Have Sex Again After Endometriosis Surgery
Abstract
Groundwork
Among subjects with endometriosis and deep dyspareunia (DD), those with endometriosis of the uterosacral ligament (USLE) have the most severe impairment of sexual role. This study examines the effect of laparoscopic excision of endometriosis on DD and quality of sex life.
METHODS
This observational accomplice prospective study included 68 women with endometriosis suffering DD (intensity of pain ≥ 6 on a 10-cm visual analogue scale). Patients underwent laparoscopic full excision of endometriosis. Following surgery, they were asked to use nonhormonal contraception devices. Earlier surgery, at vi- and at 12-calendar month follow-upwardly, patients answered a self-administered questionnaire based on the Sexual Satisfaction Subscale of the Derogatis Sexual Performance Inventory.
RESULTS
At half-dozen- and 12-calendar month follow-up, women with and without USLE had significant improvement in DD. Subjects with USLE reported increased variety in sex activity life, increased frequency of intercourse, more satisfying orgasms with sex, relaxing more easily during sex activity and being more relaxed and fulfilled later on sex. Like improvements were observed amongst women without USLE; however, for some variables statistical significance was not reached.
CONCLUSIONS
Surgical excision of endometriosis improves not just DD simply also the quality of sex life.
Introduction
Hurting is one of the major concerns of women with endometriosis and it tin bear on quality of life in numerous ways. Dyspareunia with deep penetration is a frequent component of endometriosis associated-pain. Information technology affects betwixt threescore% and 79% of the patients undergoing surgery ( Fauconnier et al., 2002; Chopin et al., 2005; Ferrero et al., 2005; Nardo et al., 2005) and between 53% and xc% of those using medical therapies ( Fedele et al., 2001; Vercellini et al., 2002). More than than 50% of women with endometriosis take suffered deep dyspareunia (DD) during their entire sex lives (primary DD) ( Ferrero et al., 2005).
When dyspareunia is referred to the rectum or lower sacrococcygeal surface area, it suggests rectovaginal or uterosacral ligament involvement (Howard, 2000). In particular, several studies correlated DD with the presence of endometriosis of the uterosacral ligaments (USLE) ( Porpora et al., 1999; Fauconnier et al., 2002). This correlation is consistent with the presence of a considerable corporeality of nerve tissue inside the uterosacral ligaments (Campbell and Arbor 1950; Butler-Manuel et al., 2000; Butler-Manuel et al., 2002); dyspareunia may be related to the stimulation of pain fibers by traction of scarred inelastic tissues ( Fauconnier et al., 2002) and by pressure on endometriotic nodules embedded in fibrotic tissues. Furthermore, information technology is known that neural invasion by endometriotic lesions is correlated with the intensity of pain ( Anaf et al., 2000).
Dyspareunia has been associated with a negative attitude toward sexuality, feet and avoidance of intercourse ( Meana et al., 1997; Jones et al., 2004). Women with dyspareunia, not surprisingly, have lower frequency of intercourse and lower levels of desire and arousal and experience fewer orgasms ( Laumann et al., 1999).
We previously demonstrated that sexual life is severely impaired amid subjects with endometriosis suffering DD ( Ferrero et al., 2005). In particular, women with USLE have the most severe impairment of sexual role, having higher intensity of pain and less satisfying orgasms than subjects without this type of lesion ( Ferrero et al., 2005).
Several studies demonstrated that both laparoscopic excision of endometriotic nodules ( Reich et al., 1991; Chapron et al., 1999; Garry et al., 2000; Abbott et al., 2004; Thomassin et al., 2004) and medical therapies ( Crosignani et al., 1996; Fedele et al., 2001; Vercellini et al., 2002; Zupi et al., 2004; Abbamonte et al., 2005; Crosignani et al., 2006; Vercellini et al., 2005; Schlaff et al., 2006) are effective in the treatment of DD; notwithstanding, the quality of sexual life after medical or surgical handling of endometriosis has not been securely investigated. In a recent observational cohort report (Ferrero et al., in press), we proved that laparoscopic full excision of endometriosis combined with 6 months of postal service-operative triptorelin (GnRH agonist) administration not only effectively treat DD simply also improves the quality of sex activity life. Although the post-operative GnRH analogue administration may delay recurrence after surgery ( Hornstein et al., 1997; Vercellini et al., 1999), patients included in our written report underwent a combined surgical and medical therapy; therefore, information technology was not possible to ascertain the specific function of laparoscopic excision of endometriosis on the efficacy of treatment.
The current study aims to examine DD and quality of sexual practice life in women who underwent complete laparoscopic excision of endometriosis and did non receive any post-operative medical handling.
Materials and methods
This observational cohort prospective study included women with endometriosis suffering DD who underwent laparoscopy at our institution. All patients underwent surgery because of pain symptoms related to the presence of endometriosis (dysmenorrhoea, nonmenstrual pelvic pain, DD, dyschezia).
But sexually active women (having had sexual intercourse in the past 12 months and at least one intercourse in the past month) with suspected endometriosis were invited to participate to the study. Before invitation to participate in the study, patients were asked to rate the intensity of DD by using a 10-cm visual analogue scale (VAS); the left farthermost represented the absence of pain, and the right extreme represented the worst possible hurting. Merely women having intensity of DD ≥ six on the VAS calibration were included in the study. Infertile patients and women who underwent bowel resection for endometriosis were excluded from the study.
None of the patients had used oral contraceptives or progestagens in the 2 months before surgery, or GnRH analogues or danazol (constructed form of testosterone) in the 6 months before laparoscopy. No patient had signs of pelvic inflammatory disease at the time of surgery. No patient had interstitial cystitis; when symptoms suggestive of interstitial cystitis (pressure, frequency, nocturia and urgency without dysuria) were nowadays, this condition was ruled out on the basis of cystoscopic findings. All women included in the study were heterosexual.
If afterwards surgery patients did not want to conceive, they were asked to apply nonhormonal contraception devices for i year.
The study was reviewed and approved by the local Institutional Review Board. The aim of the study was explained to patients; in particular, they were informed that the use of nonhormonal contraception devices post-obit surgery was important to determine the effects of surgery on sexual life. A written informed consent was signed by the patients enrolled in the written report.
