Introduction

Endometriosis is one of the most common chronic inflammatory diseases in which endometrial-like tissue grows outside the uterine cavity (1). This disease has various symptoms including dysmenorrhea, pelvic chronic pain, dyspareunia, dyschezia, dysuria, and infertility (2). Based on WHO endometriosis affects roughly 10% (190 million) of reproductive age women and girls globally (3). In the study conducted by Kadivar et al. (2012)  in Iran, the prevalence of extrapelvic endometriosis was reported as 14.8% (4). The economic burden caused by endometriosis is very high and is similar to other chronic diseases such as diabetes, Crohn's disease, and rheumatoid arthritis (5).

Definitive diagnosis of endometriosis is only possible through laparoscopy and histological confirmation. Currently, there is no cure for endometriosis. Treatment is only used to relieve symptoms. Treatment options include the administration of progesterone to prevent disease progression and surgery to remove adhesions through incision and destructive treatment (6-7). Endometriosis can significantly affect the reproductive health (6). One of the important aspects of reproductive health is sexual function (8). According to the study by Tavakol et al. (2011), all the variables related to women's sexual function are related to their sexual satisfaction (9). Sexual satisfaction as a part of sexual relations is defined as the analysis of sexual behavior based on pleasure in each person (10). According to the study of Montanari et al. (2013), women with severe endometriosis had disorders in orgasm and sexual satisfaction (11).

Chronic diseases can affect the sexual satisfaction (12). Recent studies show that sexual satisfaction of the sexual partner of women with endometriosis is lower than that of healthy women (13). The findings show that when the problems caused by endometriosis primarily involve pelvic pain, treatment aimed to relieve the clinical symptoms is not enough, and also these patients can significantly benefit from psychological interventions (14). Therefore, a psychological approach to manage endometriosis is an important therapeutic tool. It may also reduce the symptoms of depression caused by hormone therapy and strengthen women's skills in disease management (15). Cognitive-behavioral therapy (CBT) is a problem-based and time-sensitive approach to treatment that aims to reduce emotional distress and increase adaptive behavior in patients with a multitude of psychological and adjustment problems (16).

According to this approach, the individual's mentality resulting from his beliefs and attitude affects the information processing and leads to individual excitement and responses. Therefore, it seems that the person's ideas and thoughts about the problem form the type and intensity of worry (17). Among the existing psychological treatments, cognitive-behavioral therapy is less complicated in comparison with many treatment methods. Also, this type of intervention can be implemented in a shorter time frame; in addition, these interventions shape the style of healthy thinking and behavior in the form of systematic cognitive and behavioral programs in the lives of these patients (16,18). Also, cognitive-behavioral therapy is one of the most common techniques used in the treatment of sexual disorders (19-20). This method leads to a more positive attitude towards sexual relations and improves the sexual dysfunction of couples (21).

In the study of McCabe and colleagues, it was found that cognitive-behavioral therapy led to a positive attitude and thinking about sex, a more enjoyable sexual experience, improved sexual function in men and women, and reduced the probability of failure in sex (21). Fatehizadeh et al. (2013) reported that cognitive-behavioral counselling is an approach which affects women's sexual satisfaction (22). Boersen et al. (2021) in their survey, which investigated the views of patients with endometriosis regarding cognitive behavioral therapy after endometriosis surgical treatment, reported that these patients believe that CBT should be added to the standard treatment process of endometriosis as a group or individual form because CBT can improve quality of life (23).

It should be noted that group-based approaches may have advantages over individual therapy because the availability of therapists is limited. Group-based CBT may potentially be more cost-effective than individual CBT (24). In this regard, the need for counselling about reproductive and sexual health services is also part of the treatment and needs of patients with endometriosis (25). Therefore, considering the role of sexual satisfaction in marital life, quality of life, and mental health of individuals and consequently couples, as well as  the lack of studies in this field it is required to design such interventions to enhance sexual satisfaction of women with endometriosis. , Therefore, the current study was designed to determine the efficacy of group-based cognitive-behavioral counselling on sexual satisfaction of women with endometriosis.

Materials and Methods

This two-group clinical trial study with a pre-test-post-test design was conducted from March 2022 to May  on 99 women with endometriosis. The study was registered in Iranian Registry of Clinical Trials (IRCT) under code of IRCT IRCT20210919052516N1. The participants were all women with endometriosis who were referred to a  gynecological clinic as well as endometriosis clinic of an educational hospital in Mashhad, who were selected with the diagnosis of endometriosis and invited to participate in the research.

