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Endometriosis Symptoms: Painful Sex (Dyspareunia)

What is painful sex?

The third predominant symptom of endometriosis is painful sex (dyspareunia). Patients with endometriosis often find themselves experiencing physical pain when engaging in sex, which is a very personal note for patients to express to their gynecologist. Nevertheless, it must be taken into account as it can help determine the level of pain and the anatomical location to which endometriosis lesions are located.

Pain with sex (dyspareunia)
Pain with sex (dyspareunia) occurs due to fibrosis and inflammation forming around the posterior cul-de-sac. The mobility and expansion of the upper vagina that normally occurs during intercourse thus becomes much more painful and irritating.

How does endometriosis cause pain during sex?

The area behind the uterus is called the cul-de-sac, or Pouch of Douglas. Normally it is lined by the smooth peritoneum, the skin-like sheet of tissue that covers the uterus and vagina anteriorly (in front), and the rectum posteriorly (in back), keeping the rectum, vagina, and uterus free from each other. Endometriosis will frequently adhere the vagina to the rectum. The pain caused by endometriosis during sex is deep; it comes from the inflammation and fibrosis fusing the front wall of the rectum to the back wall of the vagina. Mobility and expansion of the upper posterior vagina behind the cervix normally occurs during sex, but not if endometriosis is present. The pain can be more intense in certain sexual positions than in others, depending on exactly where the endometriosis is located and how advanced it is. If it’s widespread, the woman may hurt no matter what position she’s in.

Communicating painful intimacy issues
Communicating painful intimacy issues with your partner while difficult, is essential.

The care needed to discuss painful sex

Painful sex is a very personal matter and it can be extremely difficult to discuss the physical challenges experienced during sex. When a woman visits her doctor and discusses her symptoms, it’s rare for her to voluntarily mention painful sex as being one of them. Nevertheless, it is an important fact for her to disclose, not only for the good of her physical health, but also because the symptom is one that can cause tension in, or even break up, a relationship.

Surgery for painful sex

Laparoscopic excision of endometriosis is the gold standard for conservative surgical treatment. However, in cases of painful sex, it is important to specify that there must be a focus on endometriosis infiltrating the anterior and posterior cul-de-sac. By focusing on these areas, studies have found that upon removal of the endometriosis through excision surgery, patients experience improvements in dyspareunia symptoms as well as the quality of their sex life. It is, therefore, crucial to discuss these types of findings when choosing a doctor if a patient decides that surgical excision is the right treatment option.

Others ways of managing painful sex

While dealing with painful sex can be highly difficult, there are ways and tips to keep in mind in order to find relief in this constant struggle, such as:

  • Communication: Sex is meant to be a pleasant experience between two people who care for one another. Therefore, it is important to be vocal to your provider and your partner about your symptoms, Do not stay silent and ignore yourself.

  • The timing of sex: Many women who experience dyspareunia due to endometriosis find that their pain varies depending on the timing of their menstrual cycle, and this is no coincidence. Because endometriosis is a disease of menstruation, pain can be aggravated during a woman’s period. Some couples find relief by not engaging in sex during the woman’s period.

  • Other forms of intimacy: Couples have found relief from dyspareunia symptoms by engaging in other forms of intimacy, especially during the woman’s period. Sex is not the only way to find pleasure in the bedroom. Other forms of pleasure include oral sex, mutual masturbation, etc.

The danger in "tolerating" the pain

Often, a woman experiencing pain during sex will not complain. She will tolerate it to a high degree perhaps because she does not want to interrupt the intimacy. She might be afraid of rejection or loves her partner too much to let anything stand between them. To her, the emotional side of sex, the intimacy, trumps the physical pain she has to endure. Sometimes a woman will even subconsciously refuse to accept that sex is painful because she fears how her partner will react. She may not want to be accused of not returning love or intimacy, or of having no interest in her partner.e. However, this is not the case. It is important for women suffering from endometriosis to know this is not "all in their head," nor is this the norm, but rather it is a real symptom of the disease that must be taken into account and resolved.

A partner’s role in cases of painful sex

Open communication with one’s partner is key
Open communication with one's partner is key when a woman is suffering from dyspareunia due to endometriosis.

From the partner’s perspective, it is difficult to know what a woman is going through because of how well she covers up her pain during intercourse. At worst, her partner may assume that sex is a little uncomfortable for her, but that it’s nothing to be concerned about because she is not expressing concern. Even a couple who has had a strong relationship for several years can face struggles if the disease causes the frequency of sex to diminish. This is another reason why diagnosing and treating endometriosis early is so important. Nobody wants it to reach a stage in which it is affecting the patient’s intimate relationship. For men and women whose partners are suffering from endometriosis, it is thus crucial to support their lovers. This means being mindful and listening to your partner if they say they are in pain. It can also mean accompanying them to gynecologist appointments as often times, endometriosis experts recommend couples coming in together as the partner of the patient suffering may have a keen insight to the patient’s symptoms. And above all else, partners of endometriosis patients should make sure the woman knows that they are not alone in this battle and has the help and support of her love ones.


  1. S. Ferrero et al., "Deep dyspareunia and sex life after laparoscopic excision of endometriosis." Human Reproduction, Volume 22, Issue 4, 1 April 2007 p. 1142-1148. 

  2. Paul J. Yong et al., "Anatomic sites and associated clinical factors for deep dyspareunia." The International Society for Sexual Medicine. September 2017 Volume 5, Issue 3, Pages e184-e195. 

  3. Endometriosis and Painful Sex (Dyspareunia),