Surgical handling
SAll women were operated past the same surgeon (R.V.); during surgery, all visible endometriotic lesions were removed. The extent of endometriosis was scored according to the revised classification of the American Fertility Social club (rAFS) (American Fertility Club, 1985). The location of all endometriotic lesions was recorded; in item, patients were classified according to the presence or absence of USLE independently from the presence and extent of other endometriotic lesions. All the specimens removed during surgery were histologically examined.
Evaluation of DD and sexual function
DD was defined as genital pain on deep penetration. The presence of superficial dyspareunia occurring in or effectually the vaginal entrance and characterized by discomfort early on in intercourse was non evaluated in the electric current study.
On the day before surgery, during the hospital stay, patients were invited to participate to the study by a female person doctor (A.Fifty.H.). Patients agreeing to participate in the study were informed that data were used for enquiry and that a post-operative follow-upwards would accept been performed. Each patient answered a self-administered sexual role questionnaire in a silent room where she was lonely. The questionnaire was returned to the doctor in a sealed envelope; a reference number (and non the name of the patient) was written on the questionnaire to identify the case. Final inclusion in the study was performed at the time of post-operative control (about 7 days after surgery), when the definitive histological diagnosis of endometriosis was available.
The sexual function questionnaire was previously described ( Ferrero et al., 2005; Ferrero et al., in press). This questionnaire is based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory (DSFI) (Derogatis and Melisaratos, 1979). The DSFI is a multidimensional mensurate of various aspects of psychological and sexual function, which comprises ten subscales. Single subscales can be chosen to suit specific research design; the Sexual Satisfaction Subscale consists of nine items reflecting the individual level of sexual fulfilment. The DSFI has been plant to accept high internal and examination–retest reliability equally well every bit discriminative validity (Derogatis and Melisaratos, 1979; Herold, 1985). Additional questions were created to evaluate the characteristics of sex life and DD. All questions were answered on a 6-point Likert's calibration, where i = 'strongly disagree' and 6 = 'strongly agree', the other anchor points were moderately and mildly disagree and agree.
Patients were besides asked to rate their overall level of sexual satisfaction on a nine-point scale anchored at the lower extreme by 'could non exist worse' and at the upper limit by 'could non be better' (Global Sexual Satisfaction Index, GSSI).
Patients were asked to respond all the questions with respect to the two months before surgery.
In addition, all patients answered questions on marital status, years of pedagogy and age at beginning sexual intercourse.
Follow-up was performed at 6 and 12 months from surgery during follow-up consultation at our clinic.
Statistical analysis
Statistical analysis was performed past using the Isle of mann–Whitney U-exam and χii-exam. A post-hoc intention-to-treat (ITT) assay was performed. The intent-to-treat population included all patients who underwent laparoscopy (Figurei), the end-point was an improvement in the intensity of DD by ≥ 4 points on the VAS scale. A Bonferroni correction was applied to the significance levels obtained in gild to determine whether the observed significant differences in characteristics of sex activity life may have occurred due to multiple analyses. Calculations were performed using the Statistical Package for the Social Sciences (SPSS) software (release x.0.5, SPSS Inc., Chicago, IL, USA). A P value <0.05 was considered statistically significant.
Figure 1.
Catamenia diagram of selection of the study population. The women had endometriosis, with and without inclusion of the uterosacral ligament (USLE), and suffered from deep dyspareunia (DD).
Figure i.
Period diagram of selection of the written report population. The women had endometriosis, with and without inclusion of the uterosacral ligament (USLE), and suffered from deep dyspareunia (DD).
Results
Of the 100 sexually active women approached for the study, 73 accustomed to participate, yielding a response rate of 73.0%. Two women did not take surgical/histological confirmation of endometriosis. Two patients conceived earlier the 6-calendar month follow-upwardly and one patient started oral contraception at 3 months from surgery; these patients were excluded from the study.
The remaining 68 women correspond the study population; their demographic characteristics are listed in TableI. Fifty-nine women (86.viii%) had rASF stage 3–Iv and 9 women had rASF stage I–II. Forty-four (64.7%) women had USLE. Before surgery, the mean ( ± SD) intensity of DD in the study population was 7.vi ± 1.1; subjects with USLE had significantly higher intensity of pain than women without this type of lesion (P = 0.010). No meaning difference was observed in the intensity of DD among subject with monolateral (n = 28; pain intensity, 7.eight ± i.ane) and bilateral (northward = 16; pain intensity, 8.0 ± one.1) USLE (P = 0.608).
Tabular array I.
Demographic characteristics of the study population of women with endometriosis
| n = 68 | |
|---|---|
| Historic period (years) (hateful ± SD) | 34.7 ± 4.three |
| Age at starting time sexual intercourse (years) (mean ± SD) | 19.0 ± ii.6 |
| Marital status [n (%)] | |
| Married | 38 (55.9%) |
| Cohabiting | 12 (17.6%) |
| Engaged | 10 (fourteen.7%) |
| Single | eight (11.8%) |
| Years with the current sexual partner (mean ± SD) | 9.0 ± v.1 |
| Women with alive births [n (%)] | 23 (33.eight%) |
| Women with more than than one live nascency [due north (%)] | 3 (4.four%) |
| Didactics (years) (mean ± SD) | 12.eight ± two.four |
| Contraceptive method at inclusion in the study [n (%)] | |
| Condom | 28 (41.2%) |
| Coitus interruptus | 19 (27.9%) |
| Natural family planning | 16 (23.5%) |
| Nonmedicated intrauterine device | 5 (7.4%) |
| n = 68 | |
|---|---|
| Age (years) (mean ± SD) | 34.7 ± 4.3 |
| Age at first sexual intercourse (years) (mean ± SD) | 19.0 ± two.6 |
| Marital condition [n (%)] | |
| Married | 38 (55.ix%) |
| Cohabiting | 12 (17.half-dozen%) |
| Engaged | 10 (fourteen.seven%) |
| Single | 8 (xi.8%) |
| Years with the current sexual partner (hateful ± SD) | ix.0 ± v.1 |
| Women with live births [northward (%)] | 23 (33.8%) |
| Women with more than than one live birth [due north (%)] | three (iv.4%) |
| Education (years) (mean ± SD) | 12.viii ± two.4 |
| Contraceptive method at inclusion in the study [due north (%)] | |
| Prophylactic | 28 (41.ii%) |
| Coitus interruptus | 19 (27.ix%) |
| Natural family unit planning | 16 (23.5%) |
| Nonmedicated intrauterine device | 5 (7.four%) |
Table I.
