{"paper_id":"feff0297-538c-42c4-922c-2ba8b06a6390","body_text":"Endometriosis refers to the presence of endometrial tissue (glands and stroma)\noutside of the uterus, most of which is located in pelvic organs and the peritoneum.\nThis leads to dysmenorrhea, chronic pelvic pain, sexual intercourse pain,\ninfertility, and other clinical symptoms. Endometriosis is a common and frequently\noccurring disease in women. Endometriosis is prevalent and affects an estimated 10%\nof women of reproductive age. 1\nThe quality of sexual life plays an important role in the overall quality of life.\nApproximately 70 million adult and adolescent women worldwide suffer from\nendometriosis. More than 70% of patients with endometriosis have obvious pain\nsymptoms, such as dyschezia, chronic pelvic pain, sexual intercourse pain, and fecal\npain. Approximately two thirds of women with endometriosis have sexual dysfunction\nthat is not limited to deep dyspareunia. 2  Quality of life and mental health of women are significantly negatively\naffected by dyspareunia. 3 – 6  An increasing amount of\nattention has been paid to female sexual dysfunction by women and clinicians in\nrecent years. In 1998, the American Urinary Foundation defined female sexual\ndysfunction as women who are unable to participate in the desired sexual behavior.\nIn female sexual dysfunction, there is difficulty in satisfaction or even a lack of\nsatisfaction in the process of sexual behavior. These feelings include loss of\nlibido, arousal disorder, orgasm disorder, sexual pain, and vaginal spasm. In recent\nyears, an increasing number of studies have reported that women with endometriosis\nhave a lower sexual quality of life, such as sexual functioning and\nsatisfaction. 7 , 8\nGarry et al. 9  believed that endometriosis has a serious adverse effect on women’s physical\nand mental health, sexual life, and other aspects. Most of the lesions of\nendometriosis are located in the posterior pelvic cavity. 10  These lesions form hard nodules in the uterosacral ligament, uterine rectal\ndepression, and vaginal fornix. During sexual intercourse, these nodules are\naffected by an external impact force. Tension of contractile hard lesions, which\nlack elasticity, increases and shifts, resulting in deep sexual pain. Some patients\nmay also experience pain after sexual intercourse. Because of pain, patients\nminimize the frequency of sexual life and reduce their experience of sexual life.\nThis can lead to a series of sexual dysfunction problems, such as reduced sexual\ndemand, reduced sexual arousal, and reduced orgasms. A study from Brazil showed that\n40% of women with endometriosis-related chronic pelvic pain were unsatisfied with\ntheir overall sexual life and suffered from symptoms, such as reduced frequency of\nsexual life, vaginal spasm, and even sexual aversion. 11  The quality of life and sexual satisfaction in women with endometriosis and\nchronic pelvic pain are significantly lower than in those without endometriosis and\ncan even affect the stability of marriage and family. 11 , 12  More severe deep dyspareunia\nis associated with worse sexual quality of life, independent of superficial\ndyspareunia, psychological comorbidities, and other potential confounders. 13\nTherefore, alleviating the clinical symptoms of patients, paying attention to the\nsexual life of patients, and improving the overall quality of life of patients are\nimportant issues to be addressed in the field of obstetrics and gynecology at this stage. 14  There have been few reports on sexual function of women with severe\nendometriosis, especially focusing not only on pain during intercourse, but also on\npsychological and relational dimensions (e.g., the partner’s sexual functioning). 2  Therefore, this study aimed to investigate the association between pain\nincurred by endometriosis and the quality of sexual life.\n\nA prospective, unmatched case–control study was designed by following the EQUATOR\nguidelines to identify the association of pain incurred by severe pelvic\nendometriosis and the quality of sexual life.\nPatients with stages III–IV pelvic endometriosis confirmed by laparoscopy and\npathology after an operation in the gynecological ward of the Affiliated\nHospital of Obstetrics and Gynecology, Medical College of Zhejiang University\nfrom September 2017 to August 2018 were included. The criteria for enrollment in\nthe endometriosis group were women aged between 20 and 50 years, who had sexual\nactivity within the first 4 weeks of the study, no psychological disorders and\nother diseases, and whose heterosexual spouses had no sexual dysfunction. We\nenrolled healthy women in the same period as the control group. Women with\ndiabetes mellitus, hypertension, mental disorders, or a history of chronic\nkidney disease were excluded. Both groups were women who had not received\nhormone therapy 3 months before the operation. This study was approved by the\nMedical Ethics Committee of the Women’s Hospital School of Medicine (No.