Female Sexual Function Improves After Endometrial Ablation

Abstract

Background:

Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods.

Methods:

Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF–12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test.

Results:

A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 (p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 (p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF–12 scores improved for global physical function (p < .001) and mental function (p = .002).

Conclusions:

Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.

Introduction

Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life (QOL) and contribute to sexual issues such as low sexual interest or arousal, orgasmic dysfunction, and dyspareunia. Although medical therapies (e.g., hormonal contraceptives) are available,¹ hysterectomy remains a common treatment; more than 430,000 are performed (for all indications) in the United States annually.² About 55% include concurrent bilateral salpingo-oophorectomy (BSO).³ However, early surgical menopause is associated with increased rates of cardiovascular disease, osteoporosis, cognitive impairment, mood disorder, and all-cause mortality.^4,5

Prospective hysterectomy studies describe improved mood and QOL, including sexual function, with few new symptoms or postoperative problems,^6
–8 whereas retrospective studies have reported adverse psychological effects (e.g., depression, anxiety, fatigue, and low libido).⁹ Less is known about sexual function after endometrial ablation, an attractive minimally invasive surgical option for menorrhagia in select women.¹⁰ Ablation studies in small groups of women have shown improved well-being and sexual function.^11,12 In a large population-based study of 9,000 women, even after excluding those with concurrent BSO and adjusting for age and hormone therapy, women undergoing hysterectomy still had significantly higher rates of libido loss, arousal dysfunction, and vaginal dryness than women undergoing ablation.¹³ Another comparison of hysterectomy and endometrial resection showed better social function and vitality scores after hysterectomy but similar sexual function scores for both groups.¹⁴

Here, we use validated surveys to assess sexual function and QOL after endometrial ablation.

Materials and Methods

We prospectively recruited women undergoing radiofrequency endometrial ablation for heavy menses in the Department of Obstetrics and Gynecology at Mayo Clinic (Rochester, Minnesota) from August 11, 2008, through June 3, 2013. The study was approved by the Mayo Clinic Institutional Review Board. Minimally invasive NovaSure endometrial ablation was performed by 4 surgeons at our institution.

Various hormonal options are available to patients with heavy menstrual flow. These treatments are followed by surgical options when medical management fails. Endometrial sampling is performed before endometrial ablation because ablation is contraindicated in patients with endometrial pathology; it also is not offered to women with multiple leiomyoma, suspected adenomyosis, morbid obesity, or age generally less than 35 to 40 years because of known higher failure rates.¹⁵ For the current study, eligible women were those 18 years of age and older, English speaking and writing, and currently sexually active. Patients completed surveys at baseline and at 6 months after surgery. Initial surveys were administered by registered nurse study coordinators in our outpatient clinic and same-day surgery unit. Follow-up surveys were mailed 6 months after endometrial ablation. Reminder telephone calls and letters were sent to patients to maximize completion of follow-up surveys. Each assessment included the following:

I. The 12-item Short-Form Health Survey (SF–12) instrument, a validated health-related QOL 12-item survey.¹⁶

Physical and mental health composite scores were computed using the responses to the 12 items. Scores ranged from 0–100; a score of 0 indicates the lowest level of health.

II. The Female Sexual Function Index (FSFI), a validated 19-item index assessing 6 domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain.¹⁷

Higher scores indicate better function. In a cross validation and development of clinical cutoff scores for the FSFI in 578 women, Wiegel et al.¹⁸ determined that a score of 26.55 was an optimal cutoff score for differentiating women with sexual dysfunction (<26.55) from women without sexual dysfunction (>26.55). Using this cutoff value, 77% of women were correctly identified with sexual dysfunction (specificity) and 85% of women were correctly identified with normal sexual function (sensitivity).

III. The Female Sexual Distress Scale (FSDS), a validated 12-item assessment of sexually-related personal distress in women.¹⁹ The overall score is the sum of the responses to the 12 items on a 5-point Likert scale, with 0 = never to 4 = always. Higher scores indicate more distress.

IV. An internally developed and peer group–validated 22-item survey addressing menstrual pattern, including cycle length, number of bleeding days, frequency of protection changes at heaviest flow, presence of dysmenorrhea, and medication use for symptom management. The survey also included items relating to sexual abuse, partner relationship, and body image issues.

Baseline patient information was abstracted from the medical record: age, race, parity, body mass index (BMI), and Pictorial Blood Loss Assessment Chart (PBLAC) score. PBLAC scores were not consistently obtained from patients undergoing ablation surgery before late 2009 at our institution. Three months after surgery, clinic nurses contacted patients to obtain follow-up PBLAC scores.

