Do women with endometriosis have to worry about sex?

Adenomyosis and coexisting gynecologic pathologies: How often do they coexist?

OBJECTIVE

To evaluate the presence of gynecologic pathologies accompanying adenomyosis among the hysterectomy specimens performed for various gynecologic indications.

METHODS

This multicenter retrospective cohort study included women who underwent hysterectomy for various gynecologic indications and were diagnosed with adenomyosis at tertiary care centers. Eligible women were classified into two groups based on histopathologic results: Group 1-patients with only adenomyosis (n = 102) and Group 2-patients with adenomyosis and other gynecologic pathologies (n = 1353). Demographic and clinical characteristics, ultrasound examinations, and pathology reports were collected from medical records, and differences between the groups were assessed regarding clinical and demographic data, preoperative evaluations, and surgical characteristics.

RESULTS

A total of 1455 patients were included. The adenomyosis-only group was significantly older than the group with other gynecologic pathologies. The most common coexisting condition was myoma uteri, found in 586 patients (43.3%), followed by cancer and endometrial polyp. Myoma uteri was the most common comorbidity in premenopausal women, but cancer was more prevalent in postmenopausal patients. The mean endometrial thickness was less in the adenomyosis-only group (6.5 ± 4.7 versus 8.0 ± 7.1 mm, P = 0.032). Adenomyosis was more frequent in patients with menstrual irregularities compared with pelvic pain and postmenopausal bleeding. Conversely, cancer was significantly more common in patients with postmenopausal bleeding. Overall, 351 (24.1%) patients were diagnosed with cancer, with endometrial cancer being the most common (n = 218, 62.1%).

CONCLUSIONS

Our findings suggest that adenomyosis is frequently associated with conditions such as myoma uteri, endometrial polyps, and endometrial cancer.

Investigating the link between severity of dyspareunia and female sexual distress among a group of women with endometriosis: the mediating role of body functionality appreciation

BACKGROUND

While existing studies have predominantly focused on negative body image and its potential link to female sexual distress in women with endometriosis, no studies have investigated how positive body image (ie, body functionality appreciation) mediates the association between dyspareunia severity and sexual distress in this population.

AIM

This study aimed to investigate the mediating role of body functionality appreciation in the relationship between severity of dyspareunia and sexual distress in women living with endometriosis.

METHODS

A total of 232 women with endometriosis (M = 35 years) took part in the study. Participants completed an anonymous questionnaire evaluating dyspareunia severity, functionality appreciation, female sexual distress, sociodemographic factors, and endometriosis-related clinical information. All participants were administered the following questionnaires: numerical rating scale, body functionality appreciation, female sexual distress scale.

OUTCOMES

Using a mediation model, the study analyzed both the direct and indirect effects of dyspareunia severity on sexual distress, with functionality appreciation as a mediator.

RESULTS

The findings suggest that the severity of dyspareunia significantly contributes to sexual distress both directly and indirectly, by diminishing the appreciation for body functionality.

CLINICAL IMPLICATIONS

Clinicians should not only focus on the severity of dyspareunia when evaluating sexual distress in women; instead, they should also acknowledge the protective role of positive body image. Integrated treatments that promote body functionality appreciation could enhance treatment outcomes.

STRENGTHS AND LIMITATIONS

The study is the first to examine the mediating role of body functionality appreciation in the relationship between dyspareunia severity and sexual distress in a sample of women with endometriosis; however, the assessment was cross-sectional and did not encompass other factors that may influence the connection between dyspareunia severity and sexual distress.

CONCLUSION

These findings, in addition to advancing theoretical understanding of the role of positive body image in women with dyspareunia, may be valuable in guiding the design of interventions aimed at reducing sexual distress in women with high levels of dyspareunia severity.

"No doctor ever asked me…so I thought it wasn't a valid concern": endometriosis patients' perspectives of barriers and facilitators to sexual health communication in general practice

BACKGROUND

Sexual health communication between general practitioners (GPs) and individuals with chronic diseases is well documented as an important component of sexual well-being. However, a notable gap exists in understanding factors that contribute to sexual health communication in the endometriosis context. Endometriosis-related research has focused on the assessment of sexual functioning and its role in influencing health-related quality of life, with a limited understanding of the management of sexual well-being in primary healthcare settings.

AIM

To explore how individuals with endometriosis perceive their experiences of sexual health communication with GPs to understand the barriers and facilitators of this communication in general practice.

METHODS

This study formed part of a larger online quantitative survey measuring psychological and sexual well-being in individuals with endometriosis. In total 141 participants provided responses via open-ended unlimited free-text questions focused on their experiences of sexual health communication with GPs, including their perspectives on barriers and facilitators.

RESULTS

Four overarching themes regarding barriers to sexual health communication were identified through thematic template analysis: (1) systemic factors; (2) practitioner factors; (3) patient factors; and (4) interpersonal factors. Facilitators mirrored strategies to address these barriers. Additionally, participants offered recommendations for developing resources to improve sexual health communication.

CLINICAL IMPLICATIONS

Despite patients' interest, sexual health concerns in endometriosis are commonly overlooked in general practice due to various barriers, which individuals suggest could be addressed through comprehensive GP education and practical aids including communication tools.

STRENGTHS AND LIMITATIONS

Although the sample is large for a qualitative study, the potential selection bias-stemming from participants' high levels of sexual dysfunction and motivation to discuss sexual health with a GP-may limit the diversity of perspectives. GP perspectives were not evaluated, precluding any assessment of the accuracy of individuals' perceptions of practitioner factors.

CONCLUSIONS

Individuals with endometriosis encounter various systematic, practitioner, personal, and interpersonal factors that hinder or facilitate sexual health communication in general practice. Future research should prioritize strategies to improve sexual health communication for both GPs and patients.

Self-Determined Sexual Motivation in Persons with Endometriosis and Their Partners: Dyadic Associations of Autonomous and Controlled Sexual Motivations with Sexual and Relational Well-Being and Pain

Endometriosis is a chronic pain condition characterized by the growth of endometrial-like tissue outside of the uterus. Affected individuals and their partners report consequences to sexual functioning, sexual satisfaction, and relationship quality. Previous studies in clinical and non-clinical samples have found that sexual motivation can support or detract from sexual functioning; however, similar investigations are lacking among couples with endometriosis. Informed by self-determination theory, associations between autonomous and controlled sexual motivations with sexual functioning, sexual satisfaction, and relationship satisfaction for persons with endometriosis and their partners, and pain in persons with endometriosis were investigated. Couples (n = 54) completed measures of sexual motivation, sexual functioning, sexual satisfaction, relationship satisfaction, and pain. When persons with endometriosis reported greater autonomous sexual motivation, they were more sexually and relationally satisfied. When persons with endometriosis reported higher controlled sexual motivation, their pain was more unpleasant, and they and their partners were less sexually satisfied. Finally, when partners reported greater controlled sexual motivation, both members of the couple reported significantly lower sexual functioning. While controlled sexual motivation may hinder sexual and relational well-being in couples with endometriosis, autonomous sexual motivation may support them. The findings may inform interventions to promote sexual and relational health in couples with endometriosis.

Painful sexual intercourse, quality of life and sexual function in patients with endometriosis: not just deep dyspareunia

PURPOSE

To evaluate the prevalence of deep and superficial dyspareunia in women with diagnosis of endometriosis. Secondly, to assess the temporal relation between deep and superficial dyspareunia in women reporting both symptoms (concomitant dyspareunia) and the impact on quality of life (QoL) and sexual function.

METHODS

This is a cross-sectional cohort study that included fertile women with diagnosis of endometriosis. Enrolled subjects reported pain symptoms including dyspareunia and its temporal onset and completed two one-time validated questionnaires regarding sexual function (Female Sexual Function Index) and QoL (International QoL Assessment SF-36).

