Hum. Reprod. Advance Access originally published online on December 20, 2006
Human Reproduction 2007 22(4):1142-1148; doi:10.1093/humrep/del465
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Deep dyspareunia and sex life after laparoscopic excision of endometriosis
Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Genoa, Italy
1 To whom Correspondence should be addressed at: Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132, Genoa, Italy. E-mail: simone.ferrero{at}fastwebnet.it
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Abstract |
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BACKGROUND: Among subjects with endometriosis and deep dyspareunia (DD), those with endometriosis of the uterosacral ligament (USLE) have the most severe impairment of sexual function. This study examines the effect of laparoscopic excision of endometriosis on DD and quality of sex life.
METHODS: This observational cohort prospective study included 68 women with endometriosis suffering DD (intensity of pain 
6 on a 10-cm visual analogue scale). Patients underwent laparoscopic full excision of endometriosis. Following surgery, they were asked to use nonhormonal contraception devices. Before surgery, at 6- and at 12-month follow-up, patients answered a self-administered questionnaire based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory.
RESULTS: At 6- and 12-month follow-up, women with and without USLE had significant improvement in DD. Subjects with USLE reported increased variety in sex life, increased frequency of intercourse, more satisfying orgasms with sex, relaxing more easily during sex and being more relaxed and fulfilled after sex. Similar improvements were observed among women without USLE; however, for some variables statistical significance was not reached.
CONCLUSIONS: Surgical excision of endometriosis improves not only DD but also the quality of sex life.
Key words: deep dyspareunia/endometriosis/laparoscopy/sex life/uterosacral ligament
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Introduction |
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Pain is one of the major concerns of women with endometriosis and it can affect quality of life in numerous ways. Dyspareunia with deep penetration is a frequent component of endometriosis associated-pain. It affects between 60% and 79% of the patients undergoing surgery (Fauconnier et al., 2002
; Chopin et al., 2005; Ferrero et al., 2005; Nardo et al., 2005) and between 53% and 90% of those using medical therapies (Fedele et al., 2001; Vercellini et al., 2002). More than 50% of women with endometriosis have suffered deep dyspareunia (DD) during their entire sex lives (primary DD) (Ferrero et al., 2005).
When dyspareunia is referred to the rectum or lower sacrococcygeal area, it suggests rectovaginal or uterosacral ligament involvement (Howard, 2000). In particular, several studies correlated DD with the presence of endometriosis of the uterosacral ligaments (USLE) (Porpora et al., 1999; Fauconnier et al., 2002). This correlation is consistent with the presence of a considerable amount of nerve tissue within the uterosacral ligaments (Campbell and Arbor 1950; Butler-Manuel et al., 2000; Butler-Manuel et al., 2002); dyspareunia may be related to the stimulation of pain fibers by traction of scarred inelastic tissues (Fauconnier et al., 2002) and by pressure on endometriotic nodules embedded in fibrotic tissues. Furthermore, it is known that neural invasion by endometriotic lesions is correlated with the intensity of pain (Anaf et al., 2000).
Dyspareunia has been associated with a negative attitude toward sexuality, anxiety and avoidance of intercourse (Meana et al., 1997; Jones et al., 2004). Women with dyspareunia, not surprisingly, have lower frequency of intercourse and lower levels of desire and arousal and experience fewer orgasms (Laumann et al., 1999).
We previously demonstrated that sexual life is severely impaired among subjects with endometriosis suffering DD (Ferrero et al., 2005). In particular, women with USLE have the most severe impairment of sexual function, having higher intensity of pain and less satisfying orgasms than subjects without this type of lesion (Ferrero et al., 2005).
