Unconsummated marriage: a systematic review of etiological factors and clinical management.

BACKGROUND: Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. AIM: The study sought to systematically review current evidence regarding the etiological factors and clinical management of UCM. METHODS: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples who never had sexual intercourse in case report or case series evaluating the related causes and/or management and reporting data with qualitative, quantitative, or mixed methods. The review was reported according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) statement and registered in PROSPERO with ID CRD42023433040. RESULTS: A total of 27 studies including 1638 males and 1587 females were selected. Eight (29.6%) articles were case reports involving a single couple and 19 (70.4%) studies were case series. Mean Murad score was 4.1 (range, 1-8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of studies were conducted in Egypt (n = 5 [18.4%]), Israel (n = 4 [14.9%]), and the United States (n = 4 [14.9%]). The mean age of males and females varied between 24.2 and 37.6 years and from 21 to 27.4 years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 (85.2%) studies, inability to conceive in 1 (3.7%) article, and mixed in 3 (11.1%) articles. The mean duration of UCM varied from 7 days to 3.5 years. Eight studies involving both men and women showed that vaginismus (8.4%-81%) and erectile dysfunction (10.5%-61%) were the most common causes of UCM. Three articles reported that 16.6% to 26% of all UCM cases were due to both male and female factors. Sildenafil, tadalafil, intracavernosal injection, penile plication, female genital reconstructive surgery, vaginal dilators, lubricants, psychosexual therapy, and sex education were the various treatment modalities in 27 studies to achieve consummation rate of 66.6% to 100%. STRENGTHS & LIMITATIONS: A strength is that this is the first systematic review covering the entire spectrum of UCM. Limitations comprised the low quality of most of the included articles and the large percentage of UCM cases probably not published. CONCLUSION: Erectile dysfunction and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM.

Acceptability, reliability, and validity of a vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia: a cross-sectional study.

BACKGROUND: Approximately half of people with endometriosis experience deep dyspareunia; however, there is no means of objective self-testing of endometriosis-associated deep dyspareunia. AIM: The aim of this study was to assess the acceptability, test-retest reliability, and validity of a vaginal insert for a self-assessment of endometriosis-associated deep dyspareunia. METHODS: Participants were recruited from a tertiary endometriosis center. Inclusion criteria were: 19 to 49 years of age, self-reported deep dyspareunia of ≥4 of 10, and surgically confirmed endometriosis. Participants completed 2 self-assessments using the vaginal insert to self-assess tenderness at the right and left pelvic floor, bladder, cervix-uterus, and posterior cul-de-sac (vaginal fornix). The participants recorded tenderness at each pelvic site and completed a questionnaire regarding the acceptability of the vaginal insert to assess deep dyspareunia. Test-retest reliability was assessed by correlating the tenderness scores between the 2 assessment dates. Over a 4-week period, the participants also recorded deep dyspareunia severity at each penetrative vaginal sex encounter. Validity was assessed by correlating vaginal insert tenderness to deep dyspareunia severity, and also to tenderness reported on a prior gynecologic pelvic examination. OUTCOMES: The main outcome measures were the acceptability index score, tenderness (0-10) at each pelvic site, and prospective deep dyspareunia scores (0-10) over 4 weeks. RESULTS: There were 19 participants (mean age 34 ± 7 years) who completed the study. The majority identified as female (94.7%), heterosexual (89.5%), and white (89.5%). The median acceptability index score was 0.72 (interquartile range, 0.66-0.81). For test-retest reliability, the intraclass correlation coefficients were 0.79 (P = .001) for the left pelvic floor, 0.82 (P < .001) for the right pelvic floor, 0.54 (P = .07) for the bladder, 0.89 (P < .001) for the cervix-uterus, and 0.77 (P = .003) for the cul-de-sac. The correlation between the highest self-assessed mean tenderness in each participant and self-reported deep dyspareunia over 4 weeks was r = 0.32, but correlations for each pelvic site varied significantly. Tenderness at each site on prior gynecologist pelvic exam was associated with higher self-assessed mean tenderness with the vaginal insert in each participant (effect sizes = 0.42-0.88). CLINICAL IMPLICATIONS: The vaginal insert is acceptable and reliable for the objective self-assessment of endometriosis-associated deep dyspareunia, with initial evidence of validity. STRENGTHS AND LIMITATIONS: A strength was the inclusion of participants who were avoiding sexual activity and a limitation was the small sample size. CONCLUSION: Future studies with larger sample sizes are required to further establish the validity of the vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia.

