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Quality of sex life in endometriosis patients with deep dyspareunia before and after laparoscopic treatment

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Abstract PURPOSE: The present work aims at showing how dyspareunia linked to endometriosis can affect the life of fertile age women and how surgical treatment of endometriosis can relieve painful symptoms and consequently improve sex and social life. METHODS: From a cohort of 320 women with a clinical and instrumental diagnosis of pelvic endometriosis, 67 patients were selected. These patients had deep dyspareunia that underwent laparoscopic surgical treatment. All the patients had filled out a pre- and post-surgery questionnaire. RESULTS: Six months after laparoscopic treatment, a significant reduction of dyspareunia was recorded, per VAS scores. A statistically significant improvement in sex life was observed between the pre- and post-surgical condition: in particular, an increased number of coituses and of non-difficult coituses, a higher number of patients who declared that pain did not negatively affect sexual pleasure and of patients achieving orgasm. CONCLUSIONS: The quality of the sex life in patients with endometriosis and dyspareunia showed significant improvement 6 months after laparoscopic treatment. In view of the diagnostic delay characterizing this disease and confirmed by our results, it is essential to involve a multidisciplinary team to assess all the signs and symptoms of endometriosis that may appear in a women of fertile age. This clinical approach is able to ensure a treatment that is as personalized as possible and an appropriate follow-up also with the objective of preserving reproductive performance.
GENERAL GYNECOLOGY
Quality of sex life in endometriosis patients with deep dyspareunia
before and after laparoscopic treatment
A. Lukic
1
M. Di Properzio
1
S. De Carlo
1
F. Nobili
1
M. Schimberni
1
P. Bianchi
1
C. Prestigiacomo
1
M. Moscarini
1
D. Caserta
1
Received: 7 August 2014 / Accepted: 27 July 2015
ÓSpringer-Verlag Berlin Heidelberg 2015
Abstract
Purpose The present work aims at showing how dys-
pareunia linked to endometriosis can affect the life of
fertile age women and how surgical treatment of
endometriosis can relieve painful symptoms and conse-
quently improve sex and social life.
Methods From a cohort of 320 women with a clinical and
instrumental diagnosis of pelvic endometriosis, 67 patients
were selected. These patients had deep dyspareunia that
underwent laparoscopic surgical treatment. All the patients
had filled out a pre- and post-surgery questionnaire.
Results Six months after laparoscopic treatment, a sig-
nificant reduction of dyspareunia was recorded, per VAS
scores. A statistically significant improvement in sex life
was observed between the pre- and post-surgical condition:
in particular, an increased number of coituses and of non-
difficult coituses, a higher number of patients who declared
that pain did not negatively affect sexual pleasure and of
patients achieving orgasm.
Conclusions The quality of the sex life in patients with
endometriosis and dyspareunia showed significant
improvement 6 months after laparoscopic treatment. In
view of the diagnostic delay characterizing this disease and
confirmed by our results, it is essential to involve a mul-
tidisciplinary team to assess all the signs and symptoms of
endometriosis that may appear in a women of fertile age.
This clinical approach is able to ensure a treatment that is
as personalized as possible and an appropriate follow-up
also with the objective of preserving reproductive
performance.
Keywords Endometriosis Chronic pelvic pain
Dyspareunia Female sexual disorders Quality of sex life
Introduction
Endometriosis is a chronic and invalidating pathology
affecting about 10 % of the female population of repro-
ductive age [1]. The principal symptom is chronic pelvic
pain, which can take on different forms according to the
location and seriousness of the pathology, and can manifest
as dyspareunia, dyschezia, dysmenorrhea, lower urinary
tract syndrome, etc. These symptoms have a negative effect
on the woman’s overall quality of life and in particular her
sex life. The latter is not always given sufficient attention
and consideration by the medical profession.
Sex has a multifactorial function and is dependent on the
functional integrity of the nervous, vascular, hormone, and
immune systems. An imbalance in any of these can lead to
dysfunction [2]. The localization of endometriosis nodules
in regions subject to traction during sexual intercourse,
such as the utero-sacral ligaments, as well as adhesions,
can account for the pathogenesis of dyspareunia.
Dyspareunia, defined as recurrent or persistent genital
pain during sexual intercourse [3], is the particular symp-
tom that worsens the quality of sex life in women with
endometriosis, reducing the number and quality of coituses
[47]. It is estimated that dyspareunia is present in
60–70 % of women undergoing surgery [8,9] and between
50 and 90 % in those undergoing medical hormone therapy
[10,11].
&M. Di Properzio
matilde.diproperzio@gmail.com
1
Department of Surgical and Medical Sciences and
Translational Medicine, Faculty of Medicine and Psicology,
‘Sapienza’’, University of Rome, Sant’Andrea Hospital,
Via Di Grottarossa, 1035-1039, 00189 Rome, Italy
123
Arch Gynecol Obstet
DOI 10.1007/s00404-015-3832-9
While several different studies have shown that surgical
treatment of endometriosis significantly improves the
manifestation of dyspareunia [8,9,12], there have been
relatively few investigations into the long-term effects of
the surgical treatment of endometriosis on the patients’ sex
life [5,7].
Materials and methods
Between July 2012 and July 2013, 320 women with pelvic
endometriosis were examined at the Endometriosis Unit of
the Department of Surgical and Medical Sciences and
Translational Medicine at Sant’Andrea Hospital. This
observational study selected 67 patients with deep dys-
pareunia for whom surgical treatment was recommended.
The average age of this group was 39.09 years (SD 10.26).
The local institutional review board ethically approved this
study and all patients signed informed consent. All the
women underwent gynecological examination, pelvic and
abdominal ultrasounds, and pelvic nuclear magnetic reso-
nance in order to diagnose pelvic endometriosis. The study
included women who were all of fertile age and sexually
active. However, patients having undergone medical
treatment (oral contraceptives, progestins, GnRH analogs
or Danazol) in the 6 months prior to surgery, as well as
patients with psychiatric disorders or with other
causes/concauses of deep dyspareunia (such as pelvic
varicocele, interstitial cystitis, anus elevator muscle myal-
gia or abdominal and pelvic cutaneous nerve entrapment
syndrome), were excluded.
