Love is a pain? Quality of sex life after surgical resection of endometriosis: a review

Transrectal light-guided probe assisted laparoscopic resection of deep infiltrating endometriosis: A case report

In the surgical treatment of deep infiltrating endometriosis, the completeness of lesion removal is crucial for the success of the procedure. Consequently, an array of auxiliary surgical methods are continuously being refined to improve the precision of lesion excision and minimize the incidence of complications. Among these, the traditional rectal probe aids in bowel mobilization and evaluates tissue suppleness, but lacks clear visualization of the intestinal wall thickness. To optimize lesion exposure, reduce complications, and remove lesions as completely as possible, we have enhanced this tool. This paper reports the pioneering use of a transrectal light-guided probe, invented by our medical team, in the surgical treatment of a patient with deep infiltrating endometriosis. The patient, a 26-year-old female with a seven-year history of dysmenorrhea, was initially suspected of having ovarian chocolate cysts, strongly suggesting the presence of deep endometriosis. Having ruled out surgical contraindications and completed all preoperative preparations, a laparoscopic excision of endometriotic lesions with the aid of a transrectal light-guided probe was carried out. One year post-treatment, the patient reported substantial alleviation of dysmenorrhea, the complete resolution of dyspareunia, and no long-term complications were noted. The innovation and implementation of this auxiliary surgical technique in clinical settings have demonstrated the potential to reduce surgical complications, thereby significantly improving the quality of life and long-term prognosis for patients with deep endometriosis.

How does surgery influence female sexuality in patients with endometriosis compared to those with other benign gynecological conditions?

BACKGROUND

Endometriosis is a chronic, estrogen-dependent, benign condition, affecting 10-15% of women of reproductive age. It is associated with a prevalence of sexual dysfunction that is nearly twice as high as that seen in women with other benign gynecological conditions. Our study aimed to assess the effect of surgical intervention on sexual function, as measured by the FSFI (Female Sexual Function Index) score, in women with endometriosis compared to those with other benign gynecological conditions, both before and after surgery.

METHODS

A comparative analysis was conducted at the Medical University of Vienna from 2015 to 2020. The study included patients suspected of having endometriosis, fibroids, adnexal cysts, and/or infertility. Based on findings during surgery, patients were categorized into two groups: those with endometriosis (n = 64) and control patients (n = 38). All participants completed the FSFI questionnaire before surgery and again 8 to 18 weeks after the operation.

RESULTS

No significant differences were observed in the preoperative FSFI scores between the endometriosis patients and the control group. Similarly, no significant differences were found between the two groups in postoperative scores. However, in women diagnosed with endometriosis, surgical removal of endometriotic lesions significantly increased their full-scale FSFI score, and resulted in a significant improvement in the areas "desire" and "satisfaction". Improvements were noted in all other areas as well, though they were not statistically significant.

CONCLUSIONS

Our research indicates that the surgical removal of endometriotic lesions can lead to an improvement in sexual function, as measured by the FSFI, within 8 to 18 weeks post-surgery. This improvement was not observed in the control group, which underwent surgery for other benign gynecological issues.

Endometriosis and sexual disorders: the effect of surgical and medical treatment, a multicentre cross-sectional study

Background

Sexual health is a major concern in women with endometriosis, however only a few controlled studies have examined this with validated instruments. The effect of hormonal treatments on sexual function in endometriosis is also an underrated topic. The aim of this study was to investigate sexual function of patients with endometriosis by a specific tool to better evaluate their sexual function (including different domains), and the influence of hormonal treatment or surgery on these parameters.

Methods

An observational, cross-sectional, multicentre study was conducted in a group (n=194) of sexually active, women aged 25-45 years old, with surgical or ultrasonographic diagnosis of endometriosis, referred to the Endometriosis Center of Careggi University Hospital or Negrar di Valpolicella. Sexual function was assessed by administering the Female Sexual Function Index (FSFI), which assesses the domains of desire, arousal, lubrication, orgasm, satisfaction and pain. FSFI scores were compared to those of a control group (n=58) and according to the treatment received by patients with endometriosis.

Results

Ovarian endometriosis was present in 50 patients (25.8%), deep infiltrating endometriosis in 65 patients (33.5%) and both in 79 patients (40.7%). Adenomyosis coexisted in 102 patients (52.6%). Women with endometriosis reported a mean total FSFI score of 18.3 [4.2-25.8] (< 26.55), indicating female sexual dysfunction (FSD) in all patients. At multivariate analysis, after adjusting for confounders (BMI and hormonal therapy), women with endometriosis presented significantly lower scores than controls in all the FSFI (p<0.001). Patients with endometriosis under hormonal treatments (n=124; 64%), regardless of the type, had significantly lower scores in all FSFI subscales and total score, even after adjusting for confounders-age, BMI and history of surgery.

