Sex with Endometriosis: Pain, Libido, Intimacy, Diagnosis, and Safe Solutions

This material is for informational purposes only and does not replace a consultation with a gynecologist, endometriosis specialist, pelvic pain specialist, pelvic floor physical therapist, sexologist, or psychotherapist. Seek immediate medical attention if you experience sudden, severe pain, fainting, fever, heavy bleeding, pain associated with possible pregnancy, blood in urine or stool, urinary retention, vomiting, bloating, stool retention, or gas. [1]

Why sex can be painful with endometriosis

Endometriosis is a chronic condition in which endometrial-like tissue grows outside the normal uterine lining and can cause inflammation, pain, scarring, adhesions, infertility, and decreased quality of life. The World Health Organization (WHO) notes that painful sex associated with endometriosis can lead to interrupted or avoided sexual intercourse and impact the sexual health of both the patient and her partner. [2]

Pain during sex with endometriosis is called dyspareunia, but this term covers different mechanisms. Some women experience pain deep within the pelvis during penetration, others experience it at the entrance to the vagina, others experience it after intercourse, and others experience pain associated with fear of pain, pelvic floor muscle spasms, and decreased arousal. [3]

It's important to understand that painful sex with endometriosis is not a "quirk," a "psychological weakness," or an essential part of intimate life. A 2023 review found that endometriosis is associated with decreased female sexual function, decreased satisfaction, and relationship difficulties, so this symptom should be discussed as seriously as period pain or infertility. [4]

Pain during intercourse may be the only symptom a woman is embarrassed to discuss for a long time. This leads to delayed diagnosis: the patient may avoid intimacy for years, endure pain, consider herself "different," or believe the problem is only in the relationship, although it could be due to deep endometriosis, endometrioma, adhesions, or chronic pelvic pain. [5]

Current guidelines recommend assessing sexual pain not in isolation, but in conjunction with other symptoms: painful periods, chronic pelvic pain, pain during bowel movements, pain during urination, infertility, fatigue, anxiety, depression, and the impact of the disease on daily life. [6]

Table 1. What pain during sex with endometriosis can mean

Manifestation	Possible explanation	What is important to clarify
Deep pain upon penetration	Deep endometriosis, adhesions, painful ligaments	In which positions is the pain worse?
Pain at the entrance to the vagina	Pelvic floor, vulvodynia, dryness, inflammation	Is there a burning sensation and spasm?
Pain after sex	Inflammation, muscle spasm, pain sensitization	How long does the pain last?
Pain only before menstruation	Cyclic disease activity	Connection with the menstrual cycle
Pain during sex and bowel movements	Possible posterior pelvic lesion	Is there pain when passing stool?
Pain during sex and urinary symptoms	Possible combination with urinary localization	Is there blood in the urine?

Source for the table: [7]

Table 2. Why painful sex is not considered normal

Incorrect installation	Why is it dangerous?
"Everyone hurts sometimes."	Severe or recurring pain requires evaluation.
"You just need to relax."	The cause may be organ damage.
"It's just psychological."	Mental health affects pain, but doesn't eliminate endometriosis.
"It will pass after birth."	Pregnancy is not a cure for endometriosis.
"If the ultrasound is normal, there is no disease."	Superficial lesions may be invisible
"Sex must be tolerated for the sake of the relationship."	Enduring pain increases fear and avoidance

Source for the table: [8]

Table 3. Which areas of sexual function may be affected

Zone	How does this manifest itself?
Wish	Decreased libido due to pain, fatigue, or fear
Excitation	It's harder to relax and engage in intimacy
Lubrication	May decrease with pain, anxiety, or hormone therapy
Orgasm	May be difficult due to anticipation of pain
Satisfaction	Decreased by tension and avoidance
Relationship	Misunderstandings, guilt, and distance arise.

Source for the table: [9]

Table 4. What symptoms, along with pain during sex, are especially important?

