Pain During Sex with Endometriosis: What's Really Happening

I remember the moment my boyfriend asked, "Does it hurt?" I wanted to lie. I wanted to say no, that I was fine, that this was normal for everyone. Instead, I felt tears start rolling down my face. We stopped. He held me. And I felt the deepest shame I'd ever known.

This is the part of endometriosis that doesn't show up on scans, that doesn't fit neatly into a clinical category, and that most doctors minimize. Deep dyspareunia—pain during deep penetration—affects up to 50-70% of women with endometriosis. But it's not just a physical problem. It's anatomical, neurological, and psychological. And it wrecks relationships, self-esteem, and the capacity to feel like yourself.

Let me walk you through what's actually happening in your body. Because once you understand the mechanism, the shame starts to lift. You can stop blaming yourself and start addressing what's broken.

The Anatomy: Where the Pain Comes From

When endometrial lesions implant on the uterosacral ligaments—the thick ligaments that support your uterus from behind—they create scar tissue and inflammation right where your vagina and rectum meet. During deep penetration, pressure is applied directly to these lesions. Your nervous system recognizes this as injury. Pain is the signal.

This is not psychological. This is not "all in your head." This is a nerve fiber receiving a real injury signal from damaged tissue.

But here's where it gets more complicated: your pelvic floor muscles are attached to these same ligaments. When you experience pain during sex, your muscles reflexively tense—a protective mechanism. Your pelvic floor is saying, "Something bad is happening, we need to brace." That tension is adaptive in the moment but becomes maladaptive over time.

The Neurological Piece: Central Sensitization

After repeated painful sex, something happens in your nervous system called central sensitization. Your spinal cord and brain essentially "turn up the volume" on pain signals. A touch that used to hurt a little now hurts a lot. Your nervous system has become hypervigilant, anticipating injury even when the original lesion might be healed.

This is why some women still experience dyspareunia after excision surgery—not because the surgeon missed lesions, but because their nervous system has been rewired by years of pain. The tissue might be gone. The signal is still screaming.

Researchers call this "phenotypic switching"—your pain response has switched from peripheral (caused by tissue damage) to central (caused by your nervous system's interpretation of threat). Both are real. Both require different treatment approaches.

The Psychological Trap: Shame as Its Own Prison

Here's what I don't see enough providers talk about: the psychological trauma of painful sex with endometriosis.

You want to be close to your partner. You also know it's going to hurt. So you either avoid sex (which creates distance and guilt) or endure it (which creates resentment and dissociation). Over time, you start avoiding physical touch altogether—not just sex, but kissing, cuddling, being touched. Your nervous system has learned to interpret closeness as threat.

This isn't broken. It's a completely rational response to repeated injury. But it's also profoundly lonely.

Many women internalize this as: "I'm broken. I'm not a real woman. My partner would be better off with someone else." That's the lie that endometriosis tells you, and it's almost never true. But the pain is so real, and the shame is so powerful, that you start to believe it anyway.

What Actually Helps (Beyond "Use More Lube")

Pelvic floor physical therapy: A skilled pelvic floor PT can assess whether your muscles are hypertonic (too tight) and teach you to release them. This might involve internal work, breathing techniques, or movement patterns. It's not kegels. It's active lengthening and coordination. For some patients, this alone significantly reduces dyspareunia.

Addressing the lesions: If you have uterosacral or rectovaginal lesions, excision surgery can help. Not universally, and not always completely, but it removes the tissue causing direct pain signals. Surgery should be paired with nervous system work—you're addressing both the source of the signal and the sensitivity of the receiver.

Nervous system retraining: This is where psychologically-informed physical therapy, somatic therapy, or trauma-informed sex therapy comes in. You're teaching your nervous system that closeness is safe. This takes time. It requires approaching intimacy differently—slower, more aware, with explicit communication and consent. You're literally rewiring neural pathways.

Sexological bodywork: Some providers specialize in helping patients with vaginismus or dyspareunia relearn touch and pleasure. This is not standard physical therapy—it's therapeutic work that addresses both the body and the mind's relationship to it. It's controversial in some circles, but research supports its efficacy for pain-related sexual dysfunction.

Communication and relationship work: Your partner needs to understand what's happening. Not to "fix" you, but to understand that this is complicated. That it's not about them. That patience and presence matter. Sometimes a sex therapist or couples counselor helps navigate this conversation.

The Bottom Line

Your pain during sex is real. Your desire for intimacy is also real. These two things can coexist, and you can work through it. But "just use lube" is like telling someone with a broken leg to "just stretch more." It misses the pathophysiology entirely.

You need someone who sees the dyspareunia as a problem worthy of attention—someone who doesn't minimize it, who understands it's multifactorial (anatomical, neurological, and psychological), and who is willing to partner with you in addressing all three dimensions.

And here's what I want you to know: you're not broken. Your body isn't broken. A system that ignored your pain for years is broken. A healthcare model that treats sexual dysfunction as a side note rather than a primary concern is broken. But you? You're doing your best with a complicated disease.

You deserve to feel pleasure again. And that's worth the work to get there.