Painful sex

Pain is a signal, not a personality trait

Persistent pain during sex is common and treatable, and it is very frequently dismissed. Natsal-3 found 7.5 percent of sexually active women in Britain reported painful sex lasting three months or more in the past year. Studies of vulvodynia prevalence report lifetime figures around 8–16 percent. Average time to diagnosis for endometriosis, a common cause of deep pain, is 7–8 years across health systems.

If a clinician tells you to have a glass of wine and relax, seek a second opinion. That advice has no evidence base and delays diagnosis.

Superficial pain — at the entrance

Insufficient arousal or lubrication. The most common cause and the easiest to fix. Requires more time and lubricant, not more willpower.

Vulvodynia and provoked vestibulodynia. Persistent vulval pain without an identifiable cause; provoked vestibulodynia produces burning at the vestibule on touch or attempted penetration. Real, with documented nerve fibre proliferation and central sensitisation. Managed with pelvic floor physiotherapy, topical treatments, tricyclics or gabapentinoids, and cognitive behavioural therapy; multimodal care outperforms single treatments.

Vaginismus. Involuntary protective contraction preventing penetration. Not a choice and not "not wanting it enough". Graded dilator therapy with psychological support has good trial evidence, with high rates of successful penetration after structured programmes.

Low oestrogen. Genitourinary syndrome of menopause, breastfeeding, and testosterone-associated atrophy in trans men. Highly responsive to topical oestrogen and moisturisers, and one of the most under-treated causes.

Skin conditions. Lichen sclerosus, lichen planus, eczema and psoriasis. Lichen sclerosus in particular is under-diagnosed, treatable with potent topical steroids, and carries a small vulval cancer risk if left untreated.

Infection. Thrush, bacterial vaginosis, herpes, trichomoniasis.

Allergy. Latex, spermicide, fragranced products, some lubricant ingredients.

Deep pain — with depth or thrusting

Endometriosis. Around 10 percent of people of reproductive age. Deep pain, pain worse around the period, pain with bowel movements, and heavy or painful periods. Diagnosis often requires laparoscopy; imaging can miss it.

Adenomyosis, fibroids, ovarian cysts, pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, and pelvic adhesions after surgery all produce deep dyspareunia.

Hypertonic pelvic floor. Frequently accompanies all of the above, and frequently persists after the original cause is treated, because the guarding reflex outlives it.

Cervical contact. Position-dependent; changing angle and depth resolves it. Persistent, unchanging deep pain does not.

Pain in people with penises

Peyronie's disease (fibrous plaque causing curvature and pain, affecting an estimated 3–9 percent of men), phimosis and tight frenulum, balanitis, prostatitis and chronic pelvic pain syndrome, post-orgasmic pain, and pudendal neuralgia. Chronic pelvic pain syndrome is frequently a hypertonic pelvic floor problem and responds better to physiotherapy than to repeated antibiotic courses.

Getting it taken seriously

Bring a written record: where the pain is, whether it is entry or deep, when it started, what makes it better or worse, cycle relationship, bowel and bladder symptoms, and what you have already tried. Ask directly for: an examination including a cotton-swab test where entry pain is described, infection screening, and referral to a pelvic health physiotherapist or a specialist vulval or pelvic pain clinic.

If the response is that everything looks normal, that is not the end of the assessment. Vulvodynia, hypertonic pelvic floor and early endometriosis all frequently look normal.

While waiting for treatment

Stop having painful sex. Repeated painful penetration establishes a protective reflex and central sensitisation that make treatment harder and longer. This is a clinical recommendation, not permission-seeking. Non-penetrative intimacy remains available, and pausing penetration is a treatment step rather than a retreat.

Sources

• Mitchell KR et al. "Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey." BJOG, 2017.
• Harlow BL et al. "Prevalence of symptoms consistent with a diagnosis of vulvodynia." American Journal of Obstetrics and Gynecology, 2014.
• Zondervan KT, Becker CM, Missmer SA. "Endometriosis." NEJM, 2020; NICE guideline NG73.
• Goldstein AT et al. "Vulvodynia: assessment and treatment." Journal of Sexual Medicine, 2016; ISSVD consensus terminology.
• ter Kuile MM et al. Trials of therapist-aided exposure and dilator therapy for lifelong vaginismus.
• Anderson RU et al. "Myofascial trigger point release for chronic pelvic pain syndrome in men." Journal of Urology, 2011.
• British Association of Dermatologists. Guidelines for the management of lichen sclerosus, current edition.

Last reviewed: August 2026.