By Pain during sex is not normal. It is not something you should push through. It is not a price women pay for intimacy. And it is not in your head.
Those three statements should not need to be said — but they do, because a significant proportion of women who experience painful sex have been told exactly the opposite by people they trusted. By partners who minimized it. By friends who said everyone experiences some discomfort. And sometimes, painfully, by healthcare providers who didn’t take it seriously, couldn’t identify a cause, or defaulted to reassurance rather than investigation.
An estimated 10 to 20 percent of American women experience persistent pain during sexual intercourse — a condition called dyspareunia (Latthe et al., 2006). Related conditions including vaginismus, vulvodynia, and provoked vestibulodynia affect millions more. Combined, they represent one of the most common and most undertreated areas of women’s health in the United States.
The undertreatment is not because effective treatments don’t exist. They do, and they work well. The problem is a combination of women not reporting pain, providers not asking about it, diagnostic delays that stretch into years, and a cultural assumption — still surprisingly persistent — that sexual pain in women is simply part of the deal.
It isn’t. And this article is here to explain exactly what these conditions are, what causes them, and what comprehensive treatment actually looks like.
This article is part of our Sexual Health series. For the full foundation, visit our Sexual Health Explained guide.
The Different Types of Female Sexual Pain
Sexual pain in women is not a single condition. It is a category that encompasses several distinct presentations, each with its own underlying mechanisms, typical symptom pattern, and treatment approach. Getting the diagnosis right matters enormously because the treatment differs significantly across conditions.
Dyspareunia
Dyspareunia is the medical term for persistent or recurrent pain associated with sexual intercourse. It is one of the most common sexual health complaints among American women and one of the most consistently undertreated.
Pain can occur at different points during sex and in different locations:
- Superficial dyspareunia — pain at the vaginal opening during initial penetration
- Deep dyspareunia — pain felt deep in the pelvis during thrusting, often related to internal conditions like endometriosis or ovarian cysts
- Entry dyspareunia — pain specifically during penetration
- Positional dyspareunia — pain in specific positions but not others
The location and timing of pain are clinically important because they point toward different underlying causes and different treatment approaches.
Vaginismus
Vaginismus is an involuntary contraction or spasm of the muscles surrounding the vaginal opening in response to attempted penetration — whether during sex, gynecological examination, or tampon insertion. The contraction is involuntary — the person is not choosing to close up, and cannot simply will themselves to relax.
The experience ranges from significant discomfort to complete inability to achieve penetration. Many women with vaginismus have never been able to have penetrative sex. Others develop it after a period of normal sexual function, often following a painful experience, trauma, childbirth, or a period of painful intercourse from another cause.
Vaginismus is classified as:
- Primary vaginismus — present since the first attempt at penetration; the person has never been able to have comfortable penetrative sex
- Secondary vaginismus — develops after a period of normal sexual function
- Situational vaginismus — occurs in specific situations (e.g., with a partner but not during gynecological exams, or vice versa)
- Global vaginismus — occurs in all situations involving vaginal penetration
“Vaginismus is an involuntary muscle response — not a choice, not a psychological weakness, and not a sign that something is permanently wrong. It is a conditioned neuromuscular response that responds very well to treatment when properly approached.”
Vulvodynia
Vulvodynia is chronic vulvar pain — pain, burning, stinging, or rawness in the external genital area — that lasts three months or more and has no identifiable cause (no infection, no skin condition, no neurological disease that explains it). It can be constant or intermittent, localized to one area or generalized across the vulva.
It is estimated to affect approximately 16 percent of American women at some point in their lives, making it far more common than is widely appreciated (Harlow and Stewart, 2003).
Vulvodynia significantly affects quality of life. Women with the condition report difficulties sitting for extended periods, wearing tight clothing, and engaging in physical activity — well beyond the impact on sexual function alone.
Provoked Vestibulodynia (PVD)
Provoked vestibulodynia — previously called vulvar vestibulitis — is a specific subtype of vulvodynia characterized by pain specifically at the vestibule (the tissue at the vaginal entrance) in response to touch or pressure. It is the most common cause of superficial dyspareunia in premenopausal women.
The defining feature is that pain is provoked by contact — a gynecological examination, tampon insertion, or penetration — and typically not present at rest. The vestibular tissue is often visibly red and exquisitely tender to the lightest touch.
Genitopelvic Pain / Penetration Disorder
The DSM-5 combines vaginismus and dyspareunia into a single diagnostic category called genitopelvic pain/penetration disorder (GPPPD), recognizing that these conditions frequently overlap and that the distinction between them is not always clinically clean. For practical purposes, understanding the specific symptom pattern — where the pain is, when it occurs, what triggers it — is more useful than the diagnostic label.
