{"paper_id":"a1eaa84c-fcc6-46d7-98b9-d6b8ff7f0a29","body_text":"J Nurs Midwifery Sci. 2023 December; 10(4):e137116.\nPublished online 2023 September 23.\nhttps://doi.org/10.5812/jnms-137116.\nResearch Article\nThe Effect of Hypnotherapy on the Pain Intensity of Endometriosis\nPatients Treated with Dienogest: A Pilot Double-Blind Randomized\nClinical Trial\nRoja Shahriyaripoor 1, Zohreh Shahhosseini\n 2, Mehdi Pourasghar\n 3, Zeynab Hoseinnezhad\n 4,\nRoya Shahriyaripoor\n 5 and Jila Ganji 2, *\n1Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran\n2Department of Reproductive Health and Midwifery , Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran\n3Department of Psychiatry , Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran\n4Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran\n5Department of Obstetrics And Gynecology , Bank-e-Melli Iran Hospital, Tehran, Iran\n*Corresponding author: Department of Reproductive Health and Midwifery , Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari,\nIran. Email: zhila.ganji@yahoo.com\nReceived 2023 May 08; Revised 2023 August 16; Accepted 2023 August 17.\nAbstract\nBackground: Endometriosis is a chronic disease in women of reproductive age accompanied by chronic pelvic pain and painful\nintercourse. It has a severe negative impact on these patients’ psychosocial parameters. The noninvasive treatment of endometriosis\nremains challenging.\nObjectives: This study aimed to investigate the effectiveness of hypnotherapy on the pain intensity of endometriosis patients\ntreated with dienogest.\nMethods: In this preliminary study (a pilot double-blind, randomized clinical trial), conducted from November 2021 to July 2022, 22\npatients (18 to 45 years old) with endometriosis treated with dienogest in Shahid Akbar Abadi Hospital (Tehran, Iran) were enrolled.\nVia block randomization, they were divided into a control group and an intervention group (n = 11 each). The patients of both groups\nwere given 2 mg of dienogest tablets daily as prescribed by the gynecologist. The main intervention involved hypnotherapy , which\nwas administered only for the intervention group individually for 8 weekly sessions online (on WhatsApp) for 30 - 45 minutes.\nDysmenorrhea, dyspareunia, and chronic pelvic pain were evaluated using the visual analog scale (VAS) at the beginning of the\nintervention, immediately after the intervention, and 4 weeks after the intervention in both groups. Mean, standard deviation,\nfrequency , chi-square, Fisher’s exact test, Mann-Whitney U, and Friedman test were used for data analysis.\nResults: Dysmenorrhea severity score in the intervention group was 6.30 ± 1.25 before the intervention, 5.50 ± 1.08 after the\nintervention, and 4.60 ± 0.97 during the follow-up, and the changes were significant (P < 0.001, effect size = 0.93). Dyspareunia\nseverity score was 3.14 ± 4.50 before the intervention, 2.91 ± 4.30 after the intervention, and 2.42 ± 3.50 during the follow-up. These\nchanges were also significant (P = 0.015, effect size = 0.41). However, the pelvic pain score did not significantly change despite the\naverage decrease of 0.2 during the follow-up (P = 0.135).\nConclusions: Hypnotherapy , along with drug treatment, was more effective in relieving endometriosis pain than drug treatment\nalone.\nKeywords: Endometriosis, Hypnotherapy, Pain, Dienogest, Dysmenorrhea, Dyspareunia\n1. Background\nEndometriosis is a progressive, chronic,\nestrogen-dependent disorder in women in which the\nendometrial tissue grows outside the uterine cavity and\nleads to inflammation (1). The endometrial tissue responds\nto hormonal changes and bleeding during menstruation\n(2) and leads to cysts, adhesions, and fibrosis, which may\ncause chronic pelvic pain and infertility (3). Today , the\nincidence of endometriosis is increasing in different\ncommunities. It is estimated that this chronic disease\naffects between 10 and 15% of women of childbearing age\n(4). According to the latest statistics, endometriosis afflicts\nabout 176 million women annually all over the world (5).\nCopyright © 2023, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0)\n(https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.