Demographic characteristics of the report population of women with endometriosis
| n = 68 | |
|---|---|
| Age (years) (mean ± SD) | 34.vii ± 4.3 |
| Historic period at outset sexual intercourse (years) (mean ± SD) | nineteen.0 ± two.6 |
| Marital condition [n (%)] | |
| Married | 38 (55.ix%) |
| Cohabiting | 12 (17.vi%) |
| Engaged | 10 (14.seven%) |
| Unmarried | viii (11.eight%) |
| Years with the current sexual partner (mean ± SD) | 9.0 ± 5.i |
| Women with live births [n (%)] | 23 (33.viii%) |
| Women with more than than ane live nativity [due north (%)] | three (iv.4%) |
| Education (years) (hateful ± SD) | 12.eight ± 2.four |
| Contraceptive method at inclusion in the study [n (%)] | |
| Condom | 28 (41.2%) |
| Coitus interruptus | nineteen (27.nine%) |
| Natural family planning | 16 (23.five%) |
| Nonmedicated intrauterine device | 5 (7.4%) |
| northward = 68 | |
|---|---|
| Historic period (years) (mean ± SD) | 34.seven ± 4.3 |
| Historic period at offset sexual intercourse (years) (mean ± SD) | 19.0 ± 2.6 |
| Marital condition [n (%)] | |
| Married | 38 (55.9%) |
| Cohabiting | 12 (17.6%) |
| Engaged | 10 (fourteen.7%) |
| Single | 8 (11.8%) |
| Years with the current sexual partner (hateful ± SD) | nine.0 ± 5.1 |
| Women with alive births [n (%)] | 23 (33.8%) |
| Women with more one alive nascency [n (%)] | 3 (four.4%) |
| Educational activity (years) (hateful ± SD) | 12.8 ± 2.4 |
| Contraceptive method at inclusion in the study [n (%)] | |
| Condom | 28 (41.2%) |
| Coitus interruptus | 19 (27.9%) |
| Natural family unit planning | 16 (23.5%) |
| Nonmedicated intrauterine device | five (7.4%) |
Only 52 patients completed the 12-calendar month follow-up because 7 women conceived, half dozen started oral contraception, two women did non take a sexual partner at one yr from surgery and one woman was lost at follow-up.
At both six- and 12-month follow-up, a pregnant improvement in the intensity of DD was observed in subjects with and without USLE (Tabular arrayII). At 12-month follow-upwardly, 79.iv% (27/34) of women with USLE and 77.8% (fourteen/18) of women without USLE had an comeback in the intensity of DD ≥ 4 points on the VAS calibration. At 12-month follow-upwardly, 79.4% (27/34) of women with USLE and 77.8% (14/18) of woman without USLE had an comeback in the intensity of DD ≥ 4 points on the VAS scale; amongst the other patients, only two women with USLE and one woman without USLE had the intensity of DD > vii.
Table 2.
Intensity of deep dyspareunia (DD) at baseline, half-dozen-calendar month and 12-month follow-up, based on a 10-cm visual analogue scale
| Baseline | six-calendar month follow-up | P a | 12-month follow-upwardlyb | P a | |
|---|---|---|---|---|---|
| Women with USLE | 7.6 ± 1.1c | 2.8 ± 1.9 | <0.001 | two.viii ± two.2 | <0.001 |
| (n = 44) | (n = 44) | (n = 34) | |||
| Women without USLE | 7.ane ± 1.0 | 2.four ± 1.8 | <0.001 | 2.2 ± one.8 | <0.001 |
| (n = 24) | (northward = 24) | (n = 18) | |||
| All subjects | 7.6 ± one.one | 2.7 ± ane.9 | <0.001 | 2.six ± 2.1 | <0.001 |
| (n = 68) | (n = 68) | (north = 52) |
| Baseline | 6-month follow-upwards | P a | 12-calendar month follow-upb | P a | |
|---|---|---|---|---|---|
| Women with USLE | vii.half-dozen ± one.onec | two.8 ± 1.ix | <0.001 | 2.8 ± two.two | <0.001 |
| (n = 44) | (n = 44) | (n = 34) | |||
| Women without USLE | vii.one ± 1.0 | 2.4 ± 1.viii | <0.001 | two.2 ± 1.8 | <0.001 |
| (due north = 24) | (northward = 24) | (n = 18) | |||
| All subjects | 7.6 ± 1.1 | 2.seven ± ane.9 | <0.001 | 2.6 ± ii.1 | <0.001 |
| (n = 68) | (n = 68) | (due north = 52) |
USLE, endometriosis of the uterosacral ligaments;
a P versus baseline.
bStatistical analysis was performed comparison the intensity of DD at 12-month follow-upwardly to baseline values of these subjects (data not presented).
c P = 0.01 versus without USLE.
Table 2.
Intensity of deep dyspareunia (DD) at baseline, six-month and 12-calendar month follow-up, based on a 10-cm visual analogue calibration
| Baseline | 6-month follow-up | P a | 12-calendar month follow-upb | P a | |
|---|---|---|---|---|---|
| Women with USLE | 7.vi ± 1.onec | 2.eight ± 1.ix | <0.001 | 2.8 ± ii.ii | <0.001 |
| (northward = 44) | (n = 44) | (north = 34) | |||
| Women without USLE | 7.1 ± one.0 | 2.4 ± 1.8 | <0.001 | 2.2 ± i.8 | <0.001 |
| (northward = 24) | (n = 24) | (due north = 18) | |||
| All subjects | seven.half-dozen ± 1.1 | ii.7 ± 1.nine | <0.001 | 2.6 ± 2.1 | <0.001 |
| (n = 68) | (north = 68) | (n = 52) |
| Baseline | six-calendar month follow-up | P a | 12-month follow-upb | P a | |
|---|---|---|---|---|---|
| Women with USLE | 7.6 ± 1.1c | 2.8 ± 1.9 | <0.001 | 2.8 ± 2.2 | <0.001 |
| (n = 44) | (n = 44) | (n = 34) | |||
| Women without USLE | 7.1 ± 1.0 | 2.4 ± one.viii | <0.001 | ii.2 ± i.eight | <0.001 |
| (n = 24) | (north = 24) | (northward = 18) | |||
| All subjects | vii.6 ± one.i | 2.7 ± 1.9 | <0.001 | two.6 ± ii.1 | <0.001 |
| (n = 68) | (n = 68) | (n = 52) |
USLE, endometriosis of the uterosacral ligaments;
a P versus baseline.
bStatistical assay was performed comparing the intensity of DD at 12-month follow-up to baseline values of these subjects (information non presented).
c P = 0.01 versus without USLE.