Mediterranean Diet and Oxidative Stress: A Relationship with Pain Perception in Endometriosis.

BACKGROUND: Endometriosis is a chronic and inflammatory disease associated with pelvic pain. Dietary changes may be therapeutic for chronic inflammatory processes, reducing visceral input. The aim was to evaluate the role of dietary changes according to the Mediterranean Diet (MD) on pain perception in endometriosis and their relationship with oxidative stress. METHODS: in this prospective study, we included 35 endometriosis women. At baseline (T0) and after 3 (T1) and 6 (T2) months from the start of the diet, we investigated pain intensity with VAS (Visual Analogue Scale, from 0 to 10), vitamin profile, and oxidative stress. RESULTS: we found a significant increase in the diet score (p < 0.001). At T1, patients reduced pain in terms of dyspareunia (p = 0.04), non-menstrual pelvic pain (p = 0.06), dysuria (p = 0.04), and dyschezia (p < 0.001). Dyspareunia (p = 0.002) and dyschezia (p < 0.001) were further significantly reduced also at T2. We observed a significant positive correlation between lipid peroxidation and VAS non-menstrual pelvic pain and dysuria and a significant negative correlation between Oxygen radical absorbance capacity and VAS non-menstrual pain and dyschezia. CONCLUSIONS: our findings show a clear tendency toward a relationship between pain relief in endometriosis and MD. This appears promising to treat endometriosis-related symptoms and could be considered a new effective strategy for chronic pain management in the long term.

Neuroproliferative dyspareunia in endometriosis and vestibulodynia.

INTRODUCTION: Endometriosis is a common cause of deep dyspareunia, while provoked vestibulodynia is a common cause of superficial dyspareunia. The etiology of dyspareunia in both conditions is multifactorial and may include the role of local nerve growth (neurogenesis or neuroproliferation) that sensitizes pelvic structures and leads to pain with contact. OBJECTIVES: To review the evidence for neuroproliferative dyspareunia in endometriosis and provoked vestibulodynia. METHODS: Narrative review. RESULTS: The pelvic peritoneum and vulvar vestibule receive somatic and autonomic innervation. Various markers have been utilized for nerve subtypes, including pan-neuronal markers and those specific for sensory and autonomic nerve fibers. The nerve growth factor family includes neurotrophic factors, such as nerve growth factor and brain-derived neurotrophic factor, and their receptors. Studies of endometriosis and provoked vestibulodynia have demonstrated the presence of nerve fibers around endometriosis epithelium/stroma in the pelvic peritoneum and within the vulvar vestibule. The number of nerve fibers is higher in these pain conditions as compared with control tissue. Nerve growth factor expression by endometriosis stroma and by immune cells in the vulvar vestibule may be involved in local neuroproliferation. Local inflammation is implicated in this neuroproliferation, with potential roles of interleukin 1ß and mast cells in both conditions. Several studies have shown a correlation between nerve fibers around endometriosis and dyspareunia severity, but studies are lacking in provoked vestibulodynia. There are several possible clinical ramifications of neuroproliferative dyspareunia in endometriosis and provoked vestibulodynia, in terms of history, examination, biopsy, and surgical and medical treatment. CONCLUSIONS: A neuroproliferative subtype of dyspareunia may be implicated in endometriosis and provoked vestibulodynia. Additional research is needed to validate this concept and to integrate it into clinical studies. Neuroproliferative pathways could serve as novel therapeutic targets for the treatment of dyspareunia in endometriosis and provoked vestibulodynia.

Comparison of pain catastrophizing and anxiety in patients with dyspareunia and healthy women: a cross-sectional study.