Several studies demonstrated that both laparoscopic excision of endometriotic nodules (Reich et al., 1991; Chapron et al., 1999; Garry et al., 2000; Abbott et al., 2004; Thomassin et al., 2004) and medical therapies (Crosignani et al., 1996; Fedele et al., 2001; Vercellini et al., 2002; Zupi et al., 2004; Abbamonte et al., 2005; Crosignani et al., 2006; Vercellini et al., 2005; Schlaff et al., 2006) are effective in the treatment of DD; however, the quality of sexual life after medical or surgical treatment of endometriosis has not been deeply investigated. In a recent observational cohort study (Ferrero et al., in press), we proved that laparoscopic full excision of endometriosis combined with 6 months of post-operative triptorelin (GnRH agonist) administration not only effectively treat DD but also improves the quality of sex life. Although the post-operative GnRH analogue administration may delay recurrence after surgery (Hornstein et al., 1997; Vercellini et al., 1999), patients included in our study underwent a combined surgical and medical therapy; therefore, it was not possible to define the specific role of laparoscopic excision of endometriosis on the efficacy of treatment.
The current study aims to examine DD and quality of sex life in women who underwent complete laparoscopic excision of endometriosis and did not receive any post-operative medical treatment.
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Materials and methods |
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This observational cohort prospective study included women with endometriosis suffering DD who underwent laparoscopy at our institution. All patients underwent surgery because of pain symptoms related to the presence of endometriosis (dysmenorrhoea, nonmenstrual pelvic pain, DD, dyschezia).
Only sexually active women (having had sexual intercourse in the past 12 months and at least one intercourse in the past month) with suspected endometriosis were invited to participate to the study. Before invitation to participate in the study, patients were asked to rate the intensity of DD by using a 10-cm visual analogue scale (VAS); the left extreme represented the absence of pain, and the right extreme represented the worst possible pain. Only women having intensity of DD 6 on the VAS scale were included in the study. Infertile patients and women who underwent bowel resection for endometriosis were excluded from the study.
None of the patients had used oral contraceptives or progestagens in the 2 months before surgery, or GnRH analogues or danazol (synthetic form of testosterone) in the 6 months before laparoscopy. No patient had signs of pelvic inflammatory disease at the time of surgery. No patient had interstitial cystitis; when symptoms suggestive of interstitial cystitis (pressure, frequency, nocturia and urgency without dysuria) were present, this condition was ruled out on the basis of cystoscopic findings. All women included in the study were heterosexual.
If after surgery patients did not want to conceive, they were asked to use nonhormonal contraception devices for 1 year.
The study was reviewed and approved by the local Institutional Review Board. The aim of the study was explained to patients; in particular, they were informed that the use of nonhormonal contraception devices following surgery was important to determine the effects of surgery on sexual life. A written informed consent was signed by the patients enrolled in the study.
Surgical treatment
SAll women were operated by the same surgeon (R.V.); during surgery, all visible endometriotic lesions were removed. The extent of endometriosis was scored according to the revised classification of the American Fertility Society (rAFS) (American Fertility Society, 1985). The location of all endometriotic lesions was recorded; in particular, patients were classified according to the presence or absence of USLE independently from the presence and extent of other endometriotic lesions. All the specimens removed during surgery were histologically examined.
Evaluation of DD and sexual function
DD was defined as genital pain on deep penetration. The presence of superficial dyspareunia occurring in or around the vaginal entrance and characterized by discomfort early in intercourse was not evaluated in the current study.
On the day before surgery, during the hospital stay, patients were invited to participate to the study by a female doctor (A.L.H.). Patients agreeing to participate in the study were informed that data were used for research and that a post-operative follow-up would have been performed. Each patient answered a self-administered sexual function questionnaire in a silent room where she was alone. The questionnaire was returned to the doctor in a sealed envelope; a reference number (and not the name of the patient) was written on the questionnaire to identify the case. Final inclusion in the study was performed at the time of post-operative control (about 7 days after surgery), when the definitive histological diagnosis of endometriosis was available.
The sexual function questionnaire was previously described (Ferrero et al., 2005; Ferrero et al., in press). This questionnaire is based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory (DSFI) (Derogatis and Melisaratos, 1979). The DSFI is a multidimensional measure of various aspects of psychological and sexual function, which comprises 10 subscales. Single subscales can be chosen to suit specific research design; the Sexual Satisfaction Subscale consists of nine items reflecting the individual level of sexual fulfilment. The DSFI has been found to have high internal and test–retest reliability as well as discriminative validity (Derogatis and Melisaratos, 1979; Herold, 1985). Additional questions were created to evaluate the characteristics of sex life and DD. All questions were answered on a 6-point Likert's scale, where 1 = ‘strongly disagree’ and 6 = ‘strongly agree’, the other anchor points were moderately and mildly disagree and agree.
