Painful Intercourse: Causes, Treatments, and Tips for More Comfortable Sex

One word to describe sex: intimate, perhaps? Loving. Exciting. Electric. Important? Or maybe, for you, the word is painful. You might figure it is what it is — and there’s not much you can do to change it. But just because sex is painful doesn’t mean it has to stay that way. Painful sex, or dyspareunia, is common, but not normal. The American College of Obstetricians and Gynecologists estimates that three out of four women will experience painful intercourse at some point during their lifetimes. It can happen for all kinds of reasons. Pain during sex may stem from an infection or medical condition. It could be the result of hormone changes during menopause or after pregnancy. It may be related to pelvic floor muscle issues or the body’s response to emotional trauma. 

Whatever the cause, this much is true: Painful intercourse is treatable. Read on to learn about painful intercourse, its causes and symptoms, and the best treatment options to make sex less painful, including exercise and lifestyle strategies.

Causes of Painful Intercourse

Pain during sex may be associated with a range of factors, both physical and emotional.  Some possible causes of painful intercourse include:

• Muscle-related conditions. Vaginismus is a condition that occurs when pelvic floor muscles automatically contract or spasm with penetration, resulting in discomfort or pain during intercourse. Tight pelvic floor muscles can also cause pain during sex.

• Medical conditions. This can include endometriosis, pelvic inflammatory disease, organ prolapse, uterine fibroids, pelvic floor conditions, cystitis, ovarian cysts, and others.

• Hormone issues. Estrogen levels drop during perimenopause and menopause. This can cause vaginal and urinary tissues to become thinner and drier, leading to a list of symptoms known as genitourinary syndrome of menopause (GSM). Vaginal dryness can lead to painful sex and painful intercourse after menopause is common. Other factors that may contribute to vaginal dryness include: not enough foreplay, changing estrogen levels during breastfeeding, and certain medications and medical conditions.

• Vulvodynia. This chronic pain condition affects the vulva, or area outside of the vagina, without a known cause.

• Injury or trauma to the vagina. This can result from accidents or injury during childbirth. During vaginal delivery, the perineum — the area between the rectum and vagina — may tear. Or an ob-gyn might perform an episiotomy, which is a surgical incision to enlarge the vaginal opening for delivery.  

• Infection or skin disorders. Urinary tract and vaginal yeast or bacterial infections (bacterial vaginosis) can cause painful intercourse, as can genital warts, herpes sores, and other sexually transmitted infections (STIs). Certain skin problems, such as eczema, can also play a role.

• Congenital problems. Not having a fully formed vagina or having a membrane that blocks the vaginal opening, called imperforate hymen, could cause painful intercourse.

• Surgeries or medical treatments. Scarring from pelvic surgery can cause painful intercourse. Medical treatments for cancer, such as radiation and chemotherapy, can also cause changes that make sex painful.

• Mental health issues. Anxiety, depression, or fear of intimacy can contribute to a low level of arousal and result in discomfort or pain. 

• Stress. Pelvic floor muscles tend to tighten when stress levels are high, which can contribute to pain during intercourse.

• History of sexual abuse. Not everyone with dyspareunia has a history of sexual abuse. But if you have been abused, it can contribute to your pain during sex.

Symptoms of Painful Intercourse

Pain during sex can occur with penetration, pressure, or touch. You might feel pain in your vulva, in the area surrounding the opening of your vagina (called the vestibule), or within your vagina. The perineum is a common site of pain during sex as well. You also may feel pain in your lower back, pelvic region, uterus, or bladder.

Common sensations of painful intercourse include:

• Deep aching

• Burning pain or itching

• Rawness like sandpaper or rug burn

• A prickly feeling like sitting on a cactus

• Stinging or shooting pain

Treatment Options for Painful Intercourse

There are steps you can take to help reduce pain and discomfort during sex and increase pleasure. Here are some strategies to try:

Speak up. It can feel uncomfortable to discuss your sexual needs and comfort levels with your partner. Generally, the hardest part is starting the conversation. Once you do, couples are often pleasantly surprised with the ease of conversation and the outcome. 

Take a temporary pause. Continuing to have painful sex can turn the act into a “negative reinforcer.” Your nervous system will start to associate sex with discomfort, and will be more likely to trigger pain in future encounters. A temporary break can interrupt the negative reinforcement and let you work on solutions. 

Be intimate without intercourse. When penetrative sex is painful, try other forms of intimacy: cuddling, kissing, and pain-free touching. This can calm your nervous system and help you stay connected to your partner.

Warm up for sex like you would for a workout. Gentle exercises that help open up the hips and promote relaxation of the pelvic floor may help reduce pain. You can try simple moves, such as child’s pose, inner thigh stretching, and squats.

Modify positions. Some people experience more intense pain with certain sexual positions, such as those that allow deep penetration. If a position is painful for you, experiment with other approaches. You can adjust missionary style and  hands-and-knees positions with pillows to help you control the depth of penetration and stay in your comfort zone. Spooning or side-lying positions may be more comfortable.

Other measures. Some tools, products, and treatments can make sex more comfortable:

• Lubricants to reduce vaginal friction or irritation.

• Vaginal dilators to gradually stretch your vagina and pelvic floor muscles  

• Pelvic wands for gentle internal massage, which can help release trigger points and reduce pain

• Penetration rings to limit depth of penetration during intercourse

• Vaginal estrogen products, such as creams, to treat dryness

• Antifungal products for pain due to a yeast or fungal infection

• Antibiotics for pain due to bacterial vaginosis or a sexually transmitted disease

• Lidocaine ointments, gels, or sprays to numb the area and reduce pain

Seek support.  If you have experienced trauma, especially sexual trauma, your nervous system may interpret sexual activity as threatening. So even in a comfortable and safe sexual experience, your pelvic floor muscles may tense up and cause pain. If you are struggling with pelvic pain or painful sex related to sexual trauma, consider speaking to a licensed mental health professional.

Pelvic Floor Physical Therapy for Painful Intercourse

If pelvic floor muscle problems are contributing to pain during sex, a pelvic floor physical therapist (PT) can help tailor an exercise plan that includes specific moves and modifications that are appropriate for you. A PT may recommend Kegel exercises, for example, to strengthen pelvic floor muscles and help improve sexual response, as well as diaphragmatic breathing to help relax muscles and calm your nervous system. You can see a physical therapist in person or use a program like Hinge Health to access a PT who specializes in pelvic health via telehealth/video visit.

Pelvic floor physical therapy for pelvic pain and other symptoms is a comprehensive treatment that includes education, behavioral and lifestyle strategies, movement and exercise, and manual therapy.

To increase comfort during sex, your pelvic floor PT may recommend exercises including: