In a perfect world, all sex would be consensual and enjoyable, all parties involved would be in the mood at the same time, and everyone would have a great experience. As a naturopathic physician working in women's health, I am no stranger to the question, “why does sex hurt?” And neither are a large percentage of women.
Research indicates, for a shocking 10-20% of U.S. women, sex can be extremely painful.
If you’re experiencing pain during or after sex, know that you are not alone (although it may seem like you are!) and that there are options to minimize your discomfort.
What is painful intercourse?
Painful intercourse is a broad, general term used to describe pain experienced immediately before, during, or after sex.
Many women (and even some men) experience recurrent or persistent pain in their genitals related to sexual activity.
What is dyspareunia?
The medical term for painful sexual intercourse is dyspareunia.
This is a term that encompasses all genital pain associated with sex.
Dyspareunia can refer to pain experienced upon initial penetration in the vulva or vagina. It also references deeper pain felt during sex in the pelvis or cervix.
There are two types of dyspareunia: Entry dyspareunia and Deep dyspareunia.
Entry dyspareunia refers to pain at the introitus or opening of the vagina. Deep dyspareunia refers to pain with deep vaginal penetration.
Dyspareunia can be caused by physical and medical conditions, and sometimes, can be a result of psychological trauma. In this article we’ll review some of the causes that are important to discuss with your doctor.
What are the symptoms of dyspareunia?
Symptoms of dyspareunia are characterized by localized pain in the pelvis, cervix, vagina, or vulva while having sex.
This can mean:
- Pain only during initial sexual penetration
- Pain during deeper penetration
- Throbbing pain
- A sensation of tearing or ripping
It can also mean that you experience pain during the insertion of a tampon.
What is deep dyspareunia?
Deep dyspareunia refers to pain felt deep in the pelvis during vaginal penetration — not just pain during initial penetration.
Often, this condition is associated with endometriosis, but can also be caused by:
- A tilted (retroverted) uterus — this is when the uterus curves backward
- Uterine fibroids
- Pelvic inflammatory disease
- Scar tissue from a past surgery, radiation treatment, or infection
- Ovarian cysts
- Painful bladder syndrome
With deep dyspareunia there can also be an anatomy or positional issue. Or in other words, “doggy style” might not work for you and a deep thrust with a male partner may be uncomfortable. We always want to rule out more serious issues, but we also want to be aware that anatomy plays a role and different positions can help some women.
Where is the pain felt?
For many women, pain during sexual intercourse is felt in the vulva, but it can also be located in the:
- Pelvic floor
Why Does Sex Hurt? 14 Causes of pain during sex
As varying as the types of pain with intercourse are, so are the causes. For years, many women have had their concerns regarding painful sex dismissed — or chalked up to completely psychological issues. Most experts now agree that there are multiple physical conditions that can cause discomfort and severe pain during sexual activity for women.
For you ladies with endometriosis, you’re no strangers to pain. As I discuss in this article about endometriosis, women with the condition often experience pain with bowel movements and urination. They also have general pain in the back, abdomen, and thighs.
It’s also a common cause of painful sex. Some women with endometriosis avoid sex completely due to the agony.
If you have a history of painful, heavy periods along with pain with sex, speak with your doctor about your symptoms.
One of the more “mysterious” causes of painful sex is vulvodynia. This condition can often be dismissed, so if you’re experiencing pain and a lack of support from your practitioner, don’t be disheartened. Self-advocate, get a second opinion, and don’t stop researching.
Vulvodynia refers to pain in the vulva which may have no otherwise diagnosable cause. Women with vulvodynia experience pain during sex, but can also experience discomfort when wearing tight pants or from sitting too long.
There's a connection between vulvodynia and birth control too. If you're experiencing pain with sex and have a history of hormonal birth control use (or are on it now) then be sure to mention this to your doctor.
