By Allison Danish, MPH

Endometriosis is a chronic pelvic health condition in which tissue similar to the endometrium (the lining of the uterus) grows outside the uterus. With common symptoms like pelvic pain, heavy and painful periods, fertility challenges, and GI issues (like pain with peeing and pooping)—endo can be a real pain. 

Another common symptom people with endo frequently report is painful sex. In fact, about 50% of people with endometriosis experience pain with penetrative sex or dyspareunia. But why and what can we do about it? We talked to the experts to give you the inside scoop. 

Why does endometriosis cause painful sex?

Painful sex is common with endo for a couple of reasons! It’s a complicated condition, so we’re gonna break it down into 5 main groups.

Inflammation

Fun fact: endometriosis is an inflammatory condition. This means that when that endometrium-like tissue starts growing in the pelvis, the body says “hey, you’re not supposed to be here!” and awakens an immune response. This immune response, unfortunately, doesn’t get rid of the rogue tissue—but does lead to inflammation. 

Normally, inflammation is a helpful part of the healing process, but scientists think it’s one of the big reasons why endo is painful. Natasha Orr and Kate Wahl, endometriosis researchers and PhD students at the University of British Columbia say, “There is often inflammation around endometriosis growths, which makes these areas painful to the touch.” And by touch, we mean penetration. Or pooping! Or peeing. Hence the reason why endo has a whoooole host of signs and symptoms. 

In case you’re into the nitty gritty science, this inflammation is painful for a number of reasons:

1. Immune cells responsible for this inflammatory response pop out inflammatory molecules that directly bind to pain-sensing nerve endings, resulting in pain.
2. This inflammatory response also creates new blood vessels and nerve fibers. This leads to more endometriotic tissue growth and more activation of the nerves in that part of the body. Because there’s more activation of the nerves, the body develops a lower threshold of pain in this area, so it takes less sensory input to feel pain. This is called peripheral sensitization. 

Adhesions

Adhesions are sticky bands of scar-like tissue that stick pelvic structures (like organs) together, usually occurring in moderate to severe endometriosis. Dr. Mona Orady, MD says that when someone with endometriosis has a lot of adhesions, maybe resulting in frozen pelvis, hitting the uterus during penetrative sex can hurt. 

“Adhesions make the surfaces of the organs sticky and prevent the pelvic organs from sliding and gliding, which is what is required for normal, pain free function,” says Dr. Corey Hazama, DPT. “We know that during vaginal penetration, the penetrating penis/toy/finger etc., will actually move into the space between the uterus and bladder.”

Normally during arousal, “the uterus moves up and back, making room for this to happen,” Dr. Hazama continues. “If the uterus can’t slide back or the space between the uterus and bladder is limited because endo is there, this could cause pain.”

Deep Infiltrating Endometriosis

There are 3 different kinds of endometriosis, one of them being deep infiltrating endometriosis. This type of endo affects about 20% of people with the condition, and is when the endometriotic tissue starts growing further into the tissues it’s attached to. Hence the name! Deep and infiltrating. 

This may cause painful sex when “deep infiltrating endometriosis is in the rectovaginal septum and uterosacral spaces,” says Dr. Orady. Similar to when we were talking about adhesions, the area between the vagina and the rectum and the area between the uterus and base of your spine need to be free of obstructions so your organs and tissues can slip n’ slide during penetrative sex. But when you’ve got deep endometriotic lesions in these areas, the organs can be stuck together or these growths can block the smooth movement of the organs. 

Central Sensitization

“Sometimes, the nervous system of people with endometriosis malfunctions, causing pain during non-painful events like being lightly touched. This is called central sensitization and can add to the pain someone feels during sex,” say Orr and Wahl.

Remember when we talked about peripheral sensitization earlier? This is the next step in the process. Whereas peripheral sensitization is when there’s more sensitivity to pain in a particular area, central sensitization can mean increased sensitivity to pain in other parts of the body that aren’t affected by endometriosis or pain in response to touches that aren’t normally painful. 

Endo-Related Conditions

“Many people with endometriosis also have other conditions that cause dyspareunia. For example, pelvic floor tenderness causes pain in muscles we use during sex,” say Orr and Wahl. Pelvic floor muscle dysfunction-related pain can crop up for people with endo because “once there is pain with penetration, the brain learns to expect pain every time there is penetration, which then becomes an ingrained pattern to tighten muscles in anticipation of pain,” says Dr. Hazama. “The muscles, which learn to protect the area as well, clench, because they don’t know what’s going on. They just know that this region is under threat so nothing is going in or out. This is another reason why sex can hurt—the muscles around the vagina are painful when they’re stretched.”