\n\nShahriyaripoor R et al.\nDespite these statistics, the exact prevalence of this disease\nis not known because there are no accurate non-invasive\ntools for diagnosing it; moreover, it is asymptomatic in\nsome cases (6).\nThe pelvis is the most common part of endometriosis.\nThe most prevalent and annoying symptom of this disease\nis pain, which directs the patient to medical centers\nmore than other signs and symptoms (7, 8). According\nto the definition of the International Association for the\nStudy of Pain, pain is an unpleasant sensory or emotional\nexperience that is associated with actual or potential\ninjury and has sensory and emotional dimensions. The\nsensory dimension of pain refers to the intensity of pain,\nwhile the emotional dimension refers to the level of\nunhappiness experienced by the person (9). The location\nand intensity of pain in endometriosis patients are\ndifferent, and the most common type is chronic pelvic\npain (10). The other common pains include back pain\n(with disruption of daily activities) (11), dysmenorrhea\n(painful menstruation with heavy bleeding and possible\nabsenteeism from school or work) (12), and dyspareunia\n(painful intercourse, with sexual dysfunction and\ncomplications negatively affecting couples’ relationships)\n(13, 14). Constant pain has adverse effects on all aspects of\nlife, such as familial and marital relations, social activities,\nsports, work, and education. Patients with chronic pain\nsuffer from long-term psychological problems, impaired\nphysical performance, excessive dependence on others,\nand an uncertain prognosis (15). Therefore, disease\nmanagement should aim to improve the health-related\nquality of life of patients by alleviating the symptoms and\npreventing long-term complications (14, 15).\nNowadays, psychological interventions such as\ncognitive behavioral therapy (CBT) (16), yoga (17), and\nhypnotherapy (18) are administered simultaneously with\ndrug treatments to obtain better results and reduce\nside effects in endometriosis patients (19). Hypnosis\nis a transitory state that arises from a change in a\nperson’s attention and includes phenomena such as\nchanges in awareness and memory , increased sensitivity ,\nsuggestibility , and the occurrence of responses and ideas\nthat are not present in the person’s normal state) (18).\nDue to the prevalence of endometriosis, the effect\nof psychological factors in this disease, and the dearth\nof studies on this topic, research seems necessary for\nplanning appropriate nonpharmacological treatment\nstrategies. In addition, due to the side effects of\nthis disease, high economic costs of its treatment,\ndrug interactions, and side effects which have caused\nmany problems for these patients, the achievement of\nnonpharmacological treatment methods, in parallel with\ndrug treatments, may reduce the duration of treatment\nand accelerate recovery .\n2. Objectives\nThis study aimed to determine the effect of\nhypnotherapy on reducing the pain of patients with\nendometriosis treated with dinogest.\n3. Methods\nThis was a pilot double-blind, randomized clinical trial\n(2021 - 2022) with ethical code IR.MAZUMS.REC.1400.398\nand IRCT code IRCT20110827007422N4.\n3.1. Participants\nThe participants were selected from patients with\nendometriosis who visited the Gynecology Clinic of Shahid\nAkbar Abadi Hospital (Tehran, Iran) from November 2021 to\nJuly 2022.\n3.2. Inclusion Criteria\nWomen were included if they had endometriosis\n(confirmed by laparoscopy or laparotomy and histology),\nwere treated with dienogest, were married, aged 18 - 45\nyears, complained of painful menstruation or painful\nintercourse, or had pelvic pain with a minimum score of\n5 cm on the visual analog scale (VAS) at the beginning of\nthe treatment (18), had a smartphone, and had access to the\ninternet.\n3.3. Exclusion Criteria\nWomen were excluded if they had a history of\nendometriosis treatment (laparotomy , laparoscopy , or\nhysterectomy), a history of major or minor psychiatric\ndisorders in themselves or a first-degree relative\n(father, mother, sister, brother, or child), used other\nnonpharmacological methods to reduce pain (e.g., yoga,\nherbal medicine, acupressure, acupuncture, traditional\nmedicine, and biofeedback), or were treated for anxiety ,\ndepression, or uncontrolled seizures.