Hub: intimate healthPain during sex: causes and what to do

What is dyspareunia

Dyspareunia is persistent or recurring pain in the genital area before, during or after sex. The word sounds like a rare diagnosis, but according to ACOG nearly 3 out of 4 women experience pain during sex at least once in their lives.

Most of them stay silent. Women don’t think of the pain as anything abnormal, they assume “it’s like this for everyone” and carry on.

Many women feel pain during sex and say nothing. They just clench their teeth harder and wait for him to finish.

At consultations it looks like this. A woman puts up with it for years, then starts avoiding sex, and her partner decides she has fallen out of love with him. The conversation about the pain keeps getting postponed because it is embarrassing, and a couple of years later the couple comes to me with “my desire has gone”. The desire has gone for a good reason: the body doesn’t want what hurts.

Pain during sex is part of medical classifications, and in the American DSM-5 dyspareunia and vaginismus are combined into one disorder, genito-pelvic pain/penetration disorder. What matters more for you is this: the condition has a name, it is studied and it is treated.

Where it hurts and what it can mean

Where it hurts tells you what to look for first. Superficial pain at the entrance to the vagina and deep pain inside with thrusts usually have different causes.

Where and when it hurts	What it may be	What the gynaecologist rules out
Burning at the entrance when penetration begins	Not enough lubrication, dry mucosa	Hormonal causes, side effects of medication
Sharp pain, itching and discharge	Vaginitis, thrush, infections	Swab for flora and infections
Penetration is impossible, the muscles “close up”	Vaginismus	Anatomical obstacles
Burning pain at the entrance even from touch, sitting, a tampon	Vulvodynia	Skin conditions of the vulva, infections
Pulling pain where the tear or stitches were after birth	Scar, tension in the perineal muscles	Condition of the scar
Deep pain with thrusts, worse before your period	Endometriosis, cysts, fibroids	Ultrasound, examination
Pain inside only in some positions	Depth and angle of penetration, tilted uterus	Examination, ultrasound
Burning and dryness in menopause	Genitourinary syndrome of menopause	Examination of the mucosa

People often ask about a partner who is “too big”. The vagina stretches and lengthens with arousal, so a size mismatch more often means there isn’t enough arousal or the penetration is too deep for that position. If it hurts inside only with one partner and only in certain positions, start with positions where you control the depth, and with longer foreplay.

Sometimes there are two or three causes at once. For example, after a course of treatment for thrush the infection is gone, but the muscles at the entrance keep tightening out of habit. That is why “the tests are clear” on its own is often not enough to solve the problem.

Vulvodynia

Vulvodynia is chronic pain in the vulva with no visible cause: no infection, no skin condition, and yet there is burning. The pain can come from penetration, a tampon, tight jeans, a bicycle or simply sitting.

Women with vulvodynia often go from doctor to doctor for years and hear that “everything is clear”. That wears you out more than the pain itself. The diagnosis is made once other causes have been ruled out, and it is treated by a team: a gynaecologist and a sexologist. My part of the work is to teach the pelvic floor muscles to relax and to look into the psychological reasons for this tension.

Endometriosis and deep pain

With endometriosis, tissue similar to the lining of the uterus grows outside it, and deep penetration touches the painful areas. The typical picture: pain inside with thrusts, worse before your period and in the first days of the cycle, plus very painful periods.

Endometriosis can’t be cured for good yet, but hormone therapy and surgery reduce the pain, and that is the gynaecologist’s call. Sex can be adapted in the meantime: positions with shallow penetration, intimacy on the days of the cycle when it hurts less, caresses without penetration.

What the gynaecologist rules out

The first step when there is pain is a gynaecological examination. The lubricant and the glass of wine can wait. The doctor looks for anything that needs medical treatment. And you can learn to relax the muscles and let go of the fear of pain in parallel, there is no need to wait until treatment is over.

ACOG lists the causes a doctor checks for: vaginal and urinary tract infections, skin conditions of the vulva, vulvodynia, vaginismus, changes after childbirth and in menopause, endometriosis, pelvic inflammatory disease, fibroids, ovarian cysts.

