be a multidimensional construct in people with suspected endometriosis. Thus, the calculation of the total sum scores might not be indicated or proven on a case-by-case basis. No association was found between the expected improvement and the side effects of laparoscopy in all patients. Four distinct clusters described as ‘positive’, ‘no pain, no gain’, ‘diminished’, and ‘uniform’ were identified. In line with our second hypothesis, the treatment expectation measurements TEX-Q and GEEE correlated higher with each other in terms of convergent validity compared to other psychological measurements assessed in terms of discriminant validity. This applies to the equivalent dimensions of both. Additionally, the expected improvement and worsening of disability (GEEE) and the severity of the five most prevalent endometriosis-related symptoms (NRS) led to medium-to-high positive associations of equivalent dimensions. Both scales used similar wording but focused on different constructs. Contrary to our second hypothesis of convergent validity, correlations of expected disability after laparoscopy measured by the expected PDI and most other measurements of treatment expectations were non-significant to small. However, none of the investigated measurements of treatment expectation correlated to such an extent that they measured exactly the same construct.

Comparison with existing literature

Treatment expectations measured with the TEX-Q of people with suspected endometriosis undergoing laparoscopy were slightly lower than those of the validation sample³⁴ for the total score and all dimensions, despite equal scores for the expected ‘negative impact’ of treatment. This contradicts the findings of more positive treatment expectations in surgical treatment samples undergoing endocrine or bariatric surgery than in psychosomatic samples.³⁴ Intercorrelations of dimensions were similar in both studies despite of higher correlations between the positive dimensions ‘treatment benefit’ and ‘positive impact’ (r=.75 in our sample vs. r=.48 in the validation sample³⁴) and ‘positive impact‘and ‘process‘(r=.42 vs. r=.15). Moreover, the dimension ‘behavioral control’ was significantly correlated to ‘treatment benefit’ (r=.24), ‘negative impact’ (r=.12), and ‘process’ (r=.31) in people with suspected endometriosis but not in the validation sample. Correlations of the TEX-Q and other psychological constructs were small to non-significant in our study and the validation study,³⁴ indicating discriminant validity. Interestingly, participants in our study who reported more depressive symptoms and anxiety expected more adverse events. More unfavorable expectations, that is, lower expected treatment benefit, higher negative impact, and a worse expected process, were also reported in patients with higher depressive and anxiety symptoms in the TEX-Q validation sample.³⁴ For the other assessed treatment expectation measurements, no validation data are currently available.

In line with Shedden-Mora et al. (2023)³⁴ and Younger et al. (2012),³⁰ our findings support the multidimensionality of the construct of treatment expectations: the positive and negative dimensions of treatment expectations were not correlated in these three studies. Overall, the expected side effects of laparoscopy and its improvement were not associated with the results of patients undergoing psychotherapy.⁴⁶ This contradicts the ‘no pain, no gain’ assumption.

So far, research on psychometric properties of measuring treatment expectations³⁰^,³⁴ has used heterogeneous samples including patients undergoing different surgeries, pain, psychosomatic in- or outpatient, or cancer treatment. Differences between patient groups and within patient groups could hardly be detected, but seem promising. Our cluster analysis revealed four distinct clusters in patients with suspected endometriosis that differed in terms of their treatment expectation pattern. These clusters can be described as follows. The first cluster showed a strong positive expectation, followed by no worsening or side effect expectations. For the second cluster, the ‘no pain, no gain’ assumption seems to be appropriate; these patients expected high side effects of laparoscopy and high improvement. In the third cluster, we found an overall low level of expectations for any category. The fourth cluster had a rather uniform distribution of expectations, with all expectations being of similar strength. Notably, only patients in this cluster patients also expected worsening. The largest cluster was the first with an improvement in expectation dominance, supporting the rather high expectations found in this sample.

Strengths and limitations

Our findings are based on data from a large sample of people with suspected endometriosis facing laparoscopy in a specialized center for surgical endoscopy and endometriosis, indicating high ecological validity. We assessed four measurements for treatment expectation (TEX-Q, the three items assessing expectations of the GEEE, expected NRS, and expected Pain Disability Index) simultaneously. Consequently, we were able to compare different dimensions, comprehensive questionnaires to single items, and treatment expectation measurements (TEX-Q and GEEE) to established symptom and disability scales (NRS assessing pain and PDI) adapted to the context of expectations. To our knowledge, this is the first study to investigate the treatment expectations in people with suspected endometriosis. Endometriosis is a common chronic disease that is largely underexplored and burdensome, and satisfactory treatment options are not available for many patients.

However, the timeframe of the assessed treatment expectations was not well defined in this study. People with suspected endometriosis might have different expectations for the short-, medium-, and long-term outcomes after laparoscopy. We were unable to quantify these potential differences. The order of the measurement instruments was the same for all participants, and sequence effects were possible. To enhance comprehensibility, the survey started with items referring to the past, then to the present, and finally to the future. Consequently, expected disability (expected PDI) and severity of symptoms (expected NRS) were not assessed directly after the preoperative disability and severity of symptoms. Some patients may have forgotten their reference values, leading to imprecise ratings. Finally, some anchors (i.e., the greatest improvement/worsening imaginable) might be understood unequally by participants with suspected endometriosis. Qualitative data from the embedded study module of this cohort study³³ may provide further clarifications.

Implications for practice and research

Women with suspected endometriosis are highly burdened and report rather positive expectations concerning laparoscopy, even though laparoscopy is associated with only short-term symptom improvement,¹⁵ and 20–30% do not respond satisfactorily to this treatment.¹⁶^,¹⁷ Future studies should investigate whether more positive expectations lead to better treatment outcomes, disappointment due to overly optimistic expectations or do not have any impact. Based on knowledge of other medical conditions¹ and surgical treatments,⁴^,⁵ positive yet realistic expectations (placebo effect) and reduced negative expectations (nocebo effect) may improve treatment outcomes after laparoscopy. From a clinical perspective it is also interesting what factors shape patients’ expectations. This study used data from the baseline assessment of a mixed-method clinical observational study.³³ Structured content analysis of qualitative interviews and longitudinal analyses are in progress to provide new insights to this research gap. For other patient groups it is known that prior information shape patients‘expectations: This includes verbal information (e.g., preoperative information), previous experiences (e.g., personal history of patients), observational learning (e.g., experiences and recommendations of close social contacts or media), and contextual factors (e.g., doctor-patient-relationship).⁴⁷^–⁴⁹

Our results emphasize that treatment expectations should be measured both multidimensionally and comprehensively. The expected improvement and worsening are not the anchors of a single scale. The dimension and linguistic formulation seem more important than the exactly chosen construct, that is, the disability or severity of symptoms. None of the included measurements comprised different time frames. In future research, it is important to define time frames for treatment expectation measurements, especially for patients undergoing surgery, such as laparoscopy. To generalize our findings across patient groups, provide specific recommendations for patients with symptoms of endometriosis, and classify expectations in terms of being real, that is, plausible or ideal²³^,²⁵ future qualitative and quantitative longitudinal research is needed. The four clusters of expectations need to be replicated and confirmed because of their high relevance to clinical implications. Individualized interventions could target at expectation manipulation such as focusing on i) side effect management in the ‘no pain, no gain’ and ‘uniform’ expectation clusters, ii) increased positive expectations fostering the placebo effect in the ‘diminished’ cluster, iii) decreased negative expectations reducing the nocebo effect and/or appropriate coping mechanisms, and iv) positive but yet realistic expectations in the ‘positive’ cluster.