\n3.4. Sample Size\nThe sample size was considered to be 10 people in\neach group according to the recommendations of Herzog\net al. for pilot studies (20), based on the formula for\ncalculating the sample size by the pilot method. With a 10%\nattrition rate in mind, the sample size of 22 (11 people in\nthe intervention group and 11 people in the control group)\nwas calculated, and the multiprotocol method was used to\ncalculate the missing data.\n2 J Nurs Midwifery Sci. 2023; 10(4):e137116.\n\nShahriyaripoor R et al.\n3.5. Variables\nThe primary outcome was changes in pain scores\nbetween groups over time. The participants’ satisfaction\nwith the intervention was examined as the secondary\noutcome.\n3.6. Randomization\nThe sampling method was convenient in the first stage\nto identify eligible women with endometriosis treated\nwith dienogest, and block randomization was used in the\nnext stage. The numbers were randomly generated with\nthe RANDBETWEEN command in Microsoft Excel version\n2016 in the range of 0 - 6. Blinding was performed at the\noutcome assessor level and evaluation at the analysis level.\n3.7. Procedure\nThe eligible individuals provided written informed\nconsent. Then, the demographic information form was\ncompleted by the patients of both groups who were\ntreated with dienogest at the rate of a 2mg tablet per\nday based on the standard treatment of the international\nendometriosis protocols (3).\nFor the intervention group (11 people treated with\ndienogest), an experienced researcher who was trained\nin the Iranian Scientific Society of Clinical Hypnosis and\nhad a valid certificate performed hypnotherapy . For\neach patient in the intervention group, 8 sessions of\nhypnotherapy were administered. The first session was\nface-to-face and individual and lasted for 40 minutes\n(21). The remaining 7 sessions of hypnotherapy were\nheld weekly , individually , online (on WhatsApp), and for\n30-45 minutes for the intervention group. At the end of\neach session, an audio recording of the session was made\nfor each participant (Table 1). The intervention group\nwas asked to perform hypnosis exercises at home at least\ntwice a day (for 30 minutes) and to record the number of\nexercises in the form provided to them. No intervention\nwas administered during the study for the control group\n(11 people treated with dienogest). Only after the research\nprocess was completed, to comply with research ethics, the\ncontrol group was presented with the recorded files of the\nhypnotherapy sessions.\nFor the intervention group, the number of times\nthey did the hypnosis exercises, took painkillers, or used\nother nonpharmacological methods of pain control was\nasked twice a week during a telephone interview . The\npatients of both groups were given the visual analog\nscale on 3 occasions (at the beginning of the intervention,\nimmediately after the intervention, and 4 weeks after the\nintervention). Both groups were taught to register in\nthe special forms provided to them if they received any\nTable 1. The Content of the Hypnotherapy Sessions for Endometriosis\nSession The Content of the Session\nFirst History taking, full explanation of how to do the work, and\nresolving misconceptions about hypnosis\nSecond Advanced muscle relaxation (PMR) a technique\nThird Induction and deepening\nForth Ego boost\nFifth Conditioning\nSixth Age regression\nSeventh Age progression\nEighth Reviewing previous sessions and filling out the questionnaires\na Progressive muscle relaxation\ntype of pain reliever during this period. The registration\nforms were collected at the end of each week. After the\ncompletion of the training and intervention sessions, for 4\nweeks, the process of performing the hypnosis exercises by\nthe patients was followed via telephone interviews once a\nweek (22). Four weeks after the end of the intervention, the\nresearcher checked the pain level of the participants again.\n3.8. Questionnaires\n3.8.1. Medical and Demographic Information Form\nThis form was designed after an extensive review of\nthe relevant literature and input from the research team.