I was called to see T at the emergency room in the hospital one night. She was a 28-year-old teacher and had been married for the past 2 months. T was seen by me 2 years ago for severe menstrual pain. She had endometriosis which was confirmed by a laparoscopic examination. She declined medical treatment. Instead, she chose alternative therapy.
When I saw her, she was in distressed. “Doc, I should have listened to your advice and have my condition treated. I know that endometriosis is going to affect my sexual life but I did not imagine that it could hurt me so badly,” she said. “My husband and I could not enjoy ourselves on our wedding night because of my pelvic pain. But the pain has gotten worse every time we have sex.”
T is suffering from dyspareunia or pain during sexual intercourse. Studies have shown that about two out of three women with endometriosis have this sexual issue. The pain varies from mild discomfort, sharp or stabbing pain to deep pelvic ache. It occurs not at the entrance of the vagina but on the deeper part of the pelvis during thrusting. It may last for hours or even up to a few days after sexual intercourse.
Why should Endometriosis cause Painful Sex?
Endometriosis is a chronic disease where there is a backflow of the inner lining of the uterus (endometrial tissues) into the pelvic cavity. These tissues cause irritation to the surrounding organs. As a result, scars are formed around the back of the uterus and vagina. The vagina may even get stuck to the rectum (Figure 1). Sexual penetration will pull or stretch the scarred tissues causing deep seated pain.
What may be the consequences?
Dyspareunia will take away the joy and fun of sexual intimacy. This may lead to a gradual reduction in the desire to have sex. Consequently, couples may have less and less sexual activity. This can cause tension and turmoil in their relationship. There will be additional emotional stress if couples are planning to conceive. Some men may feel anxious about having sex. Erection and/or ejaculation problems may ensue.
How to cope with the sexual issues?
- Treat the disease: Besides surgery, hormone impregnated Intrauterine device (Mirena) and medications such as GnRH agonist, Visanne and oral contraceptive pills have been used to treat endometriosis with varying degrees of success.
- Communication: Sexual intimacy is a very personal matter. Couples should have open discussions on the various sexual issues. This may allay anxiety and help in reducing the pain. Communication between couples may help the men understand the physical and emotional impact of dyspareunia better.
- Vaginal lubricant: As dyspareunia reduces sexual arousal and vaginal secretions, water based lubricants may be useful.
- Timing. The pain may be worse around menses. Avoiding sex during that time may help.
- Sexual positions: Sexual positions that cause less pain such as shallow penetration or one that the couple can control over the depth of penetration may reduce the pain.
- Other forms of sexual stimulation: Penetrative sex is not the only way for bonding between couple. Foreplay or other forms of sexual stimulation may help.
After I explained the pros and cons of various modalities of treatment, T opted to have the Mirena IUCD inserted. Other than some irregular spotting in the initial months, T had no other side effects. The dyspareunia had improved further with counselling and the use of vaginal lubricant.