Each patient was asked to fill out a questionnaire at two
different times, during the pre-surgery examination and
during the post-operative visit performed 6 months after
survey. These questionnaires are included in the medical
records. The four-part, 69-item questionnaire focused on
the patient’s anamnesis, the dyspareunia symptom, the
relation between dyspareunia and their sex life, as well as
the patient’s quality of life during the period leading up to
surgical treatment and after the 6 month follow-up period.
Dyspareunia, defined as pain experienced during sexual
intercourse, was evaluated at two different times: namely
either during, or during and after sexual intercourse, as
described by the patients in the completed questionnaire.
The questionnaire items included both a nominal type
with a dichotomous response (Yes/No) and a numerical
type. Pain intensity was evaluated using a 10-cm visual
analog scale (VAS), with zero representing the absence of
pain and ten depicting the worst pain imaginable [13].
In analyzing the different variables, the entire cohort
was subdivided according to patient age (B30 years,
between 31 and 45, and [45 years), the age of menarche
(Bor [12 years) and, lastly, taking into account the time
span between the menarche and the diagnosis of
endometriosis, the mean in the cohort being 27 years of
age.
All the patients received laparoscopic surgery by the
same surgeon: adhesiolysis, cystectomy of ovarian
endometriomas, resection of endometriosic nodules and
foci affecting the pelvic peritoneum and in particular the
recto-vaginal septum, the utero-sacral ligaments, the vesi-
cal peritoneum, the adnexa and the uterine viscera were
done when requested and applicable. During the first
6 months of post-operative follow-up in no case was any
medical therapy administered for one of the following
reasons: pregnancy intention, pregnancy planning or
medical treatment refuse.
For statistical analysis, we used Pearson’s v
2
test for
qualitative variables and Student’s ttest for quantitative
variables. A pvalue \0.05 was considered statistically
significant.
Results
Of 320 women with endometriosis, sixty-seven with deep
dyspareunia underwent laparoscopic treatment. The mean
age at the time of diagnosis was 31.09 years (SD 7.45). The
women admitted to having suffered from this pathology for
an average of 9.49 years (SD 8.33). According to the
Revised American Fertility Society Classification [14], the
intraoperative staging for endometriosis allowed the pop-
ulation examined to be classified into 32 stage III patients
and 35 stage IV patients. Forty-seven patients experienced
pain only during sexual intercourse (70.1 %), while the
remaining 20 experienced it both during and after coitus
(29.9 %).
The mean value of dyspareunia intensity decreased
significantly from 7.81 ±2.08 before surgery to a mean
post-operative value of 3.46 ±2.62 (Student’s ttest;
p\0.05). When divided into two subgroups, this result
was confirmed. In the subgroup experiencing pain exclu-
sively during sexual intercourse, the mean value of pain
intensity dropped from 8.30 ±1.78 to 3.77 ±2.77 (Stu-
dent’s ttest; p\0.05), and in the subgroup experiencing
pain during and after coitus, the mean intensity decreased
from 6.65 ±2.32 to 2.75 ±2.24 (Student’s ttest;
p\0.05). These results are summarized in Table 1.
Dividing the entire cohort into three principal groups
according to patient age—women aged less than or equal to
30 years (22.4 %), aged between 31 and 45 years
(47.7 %), and those over 45 years of age (29.9 %)—we
observed that the mean pain intensity decreased. Specifi-
cally, the first group dropped from a value of 9.40 ±1.06
prior to surgery to 3.93 ±2.84 after surgery (Student’s
ttest; p\0.05), from 7.75 ±1.74 to 3.59 ±2.80
Arch Gynecol Obstet
123
(Student’s ttest; p\0.05) in the second age group, and
from 6.70 ±2.45 to 2.90 ±2.15 (Student’s ttest;
p\0.05) in the third group.
When pain intensity prior to and after surgery was
related to the age at menarche (Bor [12 years), no sta-
tistically significant differences were found in the two
subgroups. Likewise, in the two periods observed, there
was no significant correlation between dyspareunia inten-
sity and the time elapsed between menarche and the age at
which endometriosis was diagnosed (Bor [27 years).
During the six-month follow-up period, an improvement
was observed in the patients’ quality of sex life as follows:
(1) the number of women who considered their sex life to
be satisfactory increased from 21 to 39 (Pearson’s v
2
test;
p\0.05); (2) the number of patients admitting they
achieved peak sexual pleasure increased from 37 to 50
(Pearson’s v
2
test; p\0.05); (3) the number of cases of
sexual intercourse without difficulty rose from 29 to 49
(Pearson’s v
2
test; p\0.05); and (4) the number of
patients who reported that pain related to sexual intercourse
did not have a negative effect on sexual pleasure rose from
29 to 48 (Pearson’s v
2
;p=0.004). These data are shown
in Table 2.
The number of coituses before and after surgical treat-
ment rose from 15.95 ±10.88 to 20.81 ±14.08 (Student’s
ttest; p=0.001) in the whole sample with dyspareunia,
and from 16.53 ±11.82 to 21.66 ±14.62 in the subgroup
‘pain only during sexual intercourse’’ (Student’s ttest;
p=0.001).
Examining exclusively the subgroup of women having
experienced pain only during sex, and considering the
different parameters during the pre- and post-operative
period, it is apparent that the difference between the two
periods is significant for all the parameters examined
except for how pain effects pleasure (Pearson’s v
2
test;
p=0.134, Table 2). For the subgroup of women experi-
encing pain during and after sexual intercourse, the dif-
ference in the various aspects taken into consideration in
the pre- and post-operative period attain statistical
significance for all parameters except for the number of
coituses (Student’s ttest; p=0.087).
