Education Set

The set contains 8 square prints, each with a different watercolour image and information related to vulvar anatomy + a digital set.

“What are endometriosis and adenomyosis, and what's the difference between them?”

Ali Cann (she/her) / @alicannphysio, Women’s health physiotherapist BSc, Private practice, Bexley, UK: “Endometriosis and adenomyosis are two conditions that can cause significant discomfort and impact one’s quality of life.

Endometriosis occurs when tissue similar to the lining of the uterus (endometrium) grows outside the uterus, commonly on the ovaries, fallopian tubes, and pelvic peritoneum (but can spread to other organs). This tissue responds to hormonal changes during the menstrual cycle, leading to inflammation, scarring, and the formation of adhesions. Symptoms often include pelvic pain, painful menstruation, infertility, and gastrointestinal issues.

Adenomyosis, on the other hand, involves the tissue lining the uterus (endometrium) growing into the muscular wall of the uterus (myometrium). This results in an enlarged and thickened uterus, leading to symptoms such as severe menstrual cramps, heavy menstrual bleeding, and pelvic pain, which may worsen with age or hormonal fluctuations.

While both conditions involve abnormal growth of endometrial-like tissue and share similar symptoms, their key difference lies in their location and extent of tissue involvement. Endometriosis primarily affects areas outside the uterus, while adenomyosis occurs within the uterine muscle. 

Additionally, the treatment approaches for each condition may differ based on factors such as the severity of symptoms, desire for fertility, and response to previous therapies.

In my daily practice I play a vital role in managing pelvic pain and dysfunction associated with both endometriosis and adenomyosis. By working collaboratively with other healthcare providers, including gynaecologists and pain specialists, I aim to optimise treatment outcomes and improve the overall well-being of my patients, making sure to treat the whole person and their unique symptoms.”

“What are the treatment options available for endometriosis?”

Dr. Maddalena Giacomozzi (they/them) / @treatitqueer, Endometriosis MD and President Treat it Queer Foundation / MSc Global Health / RadboudUMC / Nijmegen, The Netherlands: “Endometriosis is a chronic condition that can significantly impact one’s life. It’s crucial to consider each individual's needs and provide personalized treatment with the support of multidisciplinary healthcare teams.

To simplify, endo treatment can be broken down into four pillars:

1. Hormonal treatment. Endometriosis is hormone-dependent and remains active during menstrual cycles, so finding hormonal regulation to suppress these cycles is essential. There is a wide variety of hormonal medications available for endometriosis, and while few studies indicate which is best in each case, it’s important for each individual to find what works best for them. Examples include progestin-only tablets, the Mirena IUD, vaginal rings, hormonal patches, and oral combined contraceptives. Regardless of the medication form, the advice is typically to use it continuously without taking "stop weeks."

2. Pain management, which usually involves pain medication and/or neuromodulators, among other methods such as pain education, TENS stimulation, and warm patches. Opiates are not recommended due to their risk of addiction, high side-effects profile, and limited long-term benefits for chronic pain management. Consulting a specialized pain team may provide tailored advice.

3. Surgery. For some individuals, surgically removing endometriosis may be necessary. Different surgical options exist based on the extent and location of the endometriosis. Removing endometriosis lesions alone may not lead to total symptom relief if hormonal cycle regulation is not addressed.

4. Non-medication interventions, including pelvic floor physiotherapy, s/x counseling, nutritional adjustments, and psychotherapy.

A combination of these forms of treatment is usually needed to improve quality of life of people with endometriosis, and this may differ based on their life phase and/or personal goals.”

“How are endometriosis and adenomyosis diagnosed?”

Virginia Rivers Bulkeley (she/her) / @pelvicpainnetwork and @virginiariversbulkeley_physio / Clinical Specialist Pelvic Health Physiotherapist and Co-Founder of The Pelvic Pain Network / BSc (Hons), MSc, MCSP, POGP / NHS & private practice at The Pelvic Pain Network / Winchester, UK: “Your first point of contact would usually be your GP, then onto Gynaecology specialists. Depending on your symptoms and your local services you may then be referred, after a medical examination, for an ultrasound scan, or an MRI. Current guidelines suggest that endometriosis cannot be ruled out even if it is not visible on medical examination, ultrasound scan or MRI. This is why many symptomatic women may have a laparoscopy (keyhole surgery) to look inside the pelvis. Laparoscopy has previously been considered the gold standard for diagnosis of endometriosis but with recent advances in specialist ultrasound scanning techniques international experts suggest that improving access to specialist ultrasound imaging should increase the rate of accurate diagnosis, reducing the need for diagnostic laparoscopies.”

