Short answer: pain during sex — dyspareunia — has several distinct causes, and they need telling apart because the treatments differ entirely. The one thing they share is that enduring it makes it worse, because pain recruits a protective muscular response that becomes a cause in its own right.
Pain leads to anticipation of pain. Anticipation causes the pelvic floor to tighten protectively and reduces arousal and lubrication. Both make the next occasion more painful. This is why "pushing through" is the worst available strategy, and why early treatment is disproportionately effective.
Hormonal and tissue causes
Genitourinary syndrome of menopause
The most common cause in women over 45. Falling oestrogen thins vulval and vaginal tissue, reduces elasticity and lubrication, and can cause burning, itching and urinary symptoms alongside pain. It does not improve on its own and progresses untreated — but responds well to local vaginal oestrogen. See menopause and sex.
Other hormonal causes
Breastfeeding, some hormonal contraceptives and treatments that suppress oestrogen produce similar tissue changes at any age.
Muscular causes
Pelvic floor muscles can become overactive and hold tension involuntarily, producing pain at entry and a sensation of tightness or blocking. This may be primary, or secondary to any other painful cause. Pelvic health physiotherapy is the treatment and is genuinely effective; a GP can refer, and self-referral is possible in some areas.
Infective and inflammatory causes
Thrush, bacterial vaginosis, sexually transmitted infections and skin conditions such as lichen sclerosus all cause pain and each needs its own treatment. Recurrent thrush that keeps returning after treatment should be reassessed rather than treated repeatedly over the counter.
Deeper pain
Pain felt deep rather than at entry — particularly with position changes — points toward endometriosis, fibroids, ovarian cysts or pelvic inflammatory disease. This warrants medical assessment rather than self-management. Endometriosis in particular is diagnosed years late on average, frequently because pain was normalised.
What helps
- Get the cause identified. This is the one area where self-treating blind is least useful, because the causes need opposite approaches.
- Local vaginal oestrogen where the cause is hormonal — effective, low-dose, under-prescribed.
- Pelvic health physiotherapy where the pelvic floor is involved.
- Lubricants and vaginal moisturisers — different jobs. Lubricant for sex, moisturiser regularly for tissue condition. Water or silicone-based lubricants; avoid anything perfumed or warming on irritated tissue.
- Time and arousal. Reduced arousal produces less lubrication; more unhurried time genuinely helps, though it will not fix a tissue or muscular cause.
- Stop if it hurts. Continuing reinforces the protective response you are trying to undo.
If you suspect a hormonal cause
A female hormone panel measures oestradiol, FSH, LH and testosterone — useful context if symptoms began in your forties or fifties, and something concrete to bring to a GP.
See the female hormone testpain is new, persistent, deep rather than at entry, accompanied by bleeding after sex or between periods, or by discharge, itching or skin changes. Bleeding after sex always warrants assessment.
Common questions
Why has sex become painful?
The most common cause after 45 is genitourinary syndrome of menopause — tissue thinning and dryness from falling oestrogen. Other causes include an overactive pelvic floor, infections, skin conditions, and deeper causes such as endometriosis or fibroids.
Is vaginal dryness just a lubrication problem?
Not usually. Lubricant helps the symptom during sex, but if the cause is oestrogen-related tissue change, the tissue itself needs treating — typically with local vaginal oestrogen — or the problem continues and progresses.
What is the difference between a lubricant and a vaginal moisturiser?
A lubricant is used during sex for immediate comfort. A moisturiser is used regularly, independent of sex, to maintain tissue hydration and condition. They do different jobs and are often used together.
Can pelvic floor muscles cause painful sex?
Yes. An overactive pelvic floor holds tension involuntarily and causes pain at entry and a sense of tightness. Pelvic health physiotherapy is effective; a GP can refer and some areas allow self-referral.
Should I push through the pain?
No. Pain triggers a protective tightening of the pelvic floor and reduces arousal, both of which make the next time worse. Persisting turns a treatable problem into a self-sustaining one.
When should painful sex be checked by a doctor?
If it is new or persistent, felt deep inside, or comes with bleeding after sex, unusual discharge, itching or skin changes. Bleeding after sex should always be assessed.