As shown in Table 3, the number of coituses during the
three-month post-operative versus the three-month pre-
operative period increases significantly in both groups of
women, for those declaring they were sexually satisfied as
well as those admitting they were not sexually satisfied
prior to surgical treatment. Of the latter group comprising
46 women, 19 (41 %) declared they were sexually satisfied
after surgery, with a significant increase in the number of
coituses between the three-month pre- and post-operative
periods (from 16.42 ±7.81 to 26.42 ±11.86, Student’s
ttest; p=0.0004). The remaining 27 women did not
report any improvement in sexual satisfaction after surgical
treatment and, on going from the three-month pre- to the
post-operative period, there was no statistically significant
increase in the number of coituses.
The assessment of deterioration in the quality of life
caused by dyspareunia in the whole sample, and, in women
experiencing pain either during, or during and after inter-
course, highlighted the statistically significant improve-
ment in the overall quality of the life after surgical
treatment: with a deterioration that passed from
7.11 ±2.31 to 3.02 ±2.74 (Student’s ttest;p=0.001).
Taking into account the two separate timings of dyspare-
unia (pain either during or during and after sexual inter-
course), a statistically significant difference between the
pre- and post-operative stage is found, respectively, from
7.11 ±2.31 to 3.02 ±2.74 (Student’s ttest;p =0.001) in
the first group, and 6 ±2.34 to 2.25 ±2.24 (Student’s
ttest; p\0.05) in the second group.
The deterioration in quality of life was further examined
in 66 patients (one patients did not answer to this part of
questionnaire) who responded to questions concerning the
need to urinate, burning sensation and pain when urinating,
vaginal dryness and burning sensation after sexual inter-
course, intolerance of genital friction, genital itch, pain
caused by gynecological examination, and constipation.
The mean intensity values of the symptoms mentioned,
Table 1 Intensity of dyspareunia before and after 6-month follow-up based on a 10-cm visual analog scale
No. Period Dyspareunia
a
pvalue*
Whole sample with dyspareunia 67 Pre-operative 7.81 ±2.08 \0.05*
67 Post-operative 3.46 ±2.62
Subjects experiencing pain only during sexual intercourse 47 Pre-operative 8.30 ±1.78 \0.05*
47 Post-operative 3.77 ±2.77
Subjects experiencing pain during and after sexual intercourse 20 Pre-operative 6.65 ±2.32 \0.05*
20 Post-operative 2.75 ±2.24
* Student’s ttest
a
Values are expressed as median visual analog scale score ±SD
Arch Gynecol Obstet
123
which represent the degree of deterioration in the quality of
life, are consistently higher prior to treatment versus after
treatment: need to urinate (Student’s ttest; p\0.05),
recurrent cystitis (Student’s ttest; p=0.0006), vaginal
dryness (Student’s ttest;p\0.05), intolerance of genital
friction (Student’s ttest;p=0.0026), genital itch (Stu-
dent’s ttest; p=0.0324), vaginal burning sensation (Stu-
dent’s ttest; p=0.0009), pain caused by gynecological
Table 2 Pre-operative and post-operative sexual life quality: satisfactory sexual life, achievement of maximum pleasure, laborious sexual
intercourse, and influence of pain on sexual pleasure
Pre-operative Post-operative pvalue*
Yes No Total
Satisfactory sexual life
Whole sample with dyspareunia Yes 20 1 21 \0.05*
No 19 27 46
Total 39 28 67
Subjects experiencing pain only during sexual intercourse Yes 11 1 12 0.005*
No 16 19 35
Total 27 20 47
Subjects experiencing pain during and after sexual intercourse Yes 7 4 11 0.003*
No 0 9 0
Total 7 13 20
Achievement of maximum pleasure
Whole sample with dyspareunia Yes 37 0 37 \0.05*
No 13 15 28
Total 50 15 65
Subjects experiencing pain only during sexual intercourse Yes 25 0 25 \0.05*
No 11 9 20
Total 26 9 45
Subjects experiencing pain during and after sexual intercourse Yes 8 0 8 0.001*
No 3 9 12
Total 11 9 20
Laborious sexual intercourse
Whole sample with dyspareunia Yes 17 21 38 \0.05*
No 1 28 29
Total 18 49 67
Subjects experiencing pain only during sexual intercourse Yes 10 17 27 0.01*
No 1 19 20
Total 11 36 47
Subjects experiencing pain during and after sexual intercourse Yes 12 0 12 \0.05*
No 2 6 8
Total 14 6 20
Influence of pain on sexual pleasure
Whole sample with dyspareunia Yes 16 22 38 0.004*
No 3 26 29
Total 19 48 67
Subjects experiencing pain only during sexual intercourse Yes 10 18 28 0.134*
No 3 16 19
Total 13 34 47
Subjects experiencing pain during and after sexual intercourse Yes 6 4 10 0.003*
No 0 10 10
Total 6 14 20
* Pearson’s v
2
test
Arch Gynecol Obstet
123
examination (Student’s ttest; p\0.05), and constipation
(Student’s ttest;p=0.0021).
Dividing the entire cohort into three age groups
(B30 years, between 31 and 45 years, [45 years), the
assessment of the deterioration in the quality of life
decreases from a mean value of 8.13 ±2.70 to
3.53 ±3.25 (Student’s ttest; p\0.05) in group one, from
7.34 ±1.88 to 3.28 ±2.77 (Student’s ttest;p\0.05) in
group two, and from 5.89 ±2.26 to 2.16 ±2.12 (Stu-
dent’s ttest;p\0.05) in the third group.
When the deterioration in the quality of life before and
after surgical treatment is related to the age at menarche
(Bor [12 years) and to the mean value in the period
elapsing between the menarche and the age at which
endometriosis was diagnosed in our sample (Bor [27 -
years), no statistically significant differences were found
between the two time periods considered.
Discussion
Our data confirmed that the symptom perceived as most
responsible for the deterioration in the quality of life for
women with endometriosis is dyspareunia, and that this
symptom has a negative effect on their sexual and social
lives.
During the six-month post-surgery follow-up, these
women experienced a significant decrease in dyspareunia
as expressed by the VAS score (from 7.81 to 3.46). This
result is in agreement with the data reported in the litera-
ture, where the VAS scores 7 during the pre-operative
period and 2 in the post-operative stage was reported [5,7].
