Painful Sex in Women: Causes and What Helps

Pain during sex, medically called dyspareunia, is pain felt before, during or after intercourse, either at the entrance to the vagina or deep inside the pelvis. It is common and has a treatable cause, from vaginal dryness and infections to pelvic floor tension or conditions such as endometriosis. If pain comes back, speak to your GP — help is available.

What is painful sex?

Painful sex, or dyspareunia, is persistent or recurring pain just before, during or after sex. The pain may be felt at the opening of the vagina, inside the vagina, or deep in the pelvis, and it can feel like burning, aching, cramping or a sharp pain. It can happen every time, or only in some situations. It is a common problem: the Cleveland Clinic notes that it affects 3 out of 4 women at some point in their lives, while the World Health Organization reported a global prevalence of painful intercourse of between 8% and 21.1%, according to Patient.info. Many women do not mention it to a doctor, so the true figure may be higher.

Painful sex is not something you have to put up with, and it is not a normal part of getting older. It can affect confidence, relationships and quality of life, but most causes can be treated once the cause is found.

Is the pain at entry or deep inside?

Where the pain is felt is an important clue to its cause. Doctors usually divide dyspareunia into two types:

Type of pain	Where it is felt	Common causes
Entry (superficial) pain	At the entrance to the vagina, when penetration begins	Vaginal dryness, infection, skin irritation, vaginismus or scar tissue
Deep pain	Deep inside the pelvis, during deeper penetration	Endometriosis, pelvic inflammatory disease, fibroids, ovarian cysts or bowel and bladder problems

Some women have both types of pain, and pain can also be felt after sex has finished, or when using a tampon. Noting when the pain starts, where it is, and what makes it better or worse will help your GP work out the cause.

What causes painful sex in women?

There is rarely a single cause. Painful sex often has a mix of physical and emotional causes, and sorting them out is the first step to treatment.

Vaginal dryness and hormone changes

Dryness is one of the most common causes of pain at entry. Lower levels of oestrogen can make the vagina drier and less elastic, which leads to friction and soreness. This often affects women who have gone through the menopause and those who are breastfeeding, as the Mayo Clinic explains. Dryness can also happen when there has not been enough time for arousal before penetration, or as a side effect of some medicines.

Infections and skin conditions

Thrush, bacterial vaginosis, urinary tract infections and sexually transmitted infections such as chlamydia, gonorrhoea or genital herpes can all make sex painful, according to the NHS. Skin conditions affecting the genital area, including eczema, psoriasis and lichen sclerosus, can also cause soreness, as can irritation or allergy from spermicides, latex condoms, soaps and perfumed products.

Pelvic floor problems and vaginismus

The pelvic floor muscles support the pelvic organs. If these muscles are very tense, they can contribute to painful sex, and stress can make them tighten further. Vaginismus is a condition in which the muscles in or around the vagina tighten involuntarily when penetration is attempted, making sex painful or impossible. It can develop after a painful experience, childbirth or surgery, and the fear of pain can itself keep the muscles tense, creating a cycle that is hard to break without help.

Conditions deeper in the pelvis

Pain felt deep inside is more often linked to a condition affecting the pelvic organs. The Mayo Clinic lists endometriosis, pelvic inflammatory disease (PID), uterine fibroids, ovarian cysts, pelvic organ prolapse and adenomyosis among the possible causes. Bowel and bladder problems, such as irritable bowel syndrome (IBS) or cystitis, can also cause deep pain during sex, and scarring from pelvic surgery or childbirth — including an episiotomy or perineal tear — can play a part.

Medicines

Some medicines can lower sexual desire or arousal, which reduces lubrication and makes sex painful. The Mayo Clinic names antidepressants, blood pressure medicines, sedatives, antihistamines and some birth control pills as examples. Never stop a prescribed medicine without talking to a doctor or pharmacist first — they can discuss whether an alternative may suit you.

Emotional and psychological factors

Emotions are closely linked with sex, so they can play a real part in sexual pain. Anxiety, depression, stress, concerns about body image, relationship difficulties and fear of pain can all lower arousal and make the pelvic floor muscles tighten. A history of sexual abuse or trauma can also contribute. This does not mean the pain is imagined — physical and emotional causes usually work together, and both deserve attention. Talking therapies, including counselling or sex therapy, can help where emotional factors are involved.

What can help?

What helps depends on the cause, so the most useful first step is to find out what is behind the pain. In the meantime, these approaches help many women:

• Use a lubricant. A water-based lubricant can reduce friction and make sex more comfortable. If you use condoms, choose a water-based product, because oil-based lubricants can damage condoms and make them less effective, the NHS advises. A vaginal moisturiser used regularly can also help with general dryness.
• Allow more time for arousal. Spending longer on foreplay and waiting until you feel fully aroused before penetration increases natural lubrication and reduces pain on entry.
• Talk with your partner. Being open about what hurts, what helps and what pace feels comfortable can reduce pressure and anxiety for both of you.
• Try pelvic floor physiotherapy. A pelvic health physiotherapist can teach you to relax tense pelvic floor muscles and to strengthen them correctly. The Royal Berkshire NHS leaflet on dyspareunia describes breathing and relaxation techniques, perineal massage and graded dilators, which a physiotherapist or GP can discuss with you.
• Treat the underlying cause. Infections can be treated, and conditions such as endometriosis or skin disorders have their own treatments. Your GP can advise on what is suitable for you, including whether hormone treatment applied to the vagina may help if dryness is linked to the menopause.
• Consider counselling or sex therapy. If anxiety, fear of pain or relationship strain is part of the picture, a counsellor or sex therapist can help — your GP or sexual health clinic can refer you.

Avoid perfumed soaps, washes and creams around the genital area, and wear cotton underwear, to reduce irritation while the cause is being sorted out.

When to see a doctor

See your GP or visit a sexual health clinic if pain during sex happens often, lasts over time, is severe, or is getting worse. It is worth seeking help sooner if you also have bleeding after sex or between periods, unusual discharge, itching or soreness, a fever, pelvic pain outside of sex, or pain after a change of partner, when an STI test may be sensible. Doctors deal with problems like this every day, and there is no need to feel embarrassed about raising it.

If the pain started after a new medicine, after childbirth or after surgery, tell your GP — the timing may point to the cause. If you have experienced sexual abuse or assault and it is affecting your health, your GP can listen without judgement and help you find support.

In an emergency call 911 (US), 999 (UK) or 112 (EU)

Painful sex is common, it is not your fault, and in most cases it can be improved or resolved with the right help. The sooner you speak to a healthcare professional, the sooner you can find out what is causing it — and get back to a comfortable, enjoyable sex life.