Painful Sex: Beyond the Usual Suspects

For a lot of people, pain during sex (penetrative intercourse specifically) is an unfortunate reality that can come with mental and emotional repercussions as well as unpleasant and sometimes detrimental effects on their romantic relationships.

For many folks, this topic is difficult to talk about and, consequently, incredibly difficult to address. But when it comes to painful sex, knowledge is power.

Together, we're going to cover painful sex, how common it is (spoiler alert: if you’re experiencing sexual pain, you are FAR from alone), and some of the things that can cause it — both the well-known causes and the sneaky ones — and provide you with actional advice to help you get back on the road to sexual pleasure.

What causes pain during sex for people AFAB (assigned female at birth)?

Pain during sex (also referred to as dyspareunia) can happen to anyone with genitals, but today we’re going to focus specifically on the pain experienced by AFAB (assigned female at birth) folks or people with vulvas/vaginas who can experience sexual pain in several different areas. These include external pain that strikes the vulvar area, including the labia, the perineum, and the vaginal opening, as well as internal pain that affects the lower part of the abdomen, the uterus, the cervix, and even the inner walls of the vagina.

For the purpose of this discussion, when we say “sex,” we’re primarily referring to penetrative intercourse. Now, sex can take many forms, and there’s no “right” way for sexual pleasure and/or intimacy to look, but in terms of sexual pain for people with vulvas, we’ll be focusing on pain with penetration both during and after intercourse.

Types of Pain During Sex

Some examples of pain that affect peoples’ sex lives include:

• Pain that happens any time anything is inserted vaginally (e.g., a tampon or a gynecologist's speculum)
• Pain that happens specifically during vaginal penetration
• Pain that occurs inside the body during thrusting
• Aching or burning pain
• Pain that strikes after sexual activity and feels more like throbbing

Please note: There are many different ways people experience pain during and after sex. This list is by no means exhaustive. If you’re experiencing pain before, during, or after any sexual activity, and it’s not reflected on the list above, please know that you’re not alone!

Common Causes for Pain and Discomfort During Sex

Every doctor has a slightly different “go-to” list of the most likely suspects behind painful sex, but a quick poll of the folks in my life who have vulvas and have experienced pain (fun fact: we’re mostly sex writers and educators!) revealed that the following conditions were repeat offenders:

• Vaginal Dryness: This is when the vagina is not producing sufficient natural lubrication resulting in friction that makes penetration painful. Lots of things can cause vaginal dryness, including certain medications ranging from antihistamines to antidepressants. Vaginal dryness is also a symptom of perimenopause and menopause.
• Vaginal Atrophy: While medications or non-menopausal hormonal changes can cause it, the most common cause of vaginal atrophy is menopause, which is probably why it was mentioned so much to my crew of 40-something-year-old pals. In this condition, the lining of the vagina becomes thin, dry, and inflamed as a result of losing its typical moisture and thickness.
• Pelvic Floor Dysfunction: Like any other muscles, the pelvic floor muscles can become tense and tight. This can cause them to spasm, which can result in pain during vaginal penetration.
• Vaginismus: This condition is interesting because it’s basically the body having an uncontrollable fear response, and it can happen even if the person suffering from it is not consciously aware of being afraid. With vaginismus, the vaginal muscles involuntarily tighten up when penetration is attempted.
• Psychological Issues: So this one was divisive and with good reason. Women’s health issues are often dismissed as psychological or emotional, and that can make it difficult for women to get effective health care. That said, disorders like depression and anxiety can severely impact sexual arousal. Additionally, survivors of any kind of trauma or assault may also experience sexual pain as one of the after-effects of their ordeal.

Read More: Vaginal Dryness: What to Do When Natural Lubrication Isn't Enough

Okay, so now that we’ve gone over some of the more commonly named sources of sexual pain, let’s talk about the ones that you might not think about right away.

What else can cause pain during sex?

Again, every doctor is different. You might have a doctor who immediately thinks of one of the things we’re about to discuss, and we love that for you. But just in case you’ve ruled out all the usual suspects and still don’t have an answer, here are some more potential causes of painful sex:

