{"paper_id":"7294f72b-50bc-4dfe-8c52-4cf11e870591","body_text":"Endometriosis is an estrogen-dependent inflammatory disease, in which endometrial cells\nare found somewhere outside the uterine cavity (1). Although many endometriosis patients\nare asymptomatic, they may experience menstrual pain, intercourse pain, and chronic\npelvic pain (2). Endometriosis is one of the most common gynecological diseases. In\n2012, its prevalence was estimated to be 5-20% among women of childbearing age in Tehran\n(3). Severe pelvic pain is often associated with endometriosis, and this pain can be\nalleviated by treatments that suppress estrogen production. Endometriosis is commonly\nseen in the pelvis, ovaries, cul-de-sac, uterine ligament, pelvic peritoneum, and\nrectovaginal septum. Extrauterine endometriosis occurs when endometriosis lesions are\nfound elsewhere in the body, such as in the cervix, vulva, vagina, intestine, urinary\nsystem, abdominal wall, chest, lung, and central nervous system (4). Several studies\nhave reported an association between endometriosis and sexual dysfunction (5-7). The\nseverity of the endometriosis is also directly related to the deep dyspareunia severity\n(8). Dyspareunia is also associated with other forms of sexual disorders due to fear of\npain (9).\nEndometriosis is treated using a variety of methods, divided into 2 categories: medical\nand surgical treatments (10). Medical treatments seek to achieve hypoestrogenic status\nin the patient and to reduce patient pain but are associated with the possibility of\nrecurrence after discontinuation; moreover, the primary goal in surgical treatment is to\neliminate the whole disease and its associated symptoms (11). It is now known that\nmedical treatment alone is insufficient, and surgical intervention is needed in these\npatients (12).\nSome studies have suggested that laparoscopy not only has a positive effect on recovery\nand dyspareunia, but also can improve the individual's sexual quality of life (SQOL)\n(13-15). Endometriosis is known to increase the chance of deep dyspareunia, which can\nhave negative consequences for overall female sexual functioning and couple\nrelationships (15). Previous studies that have compared the medical and laparoscopic\ntherapies of this disease have focused on the therapeutic aspect of endometriosis and\nhave neglected the impact of this disease on other aspects of life (16-17). Also, the\nlimited previous studies that have studied the impact of this disease on sexual life\nhave only examined the effects of this disease on specific issues such as sexual\nsatisfaction and SQOL (13, 11, 14-15, 18-19). No studies have examined the effect of\nthis disease on sexual self-efficacy (SSE), which is one of the most important\ncomponents of having a successful marital relationship; these women may develop\ndifferent ways to cope with the experience of pain and recurrent loss of desire and\norgasm.\nTherefore, the present study aimed to evaluate the differences in SSE and SQOL before\nand after laparoscopic surgery of endometriosis lesions.\n\nThis cross-sectional study was conducted at Arash hospital, Tehran, Iran between\nDecember 2018 to July 2019. The sample size was calculated based on female SQOL\nbefore and 3 months after laparoscopic surgery by comparing the following means\nformula:\nwhere type I error α = 0.05, type II error β = 0.2, Z_ (1-α⁄2) = 1.96, Z_ (1-β) =\n0.84, average difference d = 2.1 and S = 2.8, based on the results of a similar study\n(20), which was a pilot study conducted by the research team.\nThe necessary sample size was thus determined to be 36 persons, given a predicted\ndrop-out rate of 10%. Participants were women who were referred to Arash hospital,\nTehran, Iran for endometriosis laparoscopy. The recruitment was through the\nnon-random convenience method.\nThe inclusion criteria were: women aged 18-40 yr who were candidates for laparoscopic\nsurgery for their endometriosis lesions, which were diagnosed by a gynecologist with\nno limitation of duration of endometriosis; ability to write and speak in Persian;\nfirst marriage; and a history of sexual activity during the past month. The exclusion\ncriteria were: known infertility problem (infertility has a strong impact on a\nwoman's psychosexual behavior and overall quality of life, so as it was a confounder\nin this study, we excluded these women); a history of mental illness or chronic\ndisease, based on the patient's file, including diabetes, heart disease, kidney\ndisease, connective tissue disease, pelvic inflammatory disease, or grade 3 or 4\npelvic prolapses; use of combined oral contraceptive pills, gonadotropin-releasing\nhormone analogs, danazol or related drugs within 6 months before surgery; use of\nantidepressants or other medications that can affect sexual function (e.g.,\nbeta-blockers, antihistamines, antipsychotics, benzodiazepines, antiepileptics);\nsmoking; or alcohol or drug substance use disorder.\nBefore laparoscopic surgery, an SSE questionnaire, the sexual quality of life-female\nquestionnaire, and a demographic information questionnaire (which collected data on\nage, gender, occupational status, etc.) were completed by all participants. The\nseverity of dyspareunia was also assessed by the visual analogue scale.