RESULTS

Among the 334 enrolled patients, 75.7% (95%) reported dyspareunia. Women were divided into four groups according to the presence and type of dyspareunia: isolated superficial dyspareunia (6.3%), isolated deep dyspareunia (26.0%), concomitant dyspareunia (43.4%) and no dyspareunia (24.3%). Women with concomitant dyspareunia reported higher NRS scores than women with isolated dyspareunia or no dyspareunia (P ≤ 0.001). The majority of women with concomitant dyspareunia (56.6%) reported that deep dyspareunia developed before superficial dyspareunia. Women with concomitant dyspareunia reported worse QoL and worse sexual function than women with isolated dyspareunia or without dyspareunia (P ≤ 0.001).

CONCLUSION

Dyspareunia is a common symptom in women with endometriosis, with many reporting concomitant deep and superficial dyspareunia. Concomitant dyspareunia can significantly impact sexual function and quality of life (QoL). Therefore, it is crucial to investigate dyspareunia thoroughly and differentiate between its types to tailor effective therapeutic strategies.

Women's Self-Management of Dyspareunia Associated With Endometriosis: A Qualitative Study

Given the limitations of medical treatment for endometriosis, self-management is a critical component of symptom management, and providing patients with information and education is a necessary complement to medical interventions. Though 50 to 70% of people with endometriosis experience dyspareunia (painful sex), there is limited knowledge of self-management specific to painful sex. A comprehensive understanding of the self-management strategies used is foundational to developing supportive care interventions that help ease pain and related psychosocial sequelae. The objective was to describe people's experiences of navigating endometriosis-associated painful sex and developing self-management strategies. We analyzed interview data from 20 women using constant comparative and thematic analysis techniques, guided by qualitative interpretive description methodology. Participants (age range 18-44 years) all identified as women and were predominately Caucasian (90%) and heterosexual (80%). Throughout their lives, the women appeared to gradually develop self-management strategies while navigating painful sexual experiences. This complex journey encompassed four phases: 1) viewing painful sex as normal, 2) experiencing evolving thoughts and emotions, 3) coming to understand painful sex and seeking help, and 4) learning strategies to navigate painful sex, these include preparing mentally and physically for sex and communicating with intimate partner(s). Women in this study developed self-management strategies over time through engagement with others who understood their challenges. Future research is warranted regarding initiatives to counter the normalization of painful sex, develop and disseminate patient-facing information, provide education specific to dyspareunia, improve access to multidisciplinary care, facilitate social connections and support, and enhance communication with intimate partners. PERSPECTIVE: In this paper, we report on the experiences of women with endometriosis-associated painful sex and their self-management strategies. Clinicians may be interested in a qualitative exploration of endometriosis-associated painful sex as they seek to further understand their patient's experiences and what strategies can be implemented to alleviate dyspareunia. DATA AVAILABILITY: The data sets generated during and/or analyzed during the current study are not publicly available as participants did not consent to making their data publicly available but are available from the corresponding author on reasonable request.

The Burden of Pelvic Pain Associated With Endometriosis Among Women in Selected European Countries and the United States: A Restricted Systematic Review

OBJECTIVE

To evaluate the burden of endometriosis-associated pelvic pain (EAPP) on health-related quality of life (HRQoL) among women living in similar socio-economic conditions.

DATA SOURCES

Searches were performed in PubMed and Embase on September 26, 2022. The review was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol (PRISMA-P) and was registered on PROSPERO (ID: CRD42023370363).

METHODS OF STUDY SELECTION

Due to the high volume of eligible publications following initial review, inclusion criteria were restricted to studies undertaken in France, Germany, Italy, Spain, the United Kingdom, and the United States. This restriction was applied before screening as these countries have broad social and economic similarities, and previous studies in the literature suggest pain reporting and experience are influenced by numerous socio-cultural factors. Eligible studies were those published between 2013 and 2022 and include a sample size of ≥50 participants. The search strategy identified all relevant publications relating to the burden of illness due to EAPP. A variety of terms are used in the literature to describe pain associated with endometriosis, and this was considered in the design of the search strategy and screening procedure.

TABULATION, INTEGRATION, AND RESULTS

The database searches resulted in a total of 6139 records. After removal of duplicates, 3855 records were assessed further. A total of 27 publications were identified as eligible. Fourteen (52%) were from Italy, 5 (19%) were multinational studies, 4 (15%) were from the United States, 3 (11%) were from Spain, and 1 (4%) was from Germany. Most studies were cross-sectional (n = 15; 56%); 7 (26%) were case-control studies; 3 (11%) were cohort studies; and 2 (7%) were longitudinal studies. These publications collectively highlighted an association between EAPP and reduced HRQoL. Several studies showed that EAPP was associated with lower HRQoL when compared with endometriosis without pain and potentially with chronic pelvic pain caused by other conditions, although the evidence is limited in this case. Moreover, the studies reported detrimental effects on general HRQoL, mental health functioning, and sexual functioning, culminating in reduced work productivity and difficulties in performing everyday activities. The associations were generally similar across study populations, including adolescents, as well as younger and older women. Results were consistent across the range of different patient-reported outcome tools used to assess HRQoL.

CONCLUSION

The existing literature suggests that, among women in selected European countries and the United States, EAPP is associated with reduced HRQoL, including impaired mental and sexual functioning, as well as reduced work performance and productivity; each of which may contribute to the societal burden of endometriosis.

Postmenopausal endometriosis: a challenging condition beyond menopause

IMPORTANCE AND OBJECTIVE

Postmenopausal endometriosis is a complex condition that challenges the conventional belief that endometriosis resolves with menopause. Despite the cessation of menstruation, a subset of women continues to experience or develop endometriosis-related symptoms during the postmenopausal period. Thus, this review aimed to shed light on postmenopausal endometriosis, exploring its clinical features, diagnostic considerations, management approaches, and the potential impact on women's health.

METHODS

PubMed/Medline, Scopus, and Web of Science databases were used for the research, with only articles in English language, using the following terms: "postmenopausal endometriosis," "menopause," "management," "treatment," and "quality of life," from inception to 2023.

DISCUSSION AND CONCLUSION

The clinical features of postmenopausal endometriosis include persistent or recurrent pelvic pain, dyspareunia, bowel, or urinary symptoms and, occasionally, abnormal vaginal bleeding. The absence of menstrual cycles presents a diagnostic challenge, as the traditional diagnostic criteria for endometriosis rely on menstrual patterns. Visual cues may be less evident, and the symptoms often overlap with other gynecological conditions, necessitating a thorough evaluation to differentiate postmenopausal endometriosis from other potential causes. Management approaches for postmenopausal endometriosis encompass surgical intervention, hormonal therapies, pain management, and individualized care. Postmenopausal endometriosis significantly impacts the quality of life, sexual health, and long-term well-being of women. Understanding the clinical features, diagnostic challenges, and management approaches of postmenopausal endometriosis is crucial for healthcare professionals to provide effective care and to improve the quality of life of women affected by this condition.

Measurement properties of sexual function assessment questionnaires in women with endometriosis: A systematic review following COSMIN guidelines

INTRODUCTION

Sexual function of patients with endometriosis should be assessed by patient-reported outcome measures (PROMs) that present high reliability and validity. The objective was to study the PROMs used to assess sexual function for patients with endometriosis to improve their selection for research and clinical practice.

MATERIAL AND METHODS

We performed a systematic literature review from January 2000 to September 2023. All studies including women with confirmed endometriosis and assessing sexual quality of life or sexual function or sexual distress were retrieved. Different properties of PROMs used for sexual dysfunction were assessed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Properties evaluated were: structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness. This literature review was registered on Prospero as 2018 CRD42018102278.