Symptom	Why is it important?
Pain during menstruation	A common symptom of endometriosis
Pain outside of menstruation	Chronic pelvic pain may occur.
Pain during defecation	Deep back form is possible
Pain when urinating	Urinary localization is possible
Infertility	Endometriosis can affect fertility.
Fatigue and anxiety	Increases the burden of illness and sexual difficulties

Source for the table: [10]

Table 5. When an in-person consultation is needed

Situation	Who to contact
Sex regularly causes pain	Gynecologist, endometriosis specialist
The pain is deep and depends on the position	Gynecologist, pelvic imaging expert
Pain at the entrance to the vagina	Gynecologist, pelvic floor specialist
There is blood in the urine or stool	Gynecologist, urologist or proctologist
There is infertility	Reproductologist and gynecologist
The pain persists after surgery	Chronic pelvic pain specialist

Source for the table: [11]

Why Pain Occurs During Sex: Deep Pain, Superficial Pain, and Pelvic Floor Pain

Deep pain during intercourse is most often associated with lesions in the posterior pelvis, uterosacral ligaments, rectovaginal region, Douglas pouch, adhesions, endometriomas, or concomitant adenomyosis. Therefore, with such pain, the doctor should inquire not only about intercourse but also about pain during defecation, menstruation, urination, and chronic pelvic pain. [12]

Superficial pain during intercourse can occur at the entrance to the vagina and is not always directly related to the depth of endometriotic lesions. A 2024 study found that patients with endometriosis experience more than just deep pain: some women experience superficial pain, and the largest group in this study experienced a combination of deep and superficial pain. [13]

In a 2024 study of women with endometriosis, isolated superficial pain occurred in 6.3 percent, isolated deep pain in 26.0 percent, combined pain in 43.4 percent, and no pain during sex in 24.3 percent. This suggests that both types of pain need to be assessed, otherwise treatment may be incomplete.[14]

Pelvic floor muscles can become part of the problem. If sex is associated with pain for a long time, the body begins to defend itself: the muscles tense, the vaginal opening becomes painful, arousal decreases, and attempts to "endure" it intensify spasms and fear of further contact. [15]

Pain may persist even after hormonal treatment or surgery if, in addition to endometriosis, central sensitization—that is, increased sensitivity of the nervous system to pain signals—has developed. Therefore, in chronic sexual pain, it is important to assess not only the gynecological anatomy but also the neuromuscular, psychological, and behavioral mechanisms. [16]

Table 6. Deep and superficial pain: differences

Sign	Deep pain	Superficial pain
Where it is felt	Inside the pelvis, deep	At the entrance to the vagina
When does it arise?	With deep penetration	At the beginning of penetration
Common causes	Deep endometriosis, adhesions, ligaments	Pelvic floor, dryness, vulvar pain
Connection with posture	Often expressed	It can happen with any penetration
What to examine	Posterior pelvis, ovaries, intestines	Vulva, vagina, pelvic floor muscles
Who to refer to	Gynecologist-expert, sometimes a surgeon	Gynecologist, pelvic floor physiotherapist

Source for the table: [17]

Table 7. Possible mechanisms of pain

Mechanism	How does it affect sex?
Deep foci	Pain during deep penetration
Adhesions	Limit organ mobility
Endometrioma	May increase pelvic pain
Pelvic floor	Creates spasm and pain at the entrance
Dryness	Increases friction and microtrauma
Pain sensitization	The pain becomes stronger than the expected stimulus

Source for the table: [18]

Table 8. What questions help the doctor

Question	Why is it important?
Pain at the beginning or deep inside?	Distinguishes between superficial and deep pain
Does it hurt after sex?	Indicates inflammation or muscle spasm
Is there pain when passing stool?	Deep posterior endometriosis is possible
Is there pain when urinating?	Urinary localization is possible
Is there dryness?	Affects the choice of assistance
Is there a fear of penetration?	Important for working with the pelvic floor and psyche

Source for the table: [19]

Table 9. Signs of the muscular component of pain

Sign	What could it mean?
Pain at the entrance to the vagina	Pelvic floor hypertonicity or vulvar pain
Inability to relax	A defensive reaction to expected pain
Pain when inserting a tampon	Possible muscular-vulvar problem
Pain after examination	The pelvic floor reacts with spasm
The pain is reduced by slow pace.	Mechanical and muscular factors are important
The pain persists after the lesions are removed.	Chronic pain assessment needed

Source for the table: [20]

Table 10. What increases pain during sex

Factor	How it works
Anticipation of pain	Increases tension and protective spasm
Dryness	Increases friction
Haste	Lack of excitement and relaxation
Deep poses	May affect painful areas
Exacerbation before menstruation	The tissues are more sensitive
Untreated chronic pain	The nervous system becomes more sensitive

