European Journal of Obstetrics & Gynecology and Reproductive Biology
More than just bad sex: sexual dysfunction and distress in patients with endometriosis
Introduction
Endometriosis is one of the most common gynaecological diseases in women's reproductive years. It is defined as endometriotic tissue outside the uterine cavity, which responds to the ovarian steroids and reacts in the same way as the endometrium during the menstrual cycle. Endometriosis has been shown to cause adhesions, local inflammatory reactions and symptoms such as dysmenorrhea, dyspareunia, chronic pelvic pain and/or a reduced level of fertility [1]. Endometriosis affects approximately 2% of the general female population and about 50–70% of symptomatic women in their reproductive years [2].
Dyspareunia, one of the most common symptoms, is classified into two types: superficial (pain in and around the vaginal introitus) and deep (pain with deep penetration) dyspareunia (SD, DD). Dyspareunia can be observed in 60–70% of women undergoing surgery [3], [4], [5] and between 50% and 90% of those using hormonal therapies [6], [7].
Sexuality is a complex phenomenon influenced by psychosocial as well as physiological factors affecting not only physical health, but also psychological wellbeing, feelings of feminity and relationship [8], [9], [10], [11]. Dyspareunia has been shown to be associated with important negative sequelae, reduced levels of sexual desire/arousal and lower frequency of sexual intercourse [12]. Sexual problems are distressing for women. Interestingly, patients with low relationship satisfaction were nearly six times more likely to have very distressing sexual problems than controls [13].
A principal pathogenic mechanism in dyspareunia is altered awareness of pain recurrence due to previous experiences of coital pain. Therefore, the focus during sexual intercourse turns to sensation of (possible) pain instead of enjoyment [14]. The experience of pain and the loss of pleasure are recurrently recognised and become reinforced by repeated experiences. This process creates a cognitive scheme of negative expectations that disturbs sexuality [14].
Young women in particular suffering dyspareunia continue to have sexual intercourse despite having pain. One reason is striving to be affirmed in their image of an ideal woman [14]. Furthermore, feelings of guilt, sacrifice and resignation may encourage this behaviour. These facts show that partner's pleasure is more important for many women than their own pleasure and wellbeing [14].
Rape has been demonstrated to have a deleterious effect on female sexual function [15], with lifetime prevalence rates of 17.6% [16]. According to Golding, sexual assault is significantly associated with dysmenorrhea, irregular menstrual bleeding and pain during sexual intercourse [17]. Premenopausal women with a posttraumatic stress disorder (PTSD) after rape are 1.5, 3.4, 2.7 and 0.6 times more likely to experience sexually transmitted infections, dyspareunia, symptomatic endometriosis and fewer pregnancies, respectively [12], [18]. Altogether, the literature shows that sexual assault has an impact on quality of sex life (QoSL). We assume the same effect in our sample and therefore, we also evaluated history of sexual assault.
To date, there is a lack of prospective studies evaluating dyspareunia in women with endometriosis and its impact on sexual function. The objective of the present analysis was to investigate the prevalence and impact of female sexual dysfunction (FSD) and sexual distress in these patients. Furthermore, psychosocial parameters, QoSL and the impact on relationship were evaluated.
Section snippets
Patient data
The present work was designed as a multicenter cohort study conducted in Austria and Germany with eight participating certified endometriosis and pelvic pain clinics from May 2011 until August 2012. Only patients with dyspareunia lasting for at least six months (and additional other pain symptoms related to endometriosis) were included. Women without a histologically proven diagnosis of endometriosis, pain symptoms of other origin or a history gynaecological malignancy or internal diseases were
Patients and surgical findings
One hundred and twenty-five patients fully completed the questionnaire and underwent surgical resection with histological proof of endometriotic disease according to surgical and histological reports. Assessed by the revAFS, 38 women (30%) had a minimal (Stage I), 31 (25%) a mild (Stage II), 29 (23%) a moderate (Stage III) and 27 (22%) patients had a severe form (Stage IV) of endometriosis.
At Stage I of the revAFS, 27 (71%) patients had sexual distress and 4 (11%) a sexual dysfunction. At Stage
Comments
Dyspareunia is four times more frequent in women with endometriosis than in controls and five times more frequent in patients with peritoneal endometriosis than in those with endometriotic cysts [24]. Dyspareunia is most severe before menstruation [25] and associated with deep infiltrating endometriotic lesions of the uterosacral ligaments (USL) [26]. Another factor for the severe coital pain may also be the traction of scarred inelastic USL during sexual intercourse [25].
Despite the fact that
Conflict of interest
No competing financial interests exist.
Acknowledgements
The authors want to thank all participating women for their support. This work was supported by the OEGEO, Österreichische Gesellschaft für Endokrinologische Onkologie.
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