{"paper_id":"1acb60ae-6586-4fdd-aef6-e6fa68da6216","body_text":"Female Sexual Function in Women with\nSuspected Deep In filtrating Endometriosis\nFunção sexual feminina em mulheres com suspeita\nde endometriose in filtrativa profunda\nRyane Vieira Lima 1 Ana Maria Gomes Pereira 1 Fernando Bray Beraldo 1 Cláudia Gazzo 1\nJoão Alfredo Martins 1 Reginaldo Guedes Coelho Lopes 1\n1 Hospital do Servidor Público Estadual, São Paulo, SP, Brazil\nRev Bras Ginecol Obstet 2018;40:115 –120.\nAddress for correspondence Ryane Vieira Lima, Medical Resident,\nAvenida Ibirapuera, 981, 04038- 034, São Paulo, SP , Brazil\n(e-mail: ryanevlm@gmail.com).\nKeywords\n► endometriosis\n► sexuality\n► deeply in filtrating\nendometriosis\nAbstract Objective To evaluate the quality of the sexual function of women with suspected\ndeep in filtrating endometriosis.\nMethods A cross-sectional, observational and prospective study was conducted\nbetween May 2015 and August 2016, in which 67 patients with deep in filtrating\nendometriosis, suspected or diagnosed, wer e assessed for epidemiological and clinical\ncharacteristics, such as pain level through a visual analog scale (VAS), features of deep\ninfiltrating endometriosis lesions and score on the Female Sexual Function Index (FSFI)\nbefore the onset of treatment. The stati stical analysis was performed using the\nsoftware STATA version 12.0 (StataCorp LLC, College Station, TX, USA) to compare\nthe variables through multiple regression analysis.\nResults The average age of the patients was 39.2 years old; most patients were\nsymptomatic (92.5%); and the predominant location of the deep in filtrating lesions was\non the rectosigmoid colon (50%), closely followed by the retrocervical region (48.3%). The\nmedian overall score on the FSFI was 23.4; in 67.2% of the cases the score was/C20 26.5 (cutoff\npoint for sexual dysfunction). Deep dyspareunia (p ¼ 0.000, confidence interval [CI]: 0.64–\n0.83) and rectosigmoid endometriosis lesions ( p ¼ 0.008, CI: 0.72 –0.95) showed signifi-\ncant correlation with lower FSFI scores, adjusted by bladder lesion, patients’ age and size of\nlesions. Deep dyspareunia (p ¼ 0.003, CI: 0.49–0.86) also exhibited significant correlation\nwith FSFI pain domain, adjusted by cyclic bowel pain, vaginal lesion and use of gonadotro-\npin-releasing hormone (GnRH) analog. These results re flect the in fluence of deep\ndyspareunia on the sexual dysfunction of the analyzed population.\nConclusion Most patients exhibited sexual dysfunction, and deep dyspareunia was\nthe pelvic painful symptom that showed correlation with sexual dysfunction.\nResumo Objetivo Avaliar a qualidade da função sexual em pacientes com suspeita de\nendometriose profunda in filtrativa.\nMétodos Foi realizado um estudo observacional transversal prospectivo entre maio\nde 2015 e agosto de 2016, no qual foram analisados os dados clínicos e\nreceived\nSeptember 16, 2017\naccepted\nJanuary 24, 2018\nDOI https://doi.org/\n10.1055/s-0038-1639593.\nISSN 0100-7203.\nCopyright © 2018 by Thieme Revinter\nPublicações Ltda, Rio de Janeiro, Brazil\nTHIEME\nOriginal Article 115\n\n\nIntroduction\nEndometriosis is characterized by the presence of endome-\ntrium-like functional tissue located outside the uterine\ncavity, most often on the pelvic peritoneum and ovaries. It\nmight present as deep and in filtrating lesions in the organs\nadjacent to the uterus —the bladder in the anterior pelvic\ncompartment, retrocervical region, rectovaginal septum,\nvaginal fornices, rectosigmoid colon and cecal appendix in\nthe posterior compartment.\n1,2 While the etiopathogenesis of\nthe disease is not well known, some evidences suggest that a\ncombination of retrograde menstrual flow with genetic,\nhormonal and immune factors and the cell response of the\neutopic endometrium might contribute to the formation and\ndevelopment of endometriosis lesions. 3\nAccording to the available studies, the prevalence of this\ndisease is 10–20% among women of reproductive age, 4 but it\nmight vary to be as high as 50% in populations of patients\nwith speci fic clinical characteristics, such as infertility and\nchronic pelvic pain.