Analysis of the dyspareunia symptom by age group seems
to indicate that women age 30 or less are those who benefit
most from surgical treatment, given the difference in pain
assessment before and after surgery. Especially considering
that for this type of patient, the initial pain level perceived
is very close to the peak value. This aspect, which is not
described in the literature, could be interpreted either as a
lower pain threshold or as the more recent onset of a
symptom that has still not been ‘‘accepted’’ by the younger
women, and which is inevitably related to concern over
their future reproductive ability. Further studies are needed
to evaluate if the intensity of dyspareunia could be related
to different age-correlated factors such as the hormonal
balance, ovarian reserve, and immunological imbalance
that characterize the psychoneuroimmune and endocrine
pathways of endometriosis.
The sample was divided into two groups according to
the age at menarche (Bor [12 years) and to the mean
value of time between the menarche and the age when
endometriosis was diagnosed (Bor [27 years). Relating
these groups to the intensity of pain experienced during
sexual intercourse before and after treatment, no statisti-
cally significant difference was found between the two
periods. This aspect is not reported in the literature. It may
thus be claimed that the effectiveness of the treatment of
dyspareunia does not seem to be affected either by the age
of first menstruation or by the length of time between the
first menstruation and the time of diagnosis. In the natural
history of endometriosis, these data could be interpreted as
indicating that the localization and/or extension of
endometriotic foci are responsible for the intensity and
typology of the pain symptoms, rather than the duration of
the disease itself [8].
In patients undergoing surgery, sex life displayed sig-
nificant improvement in all its aspects (overall sexual sat-
isfaction, achievement of maximum pleasure, laborious
sexual intercourse, influence of pain on sexual pleasure,
number of coituses). This is confirmed also in existing
literature, even when different assessment scales are used
[5,7]. On the other hand, when the pain experienced
exclusively during intercourse versus pain experienced
both during and after intercourse is analyzed, the only
parameter found that is not significantly modified by sur-
gical treatment in group one is the effect of pain on sexual
Table 3 Correlation between sexual satisfaction and number of coituses
Sexual satisfaction No. Period No. of coituses
a
pvalue*
Pre-operative Post-operative
Women with satisfactory sex life 21/67 Women with satisfactory sex life 21/67 Pre-operative 23.86 ±11.66 0.0413*
Post-operative 29.33 ±14.50
Women with unsatisfactory sex life 46/67 19/46 Pre-operative 16.42 ±7.81 0.0013*
Post-operative 26.42 ±11.86
27/46 Pre-operative 9.48 ±7.72 0.51*
Post-operative 10.22 ±6.83
*Student’s ttest
a
Values are expressed as mean ±SD during the 3 monthly pre- and post-operative periods
Arch Gynecol Obstet
123
pleasure (Pearson’s v
2
;p=0.134). While for the second
group there is not an increase in the number of coituses
(Student’s ttest; p=0.087). These data, for which no
comparison can be made for lack of literary references,
could be related to the inevitable psychological, psycho-
somatic, and social-relational aspects of the female sex life.
The correlation between sexual satisfaction in the pre-
and post-operative period and the number of coituses
reveals that there is an increase in both groups in the post-
operative stage, although the most significant increase is
for women who claimed not to be satisfied before and to be
satisfied after surgical treatment (Student’s t test;
p=0.0013). Even though there are no comparable data for
this in previous literature, it is clearly related to the lower
number of coituses in sexually unsatisfied women before
surgery.
The quality of life of the 66 women interviewed is
related to a series of symptoms affecting the genital sphere
after intercourse, and displayed a significant improvement
in the post-operative period compared to the pre-operative.
Over time, these women experience a fear of pain during
sexual intercourse, which manifests itself in a reduction of
desire and vestibular lubrication, and in painful spasms of
the pelvic floor muscles, which can lead to mechanical,
vaginal, and urethral trauma when the described genital-
urinary symptoms occur. When analyzing the sample by
age group, it is apparent how also in this case, it is the
younger women (B30 years of age) in whom during the
pre-operative period there is a greater deterioration in the
quality of life after each coitus. The explanation in this case
may be the reduced capability to accept and elaborate the
endometriosis disease in the younger women.
Very few studies have been made on the relation
between the quality of sex life in women with
endometriosis and deep dyspareunia before and after sur-
gical treatment. Ferrero et al. [7], with a sample of 68
women with endometriosis and deep dyspareunia having
undergone surgical treatment, in a 6- and 12-month follow-
up, found a significant improvement in the quality of the
sex life—defined as an increase in the number of coituses,
attainment of a more satisfactory orgasm, and reduced
difficulty in relaxing during sexual intercourse. These
aspects were analyzed through a questionnaire based on the
sexual satisfaction subscale of the derogatis sexual func-
tioning inventory (DSFI). Also Abbott et al. [5] noted a
significant improvement in the dyspareunia symptom, in
sexual pleasure and habit, as well as an equally significant
reduction in coital discomfort using the Sexual Active
Questionnaire (SAQ) with a 2–5-year follow-up in 135
women having undergone laparoscopic surgical treatment.
Most of the research on this topic, like the present work,
often has a limited follow-up, between 6 and 12 months [7,
15]. Abbot et al. [5], on the other hand, found that after
laparoscopic surgical treatment of endometriosis, the
results were maintained after a 5-year follow-up. Only
36 % of women required further surgery, and in one-third
of the cases there were no signs of residual and/or relapsing
endometriosis.
One interesting finding is related to the delay in diag-
nosing endometriosis, which in our sample was found to be
in average 9.49 years (SD 8.33), a value that is substantially
in line with literature data: 3.3 years in China [16], 7 years
in Brazil [17], 7.9 years in the UK, 11.7 in the USA [18],
and 10.7 years in Italy (Siena) [16]. This suggests that, on
the one hand, not enough attention is given to symptoms
and signs reported by the patient and, on the other, that
women are reluctant to discuss said symptoms with a spe-
cialist. It is actually estimated that only one-third of women
with a sexual dysfunction consult their GP, and eventually
consult their gynecologist only at a later stage [19].
