Attractiveness of women with rectovaginal endometriosis: a case-control study

Women with rectovaginal endometriosis were judged more physically attractive than women with peritoneal or ovarian endometriosis and than women with other benign gynecological conditions.


Paolo Vercellini, M.D., Laura Buggio, M.D., Edgardo Somigliana, M.D., Giussy Barbara, M.D., Paola Viganò, Ph.D., Luigi Fedele, M.D.

Volume 99, Issue 1, Pages 212-218, January 2013



To evaluate physical attractiveness in women with and without endometriosis.


Case-control study.


Academic hospital.


Three hundred nulliparous women.


Assessment of attractiveness by four independent female and male observers.

Main outcome measure:

A graded attractiveness rating scale.


A total of 31 of 100 women in the rectovaginal endometriosis group (cases) were judged as attractive or very attractive, compared with 8 of 100 in the peritoneal and ovarian endometriosis group, and 9 of 100 in the group of subjects without endometriosis. A higher proportion of cases first had intercourse before age 18 (53%, 39%, and 30%, respectively). The mean ± SD body mass index in women with rectovaginal endometriosis, in those with other disease forms, and in those without endometriosis was, respectively, 21.0 ± 2.5, 21.3 ± 3.3 and 22.1 ± 3.6. The median (interquartile range) waist-to-hip ratio and breast-to-underbreast ratio were, respectively, 0.75 [0.71-0.81], 0.76 [0.71-0.81] and 0.78 [0.73-0.83; P = .08], and 1.15 [1.12-1.20], 1.14 [1.10-1.17] and 1.15 [1.11-1.18; P = .044].


Women with rectovaginal endometriosis were judged to be more attractive than those in the two control groups. Moreover, they had a leaner silhouette, larger breasts, and an earlier coitarche.

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From: Headley, Shannon
Sent: Sunday, July 26, 2020 3:25 PM
To: Vercellini, Paolo
Cc: FertStert Editorial Office
Subject: Concern

Hello Gentlemen,

With the recent events and public shaming of The Journal of Vascular Surgery regarding their publication of Prevalence of Unprofessional Social Media Content among Young Vascular Surgeons, and specifically the outcry from women surgeons regarding the implicit bias and gender discrimination using the word "bikini," I wanted to bring an article to your attention privately since I am not in the business of shaming, but rather, educating.

A colleague contacted me today regarding Attractiveness of Women with Rectovaginal Endometriosis: A Case-control Study, and the stated conclusion of "Women with rectovaginal endometriosis were judged to be more attractive than those in the two control groups. Moreover, they had a leaner silhouette, larger breasts, and an earlier coitarche." DOI:

Although your methodology includes 4 independent female and male observers, I can foresee this article causing another outrage where women feel objectified or discriminated against and I wanted to bring this to your attention.

My hope is that the editors-in-chief and corresponding author will consider my feedback and make the best decision for your journal.

All the Best,

Shannon Headley, MA LPC

Student Doctor | MSIV
Go to the profile of
over 2 years ago

Hello Mrs Headley,

 The issues and the approaches of the two articles you are referring to seem very different.

 We dealt exclusively with a pathogenic hypothesis regarding the most severe endometriosis form, that is, rectovaginal endometriosis.

 A vast amount of data suggests that rectovaginal endometriosis may have a different pathogenesis with respect to ovarian and superficial peritoneal lesions. In particular, several investigators are focusing their attention on the intrauterine environment, theorizing that women with deep infiltrating endometriosis might have been exposed to an unbalanced hormonal environment, characterized by an estrogen excess, during the first trimester of pregnancy.

Moreover, independent groups consistently observed associations between endometriosis and particular phenotypic characteristics. To give you an example, our data demonstrated a strong association between blue eye colour and rectovaginal endometriosis (

 This suggests a genetic basis for this disease form. An interaction has been hypothesized also between specific genetic profiles and the intrauterine hormonal environment. Endocrine disruptors might here play a role.

 Face attractiveness is being studied for decades in females and males in different fields of medicine and research in general. It is also known that genes influence facial attractiveness and that those genes are associated also with some secondary sexual characteristics (

 In addition, there is no evidence in support of different serum estradiol levels in adult women with endometriosis compared with controls in the general female population of corresponding age. The same is true for attractiveness in young adult women (

Thus, early intrauterine rather than adult life might be the decisive phase for the future development of severely infiltrating endometriosis, be it due to genetic predisposition, unbalanced hormonal exposure, or both.