Patients were also asked to rate their overall level of sexual satisfaction on a 9-point scale anchored at the lower extreme by ‘could not be worse’ and at the upper limit by ‘could not be better’ (Global Sexual Satisfaction Index, GSSI).
Patients were asked to answer all the questions with respect to the two months before surgery.
In addition, all patients answered questions on marital status, years of education and age at first sexual intercourse.
Follow-up was performed at 6 and 12 months from surgery during follow-up consultation at our clinic.
Statistical analysis
Statistical analysis was performed by using the Mann–Whitney U-test and 
2-test. A post-hoc intention-to-treat (ITT) analysis was performed. The intent-to-treat population included all patients who underwent laparoscopy (Figure 1), the end-point was an improvement in the intensity of DD by 4 points on the VAS scale. A Bonferroni correction was applied to the significance levels obtained in order to determine whether the observed significant differences in characteristics of sex life may have occurred due to multiple analyses. Calculations were performed using the Statistical Package for the Social Sciences (SPSS) software (release 10.0.5, SPSS Inc., Chicago, IL, USA). A P value <0.05 was considered statistically significant.
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Results |
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Of the 100 sexually active women approached for the study, 73 accepted to participate, yielding a response rate of 73.0%. Two women did not have surgical/histological confirmation of endometriosis. Two patients conceived before the 6-month follow-up and one patient started oral contraception at 3 months from surgery; these patients were excluded from the study.
The remaining 68 women represent the study population; their demographic characteristics are listed in Table I. Fifty-nine women (86.8%) had rASF stage III–IV and 9 women had rASF stage I–II. Forty-four (64.7%) women had USLE. Before surgery, the mean ( ± SD) intensity of DD in the study population was 7.6 ± 1.1; subjects with USLE had significantly higher intensity of pain than women without this type of lesion (P = 0.010). No significant difference was observed in the intensity of DD among subject with monolateral (n = 28; pain intensity, 7.8 ± 1.1) and bilateral (n = 16; pain intensity, 8.0 ± 1.1) USLE (P = 0.608).
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Only 52 patients completed the 12-month follow-up because 7 women conceived, 6 started oral contraception, two women did not have a sexual partner at one year from surgery and one woman was lost at follow-up.
At both 6- and 12-month follow-up, a significant improvement in the intensity of DD was observed in subjects with and without USLE (Table II). At 12-month follow-up, 79.4% (27/34) of women with USLE and 77.8% (14/18) of women without USLE had an improvement in the intensity of DD 4 points on the VAS scale. At 12-month follow-up, 79.4% (27/34) of women with USLE and 77.8% (14/18) of woman without USLE had an improvement in the intensity of DD 4 points on the VAS scale; among the other patients, only two women with USLE and one woman without USLE had the intensity of DD > 7.
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For the ITT analysis, an improvement in the intensity of DD
4 points on the VAS scale at 12-month follow-up was achieved in 56.2% of the population (41/73), in 58.7% (27/46) of the subjects with USLE and in 56.0% (14/25) of those without USLE. Significant improvements in sex life were observed at both 6-month and 12-month follow-up in subjects with USLE (Table III); these patients had increased variety in sexual life, increased frequency of intercourse, relaxed easier during sex, had more satisfying orgasms with sex and were more relaxed and fulfilled after sex. Similar improvements were observed among women without USLE (Table IV), however for most variables statistical significance was not reached possibly due to the limited number of cases at 12-month follow-up (n = 18) and to the Bonferroni correction for multiple comparisons. Before surgery, 57.4% of the women (39/68) had frequently to interrupt the intercourse because of pain; at 12-month follow-up only 7.7% of the patients (4/52) reported this complaint (P < 0.001).
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Significant improvements in the GSSI were observed at 6-and 12-month follow-up both in women with and without USLE (Figure 2).
