“Doctor, it hurts, but I thought it was normal”
This is something I hear very often in my consultations.
Some women have been experiencing pain during sex for months, sometimes even years. Little by little, they start adapting to it: avoiding certain positions, using more and more lubricant, having sex less frequently, or simply assuming that it is something they have to live with after childbirth, during menopause, or as they get older.
But persistent pain during sex should not be normalized.
There is something important I always try to explain: pain during sex is not a diagnosis. It is a symptom.
There can be many different causes behind it, which is why a treatment that works for one woman may make no sense at all for another.
Not all pain during sex is the same
When a patient tells me that sex is painful, one of the first things I need to understand is where it hurts and what the pain feels like.
Burning or stinging around the vulva is not the same as pain specifically at the vaginal opening. A feeling of tightness, as though the entrance will not stretch or allow penetration comfortably, is also very different from deep pain during intercourse.
It is also important to know when the pain occurs: at the beginning of penetration, throughout intercourse, only in certain positions, or even after sex.
All these details can give us important clues about what may be happening.
What can cause pain during sex?
There is no single cause.
For some women, the problem is related to vaginal dryness or hormonal changes, particularly during perimenopause and menopause. The vulvar and vaginal tissues can become thinner, less elastic and more sensitive, making penetration uncomfortable or painful.
For others, the cause may involve the pelvic floor muscles. Muscles that are excessively tense can make penetration difficult and painful. This can occur, for example, in some cases of vaginismus or alongside other pain conditions.
I also see women with scars or changes following childbirth, an episiotomy or a perineal tear. Sometimes there is one specific area that feels tight, becomes painful or repeatedly tears during intercourse.
Pain may also be related to a vulvar condition, such as lichen sclerosus, or to conditions such as vulvodynia or vestibulodynia, where even relatively light touch can cause significant discomfort or pain.
Infections and some inflammatory conditions can also cause pain. When the pain is felt more deeply during intercourse, other gynecological causes, including endometriosis, may need to be considered.
And sometimes, more than one factor is present at the same time.
This is why I do not like to talk about “the treatment for dyspareunia” as though there were one solution for everyone.
“I’ve been examined and they told me everything looks normal”
I hear this very often too.
And I understand how frustrating it can be.
The fact that a routine gynecological examination does not reveal an obvious abnormality does not mean that the pain is not real or that there is no underlying cause.
In these situations, a more focused assessment may be necessary: carefully examining the vulva and vestibule, identifying exactly where the pain occurs, assessing the vaginal opening, any scars that may be present, the condition of the tissues and the pelvic floor muscles.
The patient’s story is also fundamental. Often, understanding when the pain started, how it has changed over time, and what makes it better or worse provides just as much information as the physical examination itself.
So, how is it treated?
It depends on the cause.
And this is probably the most important point in this article.
Not every woman with painful intercourse needs hormones. Not everyone needs pelvic floor physiotherapy. Not everyone needs regenerative treatments. And, of course, not everyone needs surgery.
In some cases, an underlying vulvar condition needs to be treated. In others, we need to improve the health and quality of the tissues when hormonal changes are contributing to the symptoms.
Some women benefit particularly from pelvic floor physiotherapy, while others need a specific approach to vaginismus or vulvar pain.
Regenerative treatments may have a role in selected cases. And when there is an anatomical alteration, a painful scar or a childbirth-related injury that justifies correcting it, surgical treatment may be considered.
But for me, the order is always the same:
first understand what is causing the pain, and then decide how to treat it.
Pain should not become part of your sex life
Many women wait a long time before seeking help because they feel embarrassed, because they believe the pain is normal, or because they think they simply have to learn to live with it.
There is not always an immediate solution, and some pain conditions can be complex. But that does not mean they should be ignored.
If sex repeatedly hurts, if you have started avoiding intimacy because you are afraid of the pain, or if you have noticed that something has changed compared with how sex felt before, it is worth having it assessed.
My goal during a consultation is not simply to try to make the pain disappear. It is to understand why it is happening and, from there, work with you to find the most appropriate treatment for your individual situation.
