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Sexual function is an important aspect of health and quality of life and is influenced by both medical conditions and health-care interventions, especially when gynecologic disorders are involved. Coital pain is among the main factors that affect sexual functioning, and this symptom is reported by almost half of women suffering from endometriosis.

The objective of this report is to review the current state of knowledge on the impact that endometriosis and its treatments have on the sexual function of women and their sexual partners. A systematic literature search was performed to identify studies evaluating sexual function in endometriosis patients, and a narrative analysis of is presented.

The review discusses relevant quantitative and qualitative studies analyzing the effect of endometriosis and its hormonal and surgical treatments on measures of sexual function and quality of sexual relationship.

Endometriosis negatively affects different domains of sexual function, and the presence of dyspareunia is not the only determinant of sexual health in these women. Chronic pelvic pain, advanced stages of disease and the presence of physical and mental comorbidities affect sexual function, as well as personality traits and women's expectations. Although a of studies have evaluated the effect of surgery and hormonal treatment on deep dyspareunia, overall sexual function and quality of the relationship with the partner are often under-investigated.

Multiple clinical and personal determinants affect sexual function in women with endometriosis, with potentially negative consequences on the sexual function of partners and quality of the relationship. Additional prospective and longitudinal investigations are warranted using specific instruments to analyze biopsychosocial variables of sexual pain in endometriosis patients and the effects that actual treatments have on measures of quality of sexual function and relationship.

Sexual health is a critical aspect of quality of life and is also influenced by medical conditions and health-care interventions, particularly when gynecological disorders are involved, such as gynecological cancer, breast cancer or infertility Langer et al. Although there has been great progress in understanding human sexuality and improving sexual health in recent years, health-care providers should accelerate and promote this progress to be more inclusive and comprehensive.

Sexual and reproductive health are mentioned in the United Nations Sustainable Development Goals, and they represent a target in the post agenda United Nations General Assembly,a of increasing global awareness and initiative in moving forward on global sexual health issues, including education, care and rights Hawkes, ; Temmerman et al. According to main international guidelines, endometriosis should be viewed as a chronic disease that requires a life-long individualized management plan with the aim of avoiding repeated surgical procedures.

General principles that should guide medical management of endometriosis are not different from those applicable to other chronic inflammatory disorders Vercellini et al. However, endometriosis is also a disease that affects young, sexually active women during different phases of their sexual life and during development of their sexual behavior.

Consequently, sexual health is a major concern for endometriosis patients and should also be a primary concern in endometriosis care and research. Because endometriosis is viewed as a chronic disease that affects young women during their reproductive years, it is absolutely necessary to bridge the artificial divide Saf seeking new year s day oral orgasm reproductive and sexual health in endometriosis patients and their partners.

However, the international consensus on future research priorities following the 10th World Congress on Endometriosis did not consider sexual health among symptoms and treatment outcomes Rogers et al. Three years later, recommendations for future directions for endometriosis research following the 11th World Congress on Endometriosis underlined the need to better identify clinical features of pain and quality of life, although the notion of sexual functioning did not clearly emerge Rogers et al.

The importance of analyzing overall sexual function in endometriosis patients gained direct attention only recently in an article published in by members of the World Endometriosis Society, although the importance of sexual health has been argued since Vercellini et al. Physical, mental and social dimensions characterize sexual health. The inability to engage in sexual activity in a fulfilling way may affect self-esteem, self-worth and relationships with partners Basson, The objective of this review is to analyze the current state of knowledge on the impact that endometriosis and its treatments medical and surgical have on sexual function and to provide insights into women's perspectives of sexual pain and consequences for the sexual partner.

The sexual response is a psychophysiological experience. It is a sequence of physiological events, including sexual desire, arousal and genital responses Bianchi-Demicheli and Ortigue, ; Ortigue et al. Phases of this cycle may overlap, and their order may vary. Psychological and biological factors influence the processing of sexual stimuli to allow or preclude subsequent arousal, and the type of outcome sexual or non-sexual influences future sexual motivation.

Multiple factors, including stage of life cycle, age, relationship duration, mental health and relationship happiness, influence the sexual response between individuals and within a person's own sexual life Basson, The association between coital pain and sexual dysfunction is the result of repeated experiences of sex associated with pain and fear of pain. The fearful reaction in turn negatively affects desire, arousal, reward, lubrication, loss of genital congestion and heightened pelvic floor tone in a circular model Payne et al.

Finally, central sensitization le to hyperalgesia and allodynia and secondary hyperalgesia, worsening pain perception Basson, ; Thomten and Linton, ; Thomten et al. A systematic literature search was performed to identify studies evaluating sexual function in endometriosis patients. We used the following combination of Medical Subject Headings MeSH : endometriosis, dyspareunia, sexual function, sexuality, libido, arousal, desire, orgasm, satisfaction, pleasure, pain, quality of life, marital status and relationship. All relevant articles were examined, and their reference lists were systematically reviewed to identify other studies for potential inclusion in this review.