Despite the prominent role of cognitive-affective variables, such as pain catastrophizing and anxiety in chronic pain, little is known about their relationship with dyspareunia. This study compared pain-catastrophizing and anxiety in reproductive-aged women with and without dyspareunia. A controlled cross-sectional study was conducted on 398 married women in Iran selected by convenience sampling. Sampling was performed both online and in person. Data were collected using a checklist designed for the study, including background characteristics, self-reported dyspareunia, and two standard questionnaires: the Pain Catastrophizing Scale (PCS) and the Spielberger State-Trait Anxiety Inventory-6 (STAI-6). Results showed that 49.5% of the women reported dyspareunia in the previous six months, with a reduced figure of 42% and 31% when using more specific criteria for dyspareunia. Women with dyspareunia had significantly higher scores for pain catastrophizing and anxiety than the control group without dyspareunia. Pain-catastrophizing was associated with aversion to genital contact and body image dissatisfaction. Anxiety was correlated with age, marriage duration, and sexual abuse. Managing anxiety and catastrophizing thoughts may help dyspareunia patients better cope with pain.

Efficacy of N-Acetylcysteine on Endometriosis-Related Pain, Size Reduction of Ovarian Endometriomas, and Fertility Outcomes.

BACKGROUND: Endometriosis is a chronic, estrogen-dependent, inflammatory disease, whose pivotal symptoms are dysmenorrhea, dyspareunia, and chronic pelvic pain (CPP). Besides the usual medical treatments, recent evidence suggests there are potential benefits of oral N-acetylcysteine (NAC) on endometriotic lesions and pain. The primary objective of this prospective single-cohort study was to confirm the effectiveness of NAC in reducing endometriosis-related pain and the size of ovarian endometriomas. The secondary objective was to assess if NAC may play a role in improving fertility and reducing the Ca125 serum levels. METHODS: Patients aged between 18-45 years old with a clinical/histological diagnosis of endometriosis and no current hormonal treatment or pregnancy were included in the study. All patients received quarterly oral NAC 600 mg, 3 tablets/day for 3 consecutive days of the week for 3 months. At baseline and after 3 months, dysmenorrhea, dyspareunia and CPP were assessed using the Visual Analog Scale score (VAS), while the size of the endometriomas was estimated through a transvaginal ultrasound. Analgesics (NSAIDs) intake, the serum levels of Ca125 and the desire for pregnancy were also investigated. Finally, the pregnancy rate of patients with reproductive desire was evaluated. RESULTS: One hundred and twenty patients were recruited. The intensity of dysmenorrhea, dyspareunia and CPP significantly improved (p < 0.0001). The use of NSAIDs (p = 0.001), the size of the endometriomas (p < 0.0001) and the serum levels of Ca125 (p < 0.0001) significantly decreased. Among the 52 patients with reproductive desire, 39 successfully achieved pregnancy within 6 months of starting therapy (p = 0.001). CONCLUSIONS: Oral NAC improves endometriosis-related pain and the size of endometriomas. Furthermore, it decreases Ca125 serum levels and may improve fertility in patients with endometriosis.

Successful management of penetration disorder: A holistic approach to an age-old problem.

Penetration disorder, formerly referred to as vaginismus, is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration. It is a common female psychosexual problem and is a cause of significant personal and relationship distress. In this report, we describe the successful treatment of vaginismus in a 28-year-old woman by using a combination of different interventions. This involved providing sexual education, psychotherapy, serial dilation using graded plastic dilators, sensate-focused therapy, and anti-anxiety medication.

Effect of Fractional Carbon Dioxide vs Sham Laser on Sexual Function in Survivors of Breast Cancer Receiving Aromatase Inhibitors for Genitourinary Syndrome of Menopause: The LIGHT Randomized Clinical Trial.