\nIt examined the following items: Age, the individual’s\nadequacy of monthly income, socioeconomic status, level\nof satisfaction with the socioeconomic status, home\nownership status, occupation, education level, and marital\nstatus.\n3.8.2. Visual Analog Scale\nThe visual analog scale (VAS) (1) is the most widely used\ntool for measuring pain intensity . Besides its validity and\nreliability , the most important feature of this tool is its\nease of use. The VAS for measuring pain intensity involves\nthe use of a 10cm graduated line, where a score of 10 is\nconsidered for the most severe pain and a score of 0 for\nno pain. The intensity of pain is determined by the patient\non the line. Scores of 1 - 3 indicate mild pain, 4 - 7 indicate\nmoderate pain, and 8 - 10 indicate severe pain (23). The\nVAS is the most widely used scale in endometriosis studies,\nwith a minimum clinically important difference after\ntreatment (MCID) minimal clinically important difference\n(23). The validity and reliability of this tool have been\nconfirmed in many studies. In the study of Hawker et al.,\nthe reliability of VAS was confirmed with a correlation of\n0.99 between the vertical and horizontal directions (24).\nJ Nurs Midwifery Sci. 2023; 10(4):e137116. 3\n\nShahriyaripoor R et al.\nIn Iran, the reliability of this scale was confirmed with a\ncorrelation coefficient of r = 0.88 (25, 26).\n3.9. Ethical Considerations\nThis study was approved by the Ethics Committee of\nMazandaran University of Medical Sciences (ethics code:\nIR.MAZUMS.REC.1400.398) and reported according to the\nCONSORT (Consolidated Standards of Reporting Trials)\nguidelines. All the participants signed the informed\nconsent form. There was no financial compensation.\n3.10. Data Analysis\nDescriptive and inferential statistical methods were\nused to analyze the data. The data were entered into\nSPSS v . 25 (IBM Corp., Armonk, NY, USA). Descriptive\nstatistical methods such as mean, median, standard\ndeviation (SD), and frequency were used for demographic\ncharacteristics. Effect size was used to evaluate the\nstrength of the intervention effect (27). The Shapiro-Wilk\ntest was performed to check the normality of the variables’\ndistribution. The chi-square test and Fisher’s exact\ntest were used to compare the qualitative data. The\nMann-Whitney U test was used to compare the means\nof the groups, and the Friedman test was performed to\ncompare the within-group means. The significance level\nwas P < 0.05.\n4. Results\nFigure 1 shows that 20 people (10 in the control group\nand 10 in the intervention group) completed the study .\nThe two groups did not significantly differ from each\nother in terms of education, age, occupation, satisfaction\nwith income, socioeconomic status, satisfaction with the\nsocioeconomic status, home ownership, and the family\nhistory of endometriosis (Table 2).\nUsing the Shapiro-Wilk test, we found that the data\nrelated to dysmenorrhea, dyspareunia, and pelvic pain did\nnot have a normal distribution (P < 0.05). The results of the\nFriedman test showed that the dysmenorrhea score in the\ncontrol and intervention groups had a significant decrease\nover time. In the intervention group, we saw an effect\nsize of 0.93 versus the control group (0.70). Dyspareunia\nwas significantly reduced in both intervention and control\ngroups over time, and the effect sizes were approximately\nthe same (0.44 versus 0.41, respectively). However, pelvic\npain did not significantly decline over time in the control\nand intervention groups (Table 3). The results of the\nMann-Whitney U test (Table 3) show that the effect of\nthe group in the dysmenorrhea score was not significant\nbefore the intervention, but it was significant immediately\nTable 2. Comparison of the Frequency of Demographic Variables in the Control and\nIntervention Groups at the Beginning of the Study\nVariables Control\nGroup, No.\n(%)\nIntervention\nGroup, No.