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Deep Infiltrating Endometriosis and Sexual Function

What is Endometriosis and Deep Infiltrating Endometriosis?

Endometriosis is a benign condition where endometrial tissue (the lining of the inside of the uterus) grows outside of the uterus.

About 5-10% of reproductive aged persons with female-associated genitalia have endometriosis. Symptoms can range from no symptoms to debilitating pelvic pain with dysmenorrhea, pain with periods, abdominal pain, genital pain, bladder dysfunction, bowel dysfunction and possibly other symptoms. In addition, endometriosis is known to also affect sexual quality of life. Pain with sex is called dyspareunia; while deep infiltrating endometriosis is a more severe form of endometriosis.

What is Deep Infiltrating Endometriosis? 

Deep infiltrating endometriosis (DIE) is a more severe form of endometriosis defined by endometriotic lesions that penetrate 5 or more mm beyond the peritoneal border. Cozzolino, et al found the most common symptoms of those with DIE include chronic pelvic pain (67.1%), dysmenorrhea (66.5%), dyspareunia (41.8%), constipation (32.4%), and painful urination (6.5%). 

Endometriosis, DIE & Sexuality

With the high number of people experiencing dyspareunia, it is not surprising to see that Deep Infiltrating Endometriosis is correlated with decreased quality of life and sexual function.

Jarzabek, et al found that dyspareunia is four times more common in those with endometriosis compared to controls, and five times more common in those with peritoneal endometriosis (DIE) than those with endometriotic cysts. Patients with any stage of endometriosis are likely to have some degree of sexual dysfunction, including pain with sex, reduced lubricancy, arousal, desire, orgasm leading to overall decreased frequency of sexual intercourse.

Several authors have agreed that Deep Infiltration Endometriosis in specific landmarks within the pelvic cavity increases the likelihood of sexual pain: uterosacral ligament, pouch of Douglas, posterior vaginal fornix and the anterior rectal wall. Di Donato, et al. found that the number of DIE nodules was directly proportional to reduction of sexual desire. Sexual dysfunction from endometriosis is likely due to pain, tissue fibrosis, chronic inflammation, adhered pelvic structures and possible infiltration of nerve fibers. 

How to treat endometriosis with dyspareunia: 

Endometriosis and Deep Infiltrating Endometriosis can be treated conservatively via hormonal treatments and medical management which can alleviate symptoms. However, surgical excision has been proven time and again that it can significantly restore sexual function and satisfaction. Sexual quality of life, health-related quality of life and mental health significantly improved in patients after excision surgery.

However, one study showed that sexual satisfaction with partner did not improve postoperatively (Setala et al. 2012). We must acknowledge that sexuality is multifactorial and is influenced by our physical, psychological and social well being that can also affect our relationships. Thus it is important that we not only treat the source of the pain/sexual dysfunction, but utilize a multidisciplinary approach to help treat all aspects of sexuality. A team consisting of a gynecologist, pain management specialist, nutritionist, therapist and pelvic  floor physical therapist is crucial to helping combat sexual dysfunction and pain, but can also help with other symptoms associated with endometriosis. Give us a call or send us a message.



Cozzolino M, Magro-Malosso ER, Tofani L, et al. Evaluation of sexual function in women with deep infiltrating endometriosis. Sex & Reprod Healthcare 2018;16: 6-9.

Di Donato N. Montanari G, Benfenati A, et al. J Fam Plann Reprod Health Care 2015;41:278-283. 

Fritzer N, Tammaa A, Salzer H & Hudelist G. Dyspareunia and quality of sex life after srugical excision of endometriosis: a systematic review Euro J Obstetrics & Gyne and Reprodutive Biology 2014;173:1-6. 

Jarzabek-Bielecka G, Radomaki D, Pawalczyk M et al. Dyspareunia as a sexual problem on women with endometriosis Arch Perinat Med 2010;16:51-53. 

Martinez-Zamora M, Coloma JL, Gracia M, Rius M, et al. Long-term Follow-up of Sexaul Quality of Life After Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis. J of Minimally Invasive Gynecology 2021;28(11):1912-1919.

Setala M, Harkki P, Matomaki J, et al. Sexual functioning, quality of life and pelvic pain 12 months after endometriosis surgery including vaginal resection. Acta Obstet Gynecol Scand 2012; 91:692-698. 