RESULTS

Seventy-four articles with evaluation of sexual function were included. Of the 25 PROMs assessing sexual function, the Female Sexual Function Index (FSFI) was the most frequently used (34/74 [45.9%] items), followed by the Female Sexual Distress Scale (9/74 [12.2%] items) and the Sexual Activity Questionnaire (SAQ) (8/74 [10.8%] items). The most commonly used measurement properties were "hypothesis testing" and "responsiveness". The PROMs with a high level of evidence for these two measurement properties were the FSFI, the SAQ, the Short Sexual Functioning Scale, the Sexual Satisfaction Scale for Women, Sexual Quality of Life-Female, the Brief Profile of Female Sexual Function, and the Sexual Health Outcomes in Women Questionnaire. The FSFI questionnaire appeared to be more relevant for evaluating medical treatment, and the SAQ for evaluating surgical treatment. Only one instrument was specific to endometriosis (the Subjective Impact of Dyspareunia Inventory [SIDI]).

CONCLUSIONS

In this systematic literature review of sexual function assessment questionnaires in endometriosis, the FSFI and the SAQ questionnaires emerged as having the best measurement properties according to the COSMIN criteria. The FSFI questionnaire appears to be suited for evaluating medical treatment, and the SAQ for surgical treatment. The SIDI is the only specific questionnaire, but its responsiveness remains to be defined.

Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review

OBJECTIVE

 To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients.

DATA SOURCE

 A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life.

STUDY SELECTION

 Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742).

DATA COLLECTION

 General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet.

SYNTHESIS OF DATA

 We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function.

CONCLUSION

 Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.

Post-orgasm pain associated with endometriosis and complete resolution of symptoms after laparoscopic en-bloc peritonectomy, a case report

INTRODUCTION AND IMPORTANCE

We report a rare case of post-orgasmic pain associated with endometriosis of the left hypogastric nerve and posterior vaginal wall. It is not a typical symptom of dyspareunia and has not been frequently associated with endometriosis in previous reports.

CASE PRESENTATION

A 36-year-old woman presented with post-orgasmic pain exclusively at orgasm, but no dyspareunia during intercourse. She also reported bladder irritation and secondary dysmenorrhea.

CLINICAL DISCUSSION

Physical examination revealed a small mass on the posterior vaginal wall and thickening of the left uterosacral ligament (USL) associated with severe pain. Pelvic magnetic resonance imaging (MRI) revealed endometrial tissue infiltration of the USL, hypogastric nerve tract, and posterior vaginal wall, consistent with endometriosis. Laparoscopic surgical excision was performed. Complete en bloc peritonectomy excision of the posterior pelvic compartment and complete removal of the lesions identified on MRI was performed. There were no postoperative complications and symptoms resolved completely. Histopathological examination revealed endometriosis.

CONCLUSION

Orgasm-associated pain is rarely associated with endometriosis of the hypogastric nerve. In most cases there is no obvious cause for this symptom in this type of dysorgasmia. The complete resolution of symptoms after removal of the endometriosis by peritonectomy of the posterior pelvic compartment and en bloc excision strongly suggests a causal relationship between endometriosis of the hypogastric nerve and the orgasmic pain and urinary symptoms observed in this case. Also, the effective surgical technique used to treat endometriosis.

Segmental Rectum Resection for Deep Endometriosis and Excision Similarly Improve Sexual Function and Pain

Segmental rectum resections for indications other than endometriosis were reported to result in up to 40% sexual dysfunctions. We, therefore, evaluated sexual function after low bowel resection (n = 33) for deep endometriosis in comparison with conservative excision (n = 23). Sexual function was evaluated with the FSFI-19 (Female Sexuality Functioning Index) and EHP 30 (Endometriosis Health Profile). The pain was evaluated with visual analogue scales. Linear excision and bowel resections improved FSFI, EHP 30, and postoperative pain comparably. By univariate analysis, a decreased sexual function was strongly associated with pain both before (p < 0.0001) and after surgery (p = 0.0012), age (p = 0.05), and duration of surgery (p = 0.023). By multivariate analysis (proc logistic), the FSFI after surgery was predicted only by FSFI before or EHP after surgery. No differences were found between low bowel segmental resection and a more conservative excision. In conclusion, improving pain after surgery can explain the improvement in sexual function. A deleterious effect of a bowel resection on sexual function was not observed for endometriosis. Sexual function in women with endometriosis can be evaluated using a simplified questionnaire such as FSFI-6.

Association between endometriosis and sexual satisfaction among a sample of lebanese women

BACKGROUND

Endometriosis is a complex disease that affects approximately 10% of women of childbearing age. It is characterized by the presence of endometrial-like tissue outside the uterus and often results in symptoms such as pelvic pain and infertility. This condition may disturb mental health and decrease both the mental and physical health related quality of life of women. The aim of this study was to assess the emotional state and the intimate relational aspect of life in Lebanese women living with endometriosis.

METHODS

This is a case-control study that included 317 women (65 participants with endometriosis and 252 controls (1:3 ratio)). Participants completed an online survey that included questions related to endometriosis, Sexual Satisfaction Scale for Women, Couple Satisfaction Index, Perceived Partner Responsiveness Scale and the Depression, Anxiety and Stress Scale.

RESULTS

A significantly higher mean sexual satisfaction score was found in women without endometriosis compared to those with endometriosis (90.83 vs. 83.42; p = 0.006). No significant difference was found in terms of couple satisfaction, depression, anxiety, stress, and perceived partner responsiveness between the two groups. Higher couple satisfaction (Beta = 1.30) and perceived partner responsiveness (Beta = 0.16) were significantly associated with higher sexual satisfaction, whereas higher depression (Beta=-1.70) and having endometriosis compared to not (Beta=-6.51) were significantly associated with lower sexual satisfaction.

CONCLUSION

This study validated the link between endometriosis and sexual satisfaction and invalidated the association between endometriosis and emotional state, as well as couple satisfaction and perceived partner responsiveness. Greater sexual satisfaction was, however, linked to greater perceived partner responsiveness and greater couple satisfaction, as well as decreased signs of depression, anxiety, and stress. More research is warranted to better understand how Lebanese women are coping with the disease and how clinicians may help them further.

Endometriosis Symptomatology, Dyspareunia, and Sexual Distress Are Related to Avoidance of Sex and Negative Impacts on the Sex Lives of Women with Endometriosis

BACKGROUND

Endometriosis affects approximately 10% of women and is associated with a range of symptoms including pelvic pain, abnormal bleeding, and painful sexual intercourse. However, very little is known about the relationship between endometriosis-related symptoms and sex.

METHODS

Women with a diagnosis of endometriosis (n = 2060; mean age = 30 years) completed a questionnaire measuring the frequency of endometriosis symptoms, dyspareunia, sexual distress, avoidance of sex, and the perceived negative impact of endometriosis symptoms on sex life.

RESULTS

In bivariate and multivariate logistic regression models with avoidance of sex and perceived negative impact of endometriosis symptoms on sex life as DVs, higher endometriosis symptom frequency, dyspareunia, and sexual distress were associated with greater avoidance of sex and higher perceived negative impact of endometriosis symptoms on sex life. With a two- and three-fold increase in the odds of avoiding sex and reporting a negative impact of endometriosis on sex lives, respectively, for each point increase in dyspareunia. Similarly, there was a 7% to 11% increase in avoidance of sex and the negative impact of endometriosis on sex lives, per one-point increase in symptom frequency and sexual distress.

CONCLUSIONS

The results highlight the considerable impacts of endometriosis symptomatology on women's sex lives and wellbeing. Better medical and counselling services may be needed to ameliorate the negative impact of endometriosis on women's sex lives.