Baseline characteristics of women who did and did not complete the FSFI and FSDS follow-up surveys were compared using either the 2-sample t test or Wilcoxon rank-sum test, as appropriate. The SF-12, FSFI, and FSDS were each scored using methods previously described.^16,17,19 For women who completed surveys at baseline and follow-up, scores for sexual function, sexual distress, and QOL were compared using the paired t test. All calculated p-values were 2-sided, and p-values less than .05 were considered statistically significant. Statistical analyses were performed using SAS software (version 9.2; SAS Institute, Inc.).

The study was originally designed to enroll 200 women, with the assumption that 70% (n = 140) would be compliant with returning the 6-month follow-up questionnaires. With a sample size of 140, the study was anticipated to have 80% power to detect a difference of 1.4 points between the mean baseline and follow-up FSFI full-scale scores, assuming a common standard deviation of 6.0 for each group mean and a correlation of 0.5 between baseline and follow-up scores. Recruitment targeted only those women sexually active at baseline and required correct utilization of the FSFI; in addition, enrollment took longer than anticipated, likely because of the personal nature of the questionnaires. For these reasons, the study was closed after enrolling 136 patients.

Results

During the study period, 136 women who underwent endometrial ablation completed the baseline surveys. The mean (SD) age at ablation was 44.0 (5.6) years (range, 29.7–54.8 years). Of these women, 97 completed both baseline and follow-up FSFI and FSDS surveys. Table 1 compares characteristics of women who did (n = 97) and did not (n = 39) complete the follow-up surveys. Both groups were similar with respect to age, BMI, and gravidity.

Table 1.

Patient Characteristics

	Completed Baseline and Follow-Up Surveys
Characteristic	No (n = 39)	Yes (n = 97)	p-Value ^a
Age at ablation, mean (SD), y	43.9 (6.4)	44.1 (5.3)	.80
Body mass index, mean (SD), kg/m²	28.4 (6.8)	28.2 (6.0)	.91
Gravidity, median (IQR)	3 (2–4)	3 (2–3)	.08
Parity, median (IQR)	3 (2–3)	2 (2–3)	.01
Preoperative PBLAC score^b
Scores obtained, No.	36	76	.04
Median (IQR)	261.0 (161.5–403.0)	335.5 (223.0–485.0)

Comparisons were evaluated using the 2-sample t test for age and BMI and the Wilcoxon rank-sum test for all other variables.

PBLAC scores were not consistently obtained from patients undergoing surgery before late 2009 at our institution.

IQR, interquartile range; PBLAC, Pictorial Blood Loss Assessment Chart.

The 97 women who completed the follow-up surveys did so at a median of 6.6 months (interquartile range, 5.5–7.2 months) after endometrial ablation. Table 2 summarizes the change in survey scores from baseline for the FSFI, FSDS, and SF–12. The mean scores were significantly higher on most FSFI subscales at 6 months, indicating improved sexual function, but pelvic pain and dyspareunia were unchanged. Among the 90 patients with full-scale (overall) FSFI scores at both time points, 43.3% scored below the proposed cutoff of 26.55 at baseline and were considered at risk for sexual dysfunction compared with 23.3% at the 6-month assessment (p < .001; McNemar test). The mean score on the FSDS significantly decreased at 6 months, indicating less distress compared with baseline levels. The mean change in the mental and physical components on the SF-12 QOL showed significant improvement. SF-12 QOL surveys were inadvertently mislabeled for 29 patients in the study; therefore, complete surveys were available for only 68 patients. PBLAC scores were obtained from the medical record preoperatively and at 3 months postoperatively for 53 women (55%); PBLAC scores markedly improved after ablation (median score, 326.0 vs. 2.0).

Table 2.

Comparison of Survey Scores (n = 97) ^a

Survey	Baseline, mean (SD)	After ablation (6 mo.), mean (SD)	Difference, mean (SD) ^b	p-Value ^c
FSFI
Desire	3.2 (1.1)	3.7 (1.2)	0.6 (1.2)	<.001
Arousal	4.3 (1.3)	4.7 (1.2)	0.4 (1.2)	.001
Lubrication	5.0 (1.2)	5.2 (1.2)	0.2 (1.1)	.04
Orgasm	4.3 (1.5)	4.6 (1.4)	0.3 (1.1)	.008
Satisfaction	4.4 (1.4)	5.0 (1.2)	0.5 (1.5)	<.001
Pain	5.3 (1.1)	5.5 (1.2)	0.2 (0.9)	.11
Full scale^d	26.5 (5.8)	28.8 (5.5)	2.3 (5.1)	<.001
FSDS	13.6 (10.2)	9.7 (10.2)	−3.9 (9.1)	<.001
SF–12^e
Mental scale	51.1 (7.9)	54.5 (5.3)	3.4 (8.5)	.002
Physical scale	50.2 (8.1)	53.6 (6.0)	3.5 (7.5)	<.001

Scores were considered only from women who completed the FSFI and FSDS surveys at both time points.