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Discussion |
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This prospective study demonstrates that the complete laparoscopic excision of endometriotic lesions not only decreases the prevalence and intensity of DD, but also improves the quality of sexual life. Over 75% of the patients who completed the 12-month follow-up reported significant improvements in the intensity of DD (
4 points on the VAS scale) independently from the presence of USLE at surgery. These findings were limited by the number of patients (n = 21, 28.8%) who dropped out of the study, mainly because they conceived or desired to begin oral contraception. However, a post-hoc ITT analysis proved the efficacy of surgery at 12-month follow-up in at least 55% of the subjects.
Several improvements in sexual function were observed; they were demonstrated not only by the Sexual Satisfaction Subscale of the DSFI (which reveals the respondent's quality of sexual functioning in psychometric terms) but also by the GSSI (which reflects the individual's subjective perception of her sexual behaviour). Improvements in sexual life were observed in women with USLE and, at a lower extent, in those without USLE; this finding suggests that lesions of the uterosacral ligament are not the only determinants of DD in women with endometriosis. Recto-vaginal endometriotic lesions and adhesions (periovarian or in the cul-de-sac) may contribute to painful intercourse. After surgery, women with USLE, but not those without this type of lesions, reported an increased variety in sexual life. This observation suggests that USLE may determine DD particularly when patients have intercourse in positions that increase the traction of the uterosacral ligament and the pressure on the nodules. Steege et al. (2005) suggested that the cross-wise position may facilitate intercourse in women with endometriosis suffering DD because it allows ready control over angle and depth of vaginal penetration.
Our findings are in line with previous studies documenting significant improvements in DD after surgical excision of endometriosis (Redwine and Wright, 2001; Abbott et al., 2004; Angioni et al., 2006). Recently, in a series of 104 women with endometriosis suffering DD, Chopin et al. (2005) reported a significant improvement of pain (over 4 points on a VAS scale) at the median follow-up of 3.3 years from surgery. Although several studies investigated the effect of medical and surgical therapy on DD; little attention has been given to the changes in sexual function after medical or surgical treatment.
Vercellini et al. (2002) used the revised Sabbatsberg Sexual Rating Scale to compare the effect of cyproterone acetate and contraceptive pill on sex life after conservative surgery for symptomatic endometriosis. After 6 months of treatment, a mild improvement of sexual life was observed but no significant difference was detected between the two treatment groups. A limitation of the study was the fact that, although this self-administered questionnaire evaluates various aspects of sexual life (including libido, arousal or pleasure, orgasm capacity and satisfaction), no details were provided on the characteristics of sex life and only the total scores were reported.
In a prospective study investigating the effect of radical laparoscopic excision of endometriosis on quality of life indicators, Garry et al. (2000) used a sexual activity questionnaire developed by Thirlaway et al. (1996) to investigate the impact of long-term tamoxifen treatment on the sexual functioning of women at high risk of developing cancer. The authors observed that the excision of endometriotic lesions significantly improved quality of sexual function at 4-month follow-up. These observations were subsequently confirmed by the same authors in the post-operative follow-up of 39 patients who underwent full excisional surgery for endometriosis (Abbott et al., 2004). However, the questionnaire used in these two studies investigates only three aspects of sexual life: pleasure from sexual intercourse, discomfort during sexual intercourse and habit.
We are aware that our study has some limitations. Patients included in the study underwent laparoscopy in a referral centre for the treatment of endometriosis, and not surprisingly over 85% of the patients had rASF stage III–IV. Obviously, the characteristics of sexual life of this group of women may not be identical to those of all patients with endometriosis. Another possible criticism of our study is the fact that the determination of sexual function using a questionnaire may be difficult, and we did not use the complete DSFI which has been psychometrically validated (Derogatis and Melisaratos, 1979; Herold, 1985). The length of the questionnaire, 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, followed by the GSSI and by additional questions on the characteristics of DD; this questionnaire has previously been used in other studies (Ferrero et al., 2005; Ferrero et al., in press). A further possible criticism concerning our study is that this was not a randomized placebo-controlled study; therefore, a placebo effect of surgery on DD and sexual life cannot be excluded. However, it seems unlikely that this placebo effect may persist at one year from surgery invalidating the results.