“What are the common symptoms of endometriosis and adenomyosis?”

Ali Cann (she/her) / @alicannphysio, Women’s health physiotherapist BSc, Private practice, Bexley, UK: “In my daily practice I frequently encounter individuals grappling with the challenging symptoms of endometriosis and adenomyosis. Endometriosis is characterised by tissue similar to the uterine lining growing outside the uterus, while adenomyosis involves the tissue lining the uterus embedding into its muscular wall. Both conditions often present with overlapping symptoms, including debilitating pelvic pain, particularly during menstruation or intercourse.

Endometriosis commonly manifests as chronic pelvic pain that intensifies before and during menstruation. This pain may radiate to the lower back and legs, significantly impacting daily activities. Individuals with endometriosis may also experience dysmenorrhea (painful periods), heavy menstrual bleeding, dyspareunia (painful s/x), and gastrointestinal symptoms like bloating, diarrhoea, or constipation, especially during menstruation. The location of the endometriosis can also affect where pain is felt. Additionally, fertility issues and fatigue are common.

Adenomyosis shares similar symptoms with endometriosis but tends to cause more diffuse and constant pelvic pain throughout the menstrual cycle. This pain can be accompanied by severe menstrual cramps and prolonged, heavy menstrual bleeding. Adenomyosis-related discomfort often worsens with age and may be exacerbated by uterine enlargement due to hormonal fluctuations, such as during pregnancy or hormonal therapy.”

“What are some ways to increase chances of doctors taking me seriously? No doctor thinks I have it, but my periods are wild!”

Virginia Rivers Bulkeley (she/her) / @pelvicpainnetwork and @virginiariversbulkeley_physio / Clinical Specialist Pelvic Health Physiotherapist and Co-Founder of The Pelvic Pain Network / BSc (Hons), MSc, MCSP, POGP / NHS & private practice at The Pelvic Pain Network / Winchester, UK: “It's a good idea to prepare for your consultation by considering how best to communicate your main concerns and expectations, making a plan, and taking some notes in with you. Start by describing your symptoms of concern, how they affect your everyday life and how long you have had them for. Any clear triggers, or patterns that you've noticed can be really helpful. In particular be sure to mention if you experience:

• Pelvic pain

• Period pain that affects your daily activities 

• Deep pain inside your pelvis during penetrative s/x

• Period-related or cyclical changes to your bowel habits, in particular painful bowel movements

• Period-related or cyclical changes to your bladder symptoms, in particular pain passing urine or blood in your urine. 

• Difficulty trying to conceive.”

“Will endometriosis come back after surgery to remove it?”

Dr. Isabela Bottura (she/her) / @isabela.bottura / Medical Doctor and ObGyn / Online sex coach & educator / Byron Shire, Australia: “New lesions of endometriosis might unfortunately come back after surgery, as there is unfortunately no known cure for this condition. That’s why surgery is not the first-line treatment, although it might be indicated in cases which are not responding to medical treatment, have contra-indications to it, or extensive disease such as bowel lesions that could cause obstructions. There are strategies available to try to reduce the risk of those lesions coming back, such as hormonal therapy, lifestyle, and dietary changes.”

“What’s the relationship between endometriosis and painful s/x?”

This question is answered by two experts!

Dr. Kelly Sadauckas (she/her) / @therealpelvicfloored / Doctor of Physical Therapy, OCS, WCS, Pelvic Health Physio / Board Certified in Pelvic Health & Orthopedics / Private Practice / Driggs, USA: “From an organ and tissue perspective, the inflammation from the monthly shedding of ‘endometrial-like’ tissue inside the abdomen (and wherever the endo lesions may be) causes significant pain and scar tissue development. The pain itself is enough to cause a protective reaction from the brain to “close the doors” that are the pelvic muscles, leading to painful, or less than fulfilling, intimacy.  Additionally, the scar tissue changes how easy it is for the inner organs to move around, causing certain s/xual positions to no longer be enjoyable, and as the uterus can be scarred to the ovaries, bladder or abdominal wall, it can be difficult, if not impossible, for it to contract for 0rgasm. 