Conclusions

Patients with endometriosis are at risk for FSD, encompassing not only dyspareunia, but all domains of sexual function. Hormonal treatments do not result in improvement in sexual symptoms.

Endometriosis Resection Using Nerve Sparing Versus Non-nerve Sparing Surgical Techniques

Introduction

Endometriosis is the condition in which there are ectopic endometrial tissues outside the uterine cavity. The use of nerve sparing technique has been well established in the field of oncology, leading to better quality of life following radical oncologic procedures without compromising on the long-term survival. The objective of this study is to compare the quality of life in terms of sexual function and urinary function in women undergoing nerve sparing surgeries for endometriosis and those undergoing non-nerve sparing surgeries.

Material and Methods

Data of 51 patients operated for endometriosis at Galaxy Care Laparoscopic Institute, Pune, India between 1st January 2020 till 31st December 2020 were collected and analysed. We included patients in age group between 38 and 44 years in monogamous relationship, with moderate to severe endometriosis (Revised American Society of Reproductive Medicine r-ASRM score of 16 and above 5), being operated for hysterectomy along with ureterolysis and/or bowel resection (including shaving of rectal endometriosis, discoid resection, segmental resection), and excision of large ovarian endometriomas (> 3 cm size) with cul-de-sac obliteration.

Results

The patients were evaluated for the following factors: age, parity, nature of surgery done, immediate intraoperative complications (bowel injury, bladder injury, ureteric injury), operative time in minutes, average blood loss, length of hospital stay, days to removal of foley's catheter and postoperative urinary and sexual function which were assessed on follow up visit and a 1-year follow up interview. We found that the urinary and sexual function in the group undergoing nerve sparing surgeries was significantly better than the patients undergoing non-nerve sparing surgeries.

Conclusion

Laparoscopic nerve sparing approach for clearance of endometriosis has allowed better quality of life post surgery. Proper understanding and demonstration of pelvic neuroanatomy has made this approach feasible and achievable in carefully selected patients.

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.

A Study on the Correlation Between Quality of Life and Unhealthy Emotion Among Patients With Endometriosis

Objective

To investigate the influence of quality of life (QOL) on unhealthy emotions as well as relevant factors among patients with endometriosis for supporting relevant clinical care.

Methods

A convenience sampling method was used to administer questionnaires to 139 patients with endometriosis, using the Hamilton Anxiety Inventory (HAMA), the Depression Anxiety Scale (SDS), and the SF-12 Health Survey Short Form, and the results were analyzed. The SPSS20.0 software was used for statistical analysis on relevant data. If P < 0.05, there was statistical significance.

Results

Twelve-Item Short Form (SF-12) for health survey covered two comprehensive indexes, i.e., physical component summary (PCS) and mental component summary (MCS) scores. MCS score was the main factor influencing anxiety and depression in patients with endometriosis; the higher the MCS score, the lower the anxiety and depression degrees in patients with endometriosis (OR = 0.912, 95% CI: 0.877–0.949; OR = 0.899, 95% CI: 0.866–0.933). PCS score was a factor influencing anxiety degree; the higher the PCS score, the lower the anxiety degree (OR = 0.936, 95% CI: 0.891–0.983).

Conclusion

The QOL of patients with endometriosis is negatively correlated with anxiety and depression. Therefore, improvement in QOL may help relevant patients to relieve their unhealthy emotions.

Patient-Reported Outcome Measures in Endometriosis

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients’ perspectives on their condition. In endometriosis care, physicians’ understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients’ quality of life, as well as provide a tool for patients’ self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Constellations of pain: a qualitative study of the complexity of women's endometriosis-related pain

INTRODUCTION

Prior research into endometriosis-related pain has focused on specific aspects of the pain experience such as cyclical pain, emotional aspects of pain and certain types of pain such as dysmenorrhea and dyspareunia. However, research has paid less attention to the diversity and complexity of women's pain experiences, which can lead to failure to recognise some symptoms as part of endometriosis and poor symptom management.

METHODS

We conducted qualitative semi-structured face-to-face interviews with 20 women in the United Kingdom recruited from an endometriosis self-help group with a diagnosis of endometriosis via laparoscopy. A topic guide framed questions around experiences of pain. Interviews were audio-recorded and transcribed verbatim. Transcripts were analysed using inductive thematic analysis.

RESULTS

Women experienced multiple types of pain that they felt were caused by endometriosis and affected many different parts of the body including bowel, bladder, lungs, kidneys, nerves, upper body, lower limbs and head. These pains consisted of different conceptual categories: type, pattern and intensity. These categories came together to create a complex, interrelated experience for each individual that we termed 'constellations of pain' because each woman had a complex set of pain categories and no two individuals appeared to have the same pain experience.

