Guest Post by Dr. Sallie Sarrel, PT, ATC, DPT

NOTE: This post was originally published on this blog on March 17, 2016.

Dr. Sallie Sarrel is a Women's Health Physical Therapist.

Dr. Sallie Sarrel is a Women’s Health Physical Therapist.

“We have emerged from the days of Freud and finger pointing that sexual pain is only psychological. Especially in the case of women with endometriosis, sexual pain is driven by physiologic reasons.”

Sexuality is one of the innermost characteristics of existence for both women and men. A state of mind representing our feelings about ourselves, sexuality is how we relate to people in our community and society. It is part of how we establish relationships, and how we express ourselves. Sexuality is a basic component to development and growth throughout the lifecycle. Sexual experiences drive sexuality.

For many of the 176 million women worldwide with endometriosis, sexuality has been destroyed. Painful sex or dyspareunia is one of the most devastating symptoms of the disease. Endometriosis is when tissue similar to (but not the same as) the lining of the uterus is found in areas of the pelvic cavity and sometimes elsewhere like the bowel and the diaphragm. When endometriosis infiltrates the ligaments attaching the uterus to the tailbone, the uterosacral ligaments, or an area behind the vagina called the recto-vaginal septum there is tremendous pain during sex. Additionally, endometriosis can cause pain and muscle signals to be jumbled. Then a reactive spasm to the pelvic floor occurs. It is usually a combination of all three things that causes painful sex in a woman with endometriosis.

Sex is not supposed to hurt

There is on average an 8-10 year diagnostic delay for endometriosis.  It is thought endometriosis emerges as women hormonally mature. Therefore, as a woman is developing through her formative teens and twenties and then into her thirties and beyond, the pain the disease brings alters development itself. Women who suffer from painful sex can travel through life believing that sex is supposed to hurt. This is isolating and trauma-inducing. Painful sex becomes a barrier between woman and a healthy, connected, sexual self.

Enter the Women’s Health Physical Therapist. Women’s Health Physical Therapy is a rapidly growing niche practice within physical therapy. Women’s Health therapists use every facet of their physical therapy training to evaluate and treat female clients paying specific attention to sexual medicine and the pelvic floor. Just like if the knee or shoulder hurt, a physical therapist works on the bones, fascia, muscles, and ligaments, Women’s Health or Pelvic physical therapists work on all that lines the pelvis. To women with a disease that makes sex painful, the Women’s Health Physical Therapist can be a superhero.

Endometrial adhesions affect pelvic floor muscles

Women with endometriosis need pelvic physical therapists because the base of the pelvis is lined with muscles. There are two layers of the pelvic floor: A superficial layer, which surrounds the openings of the vagina, rectum and bladder and a deep layer, which supports the organs. Adhesions from endometriosis change this support system. Disease on the organs puts tension on the muscle groups causing higher tone in some areas and muscle wasting in others.

Endometriosis also can send messages to turn the volume all the way up on the nerves that then begin to send painful messages all on their own. Central sensitization begins to drive the system towards pain with or without stimuli. Spasms in the entrance to the vagina can make penetration painful and endometriosis can make deeper penetration painful. This can leave a woman not only in pain all the time, but feeling lost and hopeless. In a private one-on-one physical therapy session women can explore all the musculoskeletal issues that compound dyspareunia felt with endometriosis.

Sexual pain with endometriosis has physiologic causes

We have emerged from the days of Freud and finger pointing that sexual pain is only psychological. Especially in the case of women with endometriosis, sexual pain is driven by physiologic reasons. A pelvic physical therapist may not be able to excise endometriosis from the pelvis but they are able to retrain the floor to help free a woman from pain. Those muscular levels in the pelvis often need some urging to release their tension. That signal from the nerves and the brain needs calming. Most of all pelvic physical therapy can be a safe space to honestly explore the physical reasons that have been hampering a woman from participating fully in her own sex life.

If penetration hurts, a physical therapist can examine those causes. If hip pain or back pain prevents sexual participation pelvic health physical therapists can treat those causes. Physical therapists treat the nerves that participate in sexual enjoyment. They work with the fascia and the tissue involved in continence. Pelvic PTs help with constipation and with control over loose stool. Women who have absence of genital sensation or an overabundance of genital sensation can all benefit from Pelvic PT. Scar tissue and adhesions, common with women who have been treated surgically for endometriosis, are also treated.

Pelvic physiotherapists offer understanding and relief

Women’s Health PTs help their patients thoroughly understand the interconnections between diet, lifestyle change, exercise and sex, enabling them to access their best quality of life after so many years of suffering from endometriosis. Pelvic PT’s are direct and understanding in their discussions of sexual pain so that no woman feels unheard or embarrassed by their pain. Nothing can be worse than having an innermost part of oneself negated and minimized because it seems like there is no help for it. It can be humiliating to call a doctor’s office and report painful sex or orgasms, only to be minimized. Women’s Health PTs do not mock. They do not minimize. They are the healthcare professionals who have chosen to help women override the shadows painful sex casts. Women don’t have to hide their pain or themselves in a misogynistic society devoid of pleasure and devoid of sexual expression.

Women who experience endometriosis often sense a total loss of control over their own bodies, while appearing to outsiders as perfectly healthy and “normal.” The natural biological activity of menstruating is painful, simple activities like going to the bathroom or sitting hurt. Many wander aimlessly through the medical system, never truly getting help until the disease has already stolen a part of their lives. Infertility permeates the disease, preventing many from fulfilling the longing for motherhood, and, adding insult to injury, painful sex creates a quarantine from rewarding relationships.

Women with endometriosis often have fear, anxiety and avoidance behaviors from years of painful sex. Using physical therapy to treat the pelvis may eliminate the musculoskeletal causes of pain and addresses many of the elements preventing a woman from being her complete self. Pelvic PTs are the hands-on manual therapists that change the systematic assault on the body endometriosis causes for its sufferers. They empower women with endometriosis to return to life and to the bedroom — and to enjoy it this time.

Dr Sallie Sarrel, PT ATC DPT is a Women’s Health Physical Therapist in New York and in New Jersey specializing in endometriosis. She has traveled throughout Asia and South America lecturing on the importance of Pelvic PT and Endometriosis. Her years of battling the disease herself provide her unique insight and compassion for women with the disease. She can be reached at

Further Resources on Pelvic Physical Therapy and Endometriosis: Five things that pelvic health physical therapy can do to improve your endometriosis-related pain

Center for Endometriosis Care

Endometriosis Foundation of America


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