Source for the table: [21]

Diagnosis of sexual pain in endometriosis

Diagnosis begins with a doctor asking directly and sensitively about sexual pain. The UK's National Institute for Health and Care Excellence recommends suspecting endometriosis if deep pain occurs during or after intercourse, especially if it is combined with painful periods, chronic pelvic pain, cyclic bowel or urinary symptoms, and infertility. [22]

It's important to describe the pain as specifically as possible: where it hurts, when it starts, whether it depends on the depth of penetration, position, day of the cycle, arousal, lubrication, bowel movements, urination, and previous surgeries. The more precise the description, the less likely it is that the problem will be dismissed as "just relax" or "it's psychological." [23]

A gynecological examination helps assess pain, uterine mobility, adnexa, uterosacral ligaments, posterior vaginal fornix, signs of endometrioma, and pelvic floor muscle response. However, a normal examination does not rule out endometriosis, especially in superficial forms or situations where pain is maintained by neural sensitization. [24]

Transvaginal ultrasound and magnetic resonance imaging (MRI) can help identify endometriomas and deep endometriosis, which may explain deep pain during intercourse. If deep endometriosis is suspected, it is especially important that imaging be performed or interpreted by a specialist with experience in endometriosis. [25]

Modern diagnostics do not always require surgery for confirmation. The American College of Obstetricians and Gynecologists (ACOG) in 2026 emphasizes that a probable diagnosis can be based on history, symptoms, and examination, and empirical treatment can be initiated concurrently with imaging to ensure the patient receives care more quickly. [26]

Table 11. What you need to tell your doctor

Information	Why is it important?
The pain is superficial or deep	Changes diagnostic search
Connection with the menstrual cycle	Supports suspicion of endometriosis
Pain during or after sex	Different mechanisms of pain
Which poses are worse?	Helps to understand the depth and direction of pain
Is there dryness?	Important for superficial pain
Is there a fear of penetration?	Indicates protective spasm and chronic pain

Source for the table: [27]

Table 12. What the doctor looks for during the examination

Find	Possible meaning
Pain in the posterior vaginal fornix	Deep posterior endometriosis
Pain in the uterosacral ligaments	Frequent area of deep pain
Limitation of uterine mobility	Adhesions or deep lesions
Ovarian mass	Possible endometrioma
Pelvic floor pain	Muscular component of pain
Visible vulvar tenderness	Superficial pain, vulvar problem

Source for the table: [28]

Table 13. What studies may be needed

Method	What helps to clarify
Diary of pain and sex	Cyclicity, postures, connection with symptoms
Gynecological examination	Pain, mobility, pelvic floor
Ultrasound examination	Endometriomas, signs of deep form
Magnetic resonance imaging	Deep endometriosis map
Urine tests	If there are urinary symptoms
Consultation with a reproductive specialist	If you have infertility or are planning to become pregnant

Source for the table: [29]

Table 14. When expert visualization is needed

Situation	Why is it important?
Deep pain during sex	Possible deep back form
Pain during defecation	The intestinal area needs to be assessed
Pain when urinating	The urinary system needs to be assessed
Endometrioma	Important for ovary and fertility
Reoperation	A map of adhesions and foci is needed
The pain is not explained by routine examination.	Endometriosis specialist needed

Source for the table: [30]

Table 15. What pain during sex can look like

Possible cause	Why does it look like endometriosis?
Adenomyosis	Uterine pain and painful periods
Vulvodynia	Superficial pain at the entrance
Pelvic floor hypertonicity	Spasm and pain upon penetration
Painful bladder syndrome	Pain, urinary symptoms, and sexual pain
Irritable bowel syndrome	Bloating and pelvic discomfort
Inflammatory diseases	Pain during sex and pelvic pain

Source for the table: [31]

What helps: medical treatment, physical therapy, psychological help, and changes in sexual behavior

Treatment for pain during sex due to endometriosis depends on the cause: deep lesions, endometrioma, adhesions, pelvic floor problems, dryness, nervous sensitization, anxiety, and relationship issues all require different approaches. The European Society of Human Reproduction and Embryology considers pain medications, hormonal therapy, and surgery as the primary treatment options for pain associated with endometriosis. [32]

