9 Root Causes of Painful Sex with Endometriosis

Today’s episode is another in the root causes series and I’m talking about the root causes of painful sex with endometriosis.

92% of you voted for this episode, so I’m assuming that if you voted, you likely struggle with this symptom. But having painful sex isn’t just part and parcel of having endometriosis - there are things that can be done, and it begins with identifying why you’re experiencing pain in the first place.

Endo is complex and the stress it puts on the body can lead to other conditions and complications developing, so we’re going to explore some of these here. If you can begin identifying even just one root cause, the road ahead to healing pain will become clearer. 

Again, this is about shining a light on the root causes so you’re no longer in the dark about your health. You don’t have to deal with them all and it’s unlikely you’ll have them all, just begin with one area and take baby steps there. 

As I’ve mentioned with all these episodes, this list isn’t exhaustive, but it does include some of the most common conditions associated with painful sex and associated with endometriosis.

TRIGGER warning: This episode briefly discusses sexual trauma.

Vulvodynia - Vulvodynia is a condition of chronic pain in the vulva area, that is usually worsened by sitting, sex, going to the toilet and movement. You may not have the pain all the time, but it is reoccurring, though some can experience the pain constantly. Many report the pain as a burning/stinging/itching/aching/throbbing sensation.

Causes can include untreated or resistant infections like candida, nerve hypersensitivity, damage or trauma to the area, pelvic floor dysfunction and chronic inflammation.

In the case of developing vulvodynia with endometriosis, I would argue that the amount of inflammation and an upregulated nervous system from years of chronic pain could in time affect the vulva area, as well as having a tight pelvic floor, which is common with endo patients.

Vaginismus - Vaginismus is a condition where the vaginal canal involuntarily spasms and closes, usually in response to some kind of penetration, though I’ve spoken to many people with vaginismus and they report this spasming to eventually happen all the time.

This is thought to occur as the body’s response to fear of penetration, even if you don’t mentally feel scared.

Vaginismus can be caused by multiple issues. It could be that endo has created so much pain internally that your body now has a fear of sex hurting and so essentially closes up shop. Constant painful, traumatic, invasive and embarrassing medical examinations that you may have endured whilst trying to get an endo diagnosis, or following one, may have triggered the onset of vaginismus as well. Uncomfortable or distressing feelings about sex like shame, guilt or trauma can also cause the condition too.

Adhesions or distorted fascia - Adhesions are web like scar tissue structures that do not show up on scans as they’re made of collagen. They grow in response to a wound or trauma and attempt to ‘knit’ an area back together, but can often continue to grow and extend, attaching to organs, wrapping around organs and sticking to surfaces.

Adhesions are VERY strong and will cause pain and discomfort, and can pull and tug on organs, restricting their movement and even function.

Fascia is a thin sheet of tissue which covers the entire body, sits below the skin and encases the muscles, bones and organs. Endo can grow on the fascia and cause puckering in the surface of it, and excisions form surgery can also cause the fascia to pucker from scar tissue. This puckering pulls the fascia out of shape and can distort the fascia across the rest of the body - think of what happens when you pinch a nice neat bed sheet.

If you have adhesions or your fascia is tight and distorted, this could result in painful sex. There may be pulling on your vagina or uterus, they may be putting pressure or causing pain on surrounding organs, which could then impact sex as the organs in the pelvic area are so closely packed together. Don’t forget, your bladder sits in front of your uterus and vaginal canal and your bowel sits directly behind. If any of these are tethered to each other and/or the pelvic wall, this could cause a lot of tension, tugging and pain during sex.

Pelvic Floor Dysfunction - Many people with endometriosis have a tight pelvic floor.

Think of your pelvic floor as a bowl made of nerves and muscle and in the bowl sits your bladder, vagina and uterus, and colon. These muscles and nerves help to control the function and sensitivity of these organs.

When you live in chronic pain due to endo, these nerves in the pelvis get used to sending out distress signals and receiving pain signals, and over time, the nervous system becomes upregulated and this path of distress becomes the default option for your nerves. They become easily triggered, even by something that wouldn’t normally cause pain.

Equally, as your muscles continuously react to chronic pain, they begin to tighten. This tightening occurs to both protect you but also as a result of the positions we often adopt when we’re in pain, like curling into a ball.

The tightness causes tension, irritates the nerves and distorts the way the organs are sitting and functioning.

Vaginitis - Vaginitis is a sort of blanket term for inflammation and irritation caused by, most commonly, some kind of infection. Symptoms include swelling, itchiness, pain and sometimes unusual discharge or some bleeding. Vaginitis isn’t common within the endo population specifically, but it is common in general.

Causes include STIs, candida overgrowth, allergic responses to chemicals in contraception, lubricants, body washes, etc., and changes in hormones. 

Endo lesions - Endo lesions cause pain, swelling and scar tissue on both the surface their attached to and the surrounding area, and can cause cramping as they shed with the hormone cycle.

Endo lesions can be found on the bowel, pouch of Douglas (between the uterus and the bowel) and bladder, amongst of course other areas such as the pelvic cavity and ovaries. These are all very close to vaginal canal, especially if the endo is in the pouch of Douglas, as penetration may be almost directly irritating these endo lesions. 

Chronic inflammation - Endo is an inflammatory disease. It creates its own inflammation, it uses inflammatory chemicals in its development and growth, and it triggers the immune system to send inflammation to the area.