 We studied facial attractiveness to verify whether differences existed between women with rectovaginal endometriosis, women with other disease forms, and women without endometriosis. A statistically significant difference was observed. Several other demographic, clinical, and phenotypic variables were also assessed. Among the latter ones, breast size was larger in women with rectovaginal endometriosis, thus providing further support to the study hypothesis.

 The study investigated many variables in addition to phenotypic characteristics, and age at first intercourse (coitarche) was among the data that women indicated in the section of the questionnaire focused on sexological aspects.

 All the women were evaluated exclusively by female examiners except for the rating of facial attractiveness, that was performed, after the end of the visit, by four other investigators (two females and two males) who were unaware of the woman’s condition.

 I understand that this article has generated disappointment, and most of the criticisms were raised several years after its publication (it appeared online in October 2012). The study was designed in 2004 and started in 2005. Fifteen years ago, we had no awareness of the possibility of being misinterpreted. Despite this, I still do not feel that this study objectified or discriminated women, and nobody involved in the study even raised the suspicion that our behaviour could be disrespectful or discriminating. Several co-workers participated and, again, almost all were females. Nobody thought that assessing facial attractiveness could be interpreted as objectification. And all the female investigators that are still working in our hospital are very surprised by the concerns raised.

 Even the wording might be badly received. As an example, the word coitarche (from Latin coitus plus‎ ancient Greek ἀρχή, i.e., beginning) that you also included in your email has been criticized. However, a search of “coitarche” in PubMed retrieved many articles published even recently in English-language journals. Indeed, in Italy, we frequently use this type of terminology for other phenomena also, such as thelarche, pubarche, and menarche.

 In conclusion, our group discussed the hypothesis to be tested after a thorough literature examination, designed and conducted this study with enthusiasm and according to what we considered a sound methodological approach and analyzed the results carefully.

 Despite the above consideration, when we understood that our article could have caused discontent, we abandoned completely this line of research. I am very sorry, but everything was done in good faith. We thought we had found another piece of evidence in favour of the genetic/intra-uterine life theory.

 I hope my words have clarified the context in which our idea was developed, and the theoretical premises underpinning our study. Rest assured that we take respect toward our patients very seriously.

 I appreciated the kindness of your email.

 Best wishes,

 Paolo Vercellini

From: Headley, Shannon
Sent: Monday, July 27, 2020 2:44 PM
To: Vercellini, Paolo
Cc: FertStert Editorial Office
Subject: Re: Concern

Dr. Vercellini, 

Thank you for taking the time to thoroughly respond to my e-mail. I appreciate both your personal thoughtfulness, and the scientific basis evident in your methodology and study design.

As I read your e-mail, I recognized your humility and respect for humankind, including women. Thank you for providing clarity that the male observers only judged the facial characteristics of women.

As I read your e-mail, I was simultaneously overcome with sadness. I realize that American women who are hurting from years of discrimination and abuse from a (slowly resolving) misogynistic culture, are not taking the time to have the discussion that you and I are currently having, and instead are assuming the worst, e.g., being objectified or degraded by men when reading the title and conclusion of your study. 

As I am sure you are aware, recently in the United States, there has been a push for systemic change regarding discrimination and racism. Minority groups who have been oppressed in our country are finally having the courage to use their voice and advocate  for their dignity and humanity. This has caused, unfortunately, a trending outrage to publicly address and shame those via social media outlets who are inappropriately identified as the oppressors, rather than recognizing the need for systemic change that is rooted in implicit bias amongst an ever changing American culture and the need for more neutral and inclusive terminology.

I am so sorry that your research has received such scrutiny. Thank you for honoring the oath of physicians worldwide to care for patients with dignity and respect.

Before we conclude our discussion, I suggest to the editors of the Journal of Fertility and Sterility to consider having a discussion to release a statement that would address 1) recognition of emotionally wounded female and minority colleagues from a historically male predominated culture, and 2) strategies to implement systemic change in research regarding culturally sensitive topics.

I respect and admire you, Dr. Vercellini. I hope that you have a wonderful evening.

All the Best,

Shannon Headley, MA, LPC
Student Doctor, MSIV

From: Headley, Shannon
Sent: Monday, July 27, 2020 7:47 PM
To: Vercellini, Paolo
Cc: FertStert Editorial Office
Subject: Re: Concern

Dr. Vercellini & CC: Editorial Board of F&S,

After reading your e-mail again, I realized a few things I did not express earlier and thought it could provide some insight to you and your co-authors, and the editorial team.

