Reproductive and Placental Research Unit

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Sexual activity, orgasm and tampon use are associated with a decreased risk for endometriosis

Please note:

This survey is no longer active. It is reproduced here as part of the publication of:

Meaddough EL, Olive DL, Gallup P, Perlin M, Kliman HJ. (2002) Sexual activity, orgasm and tampon use are associated with a decreased risk for endometriosis. Gyn Obstet Invest, 53:163-169. 

MENSTRUAL, SEXUAL, AND MEDICAL HISTORY SURVEY

 

 

            Thank you for taking the time to complete this survey.  It should take only 10-15 minutes to complete.  The focus of this study is to understand the menstrual, sexual and medical histories of women who have endometriosis.  This may help health professionals to better understand and prevent this condition.

         A second (blue) survey has been included for you to give to a friend (not a relative) who does not have endometriosis.  Please choose a female 18 years of age or older.

         This survey is anonymous and participation is voluntary.  Your individual participation in this study will not be known to anyone, including the researchers of this study or the Endometriosis Association.  Please do not put your name on this sheet.  You may freely choose not to participate.

 

 

ENDOMETRIOSIS HISTORY

 

1)  Have you ever been diagnosed with endometriosis?

            A  NO (SKIP TO #4)     B  YES

 

2)  If yes, which of the following symptoms lead you to see a health professional before you were diagnosed with endometriosis?  Please mark all that apply.

            A  NONE     B  PAIN     C  IRREGULAR BLEEDING     D  INFERTILITY

            E  OTHER

 

3)  What was your age when you were diagnosed with endometriosis?     ___

 

4)  Has anyone in your family not related by marriage ever been diagnosed with endometriosis?  Please mark all that apply.

            A  NONE     B  GRANDMOTHER     C  MOTHER     D   SISTER     E  AUNT

            F  OTHER

 

 

MENSTRUAL HISTORY

 

1)  What was your age when you had your first period?     ___

            A  I HAVE NEVER HAD A PERIOD (SKIP TO MEDICAL HISTORY)

 

2)  In the last year, approximately how many days has your period lasted (any time you are wearing a tampon, pad, or liner)?

            A  UNDER 3     B  3 TO 4     C  5 TO 6     D  7 OR MORE     E  IRREGULAR

            F  I HAVE NOT HAD A PERIOD IN THE LAST YEAR (SKIP TO #4)

 

3)  In the last year, approximately how many days has your menstrual cycle lasted?

            A  UNDER 24     B  24 TO 28     C  29 TO 32     D  OVER 32

            E  IRREGULAR

 

4)  Thinking over the years that you have been menstruating, have your periods ever stopped or become less frequent?

            A  NO (SKIP TO # 7)     B  YES

 

5)  If yes, what was the total amount of time that your periods stopped or became less frequent?

            A  UNDER 1 YEAR     B  1 TO 3 YEARS     C  4 TO 6 YEARS     D  OVER 6 YEARS

 

6)  What was your approximate age when your periods first stopped or became less frequent?  ___

 

7)  Thinking over the years that you have been menstruating, have your periods ever been heavier than usual?

            A  NO (SKIP TO #10)     B  YES

 

8)  If yes, what was the total amount of time that your periods were heavier than usual?

            A  UNDER 1 YEAR     B  1 TO 3 YEARS     C  4 TO 6 YEARS     D  OVER 6 YEARS

 

9)  What was your approximate age when your periods first became heavier than usual?  ___

 

10)  What products do you usually use when you have your period (now or in the past)?

            A  NEITHER PADS OR TAMPONS     B  ONLY PADS     C  ONLY TAMPONS

            D  PADS AND TAMPONS

 

11)  At what times in your cycle do you usually douche?

            A  NEVER     B  WHEN I AM MENSTRUATING

            C  WHEN I AM NOT MENSTRUATING     D  BOTH WHEN I AM MENSTRUATING                                                                                   AND NOT MENSTRUATING

 

 

SEXUAL HISTORY

 

            Our sexual lives are personal and private.  There are many different types of sexual behaviors that people engage in.  Some behaviors may be familiar to us, and some may not.  The following are questions which ask about your past and present sexual behaviors.

 

A.  SEXUAL BEHAVIOR

 

1)  Have you ever engaged in sexual activity (alone or with a partner) while you were having your period?

            A  NO (SKIP TO CONTRACEPTIVE BEHAVIOR)     B  YES

 

2)  How often have you had sexual intercourse during your period?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

3)  If you have ever had sexual intercourse during your period, how often did you experience orgasm?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

4)  How often have you engaged in masturbation during your period (alone or with a partner)?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

5)  If you have ever engaged in masturbation during your period (alone or with a partner), how often did you experience orgasm?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

6)  How often have you engaged in any other sexual activity during your period (alone or with a partner)?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

7)  If you have ever engaged in any other sexual activity during your period (alone or with a partner), how often did you experience orgasm?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

8)  Excluding what has been discussed above, how often have you experienced orgasm in any other way during your period (alone or with a partner)?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

B.  CONTRACEPTIVE BEHAVIOR

 

1)  If you have ever used an intra-uterine device (IUD), how long did you use it?

            A  I HAVE NEVER USED AN IUD (SKIP TO #3)     B  UNDER 1 YEAR

            C  1 TO 3 YEARS     D  4 TO 6 YEARS     E  OVER 6 YEARS

 

2)  What was your approximate age when you first used an IUD?     ___

 

3)  If you have ever used birth control pills, how long did you use them?