If pregnancy is not currently planned, hormonal therapy can reduce cyclic pain and deep pain during intercourse by suppressing the activity of endometriotic lesions. Options include combined hormonal contraceptives, progestogens, the levonorgestrel intrauterine system (IUS), and gonadotropin-releasing hormone agonists or antagonists, as indicated. [33]

Data on individual medications suggest that pain reduction may be accompanied by improvements in the sexual aspect of quality of life. A 2025 systematic review and meta-analysis of dienogest and oral contraceptives reported that dienogest improved some domains of quality of life, including sexual performance, but medication selection should still be individualized. [34]

Pelvic floor physical therapy may be particularly helpful when pain is accompanied by muscle spasms, superficial pain, pain after sex, or persists after treatment of lesions. A 2026 systematic review and meta-analysis reported that physical therapy, exercise, electrical therapy, patient education, and certain bodywork techniques can improve chronic pelvic pain, pain during sex, menstrual pain, and quality of life in endometriosis. [35]

Psychological support and sex therapy do not mean that pain is “imagined.” A 2024 systematic review and meta-analysis found that psychological interventions can reduce pain during sex and pain during defecation, as well as improve mental health, making them logical to consider as part of a comprehensive approach to chronic pain and intimacy. [36]

Table 16. Main areas of assistance

Direction	When is it especially useful?
Hormonal treatment	Cyclic pain, deep pain, pregnancy not planned
Anesthesia	Short-term pain control
Surgery	Endometrioma, deep form, treatment failure
Pelvic floor physiotherapy	Spasm, superficial pain, pain after sex
Psychotherapy	Fear of pain, avoidance, anxiety, relationships
Sexological assistance	Changing the sexual scenario and restoring intimacy

Source for the table: [37]

Table 17. What can be changed in the sexual scenario

Change	How can it help?
More time for arousal	Reduces dryness and protective tension
Using lubricant	Reduces friction and superficial pain
Slow tempo	Provides control and reduces spasm
Avoiding deep poses	Reduces contact with painful areas
Stop when in pain	Does not reinforce fear and sensitization
Intimacy without penetration	Maintains intimacy without causing pain

Source for the table: [38]

Table 18. When pelvic floor physiotherapy is especially appropriate

Sign	Why
Pain at the entrance to the vagina	Possible muscular or vulvar component
The pain persists after surgery	Foci are not the only reason
There is a spasm when trying to penetrate	Relaxation work is needed
Pain after examination	The pelvic floor reacts defensively
Pain when sitting	A muscular-fascial component is possible
There is a fear of sex	The body can become tense in advance

Source for the table: [39]

Table 19. When surgical evaluation is needed

Situation	Why
Deep pain and suspicion of deep endometriosis	It is necessary to map the outbreaks
Endometrioma with pain	The cyst may contribute to symptoms.
Pain during defecation and sex	Possible deep back form
Pain during urination and sex	Urinary localization is possible
Medicines don't help	We need to reconsider our tactics.
There is infertility	Pain and fertility treatments need to be coordinated

Source for the table: [40]

Table 20. How to evaluate the treatment outcome

Indicator	How to track
Intensity of pain during sex	Scale from zero to ten
Pain after sex	How long does it last and how strong is it?
Frequency of avoiding sex	Has there been less avoidance?
Desire and arousal	Did you improve without pressure?
Number of painkillers	Has the need decreased?
Relationship quality	Has it become easier to talk about pain?

Source for the table: [41]

Sex, Fertility, Hormones, and Pregnancy

Endometriosis can affect both sex life and fertility, but these are distinct clinical issues. Painful sex can reduce the frequency of intercourse and create psychological avoidance, while endometriosis itself can reduce the likelihood of pregnancy through inflammation, adhesions, endometriomas, and pelvic anatomy. [42]

If pregnancy is not currently planned, pain treatment often focuses on suppressing the menstrual cycle and the activity of the lesions. If pregnancy is the goal, hormonal drugs that suppress ovulation are not used as a way to increase natural pregnancy; in this situation, an assessment of age, ovarian reserve, fallopian tubes, partner, and the type of endometriosis is necessary. [43]