In conclusion, women with endometriosis and deep
dyspareunia, after a six-month follow-up, are found to have
benefited significantly from surgical treatment and to have
achieved a more satisfactory sex life. Dyspareunia is an
important symptom in women affected by endometriosis
and has a negative impact on the quality of their sex life
and their life in general. In 1992, the National Health and
Social Life Survey, when examining a sample of US adults,
found that more women (43 %) than men (31 %) suffer
from a sexual dysfunction and that dyspareunia, which is
classified as a sexual dysfunction, has a prevalence of 26 %
among sexually active women [20]. However, a recent
study has shown, unexpectedly, that only a small propor-
tion of these women (12 %) experience this sexual problem
in a stressful manner with feelings of frustration, discom-
fort, and depression [21].
The role normally expected of a gynecologist is to better
understand the natural history of this multifactorial disease,
which includes keeping up to date with latest research, with
the aim to focus on this disease, to more efficiently screen
and early diagnose it and to treat the affected patients with
the objective of preserving the fertility [22-31].
It is therefore very important to involve a number of
other professional figures in the endometriosis diagnosis,
ranging from the GP to the gastroenterologist, neurologist,
psychiatrist, etc. In view of the diagnostic delay charac-
terizing this disease, it is essential to involve a multidis-
ciplinary team to assess all the signs and symptoms that
may appear in a woman of fertile age, so as to ensure a
treatment that is as personalized as possible.
Lastly, the need also arises for further reappraisal of the
classification of endometriosis in which the natural history
of this pathology is primarily taken into account. This
should also include the condition of adenomyosis, a highly
likely cause of dyspareunia (although this disorder has still
not been sufficiently studied).
Arch Gynecol Obstet
123
The principal limitation of this study is that this is an
observational design that used a non-evaluated question-
naire for the study of dyspareunia and sexual life.
Acknowledgments The authors would like to thank Mr. Lucio
Morettini for the statistical interpretation of the data.
Compliance with ethical standards
Conflict of interest The authors declare that there are no conflicts
of interest.
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... Endometriosis, the presence of ectopic endometrial tissue, is a significant cause of gynaecologic consultation with attendant significant economic burden to society. 1,2 It is called adenomyosis (AM) when the ectopic tissue is found within the myometrium where it leads to smooth muscle hypertrophy, fibrosis and ultimately to uterine enlargement. When seen outside the uterus, the condition is called endometriosis (EM). ...
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Introduction: Endometriosis is the existence of endometrial tissue outside the endometrial cavity. It has high prevalence in women living in developed countries but is believed to be rare among indigenous African women. Objectives: This study aimed to determine the prevalence and characteristics of endometriosis in an indigenous African women population. Methods: Gynaecological specimens received and diagnosed as endometriosis in a teaching hospital's Histopathology laboratory over a 5-year period was retrospectively reviewed. Data obtained were analysed by simple statistical methods. Results: There were 25 diagnosed cases of endometriosis representing 0.9% of gynaecological specimens received in the period. Patients' average age is 38.4±8.4 years; peak age was 31-40 years (n=10; 40%). Myometrium is the most common site (n=16; 64%), other sites include umbilicus and round ligament etc. Pelvic pain, 36% and irregular uterine bleeding, 28% are most common symptoms. There was primary and secondary infertility in 20% and 16% of cases respectively. The umbilical and suprapubic masses had symptoms that synchronised with the patient's menstrual cycle. Conclusion: Endometriosis has low prevalence in our population. Women presenting with chronic pelvic pain, infertility and menstrual disorders should be evaluated for endometriosis. Population-based study is required to further characterize the condition in our population.
... It is related to a reduction in the number of sexual acts, deteriorates contact with the partner, lowers self-esteem, and it is also connected with infertility. The chronic fatigue syndrome, symptoms of depression, and anxiety disorders are found more often in women with endometriosis [57]. Mental symptoms appear more frequently in patients suffering from endometriosis for more than six months and in women with severe pain. ...
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Quality of life is related to good health, family relations, feeling of self-esteem, and ability to cope with difficult situations. Endometriosis is a chronic condition which affects different areas of life. The lack of satisfaction in everyday life is mainly due to constant pain. The process of adjusting to a life with illness is associated with negative emotions. The aim of the article is to review the current state of knowledge concerning the impact of social and medical factors on a population of women affected by endometriosis. Women with endometriosis have an impaired quality of life compared to the general female population. Psychological consequences of endometriosis include: depression, anxiety, powerlessness, guilt, self-directed violence, and deterioration of interpersonal relations. It may contribute to lower productivity at work and less satisfying intimate life. A multi-disciplinary, evidence-based care is needed. The disease can take away the ability to be physically active, obtain an education, work continuously, and interact with friends. Social support and cognitive-behavioral therapy are extremely important for healing.
... The quality of sexual life plays a pivotal role in the patient's overall quality of life. Recently, increasing studies have suggested that women with endometriosis have lower sexual quality, such as lower sexual functioning and satisfaction [11,12]. Several methods for assessing the quality of life of patients with endometriosis have been developed [8,13]. ...
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Purpose This study aimed to explore the effects of endometriosis on female sexual function. Methods PubMed, Embase, and Web of Science databases were searched to analyze the Female Sexual Function Index (FSFI) or visual analog scale (VAS) scores between women with and without endometriosis. Data from publications were generated, and the sexual function of women with and without endometriosis was systematically evaluated. Results A total of six publications were included in the study. The FSFI total score and its six domains were significantly lower in women with endometriosis: FSFI total score (P < 0.001), desire (P = 0.045), arousal (P = 0.039), pain domains (P < 0.001), lubrication (P < 0.001), orgasm (P = 0.001), and satisfaction (P < 0.001). Women with endometriosis exhibited more severity in terms of VAS scores for dyspareunia (P = 0.008) and chronic pelvic pain (P < 0.001); however, no significant severity for dysmenorrhea was observed (P = 0.118). Subgroup analysis showed that the region was not a source of heterogeneity. Publication bias was not noted in all included studies, and most results of the sensitivity analysis for the included indexes were stable, which implied that our results were relatively reliable. Conclusion The present meta-analysis provided evidence that endometriosis decreased female sexual function and increased the pain severity of dyspareunia and chronic pelvic pain.
