Evaluating the Link Between Self-Reported Endometriosis and Female Sexual Dysfunction

Of the 9,716 women included in this study, 7,118 were sexually active in the preceding 4 weeks, and were included in the main analysis. The mean age was 51.3 years. Majority were white (92.2%), partnered (84.5%), college graduates (64.9%) and perior postmenopausal (78.4%). A little over half (57.2%) met criteria for FSD and 8.7% reported a history of endometriosis. Table 1 includes patient demographics. Women with self-reported endometriosis were more likely to be overweight/obese, be current or former smokers, be less educated, and have a history of heart disease, hypertension, osteoporosis, and stroke ( Table 2 ). They were also more likely to have undergone both hysterectomy and bilateral salpingo-oophorectomy, to use hormone therapy, and have anxiety or depressed mood as compared to women without endometriosis ( Table 2 ). Women with a history of endometriosis were more likely to have FSD by the combined endpoint compared to the women without such history (62.4% vs 56.7%). When stratified by reproductive stage, the relationship between endometriosis and FSD was seen only in premenopausal women with endometriosis (74.2% of women with self-reported endometriosis meeting criteria for FSD vs 57.4% of those without endometriosis). The relationship between self-reported endometriosis and FSD was not statistically significant in perimenopausal or postmenopausal women. Likewise, in multivariable analysis, the relationship between endometriosis and FSD was only seen in premenopausal women in all 3 models. In Model 1, the association between self-reported endometriosis and FSD was statistically significant (OR 2.74 (95% CI 1.43−5.27)). After adjusting for additional variables using Models 2 and 3, the associations remained statistically significant (OR 2.55 (95% CI 1.30−5.04) and OR 2.30 (95% CI 1.13−4.68), respectively). ( Table 3 ).

The Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS) is a repository of questionnaires and other clinical information completed by all women who present to women’s clinics at Mayo Clinic in Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida. 13 A cross-sectional analysis from DREAMS was conducted utilizing questionnaires completed by women aged 18−90 years who presented to women’s clinics from May 2015 to May 2021. For this study, we only included the women who reported being sexually active within the last 4 weeks. The study was approved by the Mayo Clinic Institutional Review Board. As part of their clinical care, women provided their medical history with respect to endometriosis, diabetes, heart disease, hypertension, osteoporosis, and stroke as well as a history of abuse in the last year. Menopause status (premenopause-having regular periods; perimenopause-changes in periods but have not gone 12 months in a row without a period; postmenopause-after menopause) was ascertained based on a combination of provider and patient reports. The medical provider also indicated current use of relevant medications (selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors [SSRI/SNRIs], hormone therapy or hormonal contraceptives). Patient demographic information (age, body mass index [BMI], race, marital status, smoking status, and education level) was obtained from the electronic medical record. Associations between self-reported endometriosis and sexual function were determined. FSD was measured as a combined endpoint utilizing Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) (FSFI ≤ 26.55 and FSDS ≥ 11). The FSFI contains 19 questions concerning 6 domains of sexual function, including sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and pain. Total scores range from 1.2−36, with a score of ≤ 26.55 indicating significant sexual dysfunction. 14 , 15 The FSDS-R assesses sexual distress and consists of 13 questions with scores ranging from 0−52; scores ≥11 indicate significant sexual distress. 16 Anxiety was assessed with the Generalized Anxiety Disorder scale (GAD-7), with scores ranging from 0 to 21, where scores indicate mild (5−9), moderate (10−14), and severe (≥15) anxiety. 17 Mood was assessed with Patient Health Questionnaire Depression scale (PHQ-9), with scores ranging from 0 to 27, where scores correlate to mild (5−9), moderate (10−14), and severe (≥15) depression. 17 Relationship satisfaction was measured with KMSS, with scores ranging from 3−21, where scores ≤ 16 indicate significant relationship distress. 18 Data were summarized using means and standard deviations for continuous data, and frequencies and percentages for categorical data. Comparisons were made between those who did/did not report a history of endometriosis using t -test for continuous data and a Chi-square or Fisher’s exact test for categorical data. Data were stratified by menopause status. Multivariable logistic regression was performed to assess whether self-reported endometriosis was associated with FSD. To explore if certain confounders may explain identified relationships between endometriosis and FSD, 3 models were run, each adding additional variables. In the first model, the association between endometriosis and FSD was adjusted for multiple demographic variables known to impact female sexual functioning including age, BMI, race/ethnicity, marital status, and education. The second model adjusted for the variables in model 1 as well as women’s health variables including hormone therapy use, and hormonal contraceptive use, self-reported history of abuse within the last year, and medical co-morbidities including history of diabetes, heart disease, hypertension, osteoporosis, and stroke. The third model adjusted for the variables in model 1 and model 2 as well as mood and psychosocial factors, including anxiety (GAD-7), depression (PHQ-9), relationship satisfaction (KMSS-M), and SSRI/SNRI use. Associations were summarized using odds ratios (OR) and 95% confidence intervals (CI). All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).

Our study has multiple strengths. The link between endometriosis and sexual function has not been well-studied in cohorts that also included postmenopausal women. Further, the association has not been previously evaluated using a validated measure for assessment of sexual distress associated with sexual problems, a key component defining FSD. To our knowledge, this is the first study to do so using validated tools in a large cohort of women by menopause status that spans 3 geographic locations. Additionally, the study also considered and accounted for multiple contributors to sexual dysfunction in women. Limitations of this study include its cross-sectional design which does not allow the ability to determine the direction of the associations identified. The surveys collected were based on subjective interpretation of clinical symptoms which could be impacted by recall bias. Furthermore, the endometriosis diagnoses were self-reported rather than clinically or laparoscopically diagnosed, which could impact the reliability of the outcome. Additionally, the study population was predominantly white, partnered, employed and educated, which limits the generaliz-ability of the findings. The study included women who sought care in a women’s health clinic, and therefore may not be representative of typical patients with endometriosis. Lastly, this study did not include partner factors that may impact a woman’s sexual function, such as emotional, physical, and sexual health.

