Uterine myomas, dyspareunia, and sexual function

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1 UTERINE FIBROIDS Uterine myomas, dyspareunia, and sexual function Simone Ferrero, M.D., Luiza Helena Abbamonte, M.D., Margherita Giordano, M.D., Mauro Parisi, M.D., Nicola Ragni, M.D., and Valentino Remorgida, M.D. Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa, Italy Objective: To determine the prevalence of deep dyspareunia (DD) and characteristics of sexual life in women with uterine myomas. Design: Cross-sectional survey. Setting: University hospital. Patient(s): Three hundred seven sexually active premenopausal women who underwent surgery because of uterine myomas (group M, n 132), uterine myomas and ovarian cysts (group MC, n 84), ovarian cysts (group C, n 67), and tubal sterilization (group S, n 24). Exclusion criteria were as follows: endometriosis, pelvic inflammatory disease, interstitial cystitis, and preoperative treatment with GnRH analogues. Intervention(s): Before surgery, patients underwent transvaginal ultrasound; number and characteristics of myomas were recorded. Main Outcome Measure(s): The presence and intensity of DD were determined. Patients completed a sexualfunction questionnaire. Result(s): Patients included in the four groups had similar DD prevalence and DD intensity. No significant difference was observed in DD prevalence and pain intensity according to the number, position, and size of myomas. Deep dyspareunia intensity was higher in women with fundal and anterior myomas than in those with other myoma positions. No significant difference was observed in sexual function among the four study groups. Conclusion(s): Women with uterine myomas do not have increased prevalence or severity of DD; their sexual function is not impaired. (Fertil Steril 2006;86: by American Society for Reproductive Medicine.) Key Words: Deep dyspareunia, sexual life, sexuality, uterine myomas Uterine myomas are the most common solid pelvic tumors in women, occurring in 20% 40% of women during their reproductive years. Although they are the most common indication for hysterectomy, most patients are asymptomatic (1 3). When symptoms occur, they usually consist of abnormal uterine bleeding, pelvic pain or pressure, reduced capacity of the urinary bladder, constipation, and reproductive dysfunction (1, 3, 4). Symptoms usually correlate with the location of the myomas, their size, or concomitant degenerative changes (3, 4). Despite the prevalence of uterine myomas and the symptoms they may cause, few studies investigated the impact of symptoms on patients health-related quality of life (5 11). In particular, there has been relatively little study of the impact of uterine myomas on sexual function. The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire addressed the evaluation of sexual function; however, only two aspects Received August 21, 2005; revised and accepted April 11, Presented at the Conjoint Annual Meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society, Montreal, Canada, October 15 19, Reprint requests: Simone Ferrero, M.D., Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, Genoa, Italy (FAX: ; simone. ferrero@fastwebnet.it). related to uterine fibroids were considered: diminished sexual desire and avoidance of sexual relationships (11). Some investigators (4, 12) suggested that women with myomas may develop dyspareunia with time as the enlarging uterus and myomas exert pressure on the surrounding adnexal structures and cervix. In a population-based cross-sectional study, Lippman et al. (13) found that women with myomas are more likely to report moderate or severe dyspareunia than are women without fibroids. Recently, Okolo et al. (14) observed that women with familial prevalence of myomas had a 43.2% prevalence of dyspareunia, which was significantly higher than that observed in subjects with sporadic myomas (28.3%). This study aims to determine the prevalence of deep dyspareunia (DD) in women with uterine myomas; in addition, the characteristics of sexual life were investigated. MATERIALS AND METHODS Study Population The subjects of the study were recruited among premenopausal women scheduled for surgery in our hospital because of benign gynecological conditions between January 2002 and March Prevalence of DD and characteristics of sexual function were compared among the following four groups of patients: 1504 Fertility and Sterility Vol. 86, No. 5, November /06/$32.00 Copyright 2006 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 [1] women with uterine myomas (group M, n 132) without any other pelvic