For the ITT analysis, an improvement in the intensity of DD ≥ 4 points on the VAS calibration at 12-month follow-up was achieved in 56.ii% of the population (41/73), in 58.7% (27/46) of the subjects with USLE and in 56.0% (14/25) of those without USLE.
Significant improvements in sexual activity life were observed at both 6-month and 12-month follow-upward in subjects with USLE (TableIii); these patients had increased diversity in sexual life, increased frequency of intercourse, relaxed easier during sex, had more satisfying orgasms with sexual practice and were more relaxed and fulfilled later on sexual activity. Like improvements were observed among women without USLE (Table4), however for most variables statistical significance was not reached possibly due to the express number of cases at 12-month follow-up (north = 18) and to the Bonferroni correction for multiple comparisons. Before surgery, 57.4% of the women (39/68) had oftentimes to interrupt the intercourse because of hurting; at 12-month follow-up but 7.seven% of the patients (4/52) reported this complaint (P < 0.001).
Table III.
Sexual function at baseline and at follow-up in women with USLE
| Baseline(n = 46) | 6-month follow-up(n = 44) | P-value | 12-month follow-upa(n = 34) | P-value | |
|---|---|---|---|---|---|
| 1. Unremarkably I am satisfied with my partner | 5.ii ± i.1 | 5.2 ± 0.8 | 0.883 | 5.two ± 0.6 | 0.068 |
| 2. I feel I do non have sex often plenty | iv.iii ± 1.iii | 2.5 ± 1.0 | <0.001b | 2.7 ± one.1 | <0.001b |
| three. There is not enough variety in my sexual life | 3.ix ± 1.3 | iii.0 ± i.ii | 0.003b | 3.one ± 0.9 | 0.015 |
| four. Usually afterwards sex I experience relaxed and fulfilled | 3.0 ± 1.0 | iv.viii ± 0.nine | <0.001b | 4.six ± 1.2 | <0.001b |
| v. Usually sex does non last long enough | 3.8 ± ane.half dozen | 2.1 ± 1.3 | <0.001b | 2.5 ± i.4 | 0.002b |
| six. I am not very interested in sex | two.vii ± 1.2 | 2.eight ± 1.two | 0.955 | 2.6 ± 1.ii | 0.825 |
| vii. Usually I have a satisfying orgasm with sex | 2.3 ± one.ii | iv.3 ± 1.6 | <0.001b | 4.3 ± ane.iii | <0.001b |
| 8. Usually my partner and I take good communication almost sex | three.6 ± 1.iv | four.0 ± ane.3 | 0.114 | iv.0 ± 1.4 | 0.272 |
| 9. Frequency of intercourse (number per week) | 1.1 ± 0.half-dozen | 1.8 ± 0.8 | <0.001b | 1.9 ± 0.7 | <0.001b |
| ten. I oft have to interrupt the intercourse because of hurting | 4.2 ± one.iv | 2.ane ± 1.i | 0.032 | one.8 ± 1.3 | <0.001b |
| eleven. I experience difficulty to relax during sex | three.iv ± ane.four | ii.1 ± 1.four | <0.001b | 2.2 ± 1.four | 0.001b |
| Baseline(north = 46) | 6-month follow-upwards(n = 44) | P-value | 12-month follow-upa(northward = 34) | P-value | |
|---|---|---|---|---|---|
| 1. Commonly I am satisfied with my partner | 5.two ± 1.ane | 5.ii ± 0.8 | 0.883 | v.2 ± 0.six | 0.068 |
| 2. I feel I practise non accept sex frequently plenty | 4.3 ± 1.3 | ii.v ± 1.0 | <0.001b | 2.7 ± 1.1 | <0.001b |
| 3. There is not plenty diversity in my sexual life | 3.9 ± ane.three | 3.0 ± one.ii | 0.003b | 3.1 ± 0.ix | 0.015 |
| four. Usually after sexual practice I feel relaxed and fulfilled | 3.0 ± 1.0 | 4.8 ± 0.nine | <0.001b | four.6 ± 1.ii | <0.001b |
| five. Unremarkably sexual practice does not last long enough | three.viii ± ane.6 | 2.ane ± 1.3 | <0.001b | two.5 ± 1.4 | 0.002b |
| 6. I am not very interested in sexual practice | ii.7 ± ane.2 | 2.8 ± 1.two | 0.955 | two.half dozen ± 1.ii | 0.825 |
| 7. Normally I have a satisfying orgasm with sexual practice | ii.3 ± 1.2 | iv.three ± one.6 | <0.001b | four.iii ± ane.iii | <0.001b |
| 8. Ordinarily my partner and I have adept advice about sex | 3.six ± 1.4 | iv.0 ± ane.3 | 0.114 | 4.0 ± 1.4 | 0.272 |
| 9. Frequency of intercourse (number per calendar week) | i.1 ± 0.6 | 1.8 ± 0.8 | <0.001b | 1.9 ± 0.7 | <0.001b |
| 10. I frequently have to interrupt the intercourse because of pain | 4.2 ± one.4 | two.1 ± 1.1 | 0.032 | 1.eight ± 1.three | <0.001b |
| 11. I experience difficulty to relax during sex | 3.4 ± 1.4 | 2.1 ± i.iv | <0.001b | two.two ± ane.4 | 0.001b |
All questions, except number 9, were answered on a 6-point Likert'south scale (where ane = 'strongly disagree' and vi = 'strongly hold').
Data are presented as mean ± SD.
aStatistical analysis was performed comparing scores at 12-month follow-up to baseline values of subjects who completed this follow-upwardly (mean and SD not presented).
bSignificant after Bonferroni correction for multiple comparisons (P < 0.05).
Tabular array III.