As we found differences between the measurements of treatment expectations and dimensions, it is very interesting whether clinical outcomes may also differ depending on the chosen measurement. In the past, patients’ expectations were often assessed heterogeneously without conceptual standardization and psychometric evaluation.²³ Consequently, the selection of measurements should be carefully considered and either tailored to the respective theory-based primary outcome or defined in a general way to be applicable across treatments.

Ethical approval

Ethical approval was obtained from Psychotherapeutenkammer Hamburg, Germany (ROXWELL-2021-HH, 25^th of June 2021). This trial was registered at ClinicalTrials.gov (ID: NCT05019612).

Data availability

PsychArchives: Dataset for: Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis, https://doi.org/10.23668/psycharchives.13585.⁴⁵

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY-SA 4.0).

Acknowledgements

We thank all patients who participated in this study for their time and involvement. We thank the staff of the Frauenklinik an der Elbe and all the psychology students who worked on the ROXWELL study for their support in the recruitment process.

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Version 2

VERSION 2 PUBLISHED 11 Mar 2024

Author details Author details

Lukas A. Basedow
Roles: Conceptualization, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation

Nina Hirsing
Roles: Conceptualization, Investigation, Validation, Visualization, Writing – Review & Editing

Olaf Buchweitz
Roles: Conceptualization, Investigation, Resources, Supervision, Writing – Review & Editing

Winfried Rief
Roles: Conceptualization, Resources, Supervision, Writing – Review & Editing

Yvonne Nestoriuc
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This work was funded by internal research funding (IFF2020, 27/05/2020; grant to Prof. Dr. Yvonne Nestoriuc and Dr. Ann-Katrin Meyrose) of the Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, and was supported by funds from the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG), CRC 289 Treatment Expectation, Project Number 422744262.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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https://doi.org/10.12688/f1000research.145377.2

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© 2024 Meyrose AK et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Meyrose AK, Basedow LA, Hirsing N et al. Assessment of treatment expectations in people with suspected endometriosis: A psychometric analysis [version 2; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 13:174 (https://doi.org/10.12688/f1000research.145377.2)

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

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Version 2

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Reviewer Report 04 Oct 2024

Sonia R Grover, Royal Children's Hospital, Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Victoria, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.170250.r323254

Thankyou for the opportunity to review this paper which is highly relevant. As a gynaecologist and pain medicine specialist I am troubled by the expression ‘suspected endometriosis’.

Many studies report that only 50% of women undergoing a laparoscopy for pain will have endometriosis found. With only a 50/50 chance that endometriosis will be present, then the expression has questionable validity. The expression ‘suspected endometriosis’ may be appropriate where imaging has clearly demonstrated endometriomas or deep infiltrating endometriosis, but in Australia many laparoscopies are done for period and pelvic pain where at least ultrasound imaging has been undertaken and has been reported as basically normal. The women here would still undergo a laparoscopy having been convinced by social media, public endometriosis awareness campaigns and probably their primary care specialist as well as their gynaecologist that there is likely endometriosis present to explain their pain. I am aware that the pressure to ‘make a diagnosis’ and papers on the ‘delay to diagnosis’ have come out of Germany so I suspect there is enough similarity between our countries and attitudes to endometriosis. Yet we know that 50% of the people with period and pelvic pain will not have endometriosis found and they are often more frustrated and confused and invalidated following their laparoscopy.

Thus I agree with the previous reviewers comment that the cohort should be divided into those undergoing laparoscopy for pain and those undergoing laparoscopy where imaging has demonstrated an identifiable problem as expectation and level of suspicion will be substantially different – both at the clinician level but also thus to the patient. Efforts for others to replicate your study would likewise need to define the presentation of their population as this will influence expectations. Furthermore – it is important to know if this is a first laparoscopy or repeat laparoscopy , as this will also impact the persons response to the questions around their expectations – and this should be noted.

There is also a pressing need for studies to be undertaken exploring the outcome of women after their laparoscopy – in particular those with a “negative” laparoscopy – where endometriosis is not found – as there is a need to counter the significant media around the reported importance of endometriosis particularly in the presence of pain, when the evidence is far from clear that this is a clear relationship ( given that people who menstruate with no pain have an almost 50% rate of endometriosis).

I do hope your work will follow this cohort for >12 months and reassess as well as re-analyse this preliminary data. A question that would then also be relevant is to know whether the patients had been forewarned that the laparoscopy might be negative.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Gynaecologist and a Pain Medicine Specialist – with research interest in period and pelvic pain

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 25 Sep 2024

Claire E Lunde, Lunde Consulting, LLC, Washington, DC, USA

Approved

https://doi.org/10.5256/f1000research.170250.r321848

Thank you to the authors for thoroughly addressing my questions and concerns, and for your valuable ... Continue reading

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Reviewer Report 19 Sep 2024

Diego Raimondo, Division of Gynaecology and Human Reproduction Physiopathology, S. ORSOLA, Universitaria di Bologna, Bologna, Italy

Approved with Reservations

https://doi.org/10.5256/f1000research.170250.r325045

The study aims to psychometrically analyze and compare different treatment expectation measurements in a sample of women with suspected endometriosis. Additionally, it seeks to describe and exploratively cluster treatment expectations in this patient group.
Women with suspected endometriosis reported positive expectations concerning laparoscopy, but wide variations indicated significant interindividual differences. The identified clusters provide initial indications for individualized interventions targeting expectation manipulation.

Please discuss on side events of endometriosis surgery providing to the readers some examples and their burden (Ref -1,2)

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: endometriosis

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Version 1

VERSION 1

PUBLISHED 11 Mar 2024

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Reviewer Report 10 Jul 2024

Claire E Lunde, Lunde Consulting, LLC, Washington, DC, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.159318.r293041

Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations). New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction). It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.

Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.

Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

Keywords.
Recommend adding NRS and PDI to the keywords.

Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status? Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress? If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes. Recommend adding a table describing and comparing the four treatment expectation measures.

Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify. If possible, horizontal tables would be easier to read. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results. Table 2 reports: N female (divers) – typo?

Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Public Health, Behavioral Sciences, Neuroscience, Endometriosis, and Female-Pain,

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Author Response 09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

09 Sep 2024

Author Response
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of ... Continue reading
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

--> Thank you very much for your time and valuable feedback, especially from the clinical perspective. The manuscript has a methodological focus on expectations, but we agree that the clinical perspective is also very interesting and should be considered more deeply.

2. General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations).
New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

--> Thank you for this comment. We restructured the paragraph describing our study aims for a better flow and consistency throughout the manuscript. The first aim is now to describe treatment expectations (including cluster), the second aim is comparing expectation measures (including convergent and discriminant validity) (Introduction, p. 5 (Aims and hypotheses). We checked the order in the whole manuscript:

The first paragraph of the introduction focuses on expectations in people with (suspected) endometriosis, the second on measurement aspects.

In the results section, all results referring to the first study aim are presented first (describing expectations including cluster), all results referring to the second aim (comparing measures, especially measurement validity) afterwards.