Evaluating the Link Between Self-Reported Endometriosis and Female Sexual Dysfunction

BACKGROUND

Studies have found that women with endometriosis have a higher risk of female sexual dysfunction (FSD).

AIM

To evaluate the relationship between self-reported endometriosis and FSD utilizing validated surveys.

METHODS

A cross-sectional analysis was conducted among sexually active women aged 18-90 who presented to 3 Mayo Clinic sites from 2015 to 2021. FSD was determined utilizing a combined endpoint of Female Sexual Function Index score ≤ 26.55 and Female Sexual Distress Scale-Revised score ≥ 11. Associations between history of endometriosis and FSD were evaluated by fitting 3 multivariable logistic models and were stratified by menopause status. In the first model, the association was adjusted for age, BMI, race/ethnicity, marital status, and education. The second model adjusted for the variables in Model 1 and hormone therapy, hormonal contraceptive use, self-reported history of abuse within the last year, and co-morbidities including the history of diabetes, heart disease, hypertension, osteoporosis, and stroke. The third model adjusted for the variables in Model 1, Model 2, and anxiety, depression, relationship satisfaction, and SSRI/SNRI use.

OUTCOMES

The outcomes included self-reported endometriosis and female sexual dysfunction determined utilizing a combined endpoint of Female Sexual Function Index score ≤ 26.55 and Female Sexual Distress Scale-Revised score ≥ 11.

RESULTS

Of 7118 patients (mean age 51.3), 92.2% were white, 78.4% were peri- or postmenopausal, 8.7% reported endometriosis history, and 57.2% met the criteria for FSD. Women with endometriosis were more likely to be overweight or obese, be smokers, have had a history of heart disease and osteoporosis, have had anxiety and depressed mood, have had a hysterectomy and bilateral salpingo-oophorectomy, and have used hormone therapy. Compared to those without endometriosis, women with endometriosis were significantly more likely to have FSD only among premenopausal women (74.2% vs 57.4%). Similarly, in multivariable analysis the relationship was only seen for premenopausal women in all 3 models (Model 1: OR 2.74 (95% CI 1.43-5.27); Model 2: OR 2.55 (95% CI 1.30-5.04); Model 3: OR 2.30 (95% CI 1.13-4.68)).

CLINICAL IMPLICATIONS

These findings highlight the opportunity for healthcare practitioners to evaluate sexual function in premenopausal women with endometriosis. For peri and postmenopausal women with endometriosis, the risk of FSD was lower than for premenopausal women with endometriosis.

STRENGTHS AND LIMITATIONS

This study analyzed the association between endometriosis and FSD in women by menopause status using validated tools that included a measure of distress associated with sexual dysfunction. Limitations include its cross-sectional design which does not allow for determination of the direction of this association.

CONCLUSION

The risk for FSD associated with endometriosis depends on menopause status. Endometriosis increased the odds of FSD only in premenopausal women. Kling JM, Ghaith S, Smith T, et al. Evaluating the Link Between Self-Reported Endometriosis and Female Sexual Dysfunction. J Sex Med 2022;19:1533-1561.

Partners matter: The psychosocial well-being of couples when dealing with endometriosis

BACKGROUND

Endometriosis is often associated with severe dysmenorrhea, pelvic pain and dyspareunia and has a high impact on daily life as well as sexuality. Quality of partnership positively influences the course of various diseases and ability to cope with emotional and physical distress. However, studies focusing on the male partners of endometriosis patients are rare, and even less is known about the reciprocal relationship in these couples. Therefore, this study aims to explore the interrelations in couples with endometriosis in matters of psychological distress, sexual and partnership satisfaction and social support.

METHODS

The cross-sectional study was conducted in two university-affiliated fertility centres in Germany and Austria with n = 104 female/male couples affected by endometriosis. Participants completed a questionnaire regarding endometriosis, partnership, sexuality, stress, anxiety, depression and social support. Both women and men were asked about the impact of women's endometriosis-related pain (IEP) on their everyday life (e.g. leisure time). Data were analysed using the Actor-Partner-Interdependence Model.

RESULTS

Significant partner effects were evident: High depression, anxiety and stress scores in women were associated with a higher IEP in men (all p ≤ 0.01), reciprocally high stress and depression scores in men were correlated with a higher IEP in women (all p ≤ 0.05). Less sexual satisfaction in women was associated with a higher IEP in men (p = 0.040). There was a significant reciprocal association between the perceived lack of understanding from the social environment and a higher IEP, for both women (p = 0.022) and men (p = 0.027).

CONCLUSIONS

The male partner should be taken into account when counselling or treating women with endometriosis. Our study shows a high interdependence and reciprocal influence from both partners-positively and negatively-concerning psychological distress and sexual satisfaction. Furthermore, there ought to be more awareness for the psychosocial impact of endometriosis, especially in regard to social support and understanding. Talking about and improving sexual satisfaction as well as enhancing stress reducing techniques may hold great benefits for dealing with endometriosis. Registration number The study is registered with the German Clinical Trials Register (DRKS), number DRKS00014362.

Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?

Women with endometriosis often suffer from genito-pelvic pain. The objective of the present study was to analyze the relationship between cognitive and psycho-emotional factors and sexual functioning of women with endometriosis, comparing women with and without endometriosis. A total of 87 women with endometriosis (EG) and 100 women without endometriosis (CG) completed a socio-demographic questionnaire; the short-form of McGill Pain Questionnaire (SF-MPQ); the Female Sexual Functioning Index (FSFI); the Sexual Distress Scale (SDS); the Symptoms Checklist (SCL-90-R); the Toronto Alexithymia Scale (TAS-20); the Positive and Negative Affects Scale (PANAS); the Sexual Dysfunctional Belief Questionnaire (SDBQ); the Sexual Modes Questionnaire (SMQ); and the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). EG obtained worse scores than CG in SF-MPQ, Pain subscale of FSFI, and SDS. EG reached higher scores than CG on almost all scales of SCL-90-R and lower scores in the “Identifying Feelings” scale of TAS-20. Furthermore, EG reported more negative emotions toward sexuality than CG (PANAS) higher scores on the “Affection Primacy” scale of SDBQ and the “Helpless” sexual cognitive schema of QCSASC than CG. No significant differences were found in SMQ. Sexual health professionals should address psychological, emotional, and cognitive factors since they seem involved in patients’ sexual experiences.

Sexual function and quality of life in women with endometriosis

Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Symptoms of endometriosis represent a great source of stress and cause a substantial negative impact on the psychological parameters, on the daily life and on the physical functioning of patients. The impact of endometriosis on work attendance has very significant economic consequences, as lost productivity has an associated cost, as do career changes resulting from a decline in education due to symptoms. Endometriosis is a pathology that affects all aspects of women's lives and that thus, it must be treated with a multidisciplinary vision that includes not only a medical approach but also psychological, work, and economic support. In this specific long-term vision of patient-centered endometriosis care, aspects of quality of life and sexual health play a key role and should always be evaluated with any patient as part of a multidisciplinary management.

An Exploration of Dyadic Relationship Approach-Avoidance Goals and Relationship and Sexual Satisfaction in Couples Coping with Endometriosis

Endometriosis affects women of reproductive age and is associated with higher levels of sexual and relational distress. Despite the relational context of endometriosis, the research pertaining to dyadic relationship goals is lacking. An exploration of the relationship goals of couples coping with endometriosis can facilitate the understanding of potential protective mechanisms that mitigate the relational components of the condition. Guided by the approach-avoidance theoretical framework, the current cross-sectional study aimed to examine the role relationship goals play in sexual and relationship satisfaction in couples coping with endometriosis. Approach goals relate to the pursuit of a positive outcomes, whereas avoidance goals relate to the avoidance of negative outcomes. Women with endometriosis and their partners (N = 61) completed an online survey measuring relationship goals and relationship and sexual satisfaction. The study results indicated that, for women, their own and their partner's higher relationship approach goals were linked to higher sexual satisfaction. For partners of women with endometriosis, their own higher relationship approach goals were associated with their own higher relationship satisfaction. Higher relationship avoidance goals in both women with endometriosis and partners were associated with higher relationship satisfaction. The study's findings highlight relationship goals as relevant to the relational and sexual experience of couples coping with endometriosis. When treating women with endometriosis, the inclusion of partners and consideration of factors beyond the physical illness are important for a holistic management approach.

