Validation of the Sexual Activity Questionnaire in Women With Endometriosis

A. Oppenheimer; P. Panel; A. Rouquette; J. du Cheyron; X. Deffieux; A. Fauconnier


Hum Reprod. 2019;34(5):824-833. 

In This Article

Abstract and Introduction


Study Question: Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis?

Summary Answer: For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool.

What is Known Already: Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research.

Study, Design, Size, Duration: A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population.

Particpants/Materials, Settings, Methods: Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.

The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method).

Main Results and the Role of Chance: In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).

The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74–0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0–0.6), P = 0.01). The minimally important difference was determined at 2.2.

Limitations, Reasons for Caution: The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients.

Wider Implications of the Findings: The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ.

Study Funding/Competing Interest(s): This work was funded by the 'Direction à la Recherche Clinique et à l'Innovation' of Versailles, France and the 'Institut de Recherche en Santé de la Femme' (IRSF). The authors have no conflicts of interest to declare.


Endometriosis is a chronic gynecological disease which occurs in 5–10% of women of reproductive age (Barbara et al., 2017b). It is one of the most frequent causes of deep dyspareunia (Ferrero et al., 2008; Vercellini et al., 2011, 2013) and is associated with higher rates of interrupted intercourse (3.7 ± 1.9 over 3 months for women with endometriosis versus 2.6 ± 1.9 over 3 months for control group (P < 0.05)) and reduced frequency of sexual intercourse (Ferrero et al., 2005). Dyspareunia negatively affects different domains of sexual function leading to psychological disorders and relational distress (Meana and Lykins, 2009), and has an unfavorable emotional impact on partners (Fernandez et al., 2006). In a recent review (Barbara et al., 2017a), it was reported that two-thirds of women with endometriosis have sexual dysfunction. It is not only limited to deep dyspareunia and pain but also has a psychological component and relational dimensions including the partner's sexual functioning (that has to be taken into account in a multidimensional perspective of endometriosis treatment). This dysfunction could alter sexual quality of life and consequently negatively impact health-related quality of life (Orley and Kuyken, 1994; Garratt et al., 1995). Sexual function endpoints should thus be included in the evaluation of treatments of endometriosis. However, while several studies have demonstrated the effectiveness of medical and surgical treatment on dyspareunia (Chapron et al., 1999; Garry et al., 2000; Abbott et al., 2004; Thomassin et al., 2004), there is a paucity of data about sexual function in this setting (Fauconnier et al., 2017).

The Sexual Activity Questionnaire (SAQ) was initially developed by Thirlaway (Thirlaway et al., 1996a) to investigate the impact of long-term tamoxifen on the sexual function of women at high risk of developing breast cancer. The psychometric soundness of the questionnaire has since been validated in this population and it has been extensively used in studies of cancer therapy (Fallowfield et al., 2001; Ganz et al., 2002; Carmack Taylor et al., 2004; Wenzel et al., 2005). The SAQ has also been used and validated in the general population in Norway (Vistad et al., 2007) with good psychometric properties (good internal consistency [Cronbach's coefficient alpha of 0.86] and confirmed construct validity). In 2000, Garry et al. used the SAQ to assess the effect of endometriosis and radical laparoscopic excision on sexual quality of life (among other quality of life questionnaires) but did not provide validation of the SAQ in this population. Thus to date, the SAQ has not been validated for patients with endometriosis.

The purpose of this study was to assess the psychometric validity of the SAQ in a population of patients treated for symptomatic endometriosis. We also examined responsiveness (ability to change) and the minimally important difference (MID) (smallest difference perceived by the patient as beneficial or harmful) of the SAQ in this population.