pathology, [2] women with uterine myomas and ovarian cysts (group MC, n 84), [3] women with ovarian cysts without uterine myomas (group C, n 67), and [4] women undergoing surgery because of tubal sterilization without any pelvic pathology (group S, n 24). No patient included in the study had endometriosis or previously had undergone surgery for endometriosis. None of the patients included in the study had chronic pelvic pain, defined as nonmenstrual pelvic pain of 6 months duration that is severe enough to cause functional disability or to require medical or surgical treatment (15). None of the patients had signs of pelvic inflammatory disease at the time of surgery. No patient had interstitial cystitis, when symptoms suggestive of interstitial cystitis (i.e., urinary urgency and frequency or chronic pelvic pain) were present; this condition was ruled out on the basis of cystoscopic findings. None of the patients included in the study had received preoperative treatment with GnRH analogues. Only women who were sexually active in the 12 months before surgery were asked to participate in the study. All women included in the study were heterosexual. The study was reviewed and approved by the local institutional review board. All participants provided written informed consent before study entry. Evaluation of Myoma Presence and Distribution All women underwent a transvaginal ultrasound in the 2 weeks before surgery. The transvaginal ultrasound was performed before presence of DD and characteristics of sexual life were investigated. During transvaginal ultrasound, the presence of pelvic pathologies was evaluated and recorded. The number of myomas was determined. The volume (cm 3 ) of each myoma was evaluated by measuring the three main diameters (D1, D2, D3) and applying the formula of the ellipsoid (length height width 0.52). Location of the myomas with respect to uterine layers and their position with respect to the uterine axis was determined. During surgery, the characteristics of myomas (location and position) and other pelvic pathologies were reevaluated and recorded. Myomas were confirmed on the pathology reports for all cases included in this study. Evaluation of DD and Sexual Function Before surgery, the presence and the characteristics of DD were investigated. Deep dyspareunia was defined as genital pain on deep penetration. The presence of superficial dyspareunia occurring in or around the vaginal entrance and characterized by early discomfort was not considered in this study. The intensity of dyspareunia was assessed by using a 100-mm visual analogue scale. The left extreme represented the absence of pain, and the right extreme represented the worst possible pain. Severe DD was defined as an intensity of pain of 7. Before surgery, during the hospital stay, all women included in the study completed a sexual-function questionnaire. This questionnaire was based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory (DSFI) (16). The DSFI is a multidimensional measure of various aspects of psychological and sexual function. The Sexual Satisfaction Subscale consists of nine items reflecting the individual level of sexual fulfillment. The DSFI is one of the most thoroughly studied instruments in sexual research, and it has been found to have high internal and test retest reliability as well as discriminative validity (16, 17). The nine questions based on the DSFI were answered on a six-point Likert scale (where 1 strongly disagree and 6 strongly agree ). The sexual function questionnaire was followed by the Global Sexual Satisfaction Index (GSSI), which asks subjects to self-rate their overall level of sexual satisfaction on a nine-point scale, anchored at the lower extreme by 0 ( could not be worse ) and at the upper limit by 8 ( could not be better ) (16). Patients were asked to answer the questions with respect to the 3 months before surgery. All patients answered questions on marital status, years of education, and age at first sexual intercourse. Data on the patient s primary presenting problem, full menstrual history, and previous medical and surgical therapies were collected. During laparoscopy, the findings were recorded. Postoperative Follow-Up Women included in the study were contacted by telephone after a median time of 27 months (range, mo) after surgery. If the telephone numbers available in the patient s case notes were inaccurate, the telephone directory was used to try to identify the patient s current phone number. During the brief phone call, a standardized questionnaire was used. The presence of DD was investigated; patients also