... Pain is suggested to underlie the reduced level of physical activity [17,18], and the high prevalence of reported chronic fatigue [18][19][20], as well as the broad burden of disabilities described for some of these affected women [21]. In this regard, it has been published a relevant worse impact on everyday activities [21][22][23], sleep quality [14,17,20], relationship with their partner and reproductive planning [24,25], emotional and mental health [26,27], education [28,29], work productivity [30][31][32][33] or social life [28,29] that, in combination, leads to a significant reduction in health-related quality of life (HRQoL) [14,18,20,24,31,34]. Even more, endometriosis is acknowledged to be a risk factor for gynaecological cancer [4]. ...
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Aim: The 'Physio-EndEA' study aims to explore the potential benefits of a therapeutic exercise program (focused on lumbopelvic stabilization and tolerance to exertion) on the health-related quality of life (HRQoL) of symptomatic endometriosis women. Design: The present study will use a parallel-group randomized controlled trial design. Methods: A total of 22 symptomatic endometriosis women will be randomized 1:1 to the Physio-EndEA or usual care groups. The 'Physio-EndEA' program will consist of a one-week lumbopelvic stabilization learning phase followed by an eight-week phase of stretching, aerobic and resistance exercises focused on the lumbopelvic area that will be sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. The primary outcome measure is HRQoL. The secondary outcome measures included clinician-reported outcomes (pressure pain thresholds, muscle thickness and strength, flexibility, body balance and cardiorespiratory fitness) and patient-reported outcomes (pain intensity, physical fitness, chronic fatigue, sexual function, gastrointestinal function and sleep quality). Discussion: Findings of this study will help to identify cost-effective non-pharmacological options (such as this exercise-based intervention) that may contribute to the improvement of HRQoL in symptomatic endometriosis women.
... These feelings include loss of libido, arousal disorder, orgasm disorder, sexual pain, and vaginal spasm. In recent years, an increasing number of studies have reported that women with endometriosis have a lower sexual quality of life, such as sexual functioning and satisfaction [20,21]. ...
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Background: In the present study, we aim to report on the sexual function of women experiencing symptoms of endometriosis, analysing the clinical and psychosocial factors that may be associated. Methods: A multicentre cross-sectional study was performed to analyse the sexual function in a sample of 196 Spanish women with endometriosis, using the Female Sexual Function Inventory. Results: The Female Sexual Function Inventory (FSFI) was validated in our endometriosis study group. The mean FSFI score for the sample was 22.5 (SD 6.6), with 20.9 and 26.9 being in the 25th and 75th percentiles, respectively. Although physical sexual pain and dyspareunia were factors that influenced the sexual function of women with endometriosis, our results show that the impairment was multifactorial. Conclusions: We found impaired sexual function in women diagnosed with endometriosis. The final model included deep endometriosis, depression, age, and unemployment as strongest predictive factors for poor (deteriorated) sexual function.
... Endometriosis-associated pain (EAP) is experienced as dysmenorrhea, non-cyclical pelvic pain, and cyclical pain related to organ function including dysuria, dyschezia and deep dyspareunia (33,34). The complexity of EAP is contributed to by the different mechanisms involved. ...
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Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.
... Dyspareunia also harms the sexual life of women with endometriosis [23]. Studies have shown that the treatment of endometriosis can reduce dyspareunia and improves the sexual life and quality of life in patients [24,25]. Another important symptom of endometriosis is dysmenorrhea [26], in which previous studies showed that the treatment of endometriosis causes a significant decrease in dysmenorrhea [27]. ...
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Endometriosis is a common chronic inflammatory disease. Garlic contains components that have antiproliferative, anti-inflammatory, and antioxidative effects. The current study aimed to evaluate the effectiveness of garlic on endometriosis symptoms. This was a randomized placebo-controlled triple-blind clinical trial. A convenience sample of 60 women was randomly allocated into two groups. The intervention group received usual care supplemented with 400 mg garlic tablets, and the placebo group received identical placebo tablets. A four-part Visual Analogue Scale (VAS) was used to measure the severity of pains. The pains were measured on four occasions (before the intervention and on one-, two-, and three-month follow-ups). Data were analyzed using the t-test, chi-square, repeated measures ANOVA, and ANCOVA by SPSS 16. The overall severity of pain reduced from 6.51 ± 0.86 to 1.83 ± 1.25 in the intervention group (p
... In recent years, an increasing number of studies have reported that women with endometriosis have a lower sexual quality of life, such as sexual functioning and satisfaction. 7,8 Garry et al. 9 believed that endometriosis has a serious adverse effect on women's physical and mental health, sexual life, and other aspects. Most of the lesions of endometriosis are located in the posterior pelvic cavity. ...
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Objective Endometriosis is a common disease in women of childbearing age, leading to sexual dysfunction or loss of libido. We aimed to evaluated the effect of endometriosis on women’s sexual function. Methods We performed a prospective case–control study to determine the effect of endometriosis on women’s sexual function using a self-administered questionnaire from September 2017 to August 2018. The simplified Chinese version of the Female Sexual Function Index (FSFI) was used to assess sexual function. Results We found that sexual function of women in the endometriosis group (n=77) in all dimensions was significantly lower compared with that in the control group (n=63). The total FSFI score in patients was 25.5, which tended to be lower than that in the control group (26.7). Sexual arousal, sexual pain, and satisfaction were significantly different between the two groups. Sexual arousal and sexual pain scores were significantly lower in the endometriosis group than in the control group at the ages of 31 to 40 years. Conclusion Women with endometriosis suffer from sexual dysfunction, especially those aged 31 to 40 years. Our findings suggest that the quality of sexual life in this subpopulation needs to be improved.
... Dyspareunia secondary to endometriosis has been associated with the presence of deep infiltrating endometriosis (DIE), especially along the uterosacral ligaments. Surgical resection of DIE has been shown to improve deep dyspareunia [34][35][36][37][38]. ...