From Beyond the Pill:
“Vulvodynia is a chronic pain condition affecting the outer genitalia. Research has shown that women who begin the pill before age sixteen are nine times more likely to develop vulvodynia compared to women who have never taken it. This is due to the alteration of natural hormones.”
When you’re experiencing vaginal dryness, sex can be torture. While this condition occurs most frequently in menopausal and breast-feeding women, it can happen at any age.
Causes of vaginal dryness include:
- Decreased levels of estrogen
- Antihistamines — they are designed to dry out tissue and can affect vaginal tissue as well as your sinuses
- Drugs used to treat endometriosis
- Cancer treatments
- Diabetes — vaginal dryness is twice as likely for those with this disease
- Sjorgen’s syndrome — this auto-immune condition can cause dry eyes, mouth, and vagina .
If you are experiencing symptoms of vaginal dryness, check with your doctor about potential medication, hormone or other underlying issues. Yes, every 👏single 👏woman 👏 needs lube at some point and there is zero shame in that.
If you're looking for a new lube, check out Coconu, which is free of harsh ingredients and comes in either coconut oil or coconut water based formula. You can use the code: drbrighten to get 15% off your first order.
Urinary tract infection
A urinary tract infection (UTI) can mean serious pain during intercourse. If you’re experiencing pelvic pain and having the urge to urinate frequently, it may be best to hold off on having sex until you can get checked out by your physician.
Sexual activity can exacerbate the pain and distribute those pesky bacteria that are causing your infection even further along your urinary tract.
Definitely see your doctor ASAP if you suspect a UTI, have a fever, back pain, or feel really unwell.
Urinary tract disease
Interstitial cystitis is also known as bladder pain syndrome (BPS) or painful bladder syndrome. In addition to causing painful urination, and urinary frequency, it can also mean painful sex for women.
Urethral diverticulum, another type of urinary tract disease, causes a pocket to form along the urethra that can cause extreme pain during intercourse.
If you’re suffering from a urinary tract condition, please try to have your doctor address your concerns before engaging in sexual intercourse.
Vaginal yeast infections can wreak havoc on your sex life. Having intercourse while you have a yeast infection can be extremely painful.
As I explain in this article on yeast infections, an overgrowth of candida fungus in the vagina can cause swelling, itching, burning, and general pain. Sperm can throw off the pH of the vagina as well — shifting the environment to allow for an imbalance of vaginal flora…so it’s probably wise to abstain from sex if you can until you’ve got the condition under control.
If you’re struggling to get a yeast infection cleared up, try out a high-quality probiotic like the one I recommend. It can go a long way in restoring the good bugs throughout your body that prevent the bad ones that cause yeast overgrowth.
Sexually transmitted infection
Various sexually transmitted infections (STIs) can result in painful intercourse. The most common infections that lead to painful sex include:
For the most part, sexual pain associated with these STIs is caused by swelling and irritation. Skin lesions caused by these infections can also become extremely painful if subjected to the friction of sexual intercourse. It’s best to let your doc get these issues under control before resuming sexual activity.
Pelvic inflammatory disease
If left untreated, sexually transmitted infections can lead to pelvic inflammatory disease. This type of infection can make sex especially painful due to the pain in the pelvis and abdomen that typically accompanies this condition.
If you’re experiencing pain during sex, and bleeding, discharge, odor, or fever — it’s a good idea to get things checked out by a medical professional so you can rule out pelvic inflammatory disease. You may want to refrain from having sex until things are cleared up.
If you have an IUD, you may be at increased risk of an ascending infection. Pain with sex is always worth a trip to the doctor and if you have an IUD, this isn’t the kind of thing you should just brush off.
Some women have painful sex due to a condition called vaginismus — which causes an involuntary contraction of the vaginal muscles and makes penetration extremely difficult or impossible. The causes of vaginismus are not well understood, but it’s generally regarded as a psychological matter with physical components.
Vaginismus is more prevalent in women that have endured sexual abuse or that suffer from anxiety. However, a recent study showed that vaginal botox injections and progressive dilation greatly improved the possibility of pain-free sex.
