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.
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.