Endometriosis and Pain with Sex
Endometriosis is a chronic medical condition that is often associated with painful periods. However, many people experience pain outside of their cycle. Other common symptoms include urinary urgency and frequency, bloating, pain with bowel movements, fatigue, nausea, back pain, abdominal pain, pain with urination and pain with sex. (And that isn’t even the complete list of symptoms!)
This disease occurs when tissue similar to the endometrial lining of the uterus grows outside of the uterus. Common locations where endometriosis is found are the ovaries, fallopian tubes, outside the uterus, the ligaments around the uterus and the space between the bowel and/or bladder. This tissue can lead to adhesions or scarring, inflammation and cysts. The adhesions can impair mobility of the structures it covers or causes organs to “stick” together.
It is estimated that 1 out of every 10 cis-gendered women has Endometriosis, but since it can take 8-12 years to receive a diagnosis I personally believe that this condition is more prevalent than the current data suggests. This is also due to the fact that many of these patients experience medical gas-lighting. In a survey of over 1800 women, 90% of those with Endometriosis reported having their symptoms dismissed; with 40% reporting that their doctors told them their symptoms were a “normal part of being a woman.” Obviously, this can lead to people not seeking care and assuming their symptoms are now their “new normal.” Hopefully, with more research and advocacy patients with Endometriosis will receive appropriate care and treatment to get them living with less pain and discomfort.
Despite the negative experiences and length of time before getting diagnosed, more providers are referring patients to pelvic floor physical therapy. Patients report a variety of issues but one of the common symptoms I hear and help address is pain with sex.
There are many reasons why endometriosis can lead to painful sex. Often endometrial lesions or adhesions are found behind the uterus and these adhesions are not very elastic and this lack of visceral mobility can lead to pain with penetrative sex. Also, since the uterus and anus repetitively contract during orgasm this can irritate any lesions in this area and these lesions can also limit mobility of those structures, which can also cause pain.
Endometriosis not only causes adhesions among the pelvic organs, but it leads to chronic inflammation within the pelvis. And keep in mind that all of the pelvic organs are supported by the pelvic floor muscles. So you can imagine these muscles will react to the inflammation and adhesions in a protective mechanism and tense up. Furthermore, these muscles wrap around the vaginal opening and the anus, so any muscle tension can lead to pain with penetrative sex. Finally, several pelvic floor muscles are directly connected to the clitoris, as a result any impairments to those muscles could cause a person to have pain with external stimulation and orgasm.
Sometimes what can happen is a person attempts to have sex and it is painful, as a result the brain may hold on to that experience and tell the muscles, “The next time something tries to enter, be on alert!” So the muscles may tense up more, which can lead to more pain and this rightly causes someone to be afraid of engaging in the painful activity, which can lead to more muscle guarding and a vicious cycle is created.
Luckily, there are many things to help someone who is having pain with sexual activity. Treatment usually focuses on improving muscle tone and facilitating pelvic floor relaxation. Breathing exercises and different stretches can aide in down regulating the nervous system and relaxing the pelvic floor muscles. Depending on the person, their treatment may involve exercises to help prevent the pain-guarding cycle mentioned above. Certain tools, such as dilators, may be recommended. Another tool, called The Ohnut can be helpful as it modifies the depth of penetration which can help reduce pain.
Many people aren’t ready to return to sex, or if sex was painful for so long some people feel like they don’t know how have pleasurable sexual experiences. That is why I recommend people try and start with non-sexual pleasure. Try to find an activity that brings them joy. It doesn’t need to be anything novel, it could be a nice cup of tea or spending time cuddling their pet. Maybe they splurge on some fancy bubble bath or lotion. Do something to treat themselves and then practice being present in that moment. They should try to lean into all the senses. Notice the steam coming out of the mug. Feel how warm the cup feels on their hands. Lean into how it tastes when they take that first sip and try to really savor it.
Other times to practice this mindful meditation is during a meal or while taking a shower. From there, a person can move into more sexual activities. Maybe buy some lingerie or a new vibrator. Try listening to some erotica or reading a spicy novel (ACOTAR anyone?)
Starting solo can help build up confidence before adding in a partner. But everyone is different and that is why I encourage working with a specialist that understands sexual health and pelvic pain, so that they can receive an individualized treatment plan that works best for them and their needs. People can work with a specialist in-person or virtually, either way help is available so that people can have less pain and more pleasurable experiences.