Pain during sex should not be a reason for a woman to pressure herself to "endure it for the sake of pregnancy." If intercourse is regularly painful, it is important to seek pain management, safe sex practices, and, if necessary, reproductive counseling, as trying to overcome pain increases fear and can impair a couple's intimate life. [44]

Pregnancy is not a treatment for endometriosis. The European Society of Human Reproduction and Embryology does not recommend pregnancy alone as a treatment for the disease, as symptoms may return, and pregnancy itself does not guarantee the disappearance of lesions or chronic pain. [45]

After childbirth or after stopping breastfeeding, pain may return, so it's best to gradually restore your intimate life, without expecting "everything should be fine now." When experiencing postpartum pain, it's important to differentiate between endometriosis, perineal trauma, dryness due to hormonal changes, pelvic floor problems, fear of pain, and other causes. [46]

Table 21. Sex and pregnancy attempts with endometriosis

Situation	Correct logic
Sex is painful, pregnancy is desired	First evaluate pain and fertility, do not tolerate
Hormones help pain	They can suppress ovulation if pregnancy is desired.
There is an endometrioma	Assess ovarian reserve
There is infertility for more than twelve months	Examine a couple
Age over thirty-five years	Don't put off seeing a reproductive specialist
Pain interferes with regular intimacy	Discuss pain management and reproductive pathways

Source for the table: [47]

Table 22. What to discuss with a reproductive specialist

Question	For what
How does endometriosis affect my prognosis?	Stage and symptoms do not always equal prognosis
Do pipes need to be checked?	Adhesions can obstruct patency
What is the ovarian reserve?	Important for endometriomas
Should pain be treated before attempting?	Pain can interfere with sexual activity.
Is surgery necessary?	Benefits and risks depend on the situation.
When to move on to assisted reproductive techniques?	Time is especially important as we age.

Source for the table: [48]

Table 23. Hormonal treatment and sexual life

Possible effect	Comment
Less cyclic pain	Can improve sex
Less menstrual pain	Reduces overall pain
Decreased libido in some women	Requires a change in the scheme or an assessment of the causes
Dryness in some women	Lubricant and treatment adjustments may be required.
Mood swings	Affects desire and intimacy
Not recommended when trying to conceive	If the drug suppresses ovulation

Source for the table: [49]

Table 24. When you shouldn’t postpone a consultation

Situation	Why
Pain makes sex impossible	Need a pain plan
There is infertility	It is important not to waste time
There is an endometrioma	The ovaries need to be assessed
There is pain during defecation	Deep form is possible
There is blood in the urine or stool	Organ diagnostics are needed
The pain returned after surgery	Recurrence and pelvic floor assessment needed

Source for the table: [50]

Table 25. What to do if sex is needed only “according to the ovulation calendar”

Problem	A safer solution
Pressure on women	Discuss pain and emotional distress
Pain on penetration	Explore poses, tempo, treatments and alternatives
Fear of missing ovulation	Reproductive consultation
Frequent unsuccessful attempts	Examination of a couple
Decreased desire	Remove the obligation to "endure"
Conflicts in couples	Conversation, psychological support, sexologist

Source for the table: [51]

Relationships, communication and safe intimacy

Endometriosis affects not only the body but also relationships. A woman may experience guilt, shame, fear of rejecting her partner, anxiety about intimacy, and a feeling that the disease is "robbing her of her sexuality." A partner, in turn, may feel confused, rejected, or afraid of causing pain. [52]

A systematic review of qualitative studies shows that dyspareunia associated with endometriosis impacts psychological health, self-esteem, intimacy, and relationship behavior. Many women describe avoiding sex not as a lack of love or desire, but as a way to protect themselves from recurring pain. [53]

It's better to frame a conversation with your partner around facts rather than accusations: "It hurts when you penetrate deeply," "I need more time," "I feel better in this position," "I want intimacy, but without pain," "If pain starts, we stop." This language helps maintain intimacy and prevent sex from becoming a test of patience. [54]

Safe intimacy doesn't have to mean only penetrative sex. For many couples, temporarily transitioning to caresses, mutual stimulation, oral sex, external stimulation, non-penetrative intimacy, and slowly rebuilding trust helps maintain sexual connection while pain management is underway. [55]

If pain during sex has become chronic, it's best to involve not only a gynecologist but also a pelvic floor physiotherapist, pain specialist, psychologist, or sexologist. A review of the literature on sexual function in endometriosis emphasizes that sexual dysfunction is multidimensional, so ideal care should be interdisciplinary. [56]