\nThe SSE questionnaire used was Vaziri's SSE scale (designed based on the Schwartz SSE\nQuestionnaire), which consisted of 10 questions and was graded in a 4-choice\ncontinuum from zero (completely incorrect) to 3 (completely correct). The SSE scores\nwere divided into 3 categories: low (0-10), moderate (10-20), and high (20-30). The\nvalidity of the SSE questionnaire in Iran was assessed by Vaziri and Kashani using\nthe content validity method. The reliability of this questionnaire for total scores\nwas found to be 0.851 using Cronbach's alpha method and 0.817 using the split-half\nmethod (21).\nThe sexual quality of life-female questionnaire was designed by Simmonds et al. (22)\nand it contained 18 items categorized into the 4 themes of sexual psychology, sexual\nand marital satisfaction, self-worthlessness, and sexual repression. Assessment was\nbased on a 6-point Likert scale (strongly agree to strongly disagree) with scores\nranging from 0-5 or 1-6 for every item and a possible score range of 0-90 or 18-108.\nA higher score indicated better QOL. The validity and reliability of the Persian\nversion of this questionnaire were assessed by Masoumi and colleagues. To determine\nvalidity, the content validity index (0.91) and content validity ratio (0.84) were\nused, and to determine the reliability, the internal consistency coefficient\nCronbach's alpha (0.73) and intra-cluster correlation index (0.88) were used\n(23).\nThe subjects were followed up 3 and 6 months after their surgery and the\nquestionnaires were completed either at the time of referral to the hospital or by\nphone. Pathology results were followed up and recorded.\nEthical approval for this study was obtained from the Tarbiat Modares University\nEthics Committee, Tehran, Iran (Code: IR.MODARES.REC.1397.152). The objectives of the\nstudy were explained to the participants, and all participants provided informed\nwritten consent.\nData analysis was performed using the Statistical Package for the Social Sciences\n(SPSS) statistical program, version 22 (IBM Corp., Armonk, NY, USA). Repeated measure\nANOVA was used to compare the data of the quantitative variables before and after the\nlaparoscopic surgery. Pearson and Spearman correlations were used to assess the\nrelationships between the variables. Descriptive data were analyzed using absolute\nand relative frequency distributions, mean and standard deviation (SD). P  \n < \n  0.05 was considered as the level of significance.\n\nAll 36 participants were followed up until the end of the study. The mean age of the\nparticipants was 33.13  \n ± \n  4.69 yr (range of 20-40 yr), 66.67% (n = 24) of the study population\nwere housewives and 55.55% (n = 20) had a tertiary education. Household income was\nestimated to be moderate in 77.78% of the participants (n = 28). Baseline demographic\ncharacteristics of the participants are shown in table I.\nAll participants were fertile and had active sex with their husbands, 20 of whom were\nnulliparous (55.55%) and 16 (44.45%) were multiparous. Half of the participants (n = 18,\n50.00%) had experienced a c-section, 15 (41.66%) had experienced a vaginal delivery, and\n3 (8.34%) had experienced both. 21 (58.34%) of the subjects had used withdrawal as a\nbirth control method and 15 (41.66%) had used condoms. Based on the evaluation of the\nparticipants, 8 of the women had a dyspareunia severity score of 6 (22.23%), 10 had a\nscore of 7 (27.78%), 12 had a score of 8 (33.33%), and 6 had a score of 9 (16.66%).\n9 (25.00%) of the subjects were in stages I or II of the disease, and 75.00% (n = 27)\nwere in stages III or IV of endometriosis. Participants were also evaluated based on\nsites of endometriosis, with 91.66% (n = 33) having pelvic endometriosis and 8.34% (n =\n3) having abdominal and pelvic endometriosis.\nAccording to the post-surgical follow-up of participants, none of the participants had\nany surgical complications such as adhesion or bleeding during the follow-up period.\nThe results of the study obtained by repeated measure ANOVA and the post hoc test on\nparticipants' SSE indicated that the mean  \n ± \n  SD of pre-surgical SSE was 7.41  \n ± \n  6.45, while it was 13.47  \n ± \n  7.47 3 months after surgery (p  \n ≤ \n  0.001) and 6 months later it reached 17.77  \n ± \n  9.49 (p  \n ≤ \n  0.001). The mean  \n ± \n  SD of SQOL increased from 37.08  \n ± \n  10.06 before the surgery to 48.66  \n ± \n  11.88 3 months after surgery (p  \n ≤ \n  0.001) and 6 months later it reached 53.36  \n ± \n  15.91 (p  \n ≤ \n  0.001). Both of these showed a significant increase in mean\npostoperative value compared to mean preoperative value (Table II). At the 3-month\nfollow-up, 27.7% of participants did not have dyspareunia, 66.6% reported a decrease in\ndyspareunia ( \n > \n  20 mm decrease in the visual analogue scale), and no change was\nobserved in dyspareunia in 5.7% of the participants. At the 6-month follow-up, 75.0%\nreported no dyspareunia.\nThere was an inverse correlation between SQOL (r = -0.45, p = 0.01) and SSE (r = -0.35,\np = 0.03), and endometriosis involvement. There was no significant correlation between\nage, educational level, income level, contraception methods, age of menarche, or site of\nendometriosis with SQOL or SSE according to the Spearman and Pearson correlation tests\n(Table III).