Difference column represents the 6-month value minus the baseline value.

Paired t test.

The full-scale score was the sum of the domain scores for the 90 patients with scores for all domains at each time point.

Sixty-eight patients had SF–12 scores available at both baseline and 6 months. Of these, 64 completed the full survey and had scales scored at each time point.

FSDS, Female Sexual Distress Scale; FSFI, Female Sexual Function Index; SF–12, Short-Form Health Survey.

Table 3 summarizes the responses to select items from the internally developed survey pertaining to menstrual cycle characteristics, its effect on QOL, and sexual activity. At baseline, 39 (40.2%) reported periods lasting 7 or 8 days and 28 (28.9%) reported periods lasting 9 days or longer. Six months after ablation, 49 (50.5%) reported that they were not currently having menstrual cycles, 41 (42.2%) had a reduced cycle length, 6 (6.2%) had no change, and 1 (1.0%) had a longer cycle. At baseline, 77.9% (74/95) reported that their menstrual periods kept them from doing what they needed to do on a daily basis at least some of the time compared with 13.2% (5/38) of those still having menstrual cycles 6 months after ablation.

Table 3.

Summary of Menstrual Pattern and Physical and Psychological Function

Survey Item	Baseline, No. (%) (n = 97)	After ablation (6 mo.), No. (%) (n = 48) ^a
How many days does your period last? (Count days of both light and heavy bleeding.)
1–2 d	1 (1.0)	14 (14.4)
3–4 d	3 (3.1)	17 (17.5)
5–6 d	26 (26.8)	11 (11.3)
7–8 d	39 (40.2)	4 (4.1)
9–10 d	16 (16.5)	1 (1.0)
11–12 d	4 (4.1)	0 (0)
13–14 d	5 (5.2)	0 (0)
>15 d	3 (3.1)	1 (1.0)
How often do you change protection (pad and/or tampon) on these heaviest days?
Every 1/2-2 h	76 (78.4)	2 (2.1)
Every 2 to 3 h	11 (11.3)	5 (5.2)
Every 3 to 4 h	3 (3.1)	9 (9.3)
Every 5 to 6 h	1 (1.0)	4 (4.1)
>6 h	0 (0)	14 (14.4)
Not reported	6 (6.2)	14 (14.4)
Do your menstrual periods keep you from doing what you need to on a daily basis?
None of the time	21 (21.6)	33 (34.0)
Some of the time	63 (64.9)	4 (4.1)
Most of the time	9 (9.3)	1 (1.0)
All of the time	2 (2.1)	0 (0)
Unknown/not reported	2 (2.1)	10 (10.3)
Does your bleeding affect your emotional well-being?
Yes	67 (69.1)	6 (6.2)
No	29 (29.9)	33 (34.0)
Not reported	1 (1.0)	9 (9.3)
Does your bleeding affect your physical well-being?
Yes	70 (72.2)	6 (6.2)
No	22 (22.7)	40 (41.2)
Not reported	5 (5.2)	2 (2.1)

All women had menstrual cycles at baseline. Six months after ablation, 49 women (50.5%) reported that they were not currently having menstrual cycles.

Because sexual function and sexual distress are likely to be affected by bleeding, we compared survey scores at baseline and 6 months after ablation (Table 4). Whereas the differences in the FSFI, FSDS, and SF–12 were significant overall, the effect appears to be largely due to the subgroup who had amenorrhea after ablation (Table 5). When patients were categorized according to the severity of bleeding before ablation, those with heavy bleeding had the most significant improvement in the FSFI across all domains, with the exceptions of lubrication, which would not be expected to change with ablation, and the FSDS instrument results. Interestingly, the SF–12 was only significantly different after ablation in the moderate bleeding group.

Table 4.