• Infections: From yeast infections and UTIs to Pelvic Inflammatory Disease (PID), infections can result in pain during sex.
• Ovarian cysts: An ovarian cyst is a fluid-filled sac that can form in or on the ovary. They’re pretty common, and most people with them are usually asymptomatic, but when they become large, erupt, or become twisted, they can cause pain, including pain during sex.
• Endometriosis: Endometriosis is a chronic inflammatory condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus. During your menstrual cycle, this misplaced tissue breaks down just like normal endometrial tissue, but it has no way to leave the body. This trapped tissue can cause pain, inflammation, and scar tissue buildup. Endometriosis can be painful in general, but it's especially bothersome when it forms in the cul-de-sac, also known as the Pouch of Douglas, located behind the uterus. Since this area moves during sex, any penetration can tug on the irritated tissue, causing sharp pain during sex. Additionally, people with endometriosis may experience a deep, aching pain that lingers for hours after sex.
• Vulvodynia: Vulvodynia is chronic vulvar pain lasting at least three months without an identifiable cause.
• Interstitial Cystitis: Interstitial Cystitis or Bladder Pain Syndrome (IC/BPS) is a chronic medical condition that affects the bladder. For some, IC/BPS feels like a urinary tract infection (UTI), yet there’s no infection. It creates pressure and bladder discomfort that lasts six months or longer. IC/BPS can ruin a person’s sex life. This is because, for many, it feels as though the urethra is on fire.
• Retroverted Uterus: A “tilted” or retroverted uterus is when the uterus tilts backward toward the spine. (It’s very common in people with endometriosis.) This condition typically does not seriously impact one’s health, but it can cause pain during menstruation and sex. (If you have a tilted uterus, you may want to check out our guide for the best sex positions for a tilted uterus.)
• Weak Glutes: Okay, so this one is fun and comes with a story! I was experiencing a bunch of sex-related pain and went down the list of all the usual suspects. I was totally convinced I had boarded the menopause bus! Then, one day, I put a bunch of stuff together: My sex-related pain came with a very specific tightness around my sacrum (vertebrae that hold the pelvis and spinal cord together), and my hips were tight to the point where it was problematically painful. I’m a writer, so I sit CONSTANTLY, and I’d been in what I call my “winter polar bear” phase, where I decide working out is totally optional for several months. I took my sex educator knowledge and combined it with my knowledge from when I worked as a personal trainer and realized these things were possibly connected. Lo and behold, I discovered that, yes, apparently, weak glutes (and abs) can mess up your pelvic floor, AND, according to my physical therapist, a lot of folks keep suffering because they keep treating the pelvic floor issues without dealing with the other muscles. I went back to working out, and things are getting better. Who knew?!

Signs of these less likely suspects

The good news here is that if you are experiencing pain during sex, there are a whole lot of different things that could be causing it. So, don’t despair if your first attempts at solutions don’t get the job done.

The slightly less good news is that there’s not really a surefire way to know what you’re dealing with without a little trial and error. Much like in my story, you might have to go down a list and eliminate possible sources of pain as you zero in on what is actually causing yours. This leads us to our next question!

How can you differentiate between the usual and unusual causes of pain during sex?

It requires a combination of paying close attention to your body and being willing to talk very openly with your healthcare provider about the pain you are experiencing. Keep an eye on your symptoms.

Consider keeping a journal to record the specifics of your body, medical history, and pain. Ask yourself questions like:

• Are there any prior genital-related health conditions, surgeries, or treatments that could be causing my pain?
• What medications could be contributing to my pain, if any?
• When did my pain start?
• How often do I experience pain and when (e.g., after, during, immediately before)?
• What does the pain feel (burning, throbbing, stabbing, dull, aching, etc.)?
• Where am I feeling pain specifically?

Like I said, it took me noticing that my sacrum (that triangular bone over your tailbone) felt weird when I was experiencing sexual pain for me even to start to figure out my own pain, so don’t be afraid to try and connect some dots.

How to reduce pain during sex

First things first, get your partner on board. Make sure they understand what’s going on and make them part of the “pleasure without pain” plan. Trying to take care of this on your own can lead to a situation where they accidentally hurt you because they think it’s business as usual. This can breed resentment and make sex feel scary. No one wants that.

Together, come up with things you both enjoy that don’t aggravate the pain. If penetration is painful right now, play with different sexual activities that are fun for everyone involved, or try a buffer like the Ohnut. Just be sure you keep communicating and have fun together. A common trap people experiencing pain during sex fall into is feeling like they “owe” their partner something due to their inability to engage in their typical activities. That’s not a dynamic you want creeping into your relationship.

This can also be a great time to explore new things (or maybe not new, I don’t know you!) that don’t require penetration, like BDSM, massage, rope bondage, or electrostimulation. Have fun exploring together; you might find something new that becomes a permanent part of your sexual game plan.

Sexual pain can put a damper on your sex life, but it certainly doesn’t need to bring it to a grinding halt. There are many possible causes, meaning there are tons of potential solutions. Take your time and be kind to your