Sexual function at baseline and at follow-upwards in women with USLE
| Baseline(n = 46) | 6-month follow-upward(due north = 44) | P-value | 12-month follow-upwardlya(north = 34) | P-value | |
|---|---|---|---|---|---|
| 1. Usually I am satisfied with my partner | five.2 ± one.1 | 5.2 ± 0.8 | 0.883 | v.two ± 0.6 | 0.068 |
| 2. I feel I do not take sex activity often plenty | 4.3 ± i.3 | two.five ± 1.0 | <0.001b | 2.7 ± one.one | <0.001b |
| 3. There is not plenty diversity in my sexual life | 3.nine ± 1.3 | 3.0 ± i.two | 0.003b | 3.one ± 0.9 | 0.015 |
| four. Unremarkably afterward sex activity I feel relaxed and fulfilled | 3.0 ± i.0 | 4.eight ± 0.ix | <0.001b | iv.six ± 1.2 | <0.001b |
| v. Usually sexual practice does non last long enough | 3.8 ± i.half dozen | ii.1 ± one.3 | <0.001b | ii.5 ± 1.4 | 0.002b |
| half dozen. I am not very interested in sex | 2.7 ± 1.2 | ii.8 ± 1.2 | 0.955 | 2.half-dozen ± 1.two | 0.825 |
| 7. Ordinarily I take a satisfying orgasm with sexual practice | two.iii ± 1.2 | 4.three ± 1.six | <0.001b | 4.3 ± one.3 | <0.001b |
| 8. Unremarkably my partner and I have skilful communication nigh sex | 3.6 ± one.4 | 4.0 ± i.three | 0.114 | four.0 ± 1.4 | 0.272 |
| 9. Frequency of intercourse (number per calendar week) | i.i ± 0.6 | 1.8 ± 0.viii | <0.001b | i.ix ± 0.7 | <0.001b |
| ten. I frequently have to interrupt the intercourse because of pain | 4.ii ± i.iv | 2.one ± 1.1 | 0.032 | 1.8 ± 1.3 | <0.001b |
| 11. I experience difficulty to relax during sex activity | three.4 ± i.4 | 2.ane ± 1.four | <0.001b | 2.2 ± ane.4 | 0.001b |
| Baseline(n = 46) | half-dozen-calendar month follow-up(n = 44) | P-value | 12-calendar month follow-upwardlya(n = 34) | P-value | |
|---|---|---|---|---|---|
| ane. Unremarkably I am satisfied with my partner | 5.ii ± 1.i | v.ii ± 0.8 | 0.883 | 5.2 ± 0.6 | 0.068 |
| ii. I feel I practice non accept sex frequently enough | iv.3 ± 1.3 | two.5 ± ane.0 | <0.001b | ii.7 ± 1.i | <0.001b |
| three. There is not enough diverseness in my sexual life | 3.9 ± i.3 | three.0 ± 1.two | 0.003b | 3.1 ± 0.nine | 0.015 |
| iv. Usually after sex I feel relaxed and fulfilled | 3.0 ± one.0 | 4.8 ± 0.nine | <0.001b | four.vi ± 1.2 | <0.001b |
| v. Unremarkably sexual practice does not final long plenty | 3.8 ± 1.6 | 2.1 ± 1.3 | <0.001b | two.5 ± ane.iv | 0.002b |
| six. I am not very interested in sex activity | 2.7 ± 1.2 | 2.viii ± ane.2 | 0.955 | ii.6 ± ane.ii | 0.825 |
| 7. Usually I take a satisfying orgasm with sex | 2.iii ± 1.2 | 4.3 ± i.6 | <0.001b | iv.3 ± one.3 | <0.001b |
| 8. Usually my partner and I accept good communication about sexual practice | 3.half-dozen ± 1.four | 4.0 ± i.3 | 0.114 | iv.0 ± 1.four | 0.272 |
| 9. Frequency of intercourse (number per week) | one.1 ± 0.six | i.8 ± 0.8 | <0.001b | 1.9 ± 0.seven | <0.001b |
| x. I oftentimes take to interrupt the intercourse because of pain | iv.2 ± i.iv | 2.one ± ane.1 | 0.032 | 1.8 ± 1.three | <0.001b |
| xi. I experience difficulty to relax during sex | iii.iv ± i.iv | two.1 ± i.4 | <0.001b | two.2 ± ane.4 | 0.001b |
All questions, except number nine, were answered on a six-betoken Likert's scale (where 1 = 'strongly disagree' and six = 'strongly agree').
Information are presented every bit mean ± SD.
aStatistical analysis was performed comparing scores at 12-calendar month follow-upwards to baseline values of subjects who completed this follow-up (mean and SD non presented).
bSignificant afterward Bonferroni correction for multiple comparisons (P < 0.05).
Table 4.
Sexual function at baseline and at follow-up in women without USLE
| Baseline(northward = 25) | 6-month follow-up(n = 24) | P-value | 12-calendar month follow-upwardlya(n = 18) | P-value | |
|---|---|---|---|---|---|
| 1. Usually I am satisfied with my partner | v.3 ± 0.ix | 5.2 ± 1.0 | 0.298 | 5.3 ± one.one | 0.913 |
| 2. I feel I do not accept sex oftentimes enough | 4.2 ± 1.5 | 2.iv ± 0.seven | <0.001b | ii.3 ± 0.nine | <0.001b |
| 3. At that place is not enough multifariousness in my sexual life | three.5 ± 1.1 | 3.two ± 1.3 | 0.256 | iii.6 ± 1.v | 0.696 |
| four. Usually after sex activity I experience relaxed and fulfilled | 3.iii ± 1.two | 4.8 ± 0.ix | <0.001b | 4.6 ± 1.0 | 0.001b |
| 5. Usually sex does not concluding long enough | three.three ± 1.4 | ii.6 ± 1.i | 0.085 | ii.four ± 1.4 | 0.013 |
| 6. I am not very interested in sex | 2.5 ± 1.4 | 2.6 ± ane.iii | 0.702 | ii.six ± 1.2 | 0.988 |
| vii. Normally I have a satisfying orgasm with sex | 3.ane ± ane.0 | iv.2 ± ane.3 | 0.003b | iv.0 ± 1.0 | 0.118 |
| 8. Usually my partner and I have practiced advice about sex | iii.8 ± 0.9 | 3.6 ± 0.ix | 0.484 | 4.0 ± 1.1 | 0.355 |
| nine. Frequency of intercourse (number per calendar week) | 1.3 ± 0.ix | ii.two ± 1.1 | <0.001b | ii.ane ± 1.0 | 0.027 |
| 10. I frequently had to interrupt the intercourse because of hurting | 3.4 ± i.5 | 2.6 ± ane.1 | <0.001b | two.iv ± 0.8 | 0.037 |
