Pain during sex and pain after sex: causes explained

Pain with sex is one of the commonest problems in gynaecology and one of the least often raised. It has a medical name, dyspareunia, which simply means pain with intercourse, and it covers everything from a sharp catch at the entrance to a deep ache that only appears in certain positions, or one that only starts hours afterwards. The thing worth saying at the outset is that it is not something to be put up with, that it is extremely common, and that it is not a sign that anything is wrong with you as a person.

Pain during or after sex usually has an identifiable cause, and that cause is most often something ordinary: dryness, an infection, a skin condition, overactive pelvic floor muscles, or a condition such as endometriosis. This article sets out the framework a clinician uses to narrow the list down, names up front the findings that need attention the same day, then works through the causes grouped by where the pain is felt, gives pain after sex its own section because the timing matters, and describes what an assessment actually involves. In some people no abnormality is found on examination; the pain is no less real for that, and it still has recognised treatments. Decisions about your own case belong with the doctor who examines you.

Two questions that organise everything: where, and when

Before any examination, a clinician is listening for two things. The first is where the pain is: at the entrance, in the first few centimetres, or deep inside the pelvis. The second is when it happens: on first entry, throughout, only at a certain depth or in a certain position, only afterwards, or only at certain points in the cycle. Those two answers divide a long list of possible causes into a short one, which is why it is worth thinking about them before an appointment rather than during it.

Entrance pain, sometimes called superficial or introital pain, is felt at or just inside the vaginal opening. It is usually described as burning, stinging, rawness or a sensation of tearing, and it tends to be reproducible: the same spot hurts in the same way each time, and often with tampons or an examination as well. Deep pain is felt higher up, in the pelvis or low abdomen, is more often an ache or a cramp than a burn, and depends on depth, angle and position rather than on first contact.

It also helps to be able to answer a few more specific questions. Did it always hurt, or did it start at an identifiable point, such as after childbirth, after an infection, after starting or stopping a contraceptive, or around the menopause? Does it hurt with fingers, tampons or examinations too? Does it settle straight afterwards, or last for hours? None of this requires a diary. It requires only that you describe what you have noticed to the person examining you, in your own words.

Pain that needs assessment the same day

Most pain with sex is not an emergency, and nearly everything described on this page is assessed in an ordinary appointment. A small number of patterns are different, and they belong here rather than at the end, because the right response to them is to be seen now rather than to carry on reading.

• Severe pain coming on suddenly during or straight after sex, especially one-sided, or with faintness, dizziness or pain at the tip of the shoulder.
• Pain with fever, shivering, feeling generally unwell, offensive discharge, or pain in the back or side under the ribs.
• Heavy bleeding, bleeding that soaks through protection, or bleeding with pain and lightheadedness.
• Any pain with a positive pregnancy test, or with a late period and the possibility of pregnancy, which needs an ectopic pregnancy excluded urgently.
• Pain with an inability to pass urine, or with vomiting that will not settle.

Sudden severe pelvic pain can come from a ruptured or twisted ovarian cyst, from bleeding into the abdomen, or from an ectopic pregnancy, and those are the reasons such pain does not wait for a routine appointment. If you are pregnant, or might be, pain with sex is assessed on that basis first and quickly. Going to an emergency department or an urgent gynaecology service is the correct response to any of the findings listed above, and nothing in this article should delay that.

Entrance pain: arousal, lubrication and friction

One of the commonest and most easily missed reasons for pain at the entrance is simply that the tissues were not ready. Arousal produces lubrication from the vaginal walls and lengthens and relaxes the canal, and it takes longer than most people expect, often considerably longer than it did in earlier years. Without it, friction acts on dry mucosa, which burns at the time and then stings for a while afterwards. This is a mechanical problem rather than a disease, but it still deserves to be said plainly rather than treated as a personal failing.

Several things interfere with arousal that have nothing to do with desire: tiredness, stress, pain anticipated from a previous occasion, a new relationship, medication, and the self-monitoring that begins once sex has hurt a few times. Pain and muscle guarding feed one another, so a problem that started as dryness can carry on as muscle tension long after the dryness itself has been dealt with. That is one of the reasons an examination is useful even when the explanation appears obvious to everyone involved.