CONCLUSION

The complexity and diversity of endometriosis-related pain found in this study has implications for improving diagnosis, medical and non-medical pain management and improving the clinical encounter between women and healthcare professionals.

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.

The health-related quality of life of patients with a benign gynecological condition: a 2-year follow-up

Aim: To assess health-related quality of life (HRQoL) of patients with benign gynecological disorders. Materials & methods: Prospective 2-year follow-up with the 15D HRQoL-instrument of 311 women treated in Helsinki-area hospitals in 2012-2013. Results: The initially impaired HRQoL regarding excretion, discomfort and symptoms, and vitality and sexual activity improved after treatment. However, only sexual activity reached similar levels as in the general population. Treatment of endometriosis, fibroids and polyps resulted in best and that of unspecific pelvic pain and bleeding disorders in worst HRQoL scores. Results were independent of hospital size. Conclusion: The impaired HRQoL dimensions were improved by treatment but HRQoL still remained poorer than in the general female population. Treatment of unspecific pelvic pain and bleeding disorders needs further evaluation.

The impact of laparoscopic surgery on the symptoms and wellbeing of patients with deep infiltrating endometriosis and bowel involvement

BACKGROUND

The purpose of this study was to evaluate the symptoms and wellbeing of patients who underwent laparoscopic colorectal resection for deep endometriosis infiltrating the rectum and/or colon in a single reference center.

METHODS

We conducted a cross-sectional survey based on a structured questionnaire. All patients underwent laparoscopic discoid resection, segmental resection or shaving for deep endometriosis in a single reference center between October 2014 and October 2019. The following topics were addressed: symptoms related to endometriosis, fertility, disease recurrence and quality of life. The Institutional Review Board approved the study and signed informed consent was required before enrollment.

RESULTS

A total of 77 of 160 (48.1%) subjects agreed to answer the questionnaire and were enrolled in the study. The mean age was 36.4 years (range, 24-54 years), and 45.5% of the patients had previously undergone surgery for deep endometriosis. Complete resolution of abdominal pain was observed in 48.1% of subjects after surgery. Pelvic pain was rated on a scale of 0 (no pain) to 10 (worst pain) before and after the procedure. In this evaluation, mean pain scores were reduced after surgery (9.21 ± 1.53 × 3.99 ± 3.14; p < .001). Other positive aspects reported by interviewees were increased willingness to perform daily activities (66.2%), increased physical activity (70.1%), better work performance (72.7%), improved dyspareunia (77.9%) and increased sexual activity (71.4%). Some negative aspects reported after surgery were straining at stool (35.1%), nocturia (24.7%), liquid-feces incontinence (13%), mild urinary incontinence (13%), urinary urgency (11.7%) and flatus incontinence (7.8%). Regarding pregnancy, 59% of patients tried to conceive after surgery, and the success rate was 28.2% (46.2% spontaneous and 53.8% after in vitro fertilization or insemination).

CONCLUSIONS

Laparoscopic surgery was associated with pain reduction and improved general wellbeing in patients diagnosed with deep endometriosis and bowel involvement.

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.

The Burden of Endometriosis on Women's Lifespan: A Narrative Overview on Quality of Life and Psychosocial Wellbeing

Endometriosis is a chronic, inflammatory disease affecting more than 170 million women worldwide and up to 10% of women of reproductive age. As a consequence of inflammatory reaction and infiltration of anatomic structures, endometriosis can cause “pain symptoms” including dysmenorrhea, dyspareunia, dyschezia, dysuria, and chronic pelvic pain. In this review, we summarized the impact of endometriosis on quality of life in all its aspects including sexual life, work, and social relationships. The data research was conducted using web-based search engines and/or various electronic research databases querying for all articles related to endometriosis and quality of life from the inception of the database up to February 2020. Endometriosis has not only physical but also psychological effects, causing depression, anxiety, and compromising social relationships. Furthermore, endometriosis negatively impacts sexual life and social relationships. At last, the economic burden of endometriosis should not be underestimated, both individually and for the community, as this pathology leads to a loss of productivity at work and large use of health resources. Thus, endometriosis-related symptoms control women’s lives compromising the quality of life in all aspects. In this review, we summarized the impact of endometriosis on various aspects of women’s lives.

Elagolix reduced dyspareunia and improved health-related quality of life in premenopausal women with endometriosis-associated pain

Objectives:

The objective was to evaluate the effects of elagolix on dyspareunia in women with endometriosis-associated pain.

Methods:

Data were pooled from two similar, randomized, double-blind, placebo-controlled, 6-month phase 3 studies (Elaris Endometriosis-I and Elaris Endometriosis-II) of elagolix at two doses (150 mg QD and 200 mg BID) in women with endometriosis-associated pain. In this post hoc analysis, dyspareunia responders were defined as having a clinically meaningful decrease from baseline in the dyspareunia score and decreased or stable use of rescue analgesic agents, as recorded in a daily electronic diary. Sexual relationship was assessed using the 30-item Endometriosis Health Profile questionnaire sexual relationship module.

