Painful sex in women: when to see a doctor and when to see a therapist

“It’s not that bad. I just need to relax a bit.”

She has told herself this many times. Before sex, during it, afterwards, waiting in the bathroom for the pain to ease. She hasn’t told her partner everything, because she didn’t want to hurt him. She hasn’t told her doctor anything, because it felt embarrassing and because she was convinced the problem was her — too tense, not relaxed enough, not woman enough. A year went by, then two.

This scene is composed, but stories like it are not rare. Painful sex — the medical term is dyspareunia — is one of those problems people stay silent about for longer than they should. In this post I will explain why the first port of call is always a doctor, how a cycle of fear and tension can become woven into pain, what a partner means in all this, and where psychotherapy can help. And right at the start: I am neither a sexologist nor a sex therapist. This post does not replace an examination.

More common than people say

The large British sexual health survey Natsal-3, whose data were analysed by Kirstin Mitchell and colleagues, found that 7.5% of sexually active women had experienced pain during sex in the past year that lasted at least three months. That is roughly one woman in thirteen. The pain was often linked with other sexual difficulties, poorer wellbeing and avoiding sex.

So if it hurts for you, you are not the exception. You are one of many who mostly don’t talk about it. And because they don’t talk about it, each of them thinks she is the only one.

The pain may be felt at the entrance to the vagina, deeper in the pelvis, or only after sex, as a burning or raw feeling that lasts for hours. It may be new, or it may have been there for as long as you can remember. It may appear only during sex, or also when inserting a tampon or during a gynaecological examination. All of these differences matter to a doctor, so it is worth remembering them or writing them down.

A gynaecologist first — always

This is the most important sentence in this post: painful sex is first of all a reason to see a gynaecologist. Not because the pain is “only physical”, but because it often has a cause that can be found and treated. Some possible causes a doctor will check:

• Infections of the vagina or urinary tract that cause burning and soreness.
• Dryness and thinner tissue — for example while breastfeeding or around the menopause, when there is less oestrogen.
• Endometriosis, in which tissue similar to the lining of the womb grows outside it. The World Health Organization estimates that it affects about one in ten women of reproductive age. It often causes deep pain during sex and painful periods.
• Vulvodynia — long-lasting pain in the area of the vulva with no obvious visible cause. Its most common form is pain when the entrance to the vagina is touched.
• Skin conditions of the genitals, scarring after childbirth or surgery, and tension in the pelvic floor muscles.

Many of these conditions can be treated or at least considerably eased. That is why it is such a pity that women often wait years before speaking up. If the pain began after giving birth, there is more about that period in Sex after having a baby: why it comes back more slowly than you expect.

When the results aren’t clear

Sometimes an examination shows nothing obvious. Then it is very easy to hear — or to tell yourself — that it is “all in your head”. It isn’t. Pain for which no cause has been found at first glance is still real pain. Vulvodynia and endometriosis are known for often going unrecognised for a long time.

If you feel you were not heard, you have the right to a second opinion. It helps to bring notes to the appointment: where it hurts, when, for how long, what eases it. I described what happens when the tests show everything is fine but the body still hurts in “The tests are fine, but it still hurts”: what psychotherapy knows about psychosomatics; there is a short explanation in the knowledge base under psychosomatics.

In the official psychiatric classification DSM-5, painful sex and vaginismus were merged in 2013 into a single category — genito-pelvic pain/penetration disorder. The reason was precisely that in practice they are often intertwined: pain, the expectation of pain and involuntary muscle tension. There is more about vaginismus, where the body says no even though you want to say yes, in Vaginismus: when your body says no, even though you say yes.

The pain–fear–tension cycle

This is where a part comes in that we know well from other kinds of long-lasting pain too. Johan Vlaeyen and Steven Linton described the fear-avoidance model: when something hurts repeatedly, the body and mind start preparing for pain before it arrives. Katarina Thomtén and Steven Linton applied this model to pain during sex.

The cycle goes roughly like this. Pain during sex triggers fear that it will hurt again. At the next touch, thoughts appear such as “it’s going to be awful again” or “I won’t be able to bear it” — this is called catastrophising. Fear tightens the pelvic floor muscles and reduces arousal, so there is less lubrication and more friction. Sex hurts even more. And because it hurts, you start avoiding it — not only sex, but any touch that might lead to it.

In the short term avoidance helps — it doesn’t hurt. In the long term, though, it strengthens the cycle: the body learns that closeness is dangerous, and the fear spreads. You can find more about how avoidance works in the knowledge base. The mechanism is very similar to the one I describe in Fear of fear: how panic learns to return — except that here the body is not afraid of panic but of pain.

Importantly, this cycle does not mean you “created” the pain yourself. It often begins with an entirely physical cause — an infection, a birth injury, dryness. The cycle explains why pain sometimes remains even after the original cause has been treated.

The shame that makes silence

Women who experience pain during sex often carry more than the pain. They also carry shame — that they are not “normal”, that they can’t give their partner what he wants, that there is something wrong with them. This shame is sometimes heavier than the pain itself, because it keeps a woman quiet: with her partner, with her doctor, with her friends.

I wrote about how shame works and why it whispers exactly this in Shame: the emotion that whispers “There is something wrong with me”. Here I will add only this: shame lives on silence. When you say it to someone who responds with respect, it loses some of its power. A gynaecologist who listens calmly can be the first such person.