Developing an Educational Website for Women With Endometriosis-Associated Dyspareunia: Usability and Stigma Analysis

BACKGROUND

Endometriosis is a chronic condition that affects approximately 10% of women worldwide. Despite its wide prevalence, knowledge of endometriosis symptoms, such as pelvic pain, and treatments remains relatively low. This not only leads to a trivialization of symptoms and delayed diagnosis but also fuels myths and misconceptions about pain symptoms. At the same time, the use of web-based platforms for information seeking is particularly common among people with conditions that are perceived as stigmatizing and difficult to discuss. The Sex, Pain, and Endometriosis website is an educational resource designed to provide evidence-based information on endometriosis and sexual pain to help people understand the condition, feel empowered, dispel myths, and destigmatize endometriosis-associated sexual pain.

OBJECTIVE

The study objective is to evaluate the usability of the website and assess for destigmatizing properties of sexual health-related web-based resources.

METHODS

We conducted a usability analysis by using a think-aloud observation, a postsystem usability questionnaire, and follow-up interviews with 12 women with endometriosis. The think-aloud data were analyzed using the framework by Kushniruk and Patel for analyzing usability video data, the questionnaire data were analyzed using descriptive statistics, and the follow-up interviews were analyzed using simple content analysis. We conducted a usability assessment by deductively analyzing the interview data via a trauma-informed care framework and a content analysis approach.

RESULTS

Through usability analysis, we found the website to be simple, uncluttered, satisfying, and easy to use. However, 30 minor usability problems related to navigation; website response; the comprehension of graphics, icons, and tabs; the understanding of content; and mismatch between the website and users' expectations were reported. In our stigma analysis, we found the web content to be nonstigmatizing. The participants suggested ways in which websites could be designed to address stigma, including ensuring privacy, anonymity, inclusiveness, and factual and nonjudgmental content, as well as providing opportunities for web-based engagement.

CONCLUSIONS

Overall, the participants found the website to be useful, easy to use, and satisfying. The usability problems identified were largely minor and informed the website redesign process. In the context of the limited literature on stigma and website design, this paper offers useful strategies on how sexual health-related websites can be designed to be acceptable and less stigmatizing to individuals with sensitive health issues.

Delineating sociodemographic, medical and quality of life factors associated with psychological distress in individuals with endometriosis

STUDY QUESTION

What is the relationship between specific quality of life domains and depression, anxiety and stress in the endometriosis population?

SUMMARY ANSWER

Psychosocial domains of quality of life, such as a perception of social support and self-image, are more strongly associated with depression, anxiety and stress than pain and medical factors.

WHAT IS KNOWN ALREADY

Prior research indicates a high prevalence of anxiety and depression in individuals with endometriosis. Pain is thought to be critical in the development of psychological distress, however prior research has investigated this association without consideration of psychosocial quality of life domains such as social functioning, perceived social support and self-image.

STUDY DESIGN, SIZE, DURATION

This study is a cross-sectional analysis of baseline data collected in a longitudinal study exploring psychological distress in endometriosis (n = 584).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Individuals living with endometriosis participated in this study and were recruited via online platforms of community organizations and support groups. Demographic and medical information concerning endometriosis treatment and diagnosis was self-reported. Psychological distress and quality of life was measured using the Depression, Anxiety and Stress Scale (DASS-21), Endometriosis Health Profile-30 (EHP-30) and the Short Form Survey (SF-36v2). A series of linear regression analyses explored the relationship between specific quality of life domains and the primary outcomes of depression, anxiety and stress.

MAIN RESULTS AND THE ROLE OF CHANCE

Approximately half of the participants in this sample reported moderate to severe anxiety, depression and stress. Quality of life domains, particularly perceived social support, social functioning and self-image, were more strongly associated with psychological distress than medical or demographic factors. Pain was associated with anxiety, but not depression or stress. A greater number of endometriosis symptoms was only associated with depression.

LIMITATIONS, REASONS FOR CAUTION

These data are cross-sectional and, therefore, causality cannot be inferred from this analysis. Information about endometriosis diagnosis and treatment was self-reported, and not verified against medical records.

WIDER IMPLICATIONS OF THE FINDINGS

This study indicates that psychosocial factors may be more salient factors underlying depression, anxiety and stress in the endometriosis population than pain and medical factors. There is a need for interventions that target psychological distress in this population with a focus on the broader impact of endometriosis beyond pain and physical symptomatology.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the Research Training Program (RTP) Scholarship awarded to C.S.M. by Macquarie University. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

ACTRN12619001508167.

Long-term Follow-up of Sexual Quality of Life after Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis

STUDY OBJECTIVE

We performed a long-term follow-up to quantify the impairment of sexual quality of life (SQL) and health-related QL (HRQL) in sexually active women after laparoscopic excision of deep infiltrating endometriosis (DIE).

DESIGN

Prospective case-control study.

SETTING

Hospital Clinic of Barcelona.

PATIENTS

A total of 193 patients (after dropout and exclusions) were divided into 2 groups: one hundred twenty-nine premenopausal women with DIE (DIE group) and 64 healthy women who underwent tubal ligation (C group).

INTERVENTIONS

All patients underwent laparoscopic surgery: laparoscopic endometriosis surgery in the DIE group and laparoscopic tubal ligation in the C group. All women were followed for at least 36 months, and they completed the Medical Outcomes Study 36-item short form questionnaire to assess their HRQL and 3 self-administered questionnaires that evaluate different aspects of SQL: the generic Sexual Quality of Life-Female questionnaire, the Female Sexual Distress Scale to evaluate "sexually related distress," and the Brief Profile of Female Sexual Function to screen hypoactive sexual desire disorder. The patients with DIE as well as the controls completed the 4 questionnaires before surgery, and the patients with DIE also completed the questionnaires at 6 and 36 months after surgery.

MEASUREMENTS AND MAIN RESULTS

A comparison of the patients and controls before surgery showed a statistically significant impairment in SQL and HRQL among the patients with DIE. A statistically significant improvement in SQL and HRQL was observed in the DIE group 6 months after surgery, with scores being similar to those of the C group. An evaluation 36 months after surgery showed that SQL and HRQL were better than presurgical SQL and HRQL in the DIE group, with a slight reduction compared with the 6-month evaluation.

CONCLUSION

SQL and HRQL improved in patients with DIE undergoing complete laparoscopic endometriosis resection and were comparable to those of healthy women at 6 months after surgery, showing a slight reduction at 36 months of follow-up.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia.

METHODS

This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated.

RESULTS

Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01).

CONCLUSIONS

In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Endometriosis-associated pain: a review of quality of life, sexual health and couple relationship

INTRODUCTION

Endometriosis is a chronic gynecological disease that affects women's quality of life, sexuality, and relationship. Endometriosis-associated pain plays an essential role in well-being impairment. The present review aimed to analyze literature about endometriosis-associated pain and quality of life, sexual health, and quality of the relationship, assessing the role of the biopsychosocial factors involved and the women's pain experience.

EVIDENCE ACQUISITION

Bibliographic research of relevant articles published from 2015 to 2020 in PubMed, Google Scholar, Web of Science, Scopus, EBSCO, and Cochrane Library.

