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Endometriosis and Sexual Function | Image Courtesy of Anthony Tran via Unsplash
Endometriosis and Sexual Function | Image Courtesy of Anthony Tran via Unsplash

Endometriosis and Sexual Function Require a Specialized Approach

Endometriosis is a global disease affecting 5-15% of women during their reproductive years. It is characterized by the presence of endometrial-like tissue outside of the uterus which can trigger a local inflammatory response and can have a significant impact on patients’ quality of life.

One such domain of quality of life that is often affected is the correlation between endometriosis and sexual function. The DSM-V defines sexual dysfunction as a clinically significant disturbance in a person’s ability to respond sexually or to experience pleasure and includes pelvic pain, penetration disorders, lack of sexual interest, and/or arousal and orgasm disorders. Unfortunately, it is common, as approximately 40% of women with endometriosis and chronic pelvic pain suffer from sexual dysfunction. 

Why does painful sex occur with endometriosis?

It is thought that women with endometriosis experience dyspareunia (pain with sex) due to endometrial lesions on specific areas, such as the uterosacral ligaments, pouch of Douglas, posterior vaginal fornix and anterior rectal wall. In addition, we know that endometriosis can affect women’s menses, bladder and bowel function, and pelvic pain regardless of where they are in their cycle. All of the above can affect sexual function. There is also a high rate of depression among those with endometriosis and there is a known link between depression and decreased sexual functioning. 

In addition, there are psychological factors in play. Pluchino, et al. (2016), states,

the association between coital pain and sexual dysfunction is the result of repeated experiences of sex associated with pain and fear of pain. The fearful reaction in turn negatively affects desire, arousal, reward, lubrication, loss of genital congestion and heightened pelvic floor tone in a circular model.”

Emotional elaboration (anxious, frustrated, guilty, etc.) and cognitive elaboration (hypervigilance, catastrophizing) can also lead to poor pain perception and decreased pain tolerance. 

Infertility can also affect our feelings towards sex. For example, decreased sexual self-esteem, feelings of failure of not being able to conceive, as well as experiencing external pressures can definitely contribute to overall poorer attitudes towards sex. Fertility status, length of infertility, and IVF are associated with overall decreased sexual functioning as seen on scores on an outcome measure that specifically measures these (Female Sexual Functioning Index, or FSFI). 

Are there other options besides surgery for endometriosis to improve my sexual function?

The best way to treat endometriosis is surgical excision. There are a number of studies that show improvement in sexual functioning after surgical excision. One study showed an improvement in arousal, desire, and pain six months after surgical excision of those with deep endometrial lesions. A different study showed that six months after surgical excision of deep endometrial lesions, patients reported a significant increase in satisfaction and desire at a level similar to those reported by healthy controls! However, depending on how long one has been symptomatic, it can be more difficult to achieve a pain-free sexual lifestyle even after surgery. A systematic study summarizes a key message that although surgery can improve many symptoms, it does not necessarily resolve sexual dysfunction. The authors recommend a multidisciplinary approach with “the aim of improving global sexual functioning, and not just reducing pain at intercourse,” including addressing physical/anatomical, psychosocial, and emotional factors. 

What will Physical Therapy do to reduce endometriosis pain during sex and improve sexual dysfunction?

Pelvic floor physical therapists can help create a healthy, optimal pelvic floor. More often than not, those with symptomatic endometriosis or suspected to have endometriosis demonstrate a hypertonic (or overactive) pelvic floor. Hypertonic muscles are short, weak muscles and can develop trigger points in the muscles. The hypertonicity and trigger points can lead to pain with sex, bladder dysfunction (with symptoms of urgency, increased frequency, incomplete emptying), and bowel dysfunction (constipation, pain with defecation, and more). In addition, pelvic floor physical therapists can help address common digestive symptoms such as bloating and abdominal pain by working on visceral (abdominal fascial and organ) mobility. Visceral mobilization techniques help keep organs moving fluidly as they can sometimes be tethered by endometrial lesions.