were asked whether changes in the quality of sexual life occurred after surgery (were improved, unchanged, or worsened). Statistical Analysis Categorical data were compared by using Fisher s exact test and 2 test as appropriate. Continuous data were compared by using the one-way analysis of variance or the one-way analysis of variance on ranks (Kruskal-Wallis) with a multiple pairwise comparison test (Dunn s test). Data were analyzed by using the Sigma-Stat software package (release 3.0; SPSS Inc., Chicago, IL) and SPSS software package (release ; SPSS Inc.). A P value of.05 was considered statistically significant. RESULTS Table 1 shows the demographic characteristics of the study population and the main indications for surgery. Comparison of DD Prevalence and Intensity in the Four Study Groups No significant difference was observed in DD prevalence (P.855) among group M (39/132 [29.5%]; 95% confidence interval [CI], 21.9% 38.1%), group MC (26/84 [31.0%]; 95% CI, 21.3% 42.0%), group C (17/67 [25.4%]; 95% CI, Fertility and Sterility 1505

3 TABLE 1 Characteristics of the study population and indications for surgery. Characteristic Group M (n 132) Group MC (n 84) Group C (n 67) Group S (n 24) P Ethnicity, n (%).947 Caucasian 125 (94.7) 81 (96.4) 64 (95.5) 23 (95.8) Other 7 (5.3) 3 (3.6) 3 (4.5) 1 (4.2) Age in y (mean SD) Body mass index in kg/m 2 (mean SD) Age at first sexual intercourse in y (mean SD) Marital status, n (%).143 Married 78 (59.1) 53 (63.1) 45 (67.2) 19 (79.2) Cohabiting 20 (15.2) 12 (14.3) 7 (10.4) 5 (20.8) Separated or divorced 10 (7.6) 6 (7.1) 3 (4.5) 0 Engaged 6 (4.5) 6 (7.1) 4 (6.0) 0 Single 18 (13.6) 7 (8.3) 8 (11.9) 0 Years with current sexual partner (mean SD) Education in y (mean SD) Previous abdominal surgery, n (%) a 31 (23.5) 20 (23.8) 15 (22.4) 5 (20.8).989 Appendicitis 23 (17.4) 14 (16.7) 11 (16.4) 2 (8.3) Ovarian cyst 3 (2.3) 3 (3.6) 1 (1.5) 2 (8.3) Myoma 3 (2.3) 3 (3.6) 2 (3.0) 0 (0.0) Extrauterine pregnancy 2 (1.5) 0 (0.0) 1 (1.5) 0 (0.0) Gallbladder stones (cholecystectomy) 4 (3.0) 2 (2.4) 0 (0.0) 1 (4.2) Main indication for surgery, n (%).001 Abnormal uterine bleeding 76 (57.6) 46 (54.8) 10 (14.9) 0 (0.0) Enlarged uterus with symptoms of pelvic 27 (20.5) 10 (11.9) 0 (0.0) 0 (0.0) pressure Infertility 15 (11.4) 12 (14.3) 7 (10.4) 0 (0.0) History of recurrent miscarriage 7 (5.3) 1 (1.2) 0 (0.0) 0 (0.0) Ovarian cysts 0 (0.0) 9 (10.7) 49 (73.1) 0 (0.0) Dysmenorrhea 7 (5.3) 6 (7.1) 1 (1.5) 0 (0.0) Tubal sterilization 0 (0.0) 0 (0.0) 0 (0.0) 24 (100.0) a Sometimes more than one abdominal operation in the same patient ), and group S (6/24 [25.0%]; 95% CI, %). Similarly, no significant difference was observed in the mean ( SD) intensity of DD on the visual analogue scale among the four groups (P.581; group M, ; group MC, ; group C, ; and group S, ). The prevalence of severe DD (visual analogue scale score of 7) was 8.3% in group M (11/132), 7.1% in group MC (6/84), 7.5% in group C (5/67), and 4.2% in group S (1/24; P.912). The age (mean SD) at DD onset was similar in the four study groups ( y in group M, y in group MC, y in group C, and y in group S; P.559). No significant difference was observed in the interval between DD onset and surgery (mean SD): y in group M, y in group MC, y in group C, and y in group S (P.073). Within group M, 56 (42.4%) women had one myoma only, 47 (35.6%) had two myomas, and 29 (22.0%) had at least three myomas; no significant difference was observed in DD prevalence and pain intensity among these three groups (Table 2). Analysis of Subjects With Only One Myoma No significant difference was observed in myoma volume between subjects with and without DD ( cm 3 and cm 3 ; P.133). No significant difference was observed in DD prevalence and intensity between subjects with different myoma volumes (Table 2). No significant difference was observed in DD prevalence and intensity according to number and location of the myomas (Table 2). Similarly, no significant difference was observed in DD prevalence according to the myoma position; there was a 1506 Ferrero et al. Sexual life in women with uterine myomas Vol. 86, No. 5, November 2006