Importance: Survivors of breast cancer present more severe symptoms of genitourinary syndrome of menopause (GSM) than patients without history of breast cancer. Recently, new treatments, such as vaginal laser therapy, have appeared, but evidence of their efficacy remains scarce. Objective: To assess the safety and efficacy of carbon dioxide (CO2) vs sham vaginal laser therapy after 6 months of follow-up in survivors of breast cancer with GSM receiving aromatase inhibitors. Design, Setting, and Participants: This prospective double-blind sham-controlled randomized clinical trial with two parallel study groups was performed during October 2020 to March 2022 in a tertiary referral hospital. Survivors of breast cancer using aromatase inhibitors were assessed for eligibility, and eligible patients were randomized into the 2 treatment groups. Follow-up was conducted at 6 months. Data were analyzed in July 2022. Interventions: All patients from both groups were instructed to use the first-line treatment (FLT) based on nonhormonal moisturizers and vaginal vibrator stimulation. Patients for each group were allocated to 5 monthly sessions of fractional CO2 laser therapy (CLT) or sham laser therapy (SLT). Main Outcomes and Measures: The primary outcome was sexual function, evaluated through Female Sexual Function Index (FSFI) score. Other subjective measures of efficacy included a visual analog scale of dyspareunia, vaginal pH, a Vaginal Health Index, quality of life (assessed via Short-Form 12), and body image (assessed with the Spanish Body Image Scale). Objective measures of efficacy included vaginal maturation index, vaginal epithelial elasticity (measured in Pascals) and vaginal epithelial thickness (measured in millimeters). Measures were assessed before and after the intervention. Tolerance (measured on a Likert scale), adverse effects, and estradiol levels were recorded. Results: Among 211 survivors of breast cancer assessed, 84 women were deemed eligible and 72 women (mean [SD] age, 52.6 [8.3] years) were randomized to CLT (35 participants) or SLT (37 participants) and analyzed. There were no statistically significant differences between groups at baseline. At 6 months, both groups showed improvement in FSFI (mean [SD] score at baseline vs 6 months: CLT, 14.8 [8.8] points vs 20.0 [9.5] points; SLT, 15.6 [7.0] points vs 23.5 [6.5] points), but there was no significant difference between CLT and SLT groups in the improvement of sexual function evaluated through the FSFI test overall (mean [SD] difference, 5.2 [1.5] points vs 7.9 [1.2] points; P = .15) or after excluding women who were not sexually active (mean [SD] difference, 2.9 [1.4] points vs 5.5 [1.1] points; P = .15). There were also no differences between improvement of the 2 groups at 6 months of follow-up in the other assessed subjective outcomes, including dyspareunia (mean [SD] difference, -4.3 [3.4] vs -4.5 [2.3]; P = .73), Vaginal Health Index (mean [SD] difference, 3.3 [4.1] vs 5.0 [4.5]; P = .17), body image (mean [SD] difference, -3.7 [4.5] vs -2.7 [4.8]; P = .35), and quality of life (mean [SD] difference, -0.3 [3.6] vs -0.7 [3.2]; P = .39). Similarly, there were no differences in improvements in objective outcomes, including vaginal pH (mean [SD] difference, -0.6 [0.9] vs -0.8 [1.2]; P = .29), vaginal maturation index (mean [SD] difference, 10.2 [17.4] vs 14.4 [17.1]; P = .15), vaginal epithelial thickness (mean [SD] difference, 0.021 [0.014] mm vs 0.013 [0.012] mm; P = .30), vaginal epithelial elasticity (mean [SD] difference, -1373 [3197] Pascals vs -2103 [3771] Pascals; P = .64). There were significant improvements in the overall analysis regardless of group in many outcomes. The 2 interventions were well tolerated, but tolerance was significantly lower in the CLT group than the SLT group (mean [SD] Likert scale score, 3.3 [1.3] vs 4.1 [1.0]; P = .007). No differences were observed in complications or serum estradiol levels. Conclusions and Relevance: In this randomized clinical trial, vaginal laser treatment was found to be safe after 6 months of follow-up, but no statistically significant differences in efficacy were observed between CLT and SLT. Trial Registration: ClinicalTrials.gov identifier: NCT04619485.

Endometriosis Symptomatology, Dyspareunia, and Sexual Distress Are Related to Avoidance of Sex and Negative Impacts on the Sex Lives of Women with Endometriosis.

BACKGROUND: Endometriosis affects approximately 10% of women and is associated with a range of symptoms including pelvic pain, abnormal bleeding, and painful sexual intercourse. However, very little is known about the relationship between endometriosis-related symptoms and sex. METHODS: Women with a diagnosis of endometriosis (n = 2060; mean age = 30 years) completed a questionnaire measuring the frequency of endometriosis symptoms, dyspareunia, sexual distress, avoidance of sex, and the perceived negative impact of endometriosis symptoms on sex life. RESULTS: In bivariate and multivariate logistic regression models with avoidance of sex and perceived negative impact of endometriosis symptoms on sex life as DVs, higher endometriosis symptom frequency, dyspareunia, and sexual distress were associated with greater avoidance of sex and higher perceived negative impact of endometriosis symptoms on sex life. With a two- and three-fold increase in the odds of avoiding sex and reporting a negative impact of endometriosis on sex lives, respectively, for each point increase in dyspareunia. Similarly, there was a 7% to 11% increase in avoidance of sex and the negative impact of endometriosis on sex lives, per one-point increase in symptom frequency and sexual distress. CONCLUSIONS: The results highlight the considerable impacts of endometriosis symptomatology on women's sex lives and wellbeing. Better medical and counselling services may be needed to ameliorate the negative impact of endometriosis on women's sex lives.