\n5\nWith the help of laparoscopy, endometriosis might be\nclassified according to its anatomical localization and exten-\nsion. Among the available classi fication systems is the one\nformulated by the American Society of Reproductive Medi-\ncine, which is based on the appearance, size and depth of\nperitoneal and ovarian implants, presence, extension and\ntype of adhesions, and degree of cul-de-sac obliteration.\n6\nMore recently, the ENZIAN classi fication was developed for\ndeeply infiltrating lesions, in which the stages of disease are\ndefined according to their localization and size. 7,8 The bowel\nis frequently affected in the deep form of the disease, de fined\nas endometriosis in filtrating deeper than 5 mm under the\nperitoneum.7\nDeep in filtrating lesions can be identi fied by physical\nexamination,1 but transvaginal ultrasound 9 and magnetic\nresonance imaging 10 have been used for de finition of the\nextension of the lesions with adequate accuracy.\nThere is no con firmed correlation between extension of\nthe disease and severity of symptoms, reproductive progno-\nsis or recurrence of pain in the long run. 11\nThe clinical presentation of the disease is quite variable.\nUp to 25% of the patients might be asymptomatic, 12 30–50%\nmight report infertility, 12,13 and up to 80% complain of\nchronic pelvic pain (severe dysmenorrhea, deep dyspareunia\nand painful ovulation). 14 In addition, perimenstrual urinary\nor rectal symptoms and chronic fatigue are common clinical\ncomplaints.12,15\nThe quality of life of patients with endometriosis is\nsignificantly impaired, while deep dyspareunia considerably\naffects their sexual life. 16 In addition, dyspareunia is associ-\nated with anxiety, 17,18 reduced frequency of sexual inter-\ncourse, reduction of sexual desire and arousal, and less\norgasmic experiences. 19,20 While these are subjective phe-\nnomena, assessment of the sexual function through validat-\ned questionnaires affords a better understanding of the\nimpact of endometriosis on the quality of female sexuality.\nOne of the best-established questionnaires for this purpose is\nthe Female Function Sexual Index (FSFI), which has been\nvalidated for the Brazilian Portuguese language.\n21–23\nLaparoscopic excision of endometriotic nodules, pharma-\ncological treatment and the combination of both proved to be\nefficacious to reduce deep dyspareunia. 24–28\nConsidering the intimate relationship between endome-\ntriosis and sexual dysfunction, 17–20 we sought to assess the\nquality of the sexual function of women with suspected deep\ninfiltrating endometriosis (DIE).\nepidemiológicos de 67 pacientes com endometriose profunda presuntiva ou diag-\nnosticada, níveis de dor através de escala visual analógica (EVA) e Índice de Função\nSexual Feminina (questionário IFSF) antes do i nício do tratamento. A análise estatística\nfoi realizada utilizando o programa estatístico STATA, na versão 12.0 (StataCorp LLC,\nCollege Station, TX, USA), para comparar as variáveis por meio de regressão múltipla.\nResultados A idade média foi de 39,2 anos; houve predominância de mulheres\nsintomáticas (92,5%) e da localização de lesões de endometriose profunda em\nretossigmoide (50%) seguida pela topogra fia retrocervical (48,3%). A pontuação total\nno IFSF mostrou uma mediana de 23,4, e em 67,2% das mulheres a pontuação\nfoi /C20 26,55 ( cut-off que indica disfunção sexual). Dispareunia ( p ¼ 0.000, intervalo\nde confiança [IC]: 0.64 –0.83) e lesão endometriótica em retossigmoide ( p ¼ 0.008, IC:\n0.72–0.95) exibiram uma relação estatisticamente signi ficante com valores baixos de\npontuação no IFSF, ajustados por lesão em bexiga, idade da paciente e tamanho da\nlesão. A dispareunia de profundidade também mostrou correlação signi ficante com o\ndomínio dor do IFSF ajustado por dor cíclica intestinal, lesão vaginal e uso de análogo de\nhormônio liberador de gonadotro fina (GnRH). Os resultados re fletem a in fluência da\ndispareunia de profundidade na disfunção sexual da população do estudo.\nConclusão A maioria das pacientes apresentav a disfunção sexual e o sintoma mais\nrelacionado a esta disfunção foi dispareunia de profundidade.\nPalavras-chave\n► endometriose\n► sexualidade\n► endometriose\nprofunda in filtrativa\nRev Bras Ginecol Obstet Vol. 40 No. 3/2018\nFemale Sexual Function with Suspected Endometriosis Lima et al.116\n\n\nMethods\nThe present prospective, observational and cross-sectional\nstudy was approved by the Brazilian national ethics\ncommittee.