# Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?
## 1 Introduction  
Endometriosis is a chronic gynecological disease characterized by the presence and the growth of endometrial-like tissue outside the uterine cavity [1]. Approximately 7-10% of reproductive-aged women appear to be affected by endometriosis, although the exact prevalence rate remains unknown [2, 3]. Chronic pelvic pain (CPP)--which includes dysmerorrhea, dyspareunia, dyschezia, and dysuria--is the most common symptom in women with endometriosis and occurs up to 80% of the cases [4]. However, symptomatology can differ from woman to woman: about 20-25% of patients are asymptomatic, and about 30-50% suffer from infertility [2, 5, 6]. Endometriosis lesions are anatomically classified as superficial peritoneal endometriosis (SUP); ovarian endometriosis (OMA); deep infiltrating endometriosis (DIE) [7]. Etiopathogenesis is still controversial [8], and no definitive cure is available [9]. Because of its symptomatology, risk of infertility, delayed diagnosis, lack of definitive treatment, recurrence of the condition, and impact on female identity, endometriosis has a profound impact on quality of life (QoL) [10, 11, 12, 13, 14, 15, 16, 17, 18, 19]. It affects patients' daily activities, education, employment, relationships, and sexuality [11, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27]. Mental health maybe severely compromised [11; 28; 29]: anxiety and depression are the most common problems reported by women [14; 17; 19; 28; 29; 30; 31; 32]. Samatization, alexithymia, interpersonal sensitivity, obsessive compulsive, and phobic anxiety are also described [28; 29; 30; 33; 34]. Regarding sexuality, dyspareunia is the most common complaint [11; 13; 21; 23; 35], affecting 32-70% of patients [36]; however, difficulties in all phases of sexual response are widely reported in the literature [10; 11; 18; 21; 23; 37; 38; 39; 40; 41; 42]. The prevalence of sexual problems increases when sexual distress is considered; which is observed in women with endometriosis more than sexual symptoms [11; 43; 11]. The pain appears to play an essential role in patients' sexual health [10; 11; 13; 14; 15; 16; 17; 19; 21; 22; 36; 44; 45; 46; 47; 22; 36; 48; 49]. In this regard, the biopsychosocial (BPS) model suggests the consideration of the different aspects--biological, psychological, and socio-relational--that, interacting with each other, could influence a patient's health [12; 21; 23; 34; 36; 39; 40; 41; 44; 48; 50; 51; 52; 53; 54]. Moreover, pain is not only characterized by a somatic component but also involves cognitive and emotional components. A \"vicious circle\" in the experience of pain, with the mutual involvement and interaction of biopsychosocial factors, has been assumed in recent years [29; 30; 32; 55; 56]. In light of this consideration, interest in the association between cognitive and emotional factors, sexual dysfunctions and sexual distress, and pain perception in women with endometriosis has grown exponentially. Negative beliefs predict sexual distress beyond pain symptoms [43]. Specifically, women with negative cognitions might cope negatively with the stressor (e.g., pain and sexual problems) and might be more sexually distressed than those without dysfunctional beliefs. In addition, negative cognitions (e.g., pain catastrophizing) [57; 58; 59; 60], specific coping styles (e.g., passive) [59; 60], personality or temperament traits (e.g., worry traits, deep pessimistic concerns, external locus of control, negative beliefs about pain control) [61; 62; 60], presence of anxious and depressive symptoms [32; 57; 60], and suppression of emotions [59] could negatively affect the experience of pain. Although the literature about the influence of cognitive and emotional factors on sexual function and pain perception has increased in recent years, the presence of some aspects, such as cognitive sexual schemas, beliefs, automatic thoughts, and emotions toward sexuality, remain unexplored in women with endometriosis.