# Enriched environments: a multi-level integrative medicine intervention for endometriosis

> **NIH NIH R21** · PONCE SCHOOL OF MEDICINE · 2020 · $236,953

## Abstract

ABSTRACT
 Endometriosis is a chronic inflammatory and painful condition that affects 176 million women in their
reproductive years worldwide, and has substantial costs related to health care and loss in work productivity. The
symptoms of endometriosis—chronic, incapacitating pain and infertility—cause high levels of stress, leading to
poor quality of life (QoL) in affected women. Stress is known to affect the physiology of pelvic organs and to
disturb the HPA axis leading to chronic, painful, inflammatory disorders. We have documented a relationship
between stress, HPA dysregulation and endometriosis. In an animal model we demonstrated that stress
exacerbates disease manifestations whereas the ability to control the level of stress results in smaller lesions
and less inflammation. Further, we have identified social support as one of the parameters that most significantly
impacts QoL in women with endometriosis. Environmental enrichment (EE) can produce beneficial effects in
models of chronic diseases improving anxiety and immune-related disturbances, and can block the effects of
chronic stress on brain hippocampal integrity. We recently found that EE can effectively minimize lesion size
and numbers, and also decreased anxiety in this animal model. Together, these data support the basic premise
of this proposal: EE interventions can overcome chronic stress thus reversing the negative influences on mental
health status (depression/anxiety levels), inflammation/HPA axis (inflammatory cytokines, cortisol), and clinical
course (pain levels) of endometriosis, leading to improved QoL. The central objective of this study is to refine
and test a multi-modal intervention based on the EE paradigm tested in our animal model and translated it to the
human scenario, to produce data on its effectiveness. We hypothesize that the EE interventions can be
effectively adapted for women with endometriosis resulting in pain reduction and improved QoL.
 To test our hypothesis, our multidisciplinary team with combined expertise in endometriosis, psychology,
physiology, neuroscience, gynecology, and stress management has adapted the experimental EE model to the
human scenario. By applying a combined approach (systematic review of the literature, and input from a patient
advisory committee) the team has jointly developed six EE modules to be tested in human subjects. This study
consists of two specific aims. In Aim 1, we will assess feasibility and acceptability of the EE intervention as
adjuvant to standard of care through a collaborative approach involving a patient population, while also assessing
effectiveness of the recruitment strategies used (e.g., physician’s office vs. print and social media). Under Aim
2, we will conduct a randomized clinical trial (RCT) of the EE intervention to determine its efficacy in
improvement of pelvic pain and QoL (primary outcomes), and inflammation, HPA axis disturbances, and mental
health (depression, anxiety) (secondary outcomes), m...

## Key facts

- **NIH application ID:** 9969536
- **Project number:** 5R21HD098481-02
- **Recipient organization:** PONCE SCHOOL OF MEDICINE
- **Principal Investigator:** IDHALIZ FLORES
- **Activity code:** R21 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $236,953
- **Award type:** 5
- **Project period:** 2019-07-01 → 2023-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9969536

## Citation

> US National Institutes of Health, RePORTER application 9969536, Enriched environments: a multi-level integrative medicine intervention for endometriosis (5R21HD098481-02). Retrieved via AI Analytics 2026-05-28 from https://api.ai-analytics.org/grant/nih/9969536. Licensed CC0.

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