What are the most common causes of painful sex in women?

Painful sex affects approximately 1 in 10 women in Britain, and nearly 3 out of 4 women will experience some degree of discomfort during intercourse at some point in their lives. The pain can range from mild irritation to severe, debilitating discomfort that makes penetration impossible. It is crucial to recognise that this is not "just in your head" nor a personal failing—it is a legitimate medical concern with identifiable physical and psychological roots.

The location and timing of the pain provide important clues about the cause. Pain felt at the vaginal entrance during initial penetration typically has different causes than deep pelvic pain experienced with thrusting. Women aged 16 to 24 and those over 55 report the highest rates of painful sex, reflecting the hormonal transitions at either end of reproductive life.

1. Vaginal Dryness and Oestrogen Deficiency

Insufficient lubrication is one of the most common causes of painful sex. Without adequate moisture, friction during penetration can cause burning, stinging, or a raw sensation. This dryness often results from declining oestrogen levels, which thin the vaginal lining and reduce natural lubrication—a condition known as vaginal atrophy or Genitourinary Syndrome of Menopause.

• Menopause and perimenopause: As oestrogen drops, vaginal tissues become thinner, drier, and less elastic, making penetration uncomfortable or painful.
• Breastfeeding: Lactation temporarily lowers oestrogen, leading to vaginal dryness in new mothers.
• Hormonal contraception: Some oral contraceptives or hormonal IUDs can reduce natural lubrication.
• Cancer treatments: Chemotherapy and pelvic radiation can damage vaginal tissues and reduce oestrogen production.

2. Infections and Inflammation

Vaginal and pelvic infections create inflammation that makes the genital area hypersensitive to touch. Pain during sex is often one of the first signs that an infection requires treatment.

• Vaginal thrush (yeast infection): Causes itching, burning, and thick white discharge. The inflamed tissues become tender and painful during penetration.
• Bacterial vaginosis: An imbalance in vaginal bacteria leading to discharge, odour, and irritation.
• Sexually transmitted infections: Chlamydia, gonorrhoea, genital herpes, and trichomoniasis can all cause vaginal irritation and pain. Herpes sores at the vaginal opening are especially painful during penetration.
• Urinary tract infections (UTIs): Bladder infections can make the pelvic area tender and cause pain during or after sex.
• Pelvic inflammatory disease (PID): Untreated STIs can spread to the uterus, fallopian tubes, and ovaries, causing deep pelvic pain during intercourse.

3. Endometriosis

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus—on the ovaries, fallopian tubes, or the space between the vagina and rectum. This condition affects approximately 1 in 10 women and is a leading cause of deep, severe pain during sex.

When endometriosis tissue grows behind the vagina or on the uterosacral ligaments, penetration stretches and pulls on inflamed, scarred tissue. The pain is typically felt deep in the pelvis with thrusting and may worsen in certain positions. Endometriosis can also cause adhesions—bands of scar tissue that fuse pelvic organs together, restricting normal movement during intercourse. Many women with endometriosis report that the pain makes them avoid sex entirely, creating tension and distance in relationships.

4. Vaginismus and Pelvic Floor Dysfunction

Vaginismus is an involuntary tightening of the vaginal muscles that makes penetration painful or impossible. This reflexive muscle spasm is not under conscious control and often develops as a protective response to pain, anxiety, or previous traumatic experiences.

• Primary vaginismus: The muscles have tightened reflexively since the first attempt at penetration, making sex consistently painful or impossible.
• Secondary vaginismus: Develops after previously comfortable sex, often following childbirth, surgery, infection, or menopause.

Pelvic floor dysfunction refers to chronically tense or weakened pelvic muscles. When muscles are constantly tight (hypertonic), they become tender and painful. This tension can be a cause of pain or a consequence of guarding against anticipated pain, creating a vicious cycle. Specialised pelvic floor physiotherapy is highly effective at releasing tight muscles and desensitising the area.

5. Skin Conditions and Scarring

Skin disorders affecting the vulva and vaginal opening can make even light touch unbearable.

• Vulvodynia: Chronic, unexplained pain in the vulva described as burning, stinging, or rawness. The pain can be constant or triggered by touch.
• Lichen sclerosus: A chronic skin condition causing white, patchy, itchy skin on the vulva. The skin can become thin, cracked, and painful, particularly common in postmenopausal women.
• Contact dermatitis: Allergic reactions to soaps, perfumes, lubricants, or latex condoms can inflame vulval skin.
• Vaginal scarring: Tears from childbirth, episiotomy wounds, or previous surgery can leave sensitive scar tissue that remains painful for months or even years.

6. Other Pelvic Conditions

Several conditions affecting the pelvis and reproductive organs can cause deep pain during intercourse.

• Ovarian cysts and fibroids: Large cysts or uterine fibroids can be bumped during deep penetration, causing sharp or aching pain.
• Pelvic organ prolapse: When pelvic organs drop from their normal position, intercourse can feel uncomfortable or cause a sense of pressure.
• Interstitial cystitis (bladder pain syndrome): Chronic bladder inflammation causes pain during sex, often felt the following day as pelvic floor muscles spasm.
• Irritable bowel syndrome (IBS): Bowel cramping and bloating can make pelvic penetration uncomfortable.

7. Psychological and Emotional Factors

The mind and body are deeply connected when it comes to sexual response. Emotional distress can manifest as physical pain, and physical pain inevitably affects emotional wellbeing.

• Anxiety and stress: When you are anxious, your muscles tense up, your body produces less natural lubrication, and arousal becomes difficult—all of which can lead to pain.
• Past sexual trauma or abuse: Women who have experienced sexual assault often associate intimacy with pain or fear, leading to involuntary muscle tightening and genuine physical discomfort.
• Relationship problems: Lack of emotional connection, unresolved conflict, or feeling pressured can make it difficult to relax and become aroused, resulting in painful sex.
• Fear of pain itself: Once pain occurs, the anticipation of pain can trigger muscle guarding and create a self-perpetuating cycle of tension and discomfort.