4 TABLE 2 Deep dyspareunia according to the numbers, location, and position of myomas. Parameter n DD, n (%) DD intensity a (mean SD) Severe DD, b n (%) No. of myomas (30.4) (8.9) (34.0) (8.5) (20.7) (6.9) P value Subjects with only one myoma (n 56) Location of the myoma Intramural Subserosal Submucosal P value Position of the myoma Posterior Anterior Lateral Fundal Isthmus P value Myoma volume (cm 3 ) P value Group M (n 132) Location of the myomas Intramural (28.4) (7.4) Subserosal (31.8) (9.1) Submucosal 16 3 (18.8) (0.0) P value Position of the myomas Posterior (27.4) (4.1) Anterior (27.4) c 8 (11.0) Lateral 36 8 (22.2) c 1 (2.8) Fundal 20 8 (40.0) c 4 (20.0) Isthmus 10 3 (30.0) (0.0) P value a 100-mm visual analogue scale. b Pain intensity of 7 on the visual analogue scale. c Subjects with fundal and anterior myomas had higher DD intensity than did subjects with lateral myomas (P.05). trend for women with anterior or fundal myoma to have higher DD pain intensity, but the difference did not reach statistical significance (Table 2). Analysis of Subjects With Multiple Myomas Table 2 presents the findings obtained when the characteristics of DD of all women with any myoma in a particular location or position were compared with those of all women for whom that particular location was not present for any myoma. There was a trend for DD and severe DD to be more frequent in women with fundal myomas than in other patients with myomas, but this difference was not statistically significant. The intensity of DD was higher in women with fundal and anterior myomas than in subjects with lateral myomas (P.05). Fertility and Sterility 1507

5 TABLE 3 Sexual function in the four study groups. Parameter Group M (n 132) Group MC (n 84) Group C (n 67) Group S (n 24) P DSFI 1. Usually I am satisfied with my partner I feel I do not have sex frequently enough There is not enough variety in my sexual life Usually after sex I feel relaxed and fulfilled Usually sex does not last long enough I am not very interested in sex Usually I have a satisfying orgasm with sex Usually my partner and I have good communication about sex 9. I never experience pain during sex Intercourses per week in the past 3 mo (n) GSSI a Note: The first nine questions were based on the Sexual Satisfaction Subscale of the DSFI. a GSSI was significantly higher in group S than in group MC (Dunn s test). Analysis of Characteristics of Sexual Life No significant difference was observed in DSFI items among the four study groups (Table 3). Women included in the four groups reported a similar number of intercourses per week in the 3 months before surgery. The GSSI index was significantly higher in group S than in group C (P.05), and there was a trend for the GSSI to be higher in group S than in group M and MC, but that difference was not statistically significant (Table 3). No significant difference in DSFI and GSSI was observed according to the number of myomas or, in the case of single myoma, according to size, location, and position (data not presented). Postoperative Follow-Up Of 307 women included in the study, 268 (87.3%) were contacted by telephone, whereas 39 were lost to follow-up. At the time of the interview, 11 women were pregnant, 2 were divorced and not sexually active, and 2 were menopausal. Thirty-two women refused to participate in the telephone follow-up. Therefore, the postoperative follow-up was available for 221 women (82.5%). At follow-up, DD was reported by 80% of women who had had DD before surgery (Table 4). In particular, among subjects with DD included in group M, the symptom was not present at follow-up in only 14.3% of the cases. One woman who did not have DD at baseline, included in group MC, reported de novo DD after surgery. An improvement in the quality of sexual life at follow-up was reported by only 7.2% of women included in group M. At follow-up, the changes in quality of sexual life were similar among the four study groups (P.315). DISCUSSION It is well known that the emotional well-being of women of reproductive age may be significantly affected when an impairment of sexual function is present. Despite the high prevalence of uterine myomas in the general population, the characteristics of DD and sexual function of patients with this gynecological condition have not been investigated fully. The current study demonstrates that women with uterine myomas do not have increased prevalence or severity of DD when compared with subjects without this condition. In the past, the relationship between myomas and DD has been speculated in review articles and case reports (4, 12, 18). More recently, Lippman et al. (13) observed that women with myomas are 2.8 times more likely to report moderate to severe dyspareunia than are women without myomas; it remains unclear why these observations are in contrast with the findings of our study. Although different populations were evaluated in the two studies (care-seeking and non care-seeking women), it appears unlikely that this difference justifies the different findings of the two studies. Other investigators