Endometriosis and women's sexual functioning: a systematic review of the available evidence

Study question: What is the impact of endometriosis and its pharmacological and surgical treatments on female sexual functioning (FSF)? Summary answer: Endometriosis has a negative impact on multiple domains of sexual functioning. Medical interventions can lead to medium-/long-term improvement, but not necessarily to a definitive resolution. What is known already: Endometriosis is associated with an increased risk of dyspareunia, witch often coexists with other forms of sexual dysfunctions, such as hypoactive sexual desire, low lubrication and arousal, and orgasm disorders. This is often due to women’s fear and anticipation of pain, which represents one of the most powerful inhibitor of the sexual response cycle. As endometriosis affects about 5–10% of women of reproductive age, a large proportion of young women in their most sexually active period of life could present sexual dysfunctions caused by the disease, which may interfere with physical and psychological quality of life and with conception. Study design, size, duration: We conducted a systematic review of studies on the association between endometriosis and FSF. According to the PRISMA guidelines, we evaluated articles published between 2000 and 2016 on the correlation between: 1) the mere fact of having endometriosis and the presence of related female sexual dysfunctions; 2) the association between surgical and/or pharmacological treatments for endometriosis and related effects on FSF. Participants/materials, setting, methods: Observational and retrospective studies on the impact of endometriosis and its treatments on FSF based on adequate description of participants, setting, medical intervention, and sexual outcomes were included. In order to investigate all aspects of FSF, we included only studies in which sexual outcomes were evaluated with a comprehensive sexual questionnaire, focusing not only on dyspareunia, but also on all the other aspects of FSF. Exclusion criteria were: qualitative research, case-report, commentaries or review articles. Main results and the role of chance: 31 studies were included in this systematic review and divided in 3 categories: no-intervention studies (n = 9), investigating the association between endometriosis and FSF; surgical intervention studies (n = 17), examining postoperative sexual outcomes of surgery for endometriosis; pharmacological intervention studies (n = 5), evaluating the effects of pharmacological endometriosis treatments on FSF. The clinical scenario described by the “no-intervention studies” was that around 70% of women with endometriosis suffer from sexual dysfunction (pain at intercourse, low satisfaction, lack of desire, low arousal, orgasm difficulties), with a negative impact on women’s psychological well-being and intimate relationships. The “surgical intervention studies” showed that surgery for endometriosis may lead to improved sexual functioning, although the extent and the length of these positive effects were often poorly defined. Most articles had an exclusive focus on deep infiltrating endometriosis and radical laparoscopic surgery. Although several studies considered a post-operative pharmacological adjuvant therapy, surgery and hormonal treatment were directly compared in one study only. The paucity of “pharmacological intervention studies” might seem surprising. However, almost all of this kind of studies focused exclusively on deep dyspareunia, without considering the global female sexual functioning. Overall, pharmacological treatment leads to a medium-long term amelioration of FSF. Limitations, reasons for caution: The heterogeneity of population, instruments, and sexual outcomes considered in the different studies did not allow to pool data and accurately estimate the sexual effects of the different intervention programs for amelioration of FSF in women suffering from endometriosis. Wider implications of the findings: Since FSF is a multidimensional phenomenon deriving from the interaction of multiple physical, psychosocial, and emotional factors, we think that the best treatment program for women affected by endometriosis related sexual dysfunctions can be provided by multidisciplinary teams composed of gynaecologists, sexologists, and psychotherapists. Trial registration number: not applicable.