Specialized physical therapists would:

  • address trigger points and hypertonicity of the pelvic floor muscles
  • educate on bladder/bowel strategies to optimize function
  • teach how to use tools to improve sexual function (medical dilators, pelvic wands)
  • implement visceral mobilization of abdominal organs
  • apply autonomic nervous system downtraining techniques
  • address other musculoskeletal drivers head to toe (jaw, neck/shoulder, hips, low back, etc.) 
  • present an individualized and appropriate exercise/stretch program for you

Don’t know where to start?

Start with a pelvic floor physical therapist to get a full examination (orthopedic and pelvic floor) and help with guidance throughout your journey to the appropriate practitioners and treatments. Contact us for questions, concerns or to make an appointment.

 

References:

Barbara G, Facchin F, Meschia M et al. What love hurts. A systematic review on the effects of surgical and pharmacological treatments for endometriosis on female sexual functioning Nordic Federation of Socieities of Obstetrics and Gynecology 2017;96:668-687. 

Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2021; 000:1-10.

Donato ND, Montanari G, Benfeati A, et al. Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women. J Fam Plann Reprod Health Care 2015;41:278-283. 

Pluchino N, Wenger Jean-Marie, Petignat P, et al. Sexual function in endometriosis patients and their partners: effect of the disease and consequences of treatment. Human Reprod Update 2016;6:762-774. 

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Testimonial by Carolina J.

I had tried Pelvic Floor Physical Therapy before (with another PT) and I had a really bad (painful) experience. A friend of mine and fellow patient, told me about Heather, Laureen and Femina PT (née Fusion Wellness & Physical Therapy) and I decided to try again. I am so happy I did! Femina PT have, literally, changed my life. I was able to do again things I couldn't do for over 10 years!! Their bedside manners are impeccable, their knowledge and understanding make me feel comfortable to recommend this place to anyone in pain. Specially if you have Endometriosis. 100% recommended!!

-- Carolina J., 12/28/16 via Yelp!

Testimonial by J.H.

My last appointment with Heather was over 6 years ago but I still think of her every day. I don’t take for granted that I can easily get out of bed, care for my two active and busy young boys, run, play tennis, clean my house, or sit at a desk for several hours at a time. None of these tasks were easy for me before meeting Heather. Eight years ago my car was struck from behind by a tractor trailer that was estimated to have been speeding. I spent 3 years working with different PTs and Drs trying to heal and move on with my life. When I became pregnant and the hormone relaxin that “relaxes” all the joints of the body and the additional weight gain erased all my progress and I was suddenly in a lot of pain again. My OB sent me to Heather for one last try.

Read more: Testimonial by J.H.

Testimonial by A.W., age 32

I wanted to let you know that my pelvic floor held strong and gave me no trouble whatsoever in my trail race this morning (12 miles)! In a way, I felt like I ran better than ever because my core feels so rock solid from all the exercises you have me doing. That was especially valuable on the technical downhill - I just flew down the trail because I had confidence in my balance and form. Thank you for helping me get back to doing what I love.

-- A.W., age 32
(completed Post-partum Renewal Program using the InTone biofeedback/stim unit)

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 Jamie M.

I have been going to see Heather for a while now, and I can't tell you enough how much she has improved my quality of life. Heather specializes in issues like pelvic floor, but I see her for other orthopedic issues.

I have a lot of chronic joint pain and dysfunction issues (back, hips, neck) that require that have ongoing physical therapy maintenance. The effects of my problem joints/areas overlap and interconnect with each other in complex ways, so helping me requires really having a complete understanding of the entire skeletal and muscular system. Pain does not always appear where the problem actually is, the human body is a twisty, many-layered puzzle. I have an exercise program I do at home and I am very functional, but there are just something things I need a PT to help me out with.

Read more: Testimonial by Jamie M.

Testimonial by P.M.

I was hopeful but frankly skeptical when the doctor treating me for Interstitial Cystitis recommended that I go to Heather for physical therapy. Medication and diet helped control my IC symptoms, but I had never heard of physical therapy being used to treat IC. The education and treatment I received from Heather was a revelation. She explained that the pain I experienced with IC had helped create a cycle of muscle guarding which affected the entire pelvic area. I had no idea of the amount of tension being held there. No wonder my husband and I had not been able to have sexual intercourse for years!

Read more: Testimonial by P.M.

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