Pain during sex in women: causes, red flags and when to get it checked

Sex can be painful when tissues are dry, inflamed or tight, or when deeper pelvic structures are pushed or irritated. The mind and body also interact: expecting pain tightens the pelvic muscles, which increases pain, creating a cycle. Both physical and emotional factors are valid to discuss with a clinician.

• Vaginal dryness and thinning (genitourinary syndrome of menopause), also during breastfeeding or with some contraceptives and medicines.

• Insufficient arousal or lubrication, relationship stress, anxiety and past trauma.

• Thrush, bacterial vaginosis, urinary infections and sexually transmitted infections.

• Pelvic floor muscle tension and vaginismus, with entry pain or inability to have penetrative sex.

• Skin conditions of the vulva such as lichen sclerosus and eczema, and vulvodynia (chronic vulval pain).

• Endometriosis and adenomyosis: deep pain, painful periods and sometimes bowel or bladder symptoms.

• Pelvic inflammatory disease, ovarian cysts and fibroids, prolapse, and scarring after childbirth or surgery.

• Rarely, tumours of the cervix or ovary, which usually cause other symptoms such as bleeding.

Bleeding after sex, abnormal discharge, fever, pelvic pain outside of intercourse, unexplained weight loss, a pelvic mass or bloating, persistent pain despite treatment, and pain after recent childbirth or surgery warrant a prompt examination.

• Call 999 or go to A&E: severe sudden pelvic pain with fainting or heavy bleeding, or pain with a positive pregnancy test.

• Same-day GP or sexual health clinic: pain with fever, foul discharge or suspected infection.

• Urgent GP: bleeding after sex, or pain with persistent abnormal bleeding or a pelvic lump.

• GP within weeks: recurrent pain during sex of any type.

The doctor asks where it hurts, whether it is at entry or deep, how long, whether it happens every time, periods, bleeding, discharge, bowel and bladder symptoms, contraception, menopause, childbirth history, and emotional wellbeing, in a private, non-judgmental setting. A pelvic examination, if you agree, can identify dryness, skin disease, tender areas or prolapse.

• Vaginal and cervical swabs: for infection, including STIs.

• Cervical screening if due.

• Pelvic ultrasound (often transvaginal): for cysts, fibroids and adenomyosis.

• Laparoscopy: the definitive test for endometriosis in selected people.

• Vulval biopsy: for suspected skin disease.

Use water-based or silicone lubricants generously, allow plenty of time for arousal, and try positions that give you control. Stop if it hurts, talk to your partner and consider relaxation and pelvic floor retraining. Vaginal moisturisers and, for menopausal women, vaginal oestrogen prescribed by a doctor often help. Counselling or psychosexual therapy helps where anxiety or past experiences contribute.

The NHS route is a GP, sexual health clinic or gynaecology, with pelvic health physiotherapy and psychosexual therapy. Private gynaecology and sexual medicine services offer direct access to examination and ultrasound.