\n20150054) in 2015, and all of the participants signed informed consent\nforms.\nThe sample size was determined by  n = Z α 2 P ¯ ( 1 − P ¯ ) + Z β P 1 ( 1 − P 1 ) + P 0 ( 1 − P 0 ) 2 ( P 1 − P 0 ) 2 P ¯ = P 1 + P 0 2 .\nThis calculation was described by Fairbanks et al. 15  who studied endometriosis and sexual dysfunction\n( P 1 =0.433 [prevalence of the case group],\n P 2 =0.176 (prevalence of the control\ngroup/general population], α=0.05, β=0.15).\nDetailed records, including each patient’s age, level of education, marital\nstatus, fertility, infertility, course of the disease, dysmenorrhea, sexual\nintercourse pain, surgical methods, and postoperative diagnosis, were\ncollected to determine the factors related to sexual function in patients\nwith pelvic endometriosis. The Female Sexual Function Index (FSFI) was used\nfor evaluation of sexual function. The FSFI, which was formulated by Rosen et al. 14  in 2000, is an effective tool for screening and diagnosing female\nsexual dysfunction. The FSFI was adopted by American psychiatrists and then\ntranslated and verified in Japan, Malaysia, Italy, and Portugal. Since 2011,\na Chinese version of the FSFI Scale 16  has been widely used for evaluating female sexual function in China\nafter translation and validation. The FSFI is considered as the gold\nstandard for evaluating female sexual function. 17 , 18  This scale was formed\nwith six dimensions using 19 questions. The FSFI has the following\nquestions: 2 questions (numbers 1–2) on desire, 4 questions (numbers 3–6) on\narousal, 4 questions (numbers 7–10) on lubrication during sexual activity, 3\nquestions (numbers 11–13) on orgasms, 3 questions (numbers 14–16) on\nsatisfaction, and 3 questions (numbers 17–19) on pain. Participants\nresponded according to their true feelings. In this scale, 0 points\nrepresent asexual behavior in the last 4 weeks and 1 to 5 points indicate\ndifferent degrees of feelings (very unsatisfied, 1 point; moderately\nunsatisfactory, 2 points; moderate, 3 points; moderately satisfied, 4\npoints; very satisfied, 5 points). Each dimension score was multiplied by\nthe score of each question in the dimension and the coefficient of the\ndimension. A higher score indicated a higher quality of sexual life.\nEighty-five inpatients who were in the gynecological ward of the Affiliated\nHospital of Obstetrics and Gynecology of Zhejiang University Medical College\nwere asked to take a survey. For each patient, the study’s research aim was\nexplained, and the survey was completely confidential until written consent\nwas obtained. Electronic questionnaires were then filled out with an overall\n91% efficiency of all responses (77/85 patients). Seventy-one volunteers who\nmet the inclusion criteria of the control group also took the survey. The\nvoluntary and anonymous self-administered questionnaire survey had an\neffective response rate of 89% (63/71 volunteers) in the control group.\nWe constructed a database using Microsoft Excel® version 365 (Microsoft\nCorporation, Redmond, WA, USA). The chi-square test was used to compare\ncategorical data between the two groups. Descriptive data analysis is shown\nby mean (± standard deviation) or median (quartile 1 to quartile 3)\ndepending on the distribution of data. The Student’s t-test or Mann–Whitney\nU test was used to compare FSFI scores between the two groups. Pearson\ncorrelation coefficients were calculated to present the pain of\nendometriosis and components of sexual dysfunction. Statistical analysis was\nperformed using two-tailed tests and P<0.05 was considered a significant\ndifference. All of the data were analyzed using IBM SPSS Statistics for\nWindows, version 19.0® (IBM Corp., Armonk, NY, USA).\n\nThere were 77 women in the endometriosis group and 63 in the control group. There\nwas no significant difference in age, education level, marital status, or\nfertility between the two groups ( Table 1 ).\nComparison of sociodemographic characteristics in the endometriosis\n(cases) group and control group.