EVIDENCE SYNTHESIS

Endometriosis is associated with impairing all women's quality of life domains, and pain appears to be the most influential variable. The pain mechanism is not simple and implies several biological, psychological, and social factors. Women's sexual health is also impaired, and patients report dyspareunia, sexual dysfunctions, dissatisfaction, and distress. Partners' sexual well being is compromised as well. Endometriosis negatively influences relationship quality, and the illness burden affects both couple members.

CONCLUSIONS

A multidisciplinary team using a couple-centered and a biopsychosocial approach is crucial to provide appropriate treatment for endometriosis-associated pain. A better comprehension of all bio-psycho-social aspects implicated in women's well-being and pain experience needs more research.

Adhesion barriers in laparoscopic myomectomy: Evidence from randomized clinical trials

OBJECTIVE

To evaluate the effectiveness of different adhesion barriers in the prevention of de novo adhesion development after laparoscopic myomectomy.

METHODS

A systematic review was performed by searching seven electronic databases for all randomized clinical trials (RCTs) comparing the use of any absorbable adhesion barrier (i.e. intervention group) with either no treatment or placebo (i.e. control group) in the prevention of adhesion development after laparoscopic myomectomy.

RESULTS

Eight RCTs with a total of 748 participants (392 in the intervention group and 356 in the control group) were included. The assessed adhesion barrier methods were: oxidized regenerated cellulose (ORC) in two studies, auto-crosslinked hyaluronic acid (HA) gel in two studies, 4% icodextrin solution in one study, modified HA and carboxy-methylcellulose in one study, polyethylene glycol ester trilysine amine solution plus a borate buffer solution in one study, and polyethylene glycol amine plus dextran aldehyde polymers in another study.

CONCLUSION

Adhesion barrier methods showing the most promising results were: ORC, auto-crosslinked HA gel, and polyethylene glycol amine plus dextran aldehyde polymers.

Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis

INTRODUCTION

Several studies have assessed the histological co-existence of endometrial carcinoma (EC) and adenomyosis. However, the significance of this association is still unclear.

OBJECTIVE

To assess the prevalence of adenomyosis in women with EC for a better understanding of the association between the two diseases.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed by searching electronics databases from their inception to March 2020, for all studies that allowed extraction of data about prevalence of adenomyosis in EC patients. Adenomyosis prevalence was calculated for each included study and as pooled estimate, with 95% confidence interval (CI).

RESULTS

Eight retrospective cohort studies assessing 5573 EC patients were included in our analysis. Of total, 1322 were patients with adenomyosis, and 4251 were patients without adenomyosis. Pooled prevalence of adenomyosis in EC patients was 22.6% (95% CI 12.7-37.1%).

CONCLUSION

Adenomyosis prevalence in EC patients was not different from that reported for other gynecological conditions. The supposed association between the two diseases appears unsupported.

Endometriosis and Sexual Quality of Life

Introduction

Endometriosis is a benign gynecological disease with a high disease burden and significant, multifaceted impact on health-related quality of life (HRQoL) and sexual quality of life (SQoL).

Aim

To explore which patient- and disease-specific characteristics were independently associated with SQoL.

Methods

A literature search was carried out to identify characteristics with an evidence-based or hypothesized effect on SQoL. Subsequently, data on HRQoL in women with endometriosis (n = 224), collected between 2013 and 2018 in a prospective longitudinal Dutch cohort study performed in 7 referral centers, were used to perform a cross-sectional cohort study. Data were collected using an online self-administered survey including the validated Endometriosis Health Profile-30. Inclusion criteria were recently diagnosed endometriosis patients or newly referred patients with a clinical diagnosis of endometriosis. Patients were excluded in case of incomplete answers on the SQoL questions. Univariate analyses and multiple linear regression analyses were performed.

Outcomes

SQoL, measured by the 5-item “sexual intercourse” dimension score of the modular Endometriosis Health Profile-30 questionnaire, was the primary outcome with scores ranging from 0 to 100 (0 indicating the best and 100 indicating the worst health status).

Results

Based on a literature search, 29 characteristics potentially associated with SQoL were selected from the survey and included in the analyses. In total, 192 women (mean age 36 years) met the inclusion criteria. The majority of women (86.5%) had had intercourse in the period before completing the survey and the study population showed a mean SQoL score of 47.5 ± 29.6, indicating moderate SQoL. Worse SQoL was independently associated with dyspareunia (P < .001), worse HRQoL (P = .001), severity of dysmenorrhea (P = .017), and unemployed work status (P = .022).

Conclusion

In a cohort of women with endometriosis, worse SQoL was significantly and independently associated with the presence of dyspareunia, more severe dysmenorrhea, worse HRQoL, and unemployed work status.

van Poll M, van Barneveld E, Aerts L, et al. Endometriosis and Sexual Quality of Life. Sex Med 2020;8:532–544.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.

Acute abdominal pain in non-pregnant endometriotic patients: not just dysmenorrhoea. A systematic review

Endometriosis, defined as the presence of functional endometrial tissue outside the uterine cavity, presents mainly with pelvic pain and infertility. Acute abdominal pain in non-pregnant patients with endometriosis might be minimised as a typical feature of the disease, while endometriosis is rarely considered in the differential diagnosis of acute abdominal pain. Our objective was to conduct a systematic review of the current literature of cases of acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. We performed a PubMed/MEDLINE search of studies published from January 1990 to December 2018, selecting English language reports and series of non-pregnant patients with acute abdomen and histological confirmation of endometriosis. The studies were revised by two independent authors. Data were abstracted and compiled for analysis. Fifty articles reporting 62 patients were identified. The complications were classified according to anatomical sites in bowel, urinary tract, and genital organs emergencies. Rarely was the first diagnostic hypothesis endometriosis, misdiagnosis was frequent. The time frame from symptoms onset to management was often long. This is the first systematic review evaluating acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. These conditions are rare but possibly life-threating and require prompt diagnosis and emergent medical or surgical treatment.

Sexuality in women with endometriosis: a critical narrative review

Endometriosis is a chronic gynecological disease that generally affects young and sexually active women in different stages of their development and sexual life. Because endometriosis affects about 5-10% of women in reproductive age, it is possible to estimate that about 2-4% of those who are sexually active may suffer from sexual dysfunction caused by this disease. Surgical and pharmacological treatments of endometriosis can improve the patient's sexual function in the medium and long term, but not necessarily lead to a definitive resolution of the sexual issue. For this reason, the ideal treatment should be conducted by a multidisciplinary team, with the aim to improve overall sexual functioning and not only to reduce the painful symptoms during intercourse. In light of these considerations, the aim of this narrative review was to provide a general overview about the impact of endometriosis on sexuality of women affected and the effectiveness of surgical and pharmacological treatments in improving sexual function.

Qualitative and quantitative aspects of sex life in the context of endometriosis: a multicentre case control study

RESEARCH QUESTION

What are the specific characteristics of sexual activity in women with endometriosis compared with women without endometriosis?

DESIGN

Multicentre case control study. Participants were recruited from university hospitals, district hospitals and doctor's offices in Germany, Switzerland and Austria. A total of 565 women with endometriosis were pair-matched to 565 control women by age and ethnic background. Diagnosis of endometriosis was confirmed by histology, and disease stage was classified according to American Society for Reproductive Medicine criteria. Data on sexuality were collected using selected questions from the Brief Index of Sexual Function and the Sexual History Form.

RESULTS

Altogether, 69.1% of women with endometriosis and 77.8% of control women engaged in sexual activity during the month before the study period (P < 0.001). Overall, 42.3% of endometriosis-affected women and 30.5% of the control women desired a higher frequency of sexual activity (P < 0.001). Petting, foreplay and vaginal sexual intercourse were reported to be practised less often by women with endometriosis. Frequencies for masturbation, reciprocal masturbation, oral and anal sex were similar in both groups. Dyspareunia was negatively associated with sexual activity (OR 2.42, 95% CI 1.26 to 4.63), whereas chronic pain showed no association with sexual activity (OR 1.35, 95% CI 0.93, 1.96).