Among premenopausal women, those with self-reported endometriosis were more likely to have FSD than women without endometriosis, and this relationship was not explained by other factors, including mood symptoms, hormone therapy use, dyspareunia, or other chronic medical conditions. These findings highlight the opportunity for healthcare practitioners to screen premenopausal women with endometriosis for sexual dysfunction. Premenopausal women may also anticipate less risk of FSD as they progress through the menopause transition. Understanding these associations can help guide clinical decision-making, counseling, and treatment of FSD in women with endometriosis. Future research evaluating the impact of endometriosis on FSD risk would be clinically useful.

In this large, cross-sectional study, an association between a self-reported history of endometriosis and FSD was identified in premenopausal women, even after accounting for potential confounding variables. Our results did not find an association between endometriosis and FSD in perimenopausal or postmenopausal women. Seventy 4 percent of premenopausal women with endometriosis met the criteria for FSD. These results are similar to another study which also found a high prevalence of FSD of 73% in women aged 18−49 years with endometriosis. 19 In that study, the authors theorized that the high prevalence of FSD may be related to the intensity of pelvic pain and the presence of deep infiltrating endometriosis. 19 Similarly, a study of 182 women aged 18−40 with endometriosis found the prevalence of FSD to be 61%. 20 Utilizing the Sexual Health Outcomes in Women Questionnaire (SHOW-Q), all aspects of sexual function were affected, including satisfaction, desire, orgasm, and pelvic problem interference. 21 Our study importantly adds the key element of distress related to sexual problems. The high percentage of FSD in women with endometriosis is not unexpected given the adverse physical and mental health effects associated with endometriosis, including dyspareunia, chronic pelvic pain, depression, anxiety, and compromised social and sexual relationships. 21 When accounting for potential confounders, our study found that the association between FSD and endometriosis remained significant. Therefore, providers should be mindful of a possible link to FSD when treating endometriosis in premenopausal women. Endometriosis can occur in the posterior pelvic cavity, forming hard nodules within the uterosacral ligament, uterine rectal depression, and posterior vaginal fornix. 22 Sexual activity can cause tension of contractile hard lesions causing pain and female sexual dysfunction. Additionally, female sexual function has been found to be adversely affected by endometriosis independent of the location of lesions (deep vs peritoneal/ovarian). 6 Our study found no association between endometriosis and FSD in perimenopausal and postmenopausal women. Because endometriosis is significantly affected by hormones, the dramatic decrease of estrogen at menopause leads to decreased activity of endometriosis. 23 Endometriosis lesions typically regress at menopause, leading to improvement in pain symptoms, 24 and although not previously investigated, potentially to less sexual dysfunction. This could be reassuring to share with people with endometriosis or both conditions. Additionally, our study found that women with self-reported endometriosis were more likely to have had a hysterectomy with or without bilateral salpingo-oophorectomy compared to women without endometriosis. Studies have generally found a beneficial effect of hysterectomy on female sexual function when performed for benign disease. 25 – 27 However, in approximately 10% −20% of women, there have been adverse effects from hysterectomy on sexual function. 26 This may be due to scar tissue from surgery preventing ballooning of the upper vagina, tissue removal reducing the capacity for vasocongestion, and possible nerve damage. 26 Another theory includes that sexual function may be negatively affected specifically for women whom uterine contractions are a vital aspect of orgasm. 26 Furthermore, adverse effects on sexual function were intensified in past studies when combined with bilateral oophorectomy. 26 , 28 This finding was consistent in both pre- and postmenopausal women.

Endometriosis is a chronic, debilitating disease, affecting approximately 80 million women worldwide, including more than 10% of reproductive-aged women and 2%−5% of postmenopausal women. 1 – 6 Characterized by the presence of estrogen-sensitive endometrial-like glands in locations outside of the uterus, 7 the exact etiology of endometriosis remains unknown. 7 , 8 At clinical presentation, endometriosis can take the form of superficial peritoneal lesions, ovarian cysts, adnexal masses, or extrapelvic lesions. 8 Symptoms can range from none to dysmenorrhea, non-menstrual pelvic pain, dyspareunia, dyschezia, dysuria, infertility, and fatigue. 7 , 8 Women with endometriosis have been found to be at a higher risk of female sexual dysfunction (FSD), as determined by Female Sexual Function Index (FSFI), with lower scores in desire, arousal, lubrication, and orgasm and higher pain scores compared to women without endometriosis. 5 , 6 Sexual function may be impacted by pain associated with endometriosis, and by depression and anxiety, which commonly affect women with endometriosis. 9 , 10 Additionally, comorbid medical conditions that may affect sexual function include heart disease, hypertension, diabetes, obesity, and neurological conditions. 11 Past studies, however, have not combined female sexual problems with sexual distress to define FSD. Although endometriosis is commonly thought to be a disease of reproductive-age women, it can continue to have a negative impact on sexual function after menopause. 4 , 12 The aim of this study was to evaluate the association between a self-reported diagnosis of endometriosis and FSD as defined by the presence of sexual problem(s) and associated distress utilizing validated surveys in women across the reproductive stages. Understanding this relationship can help improve the identification of FSD in women with endometriosis.