# Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?
## 4 Discussion  
In light of the BPS approach, the aim of the present study was to explore the impact of some cognitive and psycho-emotional factors on sexual functioning, comparing women with and without endometriosis. The two groups were similar in their sociodemographic characteristics with some significant differences. The first distinction concerned the relational status. The majority of women in both groups were in a relationship, while single women were less present in the endometriosis group. This difference might be due to the snowball methodology. Therefore, further studies with a larger number of participants and a better research design are needed. Another difference was the desire to have children, which seemed higher in women with endometriosis. This could be explained by the fact that endometriosis is often associated with infertility problems or difficulty conceiving [2]. Thus, women with endometriosis in our study might be more focused on the desire to become pregnant than women without the pathology [94]. The two groups differed significantly also for the self-declaration of having a sexual problem, where EG women reported suffering from sexual difficulties more than CG ones. This was an expected result since endometriosis is often associated with sexual problems [11; 21; 23; 35; 37]. Unexpectedly, just 24.1% of EG women referred to sexual health professionals or were undergoing treatment for these disorders at the time of the study. [PERSON] et al. [12], found similar results in a study on GP, suggesting that some factors may act as barriers for seeking help, such as thinking that sex is unimportant or that experiencing GP is normal for women, or that their sexual problems cannot be solved [10; 95; 96; 97; 98]. The presence of GPP emerged from the SF-MPQ where 68.96% of women with endometriosis reported having experienced painful symptoms during sexual activities in the last 6 months. In addition, pain intensity was significantly different between the two groups: patients had worse scores than controls. The presence of GPP was not surprising even though women with endometriosis in our study were undergoing a hormonal treatment, which usually helps to mitigate pain. These treatments are useful for relieving pain and improving sexual health only in DIE or in cases where painful symptoms are closely linked to specific sites of lesions [99]. Psycho-social factors could have influenced the worst sexual functioning and the highest GPP in the women who participated in this study, as already reported in previous studies [11; 99]. Regarding sexual functioning, no significant differences emerged between the two groups in FSFI scores. In fact, both groups' mean scores seem to indicate sexual dysfunctions (FSFI total score \(\leq\) 26.55). Sexual dysfunctions are very common in the female general population; a prevalence of 40-50% is estimated [100]. Moreover, the FSFI is strongly influenced by sexual activity that a woman had in the last month and to penetrative sexual intercourse; therefore, the results obtained could not represent the real women's experience of sexuality. Furthermore, it does not assess sexual distress. In fact, the occurrence of a sexual symptom by it-self is not enough to diagnose a sexual dysfunction; the presence of significant sexual distress is required [10; 11]. It follows that FSFI results alone do not provide a real indication about differences in sexual function between patients and controls. Pain was the only FSFI scale in which groups showed significant differences; women with endometriosis having the worst scores. These findings confirm previous research highlighting that dyspureunia is the most common disorder in women with endometriosis [13; 21; 23; 35; 36; 101]. As pointed out in the literature [41; 43], when sexual distress is measured, the prevalence of sexual dysfunctions in patients with endometriosis increases.