Painful Intercourse: What To Do About It

8 min read
Painful Intercourse: What To Do About It

Sex should feel good. Plain and simple. If it doesn't, there are plenty of solutions! 

Painful sex (dyspareunia in medical talk) is more common than one may think. In fact, it is estimated that 1 in 5 women experience this at some point. 60% percent of sufferers consult three or more doctors before receiving a diagnosis, and approximately 40% are diagnosed incorrectly. Those that suffer from painful sex may not even realize there is help out there! You do not have to live with this, sex can be enjoyable and fun, and should be just that. If you, or someone you know, experience painful sex, please know that you are not alone. Finding solutions can be difficult, especially without all of the information, we hope at the very least, this article will be able to identify some missing pieces that will put you in the right direction to finding help.

Painful sex can be isolating: You are NOT alone 

Experiencing pain when there should be pleasure is unacceptable, and too many people either accept this is the way it is or do not accept this but do not know how to fix it.  And that is just an estimate from the information we have data on. Imagine how many others who simply never mentioned this to their providers, those that were not ever asked, or even those that did mention it, but were dismissed (or told to have a glass of wine and relax), as well as those that do not identify as a cis-gender female, therefore not mentioned in the data.

Many sufferers ‘tolerate’ it for far too long, how many times have you thought to yourself ‘it’s just me,` ‘it’s in my head, I’m too stressed,’ or ‘I’ll just drink a bottle of wine and get it over with.’ For some, there may be an obvious cause. For others, it may take the help of trained professionals and there may be multiple factors involved. Regardless of the cause, there are treatments, and there is hope. Finding a solution can be difficult without all of the information. 

Why sex hurts

Potential Diagnoses

There are several reasons why someone may experience painful sex. The ‘why’ is critical in understanding ‘how’ you can fix this. One important piece of information we want to highlight is that this information is specific to those having pain with intercourse when they are expecting it to be pleasurable. Of course, every instance of painful sex is not abnormal, but still may need to be addressed. For example, unwanted/non consensual sexual activity, rough sex (if unwanted), and even your first time, are examples where pain or discomfort may make sense, but this is not what this blog is intended to discuss. If you or someone you know is experiencing unpleasurable sex due to one of the above causes, please know that there are trained professionals who can help. 
The most common terms you are likely to be familiar with are ‘vaginismus’ or ‘vulvodynia.’  These terms may be a good starting point to finding answers, they shouldn’t define your life especially because they don’t tell you much of anything about WHY you are having pain. If you do not know why sex hurts, how will you understand how to make it stop hurting? 


Vaginismus is an involuntary muscle spasm in response to vaginal penetration termed in the 1800’s by Dr. J. Marion Sims. This is an older term which is still widely used today, often to describe any reason why penetration may be an issue. Historically, there has been debate in different cultures about how to go about treating this. In America, Dr. Sims believed this was a physical disorder that needed to be treated with surgery, whereas in France, it was thought to be due to a moral issue that could not be properly treated by physical methods and that the American approach was “too rational and straightforwardly physical.”  
Vaginismus is often used in the context of painful sex or more specifically because they are unable to have sex, insert a tampon, or have successful gynecological exams. Many are self-diagnosed, or often incorrectly diagnosed by a medical professional untrained in sexual health. That being said, if you have been diagnosed by a provider, the fact they even knew this term implies that they are trying to help. It means they either asked you, or they did not dismiss you when you brought it up. Regardless of how you got the diagnosis, it still doesn’t tell you why this is happening

Vulvodynia (and each type)

Vulvodynia is defined as “pain anywhere in the vulva.” Your vulva is your external genitalia - your clitoris, labia majora and minora, and vestibule which is the tissue surrounding the urethra and the vagina. It was a diagnosis that was given when there was pain for more than 6 months for no known reason. Today, we now have better terminology to describe subtypes, causes, and associated factors in vulvodynia, of which there are several. Painful sex is often associated with vulvodynia but that is not always the focus for the individual. 

Vestibulodynia, a subtype of vulvodynia, is one of the most common reasons people with vulvas experience painful sex. Vestibulodynia refers to pain specific to the tissue that surrounds the opening of the vagina. It also is not commonly evaluated by medical providers and likely the MOST common reason premenopausal people are still suffering. This tissue loves hormones, but it may also contain an excessive number of nerve endings and mast cells, which are capable of creating a lot of inflammation if triggered. There are different types, the most common being hormonally mediated vestibulodynia and neuroproliferative vestibulodynia. There are several factors involved with both types which is summarized in the table below, along with their various treatments. 

Hormonally mediated vestibulodynia refers to pain in the vestibule (area around the opening of the vagina) caused by hormones, more specifically a lack of hormones. 




  • Pain with cotton swab test throughout the vestibule
  • Redness (erythema) 
  • Pain with initial penetration (not deep)
  • Low or normal total testosterone
  • High sex hormone binding globulin (SHBG)
  • Small clitoris
  • Resorbed/small labia minora
  • Birth control pills
  • Acne medications
  • Other medications that may be used to cause reduced hormone production (i.e. Breast cancer tx, endometriosis)
  • Amenorrhea (the absence of menstruation)
  • Stop offending medication
  • Hormone topical medications
  • Systemic hormone therapies
  • Identifying and treating underlying cause of amenorrhea

Neuroproliferative vestibulodynia (NPV) refers to pain in the vestibule caused by excessive or hypersensitive nerve endings and/or mast cells causing inflammation and irritation. One may be born with this condition (congenital) which is often referred to as primary vestibulodynia or it can happen later in life (acquired).