What a visit to the gynaecologist usually includes (expand)

1. A conversation about where, when and for how long it has been hurting, and what you have already tried.
2. An examination of the vulva and vagina, sometimes checking for painful spots with a cotton swab.
3. Swabs for flora and infections.
4. A pelvic ultrasound if the pain is deep.
5. Questions about medication, contraception, breastfeeding and your cycle. If the pain started after a new medication or a change of contraception, be sure to mention it, doctors often miss such coincidences.

Ask the doctor to talk you through every step of the examination and to stop if it hurts. If you were shamed in the doctor’s office or told to “just relax”, that is a bad doctor, not a bad you. Find another one.

The infections that cause pain and discharge are covered in detail on the pages about thrush and STIs and HPV. Dryness, which most often lies behind the burning at the entrance, is covered on the page about vaginal dryness.

Vaginismus and the vicious circle of pain

Vaginismus is an involuntary tightening of the muscles around the entrance to the vagina that makes penetration impossible or very painful. A woman may want sex and still be unable to let in a penis, a tampon or the gynaecologist’s finger.

It is a reflex protection. Bring an object close to your eye, and the eye closes by itself before you even have time to think about it. Vaginismus works on the same principle: the muscles tighten by themselves to protect the entrance. At some point the body learned that penetration is dangerous: a painful first time, a rough examination, violence, a strict upbringing where sex was considered dirty, or simply a lot of fear and no information.

Then the vicious circle kicks in, the one I draw at consultations for almost every client with pain:

1. Expecting pain.
2. The body tenses in advance, there is less lubrication.
3. Penetration through tense muscles really does hurt.
4. The body gets confirmation: I was right, this is dangerous.
5. Next time the tension starts even earlier.

This circle can start without vaginismus too. A few painful episodes during thrush or after childbirth are enough, and the pain outlives its original cause.

Vaginismus responds well to work. It is treated step by step: information about your body, lowering anxiety, learning to relax the pelvic floor, working with dilators at your own pace under my guidance. Couples who go through this often say they regret only one thing: not coming sooner. That is exactly why my practicum “Orgasm. Everything you need to know” (it runs in Russian and Ukrainian) has separate lessons, “Painful sex: where it comes from and how to fix it” and “Vaginismus: diagnosis and solution”: there we break this circle step by step.

Pain during sex after childbirth

After childbirth pain during sex is very common, and there are several reasons. A healing tear or episiotomy stitches, low oestrogen while breastfeeding that leaves the mucosa dry and thin, fatigue, lack of sleep and the fear that “everything down there will tear”.

An episiotomy scar can make itself felt for a long time, especially in positions that put pressure on it. What helps here is time, long foreplay, plenty of lubricant and positions without pressure on the perineum. If the scar still hurts several months later, it is worth showing it to a gynaecologist, and for the tense muscles around it, come to me.

A separate word about timing. Nobody is obliged to go back to sex at 6 weeks just because “the doctor said it’s fine”. The doctor’s go-ahead means that physically you can. But it doesn’t make you obliged. If desire hasn’t come back yet, nothing is broken, I write about this on the page about why you don’t want your husband after birth.

Pain after sex, rather than during it, happens too. Soreness and burning the next day often point to friction without enough lubrication or to micro-tears, and a pulling pain in the lower abdomen after orgasm can come from contractions of the uterus. If pain after intimacy keeps coming back, it is worth discussing with a gynaecologist as well.

What a sexologist works with

I step in when the doctor has ruled out or is already treating the physical causes, but the pain, the fear or the avoidance remain. Working with a sexologist is part of the standard treatment for dyspareunia: ACOG also lists sex therapy among the ways to help.

At consultations we work:

• with the fear and expectation of pain;
• with the shame of telling your partner about the pain;
• with the habit of “putting up with it so that he enjoys it”;
• with arousal, because without it there is little lubrication and the mucosa is vulnerable;
• with how to arrange intimacy while penetration is painful;
• with the aftermath of traumatic experiences.

At the first meeting we usually draw up a map: when the pain started, what it coincided with, what happens in your body just before it and what you are thinking at that moment. This map alone often shows where the circle can be broken.

