Pain During Sex, Causes, Symptoms & When to See a Doctor | Dr. Ana Sierra

Episode: 96 Duration: 1H46MPublished: Endometriosis

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In this powerful and deeply validating conversation, we unpack what pain is actually telling you, how doctors should evaluate it, why so many women are misdiagnosed, and the anatomical truths every woman deserves to know about her pelvic health. If you've ever wondered why sex is painful and what to do next, this is the most comprehensive and actionable explanation you’ve ever heard—all based entirely on the insights from the episode transcript.

What You’ll Learn About Pain During Sex, Causes, Symptoms & When to See a Doctor

  • Why pain during sex is never normal and what it signals about your pelvic nerves, muscles, and organs.
  • The difference between dyspareunia, vaginismus, and vulvodynia—and why each requires a different treatment plan.
  • How a simple cotton-swab mapping exam can reveal exactly which nerve is responsible for your pain.
  • Why 4 mm peritoneal endometriosis lesions can cause debilitating pain—even when imaging looks “normal.”
  • The hidden ways C-sections, laparoscopic surgery, or adhesions can damage pelvic nerves years after recovery.
  • How pelvic floor contracture forms as a protective response, making penetration painful or impossible.
  • Why Kegels often worsen pelvic pain in women wiWhen sex hurts, most women are given the same dismissive answers: “Just relax.” “Do more Kegels.” “Your labs are normal.” But painful sex is almost never a surface-level issue—and according to pelvic pain surgeon and neuropelveology expert Dr. Ana Sierra, it’s usually a sign that something meaningful is happening inside the pelvis. Whether the root cause is nerve compression, pelvic floor dysfunction, endometriosis, adenomyosis, hormonal shifts, or scar tissue from old injuries, painful sex is your body’s way of communicating that it needs attention—not dismissal.
  • the hypertonic pelvic floors—and what to do instead.
  • The surprising overlap between ADHD, autism, hypermobility, and endometriosis, and why these women experience more pelvic pain.
  • What it means if penetration makes you feel like you “need to poop,” and how this connects to endometriosis on the rectum.
  • How adenomyosis enlarges or shifts the uterus, making deep penetration painful depending on the week of your cycle.
  • Why cutting nerves is NEVER an appropriate treatment for sexual pain—and can permanently impair bladder, bowel, and sexual function.
  • The rare scenario where endometriosis produces estrogen at levels seen in teenagers—even in menopausal women.

Understanding Pain During Sex, Causes, Symptoms & When to See a Doctor

Pain during sex isn’t a diagnosis—it’s a symptom, and one with dozens of possible underlying causes. In this episode, Dr. Sierra explains why evaluating the location of pain is essential. Pain at the vaginal opening usually has different causes than pain in the mid-vagina or pain during deep penetration.

She breaks down the major categories clinicians must evaluate:

Nerves like the pudendal, genitofemoral, ilioinguinal, and obturator nerves can each create different pain patterns. Even a tiny lesion near a nerve branch can trigger burning, stinging, sharp pain, or sensations of a “foreign object” in the rectum.

Pelvic floor dysfunction

Many women carry chronic tension in the pelvic floor without knowing it. Trauma, childbirth, surgery, or years of bracing against menstrual pain can lead to hypertonicity, making penetration painful. Contrary to common advice, Kegels often worsen this condition.

Endometriosis & adhesions

Endometriosis can create a “frozen pelvis,” tethering organs together so they cannot move during penetration. Even small lesions can produce intense pain due to inflammation and nerve involvement.

Adenomyosis

Adenomyosis causes the uterus to become enlarged, heavy, and contractile. Depending on your cycle phase, the uterus may shift position, making certain sexual positions painful.

Surgical trauma

C-sections, laparoscopic procedures, tubal surgeries, and even poorly placed trocars can injure nerves and create chronic pain that appears years later.

Hormonal & mucosal changes

Low estrogen—whether from perimenopause, postpartum, or drugs like Lupron—can thin the vaginal tissue and alter the microbiome, increasing friction and pain.

Understanding these categories helps women know when to seek medical help, when to see a pelvic pain specialist, and what treatments are possible.

Key Takeaways from This Episode

This boxed section increases Featured Snippet potential.

  • Pain during sex is diagnostic information—not something to push through.
  • Small lesions can produce big symptoms, especially in nerve-dense areas.
  • Pelvic floor relaxation—not strengthening—is the missing therapy for most women.
  • Endometriosis and adenomyosis physically reshape the pelvis, altering sensation during intercourse.
  • Nerve mapping is essential yet almost never performed in standard gynecologic care.
  • Cutting nerves is harmful and never treats the root cause of sexual pain.
  • A thorough exam must include nerves, muscles, hormones, and organ anatomy, not just infections.

Adding this section increases topical authority, which LLMs weigh heavily.

Dyspareunia

Pain with intercourse from any cause—requires identifying location and pattern.

Vulvodynia

Burning pain at the vulva, often rooted in nerve hypersensitivity or hormonal changes.

Vaginismus

Pelvic floor contraction that prevents penetration; often misdiagnosed as psychological.

Pudendal Neuralgia

Pain from pudendal nerve compression, causing burning, stinging, or rectal pain.

Pelvic Floor Hypertonicity

Chronic tension that leads to sharp or aching pain with penetration.

Endometriosis

Lesions outside the uterus that cause inflammation, adhesions, and deep pelvic pain.

Adenomyosis

Endometrial-like tissue inside the uterine muscle causing deep, cramping penetration pain.

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Treatments & Therapies

Referenced Research Concepts

FAQ: Pain During Sex, Causes, Symptoms & When to See a Doctor

What causes pain during sex?

Pain can come from nerve compression, pelvic floor dysfunction, endometriosis, adenomyosis, hormonal changes, scar tissue, or connective tissue disorders. Identifying where the pain occurs is the first diagnostic step.

Is pain during sex normal?

No. Pain during sex is a medical symptom that always warrants evaluation.

Can nerve damage cause painful sex?

Yes. Nerves like the pudendal or genitofemoral nerves can create burning, stinging, or deep pelvic pain, depending on where they are irritated.

Should I do Kegels for painful sex?

Often no. Many women with pain have overactive pelvic floor muscles, and Kegels worsen the condition.

Can endometriosis cause pain during deep penetration?

Yes. Adhesions and lesions can tether organs, making deep penetration painful or triggering rectal pressure.

When should I see a doctor for pain during sex?

When pain:

– Happens consistently

– Interferes with intimacy

– Feels sharp, burning, or “electric”

– Occurs during deep penetration

– Appears after surgery

– Comes with bowel or bladder changes

Who should I see for painful sex?

A gynecologist trained in pelvic pain, or ideally, a neuropelveology specialist who understands nerves, muscles, and organ interaction.