I am incredibly cautious to say any physical condition is simply mental emotional. Firstly, because we need to do a thorough workup to know if that is true. Secondly, this has historically been a way to dismiss women’s symptoms and is currently a reason why women don’t get the care they deserve. In fact, women have their pain dismissed much more often than their male counterparts. You can read more about medical gender bias here.
Hypertonic pelvic floor
In some women, the muscles of the pelvic floor are hypertonic. In other words, the muscles are unable to relax — they are almost constantly in a state of contraction.
While this condition is not widely understood, it is clear that women who experience it suffer from issues with bowel movements, urination, and painful sex.
Hypertonic pelvic floor can be caused by:
- Childhood patterns of “holding” urine or stool
- Work conditions that discourage regular bathroom use
- Skeletal asymmetry (like scoliosis)
- Difference in leg length
- Vaginal surgery
- Occupations that require prolonged sitting
Pelvic organ prolapse
In what’s the opposite of hypertonic musculature, some women instead have pelvic organ prolapse — a condition characterized by weak muscles of the pelvic floor.
When the muscles weaken, they are no longer able to support the pelvic organs (vagina, cervix, bladder, and rectum) — and this causes one or more of the organs to fall into or out of the vagina.
The pressure created by the falling organ can create extreme discomfort in the vagina and pelvis. Sexual intercourse can be painful and exacerbate the condition.
Pelvic organ prolapse can be caused by:
- Vaginal childbirth (but you can still have prolapse even if you’ve never had children)
- Straining during bowel movements
- Birthing a large baby over 8.5 pounds
- Chronic coughing
Don’t forget to practice your kegels, ladies. This simple exercise where you tighten and relax the muscles that control your urine flow can help prevent and treat prolapse!
How can you get dialed in on the best way to support your pelvic floor? Work with a pelvic floor specialist who can help you do a kegel right and also provide you with a holistic approach to your meet your individual needs.
Hormonal birth control
As I explain in Beyond the Pill, hormonal birth control pills work by completely stopping your natural sex hormones from being produced and replacing them with synthetic ones…this can cause changes to the vulva, which may become thinner, and therefore more irritated when subjected to friction during sex.
Furthermore, women on oral contraceptives are more likely to report:
- Pelvic pain
- Vaginal dryness
- Increased yeast infections
- Pain with sex
- Pain with orgasms
All of which have been known to cause pain during sex.
If you're on birth control now or have a history of using it, please grab my free guide to support your hormones.
When estrogen levels drop, especially due to menopause, women can begin to experience painful sex, even if they’ve had no issues up to that point.
Low estrogen means thinner and drier vaginal tissues — and this can make sex extremely uncomfortable. It’s especially important to utilize lubrication during intercourse in this instance to prevent further injury which can make sex even more painful.
Genitourinary syndrome of menopause (GSM) is the term that we physicians like to use to describe this cluster of sexual, genital and urinary symptoms women experience due to the decreased estrogen levels resulting from menopause.
Sometimes, even up to 18 months postpartum, women can experience painful intercourse. Long after the doc’s given the all clear to resume normal sexual activity, pelvic and vaginal pain persists, usually with no obvious physical reason.
This postpartum pain is more likely for women who had a difficult labor, vaginal trauma, or an episiotomy (an incision made to the perineum to make the vaginal opening wider for childbirth). According to this study, it’s also more likely for breastfeeding mothers to experience.
If you're currently postpartum, check out my first book, Healing Your Body Naturally After Childbirth.
