The third predominant symptom of endometriosis is painful sex dyspareunia. Patients with endometriosis often find themselves experiencing physical pain when engaging in sex, which is a very personal note for patients to express to their gynecologist. Nevertheless, it must be taken into account as it can help determine the level of pain and the anatomical location to which endometriosis lesions are located.
The area behind the uterus is called the cul-de-sac, or Pouch of Douglas. Normally it is lined by the smooth peritoneum, the skin-like sheet of tissue that covers the uterus and vagina anteriorly in front , and the rectum posteriorly in back , keeping the rectum, vagina, and uterus free from each other.
Endometriosis will frequently adhere the vagina to the rectum. The pain caused by endometriosis during sex is deep; it comes from the inflammation and fibrosis fusing the front wall of the rectum to the back wall of the vagina. Mobility and expansion of the upper posterior vagina behind the cervix normally occurs during sex, but not if endometriosis is present.
The pain can be more intense in certain sexual positions than in others, depending on exactly where the endometriosis is located and how advanced it is. If it is widespread, pain may be present no matter the position. Painful sex is a very personal matter and it can be extremely difficult to discuss the physical challenges experienced during sex.
Nevertheless, it is an important fact to disclose, not only for the good of her physical health, but also because the symptom is one that can cause tension in, or even break up, a relationship. Laparoscopic excision of endometriosis is the gold standard for conservative surgical treatment. However, in cases of painful sex, it is important to specify that there must be a focus on endometriosis infiltrating the anterior and posterior cul-de-sac.
