ENDOMETRIOSIS AND SEX.
The Symptom Nobody Talks About.
By Katie Rice | Accredited Naturopath & Nutritionist | Her Herbs Founder
There's a symptom that affects up to 70% of women with endometriosis. It impacts relationships, self-esteem, and quality of life in ways that go far beyond the physical. And it's the one symptom that almost never gets raised in a GP appointment.
Pain during sex.
If this is your experience, I want you to know two things. First, you are not alone. Second, there are real, evidence-informed reasons why this happens and things you can actually do about it.
Why Endometriosis Causes Pain During Sex
The medical term is dyspareunia, but the experience is far more complex than a clinical word suggests.
Endometriosis causes tissue similar to the uterine lining to grow outside the uterus, on the ovaries, fallopian tubes, bowel, bladder, and the tissue between the uterus and rectum, known as the pouch of Douglas. When endometrial lesions are present in these areas, penetration creates pressure on already inflamed, sensitive tissue. The result is pain, sometimes sharp, sometimes a deep aching pressure, sometimes pain that lingers for hours or days afterward.
There are several reasons this happens:
Lesion location. Deep infiltrating endometriosis, particularly lesions in the pouch of Douglas, is most commonly associated with painful sex. The depth of penetration and certain positions can directly compress affected tissue.
Inflammation. Endometriosis drives a chronic inflammatory state in the pelvis. Inflammation sensitises nerve endings, meaning tissue that might not normally register pain becomes highly reactive.
Pelvic floor dysfunction. This is one of the most underrecognised contributors. Women with chronic pelvic pain often develop protective muscle guarding, where the pelvic floor tightens involuntarily in anticipation of pain. Over time this becomes a pattern, and the muscles lose their ability to relax fully. This makes penetration painful regardless of lesion location.
Nervous system sensitisation. When pain has been present for a long time, the nervous system can become sensitised, essentially learning to amplify pain signals even when the original stimulus is reduced. This is called central sensitisation, and it means the pain experience can persist even after treatment of the underlying lesions.
The Emotional Weight
What the clinical literature rarely captures is what this actually does to a person.
Avoiding intimacy to avoid pain. Feeling like your body has failed you. Trying to push through because you don't want to explain, again, why sex hurts. Watching the distance grow in a relationship you want to be close in.
This is not weakness. This is what living with an undertreated, misunderstood condition does to a person over time. And it deserves to be taken seriously, not minimised, not worked around, but actually addressed.
What Can Help
The honest answer is that painful sex with endometriosis requires a multi-pronged approach. There is rarely one single fix, but there is a real pathway through it.
Specialist pelvic floor physiotherapy. This is the single most underutilised resource for women with endo-related dyspareunia. A pelvic floor physio who understands endometriosis can assess muscle tone, identify patterns of guarding, and work with you on both relaxation and rehabilitation. If you haven't seen one, this is where I'd start.
Addressing systemic inflammation. From a naturopathic perspective, reducing the inflammatory load in the body can meaningfully reduce pelvic pain over time. This includes an anti-inflammatory dietary approach, reducing refined sugars, processed foods, and pro-inflammatory oils, and increasing omega-3 fatty acids, colourful vegetables, and gut-supporting foods. This won't eliminate lesions, but it can reduce the inflammatory environment that amplifies pain.
Nervous system support. Because central sensitisation plays a role for many women, working with the nervous system is not optional, it's essential. This means prioritising sleep, managing stress load, and considering practices that actively down-regulate the threat response: breathwork, gentle movement, somatic therapies. The body needs to feel safe to release protective tension.
Magnesium. Muscle tension and cramping respond well to magnesium, and deficiency is common in women with endometriosis. Magnesium glycinate or bisglycinate are the most bioavailable forms and least likely to cause digestive upset.
Positioning and practical adaptations. Certain positions reduce deep pressure on the pouch of Douglas, typically those that allow the woman to control depth of penetration. This isn't a permanent solution, but it can reduce pain during the process of working on the underlying causes.
Open communication. With a partner, and with your practitioners. You should not have to manage this alone or in silence. If your GP dismisses painful sex as normal or unrelated to your endo, advocate for a referral to a specialist who understands the full picture.
Tracking Your Symptoms
If painful sex is part of your endometriosis experience, tracking it matters, not because you need to prove it exists, but because patterns matter clinically. Is it worse at certain points in your cycle? After certain foods? During flares? This information helps practitioners understand what's driving your pain and tailor treatment accordingly.
The Her Herbs Endometriosis Companion App includes space to log this as part of your daily symptom tracking, privately, in your own words, so that when you're ready to share it with a practitioner, the information is already there.
A Note From Katie
"Painful sex is one of the most isolating symptoms of endometriosis because it sits at the intersection of physical pain and emotional intimacy. I've sat with women in clinic who have been managing this for years without ever telling anyone, including their doctors, because they didn't know it was connected, or because they'd been made to feel like it wasn't a legitimate concern. It is legitimate. It is connected. And you deserve support for it."
- Katie Rice, Naturopath & Founder, Her Herbs
This content is for educational purposes only and does not constitute medical advice. Please consult your healthcare provider regarding your individual health concerns.