\n(%)\nP-Value\nEducation\nLower than a high\nschool diploma\n3 (27.3) 4 (36.4) 1.000 a\nUniversity 8 (72.7) 7 (63.6)\nAge, y\n19 - 35 6 (54.5) 7 (63.6) 0.655\n>35 5 (45.5) 4 (36.4)\nOccupation\nUnemployed 1 (9.1) 3 (27.3) 0.586 a\nEmployed 10 (90.9) 8 (72.7)\nSatisfaction with\nincome\nNot at all 3 (27.3) 3 (27.3) 1.000 a\nAlmost or\ncompletely\n8 (72.7) 8 (72.7)\nSocioeconomic status\nLow 1 (9.1) 2 (18.2) 1.000 a\nModerate or high 10 (90.9) 9 (81.8)\nSatisfaction with the\nsocioeconomic status\nNot at all 4 (36.4) 4 (36.4) 1.000 a\nAlmost or\ncompletely\n7 (63.6) 7 (63.6)\nHomeownership\nOwner 7 (63.6) 5 (50.0) 0.528\nTenant 4 (36.4) 5 (50.0)\nFamily history of\nendometriosis\nNo 4 (36.4) 6 (54.5) 0.392\nYes 7 (63.6) 5 (45.5)\na Fisher’s exact test\nafter the intervention with a high effect (0.73), i.e., the\npain score of the intervention group was lower than\nthat of the control group. The effect of the group on\nthe dysmenorrhea score, with a high effect of 0.79, was\nalso significant 4 weeks after the intervention, i.e., the\npain score of the intervention group was lower than\nthat of the control group. The effect of the group on\ndyspareunia score was not significant pre-intervention (P\n= 0.949). It was also nonsignificant immediately after the\nintervention. Although the dyspareunia score was less in\nthe intervention group than in the control group after 4\nweeks, the effect size was not significant. The effect of the\n4 J Nurs Midwifery Sci. 2023; 10(4):e137116.\n\nShahriyaripoor R et al.\n \n \nAssessed for eligibility (n = 134)  \nExcluded (n = 112) \n   •  Not meetingthe inclusion criteria (n = 99)  \n •  Declined to participate (n = 11) \n •  Other reasons (n = 2)  \nEnrollment  \n \n \n \n \n \n \n \n \n \n \n \nAnalyzed (n = 10)    \n \nLost to follow-up (n = 1) \nThe reason for leaving the study: Allergy to \ndienogest  \nAllocated to control (n = 11)  \n \nRoutine treatment\n \nLost to follow-up (n = 1) \n  \nThe reason for leaving the study: Personal reasons  \n \nAllocated to intervention (n = 11)  \nRoutine therapy + hypnotherapy sessions (8 \nsessions, individual, weekly, 30 - 45 minutes)  \n \nAnalyzed (n = 10)    \n \nAnalysis  \nFigure 1. Enrollment of the participants\ngroup on the score of pelvic pain before the intervention,\nimmediately after the intervention, and 4 weeks later was\nnot significant (Table 3).\n5. Discussion\nThe present study determined the effectiveness of\nhypnotherapy on the pain intensity of endometriosis\npatients treated with dienogest.\nThe findings indicated that hypnotherapy sessions,\nalong with the use of dienogest, caused a significant\nreduction in dysmenorrhea compared to dienogest alone.\nIn 2010, a retrospective study in Germany evaluated\nthe effectiveness of combined treatment of traditional\nChinese medicine and hypnotherapy (SART) as a new\ntreatment for endometriosis-related symptoms. In this\nstudy , the effect of hypnosis on relieving pain related to\nendometriosis, such as dysmenorrhea and dyschezia, was\ninvestigated, but it was not reported to be significant (18).\nThe results of the mentioned study were not completely\naligned with the results of the present study . This\ndifference can be because the 2010 study compared two\ninterventions, but only one intervention was investigated\nin the current study .\nIn the present study , the severity of dysmenorrhea\ncomplaints in the intervention group was declining and\nsignificant. Another randomized clinical trial in 2014\nexamined the effectiveness of hypnosis on dysmenorrhea\nin female freshman nursing students at the University of\nNursing and Midwifery in India. This study concluded\nthat hypnosis can be effective on primary dysmenorrhea in\nyoung girls (28). The results of this study , like the current\nstudy , showed the effect of hypnosis on dysmenorrhea, but\nthe participants of the cited study were teenage girls who\nhad dysmenorrhea and did not report any other disease\n(such as endometriosis). Another quasi-experimental\nstudy was conducted in 2015 to compare the effectiveness\nof CBT and therapeutic hypnosis on pain self-efficacy and\npain intensity in girls with primary dysmenorrhea in\nArdabil (Iran) (29). The effect of hypnosis on dysmenorrhea\nwas confirmed in this study , as in the present research. The\nimportant differences between the mentioned study and\nthe current research are the participants and objectives.