\nOn their first appointment at the endometriosis and\nchronic pelvic pain outpatient clinic of Hospital do Servidor\nPúblico Estadual Francisco Morato de Oliveira (HSPE-FMO),\n67 consecutive patients with clinical suspicion of DIE were\ninvited to participate in this study from May of 2015 to\nAugust of2016.\nWe included sexually active women of reproductive age\nwith suspected DIE at gynecological examination, ultraso-\nnography (US) or magnetic resonance (MR) images and who\nagreed to participate in the study by signing an informed\nconsent form. The participants were assured as to the\nconfidentiality of the data and were informed they could\nwithdraw their consent at any time.\nAll women were treated by means of continuous con-\ntraceptive or gonadotropin-releasing hormone (GnRH) ana-\nlog to induce amenorrhea, and the surgical procedure was\ndetermined by non-responsive pain symptoms\n1 or intestinal\nand urinary risk of complications. The surgical procedures\nwere performed laparoscopically with the aim of complete\nresection of DIE ’s lesions and histological exam was con-\nducted in all specimen. The exclusion criteria consisted of\nincomplete filling out of the sexual function questionnaire\nand the withdraw of the informed consent.\nWe first collected data on the patients ’ age, number of\npregnancies, surgical history of endometriosis, previous\ntreatment, fertility condition, urinary and intestinal com-\nplains and pain symptoms: dysmenorrhea, dyspareunia and\nnon-cyclic pelvic pain, which were quanti fied by means of\nthe visual analog scale (VAS). Also, the characteristics of the\nendometriotic lesions on imaging tests (size, location\nand degree of in filtration) were described and classi fied\npreoperatively according to the ENZIAN classi fication, as it\naffords a satisfactory morphological description per affected\ncompartment and lesion size.\n8\nAt first, before any surgical treatment, the participants\nfilled out the FSFI questionnaire; some of them had already\nreceived clinical treatment previously but that information\nwas taken into account as a possible confounding factor\ntoward statistical analysis. The FSFI is a short, speci fica n d\nmultidimensional scale, previously adapted to the Portu-\nguese language, with signi ficant reliability and validity,\n21\nwhich transforms subjective assessments into objective,\nquantifiable and analyzable data. 23 The FSFI includes 19\nquestions corresponding to 6 domains — desire, arousal,\nlubrication, orgasm, satisfaction and pain or discomfort;\nthe questions are scored from 0 to 5. We calculated the\noverall score by adding the scores of the individual items in\neach domain, then we multiplied the sum by the domain\nfactor— provided by the scale authors— and finally added the\nsix domain scores. The overall score might vary from 2 to 36,\nbeing that the higher the score the better the sexual func -\ntion.\n21,22 Scores equal to or lower than 26.55 indicate sexual\ndysfunction.29\nThe collected data were entered in a Microsoft Excel for\nWindows spreadsheet (Microsoft Corp., Redmond, WA, USA).\nThe statistical software STATA version 12.0 (StataCorp LLC,\nCollege Station, TX, USA) was used to perform descriptive and\ncomparative analysis by means of Poisson ’so rl o g i s t i cr e -\ngression to investigate the correlation of the epidemiological\nand clinical data with the scores on the FSFI.\nThe categorical variables were expressed as percentages\nand the numerical ones as mean and standard deviation,\nwhen parametric distribution was observed, or as median\nand quartiles when their distribution was nonparametric.\nFor the logistic and Poisson regression models, we\nemployed the forward stepwise method to select the varia-\nbles potentially correlated with the outcomes. After univari-\nate correlation analysis, the variables with p /C20 0.20 or others\nwith clinical relevance were selected to perform the multiple\nregressions. To improve the model fit, the signi ficance level\nfor the final correlations and adjusted multiple analysis was\nset at p /C20 0.05 with 95% con fidence interval (CI). We sub-\njected the final models to reliability tests to establish their\ngoodness-of-fit, to wit, the Hosmer-Lemeshow test was used\nfor the logistic regression model and the Pearson goodness-\nof-fit test for the Poisson regression model.