Other reasons for painful sex:
- Surgery — after hysterectomy or surgeries for urinary incontinence, dyspareunia can result
- Leiomyomata — these tumors can cause pelvic pain and pressure which makes sex painful
- Adnexal mass — these usually benign growths near the uterus or ovaries can cause discomfort during sex
- Seminal plasma allergy — in one of nature’s great mysteries, semen is actually an incompatible pH with the vagina, and by some counts, up to 40,000 women are actually allergic to it…which makes sex extremely uncomfortable
- Lichen planus — this condition can cause painful sores in various locations on the body — when located in the vagina, they cause sex to be painful
- Lichen sclerosus — postmenopausal women are at highest risk of developing these skin lesions, and when they appear on the genitals, it can mean painful intercourse
- Uterine retroversion — when the uterus is tipped backward, rather than toward the anus, sex can be quite unpleasant for many women
- Uterine fibroids — most women with fibroids don’t experience pain, but some women experience agony during sex due to their presence
How do you treat painful sex?
Fortunately, there are as many varied treatments for pain experienced during sex as there are conditions causing it.
Many physicians are finding success with a multi-pronged approach to treatment that includes counseling, minimally invasive surgery, hormone therapy, and education.
If you don’t like what your doc is suggesting, seek another opinion. Keep researching. Always, always, always self advocate. Especially if your intuition is telling you something is wrong and your physician isn’t listening.
Communicate with your partner
For many women, experiencing painful intercourse comes with feelings of inadequacy and shame.
It’s important to remember that you are not alone. Thousands of women across the globe struggle with painful sex and thousands have effectively treated their symptoms and recovered.
While effective and open communication is important in any relationship, it’s even more so in a relationship affected by sexual dysfunction. Keep those lines of communication open, and talk about what you’re experiencing and feeling with your partner — it will only serve to make the situation easier for both of you.
A lot of the time, sexual pain can be alleviated with plenty of lubrication.
If you are not producing enough natural lubrication — either due to menopause or perhaps a lack of arousal, this problem can easily be solved with lube. Be sure to use water or silicone based lubes if you’re using condoms.
Coconu is one of my favorites and comes in both water based and oil based formulas. You can even use the code: drbrighten to get 15% off your first order.
And ladies, don’t be afraid to ask for what you want and need. We aren’t made to become immediately lubricated for sex, and a bit of foreplay can go a long way towards getting everything prepared for penetration that’s not painful.
Treat the underlying condition
If your discomfort during sex is due to an infection, cyst, or tumor, it’s imperative to have proper medical treatment to resolve the underlying condition so you can resume normal sexual activity that’s pain-free. Medication to resolve your infection or surgery to remove pelvic adhesions may be recommended.
If your issue is due to weak or overactive muscles, kegel exercises or relaxation techniques may be effective in reducing your pain.
Don’t be afraid to talk to your doctor about the effect your condition is having on your sex life.
Consider hormone replacement therapy
Hormone replacement therapy (HRT) can be an appropriate choice for menopausal women looking for relief from painful sex.
This therapy can help balance estrogen and progesterone levels to reduce many symptoms that menopause can bring about — the hot flashes, irritability, and vaginal dryness. There are even some topical estrogen and DHEA creams that can be applied to the vaginal area to help reduce symptoms.
HRT is not for everyone, though, and doesn’t come without risks.
Discuss the pros and cons with your doctor, but if you have any of the following, HRT is likely not the best choice for you:
- History of cancer
- History of stroke
- History of heart attack
- History of liver problems
- History of blood clots
- History of problems with vaginal bleeding
I also recommend reading my article on progesterone cream.
Practice sex hygiene
Since a lot of women that complain of painful sex actually have an underlying condition that starts with a sexually transmitted infection, it’s important to note that proper sexual hygiene can go a long way in preventing the infection to begin with.
As I break down thoroughly in this article on bacterial vaginosis, it’s so important to use a condom when starting a new relationship or when either partner is not monogamous. Those ingenious things, when used properly, can prevent the transmission of sexually transmitted infections and can help maintain vaginal pH and flora by preventing semen from messing up the delicate balance.
Don’t forget to properly wash sex toys, either. And be mindful of switching up orifices mid-coitus. Transferring bacteria between anus and vagina or mouth is a sure-fire way to get an infection.