Assessing the experience of dyspareunia in the endometriosis population: the Subjective Impact of Dyspareunia Inventory (SIDI).

STUDY QUESTION: Is the Subjective Impact of Dyspareunia Inventory (SIDI) a reliable tool to examine the experience of dyspareunia in the context of endometriosis? SUMMARY ANSWER: In this study, the SIDI showed good structural and psychometric properties, and thus can be used as a reliable questionnaire to assess the impact of endometriosis-related dyspareunia on multiple dimensions, such as sexuality and intimate relationships. WHAT IS KNOWN ALREADY: In the endometriosis population, dyspareunia has a tremendous negative impact on psychological health, overall sexual function and couple relationships. However, there is a paucity of tools that can be effectively used in either research or clinical practice to assess the subjective components of the dyspareunia experience, including coping strategies to deal with the pain. STUDY DESIGN, SIZE, DURATION: In this cross-sectional study, the validity of the SIDI was examined by considering the responses provided by 638 participants with endometriosis and dyspareunia, who participated in an online survey conducted between 8 November and 21 December 2021. Participants were recruited using snowball sampling that involved posting the invitation to participate in the study on the social media of a patient association. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were women aged ≥18 with clinical or surgical diagnosis of endometriosis. The SIDI measures the subjective impact of dyspareunia and is composed of 16 items focused on the frequency of dyspareunia-related experiences in the last 6 months, rated on a 5-point Likert scale. Sexuality was assessed using the Female Sexual Function Index. Psychological health was measured using the Hospital Anxiety and Depression Scale and the Rosenberg Self-Esteem Scale. Sociodemographic and endometriosis-related information was collected using a researcher-made questionnaire. Statistical significance was set at P < 0.05. MAIN RESULTS AND THE ROLE OF CHANCE: Factor analysis revealed that the SIDI has a four-factor structure and allows for examining the impact of dyspareunia in terms of Sexual Concerns (Factor 1), Relationship Concerns (Factor 2), Partner Support (Factor 3) and Endurance of Pain (Factor 4). The SIDI showed good structural and psychometric properties (including internal consistency), was associated with sexual function and psychological health and was able to discriminate between participants with and without sexual dysfunction. LIMITATIONS, REASONS FOR CAUTION: Reasons for caution are related to the risk of self-selection bias depending on the study population and recruitment strategy. Moreover, all the information provided by the participants was self-reported, which may have affected the accuracy of the data collected, especially with regards to endometriosis-specific information. WIDER IMPLICATIONS OF THE FINDINGS: This study may provide a new brief tool that can be used by clinicians and researchers to assess the impact of dyspareunia from a multidimensional perspective and to consider subjective aspects that can be usefully integrated with information about pain severity, timing and localization. STUDY FUNDING/COMPETING INTEREST(S): There was no funding for this study. A.F. is the President of APE-Odv (Associazione Progetto Endometriosi-Organizzazione di volontariato (Endometriosis Project Association-Volunteer Organization)), the largest nonprofit endometriosis patient association in Italy. The other authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Presenting Symptoms and Diagnosis of Vulvar Lichen Sclerosus in Premenopausal Women: A Cross-Sectional Study.

OBJECTIVES/PURPOSE: Presenting symptoms of vulvar lichen sclerosus (LS) specific to premenopausal women are not well reported in the literature and may differ from those in postmenopausal women. This study aimed to characterize the presentation of vulvar LS among premenopausal women. MATERIALS AND METHODS: An observational web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, timing of diagnosis, alternate diagnoses, and presence of concomitant autoimmune conditions. RESULTS: Of the 956 responses received, 503 met inclusion criteria of biopsy-confirmed LS and premenopausal status. Average age of symptom onset was 27 years, and average age of diagnosis was 32 years, with a 4-year delay in diagnosis. Symptoms most present were dyspareunia (68%) and tearing with intercourse or vaginal insertion (63%). Symptoms that affect the individual most were also dyspareunia (44%) and tearing with intercourse or vaginal insertion (39%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%) and tearing with intercourse or vaginal insertion (26%). Most common skin changes included hypopigmentation (81%), vulvar fissures (72%), and labial resorption (60%), with fissures affecting the individual the most (48%). Sixty-six percent of the respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Hypothyroidism was the most common concurrent autoimmune condition (10%). CONCLUSIONS: Vulvar LS affects premenopausal women, commonly presenting with dyspareunia and tearing with intercourse. This condition should be considered and evaluated in premenopausal women presenting with vulvar symptoms and sexual pain.