\nResults\nFrom the 67 patients selected to participate in the study,\nnone matched the exclusion criteria. Data corresponding to\n67 women with age varying from 20 to 52 years old (mean:\n39.19 /C6 6.67) were analyzed. Relative to the obstetrical\nhistory of the participants, 47.8% (32) had never been\npregnant and 52.2% (35) had one to three children. The\nmost prevalent delivery route was cesarean section, corre-\nsponding to 65.6% (21) of the cases, information that was\nfound in patients ’ the medical records. About 19.4% (13) of\nthe sample had history of miscarriage, and 52.2% (35) had\nhistory of infertility. Finally, 26.2% (17) of the participants\nhad history of pelvic gynecological surgery.\nAbout 92.5% (62) of the participants were symptomatic,\nthe median duration of symptoms being 84 months (24 –\n120), that is, 7 years, varying from 1 to 420 months (35 years).\nThe most prevalent symptoms included dysmenorrhea\n(94%), dyspareunia (71.2%) and non-cyclic pain (67.2%).\nThe distribution of painful symptoms according to the VAS\nscores is described on\n►Table 1 .\nTable 1 Distribution of painful symptoms on the VAS of\nw o m e nw i t hd e e pi nfiltrating endometriosis\nVAS Dysmenorrhea\nn (%)\nDyspareunia\nn (%)\nNon-cyclic\npain\nn (%)\n0–4( m i l d ) 4( 6 ) 2 4( 3 6 . 9 ) 3 2( 4 7 . 8 )\n5–6 (moderate) 9 (13.5) 14 (21.5) 14 (20.9)\n7–10 (severe) 54 (80.5) 29 (41.6) 21 (31.3)\nAbbreviations: n, number of subjects; p,p - v a l u e ;V A S ,v i s u a la n a l o g\nscale.\nRev Bras Ginecol Obstet Vol. 40 No. 3/2018\nFemale Sexual Function with Suspected Endometriosis Lima et al. 117\n\n\nSpecific bowel and urinary symptoms were reported by the\npatients, and the most common clinical presentation of these\nspecific symptoms is the non-cyclic variety: constipation\n(28.4%), non-cyclic dyschezia (20.9%), cyclic dyschezia\n(16.4%), non-cyclic abdominal bowel pain (16.4%), cyclic ab-\ndominal bowel pain (9%), non-cyclic hematochezia (7.5%), cyclic\nhematochezia (6%), non-cyclic urinary pain (3%), cyclic urinary\npain (1.5%). About 28.4% of the sample reported constipation,\nwith an average interval of 2.28 days between stools.\nSome patients (34.3%) were referred to the outpatient\nclinic already receiving treatment, which included combined\noral contraceptives (COC) (17.9%), progestin alone (11.9%),\nand GnRH analog (4.5%).\nSixty medical records had information on the localization\nof deep in filtrating endometriosis lesions by means of spe-\ncialized imaging tests, such as magnetic resonance imaging\nof the pelvis and transvaginal ultrasound with bowel prepa-\nration. About 45% (27) of the sample exhibited lesions\nsuspected of cystic ovarian endometriosis concomitant\nwith bowel lesions, which were bilateral in 16.6% (9) of the\ncases. As to the distribution of lesions, 50% (30) were located\non the rectosigmoid colon, 48.3% (29) in the retrocervical\nregion, 11.7% (7) in the vaginal fornices, 8.3% (5) in the\nvaginal septum and 5.9% (3) on the bladder re flection.\nThe mean size of the lesions was 2.3 cm (1.6 –3.0 cm),\nvarying from 0.7 to 11.4 cm. Forty-nine cases could be\nclassified according to the ENZIAN system (\n►Table 2 ).\nLesions on the vaginal fornices, vagina or rectovaginal sep-\ntum were classi fied as ENZIAN stage A, retrocervical lesions\nas stage B and bowel lesions as stage C.\nAbout 80% (24) of the lesions reached the muscle layer of\nthe affected bowel loop wall, while 20% extended into the\nsubmucosal layer. Most lesions (73.3%) affected up to 25% of\nthe bowel loop circumference.\nThe median overall score on the FSFI was 23.4 (18 –28.6);\nthe proportion of cases with score /C20 26.55 was 67.2% (45).\nThe domain scores were: desire 3 (2.4 –3.6), arousal 3.9 (2.7 –\n4.5), lubrication 4.8 (3.3 –5.7), orgasm 4.4 (2.8 –5.6), satisfac -\ntion 4.8 (33.2 –5.2) and pain 3.6 (2 –5.2).\nWe analyzed the correlation between predictor variables\nby means of multiple regression analysis to identify possible\nconfounding factors and selected the ones with higher\nstatistical signi ficance or better fit to the model, thus reduc -\ning the odds of colinearity or confusion in the final model.