A disease in which implants of endometrial tissue spread throughout the pelvic viscera and their protective covering, the peritoneum. When examined microscopically, this ectopic tissue resembles the lining of the inner cavity of the uterus.

The tubes, ovaries, broad ligaments, omentum, and the posterior wall of the uterus may be involved by firm fibrous adhesions. There are even many instances of tying together omentum and bowel with the reproductive viscera into large pelvic masses.

The etiology of endometriosis has not been fully established. It would not serve the purposes of this text to enter into a detailed discussion of the subject. Although endometrial implants appear in many anatomical areas other than the pelvic viscera, consideration will be focused alone on local pelvic implants.

Even if there are no major adhesions in the pelvis, there are at least minor elements of continuous local peritoneal irritation. Endometrial nodules usually can be felt most effectively with simultaneous manual pelvic-rectal examination. Again, the pain created by intercourse is due to the constriction and immobilization of the peritoneum and the firming up of the soft tissues of the pelvis by adhesions.

The pelvic structures have progressively less facility to distend, expand, and move freely as the endometriosis progresses. There is consequently more local tissue resistance to involuntary vaginal expansion, uterine elevation, and male pelvic thrusting.

In all situations that create chronic irritation of the pelvic peritoneum, fixation of the uterus, or constriction of the vaginal barrel, pain with intercourse is a relatively constant finding.

Treatment for endometriosis
is either medical or surgical depending upon the degree of soft-tissue and pelvic visceral involvement. But once endometriosis has developed to a point at which there is significantly severe pain in response to coital activity, there must be definitive treatment of the condition, or the individual woman will have little hope of relief from the symptoms of progressively increasing dyspareunia.

There are three important sources for acquired dyspareunia following removal of the uterus for specific organ pathology.

(a) dyspareunia results from thoughtless surgical technique. Physicians, when performing a hysterectomy, may overlook the fact that the cervix enters the vagina through the superior wall of that organ.

When the wound in the vaginal barrel is repaired after removal of the cervix, if care is not taken to retain a superior position for the vaginal cuff, the scarred area, instead of being retained in the superior vaginal wall, may be pulled into the depth of the barrel by tissue constriction or by excessive folding or removal of vaginal tissue.

Postoperatively when the husband thrusts deeply into the vagina, the penis can come into contact with the resistant scarred area. There is little residual facility for involuntary vaginal distention in the area of the surgical scar.

Therefore, dyspareunia of significant proportion develops occasionally as a post surgical complication. Since this unfortunate result usually does not develop for months or even a year after surgery, the operating surgeon may never be made aware of the acquired dyspareunia.

(b) opportunity to acquire dyspareunia is occasioned by the surgical indications for removal of the ovaries at the time the uterus is removed, or for that matter, at any time. If post operative sex-steroid-replacement is not initiated, many women will develop senile changes in the vagina and, in time, secondary dyspareunia.

(c) dyspareunia after hysterectomy rarely comes to the attention of the operating surgeon. The etiology of the acquired dyspareunia may be subjective in origin. If the woman facing hysterectomy and/or removal of the ovaries is not reassured with her husband that there need not be reduction of sexual drive or orgasmic facility after surgery, her fantasy and her friends' "old wives' tales" may, by power of suggestion, create fears of sexual performance for the anxious woman.

If she feels that she is going to be castrated, and sex-steroid-replacement therapy is not explained and offered as indicated, she well may believe that after surgery there will be loss of ability to respond in a sexually effective manner in the future. What is worse, an uninformed husband may have similar concepts.

If anything, sexual responsivity should be higher shortly after than immediately before surgery. The pelvic pathology for which the hysterectomy or oophorectomy is indicated usually detracts from sexual effectiveness by creating a state of ill health which, in turn, reduces innate sexual tension.

When the offending condition is removed and the general state of health consequently improved, there usually is a reawakening of sexual interest. If women are not reassured before surgery, many presume that, in the future, intercourse will provide no return for them or for their husbands, or that intercourse will even be painful. Any woman has only to be sure that she will be distressed by future coital connection to take a long step toward acquired dyspareunia.

Syndrome of broad ligament
There are, of course, many factors other than the major ones of infection, endometriosis, post surgical objective and subjective complications, and the syndrome of broad-ligament laceration that create painful stimuli from irritated peritoneal and pelvic soft tissues in response to coital connection. These include tumors of the uterus, such as myomas (fibroids), ovarian cysts and solid tumors, and, carcinoma of the female reproductive tract.

Any of these tumor growths occasionally incite onset of the complaint of acquired dyspareunia. Those interested can find more definitive evaluations of this physiological source of dyspareunia in current gynecology textbooks.

Thus, the basic premise with which the Foundation approaches the problem of dyspareunia is one of elimination of possible pathological reasons for the complaint. If a woman complains of pain with intercourse, her complaint is accepted at face value, and steps are taken to identify the biophysical source of the coital distress.

The diagnosis of psychosomatic dyspareunia, unquestionably of moment in the sexual-response field, must be made by exclusion. To assign subjective origins to pelvic pain, regardless of the patient's personality structure, without definitive physical evaluation of the pelvis, can result in clinical mismanagement of patients.

Certainly there are times when, after every effort has been made to establish physical source of the pelvic pain, subjective etiology for the complaint will be considered strongly. But the initial bio physical investigative effort must be made by competent authority.