Post-hysterectomy Dyspareunia

Clinical Management of Endometriosis in Menopause: A Narrative Review

Endometriosis, an inflammatory disease primarily affecting the pelvis and peritoneum, manifests with pelvic pain, dysmenorrhea, dyschezia, dyspareunia, and infertility. Despite its ubiquity, the management of endometriosis is challenging due to its heterogeneous presentation, limitations in diagnostic methods, variable therapeutic responses, and personal and socio-cultural impact on quality of life. This review attempts to consolidate the current literature on endometriosis occurring during and beyond menopause, and to present details regarding management strategies that take into account individual outcomes and goals when managing this condition. The topics included in this review are the clinical features and differential diagnosis of pelvic pain in postmenopausal patients, imaging considerations, serum and laboratory biomarkers, indications for surgery, the principles of hormone replacement therapy, the de novo development of endometriosis after menopause, and malignant transformation. Each topic includes a summary of the current literature, utilizing clinical research, case reports, and expert opinion. Despite a better understanding of the impact of endometriosis beyond menopause, there are many limitations to this condition, specifically with regard to cancer risk and indications for surgery. The existing evidence supports the use of shared decision making and the incorporation of patient preferences in guiding clinical management. Future research endeavors must shed light on the natural history of postmenopausal endometriosis through longitudinal studies in order to foster a deeper understanding of its complicated disease course across women's lifespans.

Beyond the cuff: a consideration of factors that affect sexual function after benign hysterectomy

PURPOSE OF REVIEW

Hysterectomy is the most common gynecologic surgical procedure performed on women in the United States. While there are data supporting that hysterectomy for benign indication often does not reduce sexual function and may in fact improve sexual function as fibroids and endometriosis are resected, it remains unclear if there are factors within the perioperative period that affect sexual function in the years following surgery. To date, there is no consensus on what factors can optimize patients' sexual function after hysterectomy.

RECENT FINDINGS

We present the current literature that assesses factors which may contribute to sexual function after hysterectomy. Preoperative demographic factors, including increasing age, pelvic pain, and preoperative sexual dysfunction, play a large role in postoperative sexual function. Perioperatively, there is a growing amount of data suggesting that premenopausal salpingo-oophorectomy at the time of hysterectomy may increase the risk of sexual dysfunction after hysterectomy, and no conclusive evidence that subtotal hysterectomy improves sexual function. The route of hysterectomy and technique of cuff closure can impact sexual function after hysterectomy due to the risk of shortening the vaginal length.

SUMMARY

There is a lack of high-quality evidence that can provide a consensus on factors to optimize sexual function after hysterectomy. A growing area of research in the excision of endometriosis procedures is the consideration of nerve-sparing surgery. Considering the many variables that exist when counseling a patient on benign hysterectomy and its effects on sexual function, it is critical to understand the current research that exists with regards to these factors.

Diagnosis, causes, and treatment of dyspareunia in postmenopausal women

IMPORTANCE AND OBJECTIVES

Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women.

METHODS

This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia.

FINDINGS

Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists.

CONCLUSIONS

Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.

Sexual function after hysterectomy according to surgical indication: a prospective cohort study

BACKGROUND

Our aims were to describe characteristics of sexual function prior to and 6months following benign hysterectomy in patients with three common surgical indications, and to identify preoperative factors that influence the magnitude and direction of change in sexual function after the procedure.

METHODS

This prospective observational cohort study enrolled women (n =80) undergoing hysterectomy for benign indications. Patients were categorised into three groups according to surgical indication: (1) pelvic pain (PP), (2) abnormal uterine bleeding (AUB), and (3) pelvic organ prolapse (POP). Primary outcome was Female Sexual Function Index (FSFI), which patients completed preoperatively and 6months postoperatively.

RESULTS

The study included 80 patients, of whom 25.0% (n =20) had surgical indication of PP, 46.3% (n =37) of AUB, and 28.7% (n =23) of POP. PP patients experienced a significant improvement in overall sexual function, as well as orgasm and pain domains following hysterectomy. Significant improvements were not found in AUB and POP patients. In multivariate analysis, lower baseline sexual function (P <0.001), younger age (P =0.013), and pelvic pain<6months (P =0.020) were each independently associated with improvement in sexual function, but surgical indication was not significant.

CONCLUSION

Individual patient factors including younger age, lower baseline sexual function, and short duration of pelvic pain are associated with a higher likelihood of improvement in sexual function after hysterectomy. Surgical indication does not appear to be predictive of postoperative sexual function once accounting for other factors.

Myofascial Pain in Hysterectomy Patients

STUDY OBJECTIVE

To assess the prevalence of myofascial pain in women undergoing uncomplicated, minimally invasive hysterectomy for chronic pelvic pain, to identify clinical and demographic factors associated with preoperative myofascial pain, and examine the association between myofascial pain and postoperative pain in hysterectomy patients.

