What is Endometriosis and Deep Infiltrating Endometriosis?

Endometriosis is a benign condition where endometrial tissue (the lining of the inside of the uterus) grows outside of the uterus.

About 5-10% of reproductive aged persons with female-associated genitalia have endometriosis. Symptoms can range from no symptoms to debilitating pelvic pain with dysmenorrhea, pain with periods, abdominal pain, genital pain, bladder dysfunction, bowel dysfunction and other chronic overlapping pain conditions. In addition, endometriosis is known to also affect sexual quality of life. Pain with sex is called dyspareunia; while deep infiltrating endometriosis is a more severe form of endometriosis.

What is Deep Infiltrating Endometriosis? 

Deep infiltrating endometriosis (DIE) is a more severe form of endometriosis defined by endometriotic lesions that penetrate 5 or more mm beyond the peritoneal border. Cozzolino, et al found the most common symptoms of those with DIE include chronic pelvic pain (67.1%), dysmenorrhea (66.5%), dyspareunia (41.8%), constipation (32.4%), and painful urination (6.5%). 

Endometriosis, DIE & Sexuality

With the high number of people experiencing dyspareunia, it is not surprising to see that Deep Infiltrating Endometriosis is correlated with decreased quality of life and sexual function.

Jarzabek, et al found that dyspareunia is four times more common in those with endometriosis compared to controls, and five times more common in those with peritoneal endometriosis (DIE) than those with endometriotic cysts. Patients with any stage of endometriosis are likely to have some degree of sexual dysfunction, including pain with sex, reduced lubricancy, arousal, desire, orgasm leading to overall decreased frequency of sexual intercourse.

Several authors have agreed that Deep Infiltration Endometriosis in specific landmarks within the pelvic cavity increases the likelihood of sexual pain: uterosacral ligament, pouch of Douglas, posterior vaginal fornix and the anterior rectal wall. Di Donato, et al. found that the number of DIE nodules was directly proportional to reduction of sexual desire. Sexual dysfunction from endometriosis is likely due to pain, tissue fibrosis, chronic inflammation, adhered pelvic structures and possible infiltration of nerve fibers. 

How to treat endometriosis with dyspareunia: 

Endometriosis and Deep Infiltrating Endometriosis can be treated conservatively via hormonal treatments and medical management which can alleviate symptoms. However, surgical excision has been proven time and again that it can significantly restore sexual function and satisfaction. Sexual quality of life, health-related quality of life and mental health significantly improved in patients after excision surgery.

However, one study showed that sexual satisfaction with partner did not improve postoperatively (Setala et al. 2012). We must acknowledge that sexuality is multifactorial and is influenced by our physical, psychological and social well being that can also affect our relationships. Thus it is important that we not only treat the source of the pain/sexual dysfunction, but utilize a multidisciplinary approach to help treat all aspects of sexuality. A team consisting of a gynecologist, pain management specialist, nutritionist, therapist and pelvic  floor physical therapist is crucial to helping combat sexual dysfunction and pain, but can also help with other symptoms associated with endometriosis. Give us a call or send us a message.

References:

Cozzolino M, Magro-Malosso ER, Tofani L, et al. Evaluation of sexual function in women with deep infiltrating endometriosis. Sex & Reprod Healthcare 2018;16: 6-9.

Di Donato N. Montanari G, Benfenati A, et al. J Fam Plann Reprod Health Care 2015;41:278-283. 

Fritzer N, Tammaa A, Salzer H & Hudelist G. Dyspareunia and quality of sex life after srugical excision of endometriosis: a systematic review Euro J Obstetrics & Gyne and Reprodutive Biology 2014;173:1-6. 

Jarzabek-Bielecka G, Radomaki D, Pawalczyk M et al. Dyspareunia as a sexual problem on women with endometriosis Arch Perinat Med 2010;16:51-53. 

Martinez-Zamora M, Coloma JL, Gracia M, Rius M, et al. Long-term Follow-up of Sexaul Quality of Life After Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis. J of Minimally Invasive Gynecology 2021;28(11):1912-1919.

Setala M, Harkki P, Matomaki J, et al. Sexual functioning, quality of life and pelvic pain 12 months after endometriosis surgery including vaginal resection. Acta Obstet Gynecol Scand 2012; 91:692-698.