\nPsychological treatment in women with endometriosis is\nmore difficult due to the presence of several pains. The\nJ Nurs Midwifery Sci. 2023; 10(4):e137116. 5\n\nShahriyaripoor R et al.\nTable 3. Comparison of the Pain Score Over Time Between and Within the Two Groups\nType of Pain and Groups Before the Intervention After the Intervention Follow-up (4 Weeks After Intervention) P-Value a Effect Size\nDysmenorrhea\nControl 4.70 ± 2.41 3.20 ± 1.40 1.90 ± 0.57 0.001 0.70\nIntervention 6.30 ± 1.25 5.50 ± 1.08 4.60 ± 0.97 <0.001 0.93\nP-value b 0.076 0.001 <0.001\nEffect size 0.40 0.73 0.79\nDyspareunia\nControl 4.00 ± 3.37 2.40 ± 2.07 1.90 ± 2.02 0.013 0.44\nIntervention 4.50 ± 3.14 4.30 ± 2.91 3.50 ± 2.42 0.015 0.41\nP-value b 0.949 0.089 0.165\nEffect size 0.01 0.26 0.24\nPelvic pain\nControl 2.10 ± 2.64 1.30 ± 1.42 1.10 ± 1.10 0.062 0.27\nIntervention 1.80 ± 2.25 1.80 ± 2.25 1.60 ± 2.01 0.135 0.20\nP-value b 0.797 0.853 0.853\nEffect size 0.06 0.04 0.04\na Friedman test\nb Mann-Whitney U test\nresearch population in the cited study were girls suffering\nfrom dysmenorrhea, none of whom had endometriosis,\nand the aim of the study was to compare CBT and\nhypnotherapy (29).\nThe role of hypnotherapy in relieving chronic pelvic\npain was the second variable investigated in the current\nstudy . Although the average pelvic pain score in the\nintervention group decreased after the intervention and\nduring the follow-up, the difference was not significant\ncompared to before the study . In 2011, a study provided\na supportive intervention by several psychologists and\ngynecologists and reported a reduction in pelvic pain\nand migraines in women with endometriosis. This\nstudy , like the current research, observed the validity\nof the protocol and determined the correct sample size\nfor the generalizability of the results, but it did not\nreport significant results. Still, the average pain in the\nintervention group was reduced (30). In 2014, a study\nexplored the effectiveness of group acceptance and\ncommitment therapy on catastrophic and disabling pain\nin women with chronic pelvic pain. The intervention\ngroup underwent group acceptance and commitment\ntherapy for 8 sessions of 90 minutes. The results revealed\nthat group acceptance and commitment therapy was\neffective in women with chronic pelvic pain based on\nthe Pain Catastrophizing Scale (31). The results of this\nstudy were not in line with those of the current study .\nAlthough the interventions in the two studies were\nboth psychological, their type differed; in hypnosis, the\npresence of the instructor is needed more than in other\npsychological interventions for long-term treatment.\nIn another study , Treatment based on acceptance and\ncommitment to catastrophizing and disabling pain\ncommitment-based therapy was administered in person\nfor 8 sessions of 90 minutes (31). A meta-analysis study\nshowed that all psychological treatments can reduce\nchronic pelvic pain, but their overall results were not\nsignificant (32). The studies reviewed in this meta-analysis\ndemonstrated that face-to-face and psychological studies\nare more effective than non-face-to-face interventions (32).\nThe role of hypnotherapy in the relief of dyspareunia\nwas another finding of this study . In the current study ,\neven though the average score in the intervention group\nafter the sessions and at the follow-up significantly\ndecreased compared to before the intervention due to\nthe reduction of dyspareunia in the control group, this\nchange was not significant compared to the control group.\nA 2020 meta-analysis examined 10 studies on hypnosis\nand dyspareunia and stated the effects of hypnosis on pain\nreduction during sexual activity (OR = 3.55; 95% CI = 2.63\n- 4.79; P = 0.001). In this meta-analysis, 6 studies did not\ndeclare the results of psychological interventions to be\neffective in reducing dyspareunia, and their significance\nlevel was >0.05. However, due to the high significance\nlevel of the other 4 studies, the general index was declared\neffective and significant (33). Another study in 2018\n6 J Nurs Midwifery Sci. 2023; 10(4):e137116.