Same in the summary of the discussion and implications for practice and research

Yet, we did not describe variables such as depression, pain catastrophizing and anxiety in the introduction, because we use those only to interpret the discriminant validity of expectation measures (please see second hypothesis) and to give a brief descriptive overview of the sample under analysis. In this paper, we do not focus on relationships of those constructs from a clinical perspective. Nevertheless, we assessed those constructs in our study, because depression, pain catastrophizing and anxiety seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references).
Because readers (e.g., reviewer 1) seem to be interested in clinical data, we added what we assessed to describe the sample more deeply. (Introduction, first paragraph, p. 5, Reference list)

3. It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction).

--> Thank you for this note. We added the information that only pre-operative variables were considered to different parts of the manuscript. (Abstract – Methods p. 4; Aims and Hypotheses p.5; Methods, first sentence p.6; Discussion – Summary, first sentence p.26)

4. It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.
--> We added information on effect sizes for pain, depression, analgesic treatments, and postsurgery quality of life. (Introduction, second sentence, p.4)

5. Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.
--> We totally agree, thanks for this important recommendation. We used people and participants instead of women. (whole manuscript)

6. Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

--> Thank you for these recommendations. Due to the limited space of 300 words, we deleted the sentence about the PVE to include the age range. We restructured the order of sentences to clarify our research aims and corresponding results and conclusions (see also general comment above). We added a second recommendation for future studies and rephrased the first to clarify. Because of this we deleted some words in the abstract to comply with the word limit.
After discussion, we decided not to include all measures in the abstract due to limited space. The expectation measurement is the focus of the manuscript, the measures depressive symptoms, anxiety and pain catastrophizing were primarily used to analyse discriminant validity. (Abstract, p.4)

7. Keywords.
Recommend adding NRS and PDI to the keywords.

--> We added both to the keywords. (keywords)

8. Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

--> We added a citation for this sentence (Chiantera V, Abesadze E, Mechsner S. How to Understand the Complexity of Endometriosis-Related Pain. Journal of Endometriosis and Pelvic Pain Disorders 2017; 9(1):30–8. DOI:10.5301/je.5000271.). (Introduction, first paragraph, p. 5, reference list)

9. Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

--> We assessed depression, pain catastrophizing and anxiety in our longitudinal study, because those constructs seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references). (Introduction, first paragraph, p. 5, Reference list)

10. Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status?

--> We recruited and included only participants aged 18 and older. This was checked during the online screening process. One interested person was <18 and excluded (please see Figure 1: Flow chart). Due to the sensitive data assessed in our longitudinal study we decided to focus on adult participants. We rephrased “adult people” into “people aged 18 and older” to clarify. We defined no specific criteria related to menopausal status. (Methods section, Participants, first sentences, p.6)

11. Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress?
If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes.

--> Thank you very much for these interesting recommendations from a clinical perspective. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics. We added information about what is known to shape expectations for other patient group to the discussion section.

We added what we assessed: the self-reported duration of endometriosis symptoms, previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints are dependent on menstrual bleeding.
To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that personal history, prior treatment experiences, pre-operative information and knowledge, stress, and social support are important factors for them (among others). (Measurements, last paragraph, p.8, Results, second paragraph, p.9, Table 2, Discussion section, page 29)

12. Recommend adding a table describing and comparing the four treatment expectation measures.
--> That is a great idea to enhance comprehensibility. We added such a Table to the method section. (See new Table 1)

13. Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify.

--> N=23 reported that the unmet wish to have children is the only reason for laparoscopy, N=150 that complaints and an unmet wish to have children is the reason. Those 23 people displayed in the flow diagram were interested to participate but excluded during our screening process. To be included in our longitudinal study endometriosis-related complaints have to be present because we are interested in persisting complaints despite successful laparoscopy.
As this point seems misleading, we added this aspect describing our target population in the method section. (Methods section, Participants, p.6)

14. If possible, horizontal tables would be easier to read.
--> We ask the editorial office, whether horizontal tables are possible.

15. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results.
--> Thank you, we added this information to the table describing the total sample. (Table 3)

16. Table 2 reports: N female (divers) – typo?
--> Thanks, that was misleading. We changed the format using N(%) and three lines. (Table 4)

17. Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

--> We added some more recommendations for future studies but are careful with clinical implications. From our point of view we need some more data to develop tailored treatment approaches for patients with endometriosis, i.e.:

Longitudinal data to answer the question whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations (or whether expectations do not have an impact on post-operative outcomes - against our hypotheses)

qualitative interviews to understand expectation of people with endometriosis in more depth and knowledge about factors shaping expectations in this patient group

As we are currently analyzing the data above and this manuscript ‘only’ uses pre-operative baseline data of our mixed-method clinical observational study (over a 12-month period, plus two additional study modules) we are we are confident to provide more findings in the future to develop a tailored treatment approach for patients with endometriosis. That would be the overarching objective of our research project. (Discussion section, Implications for practice and research, first paragraph, p. 28/29)
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

--> Thank you very much for your time and valuable feedback, especially from the clinical perspective. The manuscript has a methodological focus on expectations, but we agree that the clinical perspective is also very interesting and should be considered more deeply.

2. General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations).
New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

--> Thank you for this comment. We restructured the paragraph describing our study aims for a better flow and consistency throughout the manuscript. The first aim is now to describe treatment expectations (including cluster), the second aim is comparing expectation measures (including convergent and discriminant validity) (Introduction, p. 5 (Aims and hypotheses). We checked the order in the whole manuscript:

The first paragraph of the introduction focuses on expectations in people with (suspected) endometriosis, the second on measurement aspects.

In the results section, all results referring to the first study aim are presented first (describing expectations including cluster), all results referring to the second aim (comparing measures, especially measurement validity) afterwards.

Same in the summary of the discussion and implications for practice and research

Yet, we did not describe variables such as depression, pain catastrophizing and anxiety in the introduction, because we use those only to interpret the discriminant validity of expectation measures (please see second hypothesis) and to give a brief descriptive overview of the sample under analysis. In this paper, we do not focus on relationships of those constructs from a clinical perspective. Nevertheless, we assessed those constructs in our study, because depression, pain catastrophizing and anxiety seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references).
Because readers (e.g., reviewer 1) seem to be interested in clinical data, we added what we assessed to describe the sample more deeply. (Introduction, first paragraph, p. 5, Reference list)

3. It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction).

--> Thank you for this note. We added the information that only pre-operative variables were considered to different parts of the manuscript. (Abstract – Methods p. 4; Aims and Hypotheses p.5; Methods, first sentence p.6; Discussion – Summary, first sentence p.26)

4. It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.
--> We added information on effect sizes for pain, depression, analgesic treatments, and postsurgery quality of life. (Introduction, second sentence, p.4)

5. Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.
--> We totally agree, thanks for this important recommendation. We used people and participants instead of women. (whole manuscript)

6. Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

--> Thank you for these recommendations. Due to the limited space of 300 words, we deleted the sentence about the PVE to include the age range. We restructured the order of sentences to clarify our research aims and corresponding results and conclusions (see also general comment above). We added a second recommendation for future studies and rephrased the first to clarify. Because of this we deleted some words in the abstract to comply with the word limit.
After discussion, we decided not to include all measures in the abstract due to limited space. The expectation measurement is the focus of the manuscript, the measures depressive symptoms, anxiety and pain catastrophizing were primarily used to analyse discriminant validity. (Abstract, p.4)

7. Keywords.
Recommend adding NRS and PDI to the keywords.

--> We added both to the keywords. (keywords)

8. Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

--> We added a citation for this sentence (Chiantera V, Abesadze E, Mechsner S. How to Understand the Complexity of Endometriosis-Related Pain. Journal of Endometriosis and Pelvic Pain Disorders 2017; 9(1):30–8. DOI:10.5301/je.5000271.). (Introduction, first paragraph, p. 5, reference list)

9. Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

--> We assessed depression, pain catastrophizing and anxiety in our longitudinal study, because those constructs seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references). (Introduction, first paragraph, p. 5, Reference list)

10. Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status?