Investigation of the Relationships among Self-Efficacy, Stress, and Dyspareunia during the COVID-19 Pandemic.

This study examined whether low self-efficacy and heightened perceived stress were associated with dyspareunia at two timepoints during COVID-19. Sixty-two participants (31 with and 31 without dyspareunia) completed a longitudinal online survey. Self-efficacy declined during the pandemic, and individuals with dyspareunia reported lower self-efficacy compared to those without dyspareunia. Although stress was greater for those with dyspareunia, both groups reported stress reductions over time. Lower stress was associated with increases in self-efficacy. This study is the first to examine longitudinal trends of dyspareunia during the COVID-19 pandemic and illuminates psychological factors that may influence the experience of dyspareunia.

Endometriosis: A Retrospective Analysis of Clinical Data from a Cohort of 4,083 Patients, With Focus on Symptoms.

BACKGROUND: Endometriosis is an estrogen-dependent and chronic inflammatory gynecological disease due to the presence of ectopic endometrial tissue outside the uterine cavity. This disease affects approximately 10% of the female population. In spite of its relatively high prevalence, information about its pathogenesis, diagnosis, and therapy is not complete. PATIENTS AND METHODS: We present a retrospective study performed on 4,083 patients with endometriosis, with a focus on symptoms. The archived data were analyzed investigating the distribution of symptoms among patients, the correlation of symptoms with the occupation of the patients, and finally the correlation with the other anamnestic data. Statistical associations between the data for all cases were then considered separately. RESULTS: Chronic fatigue syndrome and dyspareunia were confirmed as being among the main symptoms of endometriosis, together with bowel disorders. On the other hand, we registered a low occurrence of urinary disorders and even of chronic pelvic pain, which is usually considered among the main symptoms of endometriosis. We found an increase in incidence of symptoms starting from the age group 25-29 years up to 40-44 years and, subsequently, a significant decrease in the group aged 55-59 years. For all the symptoms analyzed, we found a higher incidence in employers, graduates and freelancers. Finally, we found a protective effect of the number of gestations on chronic fatigue syndrome. CONCLUSION: This in-depth study on such a vast cohort of affected patients clarifies some important aspects on the complex symptomatology of this still enigmatic disease. In particular, the study highlights the symptoms most closely related to endometriosis which will help speed up the diagnostic process of patients suffering from this pathology.

Deep dyspareunia: a narrative review of impact on sexual function and quality of life.

Deep dyspareunia refers to pain with deep penetration or insertion into the vagina, which affects quality of life. The aim of this narrative review was to examine how the underlying conditions that give rise to deep dyspareunia, and the symptoms of these conditions, can affect sexual function and quality of life beyond the deep dyspareunia itself. For example, deep dyspareunia may be associated with gynecological pathologies that cause cyclical pain symptoms (e.g. dysmenorrhea, dyschezia/dysuria), resulting in quality of life changes related to menstrual cycle events such as ovulation or menstruation. Recurrent dysmenorrhea can cause hyperalgesic priming that sensitizes the nervous system, leading to chronic pelvic pain that can be exacerbated with sexual activity. The coexistence of functional bowel or bladder disorders can result in urgency and frequency that affect the sexual response cycle. Myofascial/musculoskeletal origins of deep dyspareunia may affect body positioning during sexual activity. Central nervous system sensitization can underlie these different factors, and also be associated with mental health conditions, which together can cause symptomatology across body systems that can affect all aspects of one's sexual life. Recognition and management of the far-reaching impacts of deep dyspareunia and its associated comorbidities may be important in clinical care to meaningfully improve quality of life. Future research should include a comprehensive empirical validation of the hypotheses and potential mechanisms in this review.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial.