Table 26. How to talk to your partner

Phrase	Why does she help?
"I need intimacy, but I can't tolerate pain."	Separates love and pain
"It hurts me deeply."	Helps change postures
"I need more time to get excited."	Reduces dryness and spasm
"If I say stop, we stop."	Taking back control
"Let's find options without penetration."	Maintains intimacy
"I need medical attention, not pressure."	Protects borders

Source for the table: [57]

Table 27. What a partner can do

Action	Why is it important?
Don't take rejection as a sign of dislike.	Pain is not the same as numbness.
Stop contact if pain occurs	Don't reinforce fear
Respect the pace	The body needs time to relax.
Maintain treatment	Reduces loneliness
Discuss alternative intimacy	Sex is not about penetration
Don't put pressure on yourself to get pregnant	Pain and fertility require a plan

Source for the table: [58]

Table 28. Alternatives to penetration during exacerbation

Option	When it can be useful
External stimulation	For superficial or deep pain
Caresses without the goal of "definitely ending in sex"	For fear of pain
Oral stimulation	If it is comfortable for both
Massage without pressure on the abdomen	For relaxation
Mutual intimacy without penetration	To save contact
Sex break with a treatment plan	If the pain is severe

Source for the table: [59]

Table 29. When psychological or sexological help is needed

Situation	Why
Fear of any intimacy appeared	The pain lingered in anticipation
There is a feeling of guilt for refusal	Border protection is needed
The couple stopped talking about sex	The distance is growing
Sex became a duty for the sake of pregnancy	High emotional risk
After treatment the pain was less, but the fear remained.	Work with the memory of pain is needed
Do you have anxiety or depression?	The psyche intensifies the suffering from the disease

Source for the table: [60]

Table 30. Signs of a healthy approach to sex with endometriosis

Sign	What does it mean?
They don't tolerate pain	Contact is stopped or changed
There is agreement	The woman controls the process
There is flexibility	Different forms of intimacy are possible
There is treatment	Pain is not ignored
There is a conversation	The partner understands what is happening
There is a long-term plan	Intimacy is restored gradually

Source for the table: [61]

Frequently asked questions

Can you have sex with endometriosis? Yes, as long as sex doesn't cause significant pain, bleeding, worsening of the condition, or anxiety. Endometriosis itself doesn't prohibit sexual activity, but painful sex shouldn't be tolerated: it requires an assessment of the cause and the selection of a safe sexual activity. [62]

Why does sex hurt with endometriosis? Causes may include deep lesions of endometriosis, adhesions, endometrioma, pain in the uterosacral ligaments, posterior pelvic lesions, pelvic floor hypertonicity, dryness, concomitant urinary or intestinal pain syndromes, and central sensitization. [63]

Does deep pain during sex always indicate severe endometriosis? No. Deep pain raises the suspicion of deep endometriosis, but pain severity does not always accurately reflect the stage or size of the lesions. Sometimes pain is supported by pelvic floor muscles, nerve sensitivity, and associated pain conditions. [64]

If pain is only at the vaginal opening, could it also be endometriosis? Yes, patients with endometriosis can experience superficial pain, combined pain, or pain from pelvic floor and vulvar causes. A 2024 study found that a combination of superficial and deep pain is common and significantly impacts sexual function. [65]

Is it okay to tolerate pain during sex for your partner's sake? No. Tolerating pain can increase fear, protective muscle spasms, avoidance of sex, and chronic pain memory. It's best to stop, change your intimacy routine, and discuss treatment with a doctor. [66]

What positions are best for endometriosis? There are no universal positions, but those where the woman controls the depth, pace, and angle of penetration are often easier. For deep pain, positions with deep penetration are usually worse, so a slow pace, lubricant, pauses, and the ability to stop are helpful. [67]

Does lubricant help with endometriosis? Lubricant can reduce superficial pain associated with dryness and friction, but it will not eliminate deep lesions of endometriosis, adhesions, or endometriomas. If the pain is deep or cyclical, a gynecological approach is needed. [68]

Can hormone therapy improve sex? It can, if the underlying cause is cyclical endometriosis pain: pain relief often improves sex life. However, hormones can also affect libido, mood, or dryness, so a regimen needs to be tailored to your individual needs. [69]