It is also important to pee after sex to help flush the urethra of any organisms that may have found themselves there during sex.
Quit hormonal birth control or change prescriptions
If you’ve noticed an increase in pelvic pain, vaginal dryness, or yeast infections since starting the pill, it may be time to consider other options. Talk to your doctor about adjusting prescriptions or possibly going off the pill.
Check out this recent article if you’re interested in learning more about your other contraception options.
I also wrote an entire book, Beyond the Pill, about this subject — it’s been in the top 25 women's health books since it published! In it I cover what every woman should know about her hormones and body, plus give you lots more solutions on supporting a healthy sex life. It’s completely chock full of everything you need to know about post birth control syndrome and how to heal after experiencing side effects from hormonal contraception. If you’re thinking of quitting or starting the pill, it’s simply a must read.
Meet with a Pelvic Pain Expert
Real talk, sexual health is understudied and women who challenge the conventional narrative of treatment options are often dismissed and/or shamed. Find a doctor who specializes in pelvic pain. They will not only be more in tune with the current research, but they will also have extensive experience in treating women with this condition.
When there is lack of research, seeking an expert with years of experience can help you get to the root of what your issue is and improve your health.
Include a Physical Therapist as Part of Your Health Care Team
When working with patients who have concerns about pelvic pain or pain with sex, I always refer to a physical therapist. As I shared above about kegels, working with an expert to address your individual imbalances and ensure you're properly performing exercises is a must.
I also recommend pelvic floor physical therapy as part of postpartum care to support healing and prevent pelvic floor dysfunction from developing.
When to see your doctor
Please don’t hesitate to talk to your doctor if you’re experiencing pain during sex or when using a tampon.
If you have any of the following symptoms and/or pain during sex, please contact your doc and have things checked out:
- Stabbing pain
- Muscle spasms
- Vaginal dryness
- Unusual discharge
- Lesions on the vulva
- Frequent urge to urinate
Feeling uncomfortable talking about your experience with painful sex? Wondering if anyone else is feeling the same way you do? Head over to my Instagram where you’ll find a wealth of education and a community of supportive women who will help you remember that you’re not alone!
“Evaluation and Differential Diagnosis of Dyspareunia – Aafp.” https://www.aafp.org/afp/2001/0415/p1535.html.
“Painful Sexual Intercourse (Dyspareunia) – Harvard Health.” https://www.health.harvard.edu/a_to_z/painful-sexual-intercourse-dyspareunia-a-to-z.
“Painful intercourse (dyspareunia) – Symptoms and causes ….” https://www.mayoclinic.org/diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967.
“Dyspareunia—When Sex Hurts | American Sexual Health ….” http://www.ashasexualhealth.org/dyspareunia-sex-hurts/.
“Endometriosis | Endo | MedlinePlus.”
“Retroverted Uterus: Causes, Fertility, Treatment, and More.” https://www.healthline.com/health/womens-health/tilted-uterus.
“Uterine fibroids – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288.
“Pelvic inflammatory disease (PID) – Symptoms and causes ….” https://www.mayoclinic.org/diseases-conditions/pelvic-inflammatory-disease/symptoms-causes/syc-20352594.
“Ovarian Cyst Symptoms & Treatments | Cleveland Clinic.” https://my.clevelandclinic.org/health/diseases/9133-ovarian-cysts.
“Deep Dyspareunia in Endometriosis: Role of the Bladder and ….” https://www.ncbi.nlm.nih.gov/pubmed/30078464.
“Anatomic Sites and Associated Clinical Factors for Deep ….” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5562494/.
“What is Vulvodynia? – The National Vulvodynia Association.” https://www.nva.org/what-is-vulvodynia/.
“Vaginal Dryness Possible Causes | Cleveland Clinic.” https://my.clevelandclinic.org/health/symptoms/21027-vaginal-dryness/possible-causes.