A strength of our study is that the patients using hormonal contraception were excluded from the analysis. This exclusion criterion is particularly relevant because oral contraception not only can improve DD in women with endometriosis but it can also affect sexual function (Vercellini et al., 2002; Caruso et al., 2005; Guida et al., 2005; Vercellini et al., 2005).
In conclusion, the current study provides evidence that surgical removal of endometriotic lesions not only improves DD but also the quality of sex life. Future investigations should determine whether these improvements persist at long-term follow-up. In addition, it would be interesting to compare the improvements in quality of sexual life determined by surgery with the effects of medical treatment alone.
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References |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Abbamonte LH, Ferrero S, Anserini P, Remorgida V, Ragni N. (2005) Letrozole in endometriosis: efficacy and side effects. Hum Reprod 20:Suppl_1i68.[CrossRef]
Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. (2004) Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 82:878–884.[CrossRef][ISI][Medline]
American Fertility Society. (1985) Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 43:351–352.[Medline]
Anaf V, Simon P, El Nakadi I, Fayt I, Buxant F, Simonart T, Peny MO, Noel JC. (2000) Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules. Hum Reprod 15:1744–1750.
Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, Melis GB. (2006) Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up. Hum Reprod 21:1629–1634.
Butler-Manuel SA, Buttery LD, A'Hern RP, Polak JM, Barton DP. (2000) Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: the nerve content of the uterine supporting ligaments. Cancer 89:834–841.[CrossRef][ISI][Medline]
Butler-Manuel SA, Buttery LD, A'Hern RP, Polak JM, Barton DP. (2002) Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments. J Soc Gynecol Investig 9:47–56.[ISI][Medline]
Campbell R and Arbor A. (1950) The anatomy and histology of the sacrouterine ligaments. Am J Obstet Gynecol 59:1–12.[ISI][Medline]
Caruso S, Agnello C, Intelisano G, Farina M, Di Mari L, Sparacino L, Cianci A. (2005) Prospective study on sexual behavior of women using 30 microg ethinylestradiol and 3 mg drospirenone oral contraceptive. Contraception 72:19–23.[CrossRef][ISI][Medline]
Chapron C, Dubuisson JB, Fritel X, Fernandez B, Poncelet C, Beguin S, Pinelli L. (1999) Operative management of deep endometriosis infiltrating the uterosacral ligaments. J Am Assoc Gynecol Laparosc 6:31–37.[Medline]
Chopin N, Vieira M, Borghese B, Foulot H, Dousset B, Coste J, Mignon A, Fauconnier A, Chapron C. (2005) Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol 12:106–112.[ISI][Medline]
Crosignani PG, De Cecco L, Gastaldi A, Venturini PL, Oldani S, Vegetti W, Semino A, La Commare P, Vercellini P. (1996) Leuprolide in a 3-monthly versus a monthly depot formulation for the treatment of symptomatic endometriosis: a pilot study. Hum Reprod 11:2732–2735.
Crosignani PG, Luciano A, Ray A, Bergqvist A. (2006) Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain. Hum Reprod 21:248–256.
Derogatis LR and Melisaratos N. (1979) The DSFI: a multidimensional measure of sexual functioning. J Sex Marital Ther 5:244–281.[ISI][Medline]
Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Breart G. (2002) Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 78:719–726.[CrossRef][ISI][Medline]
Fedele L, Bianchi S, Zanconato G, Portuese A, Raffaelli R. (2001) Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis. Fertil Steril 75:485–488.[CrossRef][ISI][Medline]
Ferrero S, Esposito F, Abbamonte LH, Anserini P, Remorgida V, Ragni N. (2005) Quality of sex life in women with endometriosis and deep dyspareunia. Fertil Steril 83:573–579.[CrossRef][ISI][Medline]
Ferrero S, Abbamonte LH, Parisi M, Ragni N, Remorgida V. Dyspareunia and quality of sex life after laparoscopic excision of endometriosis and postoperative administration of triptorelin. Fertil Steril (in press), in press.