--> We recruited and included only participants aged 18 and older. This was checked during the online screening process. One interested person was <18 and excluded (please see Figure 1: Flow chart). Due to the sensitive data assessed in our longitudinal study we decided to focus on adult participants. We rephrased “adult people” into “people aged 18 and older” to clarify. We defined no specific criteria related to menopausal status. (Methods section, Participants, first sentences, p.6)

11. Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress?
If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes.

--> Thank you very much for these interesting recommendations from a clinical perspective. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics. We added information about what is known to shape expectations for other patient group to the discussion section.

We added what we assessed: the self-reported duration of endometriosis symptoms, previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints are dependent on menstrual bleeding.
To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that personal history, prior treatment experiences, pre-operative information and knowledge, stress, and social support are important factors for them (among others). (Measurements, last paragraph, p.8, Results, second paragraph, p.9, Table 2, Discussion section, page 29)

12. Recommend adding a table describing and comparing the four treatment expectation measures.
--> That is a great idea to enhance comprehensibility. We added such a Table to the method section. (See new Table 1)

13. Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify.

--> N=23 reported that the unmet wish to have children is the only reason for laparoscopy, N=150 that complaints and an unmet wish to have children is the reason. Those 23 people displayed in the flow diagram were interested to participate but excluded during our screening process. To be included in our longitudinal study endometriosis-related complaints have to be present because we are interested in persisting complaints despite successful laparoscopy.
As this point seems misleading, we added this aspect describing our target population in the method section. (Methods section, Participants, p.6)

14. If possible, horizontal tables would be easier to read.
--> We ask the editorial office, whether horizontal tables are possible.

15. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results.
--> Thank you, we added this information to the table describing the total sample. (Table 3)

16. Table 2 reports: N female (divers) – typo?
--> Thanks, that was misleading. We changed the format using N(%) and three lines. (Table 4)

17. Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

--> We added some more recommendations for future studies but are careful with clinical implications. From our point of view we need some more data to develop tailored treatment approaches for patients with endometriosis, i.e.:

Longitudinal data to answer the question whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations (or whether expectations do not have an impact on post-operative outcomes - against our hypotheses)

qualitative interviews to understand expectation of people with endometriosis in more depth and knowledge about factors shaping expectations in this patient group

As we are currently analyzing the data above and this manuscript ‘only’ uses pre-operative baseline data of our mixed-method clinical observational study (over a 12-month period, plus two additional study modules) we are we are confident to provide more findings in the future to develop a tailored treatment approach for patients with endometriosis. That would be the overarching objective of our research project. (Discussion section, Implications for practice and research, first paragraph, p. 28/29)
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

09 Sep 2024

Author Response
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of ... Continue reading
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

--> Thank you very much for your time and valuable feedback, especially from the clinical perspective. The manuscript has a methodological focus on expectations, but we agree that the clinical perspective is also very interesting and should be considered more deeply.

2. General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations).
New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

--> Thank you for this comment. We restructured the paragraph describing our study aims for a better flow and consistency throughout the manuscript. The first aim is now to describe treatment expectations (including cluster), the second aim is comparing expectation measures (including convergent and discriminant validity) (Introduction, p. 5 (Aims and hypotheses). We checked the order in the whole manuscript:

The first paragraph of the introduction focuses on expectations in people with (suspected) endometriosis, the second on measurement aspects.

In the results section, all results referring to the first study aim are presented first (describing expectations including cluster), all results referring to the second aim (comparing measures, especially measurement validity) afterwards.

Same in the summary of the discussion and implications for practice and research

Yet, we did not describe variables such as depression, pain catastrophizing and anxiety in the introduction, because we use those only to interpret the discriminant validity of expectation measures (please see second hypothesis) and to give a brief descriptive overview of the sample under analysis. In this paper, we do not focus on relationships of those constructs from a clinical perspective. Nevertheless, we assessed those constructs in our study, because depression, pain catastrophizing and anxiety seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references).
Because readers (e.g., reviewer 1) seem to be interested in clinical data, we added what we assessed to describe the sample more deeply. (Introduction, first paragraph, p. 5, Reference list)

3. It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction).

--> Thank you for this note. We added the information that only pre-operative variables were considered to different parts of the manuscript. (Abstract – Methods p. 4; Aims and Hypotheses p.5; Methods, first sentence p.6; Discussion – Summary, first sentence p.26)

4. It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.
--> We added information on effect sizes for pain, depression, analgesic treatments, and postsurgery quality of life. (Introduction, second sentence, p.4)

5. Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.
--> We totally agree, thanks for this important recommendation. We used people and participants instead of women. (whole manuscript)

6. Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

--> Thank you for these recommendations. Due to the limited space of 300 words, we deleted the sentence about the PVE to include the age range. We restructured the order of sentences to clarify our research aims and corresponding results and conclusions (see also general comment above). We added a second recommendation for future studies and rephrased the first to clarify. Because of this we deleted some words in the abstract to comply with the word limit.
After discussion, we decided not to include all measures in the abstract due to limited space. The expectation measurement is the focus of the manuscript, the measures depressive symptoms, anxiety and pain catastrophizing were primarily used to analyse discriminant validity. (Abstract, p.4)

7. Keywords.
Recommend adding NRS and PDI to the keywords.

--> We added both to the keywords. (keywords)

8. Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

--> We added a citation for this sentence (Chiantera V, Abesadze E, Mechsner S. How to Understand the Complexity of Endometriosis-Related Pain. Journal of Endometriosis and Pelvic Pain Disorders 2017; 9(1):30–8. DOI:10.5301/je.5000271.). (Introduction, first paragraph, p. 5, reference list)

9. Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

--> We assessed depression, pain catastrophizing and anxiety in our longitudinal study, because those constructs seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references). (Introduction, first paragraph, p. 5, Reference list)

10. Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status?

--> We recruited and included only participants aged 18 and older. This was checked during the online screening process. One interested person was <18 and excluded (please see Figure 1: Flow chart). Due to the sensitive data assessed in our longitudinal study we decided to focus on adult participants. We rephrased “adult people” into “people aged 18 and older” to clarify. We defined no specific criteria related to menopausal status. (Methods section, Participants, first sentences, p.6)

11. Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress?
If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes.

--> Thank you very much for these interesting recommendations from a clinical perspective. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics. We added information about what is known to shape expectations for other patient group to the discussion section.