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What Our Patients Have to Say


Testimonial by M.N., age 28

A personal journey and testimonial from one of my patients:

I was diagnosed with vaginismus 4 years ago. I never heard of such medical condition until after I got married. At first my husband and I didn't know what to do, we didn't know what the issues were or how to overcome it. Being born and raised in Armenia and being Christian I wasn't that open about talking to sex with others and so it wasn't easy to seek help. But eventually I went to an Ob-Gyn and luckily she knew about the medical condition (not many doctors know). She referred me to a physical therapist and I couldn't believe it and thought it's something I can handle myself. I ordered a kit from vaginismus.com and started practicing with dilators. There was some small progress but wasn't much helpful.

Read more: Testimonial by M.N., age 28

Testimonial by J.B.

My husband and I were having problems with painful intercourse. My therapist recommended that I go and get a pelvic floor evaluation from a physical therapist. Having never been treated by a physical therapist, I wondered how this really was going to help me. My husband who is a physician was very supportive and agreed that a PT evaluation would be a great idea. So i made the appointment and was blown away by what I learned. I had no idea that pelvic floor muscles could get tight and have trigger points just like any other muscle in the body. I'm a massage therapist and very familiar with tight muscles, and this new thought really amazed me. Heather's program to help relax and strengthen these muscles made such a difference. I can say that I am 100% pain free during intercourse now. Yippee! Going to the PT appointments and doing the at-home exercises was definitely a discipline, but it's 100% worth it! The rewards are amazing.

-- J.B.

Testimonial by Alexandra B.

Heather is without exaggerating AMAZING! After years of trouble with a certain part of my body, in no time, she made everything change back to equilibrium and to what would be considered normal. She explains everything in detail and therefore gives you a better understanding of why things are the way they are, and how you can work towards turning things around. I would highly recommend Heather for any type of Physical Therapy. She has created her own "Method/Therapy" through years of studying (with some of the greatest practitioners), practice and breaking down the issues of her past patients, enabling her to fine tune her own system. I'm so thankful to have found her, and I'm especially grateful for the quick recovery I've achieved, after years of distress. If you cannot afford her, I recommend you purchase her book. Although it may not be Heather in person, it can still help you to get on the right path to recovery!

-- Alexandra B., 5/20/2015 via Yelp!

Testimonial by Fritzette H.

I went to Heather after the birth of my third child. It was lucky, really, that I was referred to her, because my doctor had referred me to a surgeon for a possible hysterectomy or pelvic wall rebuild. Thankfully, I went to Heather before undergoing either surgery, she was able to fix the problem. She has studied extensively in women's health--even written a book about it--and was able to diagnose my problem, suggest a course of treatment (6 weeks), and then follow through with said treatment. By the end, as she said, I was as good as gold. Boy, was it worth it! Though uncomfortable to talk about, much less write about, it is worth getting the word out there. If you have painful intercourse, especially after birth or other trauma, the treatment may be as simple as Physical Therapy (with Heather, of course). I highly recommend her.

-- Fritzette H., 3/24/16 via Yelp!

Testimonial by R.M., Age 40

I can’t speak highly enough of the theapists at Femina Physical Therapy and how much they have helped me grow, discover, and love my body. I had had painful sex for my entire life, and didn’t know that there was anything that could be done about it. It was at the point where my husband and I were not having sex for MONTHs, because it was just too frustrating, and I hated feeling like I was the ONLY woman out there who had this problem, especially at my age. I finally brought it up to my doctor because I was turning 40 and my husband and I were barely having enough sex to conceive. And she brought up pelvic floor, PT. I didn’t even know this was a “thing”.

Read more: Testimonial by R.M., Age 40

Testimonial by Rosanna R., age 35

Heather has affected my life in the MOST POSITIVE way and I am forever grateful. My husband refers to her as the "sex doctor" so you can only imagine how happy he is with my therapy outcome.

After the birth of my son I suffered from "Vaginismus", however, at the time I just thought I was broken. My "broken vagina" affected me physically but it was an emotional struggle as well. Many women in my life also suffered with pain from sex after their babies were born so I knew I wasn't alone. They told me they "just got used to it" but I couldn't see myself living that way.

Sex wasn't just painful, it was literally impossible - IT DIDNT FIT!

Read more: Testimonial by Rosanna R.,...

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