The required information was collected using Sampling was done by available method. In this study, , the participants by simple randomization and permutation blocks method was used to generate the sequence of random assignment of the subjects to the studied groups. The sequence of random allocation of subjects was done using Random Allocation Software and the block size of two. To the best of our knowledge, when performing this study, there was no similar study which examined the therapeutic effect of the intervention on reproductive health and sexual satisfaction to be used to determine the sample size. Therefore, the effect size formula, the error of 5%, the test power of 80%, and the effect size of 0.6 were used to calculate the sample size of 44 people in each group.

Therefore, according to the sample size calculated for the main variables of the study, the interventional nature of the study, and the probability of 20% drops, 52 subjects were considered for each group. Figure 1 displays the CONSORT flow diagram of participant enrollments. Finally, 51 women were in the intervention group while 48 women were in the control group.

The researcher executed all the procedures and interventions; thus,there was no possibility of blindness .The inclusion criteria were: written informed consent to participate in the study, women of reproductive age (15-49 years), marriage, lack of chronic psychiatric disorders in the woman and her husband (self-reported), lack of known chronic diseases in the woman and her husband, having sex, diagnosis of endometriosis based on history, physical examination and the clinical imaging by the physician, lack of accidents in the last 6 months in the woman and her husband, lack of addiction to tobacco and alcohol in woman and her husband, the absence of diseases affecting the sexual function of the woman and her husband, lack of menopause, and lack of history of pelvic surgery.

Exclusion criteria during the study included not participating in more than two counselling sessions and unwillingness to continue the intervention, no adverse events occurring during the study as well as receiving another educational-counselling program during the intervention period. In both intervention and control groups, after providing the necessary explanations regarding the objectives of the research and respecting the independence of individuals to participate in the research, the participants were asked to complete the informed consent form and then the pre-test was taken.

Data collection tools is a self-report tools included  sexual satisfaction scale for women (SSSW) (26). The tool was completed by both groups before, immediately, and one month after the last counselling session. The validity of the questionnaires in this study was confirmed by obtaining the opinion of seven members of the academic staff.

Meston and Trapnell (2005) (26) designed SSSW which has 30 questions and 5 dimensions: satisfaction (questions 1-6), communication (questions 7-12), compatibility (12-19), relational anxiety (questions 19-24) and personal anxiety (questions 25-30). The scoring system of SSSW is based on a 5-points Likert scale (from entirely agree to entirely disagree). Questions 1, 4, 5, 6, 9, 10, 11, 12 are scored reversely. The scores of each dimension are obtained from the total number of questions of that dimension. The total score is calculated as follows: (satisfaction + communication + compatibility + (relational anxiety + personal anxiety)/2); a higher score indicates more satisfaction. Cronbach's alpha coefficient was reported for the dimensions of the questionnaire up to 90%, for personal anxiety up to 74%, for communication dimension, and the total sexual satisfaction score up to 94%. The validity of the scale in Iran was confirmed by Roshan Chesli et al. (2013) through content validity. The reliability of the structure using confirmatory factor analysis and convergent-divergent reliability was applied to check the reliability. Also, the retest coefficients for the sexual satisfaction score and dimensions have been obtained from 73% to 97% (27). Therefore, the validity of this questionnaire has been confirmed in previous studies in Iran. In the current study, the reliabil

ity of the sexual satisfaction questionnaire was calculated by determining internal consistency (Cronbach's alpha). Cronbach's alpha for the sexual satisfaction questionnaire was 0.833, which indicates the internal reliability of the questionnaire.

The subjects in the control group only received routine care. For the intervention group, seven counselling sessions were held (average 6-8 people) by the researcher every week for 60-90 minutes each session. Seven virtual and group counselling sessions were conducted through Skyroom among counselors and clients.

Contents of the sessions are as follows:

Also, in the seventh session and one month after the end of the counselling sessions, the SSSW was completed as a post-test by the participants of the control and intervention groups.

After collecting the data, it was analyzed in two descriptive and analytical formats. Data analysis was done using SPSS software (version 25). P<0.05 was considered statistically significant. First, the Shapiro-Wilk test was used to check the normality of the data distribution of quantitative variables. Independent t-test/Mann-Whitney was employed to compare normal/abnormal quantitative variables in two groups; analysis of variance with repeated measures/Friedman test was used to evaluate the effect of counselling for normal/abnormal quantitative variables. Wilcoxon post hoc test was used for pairwise comparisons of data with non-normal distribution. Chi-square or Fisher's exact test was used to compare qualitative variables in two groups. Paired t/Wilcoxon was applied to evaluate the effect of counselling for normal/abnormal quantitative variables. Chi-square test was used to compare qualitative variables in two groups. Analysis of covariance was applied to control confounding variables.

