Dyspareunia and infertility concerns with endometriosis

In women with endometriosis, there is a modest association between superficial dyspareunia and concerns about infertility, whereas this connection is not present between deep dyspareunia and infertility concerns, according to a cross-sectional study. Published by Canadian researchers in Sexual Medicine, the report also found that the association between superficial dyspareunia and infertility concerns persisted, even after adjusting for potential confounders.

Said principal investigator Paul Yong, MD, PhD, an assistant professor of ob/gyn at the University of British Columbia in Vancouver, Canada,“I am interested in the different types of dyspareunia in endometriosis, such as deep versus superficial, and their different causes, impacts and treatments. The goal is to have a more personalized understanding of endometriosis dyspareunia, rather than simply grouping all patients together.”

The authors noted that deep dyspareunia is a major symptom of endometriosis, but that up to 40% of women with endometriosis may be afflicted by comorbid superficial dyspareunia.

Methods
The study consisted of consenting patients who were newly referred or re-referred to the BC Women's Center for Pelvic Pain and Endometriosis, in Vancouver, between 2013 and 2017. Data on the 300 reproductive-aged participants were obtained from the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC) prospective data registry.

Findings
Odds of infertility concerns did not increase with severity of deep dyspareunia: odds ratio (OR) = 1.02; 95% confidence interval (CI): 0.95 to 1.09 (P = 0.58). However, they increased slightly with severity of superficial dyspareunia: OR = 1.09; 95% CI: 1.02 to 1.16 (P = 0.011).

Furthermore, the relationship between superficial dyspareunia and infertility concerns persisted after adjusting for endometriosis-specific factors, infertility risk factors, reproductive history and demographic characteristics: adjusted odds ratio (AOR) = 1.14; 95% CI: 1.06 to 1.24 (P < 0.001). 

Four other factors in the model that were independently associated with increased infertility concerns were previous difficulty conceiving (AOR = 2.09; 95% CI: 1.04 to 4.19; P = 0.038), currently trying to conceive (AOR = 5.23; 95% CI: 2.77 to 9.98; P < 0.001), nulliparity (AOR = 3.21; 95% CI: 1.63 to 6.41; P < 0.001), and a younger age (AOR = 0.94; 95% CI: 0.89 to 0.98, P = 0.005).

Conclusions
“We were surprised by our findings,” Dr. Yong told Contemporary OB/GYN. “We expected that both types of dyspareunia would be independently associated with patients’ concerns about their fertility, since they are unique types of pain and we previously found that both types have independent impacts on sexual quality-of-life.”

What was even more unexpected, however, was that superficial dyspareunia was more important to patients than deep dyspareunia, “given that endometriosis is traditionally seen as a cause of deep dyspareunia,” Dr. Yong said. “This points to the fact that superficial dyspareunia can occur in women with endometriosis, and can be clinically very significant in some cases.”

It is crucial that clinicians assess for both deep and superficial dyspareunia in patients with endometriosis, according to Dr. Yong. “In those with superficial dyspareunia, it may be worth screening for concerns about fertility and proactively addressing those concerns,” he said, adding that women experiencing introital dyspareunia may have difficulty achieving penetrative intercourse.

For future research studies on endometriosis, outcome measures should differentiate between deep and superficial dyspareunia, “as they are different entities,” Dr. Yong said. “If they are not differentiated, it is possible that treatment effects on a specific type of dyspareunia may not be detected.”