Painful Sex in Women

Painful sex, also called painful intercourse and medically known as dyspareunia, can happen for many reasons. Where the pain occurs often provides an important clue. Some women feel burning, tearing, tightness or pain at the vaginal opening. Others hurt only with deeper penetration, while some experience burning, soreness or throbbing after sex.

Pain at the opening may be related to vaginal dryness, genitourinary syndrome of menopause (GSM), vaginismus, pelvic floor tightness, scar tissue, vulvodynia, lichen sclerosus or infection. Deep pain may be associated with pelvic floor dysfunction, endometriosis, ovarian cysts, adhesions or other pelvic conditions. Often more than one problem contributes to the pain.

Hormones, Vaginal Dryness and GSM

Perimenopause, menopause and postmenopause can cause genitourinary syndrome of menopause (GSM). As estrogen declines, the vulva and vagina can become drier, thinner, more fragile and less elastic. Natural lubrication may decrease, and the vagina can become shorter or tighter at the opening. This can cause burning, tearing, bleeding or pain with penetration. GSM can become progressively more bothersome over time. The longer you wait, the harder it can become to reverse these changes.

Low estrogen and vaginal dryness can also occur postpartum and while breastfeeding. Inadequate arousal or lubrication, friction, prolonged sex, certain sexual positions and deeper penetration can make pain worse, especially when the underlying tissue is already dry or sensitive.

Vaginismus and Pelvic Floor Dysfunction

Vaginismus causes involuntary tightening of the muscles around the vaginal opening and pelvic floor when penetration is attempted. Sex may be painful or penetration may feel impossible.

Physical causes such as dryness, GSM, scar tissue or prior pain can contribute, but fear, anxiety, trauma or anticipating pain can also trigger pelvic floor tightening.

Vulvar and Vaginal Conditions

Lichen sclerosus can cause inflammation, fragile tissue, tearing, scarring and narrowing around the vaginal opening, making penetration painful. Vulvodynia, vaginitis, recurrent infections and other vulvar or vaginal conditions may also cause burning and pain with sex.

Pregnancy, Childbirth and Breastfeeding

Painful sex after childbirth is common. Hormonal changes, breastfeeding, vaginal dryness, pelvic floor changes, episiotomy, vaginal or perineal tears and scar tissue can all contribute. Pain can also occur after a C-section because pregnancy itself affects hormones and the pelvic floor, and breastfeeding can suppress estrogen regardless of how the baby was delivered.

Cancer and Cancer Treatment

Cancer surgery, chemotherapy, pelvic radiation, surgical menopause and hormone-blocking medications can affect hormones, lubrication, vaginal and vulvar tissue, elasticity and pelvic floor function. Women may develop vaginal dryness, GSM, narrowing, scar tissue and significant pain with penetration. These changes can be particularly pronounced after breast and gynecologic cancer treatment.

For some women, penetration is more than uncomfortable—it can be extremely painful or feel impossible. They may struggle to insert a tampon, use a sex toy or tolerate a pelvic examination, let alone have penetrative sex.

Vaginismus, pelvic floor spasm, scar tissue, GSM, vaginal narrowing and conditions such as lichen sclerosus can all contribute. The important question is not how to tolerate the pain, but why penetration hurts and what is causing it.

Painful sex is treated by identifying what is causing the pain. At Bawa Medical in Boca Raton, Dr. Kanwal Bawa uses the Bawa Method to evaluate the hormones, vaginal and vulvar tissue, blood flow, pelvic floor and any conditions that may be making penetration painful.

If the problem is related to dryness, GSM, tissue thinning or reduced blood flow, treatment may include BawaRF®, BawaWave®, the BawaShot®, hormone replacement therapy or CO₂ laser. When vaginismus, pelvic floor tightening, scar tissue or vaginal narrowing are contributing, vaginal dilation and other targeted therapies may be added.

For women with lichen sclerosus, treatment focuses on the tissue changes causing pain, tearing and narrowing. In selected patients, CO₂ laser may be incorporated into the treatment plan.

• BawaRF®
• BawaWave®
• BawaShot®
• CO₂ Laser
• Hormone Replacement Therapy
• Vaginal Dilation

1. American College of Obstetricians and Gynecologists. When Sex Is Painful.

2. Banaei M, Kariman N, Ozgoli G, et al. Prevalence of postpartum dyspareunia: A systematic review and meta-analysis. International Journal of Gynecology & Obstetrics. 2021;153(1):14-24.

3. Palma F, Volpe A, Villa P, Cagnacci A; Writing Group of the AGATA Study. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. Maturitas. 2016;83:40-44.

4. Baumgart J, Nilsson K, Stavreus Evers A, Kunovac Kallak T, Sundström Poromaa I. Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer. Menopause. 2013;20(2):162-168.