\nCharacteristics of research subjects\nScores of sexual quality of life and sexual self-efficacy of subjects before, 3\nmonths and 6 months after endometriosis laparoscopy\nCorrelation between sexual quality of life, sexual self-efficacy and\ncharacteristics of research subjects\n\nPatients with endometriosis may develop severe pain associated with the site of their\ninvolvement and severity of disease, including dyspareunia, dysmenorrhea, dysgenesis,\nand painful bowel movements that can affect their SQOL (1, 5-7).\nThe findings of our study showed a positive effect of laparoscopic surgery on SQOL and\nSSE in our participants. Numerous studies have reported a relationship between pain\nduring sexual intercourse and anxiety, less frequent or even avoiding intercourse, lower\nlevels of desire and arousal, and orgasmic disorder, which can have negative effects on\nwomen's physical and psychological well-being and may disrupt couples' relationships\n(5-7). Some studies have shown that laparoscopic surgery not only can have a positive\neffect on the recovery rate and dyspareunia but also can improve SQOL (11, 15, 24). For\nexample, Fritzer and co-authors demonstrated that laparoscopy improved SQOL in the\nparticipants of their study and reduced pain (11). A prospective case-control study\nfound that participants' SQOL was improved and pain and discomfort were decreased 6\nmonths after surgery, with a modest reduction at 36 months (15). A comparative study on\nwomen with deep endometriosis undergoing laparoscopic surgery vs. women undergoing\nnerve-sparing surgery, showed that sexual satisfaction scores improved 24 months after\nsurgery in both groups, although these were still lower than normal sexual satisfaction\nscores (24). Furthermore, Ferrero et al. (18) showed that laparoscopy resulted in a\nsignificant decrease in the severity of dyspareunia and a complete loss of pain\nsensation in 80.6% of their subjects.\nAccording to our results, the mean (SD) of preoperative SSE was 7.41 (6.45), which\nincreased to 17.77 (9.49) 6 months after surgery, and it was observed that laparoscopic\nsurgery had a positive effect on SSE. Another study showed that we can eliminate the\nunderlying sexual problems of women by increasing their SSE, so that the higher the SSE,\nthe better the sexual function; also, the higher the SSE, the better the ability to\nresolve sexual problems (e.g., dyspareunia) (25).\nThe results of the present research demonstrated that the mean score of SQOL was\nimproved by 6 months after surgery, which indicated a positive effect of laparoscopy on\nSQOL. This finding is consistent with the results of similar studies conducted in other\ncountries (15, 18, 19), which found that endometriosis laparoscopy improved the SQOL of\ntheir participants; for example, the results of the Ferrero et al. study on\npostoperative SQOL showed that the frequency of intercourse increased 62.2% compared to\nthe preoperative period, indicating a higher QOL and better sexual function in these\nwomen (18). However, this result was obtained in the follow-up period of 6 months, 1 yr,\nand sometimes 2 yr in the above studies, whereas we achieved this result in a shorter\nperiod (3 months) and the mean postoperative (6 months after surgery) severity of\ndyspareunia (1.44) in these women was significantly lower as compared to the\npreoperative phase (7.44).\nIn our study, there was an inverse correlation between SSE, SQOL and the stage of\nendometrial involvement; sexual satisfaction can decrease with the progression of the\ndisease and its impact on dyspareunia. Ferrero et al. found that women in their study\nwith higher endometrial involvement stages and endometriotic lesions of the uterosacral\nligaments experienced more pain intensity (18). Jia et al. also concluded that sexual\ndysfunction was more common in women with endometriosis, especially in those with severe\npelvic pain and advanced stages of endometriosis (26).\nThe limitations of this study included the difficulty in finding and following up\nparticipants after surgery and keeping track of the pathology results of the\nparticipants, which necessitated frequent contacts (by telephone and in person) with\nthe participants. In this study, participants may have avoided providing the correct\ninformation about their symptoms and frequency of sexual intercourse, because of\ncultural reasons. Moreover, as sexual relations involve a mutual relationship and the\nsexual function of men is likely to be influenced by the sexual function of their\nwife, it is recommended that future studies also ask about male sexual function and\nSQOL.\n\nLaparoscopic surgery for endometriosis can improve SQOL and SSE in affected women and\ncan improve dyspareunia. Given the relationship between SSE and SQOL in participants\nwith dyspareunia and due to the multifactorial nature of sexual function, it seems that\nthe application of psychosexual therapy approaches should be considered by the\nhealthcare team to improve the treatment process. Since this was a cross-sectional\nstudy, further studies such as case-control studies are recommended to evaluate the\nresults with a control group.\n\nThe authors would like to express their thanks to Tarbiat Modares University, Tehran,\nIran for its financial support of the present study, which is the result of a Master's\nthesis with the code 76946, as well as the women participating in the study and Mr.\nAhmad Heydari for their sincere cooperation.","source_license":"CC0","license_restricted":false}