The instinct at this stage is to buy something. Wanting immediate relief is entirely reasonable, and products do have a place, but a product chosen for the wrong cause delays the answer, and some make sensitive skin worse rather than better. If the pain is new, recurrent, one-sided, associated with bleeding, or accompanied by a change in the skin or in discharge, it should be looked at first. What helps is a decision for a doctor who has examined you, not one made from a shelf.

Dryness from menopause, breastfeeding and some contraceptives

Oestrogen keeps the vaginal and vulval tissues thick, elastic and naturally moist. When oestrogen falls, those tissues become thinner and more easily irritated, and lubrication arrives more slowly and in smaller amounts. The usual pattern is burning at the entrance during sex, soreness that eases over the following hours, and often urinary symptoms alongside. Fragile tissue can also bleed a little after sex, but bleeding is never assumed to be dryness: any bleeding after sex once your periods have stopped, and any bleeding between periods or after the menopause, is assessed promptly so that a cause on the cervix or in the lining of the womb can be excluded. Report it to your doctor even if dryness plainly explains the pain. Low oestrogen is the commonest cause of new pain with sex in the years around and after the menopause, and it is set out further in our article on the stages and symptoms of menopause.

The same fall in oestrogen happens temporarily while breastfeeding, with treatments that suppress ovarian function, and after surgery or treatment affecting the ovaries. Dryness related to breastfeeding usually improves as feeds reduce and cycles return. Some people also notice dryness after starting a hormonal contraceptive; the reason is less straightforward there, and it is a change to describe to the person who prescribed it rather than one to interpret yourself. Dryness that began with a contraceptive is worth raising rather than tolerating, because the class of method can often be reviewed. Neither of those conversations should begin with you stopping a method on your own.

Treatment for hormonal dryness exists and helps most people. It ranges from non-hormonal measures through to local oestrogen treatment applied to the vagina, which in most settings is prescribed. Whether it is appropriate, and in which form, depends on your own history, including any previous hormone-sensitive illness, and that is a decision for your doctor rather than something to work out from an article. The point to take from this section is that the cause is treatable, and that soreness with sex is not an inevitable part of getting older.

Infections and skin conditions at the vulva

Thrush, a yeast infection, causes itching, soreness, a thick discharge and burning that is worse with friction and for a day afterwards. Bacterial vaginosis more often changes discharge and odour than it causes pain, although it can leave the tissues tender. Genital herpes causes a distinctly sharp, raw pain with visible splits or ulcers. Trichomonas and chlamydia can both produce soreness with sex, and chlamydia may do so with very few other symptoms, which is why testing is a routine part of assessment rather than any kind of accusation.

Skin conditions are easy to miss, because vulval skin is rarely examined closely. Eczema and contact irritation from washes, wipes, pads or hair removal cause soreness and small splits at the entrance. Lichen sclerosus produces pale, thickened or crinkled skin with itching, splitting and gradual change in shape over time, and lichen planus can affect the vagina itself as well as the vulva. These are diagnoses made by looking, and they respond to prescribed treatment, so the real harm comes from the delay caused by treating them blindly at home.

This is also why persistent vulval skin change is examined rather than watched: an area that stays thickened, discoloured, ulcerated or steadily changing, or lichen sclerosus that does not settle with treatment, is occasionally precancerous or cancerous, and examination with a biopsy where needed is what settles the question. Beyond that, vulval skin needs the same ordinary care as skin anywhere on the body: plain water, nothing scented, no over-washing, and no treatment applied repeatedly without knowing what is being treated.

Scarring after childbirth, surgery or healing

A tear or an episiotomy that healed with a tight or tethered scar can leave a precise, reproducible point of pain at the vaginal opening, often felt as a catch or a tearing sensation on entry. It can appear months after a birth, once sex resumes, and it is commonly accompanied by pelvic floor muscles that have learned to tighten in anticipation. A scar that is causing pain is a physical finding, and it can be felt during a careful examination at the exact point you describe.

Pain can also follow vaginal, pelvic or perineal surgery, treatment to the cervix, or radiotherapy to the pelvis, and dryness as well as tightening forms part of the picture in those situations. Breastfeeding overlaps with the postnatal period, so low oestrogen and scarring are frequently present together, which is worth knowing because treating only one of them gives a partial result. Most of this responds to treatment, usually pelvic floor physiotherapy, sometimes a prescribed topical treatment, occasionally a minor procedure.

