Many people who have chronic pelvic pain and endometriosis experience what doctors call deep dyspareunia – pain with deep penetration during sex. The Endometriosis and Pelvic Pain Research Laboratory at BC Women’s Hospital wondered if this pain is related to tenderness of specific areas around the vagina. To answer this question, we asked 548 sexually active women under the age of 50 to rate the pain they have during sex and the amount of tenderness they felt during a physical exam of several pelvic structures. We found that pain with deep penetration was related to tenderness of the cul-de-sac and uterosacral ligaments, bladder, pelvic floor, and cervix-uterus (see the image). We also discovered that the more tender areas patients had, the more pain they experienced with deep penetration. Another interesting result was that higher symptoms of depression were related to increased tenderness of certain pelvic structures. So, what does this mean? These results suggest that managing pain during deep penetration should take into account where exactly people feel tenderness. For example, people who experience tenderness at the back of the pelvis (cul-de-sac or uterosacral ligament) may respond best to surgical treatment whereas people with tenderness at other sites might benefit from physiotherapy, psychotherapy, or sex therapy.