have suggested that location of the myomas with respect to uterine layers and their position with respect to the uterine axis are related to the severity of pain (1). In the current study, no significant difference was observed in DD prevalence according to location and position of the myomas. On the contrary, women with fundal and anterior myomas had higher DD intensity than did subjects with lateral myomas (Table 2). This finding is in line with the previous observation by Lippman et al. (13), who suggested that fundal myomas may be associated with more severe DD and pelvic pain. The current study confirmed the observation 1508 Ferrero et al. Sexual life in women with uterine myomas Vol. 86, No. 5, November 2006

6 TABLE 4 Postoperative follow-up of patients included in the four study groups. Parameter Group M (n 132) Group MC (n 84) Group C (n 67) Group S (n 24) P Patients with follow-up Total 97 (73.5) 62 (73.8) 45 (67.2) 17 (70.8) Women with DD at baseline 28 (28.9) 18 (29.0) 12 (26.7) 5 (29.4) Subjects with DD at baseline and at follow-up 24 (85.7) 15 (83.3) 10 (83.3) 4 (80.0).988 Subjects with DD at baseline but not at follow-up 4 (14.3) 3 (16.7) 2 (16.7) 1 (20.0) Changes in the quality of sexual life Improved 7 (7.2) 4 (6.5) 4 (8.9) 2 (11.8).315 Unchanged 90 (92.8) 57 (91.9) 41 (91.1) 14 (82.4) Worsened 0 (0.0) 1 (1.6) 0 (0.0) 1 (5.9) Note: Data are n (%) unless otherwise indicated. by Lippman et al. (13) that the number or size of the fibroids does not have a discernible relationship to pain symptoms. Cutler et al. (19) demonstrated elsewhere that orgasmic response is preserved in women with uterine myomas. To the best of our knowledge, for the first time, the current study evaluated in detail the characteristics of sexual life in women with uterine myomas. We demonstrated that this gynecological condition does not impair sexual function; it is important to note that sexual function was evaluated both in psychometric terms (by using the DSFI) and by determining the individual s subjective perception of sexual behavior (by using the GSSI). The strength of our study consists in the fact that all patients underwent surgery and the presence of additional pathologies was determined; in particular, all women with conditions causing DD (i.e., endometriosis, interstitial cystitis, and pelvic inflammatory disease) were excluded from the investigation. This particularly may be relevant because, as with endometriosis, myomas are hormone dependent, and it has been shown that the proportion of subjects with myomas is significantly increased among patients with endometriosis (20). We are aware that this study is characterized by some limitations. First, characteristics of DD and sexual life of women with uterine myomas were compared with those of three other groups of patients, but only one of these three groups can be considered theoretically normal (group S, women undergoing surgery because of tubal sterilization without any pelvic pathology). On the contrary, the subjects included in the other two groups were characterized by the presence of ovarian cysts (with and without uterine myomas), and they therefore cannot be considered ideal controls. However, to the best of our knowledge, there is no evidence that the presence of ovarian cysts is associated with DD or impairment of the sexual function; furthermore, no significant difference was observed in the current study when comparing group S with groups C and MC. In the light of the limited number of patients requesting tubal sterilization at our institute and in Italy in general, we decided to include the study groups C and MC. In the current study, the determination of sexual function was not performed by using the complete DSFI. The DSFI has been psychometrically validated and has been used widely in studies of normal and dysfunctional individuals (21 26). Its length, however, has made it unsuitable for routine clinical practice; in light of this, we used a questionnaire based on the Sexual Satisfaction Subscale of the DSFI. This questionnaire did not directly investigate whether the couples made adjustments to eliminate the discomfort caused by the presence of myomas (i.e., changes in coital position or limited vaginal penetration). In addition, the presence of introital dyspareunia was not evaluated in the current study; this may be a limitation of the study because women with deep discomforts may develop introital contraction as a reaction. Uterine myomas may affect the normal anatomical relationship between uterus and vagina; for example, mediumsized myomas may fill the pelvis, diminishing the