Results:

A total of 1384 women reported ⩾1 day of sexual activity at baseline (35 days prior to and including day 1 of treatment). Of these 1384 women, 1297 (94%) reported ⩾1 day of any dyspareunia (mild, moderate, or severe), of which 51% reported ⩾1 day of severe dyspareunia. Among sexually active women who reported any dyspareunia at baseline, both elagolix doses led to improvements in dyspareunia. Women in the 200-mg BID group showed more months at which the dyspareunia response rates were statistically significantly greater than placebo, particularly in a subgroup of women with severe dyspareunia at baseline. Compared to placebo, both elagolix doses led to statistically significantly greater improvements in the mean 30-item Endometriosis Health Profile sexual relationship module score.

Conclusion:

Up to 6 months of elagolix treatment improved dyspareunia in women with endometriosis-associated pain in a dose-dependent manner, with 200-mg BID dose showing the most significant improvements in dyspareunia and quality of sexual relationships compared with placebo.

Health-related quality of life (Nottingham Health Profile) in patients with endometriomas: correlation with clinical variables and self-reported limitations

INTRODUCTION

Endometriosis is a chronic disease that involves the development of endometrium outside the uterine cavity with pain component predominance. The aim of the study was to discuss the occurrence of health problems in patients with endometriomas and simple cysts and the effect of these problems on the daily functioning of the patients.

MATERIAL AND METHODS

The study included patients (n = 40) treated laparoscopically and/or by laparotomy due to lesions in the form of endometriomas or simple cysts. The control group (n = 36) consisted of healthy patients of the Gynecological Clinic, with no changes in adnexa confirmed in vaginal ultrasound examination. The original authors' questionnaire and the Nottingham Health Profile Questionnaire (NHP) were used as research tools.

RESULTS

Analysis of the correlation with Spearman's test demonstrated a statistically significant relationship between the size of the tumor and the occurrence of sleep disorders only in the group of women suffering from endometriomas (r = -0.348; p = 0.041). Women with endometriomas significantly more often reported problems (Cramer's V) in the sphere of "paid work" (p < 0.001), "housework" (p < 0.001), in social life (p < 0.001), problems in sexual life (p < 0.001) as well as problems in continuing hobbies (p < 0.001) and in spending free time (p < 0.001).

CONCLUSIONS

Since the stage of endometriosis does not correlate with subjective complaints, it seems that an additional routine evaluation of quality of life, including an assessment of the severity of the disease, is warranted. Routine use of the Nottingham Health Profile Questionnaire in patients with endometriosis can improve also the assessment of the treatment.

Evaluation of sexual function in women with deep infiltrating endometriosis

INTRODUCTION

The influence of deep infiltrating endometriosis (DIE) on sexual function has been poorly studied. The aim of this study was to evaluate the impact of DIE on sexual function by administering questionnaires to women.

METHODS

Women with a clinical and ultrasound diagnosis of DIE and histological confirmation of endometriosis were included in the study. In interview, women were asked to rate five pain symptoms, dysmenorrhea, dyspareunia, dyschezia, dysuria and Cronic Pelvic Pain (CPP), on a visual analogue scale (VAS), and sexual function was assessed using the Female Sexual Function Index (FSFI).

RESULTS

A total of 170 women with DIE were identified. A VAS score of 7 or more was taken to indicate that a symptom was 'severe'. Dysmenorrhea was reported to be severe by 66.5% of the sample, dyspareunia by 41.8%, dyschezia by 32.4% and dysuria by 6.5%. Mean FSFI scores did not differ significantly between women with and without endometriosis lesions at particular sites, except for rectovaginal nodules, which were found to be associated with more impaired sexual activity and sexual function.

CONCLUSIONS

Women with DIE had significant impairment of sexual activity when a partial or total infiltration of the rectovaginal septum occurred. Particular attention should be given to women with this kind of lesion.

Use of radioguided surgery in abdominal wall endometriosis: An innovative approach

Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity. The occurrence of endometriosis in the anterior abdominal wall is often associated with previous cesarean section, once the spread of endometrial cells during the surgical procedure is a biologically fact possible. A 43-year-old patient, with cesarean section history and pelvic endometriosis diagnosed for over 10 years, presented with progressive abdominal pain. Tests showed cystic image with 1.6 cm of diameter and debris, located in mid-lower portion of the rectus abdominis left, suggesting abdominal wall endometriosis. This abdominal wall lesion was not identifiable in the clinical examination (impalpable), which is why we opted for the use of preoperative marking technique with radioisotope called Radioguided Occult Lesion Localization (ROLL™). The use of ROLL™ in this case allowed rapid surgical identification of endometriotic lesion and its complete excision.