Results

The mean age of the participants was 35.30 ± 5.60 years. Most of the participants in the study had university education (65%) and were housewives (57.1%). Moreover, 48.5% of women had a history of infertility and 34% had dyspareunia.

Only the variables of length of menstrual cycle, the number of pads used during menstruation, and the mean number of intercourses per week were significantly lower in the intervention group compared to the control group (P=0.008, P=0.001 and P=0.031, respectively), but the two groups were not significantly different in terms of other variables (P>0.05).

Also, the variables of the number of sexual relations with spouse from the beginning of the disease to the time of the interview (P=0.005) and the effect of endometriosis on sexual desire (P=0.001) were significantly different in the counselling and control groups, but the two groups were not significantly different in terms of other variables (P>0.05) (Tables 1 and 2).

Before the intervention, the mean total sexual satisfaction score in the counselling group was 83.0±25.5 and in the control group was 81.6±20.0, which did not show a statistically significant difference between the two groups (P=0.590). The mean total sexual satisfaction score in the counselling group immediately after

the intervention (102.6±12.4) was significantly higher than the control group (81.5±19.9) (P<0.001). One month after the intervention, the mean total score of sexual satisfaction in the counselling group (94.0±17.3) was significantly higher than the control group (81.6±19.4) (P=0.003).

The difference in the total score of sexual satisfaction immediately after the intervention compared to before the intervention increased by 19.9±16.7 in the counselling group and decreased by -0.1±1.5 in the control group (P<0.001).

The difference in the total score of sexual satisfaction one month after the intervention compared to before the intervention increased by 11.4±13.1 in the counselling group and by 0.0±2.3 in the control group, and this difference was statistically significant in the two groups (P<0.001).

The difference in the total score of sexual satisfaction one month after the intervention compared to immediately after the intervention decreased by -8.5±8.7 in the counselling group and increased by 0.0±1.7 in the control group, and this difference was statistically significant in the two groups (P<0.001).

Friedman's test showed a statistically significant difference between different measurements in the counselling group (P<0.001). The Wilcoxon post hoc test showed a significant difference immediately after the intervention compared to before the intervention (P<0.001); there was a significant difference one month after the intervention compared to before the intervention (P<0.001) and a significant difference one month after the intervention compared to immediately after the intervention (P<0.001). In the intragroup comparison of sexual satisfaction in the control group, the analysis of variance test with repeated measures showed no significant difference between the stages (P=0.930) (Table 3).

In terms of sexual satisfaction in the counselling group, in the satisfaction dimension of the questionnaire, there was a statistically significant difference in the scores of immediately after the intervention (25.7±3.5) and one month later (23.7±4.5) compared to the beginning of the study (20.2±7.4) (P<0.001).

In terms of communication dimension of the questionnaire, the scores obtained immediately after the intervention (26.1±3.7) and one month later (24.8±4.7) had a statistically significant difference compared to the beginning of the study (22.8±5.6) (P<0.001).

In terms of compatibility dimension of the questionnaire, the scores obtained immediately after the intervention (25.2±4.2) and one month later (23.2±5.5) had a statistically significant difference compared to the beginning of the study (20.4±8.1) (P<0.001).

In terms of personal anxiety dimension of the questionnaire, there was a statistically significant difference in the score immediately after the intervention (26.3±2.8) and one month later (23.9±4.2) compared to the beginning of the study (19.9±6.9) (P<0.001).

In terms of relational anxiety dimension of the questionnaire, the scores obtained immediately after the intervention (25.5±4.0) and one month later (22.3±5.5) had a statistically significant difference compared to the beginning of the study (19.4±7.2) (P<0.001). In the intragroup comparison in the control group, Friedman test in all dimensions showed no significant difference between the stages (Table 4).

Discussion

The current research was conducted with the aim of examining the efficacy of cognitive-behavioral counselling on  sexual satisfaction of women with endometriosis. The findings indicated that cognitive-behavioral counselling improves the mean sexual satisfaction score in women with endometriosis which indicates the effect of this counselling approach on sexual issues. Endometriosis is one of the most common chronic inflammatory diseases in women which has negative effects on the sexual function of affected women, and in general, the presence of chronic diseases is one of the most important factors that can affect sexual satisfaction (8).