Shame often has a history as well. If you grew up in a family where bodies and sex were not talked about, or were talked about with mockery or severity, it is all the harder to find the words now. That is not your fault. It is something you brought with you, and something that can slowly be reshaped.

The partner’s role

The partner is almost always present in this story, even when the two of you don’t talk about it. And their response matters more than either of you thinks.

Natalie Rosen, Sophie Bergeron and colleagues studied how partners respond to women with pain at the entrance to the vagina. They found that responses which overprotect and avoid the pain together — for example excessive worry, or immediately stopping all closeness — were linked with more pain. Responses that encourage adapting — tenderness, praise, looking for other forms of closeness that don’t hurt — were linked with less pain and greater sexual satisfaction. Hostile responses, anger or reproach, were also linked with more pain.

It does not follow that the partner is to blame for the pain. It follows that they can be part of the way out of it. This is how a first conversation might sound (composed, not a real person):

“I need to tell you something. It’s been hurting for a long time when we’re together.”
“Why didn’t you tell me before?”
“Because I was afraid you’d be disappointed. Or that you’d think I don’t want you.”
“I don’t want it to hurt you. But I do want to be with you.”
“Me too. I just don’t know how any more.”
“Then let’s find out together. A doctor first?”

In this conversation the partner does two things at once: he doesn’t deny the pain, and he doesn’t walk away from closeness. That is exactly what research describes as a supportive response. It doesn’t have to be perfect. It is enough that he stays.

What helps

Painful sex is treated best when the body, the experience and the relationship are addressed together. That often means several professionals:

• A gynaecologist looks for and treats physical causes and refers you on when needed.
• A pelvic floor physiotherapist helps with muscle tension and with learning to relax.
• A specialist in sexual medicine (sexologist) works with sexual dysfunction and pain as a whole.
• Psychotherapy — individual or couples — can help with fear, shame, personal history and the way a couple talks.

In a randomised trial, Sophie Bergeron and colleagues compared cognitive-behavioural couple therapy with a topical medication for women with pain at the entrance to the vagina. Women improved in both groups, and the couple-based approach proved at least an equivalent option — which shows that the relationship is not just a backdrop to the pain but can become part of the treatment.

Where couples therapy has a place

In couples therapy, intimacy is not a separate subject but part of the whole: how partners trust each other, how they talk about what hurts, whether they can show each other their vulnerability. Painful sex often brings a silence into a couple that spreads far beyond the bedroom. One withdraws so as not to be pushy. The other withdraws so as not to disappoint. After a while they no longer touch even in the kitchen.

In sessions we can look at exactly this: how the silence settled between you, what each of you hears in it and what each of you misses. In relational family therapy, in which I am training, we often also look at what each of you brought from your own family about the body, closeness and whether problems may be talked about at all. I described how a couple can talk when their desires don’t match in When your desires don’t match: sex in a long relationship.

What couples therapy does not do: it doesn’t make diagnoses and it doesn’t treat physical causes. That is what the gynaecologist, the physiotherapist and the specialist in sexual medicine are for.

Exercise: a conversation outside the bedroom

This exercise is not about sex, but about talking about it. Do it on a walk or at the kitchen table — never in bed.

1. Choose a calm moment when neither of you is tired or hurt. Before you begin, breathe in slowly a few times and breathe out for longer — the knowledge base describes breathing with a longer out-breath.
2. The one who is in pain says one thing she would like her partner to know. Without apologising. “I’d like you to know that …”
3. The partner sums it up in their own words, without immediately suggesting a solution: “What I’m hearing is …” Only then does he say one thing of his own.
4. Together, write down three forms of closeness that don’t hurt right now and that you both enjoy. Let them be allowed this week with no expectation that they lead to sex.
5. Agree on one concrete step — for example, who will call the gynaecologist and when. If that’s already done, when you will talk about it again.

Where this doesn’t apply

A few limits that matter.

Not all pain is a fear cycle. If the pain persists, changes, or comes with bleeding, discharge or a fever, it needs a doctor urgently — not an exercise or a conversation. Psychological models must never become a reason to overlook a physical cause.

Not every couple is the right path. If the pain comes with pressure that you “have to”, if your partner demands sex despite the pain or forces you, that is not a communication problem but violence. In that case couples therapy is not the right kind of help. In Slovenia you can call the SOS helpline for women and children who are victims of violence on 080 11 55, and if you are in danger, the police on 113 or 112.

It isn’t always the relationship that needs help. Sometimes the pain comes with memories of abuse or a traumatic birth. Then individual therapy, where there is space just for you, may be needed first.

There is no quick fix. Treatment often takes months. Progress is not a straight line — there are good weeks and harder ones. That is not a sign it isn’t working.

What to remember

• Painful sex is common — in a British survey 7.5% of sexually active women experienced it — and it is not something you have to put up with.
• The first port of call is always a gynaecologist: infections, dryness, endometriosis, vulvodynia and other causes can often be treated.
• Pain can be kept going by a pain–fear–tension–avoidance cycle, even after the original cause has been treated.
• Your partner’s response counts: tenderness and looking for other forms of closeness help more than overprotection or reproach.
• What works best is several professionals working together — psychotherapy never replaces an examination.