DESIGN

A retrospective cohort study.

SETTING

A tertiary care teaching hospital.

PATIENTS

A total of 353 adult women who underwent uncomplicated, minimally invasive hysterectomy between January 2014 and 2016.

INTERVENTIONS

All women underwent a preoperative pelvic floor examination. Myofascial pain was diagnosed as tenderness and reproduction of pain symptoms in at least 2 of 6 pelvic floor muscles. Demographics, comorbidities, and intraoperative characteristics were compared between women with and without preoperative myofascial pain.

MEASUREMENTS AND MAIN RESULTS

Of the 353 women who underwent hysterectomy, the prevalence of myofascial pain was 42.7% (86.0% in patients with chronic pelvic pain [CPP] compared with 13.7% without CPP). Women with myofascial pain were more likely younger, Caucasian, sexually active, and with comorbid pain conditions. Patients with myofascial pain used a greater number of adjuvant pain medications before surgery including opiates (29.5%) but were only half as likely to use muscle relaxants (12.1%) for preoperative pain control. Contrastingly, in women without myofascial pain before surgery, controlled substances such as opiates (8%, p <.01) and benzodiazepines (3%, p <.01) were used at a three- fold lower frequency. Postoperative pain score was higher in patients with myofascial pain, with 37% reporting a visual analog scale score greater than 5 at the routine postoperative visit compared with only 1% of patients without myofascial pain.

CONCLUSION

Myofascial pelvic pain must be considered in the evaluation of CPP, especially in surgical candidates. Women with myofascial pelvic use a greater amount of pain medication preoperatively and have higher pain scores postoperatively. Identification of these high-risk patients before surgery may improve pre and postoperative pain management with a multimodal therapy approach.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE

To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance.

METHODS

This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail.

RESULTS

Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region.

CONCLUSION

Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.

Recovery time period and quality of life after hysterectomy

Background: Women who had undergone hysterectomy have to overcome problems related to sexual and reproductive health. They often suffer a decline in self-esteem due to sexual dysfunction and the inability to give birth, along with their quality of recovery. This study aims to describe the relationships between recovery time and the components of quality of life after hysterectomy.

D esign and methods: 103 women post-hysterectomy from several community-integrated health center in Surabaya were selected using the total sampling technique.

Results: Findings show that there is relationship between recovery time period and sexual activity (P=0.000). However, no significant relationship exists between recovery time period personal relationships and social support.

Conclusions: It is recommended that nurses should improve their social support for women and families during recovering, to avoid pathological stress and improve quality of life.

Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

INTRODUCTION

Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia.

AIMS

To review the pathophysiology of deep dyspareunia, and to propose future research priorities.

METHODS

A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)).

MAIN OUTCOME VARIABLE

Deep dyspareunia (present/absent or along a pain severity scale).

RESULTS

The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes.

CONCLUSION

We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.

Hospital-associated Costs of Chronic Pelvic Pain in Canada: A Population-based Descriptive Study

OBJECTIVE

To determine the hospital-related costs incurred by women requiring surgery or inpatient admission for chronic pelvic pain in Canada.

METHODS

We conducted a population-based, cross-sectional study, focusing on women ages 15-59 with a most responsible International Classification of Diseases diagnosis of pelvic and perineal pain, dysmenorrhea, or dyspareunia who had surgery or inpatient admission with a discharge date between April 1, 2008 and March 31, 2012. This study was based on the Canadian Institute for Health Information Discharge Abstract database and the National Ambulatory Care Reporting System. Clinical diagnoses and interventions and resource intensity weights (RIW) were extracted. Hospital costs were estimated by multiplying cost per weighted case (CPWC) calculated at the national level with respective RIWs.

RESULTS

Over four years, there were 34 346 cases of surgery or inpatient admission for chronic pelvic pain amounting to $100.5 million with an average cost of $25 million per year. Pelvic and perineal pain accounted for 61.5% (n = 21 127) of the cases, while dysmenorrhea accounted for 31.8% (n = 10 936), and dyspareunia accounted for 6.6% (n = 2283). The vast majority of the cases (92.9%, n = 31 923) were associated with surgical interventions, with the most common surgeries being hysterectomy (47.1%, n = 16 189), followed by laparoscopy (25.8%, n = 8850), adnexal surgery (6.8%, n = 2349), and other procedures (11.6%, n = 3968).

CONCLUSION

While these estimates do not take into account non-hospital related costs, such as outpatient treatment, loss of productivity, and impact on quality of life, this study demonstrates that chronic pelvic pain represents a considerable economic burden to Canada's health care system.