| 11. I have experienced difficulty to relax during sex | iii.1 ± 1.3 | two.3 ± one.5 | 0.016 | 1.9 ± 0.eight | 0.012 |
| Baseline(n = 25) | 6-month follow-up(north = 24) | P-value | 12-month follow-upa(northward = 18) | P-value | |
|---|---|---|---|---|---|
| 1. Usually I am satisfied with my partner | five.3 ± 0.ix | 5.two ± one.0 | 0.298 | 5.3 ± 1.1 | 0.913 |
| 2. I feel I exercise non have sex activity frequently enough | 4.two ± ane.v | ii.four ± 0.seven | <0.001b | 2.iii ± 0.nine | <0.001b |
| 3. At that place is not enough variety in my sexual life | 3.5 ± 1.1 | 3.two ± i.3 | 0.256 | 3.half dozen ± one.5 | 0.696 |
| 4. Usually later on sex I feel relaxed and fulfilled | iii.3 ± i.2 | 4.eight ± 0.9 | <0.001b | 4.six ± 1.0 | 0.001b |
| v. Usually sexual activity does not concluding long plenty | 3.3 ± 1.4 | 2.6 ± 1.1 | 0.085 | two.4 ± ane.4 | 0.013 |
| 6. I am not very interested in sex | 2.v ± i.4 | ii.6 ± one.3 | 0.702 | 2.6 ± 1.2 | 0.988 |
| seven. Usually I take a satisfying orgasm with sex | 3.1 ± 1.0 | 4.two ± 1.iii | 0.003b | iv.0 ± ane.0 | 0.118 |
| 8. Usually my partner and I have proficient advice almost sex | 3.8 ± 0.9 | 3.half dozen ± 0.9 | 0.484 | 4.0 ± 1.1 | 0.355 |
| nine. Frequency of intercourse (number per week) | one.3 ± 0.nine | two.2 ± i.one | <0.001b | two.1 ± 1.0 | 0.027 |
| x. I frequently had to interrupt the intercourse considering of pain | 3.4 ± 1.v | ii.six ± i.one | <0.001b | 2.four ± 0.viii | 0.037 |
| 11. I take experienced difficulty to relax during sex | 3.one ± 1.iii | 2.iii ± i.5 | 0.016 | one.9 ± 0.viii | 0.012 |
All questions, except number 9, were answered on a 6-point Likert's scale (where ane = 'strongly disagree' and 6 = 'strongly agree').
Data are presented every bit mean ± SD.
aStatistical analysis was performed comparison scores at 12-month follow-up to baseline values of these subjects (data not presented).
bSignificant after Bonferroni correction for multiple comparisons (P < 0.05).
Table 4.
Sexual function at baseline and at follow-upwards in women without USLE
| Baseline(n = 25) | 6-month follow-up(northward = 24) | P-value | 12-month follow-upa(n = 18) | P-value | |
|---|---|---|---|---|---|
| 1. Usually I am satisfied with my partner | 5.3 ± 0.9 | 5.two ± one.0 | 0.298 | 5.3 ± ane.1 | 0.913 |
| 2. I feel I do not take sex often plenty | 4.ii ± i.5 | two.4 ± 0.seven | <0.001b | 2.three ± 0.9 | <0.001b |
| 3. There is not enough diversity in my sexual life | 3.5 ± 1.one | 3.2 ± 1.3 | 0.256 | 3.6 ± 1.five | 0.696 |
| 4. Usually after sex activity I experience relaxed and fulfilled | 3.3 ± 1.2 | 4.eight ± 0.9 | <0.001b | four.6 ± 1.0 | 0.001b |
| 5. Usually sex does non last long plenty | three.3 ± i.4 | ii.6 ± i.i | 0.085 | 2.4 ± 1.4 | 0.013 |
| 6. I am not very interested in sex | 2.5 ± 1.4 | two.half dozen ± 1.three | 0.702 | 2.half dozen ± 1.2 | 0.988 |
| vii. Ordinarily I have a satisfying orgasm with sex | three.ane ± 1.0 | 4.2 ± 1.3 | 0.003b | 4.0 ± 1.0 | 0.118 |
| eight. Unremarkably my partner and I take good advice about sex | 3.8 ± 0.9 | 3.6 ± 0.9 | 0.484 | 4.0 ± 1.one | 0.355 |
| ix. Frequency of intercourse (number per calendar week) | i.3 ± 0.9 | 2.2 ± 1.1 | <0.001b | 2.1 ± 1.0 | 0.027 |
| 10. I often had to interrupt the intercourse because of pain | 3.4 ± ane.five | 2.6 ± 1.1 | <0.001b | 2.4 ± 0.8 | 0.037 |
| 11. I accept experienced difficulty to relax during sex | iii.ane ± 1.iii | 2.3 ± 1.v | 0.016 | ane.9 ± 0.eight | 0.012 |
| Baseline(n = 25) | 6-month follow-up(n = 24) | P-value | 12-month follow-upa(n = 18) | P-value | |
|---|---|---|---|---|---|
| 1. Usually I am satisfied with my partner | five.3 ± 0.9 | 5.2 ± 1.0 | 0.298 | five.3 ± i.1 | 0.913 |
| 2. I feel I practice not have sex oftentimes enough | 4.2 ± 1.5 | ii.4 ± 0.vii | <0.001b | 2.3 ± 0.9 | <0.001b |
| three. There is non enough variety in my sexual life | 3.5 ± ane.ane | 3.2 ± 1.3 | 0.256 | 3.six ± 1.five | 0.696 |
| iv. Normally after sex I feel relaxed and fulfilled | 3.3 ± ane.2 | 4.8 ± 0.9 | <0.001b | iv.half dozen ± i.0 | 0.001b |
| five. Unremarkably sexual practice does not terminal long enough | 3.3 ± i.iv | 2.6 ± 1.1 | 0.085 | two.4 ± one.four | 0.013 |
| 6. I am not very interested in sex | 2.five ± 1.4 | 2.6 ± one.3 | 0.702 | 2.6 ± i.2 | 0.988 |
| vii. Unremarkably I accept a satisfying orgasm with sex | 3.i ± one.0 | four.2 ± 1.3 | 0.003b | 4.0 ± 1.0 | 0.118 |
| 8. Usually my partner and I have good advice about sex activity | iii.8 ± 0.9 | 3.6 ± 0.9 | 0.484 | 4.0 ± 1.one | 0.355 |
| nine. Frequency of intercourse (number per week) | 1.three ± 0.9 | 2.2 ± 1.1 | <0.001b | two.ane ± 1.0 | 0.027 |
| 10. I frequently had to interrupt the intercourse considering of pain | 3.4 ± 1.5 | 2.vi ± 1.1 | <0.001b | 2.4 ± 0.8 | 0.037 |
| 11. I have experienced difficulty to relax during sex | 3.1 ± i.3 | 2.3 ± ane.five | 0.016 | i.9 ± 0.8 | 0.012 |
All questions, except number nine, were answered on a six-point Likert'south scale (where 1 = 'strongly disagree' and 6 = 'strongly concord').