CONCLUSIONS

Women with endometriosis have lower frequencies of petting, foreplay and vaginal sexual intercourse than control women; this difference has to be attributed, at least in part, to dyspareunia. Potentially pain-free sexual options are used to a limited degree. As endometriosis-affected women desire higher levels of sexual activity, sexual counselling should be included in medical support.

Painful Love: Superficial Dyspareunia and Three Dimensional Transperineal Ultrasound Evaluation of Pelvic Floor Muscle in Women with Endometriosis

We conducted an observational study between March 2015 and March 2018 in our academic center. Symptomatic, sexually active women with clinical and sonographic diagnosis of deep infiltrating endometriosis (DIE) or isolated ovarian endometriosis were enrolled. Women were asked to rank endometriosis-related symptoms, especially superficial and deep dyspareunia. Moreover, 3D transperineal ultrasound was performed to assess the levator hiatus area (LHA) evaluating pelvic floor muscle (PFM) morphometry. Women with endometriosis seem to have a high prevalence of superficial dyspareunia and three-dimensional transperineal ultrasound seems to be a viable technique to assess PFM morphometry in these women.

When Solving Dyspareunia Is Not Enough to Restore Sexual Function in Women With Deep Infiltrating Endometriosis Treated With Dienogest

The aim of the study was to evaluate dyspareunia and sexual function (SF) in women with deep infiltrating endometriosis (DIE) who were treated with dienogest (DNG) for 12 months. The prospective cohort study took place at the University of Campinas, Brazil, and included 30 women with sonographic diagnosis of DIE and sexual dysfunction treated with 2 mg/daily DNG for 12 months. SF parameters were assessed by the Female Sexual Function Index (FSFI) before and after treatment, and dyspareunia was quantified through the visual analog scale (VAS) during the follow-ups performed every three months. Statistical analysis was performed by ANOVA test and through the use of software SAS, Version 9.4. Women were on average 36.13 ± 6.24 years old, and all of them showed sexual dysfunction (FSFI =17.6 ± 5.7) before DNG; 88.3% had dyspareunia as the main symptom related to DIE (VAS before: 5.3 ± 3.1). At the end of the treatment, dyspareunia showed a decrease of intensity (VAS after: 3.7 ± 3.3; p = .0093) and an improvement on FSFI index was accomplished (p = .0023); however, it did not restore SF completely, considering the FSFI cutoff < 26.55. Long-term treatment for DIE with DNG has provided a decrease in dyspareunia and also an enhancement of SF, although SF has not been restored to normal levels.

Psychosocial impact of endometriosis: From co-morbidity to intervention

Endometriosis-associated pelvic pain is a major health concern in women of childbearing age. Controlled studies have shown that endometriosis can adversely affect women and their partners' general psychological well-being, relationship adjustment and overall quality of life. Furthermore, women with endometriosis report significantly more sexual dysfunctions compared to healthy women. Empirical studies indicate that specific psychosocial factors may modulate pain experience, pain-related distress and treatment outcome. Research on psychosexual interventions in endometriosis treatment is limited but shows to be effective in reducing endometriosis-related pain and associated psychosexual outcomes. An individualized, couple-centered, multimodal approach to care, integrating psychosexual and medical management for endometriosis, is thought to be optimal.

Different Characteristics of the Female Sexual Function Index in a Sample of Sexually Active and Inactive Women

BACKGROUND

The Female Sexual Function Index (FSFI) is a widely used measurement tool to assess female sexual function along the six dimensions of desire, arousal, lubrication, orgasm, satisfaction, and pain. However, the structure of the questionnaire is not clear, and several studies have found high correlations among the dimensions, indicating that a common underlying "sexual function" factor might be present.

AIM

To investigate whether female sexual function is best understood as a multidimensional construct or, alternatively, whether a common underlying factor explains most of the variance in FSFI scores, and to investigate the possible effect of the common practice of including sexually inactive women in studies using the FSFI.

METHODS

The sample consisted of 508 women: 202 university students, 177 patients with endometriosis, and 129 patients with polycystic ovary syndrome. Participants completed the FSFI, and confirmatory factor analyses were used to test the underlying structure of this instrument in the total sample and in samples including sexually active women only.

OUTCOMES

The FSFI is a multidimensional self-report questionnaire composed of 19 items.

RESULTS

Strong positive correlations were found among five of the six original factors on the FSFI. Confirmatory factor analyses showed that in the total sample items loaded mainly on the general sexual function factor and very little variance was explained by the specific factors. However, when only sexually active women were included in the analyses, a clear factor structure emerged, with items loading on their six specific factors, and most of the variance in FSFI scores was explained by the specific factors, rather than the general factor. University students reported higher scores, indicating better functioning compared with the patient samples.

CLINICAL TRANSLATION

The reliable and valid assessment of female sexual function can contribute to better understanding, prevention, and treatment of different sexual difficulties and dysfunctions.

STRENGTHS AND LIMITATIONS

This study provides a rigorous statistical test of the structure of the FSFI and an explicit decision rule for categorizing sexually inactive women. Limitations include a lack of control over the circumstances of data collection.

CONCLUSION

This study supports the use of the FSFI as a multidimensional measurement of female sexual function but highlights the need to establish clear decision rules for the inclusion or exclusion of sexually active and inactive respondents. Hevesi K, Mészáros V, Kövi Z, et al. Different Characteristics of the Female Sexual Function Index in a Sample of Sexually Active and Inactive Women. J Sex Med 2017;14:1133-1141.

What Is Known and Unknown About the Association Between Endometriosis and Sexual Functioning: A Systematic Review of the Literature

It is well known that endometriosis is associated with an increase in the risk of deep dyspareunia, with potential negative effects on global female sexual functioning and couple relationship. The aims of this study were to review the literature on the impact of endometriosis on female sexual functioning and to suggest new avenues for future research and treatment strategies. An electronic database research was performed to identify all the studies on the relation between endometriosis and sexual functioning published in the period 2000 to 2016. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After the screening process, a total of 9 studies investigating the relation between endometriosis and female sexual functioning were considered. Overall, these studies indicated that around two thirds of women with endometriosis have some form of sexual dysfunction not limited to deep dyspareunia. These findings suggest that the global sexual impact of endometriosis requires further investigation, focusing not only on pain during intercourse but also on psychological and relational dimensions, including partner's sexual functioning. Because sexual functioning is a complex, multidimensional phenomenon, the ideal treatment for endometriosis-related sexual dysfunctions should be conducted by a multidisciplinary team composed of gynecologists, sexologists, and psychologists/psychotherapists.

Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care

Endometriosis has a multifactorial etiology. The onset and progression of the disease are believed to be related to different pathogenic mechanisms. Among them, the environment and lifestyle may play significant roles. Diet, dietary supplements, physical exercise, osteopathy, massage, acupuncture, transcutaneous electrical nerve stimulation, and Chinese herbal medicine may represent a complementary and feasible approach in the treatment of symptoms related to the disease. In this narrative review, we aimed to examine the most updated evidence on these alternative approaches implicated in the self-management of the disease. In addition, several studies have demonstrated that endometriosis may negatively impact mental health and quality of life, suggesting that affected women may have an increased risk of developing psychological suffering as well as sexual problems due to the presence of pain. In light of these findings, we discuss the importance of integrating psychological interventions (including psychotherapy) and sexual therapy in endometriosis treatment.

Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected

STUDY QUESTION

To what extent are endometriosis and its related physical and mental symptoms associated with the perceived level of sexual functioning in women and their male partners?