What Causes Female Sexual Pain
The causes of sexual pain in women span physical, neurological, hormonal, psychological, and relational factors — and most cases involve more than one contributing dimension.
Hormonal Causes
Estrogen deficiency is one of the most common causes of sexual pain, particularly after menopause. Estrogen maintains the health, elasticity, and lubrication of vaginal tissue. When estrogen declines — whether through natural menopause, surgical menopause, breastfeeding, or hormonal contraceptive use — the consequences include:
- Vaginal dryness
- Thinning and fragility of vaginal tissue (vaginal atrophy)
- Reduced natural lubrication
- Decreased tissue elasticity
- Increased susceptibility to micro-tears during sex
This constellation of changes — now formally called Genitourinary Syndrome of Menopause (GSM) — affects an estimated 50 to 60 percent of postmenopausal women and is significantly underdiagnosed and undertreated (Portman and Gass, 2014).
Structural and Gynecological Causes
Endometriosis is one of the most significant causes of deep dyspareunia. In endometriosis, tissue similar to the uterine lining grows outside the uterus — on the ovaries, fallopian tubes, bladder, bowel, or pelvic wall. During sex, particularly deep thrusting, this tissue is compressed or stretched, causing significant pain. Many women with endometriosis experience painful sex for years before receiving an accurate diagnosis.
Other structural causes include:
- Ovarian cysts — pressure or rupture during sex
- Uterine fibroids — depending on location and size
- Pelvic inflammatory disease (PID) — inflammation of the reproductive organs, often from untreated STIs
- Pelvic adhesions — scar tissue from surgery, infection, or endometriosis
- Retroverted uterus — a uterus that tilts backward rather than forward; can cause deep pain in certain positions
Pelvic Floor Dysfunction
The pelvic floor muscles — a hammock of muscles spanning the bottom of the pelvis — play a critical role in sexual pain. When these muscles are hypertonic (chronically tight and unable to relax), they produce pain during penetration and can contribute to or maintain both vaginismus and dyspareunia.
Pelvic floor dysfunction can develop from:
- Chronic holding or bracing patterns in response to anticipated pain
- Trauma — physical or sexual
- Childbirth injuries
- Chronic stress and anxiety
- Postural habits
- Previous pelvic surgery
Crucially, pelvic floor dysfunction is often both a cause and a consequence of sexual pain — a painful experience leads to protective muscle bracing, which causes more pain, which causes more bracing. Breaking this cycle is central to treatment.
Skin Conditions
Several skin conditions affecting the vulva can cause pain during sex:
- Lichen sclerosus — a chronic inflammatory condition causing thin, white, fragile vulvar tissue; significant cause of pain and sexual dysfunction
- Lichen planus — inflammatory condition affecting mucous membranes including the vagina
- Contact dermatitis — allergic or irritant reactions to soaps, lubricants, latex, or hygiene products
Neurological Factors
In some cases of vulvodynia and PVD, the mechanism involves peripheral nerve sensitization — the nerve endings in the vulvar tissue become hypersensitized, responding to normally non-painful stimuli as if they were painful. This is similar to the mechanism of other chronic pain conditions and explains why some women with PVD have pain from the lightest touch.
Psychological and Relational Factors
Psychological factors rarely cause sexual pain in isolation, but they almost always contribute to its maintenance and severity. These include:
- Anxiety and hypervigilance — anticipatory anxiety about pain activates the sympathetic nervous system and increases pelvic muscle tension
- Sexual trauma history — a significant contributor to vaginismus and sexual pain avoidance
- Relationship dynamics — pressure, conflict, or feeling obligated around sex
- Fear-avoidance cycle — fear of pain leads to avoidance, which prevents the pain from resolving and maintains anxiety about future encounters
- Depression — affects pain perception and motivation to engage with treatment
“Sexual pain and psychological factors exist in a cycle that is genuinely bidirectional. Pain causes anxiety. Anxiety increases muscle tension. Increased muscle tension causes more pain. Breaking the cycle requires addressing both sides — which is why purely physical or purely psychological treatment rarely produces complete resolution.”
The Diagnostic Gap: Why It Takes So Long
The average time between the onset of sexual pain symptoms and a correct diagnosis in the United States is between four and six years (Harlow et al., 2014). That is an extraordinary delay for a condition that significantly affects quality of life.