\n\nShahriyaripoor R et al.\nexplored the effect of cognitive-behavioral hypnotherapy\non the improvement of anxiety and sexual performance\nof women with vaginismus (34). The cited study found\nthat group, individual, and self-hypnosis hypnotherapy\ncan alleviate anxiety and improve vaginismus. One of the\ncomplaints of the women participating in this study was\npain at the beginning of intercourse, which significantly\nchanged with hypnosis (34). The main reason for the\ndifference in the results is the difference in the type of\nintervention.\nThe limitations of the present study include the\nsample size and the impossibility of generalizing\nthe results to the entire population. Besides, since\nthe statistical population comprised married women\nwith endometriosis aged 18 - 45 years who could use\nsmartphones and had access to the internet, it is not\npossible to generalize the findings to the entire target\npopulation.\nOne of the strengths of this study is the consistent,\nweekly , and individual sessions for each patient. Moreover,\nduring the week, home exercises were followed up,\nthe necessity of performing hypnosis during the day\nwas reminded, the questions were answered, and their\nproblems were resolved over phone calls. In conducting\nthis study , blinding was carried out at the evaluator\nand analyzer level, which contributed to the strength of\nthe results. Another strength of this research was the\nfollow-up 4 weeks after the end of the intervention.\n5.1. Conclusions\nThis preliminary study revealed that the treatment\nof endometriosis with hypnotherapy and Dienogest\ncan lead to a significant reduction of pain, especially\ndysmenorrhea, in patients with resistant endometriosis.\nHypnotherapy is a valuable complementary treatment\nmethod as part of a multifaceted approach to\nendometriosis treatment. Although the effect of\nhypnotherapy in decreasing dyspareunia was clinically\nsignificant, the reduction in dyspareunia pain and chronic\npelvic pain was not statistically significant; therefore,\nmore studies should be conducted in this field with larger\nsamples.\nAn important implication of this study is the progress\nand necessity of hypnotherapy science. In emergencies\nsuch as the COVID-19 pandemic, when quarantine must be\nobserved, or when it is not possible to visit the patient in\nperson to start or continue the treatment process for any\nreason, hypnotherapy can be administered throughout\nthe treatment process online and remotely . The second\nimplication is that this study was a prelude to larger\nexperimental studies.\nAcknowledgments\nWe appreciate all participants in this study . This\nresearch was funded by the Vice Chancellor of the\nMazandaran University of Medical Sciences, Sari, Iran.\nFootnotes\nAuthors’ Contribution: SR participated in designing\nthe evaluation and helped draft the manuscript. SZ\nparticipated in designing the evaluation, performed\nparts of the statistical analysis, and helped draft the\nmanuscript. PAM re-evaluated the clinical data and\nrevised the manuscript. HZ collected and interpreted the\nclinical data and revised the manuscript. SR re-analyzed\nthe clinical data and revised the manuscript. GJ conceived\nand designed the evaluation, performed parts of the\nstatistical analysis, and drafted the manuscript. All the\nauthors read and approved the final manuscript.\nClinical Trial Registration Code:\nIRCT20110827007422N4.\nConflict of Interests: The authors declare that they have\nno conflict of interest.\nData Reproducibility: The dataset presented in the study\nis unavailable on request from the corresponding author\nduring submission or after publication.\nEthical Approval: This study was approved by the Ethics\nCommittee of Mazandaran University of Medical Sciences\nunder the ethical code of IR.MAZUMS.REC.1400.398 and\nreported according to the CONSORT guidelines.\nFunding/Support: The Research Deputy of Mazandaran\nUniversity of Medical Sciences supported this study\n(https://research.mazums.ac.ir/).\nInformed Consent: All the participants signed informed\nconsent forms.\nReferences\n1. Fuldeore MJ, Soliman AM. 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