Painful Intercourse (Dyspareunia): Causes & Treatment

When the pain began is the other big clue.

Whatever starts the pain, the body's reaction can keep it going after the original cause has healed. In the British survey, painful sex was most strongly linked to vaginal dryness and to anxiety about sex.1

Pain makes the pelvic floor tighten. Tight muscles and worry reduce arousal and lubrication, and less lubrication means more friction and more pain the next time. That is why treatment often works on more than one thing at once: the cause, the muscles, the dryness and the worry.

There is no single test for dyspareunia. Your clinician will ask about your symptoms and, when you are ready, do a gentle examination. Some use a mirror so you can see what they are explaining, which can make the exam easier and more useful.2

You are in control of any exam. You can ask for a smaller speculum, bring a support person, or stop at any time.

Treatment works best when it is matched to the cause, and many people need more than one approach.2 Use this table to see where you might start, then make a plan with your clinician.

A pelvic floor physiotherapist checks whether your muscles are tight, tender or weak, and teaches them to relax and lengthen. In a randomized trial of 64 women with painful sex, three months of electrotherapy, manual therapy and pelvic floor exercises improved pain, muscle function and sexual function compared with a waiting list.8 Dilators are often part of the program. For step-by-step home use, see using dilators at home in our vaginismus guide.

A water-based lubricant reduces friction during sex, and a vaginal moisturizer used a few times a week keeps tissue more comfortable in between. After menopause, low-dose vaginal estrogen is the usual next step, and a Cochrane review found it relieved symptoms better than placebo, although most of the evidence was of low quality.7 A later trial of 302 postmenopausal women found something surprising: after 12 weeks, symptoms had improved by about the same amount with vaginal estrogen, a vaginal moisturizer, or a plain placebo gel.5 Regular use of a simple gel may do more than people expect.

Therapy works on the worry and avoidance that keep pain going, and it can help couples talk about sex while pain is being treated. In a trial of 97 women with provoked vestibulodynia, group cognitive behavioural therapy and a steroid cream both reduced pain, but six months later the therapy group had less pain, better sexual function and more satisfaction with their treatment.10

Deep pain usually means looking for a cause in the pelvis, such as endometriosis or a bladder or bowel condition, and treating it. A pelvic floor physiotherapist can help with the muscle tenderness that often comes with these conditions. Positions that keep penetration shallow can help in the meantime.

We think you should know. A 2023 review of 19 physiotherapy studies found that physiotherapy improved pain and quality of life, mainly when electrotherapy was combined with pelvic floor muscle training, but it did not find a clear improvement in overall sexual function.11 The dilator study for entry pain was small and had no comparison group,9 and many trials include only one cause, such as vestibulodynia or menopause. Matching treatment to the cause, with a clinician who knows you, is the most reliable route.

These are tools that pelvic health clinicians commonly recommend as part of a treatment plan. They work best with professional guidance.

Browse all vaginal dilators and pelvic wands. Clinicians can request patient brochures for their practice.