Lifestyle factors and symptom burden in endometriosis: an exploratory mixed-methods analysis of nutrition, physical activity, and psychosocial well-being

BACKGROUND: Endometriosis affects approximately 10% of reproductive-age women worldwide, with symptom burden significantly impacting quality of life. While current treatment guidelines focus primarily on hormonal and surgical interventions, the role of lifestyle factors in symptom management remains underexplored. Major clinical guidelines acknowledge insufficient evidence for specific lifestyle recommendations, highlighting the need for exploratory research. Therefore, our aim is to explore potential associations between lifestyle factors (nutrition, physical activity, psychosocial well-being) and symptom burden in women with endometriosis using a mixed-methods approach. METHODS: A convergent mixed-method design combining a cross-sectional online survey (n = 378) with semi-structured expert interviews (n = 5) was conducted between January and March 2025. Lifestyle factors were assessed using study-specific composite indices for dietary habits, physical activity, and psychosocial well-being. Symptom burden was evaluated using validated endometriosis-related items informed by established assessment tools and 11-point numeric rating scales for symptom frequency and intensity. RESULTS: In exploratory analyses, the Dietary Habits Index was not significantly associated with overall symptom burden in the study cohort. However, subgroup analysis revealed a weak negative correlation in participants without food intolerances (β = -0.144, p = 0.021). Physical activity and psychosocial well-being indices showed weak associations with symptom burden (physical activity: β = 0.133, p = 0.010; psychosocial well-being: β = -0.261, p < 0.001). Expert interviews emphasized the importance of individualized, multimodal approaches and highlighted psychosocial factors as particularly relevant for symptom management. CONCLUSIONS: This exploratory study identified weak and context-dependent associations between selected lifestyle factors and endometriosis symptom burden, with psychosocial well-being showing the most consistent relationship. The findings highlight the potential relevance of individualized lifestyle support as an adjunct to conventional medical care. Given the cross-sectional design and methodological limitations, these hypothesis-generating findings require confirmation in longitudinal and intervention studies.