From an emotional perspective, the human s/xual response is complicated; but if a human is in pain all the time, that is going to change how they feel about themselves, and affect their body response to intimate relations. And if those relations are painful due to the tight pelvic muscles, and scarring of the organs, that will further reduce libido – and now someone expects s/x to hurt, so why bother? And the pain → tight muscles → painful-s/x → reduced libido → tighter pelvic muscles → more painful s/x continues :(”

Rachel Andrew (she/her) / @pelvicphysiotas / APA Titled Pelvic Health Physiotherapist, Cinical Masters Continence and Womens Health, BSc Physiotherapy / Private practice within a large multi-disciplinary clinic / Hobart, Australia: “Endometriosis is an inflammatory disease. Periods come longer, with a heavier bleed, usually started younger. Periods produce an inflammatory substance that makes the pelvic floor muscles cramp. Endo is closely related to IBS, diarrhoea increases tension in these muscles. The pelvic floor muscles are a dynamic bowl of muscles, and other tissues, really important for bladder, bowel and sexual function. A group of muscles go from the tailbone to behind the pubic bone. The clitoris sits in front of these, inside other muscles under your labia. With s/x, these muscles need to be flexible to pump blood into the clitoris, so it can swell, and then this arousal helps relax the muscles. If the muscles are already crampy, it’s hard to get physically aroused, even with desire, and hard to get muscle relaxation and opening, before the “cramp” that is orgasm. Women and AFAB can feel they have lost their “libido” (but that’s another whole story!). With endometriosis, you can have adhesions, or enlarged ovaries, and these can also cause deep “dyspareunia” or pain with s/x, but pelvic floor muscles can also cause this. The entrance of the vagina has a really important muscle point between the vaginal opening and the rectum, the perineal body. This is where all the deep and superficial muscles attach to each other, and if you have pain on entry, this can be where you need to work. With hormonal changes from OCP or IUDs, your skin can feel dry or itchy. This can cause tension in these muscles too, if you are sore. It can be worth discussing oestrogen cream with your family doctor, and asking them to check that you don’t have any untreated vulval skin conditions. Don’t sit on these issues – pun intended – discuss with a health professional.”

“I feel more like a patient than like a sxual being. How do I return to feeling that my vulva and vagina are pleasurable body parts instead of medical objects?”

This question is answered by three experts!

Dr. Isabela Bottura (she/her) / @isabela.bottura / Medical Doctor and ObGyn / Online s*x coach & educator / Byron Shire, Australia: “Disconnection from pleasure is so common in people who suffer from chronic pelvic pain, painful sex, and go through several medical investigations! I would recommend acknowledging what you’ve been through, allowing the feelings to be there, listening to this part of you that has been through so much. Then connect with the part of you who knows that you deserve pleasure. Have the intention to rewrite your pleasure narrative, and rebuild your relationship with your vulva and vagina. Go slow, listen to your body. Then, slow down even more. Gently explore touch, noticing different sensations, what feels good. Vulva gazing with a mirror can also be a super powerful practice. In pleasure with a partner or lover, I encourage you to communicate your boundaries, your needs, and what feels pleasurable to you.”

Rachel Andrew (she/her) / @pelvicphysiotas / APA Titled Pelvic Health Physiotherapist, Cinical Masters Continence and Womens Health, BSc Physiotherapy / Private practice within a large multi-disciplinary clinic / Hobart, Australia: “Usually the advice is to stop any s/x that is painful. I always think of it as the body and brain being too “excited” and perceive all sensations (also the good ones) as pain. I intersperse home physio with in-clinic manual therapy and we go through challenging areas, discussing return to s/x. Often clients use smells, flowers, treats, music, candles or starting to think of favourite things – for example times they have enjoyed with their partner, or themselves; things that do make them feel happy and relaxed as they are doing exercises. Going for a short run, or brisk walk: this mimics arousal. We start associating the sensations with less pain, then general pleasure, and then can start to bring in sensual and s/xual pleasure. 

“Pants on fun” can be great to build intimacy, and nothing is off the cards as long as it doesn’t hurt. If you’re interested in p/netrative s/x you can start with ‘trainers’ (dilators): I call them ‘trainers’ as you are training your body in sensations, not just “trying to make the hole bigger”. You go from outside (vulva) to inside (vagina), smaller to larger, from still to movement and from slow to fast. This helps with a circular stretch of the muscles, and allows you to play with sensations that might be involved with the s/x you enjoy. Another tool is a wand. These have a curve and are designed to fit the bowl of the pelvic floor, to reach into the hip muscles and the back wall. Often individuals may need to use both. There are vibrating wands, maybe including self-pleasure into the session, teaching a partner what feels pleasurable; involving them in some way. From beginning to end, lots of kissing and hugs along the way – releasing good hormones!”