Comparison of Survey Scores at Baseline and 6 Months After Ablation, Stratified by Postoperative Menstrual Status

				Currently Having Menstrual Cycles 6 mo. After Ablation
	Overall (n = 97) ^b			No. (n = 49)			Yes (n = 48)
Survey ^a	Baseline	After ablation (6 mo.)	p-Value ^c	Baseline	After ablation (6 mo.)	p-Value ^c	Baseline	After ablation (6 mo.)	p-Value ^c
FSFI
Desire	3.2 (1.1)	3.7 (1.2)	<.001	3.0 (1.0)	3.8 (1.3)	<.001	3.3 (1.1)	3.7 (1.2)	.02
Arousal	4.3 (1.3)	4.7 (1.2)	.001	4.1 (1.3)	4.7 (1.3)	.001	4.5 (1.1)	4.7 (1.2)	.25
Lubrication	5.0 (1.2)	5.2 (1.2)	.04	4.8 (1.4)	5.3 (1.1)	.005	5.2 (1.0)	5.2 (1.3)	.75
Orgasm	4.3 (1.5)	4.6 (1.4)	.008	4.3 (1.6)	4.7 (1.5)	.003	4.4 (1.4)	4.6 (1.4)	.31
Satisfaction	4.4 (1.4)	5.0 (1.2)	<.001	4.4 (1.5)	5.0 (1.1)	.005	4.5 (1.3)	4.9 (1.3)	.05
Pain	5.3 (1.1)	5.5 (1.2)	.11	5.5 (0.9)	5.7 (0.6)	.03	5.2 (1.2)	5.3 (1.6)	.63
Full scale^d	26.5 (5.8)	28.8 (5.5)	<.001	25.9 (6.0)	29.2 (5.4)	<.001	27.1 (5.5)	28.4 (5.7)	.08
FSDS	13.6 (10.2)	9.7 (10.2)	<.001	13.5 (10.0)	8.8 (8.6)	<.001	13.7 (10.6)	10.8 (11.8)	.09
SF–12^e
Mental scale	51.1 (7.9)	54.5 (5.3)	.002	50.1 (8.6)	54.7 (5.2)	.005	52.0 (7.2)	54.2 (5.4)	.15
Physical scale	50.2 (8.1)	53.6 (6.0)	<.001	50.5 (8.4)	54.2 (5.7)	.006	49.9 (7.8)	53.1 (6.5)	.03

Results are reported as mean (SD).

Scores were considered only from women who completed the FSFI and FSDS surveys at both time points.

Paired t test.

The full-scale score was the sum of the domain scores for the 90 patients with scores for all domains at each time point.

Sixty-eight patients had SF–12 scores available at both baseline and 6 months; of these, 64 completed the full survey and had scales scored at each time point.

Table 5.

Comparison of Survey Scores at Baseline and 6 Months After Ablation, Stratified by Bleeding Severity

	Bleeding Severity
	Mild (n = 14)			Moderate (n = 53)			Heavy (n = 28)
Survey ^a	Baseline	After ablation (6 mo.)	p-Value ^b	Baseline	After ablation (6 mo.)	p-Value ^b	Baseline	After ablation (6 mo.)	p-Value ^b
FSFI
Desire	3.3 (1.1)	3.9 (1.2)	.14	3.3 (1.0)	3.8 (1.2)	.003	2.9 (1.1)	3.5 (1.2)	.002
Arousal	4.2 (1.3)	4.9 (1.2)	.06	4.3 (1.3)	4.7 (1.3)	.02	4.3 (1.2)	4.7 (1.1)	.04
Lubrication	4.8 (1.5)	5.4 (0.9)	.11	5.1 (1.1)	5.3 (1.2)	.17	4.9 (1.3)	5.2 (1.2)	.14
Orgasm	4.3 (1.7)	4.9 (1.5)	.05	4.4 (1.4)	4.7 (1.4)	.17	4.2 (1.7)	4.6 (1.5)	.05
Satisfaction	4.3 (1.7)	5.0 (1.3)	.23	4.4 (1.3)	4.9 (1.1)	.01	4.6 (1.4)	5.3 (1.1)	.02
Pain	5.6 (0.8)	5.9 (0.2)	.08	5.4 (1.1)	5.4 (1.4)	.73	5.1 (1.1)	5.4 (1.0)	.07
Full scale^c	25.9 (6.8)	29.5 (4.9)	.09	26.9 (5.4)	29.1 (5.1)	.003	26.1 (6.2)	28.7 (5.6)	.004
FSDS	15.0 (14.7)	9.2 (10.8)	.06	12.5 (9.6)	9.2 (10.0)	.02	14.0 (9.0)	9.5 (9.1)	.02
SF–12^d
Mental scale	48.7 (9.8)	55.0 (3.3)	.20	49.9 (8.7)	54.0 (6.5)	.02	53.0 (6.2)	54.7 (4.0)	.17
Physical scale	51.5 (5.9)	54.3 (2.7)	.27	48.1 (9.5)	52.9 (7.5)	.004	52.3 (6.1)	54.3 (4.6)	.15

Results are reported as mean (SD). Scores were considered only from women who completed the FSFI and FSDS surveys at both time points.