We added what we assessed: the self-reported duration of endometriosis symptoms, previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints are dependent on menstrual bleeding.
To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that personal history, prior treatment experiences, pre-operative information and knowledge, stress, and social support are important factors for them (among others). (Measurements, last paragraph, p.8, Results, second paragraph, p.9, Table 2, Discussion section, page 29)

12. Recommend adding a table describing and comparing the four treatment expectation measures.
--> That is a great idea to enhance comprehensibility. We added such a Table to the method section. (See new Table 1)

13. Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify.

--> N=23 reported that the unmet wish to have children is the only reason for laparoscopy, N=150 that complaints and an unmet wish to have children is the reason. Those 23 people displayed in the flow diagram were interested to participate but excluded during our screening process. To be included in our longitudinal study endometriosis-related complaints have to be present because we are interested in persisting complaints despite successful laparoscopy.
As this point seems misleading, we added this aspect describing our target population in the method section. (Methods section, Participants, p.6)

14. If possible, horizontal tables would be easier to read.
--> We ask the editorial office, whether horizontal tables are possible.

15. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results.
--> Thank you, we added this information to the table describing the total sample. (Table 3)

16. Table 2 reports: N female (divers) – typo?
--> Thanks, that was misleading. We changed the format using N(%) and three lines. (Table 4)

17. Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

--> We added some more recommendations for future studies but are careful with clinical implications. From our point of view we need some more data to develop tailored treatment approaches for patients with endometriosis, i.e.:

Longitudinal data to answer the question whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations (or whether expectations do not have an impact on post-operative outcomes - against our hypotheses)

qualitative interviews to understand expectation of people with endometriosis in more depth and knowledge about factors shaping expectations in this patient group

As we are currently analyzing the data above and this manuscript ‘only’ uses pre-operative baseline data of our mixed-method clinical observational study (over a 12-month period, plus two additional study modules) we are we are confident to provide more findings in the future to develop a tailored treatment approach for patients with endometriosis. That would be the overarching objective of our research project. (Discussion section, Implications for practice and research, first paragraph, p. 28/29)
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

--> Thank you very much for your time and valuable feedback, especially from the clinical perspective. The manuscript has a methodological focus on expectations, but we agree that the clinical perspective is also very interesting and should be considered more deeply.

2. General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations).
New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

--> Thank you for this comment. We restructured the paragraph describing our study aims for a better flow and consistency throughout the manuscript. The first aim is now to describe treatment expectations (including cluster), the second aim is comparing expectation measures (including convergent and discriminant validity) (Introduction, p. 5 (Aims and hypotheses). We checked the order in the whole manuscript:

The first paragraph of the introduction focuses on expectations in people with (suspected) endometriosis, the second on measurement aspects.

In the results section, all results referring to the first study aim are presented first (describing expectations including cluster), all results referring to the second aim (comparing measures, especially measurement validity) afterwards.

Same in the summary of the discussion and implications for practice and research

Yet, we did not describe variables such as depression, pain catastrophizing and anxiety in the introduction, because we use those only to interpret the discriminant validity of expectation measures (please see second hypothesis) and to give a brief descriptive overview of the sample under analysis. In this paper, we do not focus on relationships of those constructs from a clinical perspective. Nevertheless, we assessed those constructs in our study, because depression, pain catastrophizing and anxiety seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references).
Because readers (e.g., reviewer 1) seem to be interested in clinical data, we added what we assessed to describe the sample more deeply. (Introduction, first paragraph, p. 5, Reference list)

3. It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction).

--> Thank you for this note. We added the information that only pre-operative variables were considered to different parts of the manuscript. (Abstract – Methods p. 4; Aims and Hypotheses p.5; Methods, first sentence p.6; Discussion – Summary, first sentence p.26)

4. It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.
--> We added information on effect sizes for pain, depression, analgesic treatments, and postsurgery quality of life. (Introduction, second sentence, p.4)

5. Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.
--> We totally agree, thanks for this important recommendation. We used people and participants instead of women. (whole manuscript)

6. Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

--> Thank you for these recommendations. Due to the limited space of 300 words, we deleted the sentence about the PVE to include the age range. We restructured the order of sentences to clarify our research aims and corresponding results and conclusions (see also general comment above). We added a second recommendation for future studies and rephrased the first to clarify. Because of this we deleted some words in the abstract to comply with the word limit.
After discussion, we decided not to include all measures in the abstract due to limited space. The expectation measurement is the focus of the manuscript, the measures depressive symptoms, anxiety and pain catastrophizing were primarily used to analyse discriminant validity. (Abstract, p.4)

7. Keywords.
Recommend adding NRS and PDI to the keywords.

--> We added both to the keywords. (keywords)

8. Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

--> We added a citation for this sentence (Chiantera V, Abesadze E, Mechsner S. How to Understand the Complexity of Endometriosis-Related Pain. Journal of Endometriosis and Pelvic Pain Disorders 2017; 9(1):30–8. DOI:10.5301/je.5000271.). (Introduction, first paragraph, p. 5, reference list)

9. Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

--> We assessed depression, pain catastrophizing and anxiety in our longitudinal study, because those constructs seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references). (Introduction, first paragraph, p. 5, Reference list)

10. Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status?

--> We recruited and included only participants aged 18 and older. This was checked during the online screening process. One interested person was <18 and excluded (please see Figure 1: Flow chart). Due to the sensitive data assessed in our longitudinal study we decided to focus on adult participants. We rephrased “adult people” into “people aged 18 and older” to clarify. We defined no specific criteria related to menopausal status. (Methods section, Participants, first sentences, p.6)

11. Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress?
If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes.

--> Thank you very much for these interesting recommendations from a clinical perspective. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics. We added information about what is known to shape expectations for other patient group to the discussion section.

We added what we assessed: the self-reported duration of endometriosis symptoms, previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints are dependent on menstrual bleeding.
To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that personal history, prior treatment experiences, pre-operative information and knowledge, stress, and social support are important factors for them (among others). (Measurements, last paragraph, p.8, Results, second paragraph, p.9, Table 2, Discussion section, page 29)

12. Recommend adding a table describing and comparing the four treatment expectation measures.
--> That is a great idea to enhance comprehensibility. We added such a Table to the method section. (See new Table 1)

13. Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify.

--> N=23 reported that the unmet wish to have children is the only reason for laparoscopy, N=150 that complaints and an unmet wish to have children is the reason. Those 23 people displayed in the flow diagram were interested to participate but excluded during our screening process. To be included in our longitudinal study endometriosis-related complaints have to be present because we are interested in persisting complaints despite successful laparoscopy.
As this point seems misleading, we added this aspect describing our target population in the method section. (Methods section, Participants, p.6)

14. If possible, horizontal tables would be easier to read.
--> We ask the editorial office, whether horizontal tables are possible.

15. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results.
--> Thank you, we added this information to the table describing the total sample. (Table 3)

16. Table 2 reports: N female (divers) – typo?
--> Thanks, that was misleading. We changed the format using N(%) and three lines. (Table 4)

17. Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

--> We added some more recommendations for future studies but are careful with clinical implications. From our point of view we need some more data to develop tailored treatment approaches for patients with endometriosis, i.e.:

Longitudinal data to answer the question whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations (or whether expectations do not have an impact on post-operative outcomes - against our hypotheses)

qualitative interviews to understand expectation of people with endometriosis in more depth and knowledge about factors shaping expectations in this patient group

As we are currently analyzing the data above and this manuscript ‘only’ uses pre-operative baseline data of our mixed-method clinical observational study (over a 12-month period, plus two additional study modules) we are we are confident to provide more findings in the future to develop a tailored treatment approach for patients with endometriosis. That would be the overarching objective of our research project. (Discussion section, Implications for practice and research, first paragraph, p. 28/29)
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Reviewer Report 01 Jul 2024

Michel Canis, CHU Clermont-Ferrand, Department of Gynecologic Surgery, Université Clermont Auvergne, Clermont-Ferrand, France

Approved with Reservations

https://doi.org/10.5256/f1000research.159318.r268828

This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.

When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Endometriosis and minimally invasive surgery

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Author Response 09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

09 Sep 2024

Author Response

Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. ... Continue reading Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

--> Thank you very much for your valuable clinical perspective and suggestions on how to improve our manuscript.

2. I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

--> In this manuscript, we included people with suspected endometriosis who filled out our online questionnaire before laparoscopy. Unfortunately, we have no data about the anatomical severity of the disease, only limited and self-reported data for those participants.
A subsample of 395 people underwent laparoscopy and received an endometriosis diagnosis. We have more medical data (e.g., #ENZIAN, rASRM, deep infiltration) for that subsample, which was followed for one year after the laparoscopy. Two manuscripts are currently in progress, analyzing these medical and psychological factors in comparison.

3. Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.
When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

--> We agree that the factors you mentioned likely shape patients’ expectations. Unfortunately, we have limited medical information for this large sample (please see comment above). However, we have added the following data we assessed to the manuscript: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics.

To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that pre-operative information, fears, personal history, and prior experiences are important factors for them (among others). We added this aspect to the section “implications for practice and research”. (Measurements – last paragraph p. 8; Results Table 2 and Descriptive characteristics page 9; Discussion section page 29)

Finally, this manuscript has a methodological focus on expectations but we agree that the clinical perspective is also very interesting. We have added sentences to the discussion section of this manuscript to highlight the clinical perspective and the implications for future research.
(Discussion section, page 28/29)
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

--> Thank you very much for your valuable clinical perspective and suggestions on how to improve our manuscript.

2. I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

--> In this manuscript, we included people with suspected endometriosis who filled out our online questionnaire before laparoscopy. Unfortunately, we have no data about the anatomical severity of the disease, only limited and self-reported data for those participants.
A subsample of 395 people underwent laparoscopy and received an endometriosis diagnosis. We have more medical data (e.g., #ENZIAN, rASRM, deep infiltration) for that subsample, which was followed for one year after the laparoscopy. Two manuscripts are currently in progress, analyzing these medical and psychological factors in comparison.

3. Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.
When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

--> We agree that the factors you mentioned likely shape patients’ expectations. Unfortunately, we have limited medical information for this large sample (please see comment above). However, we have added the following data we assessed to the manuscript: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics.

To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that pre-operative information, fears, personal history, and prior experiences are important factors for them (among others). We added this aspect to the section “implications for practice and research”. (Measurements – last paragraph p. 8; Results Table 2 and Descriptive characteristics page 9; Discussion section page 29)

Finally, this manuscript has a methodological focus on expectations but we agree that the clinical perspective is also very interesting. We have added sentences to the discussion section of this manuscript to highlight the clinical perspective and the implications for future research.
(Discussion section, page 28/29)
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Author Response 09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

09 Sep 2024

Author Response

Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. ... Continue reading Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

--> Thank you very much for your valuable clinical perspective and suggestions on how to improve our manuscript.

2. I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

--> In this manuscript, we included people with suspected endometriosis who filled out our online questionnaire before laparoscopy. Unfortunately, we have no data about the anatomical severity of the disease, only limited and self-reported data for those participants.
A subsample of 395 people underwent laparoscopy and received an endometriosis diagnosis. We have more medical data (e.g., #ENZIAN, rASRM, deep infiltration) for that subsample, which was followed for one year after the laparoscopy. Two manuscripts are currently in progress, analyzing these medical and psychological factors in comparison.

3. Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.
When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

--> We agree that the factors you mentioned likely shape patients’ expectations. Unfortunately, we have limited medical information for this large sample (please see comment above). However, we have added the following data we assessed to the manuscript: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics.

To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that pre-operative information, fears, personal history, and prior experiences are important factors for them (among others). We added this aspect to the section “implications for practice and research”. (Measurements – last paragraph p. 8; Results Table 2 and Descriptive characteristics page 9; Discussion section page 29)

Finally, this manuscript has a methodological focus on expectations but we agree that the clinical perspective is also very interesting. We have added sentences to the discussion section of this manuscript to highlight the clinical perspective and the implications for future research.
(Discussion section, page 28/29)
Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

--> Thank you very much for your valuable clinical perspective and suggestions on how to improve our manuscript.

2. I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

--> In this manuscript, we included people with suspected endometriosis who filled out our online questionnaire before laparoscopy. Unfortunately, we have no data about the anatomical severity of the disease, only limited and self-reported data for those participants.
A subsample of 395 people underwent laparoscopy and received an endometriosis diagnosis. We have more medical data (e.g., #ENZIAN, rASRM, deep infiltration) for that subsample, which was followed for one year after the laparoscopy. Two manuscripts are currently in progress, analyzing these medical and psychological factors in comparison.

3. Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.
When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

--> We agree that the factors you mentioned likely shape patients’ expectations. Unfortunately, we have limited medical information for this large sample (please see comment above). However, we have added the following data we assessed to the manuscript: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics.

To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that pre-operative information, fears, personal history, and prior experiences are important factors for them (among others). We added this aspect to the section “implications for practice and research”. (Measurements – last paragraph p. 8; Results Table 2 and Descriptive characteristics page 9; Discussion section page 29)

Finally, this manuscript has a methodological focus on expectations but we agree that the clinical perspective is also very interesting. We have added sentences to the discussion section of this manuscript to highlight the clinical perspective and the implications for future research.
(Discussion section, page 28/29)
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Michel Canis, Université Clermont Auvergne, Clermont-Ferrand, France
Claire E Lunde, Lunde Consulting, LLC, Washington, USA
Diego Raimondo, Universitaria di Bologna, Bologna, Italy
Sonia R Grover, The University of Melbourne, Melbourne, Australia

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04 Oct 2024 | for Version 2

Sonia R Grover, Royal Children's Hospital, Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Victoria, Australia

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

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Gynaecologist and a Pain Medicine Specialist – with research interest in period and pelvic pain

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25 Sep 2024 | for Version 2

Claire E Lunde, Lunde Consulting, LLC, Washington, DC, USA

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Approved

Thank you to the authors for thoroughly addressing my questions and concerns, and for your valuable contributions to advancing the understanding of endometriosis. The manuscript is scientifically sound in its current form.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Public Health, Behavioral Sciences, Neuroscience, Endometriosis, and Female-Pain,

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19 Sep 2024 | for Version 2

Diego Raimondo, Division of Gynaecology and Human Reproduction Physiopathology, S. ORSOLA, Universitaria di Bologna, Bologna, Italy

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

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endometriosis

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10 Jul 2024 | for Version 1

Claire E Lunde, Lunde Consulting, LLC, Washington, DC, USA

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Public Health, Behavioral Sciences, Neuroscience, Endometriosis, and Female-Pain,

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Author Response

09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. Summary.
Thank you for the opportunity to review the manuscript entitled “Assessment of treatment expectations in women with suspected endometriosis: A psychometric analysis” submitted to F1000Research. The well-written manuscript compared different but related measurements for assessing treatment expectations and thoroughly explored treatment expectations in a large sample of adult patients presenting for endometriosis-suspected laparoscopic surgery. The overarching aims of the current study were to:
(1) Psychometrically analyze and compare four treatment expectation measurements: TEX-Q, GEEE, NRS, & PDI.
(2) Describe treatment expectations and potentially influential factors (e.g., depression, anxiety, pain catastrophizing) in adult patients with suspected endometriosis.
I recommend adding a third aim: (3) Compare treatment expectation results to those of similar conditions and the general population.