Rachel Gelman (she/her) / @pelvichealthsf / Pelvic floor physical therapist, DPT, and sexuality counselor / Owner of Pelvic Wellness & Physical Therapy / San Francisco, USA: “There are many reasons why endometriosis can lead to painful s/x. Often endometrial lesions or adhesions are found behind the uterus and these adhesions are not very elastic and this lack of visceral mobility can lead to pain with penetrative s/x. The uterus and anus contract during org/sm so any lesions in this area can also limit mobility and contribute to pain. Since endometriosis is causing adhesions and chronic inflammation, the pelvic floor muscles which support all the pelvic organs are essentially wanting to protect the area and tense up in response. Pelvic floor muscle tension can lead to pain with s/x.”

“Is there ongoing research or promising developments in the treatment of endometriosis and adenomyosis?”

This question is answered by two experts!

Dr. Fran Yarlett (she/her) / @get.the.lowdown / GP who specialises in sexual and reproductive health, MBBCh (Hons) BSc (Hons) MRCP (2016) MRCGP DFSRH / Medical Director at The Lowdown / London, UK: “Yes! Menstrual disorders are named in the UK Government’s Women’s Health Strategy as a priority area to improve care and the World Health Organisation is “partnering with multiple stakeholders, including academic institutions, non-state actors and other organizations that are actively involved in research to identify effective models of endometriosis prevention, diagnosis, treatment, and care”. This hopefully means continued investment into research and more support for those who suffer from endometriosis and adenomyosis. One of the most exciting areas of research is into diagnosis of endometriosis. As we know, a formal diagnosis often requires invasive surgery, which is not ideal. Research into specific bio markers like blood tests and urine tests to diagnose endometriosis is ongoing. The development of advanced ultrasound techniques is really exciting. Professionals who can use the advanced technique are more able to diagnose endometriosis on ultrasound alone and we hope more practitioners can access this high quality training soon so it is available worldwide.”

Virginia Rivers Bulkeley (she/her) / @pelvicpainnetwork and @virginiariversbulkeley_physio / Clinical Specialist Pelvic Health Physiotherapist and Co-Founder of The Pelvic Pain Network / BSc (Hons), MSc, MCSP, POGP / NHS & private practice at The Pelvic Pain Network / Winchester, UK: “Yes! Whilst it might feel like we are starting on a back foot because of a well established gender "pain gap" in previous research, there is lots of great endometriosis research happening across specialities at the moment. Lots of fantastic new work was presented at the World Congress on Endometriosis in Edinburgh last year covering all aspects of care; investigating the potential causes of endometriosis, improving diagnostic techniques, and improving treatment options. Current research suggests that a whole person approach is required to provide comprehensive treatment for the symptoms of endometriosis, this commonly involving diagnostic specialists, surgeons, pain doctors, psychologists, and physiotherapists. If you'd like to find out more about research happening in the UK, the teams at the University of Edinburgh and the University of Oxford are leaders in this field.”

“Does endometriosis affect the development of a child during pregnancy?”

Dr. Fran Yarlett (she/her) / @get.the.lowdown / GP who specialises in sexual and reproductive health, MBBCh (Hons) BSc (Hons) MRCP (2016) MRCGP DFSRH / Medical Director at The Lowdown / London, UK: “Endometriosis and adenomyosis can have a small increased risk of miscarriage in the 1st trimester of a pregnancy. Those with endometriosis can also have an increased risk of an ectopic pregnancy compared to women without endometriosis. 

Endometriosis does not affect the development of a child, but may increase the risk of complications during pregnancy (such as gestational diabetes, high blood pressure, placenta praevia and preterm labour). However, the research into these complications has been low quality so guidelines don’t suggest that anyone pregnant with endometriosis needs additional monitoring, and certainly endometriosis alone should not stop anyone from becoming pregnant.”

“I come from a background without medical/financial resources. How can I find good treatment?”

Dr. Isabela Bottura (she/her) / @isabela.bottura / Medical Doctor and ObGyn / Online s*x coach & educator / Byron Shire, Australia: “It is unfortunately a reality that different people have different privileges when it comes to access to high-quality healthcare. Different countries have different medical systems and resources, and even private insurances often don’t cover the most qualified specialists. In the public health system, the best doctors are usually in university hospitals, so I’d recommend those if you have the option. Looking for resources online such as in pages like this can also provide you with high-quality information to empower you to ask the right questions and identify good professionals who know what they are talking about.”

“What are the long-term effects of untreated endometriosis, and how do endometriosis and adenomyosis affect fertility?”