Ferrero et al. (2005) have shown that the symptoms of endometriosis (especially pain, which was the main concern of the participants in our study) affect intimacy and especially sexual satisfaction of women. This issue may be related to the direct relationship between dyspareunia and decreased sexual satisfaction (more pain during intercourse, reduced number of intercourse, less satisfying intercourse) (28). The relationship between pain and sexual satisfaction can also be explained by the cognitive model theory of negative expectations of sexual experiences. This theory states that the experience of pain and loss of pleasure is reinforced by repeated experiences of pain. In addition, this relationship could be due to the theory of central sensitivity. Pain in patients with endometriosis can become independent and recur even in the absence of environmental stimulation. This could mean that pain associated with this disease, and not necessarily dyspareunia, can affect the sexual experience of an affected woman. Interestingly, women with dyspareunia continue to have sex despite pain indicating that this may be an attempt by these women to try to prove themselves in their ideal female image. These findings show that the partner's pleasure can be more important for many women than their own pleasure and well-being (29). Therefore, these findings are consistent with the results of the present study.

Elsayed et al. (2018) in an interventional study titled "Evaluation of the effect of educational intervention on the quality of life and sexual function in women with endometriosis" found that the educational program was effective on the quality of life and sexual function in women with endometriosis and statistically significant difference was observed in the intervention group before and after the intervention (30). Since all variables related to women's sexual function are related to their sexual satisfaction (9) and the educational intervention was able to be effective on the sexual function of women with endometriosis, these findings are in accordance with the results of the current research.

According to the research of Babakhani et al. (2018)  some incompatible thoughts, attitudes, and beliefs about different aspects of sex can affect a person's sexual activity and reaction to the stages of the sexual cycle. They also showed that cognitive-behavioral counselling sessions caused a significant increase in all behavioral fields and sexual function of women. Among the available psychological treatments, cognitive-behavioral therapy seems to be suitable for endometriosis, because this type of intervention is less complicated compared to many treatment methods, which makes it suitable for patients suffering from chronic pain diseases.

Moreover, this type of intervention can be implemented in a shorter time frame, and also, these interventions shape healthy thinking and behavior in the form of systematic cognitive and behavioral programs in the lives of these patients, even when considering the continuation of treatment and related costs, cognitive-behavioral therapy is cheaper than drug therapy (16, 18, 31). Also, cognitive-behavioral therapy is one of the most common techniques used in the treatment of sexual disorders (19,20). Since all the variables related to women's sexual function are related to their sexual satisfaction and the present study was able to increase the sexual satisfaction of women with endometriosis by holding cognitive-behavioral counselling sessions, it is consistent with the present study.

Fatehizadeh et al. (2013) showed that cognitive-behavioral counselling compared to solution-oriented counseling has a greater effect on women's sexual satisfaction. Therefore, counselling can be used to prevent and improve women's sexual problems in educational, counselling, and treatment centers (22). In the cognitive-behavioral therapy sessions, not only irrational beliefs are challenged by cognitive techniques such as thought injection and logical analysis, but also the person is trained in behavioral and coping skills techniques such as muscle relaxation, problem-solving skills, self-expression, and interpersonal skills. After several consecutive therapy sessions, on the one hand, the person's negative spontaneous thoughts are transformed into purposeful thoughts which are more compatible with objective reality, and their cognitive processing becomes more logical. These results are also consistent with the findings of the current research.

McCabe et al. (2001) showed that after the treatment, the respondents had lower levels of sexual dysfunction, as well as experienced more pleasurable perceived sex, fewer aspects of the negative impact of sexual dysfunction in their relation and less chance of sexual failure. Accordingly, cognitive-behavioral therapy leads to a positive attitude and thinking about sex, a more enjoyable sexual experience, and improved sexual performance in women, and reduces the probability of sexual failure (21), which is consistent with the results of the present study.

In Udson et al.'s research in 2013, the findings showed that sexual satisfaction and the partner's sexual satisfaction of women with endometriosis is lower than that of healthy women, and they emphasized the need to implement intervention programs to increase sexual satisfaction of these women (13). These results are in line with the findings of the present study. The level of sexual satisfaction in these women is also low in the present study.