Data are presented as mean ± SD.
aStatistical assay was performed comparison scores at 12-calendar month follow-up to baseline values of these subjects (information non presented).
bSignificant afterwards Bonferroni correction for multiple comparisons (P < 0.05).
Pregnant improvements in the GSSI were observed at 6-and 12-calendar month follow-up both in women with and without USLE (Figureii).
Figure 2.
Results of the Global Sexual Satisfaction Index (GSSI). GSSI asks subjects to self-rate their overall level of sexual satisfaction on a scale of 0–eight. At 6-month and 12-month follow-upwards, the GSSI was significantly increased in women with and without USLE when compared with baseline values.
Figure ii.
Results of the Global Sexual Satisfaction Alphabetize (GSSI). GSSI asks subjects to self-rate their overall level of sexual satisfaction on a scale of 0–viii. At 6-month and 12-month follow-up, the GSSI was significantly increased in women with and without USLE when compared with baseline values.
Discussion
This prospective study demonstrates that the complete laparoscopic excision of endometriotic lesions not simply decreases the prevalence and intensity of DD, but also improves the quality of sexual life. Over 75% of the patients who completed the 12-month follow-up reported significant improvements in the intensity of DD (≥4 points on the VAS calibration) independently from the presence of USLE at surgery. These findings were limited by the number of patients (northward = 21, 28.8%) who dropped out of the study, mainly considering they conceived or desired to brainstorm oral contraception. However, a post-hoc ITT analysis proved the efficacy of surgery at 12-month follow-upwardly in at least 55% of the subjects.
Several improvements in sexual function were observed; they were demonstrated not only by the Sexual Satisfaction Subscale of the DSFI (which reveals the respondent'southward quality of sexual functioning in psychometric terms) merely as well by the GSSI (which reflects the individual's subjective perception of her sexual behaviour). Improvements in sexual life were observed in women with USLE and, at a lower extent, in those without USLE; this finding suggests that lesions of the uterosacral ligament are non the only determinants of DD in women with endometriosis. Recto-vaginal endometriotic lesions and adhesions (periovarian or in the cul-de-sac) may contribute to painful intercourse. After surgery, women with USLE, but not those without this blazon of lesions, reported an increased variety in sexual life. This observation suggests that USLE may determine DD particularly when patients accept intercourse in positions that increase the traction of the uterosacral ligament and the pressure on the nodules. Steege et al. (2005) suggested that the cantankerous-wise position may facilitate intercourse in women with endometriosis suffering DD considering it allows gear up control over bending and depth of vaginal penetration.
Our findings are in line with previous studies documenting significant improvements in DD after surgical excision of endometriosis (Redwine and Wright, 2001; Abbott et al., 2004; Angioni et al., 2006). Recently, in a series of 104 women with endometriosis suffering DD, Chopin et al. (2005) reported a significant comeback of pain (over 4 points on a VAS calibration) at the median follow-up of 3.3 years from surgery. Although several studies investigated the effect of medical and surgical therapy on DD; little attending has been given to the changes in sexual role after medical or surgical treatment.
Vercellini et al. (2002) used the revised Sabbatsberg Sexual Rating Scale to compare the consequence of cyproterone acetate and contraceptive pill on sex life subsequently conservative surgery for symptomatic endometriosis. Later vi months of handling, a mild improvement of sexual life was observed but no significant difference was detected between the two handling groups. A limitation of the study was the fact that, although this cocky-administered questionnaire evaluates various aspects of sexual life (including libido, arousal or pleasure, orgasm chapters and satisfaction), no details were provided on the characteristics of sexual activity life and only the full scores were reported.
In a prospective written report investigating the effect of radical laparoscopic excision of endometriosis on quality of life indicators, Garry et al. (2000) used a sex questionnaire developed by Thirlaway et al. (1996) to investigate the bear upon of long-term tamoxifen treatment on the sexual performance of women at high risk of developing cancer. The authors observed that the excision of endometriotic lesions significantly improved quality of sexual role at 4-calendar month follow-up. These observations were subsequently confirmed past the same authors in the post-operative follow-up of 39 patients who underwent full excisional surgery for endometriosis ( Abbott et al., 2004). However, the questionnaire used in these two studies investigates only three aspects of sexual life: pleasance from sexual intercourse, discomfort during sexual intercourse and habit.
We are aware that our study has some limitations. Patients included in the study underwent laparoscopy in a referral center for the treatment of endometriosis, and not surprisingly over 85% of the patients had rASF phase III–IV. Manifestly, the characteristics of sexual life of this group of women may not be identical to those of all patients with endometriosis. Another possible criticism of our study is the fact that the conclusion of sexual function using a questionnaire may be hard, and we did not use the complete DSFI which has been psychometrically validated (Derogatis and Melisaratos, 1979; Herold, 1985). The length of the questionnaire, however, has made it unsuitable for routine clinical exercise. In light of this, we used a questionnaire based on the Sexual Satisfaction Subscale of the DSFI, followed past the GSSI and by additional questions on the characteristics of DD; this questionnaire has previously been used in other studies ( Ferrero et al., 2005; Ferrero et al., in printing). A further possible criticism concerning our study is that this was non a randomized placebo-controlled study; therefore, a placebo effect of surgery on DD and sexual life cannot be excluded. However, it seems unlikely that this placebo effect may persist at one yr from surgery invalidating the results.
A strength of our report is that the patients using hormonal contraception were excluded from the analysis. This exclusion criterion is particularly relevant because oral contraception non only can ameliorate DD in women with endometriosis but it can also affect sexual function ( Vercellini et al., 2002; Caruso et al., 2005; Guida et al., 2005; Vercellini et al., 2005).
In conclusion, the current report provides evidence that surgical removal of endometriotic lesions not but improves DD simply likewise the quality of sexual practice life. Futurity investigations should determine whether these improvements persist at long-term follow-up. In addition, information technology would be interesting to compare the improvements in quality of sexual life adamant by surgery with the furnishings of medical treatment lone.
