Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates

Avrilynn Ding; Heather Noga; Katrina N Bouchard; Mohamed A Bedaiwy; Caroline Lee; Catherine Allaire; Natasha L Orr; Paul J Yong

doi:10.1093/jsxmed/qdae084

General Gynecology · Pelvic Pain

Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates

Ding A, Noga H, Bouchard KN, Bedaiwy MA, Lee C, Allaire C, Orr NL, Yong PJ

Published September 3, 2024 The journal of sexual medicine

DOI 10.1093/jsxmed/qdae084 PMID 39039031 PMC PMC11372072

RRM Academy Synopsis

Pain worsened by orgasm affected 14% of endometriosis surgery patients

About 14 out of 100 surgical patients with endometriosis reported pain worsened by orgasm. The registry study covered 358 patients at one referral center. Orgasm pain was linked to sore pelvic floor muscles and higher scores on a pain-sensitivity quiz. Uterine tenderness and adenomyosis showed no difference.

Key Findings

Of 358 participants, 49 (14%) had pain in the pelvis or lower belly over the past 3 months that orgasm made worse. The other 309 (86%) did not.
With orgasm pain, pelvic floor myalgia was more common (Cohen's h = 0.40, P = .01) and Central Sensitization Inventory scores were higher (Cohen's d = 0.60, P < .001).
Scores were higher for depression (PHQ-9; Cohen's d = 0.59, P < .001), anxiety (GAD-7; d = 0.48, P = .002) and sexual distress (FSDS-R; d = 0.68, P < .001).
Uterine tenderness and ultrasound evidence of adenomyosis showed no differences between the groups.
Ovarian endometriosis appeared in 52% of participants without orgasm pain and 35% of those with it. The gap was not significant after correction for multiple comparisons.

Interpretation

The EPPIC registry compared two groups at one referral center, so the results show association and cannot show cause. A single yes/no question defined the outcome, and only 49 participants reported the pain. The authors state that one tertiary center draws more severe symptoms, and that a larger sample may be needed to detect uterine links. The registry held no data on how often participants had orgasms or whether orgasms were partnered or solo. The authors call for further research on prevalence, impact and treatments.

RRM Context

Restorative reproductive medicine looks for the underlying causes of pelvic pain. The paper's introduction calls endometriosis pain multifactorial, with peripheral and central mechanisms. Surgical findings differed little between the groups. The authors add that surgery findings match pain symptoms only in part. Sore pelvic floor muscles and a sensitized nervous system sit alongside lesion anatomy as possible contributors.

Our editorial summary of this paper, not the article's abstract.

Abstract

Background

Pelvic pain worsened by orgasm is a poorly understood symptom in patients with endometriosis.

Aim

To assess the prevalence of pelvic pain worsened by orgasm in patients with endometriosis and explore its association with potential etiologic factors, including pelvic floor myalgia, uterine tenderness and adenomyosis, and central nervous system sensitization.

Methods

An analysis was done of a prospective data registry based at a tertiary referral center for endometriosis. Eligible participants were patients aged 18 to 50 years who were referred between January 1, 2018, and December 31, 2019, diagnosed with endometriosis, and subsequently underwent surgery at the center. Clinical features were compared between participants reporting worsening pelvic pain with orgasm and those without worsening pain with orgasm, including patient-reported variables, physical examination findings, and anatomic phenotyping at the time of surgery. Pelvic floor myalgia and uterine tenderness were assessed by palpation on pelvic examination, adenomyosis by ultrasound, and central nervous system sensitization via the Central Sensitization Inventory (range, 0-100).

Outcomes

Outcomes included pelvic or lower abdominal pain in the last 3 months that worsened with orgasm (yes/no).

Results

Among 358 participants with endometriosis, 14% (49/358) reported pain worsened by orgasm while 86% (309/358) did not. Pain with orgasm was significantly associated with pelvic floor myalgia (55% [27/49] vs 35% [109/309]; Cohen's h = 0.40, P = .01) and higher scores on the Central Sensitization Inventory (mean ± SD, 53.3 ± 17.0 vs 42.7 ± 18.2; Cohen's d = 0.60, P < .001) but not with uterine tenderness or adenomyosis. Other clinical features associated with pain with orgasm were poorer sexual health (higher scores: deep dyspareunia, Cohen's h = 0.60; superficial dyspareunia, Cohen's h = 0.34; and Female Sexual Distress Scale-Revised, Cohen's d = 0.68; all P < .05) and poorer mental health (higher scores: Patient Health Questionnaire-9, 12.9 ± 6.7 vs 9.1 ± 6.3, Cohen's d = 0.59, P < .001; Generalized Anxiety Disorder-7, 9.4 ± 5.6 vs 6.8 ± 5.5, Cohen's d = 0.48, P = .002). Anatomic findings at the time of surgery did not significantly differ between the groups.

Clinical Implications

Interventions targeting pelvic floor myalgia and central nervous system sensitization may help alleviate pain worsened by orgasm in patients with endometriosis.

Strengths and Limitations

A strength is that pain worsened by orgasm was differentiated from dyspareunia. However, pain with orgasm was assessed by only a binary question (yes/no). Also, the study is limited to a single center, and there were limited data on sexual function.

Conclusion

Pelvic pain exacerbated by orgasm in people with endometriosis may be related to concurrent pelvic floor myalgia and central sensitization.

Topics

General Gynecology › Pelvic Pain › Chronic Pelvic Pain · Endometriosis › Pathophysiology › Inflammation and Immunology · Sexual Health › Sexual Pain › Dyspareunia

Avrilynn Ding, Heather Noga, Katrina N Bouchard, Mohamed A Bedaiwy, Caroline Lee, Catherine Allaire, Natasha L Orr, Paul J Yong

A Ding, H Noga, K Bouchard, M Bedaiwy, C Lee, Cathy Allaire, Kate Allaire, C Allaire, N Orr, P Yong

PMID 39039031 39039031 DOI 10.1093/jsxmed/qdae084 10.1093/jsxmed/qdae084 Ding et al. 2024, Ding 2024

Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates

Pain worsened by orgasm affected 14% of endometriosis surgery patients

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

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