The findings of this study are significant as they provide new insights into treatment expectations for a wide range of patients with endometriosis. These insights could have important implications for personalized patient care and improved treatment outcomes.

--> Thank you very much for your time and valuable feedback, especially from the clinical perspective. The manuscript has a methodological focus on expectations, but we agree that the clinical perspective is also very interesting and should be considered more deeply.

2. General.
The study aims, and hypotheses could be more consistent throughout the manuscript. It would be helpful to the reader if the flow were consistent for each section (e.g., study Aim 1: compare treatment measures; Study Aim 2: describe treatment expectations).
New topics and variables are introduced throughout the manuscript. For example, depression, pain catastrophizing, anxiety, and previous experience with laparoscopy aren’t really mentioned in the abstract or introduction. The same is true when comparing treatment expectations to other conditions and the general population. To improve the manuscript’s readability and coherence, the authors could consider providing a clear outline of the manuscript’s structure in the introduction.

--> Thank you for this comment. We restructured the paragraph describing our study aims for a better flow and consistency throughout the manuscript. The first aim is now to describe treatment expectations (including cluster), the second aim is comparing expectation measures (including convergent and discriminant validity) (Introduction, p. 5 (Aims and hypotheses). We checked the order in the whole manuscript:

The first paragraph of the introduction focuses on expectations in people with (suspected) endometriosis, the second on measurement aspects.
In the results section, all results referring to the first study aim are presented first (describing expectations including cluster), all results referring to the second aim (comparing measures, especially measurement validity) afterwards.
Same in the summary of the discussion and implications for practice and research

Yet, we did not describe variables such as depression, pain catastrophizing and anxiety in the introduction, because we use those only to interpret the discriminant validity of expectation measures (please see second hypothesis) and to give a brief descriptive overview of the sample under analysis. In this paper, we do not focus on relationships of those constructs from a clinical perspective. Nevertheless, we assessed those constructs in our study, because depression, pain catastrophizing and anxiety seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references).
Because readers (e.g., reviewer 1) seem to be interested in clinical data, we added what we assessed to describe the sample more deeply. (Introduction, first paragraph, p. 5, Reference list)

3. It would be helpful if the authors explicitly stated that only the variables pre-surgery were analyzed. Thus, the effects in clinical practice must be inferred from other conditions researched, such as acute/chronic pain, surgeries, breast cancer, and psychiatric disorders (as listed in the introduction).

--> Thank you for this note. We added the information that only pre-operative variables were considered to different parts of the manuscript. (Abstract – Methods p. 4; Aims and Hypotheses p.5; Methods, first sentence p.6; Discussion – Summary, first sentence p.26)

4. It would be helpful for the reader if the authors listed these specific clinical effects and recommendations for future researchers/clinicians.
--> We added information on effect sizes for pain, depression, analgesic treatments, and postsurgery quality of life. (Introduction, second sentence, p.4)

5. Since 13 individuals identified as non-binary, I recommend that the title and manuscript use people or patients with endometriosis rather than women with endometriosis.
--> We totally agree, thanks for this important recommendation. We used people and participants instead of women. (whole manuscript)

6. Abstract.
The abstract provides a concise overview of the study, but it could be improved by including all measures given – depression, anxiety, and pain catastrophizing measures are not listed. In the results section of the abstract, the abbreviation PVE should be spelled out. The authors should also include results for both aims. The average age and age range for the sample should be listed. Lastly, the authors should provide a brief statement on the implications of their findings, which will help readers understand the significance of the study.

--> Thank you for these recommendations. Due to the limited space of 300 words, we deleted the sentence about the PVE to include the age range. We restructured the order of sentences to clarify our research aims and corresponding results and conclusions (see also general comment above). We added a second recommendation for future studies and rephrased the first to clarify. Because of this we deleted some words in the abstract to comply with the word limit.
After discussion, we decided not to include all measures in the abstract due to limited space. The expectation measurement is the focus of the manuscript, the measures depressive symptoms, anxiety and pain catastrophizing were primarily used to analyse discriminant validity. (Abstract, p.4)

7. Keywords.
Recommend adding NRS and PDI to the keywords.

--> We added both to the keywords. (keywords)

8. Introduction.
Please provide a citation for the following sentence on page 4: The five most prevalent symptoms of endometriosis are dysmenorrhea, abdominal pain, dyspareunia, dyschezia, and dysuria.

--> We added a citation for this sentence (Chiantera V, Abesadze E, Mechsner S. How to Understand the Complexity of Endometriosis-Related Pain. Journal of Endometriosis and Pelvic Pain Disorders 2017; 9(1):30–8. DOI:10.5301/je.5000271.). (Introduction, first paragraph, p. 5, reference list)

9. Recommend describing the often-comorbid relationship between anxiety, depression, pain catastrophizing, and endometriosis-related pain & disability.

--> We assessed depression, pain catastrophizing and anxiety in our longitudinal study, because those constructs seem to be associated with persistent complaints after laparoscopy. To make that clear, we added a sentence to the introduction (and three references). (Introduction, first paragraph, p. 5, Reference list)

10. Methods.
Please clarify whether the study recruited participants exclusively aged 18 and older or included a broader age range. Were there any specific criteria related to menopausal status?

--> We recruited and included only participants aged 18 and older. This was checked during the online screening process. One interested person was <18 and excluded (please see Figure 1: Flow chart). Due to the sensitive data assessed in our longitudinal study we decided to focus on adult participants. We rephrased “adult people” into “people aged 18 and older” to clarify. We defined no specific criteria related to menopausal status. (Methods section, Participants, first sentences, p.6)

11. Consider including details about participants’ family history, especially if close relatives (e.g., mother, sister, aunt) had endometriosis or underwent laparoscopic surgery. These social factors may impact expectations. Was this the participant’s first surgery or significant medical treatment? Were there any previous trauma experiences or current chronic stress?
If possible, include the duration of endometriosis symptoms, age at diagnosis, treatments attempted, and any prior endocrine therapy. Many patients use social networks or endometriosis support groups for information. Recommend acknowledging the influence of these sources and other anecdotal evidence. Include how well-informed participants were about endometriosis and the possible surgical outcomes.

--> Thank you very much for these interesting recommendations from a clinical perspective. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics. We added information about what is known to shape expectations for other patient group to the discussion section.