Several factors contribute to this gap:
- Women don’t report it — out of embarrassment, normalization of pain, or resignation
- Providers don’t ask — sexual pain is not routinely included in gynecological or primary care assessments
- Inadequate examination — PVD in particular requires a specific diagnostic test (the cotton swab test, or Q-tip test) that many providers don’t perform
- Misdiagnosis — sexual pain is frequently attributed to infection, lack of arousal, or psychological factors without proper investigation
- Dismissal — women’s pain is disproportionately undertreated and dismissed across medicine generally, and sexual pain is no exception
If you have been experiencing sexual pain and have not received a diagnosis that makes sense to you, seeking evaluation from a provider specifically experienced in vulvodynia, pelvic floor dysfunction, or sexual pain — including a urogynecologist, a pelvic floor physical therapist, or a provider at a vulvodynia clinic — is entirely appropriate.
Treatment: What Actually Works
Treatment of female sexual pain is most effective when it is comprehensive — addressing all the contributing factors rather than treating the symptom alone. The good news is that highly effective treatments exist for virtually every cause of sexual pain, and most women who engage with comprehensive treatment experience significant improvement.
Pelvic Floor Physical Therapy
Pelvic floor physical therapy is the single most evidence-based treatment for vaginismus and many cases of dyspareunia and PVD. A specialized physiotherapist assesses the pelvic floor muscles, identifies dysfunction, and uses a combination of manual therapy, biofeedback, relaxation techniques, and graduated exercises to restore normal muscle function.
What pelvic floor PT involves:
- Internal and external assessment of pelvic floor muscle tone and trigger points
- Manual release of hypertonic (too-tight) muscles
- Biofeedback to help women learn to consciously relax pelvic floor muscles
- Dilator therapy — graduated vaginal dilators used to progressively desensitize the vaginal opening and teach the muscles to relax with penetration
- Home exercise program
Pelvic floor physical therapy has strong evidence for vaginismus (Melnik et al., 2019) and significant evidence for PVD and dyspareunia. It is often the treatment that produces the most durable results because it addresses the neuromuscular dysfunction directly.
Topical Treatments
- Topical lidocaine — a local anesthetic applied to the vestibule before sex; reduces pain in PVD and allows women to engage in sexual activity while undergoing other treatments
- Topical steroids — for lichen sclerosus and inflammatory skin conditions
- Compounded topical medications — including low-dose topical testosterone or estrogen applied locally, used by some specialized providers for vulvodynia and PVD
Hormonal Treatment
- Local vaginal estrogen — cream, ring (Estring), or tablet (Vagifem) applied directly to the vaginal tissue; highly effective for GSM and estrogen-deficiency dyspareunia; minimal systemic absorption makes it safe for most women including those who cannot take systemic hormone therapy
- Ospemifene (Osphena) — an oral selective estrogen receptor modulator (SERM) approved for dyspareunia due to GSM in postmenopausal women
- Intrarosa (prasterone/DHEA) — a vaginal suppository that is converted to estrogen and testosterone locally; approved for dyspareunia due to GSM
Psychological Treatment
- Cognitive behavioral therapy — addresses the fear-avoidance cycle, catastrophizing, and unhelpful beliefs about pain and sexuality
- Mindfulness-based approaches — growing evidence for pain management and improving sexual function in women with chronic sexual pain
- Sex therapy — with an AASECT-certified sex therapist; addresses the sexual and relational dimensions
- Couples therapy — when relationship dynamics are significantly contributing
Surgical Treatment
Vestibulectomy is a surgical procedure that removes the painful vestibular tissue in women with severe, refractory provoked vestibulodynia who have not responded to conservative treatment. Success rates in appropriately selected patients are high — approximately 60 to 90 percent improvement in pain — but surgery is reserved for cases that have not responded to comprehensive conservative treatment (Goldstein et al., 2006).
Treatment for Endometriosis-Related Pain
- Hormonal suppression — hormonal contraceptives, GnRH agonists, or progestins to suppress endometriosis activity
- Laparoscopic surgery — surgical removal of endometriosis lesions; can significantly improve deep dyspareunia
- Positioning during sex — certain positions minimize deep thrusting and reduce pain; rear-entry positions are often more painful for women with endometriosis; woman-on-top positions allow more control of depth
| Condition | Primary treatment approach |
|---|---|
| Vaginismus | Pelvic floor physical therapy; graduated dilators; CBT |
| Provoked vestibulodynia (PVD) | Pelvic floor PT; topical lidocaine; CBT; vestibulectomy if refractory |
| Vulvodynia | Multimodal — PT, topical medications, CBT, low-oxalate diet in some cases |
| GSM / menopausal dyspareunia | Local vaginal estrogen; ospemifene; lubricants and moisturizers |
| Endometriosis-related deep pain | Hormonal suppression; laparoscopic surgery; positioning |
| Lichen sclerosus | Topical steroids; ongoing monitoring |
| Pelvic floor dysfunction | Pelvic floor physical therapy as primary treatment |
Practical Interim Strategies
While working through treatment, several practical strategies can reduce pain and maintain intimacy:
- Lubricants — high-quality water-based or silicone-based lubricants significantly reduce friction and discomfort. Avoid glycerin, parabens, and flavored lubricants, which can cause irritation. Good options include Sliquid, Uberlube, and YES lubricants.