Some other conditions that are associated with painful sex and commonly co-occur with endo include: painful bladder syndrome, irritable bowel syndrome, abdomino-pelvic myalgia, and vulvodynia. 

To learn more about dyspareunia and endometriosis, Natasha Orr and Kate Wahl recommend checking out this website and videos created by researchers in collaboration with people with endometriosis.  

What can you do about painful sex caused by endometriosis?

So… we just talked a lot about why endometriosis can make the horizontal mambo less-than-comfy. But what can we do about it? Thankfully… you’ve got options!

Seek Out Medical Care

It’s always important to seek out healthcare professionals if you’re struggling with painful sex, but particularly endometriosis because it can get worse over time without intervention. Endometriosis specialists and pelvic PTs are two particular kinds of healthcare practitioners that are integral to decreasing endometriosis-related dyspareunia. Here’s what treatment might look like:

Medicine

Dr. Orady says treatment “depends on the full spectrum because nobody comes in with just deep dyspareunia; The pain is usually multifactorial.” She explains that patients often experience a range of related issues like lack of arousal, vaginismus, dryness, and vestibulodynia. As a result, it's necessary to give each component the attention it deserves in order to effectively ease the pain.

For instance, if a structural cause is identified, surgery may be required; In cases of vestibulodynia (pain around the vaginal entrance), the initial treatment may involve steroid creams or injections; Vaginismus can be managed with physical therapy, dilators, sex therapy, and injections; Addressing arousal difficulties often necessitates sex therapy, particularly if there is a long-standing problem or a history of trauma. Overall, a comprehensive approach to treatment is essential in order to tackle the full spectrum of symptoms associated with deep dyspareunia.

Physical Therapy

Physical therapy can also be a valuable approach in addressing painful sex caused by endometriosis. Dr. Hazama says, “We work on downtraining for the central nervous system for the upregulation and hypersensitivity of the brain, through breathing and muscle relaxation training.” Physical therapists can help their patients “elongate tight, shortened muscles and retrain them to “let go;” work to create mobility of organs for more sliding and gliding; and maintain and build flexibility and strength.” 

Pelvic Gym’s Endometriosis program can be a helpful starting point to start gaining the tools to relax your muscles and your mind.

Not sure how to find an endometriosis expert or a pelvic PT? Check out these resources for finding a healthcare expert in your area. If you’re not sure how to talk about your symptoms with your doctor, fill out the Pelvic Pain Assessment, a free tool designed to help you communicate exactly what you’re feeling.

Try Different Sex Positions

If you have endometriosis, you probably already know that some positions are more comfortable than others. Some people have more abdominal tenderness, others more pain deeper inside the body, while some people might experience entry or vulvar pain—or maybe a little bit of each! Check out this sex position guide so you can find your new favorite sex position—as recommended by a pelvic floor physical therapist. 

Have Sex Without Penetration

While people with endo can experience vulvar pain that can make even non-penetrative sex uncomfortable, it’s important to know that taking penetration off the table is totally an option! There are lots of great ways to have sex or intimately connect without anything ever going inside—and it can be really helpful to take a break from it, especially if you have some fears around penetration. Read more in 7 Ways to Get Sexy—Without Penetration.

Plan When You Have Sex

Endometriosis is an estrogen-dependent condition, meaning pain tends to get worse when Aunt Flow’s in town. It can be helpful to keep a journal of your cycle and how your pain fluctuates throughout so you can plan accordingly. Phendo (an app for tracking endo symptoms that contributes to research), Endometrix (an endo symptom-logging app), and Clue (a secure period-tracking app) can be helpful tools for keeping a digital record.

Try Out Bedroom Additions

When it comes to painful sex, bedroom accessories can make a world of difference. Ohnut is a wearable stack of rings that can decrease the depth of penetration, helping with deep pain during sex. 

Lube can also be very helpful for decreasing pain associated with dryness and friction—but the lube you use matters! Not all brands are safe for your body, or are suitable for sensitive skin. Oh Naturale Organic Aloe Lube is a great water-based and body-safe option. Be sure to check out our Definitive Guide to Lube to get the lay of the (lubrication) land.

For similar reasons, suppositories can be helpful for reducing dryness and discomfort. Some suppositories also include ingredients like CBD to up their pain-relieving power.

Endometriosis can cause sex to be less-than-comfortable for a variety of reasons. But even though this pain is common for people with endo, it’s not just something you have to live with. There are treatments and tools that can help you have the kind of sex you want to have.