Executive Functions Mediate Between Endometriosis Burden and Women’s Daily Life

Purpose: To examine (1) group differences in executive functioning, disease burden, occupational balance and quality of life between women with endometriosis and healthy controls; (2) associations between pain-related and psychological disease burden -specifically pain catastrophizing and emotional distress- and occupational balance and quality of life; and (3) whether executive functioning mediates the relationships between disease burden and quality of life and occupational balance. Patients and Methods: This cross-sectional correlational study included 103 women aged 18– 35 years, compromising 43 women with clinically confirmed endometriosis recruited from a specialized endometriosis clinic and 60 age-matched healthy controls. Disease burden was assessed using measures of pain severity (Visual Analog Scale – VAS), pain catastrophizing (Pain catastrophising scale -PCS), and emotional distress (Depression Anxiety Stress Scale – DASS21). Executive functioning (Barkley Deficits in Executive Functioning Scale–Short Form -BDEFS-SF), occupational balance (Occupational Balance Questionnaire – OBQ11), and quality of life (World Health Organization Quality of Life–BREF - WHOQOL-BREF). Socio-demographic and clinical characteristics were collected to characterize the study sample and inform interpretation of the findings. Mediation analyses were conducted to examine executive functioning as a mechanism linking disease burden to functional outcomes, using Hayes’ PROCESS. Results: Compared with healthy controls, women with endometriosis reported significantly greater pain severity, pain catastrophizing, emotional distress, and executive functioning difficulties, alongside lower occupational balance and reduced quality of life (all p < 0.001). Within the endometriosis group, higher levels of pain catastrophizing and emotional distress were associated with poorer executive functioning, which in turn was associated with lower occupational balance and quality of life (all p < 0.001). Mediation analyses indicated that executive functioning fully mediated the associations between psychological disease burden and both quality of life and occupational balance, such that the direct associations between psychological disease burden and functional outcomes were no longer significant after accounting for executive functioning. Conclusion: Executive functioning represents a central mechanism through which pain-related and psychological disease burden translate into disruptions in daily life among women with endometriosis. These findings extend symptom-based models toward a more integrative, function-oriented understanding of endometriosis and highlight executive functioning as a meaningful target for comprehensive, person-centered assessment and intervention. Keywords: endometriosis, meta-cognition, executive functions, occupational balance, quality of life