According to the study by Samantha Litzinger et al. (2005) on "investigating relationships between couples, sexual satisfaction, and marital satisfaction" (32), couples' communication skills may have a great impact on sexual and relational satisfaction, as well as other factors of sexual satisfaction ( sexual frequency and orgasm). Women who experienced positive acts in their sexual relationships were more likely to have husbands who were sexually and relationally satisfied, as well as to feel satisfied themselves. So that the results of the present study show that establishing correct communication and sexual satisfaction with the spouse in women with endometriosis participating in the present study is a predictor of their sexual satisfaction. Therefore, it is consistent with the results of the present study.

Kfoury et al. (2023) conducted a case-control study. The participants completed an online survey that included questions about endometriosis, SSSW, the couple's satisfaction index, partner perceived responsiveness scale, and depression, anxiety, and stress scale. There was a relationship between endometriosis and impaired sexual satisfaction (33), which is consistent with the present study. Also, there was no relationship between endometriosis and couple's satisfaction and also stress, and anxiety, which are not consistent with the results of our study. The study by Kfoury et al. was conducted on Lebanese women, the sex is complex thus Psychological, social, physical, and individual factors should be considered when discussing this issue. Therefore, the possible reason for the inconsistency of the results of their study with our study may be different cultures.

According to the results of the study by Barneveld et al. (2022) on "depression, anxiety and related factors in endometriosis" (34), the symptoms of depression and anxiety frequently occur in patients with endometriosis and are associated with chronic pain (34). Anxiety is a natural response to threat and danger and a part of normal human experience, but if this response is excessive lasts more than three weeks, and disrupts daily life, it can be a mental health problem. So the results of the present study show that the level of personal anxiety in women with endometriosis participating in this study is a predictor of their sexual satisfaction. Therefore, it is consistent with the findings of the present study.

In explaining these findings and considering the alignment of the above studies with the present study, it can be said that educational and counselling interventions are effective in improving the sexual satisfaction of women with chronic diseases. Therefore, in the current study, it was tried that the problems of women with endometriosis regarding sexual satisfaction be discussed in a consultation environment, so that each of the research subjects, by discussing their problems in this field, will receive correct information about endometriosis and its effects on sexual satisfaction, which will increase their level of sexual satisfaction and consequently family. Among the limitations of this research, we can mention the issue of sex, which may still be considered taboo by some Iranian women, as well as ensuring the correctness of the answers given by the participants was another limitation of this study that was tried to ensure the honesty of the participants in answering the questionnaires by providing explanations and convincing people. The study also has some strengths. According to our knowledge, this study is the first study that evaluates the effect of counselling on the sexual satisfaction of women with endometriosis, which is an important factor in the quality of life of patients.

The results of the present research can be used to provide cognitive-behavioral group counselling on sexual satisfaction of women with endometriosis who are referred to health care centers and gynecology and obstetrics clinics in order to improve sexual health and reduce the complications caused by the disease and lack of awareness and subsequently improve sexual satisfaction, increase satisfaction and finally improving the quality of sexual life of women with endometriosis.

Conclusion

The results of the present study can provide health care providers, midwives, and gynecologists with a new way of providing cognitive-behavioral counselling services, which will lead to  reduce the complications caused by endometriosis  improve sexual satisfaction of women with endometriosis. In future studies, it is suggested to investigate the educational and counselling needs of women with endometriosis in the field of sexual health, as well as to compare other counselling methods with the method used in this study on the sexual satisfaction of women with endometriosis.

Declarations

Acknowledgements

This study is the result of a research proposal that was approved by Mashhad University of Medical Sciences .We hereby thank and appreciate The Vice president for Research of Mashhad University of Medical Sciences ,the cooperation of engaging staff in the study settings and the women participating in the research, and also to all the researchers whose studies were used in this study.

Conflicts of interest

The authors declared no conflicts of interest.

Funding

The authors would like to appreciate the Vice Chancellor for Research which financially supported the study

Ethical approval

After receiving approval from the Ethics Committee of Mashhad University of Medical Sciences, the researcher informed the participants about the research aim, obtaining written consent maintaining the confidentiality, and allowing the participants to withdraw from the study at any time during the study.

Code of Ethics

The ethics committee of Mashhad University of Medical Sciences approved the study with the code of IR.MUMS.NURSE.REC.1400.064.

Use of Artificial Intelligence (AI)

We have not used any AI tools or technologies to prepare this manuscript

Authors’ contribution

MN, FEA, AG, and LH participated in the design of the study, analysis, and draft of the manuscript. MN, FEA and SMA corporated in the gathering of the counseling content; MN carried out the data collection; JJ interpreted the data;. All authors read and approved the final manuscript.