We added what we assessed: the self-reported duration of endometriosis symptoms, previous experience with laparoscopy (yes/no), current endocrine therapy (yes/no), and whether complaints are dependent on menstrual bleeding.
To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that personal history, prior treatment experiences, pre-operative information and knowledge, stress, and social support are important factors for them (among others). (Measurements, last paragraph, p.8, Results, second paragraph, p.9, Table 2, Discussion section, page 29)

12. Recommend adding a table describing and comparing the four treatment expectation measures.
--> That is a great idea to enhance comprehensibility. We added such a Table to the method section. (See new Table 1)

13. Results.
Figure 1 reports n=23 unmet wish to have children, and Table 1 reports n=150 unmet wish to have children -- please clarify.

--> N=23 reported that the unmet wish to have children is the only reason for laparoscopy, N=150 that complaints and an unmet wish to have children is the reason. Those 23 people displayed in the flow diagram were interested to participate but excluded during our screening process. To be included in our longitudinal study endometriosis-related complaints have to be present because we are interested in persisting complaints despite successful laparoscopy.
As this point seems misleading, we added this aspect describing our target population in the method section. (Methods section, Participants, p.6)

14. If possible, horizontal tables would be easier to read.
--> We ask the editorial office, whether horizontal tables are possible.

15. Previous experience with laparoscopy was reported in the cluster results but not the descriptive results.
--> Thank you, we added this information to the table describing the total sample. (Table 3)

16. Table 2 reports: N female (divers) – typo?
--> Thanks, that was misleading. We changed the format using N(%) and three lines. (Table 4)

17. Discussion.
What specific individual patient metrics/characteristics do the authors suggest should be investigated in future studies? Similar to the abstract, a more in-depth analysis of the conclusions and implications should be included. What should a clinical population do with the current findings, and what implications should be considered for future studies? This is a fantastic study – specific steps on “what next” would be incredibly beneficial to understanding tailored treatment approaches for patients with endometriosis.

--> We added some more recommendations for future studies but are careful with clinical implications. From our point of view we need some more data to develop tailored treatment approaches for patients with endometriosis, i.e.:

Longitudinal data to answer the question whether more positive expectations lead to better treatment outcomes or disappointment due to overly optimistic expectations (or whether expectations do not have an impact on post-operative outcomes - against our hypotheses)
qualitative interviews to understand expectation of people with endometriosis in more depth and knowledge about factors shaping expectations in this patient group

As we are currently analyzing the data above and this manuscript ‘only’ uses pre-operative baseline data of our mixed-method clinical observational study (over a 12-month period, plus two additional study modules) we are we are confident to provide more findings in the future to develop a tailored treatment approach for patients with endometriosis. That would be the overarching objective of our research project. (Discussion section, Implications for practice and research, first paragraph, p. 28/29)

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01 Jul 2024 | for Version 1

Michel Canis, CHU Clermont-Ferrand, Department of Gynecologic Surgery, Université Clermont Auvergne, Clermont-Ferrand, France

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Endometriosis and minimally invasive surgery

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Responses (1)

Author Response

09 Sep 2024

Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany

Numbered Reviewer’s comments --> Authors’ responses in italic (Change in manuscript new word version in parentheses)

1. This is large study about patients expectation before a laparoscopic treatment of endometriosis. This point is very interesting. The methods used appear appropriate, but I am not a specialist of treatment expectations studies.

--> Thank you very much for your valuable clinical perspective and suggestions on how to improve our manuscript.

2. I would suggest to include data about the anatomical severity of the disease. A global approach of endometriosis is in my mind always somewhat misleading. Treatment expectations from a laparoscopic procedure are likely very different from a patient who has a mechanical infertility related to adhesions to another one who has no disease at ultrasound and complains of severe pain.

--> In this manuscript, we included people with suspected endometriosis who filled out our online questionnaire before laparoscopy. Unfortunately, we have no data about the anatomical severity of the disease, only limited and self-reported data for those participants.
A subsample of 395 people underwent laparoscopy and received an endometriosis diagnosis. We have more medical data (e.g., #ENZIAN, rASRM, deep infiltration) for that subsample, which was followed for one year after the laparoscopy. Two manuscripts are currently in progress, analyzing these medical and psychological factors in comparison.

3. Data about pre operative information and particularly about the risks of complications would be essential to understand these expectation. A patient "afraid of a bowel fistula" may have different expectation that patients with expected minimal or moderate disease based on preoperative imaging.
When dealing with pain treatment these data would be very interesting. I would also recommend to collect data about the personal history of these patients, trauma and violence may influence the trust in treatment and the results of this very interesting study. I think that most of these data are available to the authors and could be added to the paper.

--> We agree that the factors you mentioned likely shape patients’ expectations. Unfortunately, we have limited medical information for this large sample (please see comment above). However, we have added the following data we assessed to the manuscript: self-reported duration of symptoms, previous experience with laparoscopy, current endocrine therapy, and whether complaints are dependent on menstrual bleeding. Due to the limited space in the preoperative online questionnaire and the lack of previous evidence focusing on the expectations of patients with endometriosis, we decided to concentrate on assessing expectations through various measurements as well as disability, complaints, anxiety, depression, sociodemographics, and some medical characteristics.

To the best of our knowledge, our study is the first to investigate expectations in patients with endometriosis. To gain a deeper understanding of these expectations, we also conducted qualitative interviews before and after laparoscopy in an additional study module. The corresponding manuscript is currently under review, and if possible, we would be pleased to link it to this manuscript. As you suggested, patients reported that pre-operative information, fears, personal history, and prior experiences are important factors for them (among others). We added this aspect to the section “implications for practice and research”. (Measurements – last paragraph p. 8; Results Table 2 and Descriptive characteristics page 9; Discussion section page 29)

Finally, this manuscript has a methodological focus on expectations but we agree that the clinical perspective is also very interesting. We have added sentences to the discussion section of this manuscript to highlight the clinical perspective and the implications for future research.
(Discussion section, page 28/29)

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Assessment of treatment expectations in people with suspected endometriosis: A psychometric analysis

Abstract

Background

Method

Results

Conclusions

Trial Registration Number

Keywords

Revised Amendments from Version 1

Introduction

Measurement of expectations

Aims and hypotheses

Methods

Participants

Recruitment and procedure

Measurements

Table 1. Overview of expectation measurements under analysis.

Statistical analysis

Results

Descriptive characteristics

Figure 1. Flow chart of study participation.

Table 2. Descriptive characteristics of the sample under analysis (N=699).

Figure 2. Distributions of treatment expectation measurements using raincloud plots.

Cluster of treatment expectations

Figure 3. Silhouette and elbow plots for the exploration of possible factors.

Table 3. Characteristics of the four identified clusters.

Figure 4. Distribution of the GEEE values for each cluster.

Convergent validity: Bivariate associations of all treatment expectation measurements

Figure 5. Heatmap representing pearson correlation coefficients between treatment expectation measurements and further psychological constructs.

Table 4. Correlation matrix including all treatment expectation measurements and further psychological constructs under analysis (N=699).

Discriminant validity: Bivariate associations of treatment expectation measurements and further psychological constructs

Discussion

Summary

Comparison with existing literature

Strengths and limitations

Implications for practice and research

Ethical approval

Data availability

Acknowledgements

References

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