I give homework for the body, because talking alone won’t relax the muscles. These are exercises for pelvic floor awareness, breathing, getting to know your vulva, a gradual return to touch with no goal. For some women pelvic floor muscle training works well too, but with spasm the main task is not to strengthen, but to learn to relax, and that is the first thing I teach on the practicum “Healthy and Desired” (it runs in Russian and Ukrainian): everyone knows how to tense, but relaxing the pelvic floor muscles is something we learn separately. A relaxed body alone isn’t enough, though: we also look at the head, where the expectation of pain lives, and at the state you live your day in. Fix just one thing, and a couple of months later the pain comes back. I write about this difference in detail in the piece on intimate gymnastics.

What this looks like in real life. One of my students put up with agonising pain for two years after giving birth because of her episiotomy stitches. A few weeks in, she wrote: “Sex was agonisingly painful at first, but thanks to the course that is in the past! I have become more confident and relaxed!”

Each step on its own works only for a short while: lubricant without relaxing the muscles, relaxation without working on the fear. That is why on the “Healthy and Desired” practicum I go through three levels at once: in the body part we first learn to relax the pelvic floor muscles, and only then to strengthen them, with trainers from the PionBox and short video reports; in the block on the psyche we work through the fear, the shame and “putting up with it so that he enjoys it”; and we restore your state with practices. That way the result stays with you for a long time, not for a couple of weeks.

How to relieve pain during sex right now

While you are looking for the cause, sex doesn’t have to be torture. A few things help almost everyone, and none of them replaces a doctor.

Stop when it hurts. It is not a whim and it doesn’t ruin the evening. Every time you carry on through the pain, you reinforce that very circle.

Give your body time. A woman needs more time to get aroused, and the vagina lengthens and gets wet only with enough arousal. 5 minutes of foreplay is often too little.

Use lubricant. Don’t be shy about it, it is not a sign that something is “wrong” with you. If it hurts with a condom, try a water-based or silicone-based lubricant.

Choose positions where you control the depth and the pace, for example on top. With deep pain, skip the positions that cause it. Your “that hurts” is the main guide here.

Widen what sex means. While penetration is painful, intimacy can do without it: caresses, oral sex, masturbating together. Many couples who take penetration off the table for a while start enjoying themselves for the first time in years.

How to tell your partner about the pain

Many women stay silent about the pain so as not to hurt the man’s feelings and not to seem “defective”. Meanwhile your partner sees that you avoid sex and draws his own, usually wrong, conclusions.

It is better to talk not in bed and not right after turning him down, but at a calm moment. For example: “It hurts me during sex, and I want that to change. It’s not about you, and it’s not that I don’t want you. I’ve booked a doctor’s appointment. For now, let’s try it differently.” A phrase like that takes the blame off him and makes him your ally.

If your partner responds by pushing, rushing you or taking offence, then his reaction is what needs discussing. How to have these conversations is covered on the page about boundaries and consent in bed and at a consultation with me.

Takeaways

Any persistent pain during sex that gets in the way of pleasure is a reason to think about your women’s health. If sex brings discomfort, that is not normal. Pain is not something to put up with, and certainly not something to resign yourself to.

But do you know what matters most? In most cases this problem can be solved. Dryness, spasms, lack of sensitivity, fear of pain, not wanting to make love with your partner: all of this can change.

I’m taking this chance to invite you to the practicum “Healthy and Desired”. There we work with the body, with your inner psychological state and with the pelvic floor muscles. You will learn to feel your body, to control it, to get rid of discomfort and finally to enjoy intimacy.

If you understand that something is wrong but don’t know where to start, start by taking care of yourself. I will show you the way.

Don’t put it off

If you are reading this and recognise yourself, don’t put it off. Pain doesn’t go away on its own, as hundreds of thousands of my followers can confirm. Every time you put up with it, the body expects pain sooner, desire fades, and the distance in the couple grows. In a year the same task will cost more: in energy and in the relationship. Start today, you didn’t read all the way to the end for nothing.

You have two paths.

1. Sort it out on your own: put up with it, buy yet another lubricant, go from doctor to doctor and hear “everything is clear” (you have probably done this already…).
2. Sort it out with me. You can come to a free consultation: I or my team will help you find what keeps the pain going in your case: the body, the fear or the habit of putting up with it. Knowing the cause and knowing what to do in your particular case are different things. And if you already know you want to work with the body, the head and your state at once, come to me on the practicum “Healthy and Desired”.