- Vaginal moisturizers — used regularly (not just during sex), products like Replens and Revaree help maintain vaginal tissue hydration
- Positioning — positions with woman-on-top or side-lying allow more control of depth and angle, reducing pain in many cases
- Penetration is not the only option — expanding the definition of sex to include non-penetrative activities reduces pressure and allows intimacy to continue without pain
- Cold packs — applied to the vestibule after sex can reduce post-coital burning in PVD
Finding Specialized Care in the United States
General gynecologists vary significantly in their experience and comfort with sexual pain conditions. For complex or long-standing cases, seeking out specialized care produces better outcomes.
Resources for finding specialized providers:
- National Vulvodynia Association (NVA) — nvaweb.org maintains a provider directory
- International Society for the Study of Vulvovaginal Disease (ISSVD) — issvd.org
- Pelvic floor physical therapists — searchable through the American Physical Therapy Association at ptlocator.apta.org
- AASECT-certified sex therapists — aasect.org for therapists experienced in sexual pain
- Endometriosis Foundation of America — endofound.org for endometriosis specialists
Frequently Asked Questions
Q: Is it normal for sex to hurt sometimes?
Occasional mild discomfort during sex — from insufficient arousal and lubrication, a particular position, or a specific circumstance — can be normal. Persistent, recurring pain during sex is not normal and is not something that should simply be endured. If pain is a consistent feature of your sexual experience, it warrants evaluation by a healthcare provider.
Q: I’ve never been able to have penetrative sex. Is something permanently wrong with me?
No. Primary vaginismus — the inability to achieve comfortable penetrative sex from the beginning — is a treatable condition, not a permanent state. Pelvic floor physical therapy, graduated dilator therapy, and psychological support have high success rates for vaginismus. Many women who have never been able to have penetrative sex go on to achieve comfortable penetration with appropriate treatment.
Q: My gynecologist told me to just use more lubricant. Is that enough?
Lubricant can help with some causes of sexual pain — particularly insufficient arousal and mild dryness. But it is not adequate treatment for vaginismus, PVD, vulvodynia, endometriosis, lichen sclerosus, or pelvic floor dysfunction. If lubricant alone has not resolved your pain, a more comprehensive evaluation is warranted. Consider asking for a referral to a provider specifically experienced in sexual pain conditions.
Q: Does painful sex mean I don’t want sex or am not attracted to my partner?
No. Sexual pain is a physical or psychophysiological condition — not a measure of attraction or desire. Many women with painful sex have normal or high levels of sexual desire and are frustrated by the disconnect between wanting sex and finding it painful. Interpreting sexual pain as a sign of reduced attraction adds an unnecessary and inaccurate relational dimension to an already difficult situation.
Q: Will this get better on its own?
Some causes of sexual pain — like temporary dryness from dehydration or stress — resolve on their own. Most persistent sexual pain conditions do not resolve without treatment. The longer sexual pain goes unaddressed, the more the fear-avoidance cycle tends to entrench, and the more the muscles, nerves, and psychological patterns around pain solidify. Earlier treatment generally produces better outcomes.
This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for personal health concerns.
References
Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749–755. https://pubmed.ncbi.nlm.nih.gov/16565070
Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58(2):82–88. https://pubmed.ncbi.nlm.nih.gov/12744420
Harlow BL, Kunitz CG, Nguyen RH, Rydell SA, Turner RM, MacLehose RF. Prevalence of symptoms consistent with a diagnosis of vulvodynia. Am J Obstet Gynecol. 2014;210(1):40.e1–8. https://pubmed.ncbi.nlm.nih.gov/23958344
Portman DJ, Gass ML. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063–1068. https://pubmed.ncbi.nlm.nih.gov/25160739
Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;12:CD001760. https://pubmed.ncbi.nlm.nih.gov/23235583
Goldstein AT, Klingman D, Christopher K, Johnson C, Marinoff SC. Surgical treatment of vulvar vestibulitis syndrome: outcome assessment derived from a postoperative questionnaire. J Sex Med. 2006;3(5):923–931. https://pubmed.ncbi.nlm.nih.gov/16942534
American College of Obstetricians and Gynecologists (ACOG). When Sex Is Painful. 2022. https://www.acog.org/womens-health/faqs/when-sex-is-painful
National Vulvodynia Association (NVA). About Vulvodynia. 2023. https://www.nvaweb.org/vulvodynia