  • Pain with cotton swab test throughout the vestibule
  • Possible erythema in vestibule, tissue may be normal in appearance
  • Usually notable in history that initial tampon insertion is difficult/impossible
  • Possible belly button sensitivity life-long
  • Usually severe pain or inability for any penetration
  • Reactions to penetration may often be portrayed as exaggerated or excessive
  • Genetic predisposition (you are born with it)
  • Surgery (vestibulectomy)





  • Usually a period of time where there was no issues before onset of triggering factor
  • Mix of findings of both hormonal and congenital neuroproliferative subtypes
  • Likely an underlying predisposition 
  • Recurrent yeast or other vaginal infections, STI’s
  • The over the counter medication Monistat 
  • Surgery (vestibulectomy)


This is a very general overview and there are many more factors/causes and descriptors that represent vestibulodynia. It is important to know that 90% of those with vestibulodynia also have pelvic floor dysfunction. 

Pelvic floor dysfunction

More often than not, those that are diagnosed with ‘vaginismus’ really just have pelvic floor dysfunction. Pelvic floor dysfunction has a number of causes and factors that could be involved such as posture, previous injuries, hip and low back issues, endometriosis, inflammatory conditions to the vulva (bacterial vaginosis, lichen sclerosus, lichen planus), medications and therapies used to treat cancers (radiation therapy, aromatase inhibitor drugs, immunotherapies), surgeries that affect the vulva, vagina, and pelvis, breastfeeding for some, and postpartum complications such as tearing. 

Available Treatments

While there are many treatments, providers, and tools that help, different treatments are aimed at different causes. Knowing what your cause or causes are, will help you determine the right treatment plan. 

Vaginal dilators

Vaginal dilators, sometimes referred to as vaginal trainers, are the first tool that one may find when researching painful sex, or vaginismus. Dilators can be a very important part of one’s treatment and journey toward pleasureable sex. Determining when they are appropriate is important. For example, if you have vestibulodynia AND tight muscles, your dilators may not be effective initially because the vestibule issue may be driving the muscle tightness. Every time you insert your dilator, you touch that tissue which causes your muscles to clench. Sound familiar? However, they may come in very handy once the vestibulodynia is treated. 

Vaginal dilators are also very helpful for addressing various causes of pelvic floor muscle tightness when that is the primary issue. They are also extremely helpful and required after certain types of surgeries or medical treatments such as gender affirming surgery, radiation therapies, and post-vestibulectomy to name a few. They also may be the key in helping transition from therapy to actual sex, or to reduce fear or desensitize or improve your tolerance around medical procedures, using tampons, or even preparing for childbirth. 

Dilators have come a long way since they were initially developed. Initially, they were made out of hard plastic and not very appealing. Our dilators were developed to be easy to use with your comfort in mind.  

Pelvic floor physical therapy

Pelvic floor physical therapy (PFPT) should be a first-line treatment if you are experiencing painful sex. Meaning, unless you suspect an infection as the cause of your pain, you should consider PFPT before other treatments. Not only can your physical therapist (PT) help you identify the cause of your pain, they will be able to provide you with resources and recommendations that are appropriate for you. They will also provide direct treatment and can make appropriate referrals to other providers so you do not have to navigate this alone. Physical therapy involves a variety of  treatments including manual therapy, specific therapeutic exercises, education, and home programs based on your individual needs, often including dilators. Ask your PT if NewFlora dilators are right for you!


There are several instances in life where there are critical hormonal shifts that may affect the vulvar tissues resulting in pain. Different periods of life such as peri-menopause and menopause (natural or medically induced) and breast feeding are times when we may have insufficient hormone production resulting in vulvar pain. Additionally, vulvar pain may arise after starting certain medications that may alter your body's natural hormone production such as birth control pills, acne medications, and certain medications to treat various cancers. In these cases, such as in the case of hormonally mediated vestibulodynia, you will want to find a provider familiar and trained in sexual medicine to provide medical management. This is usually combined with pelvic floor physical therapy. 

Sexual medicine providers

If you have seen a provider and you still feel lost, know that there are specific providers that have additional training in the field of sexual medicine. These providers can be urologists, physical therapists, OBGYNs (gynecologists), psychologists, nurse practitioners, and pain management providers, among others. We trust our providers to give us the information we need, but this is an area that is largely ignored in our society, and your current provider may not even know this area of medicine exists. Luckily, there are some great providers ready and willing to help you, and below you will find information on locating a provider near you. If you are not able to find a provider local to you, many providers will offer digital health consultations and can help you understand your cause, find providers near you, or help you with discussing your case with your current provider. 
If you are experiencing painful penetration, it is very likely your pelvic floor is involved. While it is important to seek help to understand the underlying factors, NewFlora dilators will likely be beneficial in helping you meet your goals. Click below to check out what makes us unique!

  1. Vulvodynia: get the facts. Retrieved from
  2. Henzell, H. Berzinks, K., & Langford, J. (2017). Provoked vestibulodynia: current perspectives. Int J Womens Health, Vol 9: 631-642.
  3. Reissing, E., Brown, C., Lord, M., et al. (2005). Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome. J Psychosomatic Obstetrics Gynecol. 26(2): 107-113.


Dr. Lindsay Durand-Massumi DPT

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