OBJECTIVES: Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia. METHODS: This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated. RESULTS: Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01). CONCLUSIONS: In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Disfunção sexual em mulheres com câncer do colo do útero submetidas à radioterapia: análise de conceito / Disfunción sexual en mujeres con cáncer de cuello uterino sometidas a radioterapia: análisis de concepto / Sexual dysfunction in women with cervical cancer undergoing radiotherapy: concept analysis

Resumo Objetivo analisar o conceito de disfunção sexual em mulheres com câncer do colo do útero submetidas a tratamento radioterápico. Método estudo de análise de conceito fundamentado no referencial metodológico proposto por Walker e Avant, o qual é composto por oito etapas: seleção do conceito; determinação dos objetivos da análise conceitual; identificação dos possíveis usos do conceito; determinação dos atributos críticos ou essenciais; construção de um caso modelo; construção de casos adicionais; identificação dos antecedentes e consequentes do conceito; e definição das referências empíricas. Resultados a amostra final resultou em 11 artigos, que identificaram 4 atributos críticos, 18 antecedentes e 07 consequentes do conceito, os quais permitiram a construção de uma definição conceitual e elaboração de um caso-modelo, com a finalidade de exemplificar o contexto social no qual o conceito encontra-se inserido. Conclusão e implicações para prática alterações na estrutura corporal, déficit de conhecimento, diminuição da frequência das relações sexuais, dispareunia e indiferença do parceiro são alguns dos principais antecedentes e consequentes da disfunção sexual na população estudada. Entretanto, esses fatores ainda são pouco conhecidos, o que limita a realização de ações de promoção, prevenção e reabilitação sexual, sobretudo no campo da enfermagem.

Resumen Objetivo analizar el concepto de disfunción sexual en mujeres con cáncer de cuello uterino sometidas a tratamiento radioterápico. Método estudio de análisis de concepto basado en el marco metodológico de Walker y Avant, compuesto por ocho etapas: selección del concepto; determinación de los objetivos del análisis conceptual; identificación de posibles usos del concepto; determinación de atributos críticos o esenciales; construcción de un caso modelo; construcción de casos adicionales; identificación de antecedentes y consecuentes del concepto; y definición de referencias empíricas. Resultados La muestra final resultó en 11 artículos: 04 críticos, 18 antecedentes y 07 consecuentes del concepto, lo que permitió la construcción de una definición conceptual y la elaboración de un caso modelo con el fin de ejemplificar el contexto social en que se inserta el concepto. Conclusión e implicaciones para la práctica Cambios en la estructura corporal, déficit de conocimiento, disminución de la frecuencia de las relaciones sexuales, dispareunia y la indiferencia de la pareja son algunos de los principales antecedentes y consecuentes de la disfunción sexual en la población estudiada. Sin embargo, estos factores aún son poco conocidos, lo que limita la realización de acciones de promoción, prevención y rehabilitación sexual, especialmente en el campo de la enfermería.

Abstract Objective to analyze the concept of sexual dysfunction in women with cervical cancer undergoing radiotherapy. Method a concept analysis study based on the methodological framework proposed by Walker and Avant, which consists of eight stages: concept selection; determination of the objectives of the conceptual analysis; identification of possible uses of the concept; determination of critical or essential attributes; construction of a model case; construction of additional cases; identification of the antecedents and consequences of the concept; and definition of empirical references. Results the final sample resulted in 11 articles, which identified 4 critical attributes, 18 antecedents and 07 consequences of the concept, which allowed the construction of a conceptual definition and the elaboration of a model case in order to exemplify the social context in which the concept is inserted. Conclusion and implications for practice changes in body structure, lack of knowledge, decreased frequency of sexual intercourse, dyspareunia, and partner's indifference are some of the main antecedents and consequences of sexual dysfunction in the studied population. However, these factors are still little known, which limits the performance of actions of promotion, prevention and sexual rehabilitation, especially in the field of nursing.

Prevalence and Characteristics of Postpartum Vulvovaginal Atrophy and Lack of Association With Postpartum Dyspareunia.

