Painful sex is common, and almost always treatable

Surveys consistently find that a large minority of women experience pain with sex at some point, and that most do not raise it with a clinician. The reasons are predictable: embarrassment, an assumption that it is normal, and previous experiences of being told to relax and have a glass of wine.

Pain with sex is a symptom. It has a differential diagnosis. Nearly all of the causes are treatable.

Where it hurts is the most useful question

Pain at the entrance, on initial penetration points toward the vulva, the vestibule, or the pelvic floor.

Deep pain, on thrusting or in certain positions points toward the pelvis — the uterus, ovaries, bowel, bladder, or the pelvic side walls.

That single distinction narrows the list enormously, and it is the first thing a clinician should ask.

Entrance pain: the common causes

Insufficient lubrication. Frequently a consequence of insufficient arousal rather than a deficiency — responsive desire means arousal often needs more time and context than expected. Desire is responsive as often as it is spontaneous.

Low oestrogen. Vaginal tissue is oestrogen-dependent. The two situations where this dominates are breastfeeding, where oestrogen is suppressed, and perimenopause and after, where it falls. Both respond well to lubricant, moisturisers and topical oestrogen — which is safe in breastfeeding and safe for nearly everyone postmenopausally. The menopause symptom almost nobody is offered treatment for.

Pelvic floor overactivity. A pelvic floor held in constant partial contraction makes penetration painful or impossible. This is the mechanism behind vaginismus, and it is also the reason pain from any cause becomes self-sustaining: pain leads to guarding, guarding causes pain. Pelvic floor physiotherapy is the treatment and it is effective. The pelvic floor is a muscle group.

Vulvodynia and provoked vestibulodynia — pain on touch at the vestibule without visible abnormality. Real, reasonably common, and managed with a combination of physiotherapy, topical treatments, neuromodulators and psychological support.

Skin conditions. Lichen sclerosus is the important one: a chronic inflammatory condition causing itching, whitening, fragility, splitting and eventually architectural change. It is frequently misdiagnosed as thrush for years. It responds well to potent topical steroids, and untreated it carries a small risk of vulval cancer, so a proper diagnosis matters. Eczema, lichen planus and contact dermatitis from soaps, wipes and detergents are also common.

Infection. Thrush, bacterial vaginosis, herpes, trichomonas.

Scar tissue from perineal tearing or episiotomy, which responds to scar massage and physiotherapy.

Deep pain: the common causes

Endometriosis and adenomyosis. Deep pain, particularly worse around your period and in certain positions, is a classic feature and one of the most useful pointers toward the diagnosis. Endometriosis and the seven-year wait.

Ovarian cysts.

Fibroids, depending on position.

Pelvic inflammatory disease, current or previous, with resulting adhesions.

Interstitial cystitis / bladder pain syndrome.

Irritable bowel syndrome, where a distended, sensitised bowel produces pain on deep pressure.

Pelvic congestion syndrome, less commonly.

The loop that makes it worse

Whatever starts it, the pattern that follows is consistent. Pain leads to anticipation of pain. Anticipation raises pelvic floor tone and reduces arousal and lubrication. Both make the next time more painful.

That loop is why treating only the original cause sometimes fails, and why pelvic floor physiotherapy is so often the missing component even when the primary problem is elsewhere. It is also why "just relax" is both useless advice and, annoyingly, pointing at something real — the guarding is genuine and involuntary, and it requires actual treatment rather than instruction.

What a proper assessment involves

A history that establishes: where the pain is, when it started, whether it is with all partners and all activities, whether it is present with tampons or examinations, what makes it better or worse, and whether it relates to your cycle.

Then an examination — external inspection of the vulval skin, a gentle single-digit assessment of pelvic floor tone and specific tender points, and a speculum and bimanual only if tolerated. Swabs where infection is plausible. Ultrasound where deep pain suggests a pelvic cause.

If you are examined without being asked where it hurts, or told everything looks fine with no further plan, that is a reason to seek another opinion. How to prepare for a ten-minute appointment and why women wait longer for a diagnosis.

What to do meanwhile

Use a good lubricant generously — silicone-based lasts longest; avoid products with glycerin, fragrance or high osmolality if you are prone to irritation. Stop using soap, wipes and washes on the vulva; plain water or an emollient is better. Treat any constipation. And stop having painful sex, because continuing reinforces the loop. That is not giving up; it is removing the thing that is training your body to expect pain.

Record where and when

The two questions that most efficiently sort this out — where exactly, and does it relate to your cycle — are hard to answer from memory and easy to answer from a few weeks of notes.

Cyclical deep pain points at endometriosis. Entrance pain that started with breastfeeding points at oestrogen. Pain that started after a birth points at scar tissue or pelvic floor changes. Each of those goes to a different place.

Naked is built to make that record simple and to line it up against your cycle, so what you take into an appointment is a pattern rather than an apology. It is a subject most people find hard to raise; having it written down makes raising it considerably easier.