pelvic capacity, whereas very large myomas may lift the uterus up out of the pelvis and lengthen the vagina. Obviously, these changes in pelvic anatomy may affect sexual function; their evaluation (for example through a pelvic organ prolapse quantification exam) could have strengthened the findings of the current study. However, a major impact of myomas on sexual behavior appears unlikely because no significant difference was observed in various aspects of sexual life (including orgasm quality and fulfillment after intercourse) and in GSSI among the four study groups. A final limitation of the current study may be that the postoperative follow-up was not performed by using the Fertility and Sterility 1509

7 same questionnaire used preoperatively, and only a few standardized questions were asked of the patients during the telephone interview. We are aware that a brief phone call may not represent the best instrument for investigating sexual life; however, evaluation of sexuality after surgery was not the main aim of the current study. In conclusion, the current study demonstrates that women with uterine myomas do not have increased prevalence and severity of DD when compared with subjects without this type of gynecological disorder; their sexual function is not impaired. REFERENCES 1. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94: Lumsden MA, Wallace EM. Clinical presentation of uterine fibroids. Baillieres Clin Obstet Gynaecol 1998;12: Stovall DW. Clinical symptomatology of uterine leiomyomas. Clin Obstet Gynecol 2001;44: Dwyer N, Hutton J, Stirrat GM. Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 1993;100: Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women s Health Study: I. Outcomes of hysterectomy. Obstet Gynecol 1994;83: Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women s Health Study: II. Outcomes of nonsurgical management of leiomyomas, abnormal bleeding, and chronic pelvic pain. Obstet Gynecol 1994;83: Ruta DA, Garratt AM, Chadha YC, Flett GM, Hall MH, Russell IT. Assessment of patients with menorrhagia: how valid is a structured clinical history as a measure of health status? Qual Life Res 1995; 4: Lamping DL, Rowe P, Clarke A, Black N, Lessof L. Development and validation of the Menorrhagia Outcomes Questionnaire. Br J Obstet Gynaecol 1998;105: Spies JB, Warren EH, Mathias SD, Walsh SM, Roth AR, Pentecost MJ. Uterine fibroid embolization: measurement of health-related quality of life before and after therapy. J Vasc Interv Radiol 1999;10: Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol 2002;99: Guarnaccia MM, Rein MS. Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy. Clin Obstet Gynecol 2001;44: Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003;80: Okolo SO, Gentry CC, Perrett CW, Maclean AB. Familial prevalence of uterine fibroids is associated with distinct clinical and molecular features. Hum Reprod 2005;20: Howard FM. Chronic pelvic pain. Obstet Gynecol 2003;101: Derogatis LR, Melisaratos N. The DSFI: a multidimensional measure of sexual functioning. J Sex Marital Ther 1979;5: Herold ES. Review of Derogatis Sexual Functioning Inventory. In: Mitchell JV, ed. 9th mental measurement year book. Lincoln, NE: University of Nebraska Press, 1985: Jones KD, Lehr ST, Hewell SW. Dyspareunia: three case reports. J Obstet Gynecol Neonatal Nurs 1997;26: Cutler WB, Zacker M, Genovese-Stone E, Friedman E. Sexual response in women. Obstet Gynecol 2000:95:19S. 20. Hemmings R, Rivard M, Olive DL, Poliquin-Fleury J, Gagne D, Hugo P, et al. Evaluation of risk factors associated with endometriosis. Fertil Steril 2004;81: Leiblum SR, Aviv A, Hamer R. Life after infertility treatment: a long-term investigation of marital and sexual function. Hum Reprod 1998;13: Limbos MM, Joyce DP, Chan CK, Kesten S. Psychological functioning and quality of life in lung transplant candidates and recipients. Chest 2000;118: Yip SK, Chan A, Pang S, Leung P, Tang C, Shek D, et al. The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function. Am J Obstet Gynecol 2003;188: Li RH, Lo SS, Teh DK, Tong NC, Tsui MH, Cheung KB, et al. Impact of common contraceptive methods on quality of life and sexual function in Hong Kong Chinese women. Contraception 2004;70: Cho SR, Park ES, Park CI, Na SI. Characteristics of psychosexual functioning in adults with cerebral palsy. Clin Rehabil 2004;18: Ferrero S, Esposito F, Abbamonte LH, Anserini P, Remorgida V, Ragni N. Quality of sex life in women with endometriosis and deep dyspareunia. Fertil Steril 2005;83: Ferrero et al. Sexual life in women with uterine myomas Vol. 86, No. 5, November 2006