Vulvodynia: pain without a visible cause

Sometimes the examination is normal and the pain is still entirely real. Vulvodynia is vulval pain lasting three months or longer, usually burning, rawness or a feeling of being cut, without a skin condition, infection or other finding that explains it. It may be provoked, meaning it appears only on touch or pressure such as intercourse, tampon insertion or prolonged sitting, or unprovoked and present much of the time. Its cause is not known. Irritation or over-sensitivity of the nerves in the vulva, previous infections, hormonal change and pelvic floor muscle dysfunction are all thought to contribute in different people, and it is a recognised diagnosis rather than a label for an unsolved case.

Terminology here genuinely differs between classification systems. Some classifications group persistent vulval pain and difficulty with penetration together under a single heading covering genito-pelvic pain and penetration difficulty, while others keep vulvodynia, vaginismus and pelvic floor overactivity as separate entities that commonly coexist. The practical consequence is modest: the assessment is much the same, and so is the approach, which usually combines pelvic floor physiotherapy, attention to skin care, prescribed medication in selected cases, and psychosexual support where pain has come to be anticipated.

Pelvic floor overactivity and vaginismus

The pelvic floor muscles surround the vaginal opening and are partly under voluntary control, which means they respond to expectation. Once pain has occurred, the muscles tighten before entry, narrowing the opening and producing exactly the pain that was feared. Overactive pelvic floor muscles cause pain at the entrance, a sensation of a wall or a barrier, pain that eases when you relax and worsens when you try harder, and frequently an ache afterwards that outlasts the act itself by hours.

Vaginismus sits at the far end of that spectrum: an involuntary tightening of the muscles around the entrance that makes penetration painful or impossible, sometimes present from the first attempt and sometimes appearing after years without any difficulty. It is not a decision and it is not a sign of reluctance. It is diagnosed on history and examination, and it responds well to treatment, most often pelvic floor physiotherapy with graded self-directed work and, where helpful, psychosexual therapy. Progress is normally gradual rather than sudden.

Because the muscles react to pain from any source, overactivity is frequently a second cause layered over a first. Dryness, a healed tear, thrush or endometriosis can each set it off, and it can continue long after the original problem has resolved. That is why a clinician treating pain with sex will often address two things at the same time, and why finding one cause is not a reason to stop looking for another. Say so if treating the obvious cause only partly helped.

Deep pain: endometriosis, adenomyosis and fibroids

Deep pain that depends on depth and position, is worse at certain points in the cycle and carries on after sex is the classic pattern of endometriosis. Deposits behind the uterus, and in the space between the uterus and the rectum, are tender on contact, and the pain is typically described as a deep, bruising ache lasting hours. Painful periods, pain on opening the bowels around a period and difficulty conceiving often accompany it, and it is covered in our article on endometriosis and fertility.

Adenomyosis, where endometrial tissue sits within the muscle of the uterine wall, produces a heavy, tender, enlarged uterus and can cause deep pain with sex alongside heavy and painful periods. Fibroids depend on position rather than size alone: those sitting low, towards the cervix, or on the back wall of the uterus are the ones more likely to hurt with deep contact, while others of similar size cause nothing at all. Both are assessed with examination and imaging, usually pelvic ultrasound.

None of these is diagnosed from symptoms alone, and a normal ultrasound scan does not exclude endometriosis, which is one reason the condition is so often recognised late. If the pattern described here fits what you experience, say it clearly to the clinician assessing you and ask what the next step would be if the first scan is normal. Being persistent about a pain that is affecting your life is reasonable, and in this condition it is frequently necessary.

Deep pain: cysts, infection, uterine position, bowel and bladder

An ovarian cyst can cause deep pain on the side it sits, particularly with pressure or in certain positions, and most cysts are simple, common and not harmful in themselves. Pelvic inflammatory disease, infection of the upper genital tract, causes deep pain with sex together with pelvic pain, abnormal discharge, irregular bleeding and sometimes fever, and it needs prompt treatment because untreated infection damages the fallopian tubes. Deep pain of that kind alongside an untreated infection is a reason to be assessed quickly rather than to wait and see.

A retroverted uterus, one that tilts backwards, is a normal variation and causes no symptoms in most people who have one. In a minority it brings the uterus and ovaries into the line of deep contact in certain positions, producing position-dependent deep pain, and the simplest clue is that changing position changes the pain. It is explained further in our article on the retroverted uterus, including why it is usually a description rather than a diagnosis.