Inflammation causes pain and swelling, and as the endo lesions are chronic, this swelling and pain can spread throughout the pelvis as the body attempts to get our attention. Meaning that even if you’re vaginal canal or surrounding area isn’t directly being affected by endo, you may experience pain there.

IBS - Many people with endo experience IBS like symptoms, which can include bloating, gas, constipation and diarrhea. All of these can make the abdomen and pelvic area tight, swollen, painful and uncomfortable.

Your intestines sit right above your uterus and your colon is right behind the vagina and uterus, so if your intestines are inflamed and swollen, the chances are that these are going to be putting pressure on surrounding organs and the inflammation and pain signals will also likely spread to these as well.

Equally, IBS problems cause leaky gut. Leaky gut allows allergens and particles to flow through the gut barrier, causing an immune reaction which releases inflammation into the body. Toxins from infections and problems like SIBO can also pass through the barrier and end up in the pelvic cavity, creating further inflammation. 

Upregulated nervous system - The brain is designed to protect us from threats. If you have experienced chronic pain, this may have created a loop where the nerves are signalling distress signals to the brain, which then registers with pain to alert us to the problem, inflammation is released but the endo lesions don’t heal, so more distress signals are released and so on. Eventually, over time, this becomes your nervous system’s default pattern - it associates the pelvic areas with danger.

This is made worse if you’re experiencing chronic stress or acute moments of stress, if you feel unsafe in your body, your home or with your sexual partner. This stress is telling the brain it’s right to feel unsafe and the danger signals are heightened. 

Of course, if you’ve experienced sexual trauma this is likely to have had an impact on your brain’s perception of safety in your pelvis and pain may be the brain’s way of alerting you to that trauma, whether past or present.

Scroll to my show notes to learn more about diagnosing these conditions or getting help identifying these issues, and for references and further reading/listening.

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This episode is sponsored by my free guide ‘A Natural Pain Relief Tool Kit for Endometriosis’. This four page guide includes evidence based and effective remedies which you can use at home to reduce your pain with endo. Download your copy here.

My cookbook This EndoLife, It Starts with Breakfast is out now! Get 28 anti-inflammatory, hormone friendly recipes for living and thriving with endometriosis. Order your copy here.

If you feel like you need more support with managing endometriosis, you can join Your EndoLife Coaching Programme. A 1-to-1 three month health and life coaching programme to help you thrive with endometriosis. To find out more about the programme and to discuss whether it could be right for you, email me at [email protected] or visit my website.

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Show Notes

Vulvodynia

National Vulvodynia Association

Functional Nutrition Treatment of Vulvodynia, Irritable Bowel Syndrome, and Depression: A Case Report

NHS vulvodynia page

An Integrative Approach to Healing Vulvodynia w/Hannah Matluck of the V Hive

The Changing Landscape of Sexual Health In Medicine w/Dr. Heather Quaile

Vaginismus

Vaginismus And The Overlaps Between Pelvic Pain Conditions With Shelby Hadden of Tightly Wound

Self-Love And Reclaiming Womanhood With Oliwia Drzymuchowska Of Womanology

The Vaginismus Network

NHS vaginismus

Adhesions and distorted fascia

The Healthy Gut Podcast Ep.25: Adhesions And SIBO With Larry And Belinda Wurn

The Healthy Gut Podcast Ep.33: Visceral Mobilisation With Alyssa Tait

The Period Party Podcast: Mercier Therapy for Conditions with Dr. Jennifer Mercier

The Best Surgery for Endometriosis with Dr. Andrew Cook

Pelvic Floor Dysfunction

Equal Treatment for Black Endometriosis Patients and Pelvic Floor Physiotherapy for Painful Sex, Interstitial Cystitis and Endometriosis with Dr. Juan Michelle Martin

Your Brain on Pain - How Your Nervous System Affects Interstitial Cystitis and Endo Pain with Dr. Nicole Cozean

Pelvic Floor Therapy for Endometriosis with Heba Shaheed of The Pelvic Expert

Vaginitis

NHS vaginitis

Endo lesions

The Best Surgery for Endometriosis with Dr. Andrew Cook

Six Tips for Reducing Endometriosis Pain in The Week Before Your Period

Inflammation

Outsmart Endometriosis: The Elimination 'Undiet' for Endometriosis with Dr Jessica Drummond

Antioxidants for Endometriosis

Anti-inflammatory Living for Endometriosis

What is The Endometriosis Diet with Henrietta Norton of Wild Nutrition

IBS

Dr. Ruscio How To Heal Leaky Gut

Understanding The Endometriosis Belly, Part 1

Understanding The Endometriosis Belly, Part 2

Understanding The Endometriosis Belly, Part 3: SIBO Symptoms

“Leaky Gut” and Pelvic Pain Dr. Jessica Drummond

The SIBO, Endometriosis and Interstitial Cystitis Connection wth Dr. Allison Siebecker

How To Treat SIBO with Dr Allison Siebecker

How Do You Know When to Test for SIBO?

How to Test for SIBO at Home

Upregulated Nervous System

Your Brain on Pain - How Your Nervous System Affects Interstitial Cystitis and Endo Pain with Dr. Nicole Cozean

Taking An Integrative Approach to Endometriosis with Jessica Drummond of The IWHI

Anti-inflammatory Living for Endometriosis

Healing Endometriosis-Associated Dyspareunia and Rediscovering Pleasure with Elena of The Yoni Empire

Communication, Relationships and Endometriosis with Melanie Cox

Endometriosis and Energy Healing with Aubree Deimler of Peace with Endo