\nFSFI dimensions and a descriptive analysis of dimension scores, including the\nrange of scores, coefficient, and minimum and maximum scores, for each dimension\nare shown in  Table\n2 . The total score ranged from 2.8 to 34.5.\nFemale Sexual Function Index scoring.\nScore=∑ (score for each question × influence coefficient).\nCorrelation coefficient analysis showed that all dimensions of the FSFI showed\ninter-correlation ( Table\n3 ). This finding indicated that the FSFI scale had good internal\nconsistency. The correlation between vaginal lubrication and sexual pain was\nrelatively high (0.787), followed by the correlation between vaginal lubrication\nand orgasm (0.737).\nCorrelations among FSFI dimensions (n=140).\nValues are correlation coefficients.\nFSFI, Female Sexual Function Index.\nWe found that endometriosis significantly affected multiple aspects of sexual\nfunction. The total FSFI score tended to be lower in the endometriosis group\nthan in the control group (P=0.068). The median sexual arousal, satisfaction,\nand sexual pain scores were significantly lower in the endometriosis group than\nin the control group (all P<0.05). There was no significant difference in the\nscores for sexual desire and orgasm between the two groups. The mean values of\nsix dimensions in the control group were higher than those in the endometriosis\ngroup, which indicated that the sexual function of patients with endometriosis\nwas affected in each dimension ( Table 4 ).\nComparison of FSFI dimension scores between the two groups.\nFSFI, Female Sexual Function Index; P 25 , 25th percentile;\nP 75 , 75th percentile.\nThere were no differences in FSFI scores for the ages of 20 to 30 years and for\n41 to 50 years between the endometriosis and control groups. However,\nparticipants aged 31 to 40 years in the endometriosis group had a lower sexual\narousal score (P=0.002), sexual pain score (P=0.036), and vaginal lubrication\nscore (P=0.069) during sexual activity than the control group. The total score\nof this age group tended to be significant between the groups (P=0.06) ( Table 5 ).\nComparison of the FSFI component scores between the two groups in\nrelation to age.\na Normally distributed data in the endometriosis group;\n b normally distributed data in the control group.\nFSFI, Female Sexual Function Index; P 25 , 25th percentile;\nP 75 , 75th percentile, SD, standard deviation.\n\nEndometriosis is a common gynecological disease, which occurs in women of\nchildbearing age. Sexual function and quality of sexual life of patients are\naffected by varying degrees in disease and treatment. The quality of sexual life\nplays an important role in the prolonged life span of the modern era. Our study used\nthe Chinese version of the FSFI to determine sexual function of patients with\nendometriosis. In China, female sexual dysfunction is a sensitive topic, and women\nare ashamed to talk publicly about the quality of sexual life. This issue caused a\nbarrier for acceptance of our survey.\nSexual dysfunction refers to the fact that woman cannot participate in their desired\nsexual life because of reasons, such as unmet sexual desire, arousal disorder,\norgasm disorder, and sexual pain. Endometriosis can cause more serious sexual pain,\nwhich is due to the effect of sexual activity. This results in an increase in\ntension of the uterine sacral ligament, displacement, deep sexual pain, and pain\nafter sexual intercourse. Montanari et al. 19  found that patients with deep infiltrating endometriosis had impaired sexual\nfunction and sexual pain, and vaginal ectopic lesions were related to sexual\ndysfunction. Ferrero et al. 3 , 20  found that the pain score of deep sexual pain in patients with\nsacral ligament lesions was significantly higher than that in patients with ectopic\nlesions located in other areas. The number of times of sexual intercourse per week\nin these patients was significantly decreased, as well as satisfaction and pleasure\nafter sexual intercourse. Long-term illness can cause anxiety, depression, and other\npsychological symptoms. Women with sexual dysfunction show inferiority, a lack of\nself-confidence, and fear of pain caused by sexual intercourse, which affect the\nfeelings of couples and seriously affect women’s health and quality of life. Our\nstudy showed significant differences in the quality of sexual life between women\nwith endometriosis and healthy women. The main manifestations in women with\nendometriosis were difficulty in subjective arousal, poor vaginal lubrication during\nsexual activity, sexual pain, and decreased satisfaction with sexual life. We also\nfound that endometriosis complicated by sexual dysfunction mainly occurred in women\naged 31 to 40 years. Therefore, the time of active sexual function coincides with\nthe incidence of endometriosis in terms of age. We did not find that the education\nlevel, marital status, or reproductive status affected the quality of sexual\nlife.