The bowel and the bladder sit immediately behind and in front of the vagina, so they belong on any list of causes of deep pain. Irritable bowel syndrome, constipation and inflammatory bowel disease all cause pain with pressure. Interstitial cystitis, also called bladder pain syndrome, produces pain as the bladder fills, urinary urgency and deep pain with sex, and it is often mistaken for repeated infection because the symptoms overlap while the urine cultures keep coming back clear.

Pain after sex specifically

Pain that begins or persists after sex rather than during it is a common and quite distinct complaint, and it is worth describing precisely, because the timing narrows the cause considerably. Cramping low in the abdomen for minutes to hours usually comes either from uterine contraction, which is normal in itself after orgasm but exaggerated where adenomyosis, fibroids or endometriosis are present, or from deep contact with a tender structure that goes on aching once it has been pressed against.

Aching, heaviness or a dragging sensation at the entrance and through the pelvic floor for the rest of the day points to muscle rather than to an organ. Muscles that have held a contraction behave afterwards like any other overworked muscle in the body. Pelvic floor physiotherapy is the treatment most often used for this, and it is worth asking about early, because it is frequently offered late rather than first. How much it helps varies from person to person, and whether it fits your case is for the clinician who examines you to judge.

• Cramping for minutes to hours: uterine contraction, often exaggerated where adenomyosis, fibroids or endometriosis are present.
• Aching or spasm at the entrance and in the pelvic floor: overactive pelvic floor muscles, usually with an original cause that started elsewhere.
• Burning on passing urine, urgency or frequency beginning within a day: urinary tract irritation or infection, which is common after sex and is treated rather than tolerated; with a temperature, shivering or pain in the back or side, it needs assessment the same day.
• Soreness with light spotting: often fragile tissue from low oestrogen or a small skin split, but bleeding after sex is never assumed to be either. Report any bleeding after sex to your doctor, and arrange prompt assessment if your periods have stopped, or if you also bleed between periods, so that a cause on the cervix or in the lining of the womb can be excluded.
• Pain that steadily worsens over hours instead of settling, particularly with fever or feeling unwell: assessment the same day.

What assessment involves, and why it starts with being examined

Assessment begins with the history, and the questions are the ones set out at the start: where, when, since when, and what else is happening. It then moves to an examination, because most causes at the entrance are visible or can be felt, and because an examination is how a specific tender point, a skin change, a scar or an overactive pelvic floor is identified at all. An examination can be done gently and in stages, and it is reasonable to say beforehand that you are anxious, to ask for it to go slowly, and to stop it at any point.

• Inspection of the vulva and the vaginal entrance in good light, which is how skin conditions, small splits and scars are found.
• A gentle internal examination, often with one finger first, to map tender points and to assess pelvic floor muscle tone.
• Swabs for infection, and urine testing where urinary symptoms form part of the picture.
• Pelvic ultrasound where the pain is deep, to look at the uterus and the ovaries.
• Onward referral where it is needed, commonly to pelvic floor physiotherapy, to a vulval skin service, or to a gynaecologist with an interest in pelvic pain.

Treatment follows the cause, and in this area it is common for more than one thing to be treated at once: the skin condition and the muscle guarding, the dryness and the anticipation. Clinicians differ over the order to start in: some treat an identified cause first and then reassess, while others begin pelvic floor work alongside it from the outset. Either way, what should not happen is being told that nothing was found and that nothing can be done. Take the pattern you have noticed to your own doctor, and ask to be examined.

Related Reading

• Bleeding after sex with no pain: causes, assessment and when to be seen
• Endometriosis and Fertility: Symptoms, Diagnosis and Getting Pregnant
• What is menopause? The stages, symptoms and age range explained
• UTI after sex: why it happens and what reduces the risk
• Retroverted uterus: what a backward tilt means for fertility and pregnancy
• Recurrent UTIs in women: why they return and what gets checked

Sources and references

This article is supported by the following independent, authoritative sources:

• ACOG, When Sex Is Painful
• NHS, Vaginal dryness
• NHS, Vaginismus
• NHS, Vulvodynia (vulval pain)
• NHS, Pelvic inflammatory disease
• NICE, Endometriosis: diagnosis and management (NG73)