\nMultiple logistic regression evidenced signi ficant correla-\ntion between dyspareunia and sexual dysfunction (FSFI\nscore /C20 26.55) adjusted by lesion size and patients ’ age, as\nshown in\n►Table 3 .\nThe Poisson multiple regression detected signi ficant in-\nverse correlation of variables dyspareunia and rectosigmoid\nlocalization with higher overall score on the FSFI, adjusted by\nage, lesion size and presence of lesions in the bladder, as\ndescribed in\n►Table 4 .\nThe Poisson multiple regression was also used to analyze\nthe correlation between the study variables and sexual\nfunction domains — desire, arousal, lubrication, orgasm,\nsatisfaction and pain or discomfort. No statistically signi fi-\ncant correlation was found between the selected predictor\nvariables and desire, arousal, lubrication, orgasm or satisfac -\ntion. In turn, variable deep dyspareunia exhibited inverse\ncorrelation with higher score on the FSFI domain pain,\nadjusted by cyclic bowel pain, endometriosis lesion on the\nvaginal fornix and use of GnRH analog (\n►Table 5 ).\nDiscussion\nThe average age of the patients in the present study corre-\nsponds to the age range in which endometriosis is usually\ndiagnosed, that is, the fourth decade of life. 30,31 Relative to\nthe obstetrical history, the prevalence of women with no\nprevious pregnancy and primary or secondary infertility was\nTable 2 Distribution of deep in filtrating endometriosis lesions\naccording to the ENZIAN classi fication\nLesion\nsize (cm)\nGrade Compartment\nAB C\n< 11 1 2 1\n1– 3 2 3 14 18\n> 33 1 4 5\nTable 3 Multiple logistic regression of predictor variables and\nsexual dysfunction corresponding to patients with deep\ninfiltrating endometriosis\nVariables Unadjusted\nanalysis\np (CI)\nFinal adjusted\nmodel\np (CI)\nDyspareunia 0.002 (0.68 –3.01) 0.003 (2.75 –140.54)\nLesion size 0.112 ( /C0 0.01–0.11) 0.052 (0.991.22)\nAge 0.225 ( /C0 0.02–0.12) 0.069 (0.99 –1.23)\nAbbreviations: CI, con fidence interval; p,p - v a l u e .\nHosmer-Lemeshow ¼ 0.6255.\nTable 4 P o i s s o nm u l t i p l er e g r e s s i o na n a l y s i so fp r e d i c t o r\nvariables and overall score on FSFI corresponding to patients\nwith deep in filtrating endometriosis\nVariables Unadjusted\nanalysis\np (CI)\nAdjusted\nanalysis\np (CI)\nDyspareunia 0.000 ( /C0 0.34–0.13) 0.000 (0.64 –0.83)\nRectosigmoid\nlesion\n0.041 ( /C0 0.21–0.00) 0.008 (0.72 –0.95)\nBladder\nreflection\nlesion\n0.052 ( /C0 0.35–0.00) 0.151 (0.43 –0.13)\nLesion size 0.059 ( /C0 0.007–0.00) 0.470 (0.99 –1.00)\nAge 0.067 ( /C0 0.01–0.00) 0.174 (0.98 –1.00)\nAbbreviations: CI, con fidence interval; FSFI, female sexual function\nindex; p,p - v a l u e .\nPearson goodness-of- fit ¼ 0.2304.\nRev Bras Ginecol Obstet Vol. 40 No. 3/2018\nFemale Sexual Function with Suspected Endometriosis Lima et al.118\n\n\nhigh, which might be explained by the effect of immune cells\nand the hostile environment caused by the disease. 32\nAs the sample was composed of women cared for at an\noutpatient clinic for treatment of chronic pelvic pain, the\nhigh prevalence of symptomatic patients (92.5%) is easy to\nunderstand.\nIn the present study, the prevalence of dysmenorrhea and\ndyspareunia was 94% and 71.2%, respectively. These rates are\nmuch higher than the ones reported by Bellelis et al (2010);29\nhowever, these authors only considered severe painful\nsymptoms. Despite the low prevalence, speci fic bowel and\nurinary symptoms were also reported by the patients.\nAs the present study also shows, bowel complaints are\ncommon manifestations among patients with DIE and might\ninterfere with the bowel function; 2 and overall quality of life\nand sexual function·. We were not able to establish a direct\nrelationship between lesion size or location and FSFI scores\nindicative of sexual dysfunction, which agrees with reports\nby other authors. 11\nAs concerns the negative impact of symptoms on the\nfemale sexual function, the prevalence of sexual dysfunction\namong the patients with suspected or confirmed diagnosis of\nDIE was 67.2%. In the studies by Di Donato et al (2014) 16 and\nJia et al (2013), 33 this rate was 58% and 73%, respectively.