OBJECTIVE: Breastfeeding-related hypoestrogenic state has been reported as a possible risk factor for postpartum dyspareunia. This study aimed to evaluate the prevalence and characteristics of postpartum vulvovaginal atrophy according to 3 different diagnostic methods and to estimate its association with postpartum dyspareunia and daily vulvovaginal symptoms. METHODS: This is a prospective cohort study of puerperal women attending a routine postpartum checkup. Participants completed a questionnaire and underwent a gynecological examination. Atrophy was diagnosed separately according to gynecologist impression, vaginal pH measurement (≥5.1), and cytologic vaginal maturation index. Patients were followed up with a telephone survey 2-3 months later, inquiring about symptoms possibly associated with atrophy. RESULTS: Of 117 participants, vaginal atrophy was diagnosed in 48% by gynecological examination, 62% by a pH level of 5.1 or greater, and 40.2% had cytological atrophy. Of the 35.9% of women who had resumed sexual intercourse (42/117), 69% reported dyspareunia. No significant association was found between dyspareunia and atrophy parameters. There was no difference in the rates of dyspareunia among women who were exclusively breastfeeding (21/27 = 78%), partially breastfeeding (4/7 = 57%), or not breastfeeding (4/8, 50%). Atrophy was more common in breastfeeding women according to the 3 criteria (gynecological examination: 57.6% vs 16.7%, p = .006; pH: 70% vs 22%, p < .001; vaginal maturation index: 51.1% vs 0%, p < .001). Of the 117 participants, 47% reported daily vulvovaginal symptoms. Those with daily symptoms reported more dyspareunia as compared with those without daily symptoms (85% vs 52%, p = .025). CONCLUSIONS: A high prevalence of atrophy was observed in puerperal women in association with breastfeeding. There was no significant association between atrophy and dyspareunia or daily vulvovaginal symptoms.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study.

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.

Early onset of action with a 17ß-estradiol, softgel, vaginal insert for treating vulvar and vaginal atrophy and moderate to severe dyspareunia.

OBJECTIVE: The softgel 17ß-estradiol (E2) vaginal inserts (4 and 10 µg; Imvexxy; TherapeuticsMD, Boca Raton, FL) are FDA approved for treating moderate to severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy (VVA). The objective here was to determine responder rates at week 2 and whether week-2 findings predicted week-12 responders in the REJOICE trial. METHODS: Postmenopausal women received E2 vaginal inserts 4, 10, or 25 µg, or placebo for 12 weeks. Proportion of responders (having ≥2 of the following: vaginal superficial cells >5%, vaginal pH <5.0, or dyspareunia improvement of ≥1 category) were calculated. Odds ratios (ORs) for positive response at week 12 given a positive response at week 2 were determined in the efficacy evaluable (EE) population. RESULTS: The responder rate (in EE population [n = 695]) was 74% to 82% with E2 inserts versus 24% with placebo at week 2, and 72% to 80% versus 33% at week 12. Positive treatment responses were 9- to 14-fold higher with vaginal E2 than with placebo at week 2, and 5- to 8-fold higher at week 12. Response at week 2 predicted response at week 12 in the total population (OR 13.1; 95% CI, 8.8-19.7) and with active treatment only (OR 7.9; 95% CI, 4.7-13.2). CONCLUSIONS: A high percentage of postmenopausal women with moderate to severe dyspareunia responded with the E2 softgel vaginal insert at week 2, and a positive response at week 2 predicted a positive response at week 12.

[Clinical investigation of Sexual pain in patients with endometriosis]. / Les dyspareunies chez les patientes atteintes d'endométriose.

Endometriosis can negatively affects many aspects of womens'life, including their sexuality. Deep or superficial dyspareunia is reported by nearly half of women with endometriosis. The pain has chronic inflammatory, neuropathic or muscular components. Repetition of painful experiences, but also treatments for endometriosis can lead to other sexual disorders such as lack of desire and arousal. We present a narrative review exploring the causes of sexual pain in endometriosis patients and how they could deteriorate quality of sexual life if unrecognized.

L'endométriose touche les femmes en âge de procréer et affecte de nombreux aspects de leur vie, notamment leur sexualité. Des dyspareunies profondes ou superficielles sont rapportées par près de la moitié des femmes souffrant de cette affection. Les douleurs ont pour origine notamment une réaction inflammatoire chronique au niveau des lésions et ont une composante neuropathique. La répétition d'expériences douloureuses, mais aussi les traitements de l'endométriose peuvent entraîner d'autres troubles sexuels tels que l'absence de désir et d'excitation. Nous présentons ici une revue narrative de la littérature explorant les causes de ces troubles et les mécanismes qui mènent à leur chronicisation.