Garry R, Clayton R, Hawe J. (2000) The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 107:44–54.[Medline]
Guida M, Di Spiezio Sardo A, Bramante S, Sparice S, Acunzo G, Tommaselli GA, Di Carlo C, Pellicano M, Greco E, Nappi C. (2005) Effects of two types of hormonal contraception—oral versus intravaginal—on the sexual life of women and their partners. Hum Reprod 20:1100–1106.
Herold ES. (1985) Review of Derogatis Sexual Functioning Inventory. In Mitchell JV (Ed.). 9th Mental Measurement Year Book(University of Nebraska Press, Lincoln, (NE)) pp. 453–455.
Hornstein MD, Hemmings R, Yuzpe AA, Heinrichs WL. (1997) Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis. Fertil Steril 68:860–864.[CrossRef][ISI][Medline]
Howard FM. (2000) Endometriosis and endosalpingiosis. In Howard FM, Perry CP, Carter JE, El-Minawi AM, Li RZ (Eds.). Pelvic pain, Diagnosis and Management(Lippincott Williams & Wilkins, Philadelphia) pp. 125–150.
Jones G, Jenkinson C, Kennedy S. (2004) The impact of endometriosis upon quality of life: a qualitative analysis. J Psychosom Obstet Gynaecol 25:123–133.[CrossRef][Medline]
Laumann EO, Paik A, Rosen RC. (1999) Sexual dysfunction in the United States: prevalence and predictors. JAMA 281:537–544.
Meana M, Binik YM, Khalife S, Cohen DR. (1997) Biopsychosocial profile of women with dyspareunia. Obstet Gynecol 90:583–589.[Abstract]
Nardo LG, Moustafa M, Gareth Beynon DW. (2005) Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator. Fertil Steril 83:735–738.[CrossRef][ISI][Medline]
Porpora MG, Koninckx PR, Piazze J, Natili M, Colagrande S, Cosmi EV. (1999) Correlation between endometriosis and pelvic pain. J Am Assoc Gynecol Laparosc 6:429–434.[CrossRef][ISI][Medline]
Redwine DB and Wright JT. (2001) Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril 76:358–365.[CrossRef][ISI][Medline]
Reich H, McGlynn F, Salvat J. (1991) Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 36:516–522.[ISI][Medline]
Schlaff WD, Carson SA, Luciano A, Ross D, Bergqvist A. (2006) Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril 85:314–325.[CrossRef][ISI][Medline]
Steege JF, Lamvu G, Zolnoun D. (2005) Treatment of pain associated with endometriosis. In Sutton C, Jones K, Adamson GD (Eds.). Modern Management of Endometriosis(Taylor & Francis, London, UK) pp. 273–287.
Thirlaway K, Fallowfield L, Cuzick J. (1996) The Sexual Activity Questionnaire: a measure of women's sexual functioning. Qual Life Res 5:81–90.[CrossRef][ISI][Medline]
Thomassin I, Bazot M, Detchev R, Barranger E, Cortez A, Darai E. (2004) Symptoms before and after surgical removal of colorectal endometriosis that are assessed by magnetic resonance imaging and rectal endoscopic sonography. Am J Obstet Gynecol 190:1264–1271.[CrossRef][ISI][Medline]
Vercellini P, Crosignani PG, Fadini R, Radici E, Belloni C, Sismondi P. (1999) A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis. BJOG 106:672–677.[CrossRef]
Vercellini P, De Giorgi O, Mosconi P, Stellato G, Vicentini S, Crosignani PG. (2002) Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis. Fertil Steril 77:52–61.[CrossRef][ISI][Medline]
Vercellini P, Pietropaolo G, De Giorgi O, Pasin R, Chiodini A, Crosignani PG. (2005) Treatment of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate. Fertil Steril 84:1375–1387.[CrossRef][ISI][Medline]
Zupi E, Marconi D, Sbracia M, Zullo F, De Vivo B, Exacustos C, Sorrenti G. (2004) Add-back therapy in the treatment of endometriosis-associated pain. Fertil Steril 82:1303–1308.[CrossRef][ISI][Medline]
Submitted on August 22, 2006; resubmitted on November 1, 2006; accepted on November 8, 2006.
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