When is surgery necessary for painful sex? Surgery is considered in cases of endometrioma, deep endometriosis, severe pain, medication ineffectiveness, bowel or urinary tract involvement, and when pain is combined with infertility. The decision should take into account the risks of surgery and pregnancy plans. [70]

Does pelvic floor physical therapy help? For some patients, it does, especially if there is spasm, superficial pain, pain after sex, or pain that persists after treatment of the affected areas. Systematic reviews from 2025 to 2026 show potential benefits of physical therapy for pain during sex and chronic pelvic pain. [71]

Is a sexologist or psychologist necessary? It is necessary if the pain has led to a fear of intimacy, avoidance of sex, conflicts, guilt, anxiety, depression, or if the fear of pain persists after medical treatment. Psychological help does not negate the physical nature of endometriosis, but rather helps manage chronic pain and relationships. [72]

Does sex affect the growth of endometriosis? There is no reliable evidence that sex itself "accelerates" the growth of endometriotic lesions. However, painful sex can increase muscle spasms, fear, inflammatory irritation, and avoidance, so it's important to focus on symptoms and safety. [73]

Is it possible to get pregnant if sex is painful due to endometriosis? Sometimes it is possible, but if the pain interferes with regular sex or pregnancy doesn't occur, there's no need to endure the pain. It's important to evaluate the couple's fertility, ovarian reserve, fallopian tubes, endometriomas, age, and male factors. [74]

Will pregnancy cure pain during sex due to endometriosis? No, pregnancy is not a cure for endometriosis. Some women experience temporary relief of symptoms, but the pain may return after childbirth or after menstruation resumes. [75]

Key points from experts

Professor Christian M. Becker, Professor of Reproductive Sciences at the University of Oxford, Co-Director of the Oxford Endometriosis CaRe Centre, and Chair of the European Society of Human Reproduction and Embryology Guidelines Development Group on Endometriosis. Key message: endometriosis treatment should be tailored to pain, fertility, disease location, side effects, cost, availability, and patient preference; sexual pain should be part of this individualized plan, not a secondary complaint. [76]

Professor Andrew W. Horne, PhD, FRCG, Professor of Gynaecology and Reproductive Sciences, University of Edinburgh, and Director of the Centre for Reproductive Health. Key message: Endometriosis should be considered as a disease of pelvic pain and quality of life, so pain during sex requires multidisciplinary care, not just the assessment of lesions at surgery. [77]

Paul Yong, MD, PhD, FRCC, is an associate professor at the University of British Columbia, a gynecologist, and an endometriosis pain researcher. Key point: Deep pain during sex in endometriosis has multiple mechanisms, including lesions, urinary and intestinal pain syndromes, pelvic floor muscles, and central sensitization, so some patients do not respond to “traditional” therapy alone. [78]

Stacey Missmer, PhD, professor of obstetrics, gynecology, and reproductive biology, is a researcher in endometriosis and women's health epidemiology. Key message: Endometriosis requires long-term study and follow-up because it impacts not only pain and fertility but also many aspects of health and life, including sexual well-being and relationships. [79]

American College of Obstetricians and Gynecologists. Key message of the 2026 guideline: A probable clinical diagnosis of endometriosis can be based on history, symptoms, and examination, and treatment can be initiated concurrently with imaging to help patients more quickly receive pain relief, including pain with sex. [80]

Brief conclusions

Sex with endometriosis is possible, but it shouldn't be a painful experience. Pain during intercourse can be deep, superficial, or a combination of these, and its causes include endometriosis lesions, adhesions, endometriomas, pelvic floor dryness, urinary and intestinal pain syndromes, anxiety, and pain sensitization. [81]

The modern approach requires asking directly about sexual pain, distinguishing between deep and superficial pain, conducting an examination and expert visualization as indicated, and selecting treatment individually: hormonal therapy, pain relief, surgery, pelvic floor physiotherapy, psychological and sexological assistance can complement each other. [82]

The main rule for the patient and the couple: do not tolerate pain for the sake of "normal sex" or pregnancy. Safe intimacy is built on consent, control over depth and pace, the ability to stop, alternative forms of intimacy, and a medical plan that treats the cause of the pain rather than forcing the woman to adapt to suffering. [83]