\nTherefore, endometriosis, which is a benign gynecological disease, can affect female\nsexual function to a certain extent. This suggests that clinicians and nurses need\nto take active measures to improve the quality of sexual life of patients with endometriosis. 21  Radical laparoscopic excision of endometriosis offers an effective treatment\noption and leads to a significant improvement in dyspareunia and quality of sexual life. 22  Buggio et al. 23  discussed the importance of integrating psychological interventions\n(including psychotherapy) and sexual therapy in treatment of endometriosis.\nTherefore, in clinical practice, patients with endometriosis should be offered\ntargeted psychological counseling, and their coping styles should be enhanced. In\nparticular, these patients should be informed that they can return to a normal\nsexual life after 3 months of follow-up evaluation. Additionally, patients should\nunderstand the anatomical structure and physiological function of the female\nreproductive system, surgical methods, and the effect of treatment. This could\nreduce the unnecessary psychological burden and increase self-efficacy. 24  Doctors should actively communicate with patients and their spouses, discuss\nissues about sexual life, and provide them with more sexual knowledge and guidance\nof rehabilitation. Doctors should also not only pay attention to the patients’\nphysical and mental health, as well quality of life, but also to their spouses. 25  These patients need to be provided with sufficient health education, and if\nnecessary, patients should be guided in the use of vaginal lubricants to improve the\nquality of sexual life. 26  Patients with endometriosis need to understand the physical and mental\nchanges after surgery and learn to cope with changes, especially psychological support. 27\nOur study has some strengths and limitations. A strength of this study is that we\nexamined the quality of sexual life of women, which is a cultural taboo in China,\nand that makes this study innovative because of the social context. We compared the\nquality of sexual life between women with and those without endometriosis. Our study\nalso has a few limitations. First, because of the nature of the cross-sectional\nstudy, we are unable to generate a causal reference. Second, the sample was\nrelatively small. However, the endometriosis group mainly comprised patients with\nsevere endometriosis. Reporting the quality of sexual life in such a special\npopulation and informing future clinical practice are important. Moreover, this\nstudy did not evaluate general quality of life. However, sexuality is an important\ncomponent of health-related quality of life because progressive reduction in pain\nreported by women over the treatment period could have contributed to improving\ntheir quality of life and their sexual life. 28  This may have caused bias and affected the outcome.\n\nChinese women of childbearing age with endometriosis have significantly impaired\nsexual function compared with women of childbearing age without endometriosis.\nSexual dysfunction mainly manifests as difficulty in subjective arousal, poor\nvaginal lubrication during sexual activity, sexual pain, and decreased satisfaction\nof sexual quality of life. Additionally, Chinese women with endometriosis\ncomplicated by sexual dysfunction are most likely to aged 31 to 40 years.\n\nOur findings on related factors of sexual dysfunction in patients with endometriosis\nprovide a theoretical and practical basis for improving the quality of life of\npatients with endometriosis. Our findings will be useful for determining the effect\nof nursing intervention on sexual dysfunction of patients with endometriosis, and\ncorresponding nursing measures could be proposed in the near future. Medical\nfacilities may consider setting up endometriosis support groups to systematically\nmanage patients with endometriosis, strengthen education, and ensure that they\nreceive early and reasonable treatment. Community-based social media will be useful\nfor health education to address endometriosis and promote peer support, and\neventually improve the quality of life of patients with endometriosis.","source_license":"CC0","license_restricted":false}