SUMMARY ANSWER

Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected.

WHAT IS KNOWN ALREADY

Women with endometriosis suffer from more dyspareunia, lower sexual functioning, and lower quality of life. In qualitative studies, partners of women with endometriosis report that endometriosis affected their quality of life and produced relational distress.

STUDY DESIGN SIZE, DURATION

In this cross-sectional study, sexual functioning in women with endometriosis (n = 83) and their partners (n = 74) was compared with sexual functioning in a control group of women attending the outpatient department for issues related to contraception (n = 40), and their partners (n = 26).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women and partners were recruited in the Maastricht University Medical Centre (MUMC) and the VieCuri Medical Centre Venlo between June 2011 and December 2012. All participants were asked to complete a set of online questionnaires.

MAIN RESULTS AND THE ROLE OF CHANCE

Response rates were 59.3% (83/140) for women with endometriosis and 52.3% (74/140) for their partners. Response rates in the control group were respectively 43.2% and 27.4% (41/95 and 27/95), of whom 40 women and 26 partners could be included in the study. Women with endometriosis as compared with the control group, reported significantly more frequent pain during intercourse (53% versus 15%, P < 0.001); higher levels of chronic pain (median VAS 2.0 cm versus 0.0 cm, P < 0.001); more impairment of sexual functioning (median Female Sexual Function Index 25.4 versus 30.6, P < 0.001); more impairment of quality of life (median Short Form-12 66.3 versus 87.2, P < 0.001); more pain catastrophizing (mean Pain Catastrophizing Scale 17.8 versus 8.5, P < 0.001), more depression and anxiety symptoms (median Hospital Anxiety and Depression Scale for depression 7 versus 4, P < 0.001 and for anxiety 4 versus 1, P < 0.001). Sexual functioning was comparable between male partners of women with endometriosis and male partners of the control group based on the International Index of Erectile Function. Logistic regression analyses showed that dyspareunia (OR 0.54; 95% CI 0.39-0.75) and depressive symptoms (OR 0.761; 95% CI 0.58-0.99) were independent and significant negative predictors for sexual functioning. Chronic pelvic pain (OR 0.53; 95% CI 0.35-0.81) and depressive symptoms (OR 0.65; 95% CI 0.44-0.96) were independent and significant negative predictors for quality of life.

LIMITATIONS, REASONS FOR CAUTION

Patient recruitment was performed in one tertiary care centre and to a lesser extent one general hospital, possibly leading to an over-representation of patients with more severe endometriosis. All participating women had a partner and are therefore 'survivors' in relationship terms. This may have led to an underestimation of the impact of endometriosis on sexual functioning.

WIDER IMPLICATIONS OF THE FINDINGS

It would be worthwhile to further explore the role of depressive symptoms in women with symptomatic endometriosis and to assess the effect of treatment of depressive symptoms on sexual functioning and quality of life. The fact that the partners did not report impaired sexual functioning could be a reassuring thought to women that might be discussed in the consulting room.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the MUMC. An unconditional research grant was given by the Dutch Society of Psychosomatic Obstetrics and Gynaecology (21 June 2011).

TRIAL REGISTRATION NUMBER

Not applicable.

Sexual function in endometriosis patients and their partners: effect of the disease and consequences of treatment

BACKGROUND

Sexual function is an important aspect of health and quality of life and is influenced by both medical conditions and health-care interventions, especially when gynecologic disorders are involved. Coital pain is among the main factors that affect sexual functioning, and this symptom is reported by almost half of women suffering from endometriosis. However, sexuality is a complex phenomenon driven by social, psychological and biological/hormonal factors and the presence of endometriosis might further affect domains of sexual function and the quality of a sexual relationship.

OBJECTIVE AND RATIONALE

The objective of this report is to review the current state of knowledge on the impact that endometriosis and its treatments have on the sexual function of women and their sexual partners.

SEARCH METHODS

A systematic literature search was performed to identify studies evaluating sexual function in endometriosis patients, and a narrative analysis of results is presented. The review discusses relevant quantitative and qualitative studies analyzing the effect of endometriosis and its hormonal and surgical treatments on measures of sexual function and quality of sexual relationship.

OUTCOMES

Endometriosis negatively affects different domains of sexual function, and the presence of dyspareunia is not the only determinant of sexual health in these women. Chronic pelvic pain, advanced stages of disease and the presence of physical and mental comorbidities affect sexual function, as well as personality traits and women's expectations. Although a number of studies have evaluated the effect of surgery and hormonal treatment on deep dyspareunia, overall sexual function and quality of the relationship with the partner are often under-investigated.

WIDER IMPLICATIONS

Multiple clinical and personal determinants affect sexual function in women with endometriosis, with potentially negative consequences on the sexual function of partners and quality of the relationship. Additional prospective and longitudinal investigations are warranted using specific instruments to analyze biopsychosocial variables of sexual pain in endometriosis patients and the effects that actual treatments have on measures of quality of sexual function and relationship.

Validation of the Turkish Version of the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) in Turkish-Speaking Women

INTRODUCTION

The Sexual Health Outcomes in Women Questionnaire (SHOW-Q) is designed to evaluate the sexual life of women for satisfaction, orgasm, desire, and pelvic problem interference. The SHOW-Q is important for evaluating worsening of sexual life for patients with pelvic problems and the management of these women to improve their sexual life.

AIMS

To validate the Turkish versions of the SHOW-Q for Turkish-speaking women.

METHODS

The Turkish version of the SHOW-Q was generated by two independent professional English-to-Turkish translators. The translated version of the SHOW-Q was reverse translated by two bilingual translators whose native language was English. Women with at least one symptom related to pelvic problems (n = 71) and those with no symptoms (n = 38) were included in the present study.

MAIN OUTCOME MEASURES

Test-retest reliability analysis, content-face validity, internal consistency reliability, item-total correlations, convergent validity, construct validity, and factorial validity were performed to assess the psychometric properties of the Turkish versions of the SHOW-Q.

RESULTS

Test-retest reliability demonstrated good correlation for all subscales. Cronbach α values ranged from 0.735 to 0.892 and indicated high internal consistency. There was a strong correlation for the corresponding subscales between the SHOW-Q and the Female Sexual Function Index. The mean score of each SHOW-Q subscale showed significant differences between symptomatic and asymptomatic patients.

CONCLUSION

The Turkish version of the SHOW-Q is a valid and reliable instrument that can be used to evaluate the sexual life of Turkish-speaking women with different pelvic problems.

Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women

BACKGROUND

Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with significant impairment of sexual function.

AIM

To objectively evaluate the impact of laparoscopic excision of endometriosis on sexual function in patients with deep infiltrating endometriosis (DIE) compared to healthy women.

SETTING AND DESIGN

Prospective study, including 250 patients with a diagnosis of DIE scheduled for laparoscopic surgery and 250 healthy women.

METHODS

A sexual activity questionnaire, SHOW-Q (Sexual Health Outcomes in Women Questionnaire), was used to collect data pertaining to women's satisfaction, orgasm, desire and pelvic problem interference with sexual function. Women with DIE underwent complete excision of endometriotic lesions. All participants were asked to complete the SHOW-Q questionnaire before and after surgery.

RESULTS

SHOW-Q scores in the endometriosis group before and 6 months after surgery were compared with the healthy group scores. A significant improvement was found between pre- and post-treatment in the scores of the satisfaction scale, desire scale and pelvic problem interference scale of SHOW-Q. The distribution of post-surgery SHOW-Q scores was comparable to healthy women's scores apart from the orgasm scale score, which was unchanged in the post-surgery group.

CONCLUSIONS

The surgical approach to treatment has a positive impact not only on organ impairment but also on sexual function in women affected by DIE.