Selection criteria included retrospective and prospective studies and the analysis of qualitative and quantitative variables. Only studies investigating sexual function in endometriosis patients were included.

Studies investigating pelvic pain and dyspareunia without the concomitant analysis of sexual, psychological and social variables were arbitrarily excluded. Additional cross-references were identified during the review search. Pain during sexual intercourse is one of the main symptoms among endometriosis patients, and women with endometriosis are at an increased risk of experiencing sexual pain compared with the normal population. In a large case—control study evaluating more than women with endometriosis, symptoms associated with sexual intercourse occurred in Specifically, the presence of dyspareunia is an independent risk considered to be affected by endometriosis, with an adjusted OR of 6.

In the same study, multivariate Saf seeking new year s day oral orgasm analysis showed that sexual pain and chronic pelvic pain but not dysmenorrhea negatively affected both the physical health and mental health domains in the SF36 questionnaire De Graaff et al. Patients enrolled in that study experienced multiple medical treatments, including hormonal and fertility treatments and in most cases, at least one surgical intervention De Graaff et al.

A retrospective qualitative study evaluating the long-term consequences of endometriosis over 15 years showed that A ificant correlation between dyspareunia and a negative influence on relationships was Saf seeking new year s day oral orgasm evidenced Fagervold et al. A similar prevalence of sexual pain was reported in two additional studies Jones et al.

The presence of deep dyspareunia caused by endometriosis is mostly associated with deep lesions infiltrating the utero-sacral ligaments, the pouch of Douglas, the posterior Saf seeking new year s day oral orgasm wall, and the rectum and is less frequently associated with ovarian and bladder lesions Fauconnier et al. Reviewing the anatomical and biological causes of dyspareunia in endometriosis is beyond the scope of this review, and many other articles have extensively examined pain symptoms Fauconnier and Chapron, ; Brawn et al.

However, some considerations are critical for the analysis of the effects of chronic sexual pain on overall sexual function, specifically in endometriosis: 1 Dyspareunia may be particularly harmful because it usually occurs whenever intercourse is attempted, whereas dysmenorrhea typically afflicts women during menstruation Vercellini et al. The presence of these symptoms is also associated with a higher prevalence of depression symptoms OR 1.

In this cohort, dyspareunia was independently associated with pelvic floor tenderness in a multiple logistic regression analysis OR 4. The latter is Saf seeking new year s day oral orgasm with modifications in the behavioral and functional brain response to noxious stimuli, changes in brain structure, activity of hypothalamic—pituitary—adrenal axis and autonomic nervous system and consequently personal distress Morotti et al.

Although the prevalence of deep dyspareunia and chronic pelvic pain have been widely investigated in endometriosis, female sexual function and the relationship with the sexual partner have been scantly examined in the last decades. Indeed, deep dyspareunia occurrence and intensity has been considered for long time the only instrument to assess sexual functioning in endometriosis.

One of the first assessments of sexual function in endometriosis was done inwhere the analysis of 17 patients with minimal or mild symptomatic endometriosis showed an increased rate of sexual avoidance using the Golombok Rust Inventory of Sexual Satisfaction questionnaire, in comparison to controls Waller and Shaw, Avoidance was also confirmed in other qualitative studies where the majority of women who suffered dyspareunia avoided or reduced sexual intercourse Jones et al. Insexual health was evaluated among a cohort of patients suffering from deep dyspareunia caused by different genital diseases.

Patient with deep endometriosis infiltrating the utero-sacral ligaments showed more pain based on visual analog scale VAS and lower scores in the Global Sexual Satisfaction Index GSSI than patients with peritoneal endometriosis and non-endometriosis patients Ferrero et al. In addition, sexual pain of patients with deep implants affected the intensity of the orgasm and satisfaction, causing a less relaxed and fulfilled state compared with controls. The presence of endometriosis any type was also associated with a reduction of the quality of communication with the partner about sex Ferrero et al.

Vercellini et al. Indeed, no ificant correlation was observed between deep dyspareunia VAS scores and sexual rating scale. Specifically, rectovaginal endometriosis negatively affects current sexual interest and activity, and sexual satisfaction, sexual pleasure, and ability to reach orgasm, with ORs ranging from 2. This is a item questionnaire suitable for self-assessment of sexual functioning that evaluates six subdomains separately, including sexual interest, sexual activity, satisfaction of sexual life, experience of sexual pleasure, orgasm capacity and sexual relevancy Garratt et al.

In the rectovaginal endometriosis group, the risk of being sexually unsatisfied or feeling little or no sexual pleasure was three times higher, and the risk of engaging in limited or no sexual activity and of reduced capacity to reach orgasm was approximately two times higher, compared with subjects in the non-endometriosis group Vercellini et al. The FSFI is a item questionnaire that has been developed as a brief, multidimensional self-report instrument for assessing the key dimensions desire, arousal, lubrication, orgasm, satisfaction and pain of sexual function in women.