Article
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Purpose of Review The purpose of this article is to provide general considerations for the work up and management of dyspareunia, describe the various causes, provide first line treatment options, and note when surgical management is indicated. We also aim to provide additional resources for management. Recent Findings Recent studies have demonstrated the complex nature of female sexual dysfunction and the multimodal treatment options that are often needed including surgical intervention. Summary Recurrent or persistent discomfort before, during, or after intercourse may occur in approximately 15% of women. The differential diagnosis of dyspareunia is vast. A thorough history and physical exam are imperative for diagnosis and treatment of dyspareunia.
Article
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Background: Endometriosis is likely to affect sexuality and intimate relationships but the effect endometriosis has on partners remains overlooked and the existing studies show conflicting results. The effect of the disease and its treatment on the couple may be pronounced given the absence of an obvious cause or cure, the likelihood of chronic recurring symptoms, and the potential impact on both sex and fertility. Materials and methods: We followed the PRISMA guidelines to conduct this systematic review, which involved a database search of published available research related to the effects of endometriosis treatment on sexual function, couple’s relationship and on the partner published between 2000 and 2020. Results: The studies considered revealed that women with endometriosis report a significant effect of the disease on sexuality and relationship. Also, most of the published studies suggest that the impact on partners may be profound, affecting many life domains including sex, intimacy and the relationship in general. Conclusions: Data suggests that male partners should not be overlooked in the treatment of endometriosis and that psychosocial support including sexual and couple therapy might be beneficial.
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The aim of this study is to evaluate prospectively the presence of endometriosis in the peritoneum of the ovarian fossa of patients affected by endometriomas and its correlation with the adhesion between this peritoneum and endometrioma. Patients presenting ovarian endometriomas and candidate to laparoscopy were considered for inclusion in the study. Patients underwent laparoscopic excision of endometriomas. The presence of adherence of the ovarian fossa to endometrioma was investigated. In all patients, the removal of a peritoneum fragment from the ovarian fossa of the affected ovary was carried out. 68 patients were enrolled in the study. 48 patients presented adhesions to the ovarian fossa. Histopathologic examination of the peritoneum of the ovarian fossa revealed the presence of endometriosis in 87 % of patients presenting adhesions of the endometriomas with ovarian fossa; surprisingly it was present only in 15 % of patients not presenting this condition (p < 0.0001). Pain symptoms were more frequent in patients with endometriomas adhesion to the ovarian fossa. CA125 levels were not statistically significantly different between groups. At 12-month follow-up, four patients presented endometrioma recurrence. All of them presented adhesion of the ovarian fossa to the endometrioma in the first operation. There is a strong association between adhesion of the endometriomas to the ovarian fossa and the presence of endometriosis on the peritoneal surface of the fossa. This condition significantly correlates with pain symptoms and may predict endometrioma recurrence. The removal of this peritoneum in case of adherent endometrioma may potentially reduce the incidence of recurrence.
Article
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Purpose: In a series of publications, we had developed the concept that uterine adenomyosis and pelvic endometriosis as well as endometriotic lesions at distant sites of the body share a common pathophysiology with endometriosis constituting a secondary phenomenon. Uterine auto-traumatization and the initiation of the mechanism of tissue injury and repair (TIAR) were considered the primary events in the disease process. The present MRI study was undertaken (1) to corroborate this concept by re-visiting, in view of discrepant results in the literature, the association of adenomyosis with endometriosis and (2) to extend our views concerning the mechanisms of uterine auto-traumatization. Patients and methods: MRI was performed in 143 women attending our center, in whom, on the basis of transvaginal sonography (TVS) and historical data, such as documented endometriosis and dysmenorrhea of various degrees of severity, the presence of uterine adenomyosis was suspected. In addition to the measurement of the diameter of junctional zone (JZ) of the anterior and posterior walls in the mid-sagittal plane, the diagnosis of adenomyosis was based on visualization, in that all planes were analyzed with scrutiny. By this method of "visualization" all transient enlargement of the JZ, such as peristaltic waves of the archimyometrium and sporadic neometral contractions that might mimic adenomyotic lesions could be excluded. At the same time, this method allowed to lower the limit of detection in terms of thickness of the JZ for assured diagnosis of adenomyosis. Furthermore, the localizations of the individual lesions, their shapes and patterns were described. Results: With the method of 'visualization', the diagnosis of uterine adenomyosis could be verified in 127 of the 143 patients studied. The prevalence of endometriosis in adenomyosis was 80.6% and the prevalence of adenomyosis in endometriosis was 91.1%. As concluded from their localization within the uterine wall, the adenomyotic lesions predominantly developed in the median region of the upper two-thirds of the uterine wall. Cystic cornual angle adenomyosis was a distinct phenomenon that was only observed in patients suffering from extreme primary dysmenorrhea. Aside from this, the majority of the patients complained of primary dysmenorrhea (80%). On the basis of these findings and the fact that particularly extreme primary dysmenorrhea is associated with high intrauterine pressure, menstrual 'archimetral compression by neometral contraction' has to be considered as an important cause of uterine auto-traumatization in addition to uterine peristalsis and hyperperistalsis. Both mechanical functions of the non-pregnant uterus exert their strongest power in the upper region of the uterus, which is compatible with the predominant localization of the adenomyotic lesions. Conclusions: The data confirm our previous results of a high association of adenomyosis with endometriosis and vice versa. Our view of the mechanism of uterine auto-traumatization by mechanical functions of the non-pregnant uterus has to be extended, in that 'archimetral compression by neometral contractions' could be realized as the predominant cause of mechanical strain to the non-pregnant uterus. The data of this study confirm our concept of the etiology and pathophysiology of adenomyosis and endometriosis in that the process of chronic proliferation and inflammation is induced at the level of the archimetra by chronic uterine auto-traumatization. Furthermore, with respect to the diagnosis of uterine adenomyosis (and consequently endometriosis) this study shows a high degree of accordance between the findings in real-time TVS and MRI.