“How Diabetes Affects a Woman's Sexual Health: From Vaginal ….” https://www.webmd.com/diabetes/head2toe-15/diabetes-women-sexuality.
“Sjogren's syndrome – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/symptoms-causes/syc-20353216.
“Yeast infection (vaginal) – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/yeast-infection/symptoms-causes/syc-20378999.
“Sexually transmitted infections | womenshealth.gov.” https://www.womenshealth.gov/a-z-topics/sexually-transmitted-infections.
“STD Facts – Genital Herpes – CDC.”https://www.cdc.gov/std/herpes/stdfact-herpes.htm.
“STD Facts – Gonorrhea – CDC.” https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm.
“STD Facts – Trichomoniasis – CDC.”https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm.
“Molluscum Contagiosum | Poxvirus | CDC.” https://www.cdc.gov/poxvirus/molluscum-contagiosum/index.html.
“Vaginismus – Cleveland Clinic.” https://my.clevelandclinic.org/health/diseases/15723-vaginismus.
“Sexual behavior and oral contraception: a pilot study. – NCBI.” https://www.ncbi.nlm.nih.gov/pubmed/22188640.
“Hormonal contraception and female pain, orgasm and sexual ….” https://www.ncbi.nlm.nih.gov/pubmed/24286545.
“Pain with Penetration, Sexual Side Effects of Menopause | The ….” https://www.menopause.org/for-women/sexual-health-menopause-online/sexual-problems-at-midlife/pain-with-penetration.
“What is Interstitial Cystitis/Bladder Pain Syndrome? – Urology ….” https://www.urologyhealth.org/urologic-conditions/interstitial-cystitis.
“What is Urethral Diverticulum? – Urology Care Foundation.” https://www.urologyhealth.org/urologic-conditions/urethral-diverticulum.
“Recognition and Management of Nonrelaxing Pelvic Floor ….” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498251/.
“Scoliosis – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/scoliosis/symptoms-causes/syc-20350716.
“Genitourinary syndrome of menopause: Underdiagnosed and ….” https://www.contemporaryobgyn.net/menopause/genitourinary-syndrome-menopause-underdiagnosed-and-undertreated.
“Persistent genital and pelvic pain after childbirth. – NCBI.” https://www.ncbi.nlm.nih.gov/pubmed/19170851.
“Risk Factors for Dyspareunia After First Childbirth. – NCBI – NIH.” https://www.ncbi.nlm.nih.gov/pubmed/27500349.
“Pelvic organ prolapse | womenshealth.gov.” https://www.womenshealth.gov/a-z-topics/pelvic-organ-prolapse
“What to do about pelvic organ prolapse – Harvard Health.” https://www.health.harvard.edu/womens-health/what-to-do-about-pelvic-organ-prolapse.
“Uterine leiomyomata: etiology, symptomatology, and … – NCBI.” https://www.ncbi.nlm.nih.gov/pubmed/7026295.
“Seminal plasma hypersensitivity reactions: an updated review..” https://www.ncbi.nlm.nih.gov/pubmed/21913207.
“Differential diagnosis of sexual pain in women – UpToDate.” https://www.uptodate.com/contents/differential-diagnosis-of-sexual-pain-in-women.
“Lichen planus – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/lichen-planus/symptoms-causes/syc-20351378.
“Lichen sclerosus – Symptoms and causes – Mayo Clinic.” https://www.mayoclinic.org/diseases-conditions/lichen-sclerosus/symptoms-causes/syc-20374448.
“Hysterectomy – ACOG.” https://m.acog.org/Patients/FAQs/Hysterectomy.
“Fibroids: Are They Making Sex Painful for You? – Health ….” https://health.clevelandclinic.org/best-treatment-uterine-fibroids-besides-hysterectomy/.
“Deep Dyspareunia Improves With Interdisciplinary Treatment ….” https://www.issm.info/news/sex-health-headlines/deep-dyspareunia-improves-with-interdisciplinary-treatment-approach-study-finds/.