References
, , , , .
Letrozole in endometriosis: efficacy and side furnishings
,
Hum Reprod
,
2005
, vol.
twenty
Suppl 1
pg.
i68
, , , , , .
Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial
,
Fertil Steril
,
2004
, vol.
82
(pg.
878
-
884
)
American Fertility Gild
Revised American Fertility Club nomenclature of endometriosis: 1985
,
Fertil Steril
,
1985
, vol.
43
(pg.
351
-
352
)
, , , , , , , .
Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules
,
Hum Reprod
,
2000
, vol.
15
(pg.
1744
-
1750
)
, , , , , , .
Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-upward
,
Hum Reprod
,
2006
, vol.
21
(pg.
1629
-
1634
)
, , , , .
Pelvic nerve plexus trauma at radical hysterectomy and elementary hysterectomy: the nerve content of the uterine supporting ligaments
,
Cancer
,
2000
, vol.
89
(pg.
834
-
841
)
, , , , .
Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative written report of nervus types in the uterine supporting ligaments
,
J Soc Gynecol Investig
,
2002
, vol.
9
(pg.
47
-
56
)
, .
The anatomy and histology of the sacrouterine ligaments
,
Am J Obstet Gynecol
,
1950
, vol.
59
(pg.
i
-
12
)
, , , , , , .
Prospective study on sexual beliefs of women using thirty microg ethinylestradiol and 3 mg drospirenone oral contraceptive
,
Contraception
,
2005
, vol.
72
(pg.
19
-
23
)
, , , , , , .
Operative management of deep endometriosis infiltrating the uterosacral ligaments
,
J Am Assoc Gynecol Laparosc
,
1999
, vol.
half dozen
(pg.
31
-
37
)
, , , , , , , , .
Operative management of securely infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification
,
J Minim Invasive Gynecol
,
2005
, vol.
12
(pg.
106
-
112
)
, , , , , , , , .
Leuprolide in a three-monthly versus a monthly depot formulation for the treatment of symptomatic endometriosis: a pilot study
,
Hum Reprod
,
1996
, vol.
11
(pg.
2732
-
2735
)
, , , .
Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain
,
Hum Reprod
,
2006
, vol.
21
(pg.
248
-
256
)
, .
The DSFI: a multidimensional measure of sexual functioning
,
J Sex Marital Ther
,
1979
, vol.
5
(pg.
244
-
281
)
, , , , , .
Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis
,
Fertil Steril
,
2002
, vol.
78
(pg.
719
-
726
)
, , , , .
Apply of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis
,
Fertil Steril
,
2001
, vol.
75
(pg.
485
-
488
)
, , , , , .
Quality of sexual activity life in women with endometriosis and deep dyspareunia
,
Fertil Steril
,
2005
, vol.
83
(pg.
573
-
579
)
, , , , .
Dyspareunia and quality of sexual activity life afterwards laparoscopic excision of endometriosis and postoperative administration of triptorelin
,
Fertil Steril
(in printing), in press
, , .
The issue of endometriosis and its radical laparoscopic excision on quality of life indicators
,
BJOG
,
2000
, vol.
107
(pg.
44
-
54
)
, , , , , , , , , .
Effects of two types of hormonal contraception—oral versus intravaginal—on the sexual life of women and their partners
,
Hum Reprod
,
2005
, vol.
twenty
(pg.
1100
-
1106
)
. .
Review of Derogatis Sexual Operation Inventory
,
9th Mental Measurement Yr Volume
,
1985
Lincoln, (NE)
University of Nebraska Printing
(pg.
453
-
455
)
, , , .
Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis
,
Fertil Steril
,
1997
, vol.
68
(pg.
860
-
864
)
. , , , , .
Endometriosis and endosalpingiosis
,
Pelvic pain, Diagnosis and Management
,
2000
Philadelphia
Lippincott Williams & Wilkins
(pg.
125
-
150
)
, , .
The impact of endometriosis upon quality of life: a qualitative analysis
,
J Psychosom Obstet Gynaecol
,
2004
, vol.
25
(pg.
123
-
133
)
, , .
Sexual dysfunction in the U.s.a.: prevalence and predictors
,
JAMA
,
1999
, vol.
281
(pg.
537
-
544
)
, , , .
Biopsychosocial contour of women with dyspareunia
,
Obstet Gynecol
,
1997
, vol.
90
(pg.
583
-
589
)
, , .
Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator
,
Fertil Steril
,
2005
, vol.
83
(pg.
735
-
738
)
, , , , , .
Correlation between endometriosis and pelvic pain
,
J Am Assoc Gynecol Laparosc
,
1999
, vol.
6
(pg.
429
-
434
)
, .
Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection
,
Fertil Steril
,
2001
, vol.
76
(pg.
358
-
365
)
, , .
Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis
,
J Reprod Med
,
1991
, vol.
36
(pg.
516
-
522
)
, , , , .
Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain
,
Fertil Steril
,
2006
, vol.
85
(pg.
314
-
325
)
, , . , , .
Treatment of hurting associated with endometriosis
,
Mod Management of Endometriosis
,
2005
London, UK
Taylor & Francis
(pg.
273
-
287
)
, , .
The Sex activity Questionnaire: a measure of women's sexual functioning
,
Qual Life Res
,
1996
, vol.
5
(pg.
81
-
90
)
, , , , , .
Symptoms earlier and after surgical removal of colorectal endometriosis that are assessed by magnetic resonance imaging and rectal endoscopic sonography
,
Am J Obstet Gynecol
,
2004
, vol.
190
(pg.
1264
-
1271
)
, , , , , .
A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis
,
BJOG
,
1999
, vol.
106
(pg.
672
-
677
)
, , , , , .
Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic hurting after conservative surgery for symptomatic endometriosis
,
Fertil Steril
,
2002
, vol.
77
(pg.
52
-
61
)
, , , , , .
Handling of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate
,
Fertil Steril
,
2005
, vol.
84
(pg.
1375
-
1387
)
, , , , , , .
Add together-back therapy in the handling of endometriosis-associated hurting
,
Fertil Steril
,
2004
, vol.
82
(pg.
1303
-
1308
)
© The Author 2006. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Have Sex Again After Endometriosis Surgery
Source: https://academic.oup.com/humrep/article/22/4/1142/695457