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Purpose: To evaluate the role of post-surgical medical treatment with GnRHa in patients with DIE (Deep Infiltrating Endometriosis) that received complete or incomplete surgery laparoscopic excision. Methods: Hundred fifty-nine patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain undergoing laparoscopic surgery in academic tertiary-care medical center. Eighty patients underwent complete laparoscopic excision of DIE (Arm A) while 79 patients underwent incomplete surgery (Arm B). After surgery each surgical arm was randomized in two groups: no treatment groups 1A [40 pts] and 1B [40 pts] and GnRHa treatment for 6 months groups 2A [40 pts] and 2B [39 pts]. Pain recurrence and quality of life were evaluated in follow-up of 12 months and compared between groups. Results: No differences were observed between patient groups 1A and 2A. Groups 1A, 2A and 2B obtained significantly lower pain scores than those achieved by the group 1B undergoing incomplete surgical treatment and no post-surgical therapy. At 1-year follow-up patients treated with en-block resection (Groups 1A and 2A) showed the lowest pain scores and the highest quality of life in comparison with the other two groups (Group 1B and 2B). Conclusion: GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment. It seems that it has no role on post-surgical pain when the surgeon is able to completely excise DIE implants.
Article
Objektive: The aim of the current study was to evaluate the prevalence and the impact of sexual dysfunction, sexual distress and interpersonal relationships in patients with endometriosis. Methods: A questionnaire-based multicentre cohort study was conducted in eight tertiary referral centres in Austria and Germany. One hundred and twenty-five patients with histologically proven endometriosis and dyspareunia were included. The Female Sexual Function Index and the Female Sexual Distress Scale were used to screen women's sexuality. Additionally, we evaluated psychological parameters and pain intensity during/after sexual intercourse via a self-administered questionnaire. Results: Female sexual distress and sexual dysfunction were observed in 97/125 and 40/125 patients. Statistically significant correlations were found between sexual dysfunction and pain intensity during/after sexual intercourse (p < 0.01/p < 0.01), a lower number of episodes of sexual intercourse per month (p < 0.01), greater feelings of guilt towards the partner (p < 0.01) and fewer feelings of femininity (p < 0.01). Thirty-eight out of 125 women agreed that the primary motivation for sexual intercourse was to conceive and nearly half of women (46%) included stated that satisfying the partner acted as primary motivation for sexual contact. Conclusion: Overall, our findings demonstrate that dyspareunia as a common complaint in patients with endometriosis causes a severe impairment of sexual function, relationship and psychological wellbeing.
Article
BACKGROUND: The study aim was to assess the time elapsed between onset of symptoms and diagnosis of endometriosis, and to identify the factors associated with diagnostic delay in a group of Brazilian women. METHODS: In this retrospective cohort study, 200 women with surgically confirmed endometriosis were interviewed at an endometriosis outpatient clinic. RESULTS: The median (interquartile range) time elapsed from onset of symptoms until diagnosis of endometriosis was 7.0 (range 3.5–12.1) years. The younger the women at onset of symptoms, the longer the period for diagnosis to be made: the median delay was 12.1 (range 8.0–17.2) years in women aged ≤19 years, and 3.3 (range 2.0–5.5) years in women aged ≥30 years. The median time period between onset of symptoms and diagnosis was 4.0 (2.0–6.0) years for women whose main complaint was infertility, but 7.4 (3.6–13.0) years for those with pelvic pain. CONCLUSIONS: The delay in diagnosis of endometriosis was considered to be long, and especially so for young women with pelvic pain. More information relating to endometriosis should be offered to general physicians and gynaecologists in order to reduce the time taken to diagnose this condition.
Article
To compare two different surgical techniques, stripping or cystectomy, in patients treated with the same post-operative medical therapy in terms of recurrence of endometrioma, recurrence of pain and spontaneous pregnancy rate within 2 years from surgery. The inclusion criteria of this study were: (1) 25-40 years old; (2) ovarian endometrioma more than 3 cm of diameter detected by transvaginal ultrasonography (3) regular menstrual cycle (4) post-operative treatment with GnRH analogs, (5) tubal patency assessed by laparoscopic chromopertubation (6) normal human semen characteristics. Exclusion criteria were uterine myoma, previous medical treatment for endometriosis, presence of adenomyosis, previous surgery of ovarian endometrioma, multiple cysts, bilateral involvement, co-existence of deep endometriosis. Patients were assigned to two study groups: group A (N = 45) patients undergoing stripping technique and group B (N = 64) patients undergoing cystectomy technique for ovarian endometrioma. In group B the percentage of ultrasonographic recurrence (15.4 %, N = 15) is much lower than in group A (55.6 %, N = 25). (p value 0.001). In group B the percentage of symptomatic recurrence (21.8 %, N = 14) is much lower than in group A (53.3 %, N = 24) (p value 0.001). Spontaneous pregnancy rate in group A patients was of 4.4 % (N = 2) and in group B 22.3 % (N = 21), (p value 0.0072). However, the percentage of specimen with adjacent healthy ovarian tissue was lower in group A (26.6 %) than in group B (50 %) (p value 0.01). Among the different treatment options for surgical treatment of ovarian endometrioma, in our experience cystectomy appears to be the most appropriate treatment, both in terms of recurrence and pregnancy rate.
Article
Endometriosis-associated pelvic pain appears due to persistent nociceptive stimulation, but the precise mechanisms remain poorly understood. A search was conducted to screen and select articles from PubMed. Neurotrophins (NTs), a family of neuronal growth factors, are overexpressed in endometriosis and encompass NGF, BDNF and NT-3 and NT-4/5. NT receptors, TrkA and p75NTR, and NT receptor-interacting proteins, MAGE and NDN, were also expressed. NTs and their receptors play a role in the development and maintenance of neural tissues in non-neuronal cell types such as endometriosis. Nerve fibers contain unmyelinated sensory C, myelinated sensory Adelta and adrenergic nerve fibers that innervate abnormal cell growths. An increased release of proinflammatory cytokines from endometriotic lesions is responsible for the excessive sensory innervation and development of chronic pelvic pain. The preponderance of the inflammatory milieu and subsequent hyperinnervation might be involved in the pathophysiology of pain generation in women with endometriosis.