\nWe found a direct correlation between dyspareunia and\nsexual dysfunction, de fined as an FSFI score below 26.55. 29\nIn addition, we detected an inverse correlation between\ndyspareunia and bowel lesion with a higher FSFI score. The\ncorrelation is inverse in this case because higher FSFI scores\nindicate better sexual function, therefore, lesion size and\ndyspareunia correlated with lower scores, which is indicative\nof sexual dysfunction. Relative to the individual FSFI\ndomains, our models detected a correlation between dyspar-\neunia and the pain domain.\nIt is a fact well established in the literature that the\nexperience of pain is reinforced in subsequent intercourse\nexperiences, which creates a cognitive pattern characterized\nby negative expectations, which in turn affects the sexual\nfunction and causes suffering, anguish or interpersonal\ndifficulties, making the women unable to participate in\nintercourse as they would wish.\n18,20,34,35\nRectosigmoid lesions are the most prevalent form of\npresentation of DIE and usually cause painful symptoms,\nand its prevalence might account for the inverse correlation\nfound between FSFI scores and lesions in that location.\nWe did not find a statistically signi ficant correlation\nbetween the analyzed predictor variables and the FSFI\ndomains desire, arousal, lubrication, orgasm or satisfaction.\nOnly the variable deep dyspareunia exhibited an inverse\ncorrelation with higher scores on the pain domain. Other\nauthors observe that patients with endometriosis develop\nstrategies to cope with pain due, for instance, to a desire to\nbecome pregnant, which may have increased the individual\nscores on the other FSFI domains.\n36\nThe lack of information on the partners ’ or relationship\nstatus is a limitation of the FSFI. Further limitations of the\npresent study derive from the lack of assessment of other\nfactors, such as comorbidities, family and religious aspects,\nand the women ’s personal values, which determine their\nsexual choices and behaviors.\nIn addition, the lack of randomization, the study design\nand the small sample size might limit the interpretation and\nexternal validity of the results of the present study. However,\nwe have already developed a research line to continue the\nlongitudinal investigation so as to compare the sexual func -\ntion outcomes before and after treatment for DIE, as the\nresults might afford a better understanding of the effects of\ntherapeutic interventions on the quality of the female sexual\nexperience.\nConclusion\nThe results of the present study show that dyspareunia\nexerts a negative in fluence on the overall FSFI score and\nalso on the pain domain. These findings reinforce the fact\nthat female sexual dysfunction is a public health problem in\nwomen with suspected DIE, thus demanding special atten-\ntion from gynecologists.\nConflicts to interest\nThe authors declare that there are no con flicts of interest.\nReferences\n1 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C.\nDeep endometriosis infiltrating the recto-sigmoid: critical factors\nto consider before management. Hum Reprod Update 2015;21\n(03):329–339. 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Doi: 10.1016/j.ejogrb.2008.01.014\nTable 5 Poisson multiple regression of predictor variables and\ndomain pain in patients with deep in filtrating endometriosis\nVariables Unadjusted\nanalysis\np (CI)\nAdjusted\nanalysis\np (CI)\nDyspareunia 0.000 (0.45 –0.75) 0.003 (0.49 –0.86)\nCyclic bowel pain 0.065 (0.97 –2.12) 0.256 (0.84 –1.87)\nLesion on vaginal\nfornix\n0.152 (0.43 –1.13) 0.236 (0.46 –1.21)\nUse of GnRH\nanalogue\n0.159 (0.24 –1.25) 0.291 (0.06 –2.29)\nAbbreviations: CI, con fidence interval; GnRH, gonadotropin-releasing\nhormone; p,p - v a l u e .\nPearson goodness-of- fit ¼ 0.99.\nRev Bras Ginecol Obstet Vol. 40 No. 3/2018\nFemale Sexual Function with Suspected Endometriosis Lima et al. 119\n\n\n5 Alkatout I, Egberts JH, Mettler L, et al. [Interdisciplinary Diagnosis\nand Treatment of Deep In filtrating Endometriosis]. Zentralbl Chir\n2016;141(06):630–638. Doi: 10.1055/s-0034-1383272\n6 Nácul AP, Spritzer PM. [Current aspects on diagnosis and treat-\nment of endometriosis]. 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