This test has the advance to investigate pain symptoms and provide a cut score for differentiating women with and without sexual dysfunction Wiegel et al. The FSFI has been widely tested and validated in different cultural environments and medical conditions and it has been also proposed as valid instrument to assess sexual function in endometriosis in a recent consensus paper Vercellini et al.

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The FSDS was developed to provide a standardized, quantitative measure of sexually related personal distress in women with sexual dysfunction Derogatis et al. When sexual dysfunction was diagnosed, patients also had a ificantly fewer episodes of sexual intercourse per month and greater fear of separation because of coital pain Saf seeking new year s day oral orgasm patients without sexual dysfunction Fritzer et al. Specifically, compared with the patients with no to mild pelvic pain, those with moderate-to-severe pelvic pain had a 3.

The presence of advanced states of disease also affected the desire domain, in addition to sexual satisfaction, orgasm and pain, when analyzed separately using the Sexual Health Outcomes in Women Questionnaire SHOW-Q Montanari et al. The SHOW-Q is a recently developed item scale for the assessment of four domains of sexual function: satisfaction, orgasm, desire and pelvic problem interference Learman et al.

Adaptation of the fear-avoidance model in endometriosis patients. Biopsychosocial variables of sexual pain play a critical role in the fear-avoidance model. Senses of incertitude, fear, expectations and guilt are often reported in qualitative studies. As result, decreased lubrification and loss of genital congestion also worsened by pharmacological hypogonadism heighten pelvic floor tone, risk of vaginismus and pain.

Central sensitization caused by chronic pelvic pain le to hyperalgesia and allodynia, worsening dyspareunia in a circular model. Hallmarks of endometriosis, such as delay of diagnosis and worsening and recurrence of pain, exacerbate dyspareunia and dysfunctional behavior, prolonging the distress.

Although dyspareunia can be considered the first step in the development of sexual dysfunction, additional factors characterize the evolution towards an impairment of sexual health. According to the fear-avoidance model, multiple biopsychosocial variables influence sexual distress Fenton, ; Desrochers et al. Some of them may be related to the evolution of disease toward advanced stages and worsening of pain intensity or duration and the development of chronic pelvic pain Tripoli et al. Infertility can affect an intimate relationship in a range of ways Glover et al.

Evidence also indicates that infertility status, length of infertility and IVF are associated with worse scores in all domains of the FSFI Ashraf et al. How do fertility concerns and infertility treatment affect sexual health in endometriosis patients and their partners? Does the length of infertility and sexual pain play a role in predicting the worsening of sexual functioning? What is the effect of getting pregnant on sexual functioning? The available evidence, unfortunately, does not address these questions. Endometriosis patients suffering from dyspareunia experience a sense of guilt towards their partner, lower feelings of femininity, alteration of body image and alexithymia, which, in turn, exacerbate sexual dysfunction Fritzer et al.

In a cohort of patients with chronic pelvic pain due to endometriosis, catastrophizing, a well-known pain-coping mechanism, played a pivotal role in pain experience, severity and recurrence Martin et al. Although dyspareunia and Saf seeking new year s day oral orgasm health was not assessed in this cohort, catastrophizing was a ificant predictor of pain at 1 year of follow-up, and women who showed severe catastrophizing at baseline had higher pain at follow-up Martin et al.

Interestingly, across control subjects and the chronic pain population, patients with high levels of catastrophizing show augmented musculoskeletal tenderness and intensified pain sensitivity. This population has a higher risk of developing post-surgical and persistent pain syndromes Turner et al. The long delay between the first onset of symptoms of the disease and diagnosis may also play a role in sexual functioning.

Coupled with the delay in endometriosis diagnosis, the perpetuation of painful sexual episodes in young women may exacerbate fear, catastrophizing and avoidance Fig. Symptomatic patients have frequently reported that they felt a sense of relief, legitimation, liberation and empowerment, when the nature of disease is identified, replacing incertitude and frustration Cox et al.

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An association between endometriosis and psychiatric disturbances such as depression, anxiety and increased stress has also been identified and widely described Cheong et al. Younger patients have an elevated likelihood of developing major depression, any depression disorders and anxiety disorders Chen et al. Depression is often associated with chronic illness and independently le to a higher prevalence of sexual dysfunction Piazza et al.

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However, whether mood disorders predict sexual dysfunction in endometriosis patients is unknown, and no study has specifically addressed this issue. Thus, the presence of a causal effect, although likely, can only be hypothesized. The effects of endometriosis on relationships have not been featured prominently in the available literature. Moreover, the social and relationship dimension of pain constantly influences the changing dynamic of pain.

A reduction in the quality of communication about sex with the partner has been assessed in different studies on endometriosis. Ferrero et al. In the retrospective qualitative study by Fagervold et al.

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