            A  I HAVE NEVER USED BIRTH CONTROL PILLS (SKIP TO #5)

            B  UNDER 1 YEAR     C  1 TO 3 YEARS     D  4 TO 6 YEARS     E  OVER 6 YEARS

 

4)  What was your approximate age when you first used birth control pills?     ___

 

5)  If you have ever received a Norplant insertion, how long did you use it?

            A  I HAVE NEVER USED NORPLANT (SKIP TO #7)     B  UNDER 1 YEAR

            C  1 TO 3 YEARS     D  4 TO 6 YEARS     E  OVER 6 YEARS

 

6)  What was your approximate age when you first received a Norplant insertion?   ___

 

7)  Have you ever used a contraceptive sponge while you were menstruating?

            A  NO (SKIP TO # 10)     B  YES

 

8)  If yes, how often have you used a contraceptive sponge while you were menstruating?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

9)  What was your approximate age when you first started to use a contraceptive sponge while your were menstruating?     ___

 

10)  Have you ever used a diaphragm while you were menstruating?

            A  NO (SKIP TO # 13)     B  YES

 

11)  If yes, how often have you used a diaphragm while you were menstruating?

            A  NEVER     B  RARELY     C  SOMETIMES     D  OFTEN

 

12)  What was your approximate age when you first started to use a diaphragm while your were menstruating?     ___

 

13)  If you have ever received Depoprovera injections, how long did you receive them?

            A  I HAVE NEVER USED DEPOPROVERA (SKIP TO MEDICAL HISTORY)

            B  UNDER 1 YEAR     C  1 TO 3 YEARS     D  4 TO 6 YEARS     E  OVER 6 YEARS

 

14)  What was your approximate age when you first started to receive Depoprovera injections? ___

 

 

 

 

 

 

MEDICAL HISTORY

 

1)  How many times have you been pregnant?     ___

 

2)  How many biological children do you have?     ___

            A  NONE (SKIP TO # 4)

 

3)  If you breastfed your child/children, what was the total number of years you did this for all of your children?

            A  LESS THAN 6 MONTHS     B  6 MONTHS TO 1 YEAR     C  2 TO 3 YEARS

            D  4 TO 5 YEARS     E  OVER 5 YEARS

 

4)  If you have ever received estrogen replacement therapy, how long did you receive this treatment?

            A  I HAVE NEVER RECEIVED ESTROGEN REPLACEMENT THERAPY (SKIP TO        #6)     B  UNDER 1 YEAR   C  1 TO 3 YEARS   D  4 TO 6 YEARS   E  OVER 6 YEARS

 

5)  What was your approximate age when you first started to receive estrogen replacement therapy?

            ___

 

6)  Have you ever been diagnosed with a sexually transmitted disease that was treated with antibiotics?

            A  NO (SKIP TO #8)     B  YES

 

7)  What was your approximate age when you were first diagnosed with this sexually transmitted disease?     ___

 

8)  If you have ever had your fallopian tubes tied (tubal ligation) or surgically treated for any reason, what was your approximate age when this occurred?     ___

            A  I HAVE NEVER HAD SURGERY ON MY TUBES

 

9)  If you have ever had surgery to remove your uterus (hysterectomy), what was your approximate age when you had it removed?     ___

            A  I HAVE NOT HAD MY UTERUS REMOVED

 

10)  If you have ever been diagnosed with blockage of the cervix (cervical stenosis), what was your approximate age when you were diagnosed?     ___

            A  I HAVE NEVER BEEN DIAGNOSED WITH CERVICAL STENOSIS

 

11)  If you have ever taken any antidepressant, antianxiety or muscle relaxant medications, what was the total amount of time that you took these medications?

            A  I HAVE NEVER TAKEN ANY OF THESE MEDICATIONS (SKIP TO SOCIAL      HISTORY)     B  UNDER 1 YEAR     C  1 TO 2 YEARS     D  3 TO 4 YEARS

            E  5 YEARS OR MORE

 

12)  What was your approximate age when you first started to take any of these antidepressant, antianxiety or muscle relaxant medications?     ___

 

 

 

 

 

 

 

SOCIAL HISTORY

 

1)  How often do you exercise?

            A  I DO NOT EXERCISE (SKIP TO #4)     B  DAILY     C  WEEKLY

            D  MONTHLY     E  OCCASIONALLY

 

2)  How long have you maintained this exercise schedule?

            A  UNDER 1 YEAR     B  1 TO 2 YEARS     C  3 TO 4 YEARS     D  5 YEARS OR       MORE

 

3)  What was your approximate age when you started this exercise schedule?     ___

 

4)  If you were ever a smoker, approximately how many packs did you smoke each week?

            A  I HAVE NEVER BEEN A SMOKER (SKIP TO #6)     B   LESS THAN 1     C  1 TO 3

            D  4 TO 6     E  7 OR MORE

 

5)  What was your approximate age when you first started to smoke this many packs each week?__

 

6)  What is your present age?     ___

 

7)  What is your current religious preference?

            A  NONE     B  CATHOLIC     B  JEWISH     C  PROTESTANT     D  OTHER

 

8)  What is your highest educational level?

            A  LESS THAN GRADE SCHOOL     B  GRADE SCHOOL/JUNIOR HIGH SCHOOL

            C  HIGH SCHOOL     D  SOME COLLEGE     E  SOME GRADUATE SCHOOL

 

9)  How do you describe yourself?

            A  WHITE     B  BLACK/AFRICAN AMERICAN     C  NON-BLACK HISPANIC

            D  ASIAN     E  OTHER

 

 

THANK YOU FOR COMPLETING THIS SURVEY

 

 

 

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Send email to: harvey.kliman@yale.edu

 

Last modified 6.9.02