Dr. Fran Yarlett (she/her) / @get.the.lowdown / GP who specialises in sexual and reproductive health, MBBCh (Hons) BSc (Hons) MRCP (2016) MRCGP DFSRH / Medical Director at The Lowdown / London, UK: “Both adenomyosis and endometriosis can cause heavy and prolonged bleeding, if untreated, this can lead to anaemia and symptoms of dizziness, fatigue and shortness of breath. Both conditions can cause chronic pain which can affect your quality of life. Untreated endometriosis and adenomyosis may both reduce fertility if left untreated, but fertility treatment can often help you get pregnant. We should never forget the impact of these conditions and their symptoms on your mental health, relationships, working life and sexual wellbeing - which for many are the most longstanding features when dealing with these symptoms for a long time. Endometriosis can affect fertility and it also depends on the severity of your condition. Of those couples trying to conceive naturally where endometriosis is a factor, most (60 to 70%) will get pregnant within 1 year of trying, compared to 84% of couples where endometriosis is not an issue. 75% of people with mild endometriosis will conceive within 1 year. 50% of people with moderate endometriosis and 25% with severe endometriosis will conceive within one year of trying. If you have a known condition that could cause fertility problems such as endometriosis, you may wish to consult specialist fertility services sooner than waiting for one year of trying.”

 “How can I center pleasure in my life again?”

Rachel Gelman (she/her) / @pelvichealthsf / Pelvic floor physical therapist, DPT, and sexuality counselor / Owner of Pelvic Wellness & Physical Therapy / San Francisco, USA: “There are many reasons why endometriosis can lead to painful s/x. Often endometrial lesions or adhesions are found behind the uterus and these adhesions are not very elastic and this lack of visceral mobility can lead to pain with penetrative s/x. The uterus and anus contract during org/sm so any lesions in this area can also limit mobility and contribute to pain. Since endometriosis is causing adhesions and chronic inflammation, the pelvic floor muscles which support all the pelvic organs are essentially wanting to protect the area and tense up in response. Pelvic floor muscle tension can lead to pain with s/x.”

“How does endometriosis affect trans and gender diverse people? How does it interact with gender affirming care?”

Dr. Maddalena Giacomozzi (they/them) / @treatitqueer, Endometriosis MD and President Treat it Queer Foundation / MSc Global Health / RadboudUMC / Nijmegen, The Netherlands: “Endometriosis typically affects people born with ovaries and a uterus. This means that it impacts cisgender women and also transmasculine and gender diverse people born with these organs. 

The few studies that are available on this topic show that endometriosis may occur at higher rates in trans and gender diverse (TGD) people than in cisgendered women, with rates of up to 25% reported in TGD people in some studies, compared to rates of 5-10% in cisgender women. 

Diagnosis and treatment for TGD people can also be more challenging to access for several reasons: some patients may avoid seeking treatment due to particular discomfort with internal pelvic exams, and, sometimes, even when TGD people seek care, healthcare providers may dismiss their menstrual pain as gender dysphoria.

Many TGD people use testosterone as part of gender affirming hormonal therapy. While testosterone treatment stops menstrual bleeding for 80% of patients in their first year of use, it does not shut down ovarian and endometrial activity. For this reason, testosterone is often not an effective treatment for endometriosis.

Oral combined contraceptives ("the pill") are often not the first choice for TGD people with endometriosis symptoms. Instead they often prefer using progestin-only medications or Danazol, both of which can be used either alone or in combination with testosterone. 

While there have been a few case reports of endometriosis in cisgender men born without ovaries or a uterus, it remains unclear whether transfeminine people taking estrogen are at increased risk for endometriosis.”

“How does endometriosis affect sexual health?”

Dr. Maddalena Giacomozzi (they/them) / @treatitqueer, Endometriosis MD and President Treat it Queer Foundation / MSc Global Health / RadboudUMC / Nijmegen, The Netherlands: “Endometriosis can affect sexual health in different ways. Depending on the location and severity of symptoms, certain sexual practices could be painful. 

Specifically, people with adenomyosis can experience painful orgasms and/or pelvic cramps after engaging in sex. Meanwhile, people with deep endometriosis could feel discomfort or pain associated with penetrative sex, some positions being more painful than others. Additionally, certain medications used for endometriosis can decrease sexual interest or desire, and it may be more difficult to become aroused while taking them. 

For these reasons, if you're experiencing any of these symptoms, it's important to explore ways in which you can experience pleasure, and to take time to honestly and openly communicate with your potential sexual partners about your lived experience, desires, expectations, and boundaries.”