Paired t test.

The full-scale score was the sum of the domain scores for the n = 12, 50, and 26 patients with scores for all domains at each time point, respectively.

Of the n = 7, 35, and 24 patients with SF–12 scores available at both baseline and 6 months, n = 7, 32, and 23 patients completed the full survey and had scales scored at each time point, respectively.

Discussion

This prospective study showed significantly improved female sexual function and QOL after endometrial ablation using validated survey instruments (FSFI, FSDS, and SF–12) and the internally developed menstrual survey. The mean full-scale FSFI score for the 90 women with FSFI scores at both time points showed clinical improvement (26.5 to 28.8; p < .001), and the percentage at risk for sexual dysfunction decreased from 43.3% to 23.3%. In this cohort, desire and satisfaction had the greatest degree of change (each improved by 27%) after ablation (p < .001 for each domain). With a decrease in duration and amount of menstrual bleeding, desire and satisfaction might be expected to show greater improvement than sexual lubrication and pain, given that these latter 2 aspects of sexual function are less likely to be as affected by outcomes of minimally invasive surgery. Improved menstrual periods after surgery would likely not alter sexual pain issues such as vulvodynia, vaginismus, and pelvic floor dysfunction. Our findings show the association of heavier bleeding before ablation with greater improvement across sexual function survey instruments, especially in the setting of amenorrhea after ablation. This finding potentially is meaningful when counseling women about expectations for post-procedural bleeding and sexual function.

The FSDS showed less personal distress associated with sexual function, with scores significantly decreasing from 13.6 to 9.7 (p < .001). Personal distress associated with sexual function is an important factor for distinguishing between women who do and do not have more optimal sexual function.²⁰ In assessing QOL, SF–12 scores improved for global physical and mental function after endometrial ablation (p < .001 and p = .002, respectively). Enhanced physical and psychological well-being has proven markedly beneficial in optimizing QOL after surgical management for heavy vaginal bleeding.^6
–8

Endometrial ablation is a well-established, effective, and minimally invasive treatment for heavy menses in appropriately selected candidates without significant uterine pathology. The likelihood of improving bleeding with endometrial ablation can be predicted before surgery.¹⁵ As expected, PBLAC scores markedly decreased in our cohort after endometrial ablation. Similarly, our internally developed survey of bleeding showed post-ablation improvement in the duration of menstrual bleeding, frequency of protection change, and emotional and physical well-being related to menses.

The strengths of the study include prospective enrollment of patients and use of validated survey instruments to assess sexual function, personal distress, and general well-being before and after ablation. Additionally, 71% of participants responded to the 6-month follow-up surveys. Limitations of our study include enrollment over several years, likely because of the personal nature of the study surveys. This was a small study, with 90 women completing all questions of each survey. It is possible that the women with the greatest improvement in menstrual bleeding after ablation were more likely to complete the second set of surveys compared with women who did not have markedly different outcomes after surgery. Women undergoing ablation did not qualify for the study if they were not sexually active within 4 weeks of their surgery, based on FSFI survey requirements. SF–12 QOL surveys were inadvertently mislabeled and unavailable for final analysis for 29 patients; therefore, SF–12 surveys before and after the procedure were available for only 68 patients. Age range of the participants was somewhat limited by previously published selection criteria from our institution showing ablation to be most effective for patients in their mid-40s and older.¹⁵ Generalizability was limited by the primarily white, parous population with similar mean BMI at a single Midwestern institution.

We used validated sexual function, sexual distress, and QOL surveys to show statistically significant and clinical improvement in bleeding and in global and sexual well-being in women after endometrial ablation. Minimally invasive endometrial surgery appears to be an excellent option for women who are concerned about sexual well-being but want to avoid hysterectomy and its inherent risks and sequelae. Our study reports that women undergoing endometrial ablation for heavy menses have improved sexual function and QOL with less personal distress, likely comparable to hysterectomy. Our study supports prior favorable psychosexual findings^13,14 after ablation. Female sexual function is complex, affected by numerous factors such as the partner relationship, physical and psychological health issues of the woman and her partner, aging, medications, social factors in rearing children, caring for aging parents and others, career challenges, and other life and personal stressors. Greater understanding of the impact of surgical effects on the physical, emotional, and sexual well-being of women is necessary to maximize outcomes and enhance QOL.

Footnotes

Acknowledgment

This study was supported by an internal grant from the Mayo Clinic Department of Obstetrics and Gynecology. We thank Maureen Lemens, RN, for her assistance in this study.

Author Disclosure Statement

No competing financial interests exist.

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