Often the Abstract is the only aspect of the manuscript that people read, unfortunately, before making an assumption about the research. Most do not continue reading to get the full picture. This is the fault of no one but the reader.

For this reason, it is imperative that as researchers we state conclusions that will support our research yet be as neutral as possible. I agree that fifteen years ago, you could not have foreseen how facial attractiveness could have been misinterpreted as women being objectified.

I think that the verbiage used to state the conclusion painted a mental picture that independent observers rated the silhouettes and breasts of rectovaginal endometriosis patients to assess their attractiveness, rather than interpreting it as you stated: genes and subsequent hormones unique to rectovaginal endometriosis patients correlate to a statistically significant increase in facial attractiveness in rectovaginal endometriosis patients.

I think this same line of thought also applies to the stated objective in the abstract: to evaluate physical attractiveness in women with and without endometriosis. Perhaps it could have stated instead, “to evaluate facial attractiveness in women with and without endometriosis.” But again, I am offering alternative ways of stating the title given the current climate of America and the need for systemic change.

I also think the English word, “judged,” has a more negative connotation in America than perhaps a more neutral word like, “assessed.” And as stated in my previous e-mail, the current climate regarding women feeling degraded by a (slowly resolving) misogynistic culture is likely why women are targeting your article. Would using scientific terminology like “Phenotypic attractiveness in women with rectovaginal endometriosis: a case-control study” be more neutral and subsequently, cross-culturally sensitive? I am not quite sure, but I think this is the kind of discussion that needs to take place amongst the editorial board.

I hope that my insights will be well-received. 

All the Best,

Shannon Headley, MA, LPC
Student Doctor, MSIV

Go to the profile of wernich
over 2 years ago

when you wonder why there is so little progress being made in the foght against endometriosis, you only need to look at the garbage studies like this where instead of trying to find out more about endometriosis, they only want to make a list of which of their patients they'd like to have sex with. utterly disgusting and shameful.

Go to the profile of Serena Nena
over 2 years ago

This is disgusting. What a waste of money, time and resources and it's an insult to women, especially the ones suffering with endometriosis.

Go to the profile of Andrew Lockley
over 2 years ago

The retraction of this paper is an absolute disgrace to science. We do not throw our results into the memory hole because they cause "discomfort". It is the job of science to speak the truth, regardless of who that truth causes "distress" to. It sure caused the Catholic Church a lot of distress when Galileo pointed out that the earth was not the centre of the universe, but it didn't make it any less true. If the methodology is sound - as the researchers say it is - then this paper should stay up to contribute to public knowledge. Bowing to the snowflakes and cry-bullies who demand we conceal the truth casts us back into the dark ages, where belief was rooted in superstition, not fact. We must not give up an inch to this mob. In this specific instance, the retraction has denied us crucial knowledge that may help understand not only a medical condition, but also a wider set of factors affecting human development, behaviour and evolution. We have lost something of great value. 

Go to the profile of Ilik TheBeaters
over 2 years ago

What a joke! Can someone explain how this is helpful to women with endometriosis? "Crucial knowledge"!? Are my breasts big enough to be considered "attractive"? Do I have too much or too little body fat to be considered "attractive"? Maybe my endometriosis is growing in the wrong place!? Maybe I can see one of those doctors and he can put the endo in the place that will make me more attractive? I guess it doesn't matter that endometriosis can result in blinding pain, it can make organs attach to each other, it can cause infertility. But all this doesn't matter. What matters is that you are "attractive" or not. The "truth" here is that once again we have science coming from places of misogyny and racism.

Go to the profile of Andrew Lockley
over 2 years ago

It's helpful in that it gives an insight into potential causal mechanisms (detailed in the paper) and the possible evolutionary driving forces. Be

Go to the profile of Emmanuel Goldstein
about 2 years ago

Oh yes?  What causal mechanisms are those detailed in the paper that you don't seem to remember? Associations between endometriosis and particular phenotypic characteristics are legitimate as mentioned above (blue eye colour and rectovaginal endometriosis). However, how is beauty an objective genetic variable here? Please, are there genes associated with beauty? Beauty profiles have a history of variability. Women with thinner lips were most beautiful. Nowadays, it's the opposite. 

Go to the profile of Kathleen Barry Johnson
over 2 years ago

There can be ZERO "good faith" in a study like this. Who approved the design of this investigation? All of you need to be fired and stripped of any rewards you might have garnered in your lifetimes. How could you think this was (1) relevant; (2) scientifically valid; (3) not grossly exploitive of your study subjects. All of you suck.