Painful sex in women: how common it is and what actually causes it

Painful sex is common and, in most cases, treatable: in a national British survey, 7.5% of sexually active women reported pain during sex lasting at least three months in the past year [s1]. The pain has many causes — vaginal dryness, vulval pain conditions, infections, pelvic conditions such as endometriosis, and involuntary muscle tightening — and identifying which one applies is the key to treatment [s2].

Because painful sex, known clinically as dyspareunia, is under-reported and often assumed to be untreatable, the size of the problem and the breadth of its causes are worth setting out plainly.

How common it is

The best population estimate comes from Natsal-3, a probability sample survey drawn from the British Postcode Address File that interviewed 15,162 adults, including 8,869 women, at home between 2010 and 2012; 6,669 women were sexually active and answered the relevant questions [s1]. Painful sex — physical pain from sex lasting three months or more in the past year — was reported by 7.5% of them (95% CI 6.7-8.3), roughly one in 13 [s1]. It was not always trivial: about a quarter of those women had symptoms very often or always, lasting six months or more, and causing distress [s1].

The survey also showed how rarely the pain stands alone. Reporting painful sex was strongly associated with vaginal dryness (age-adjusted odds ratio 7.9), anxiety about sex (6.34) and lacking enjoyment in sex (6.12), and more modestly with not sharing a partner's level of interest in sex (2.56), a history of non-volitional sex (2.17) and depressive symptoms (1.68) [s1]. Those associations are cross-sectional and cannot establish cause and effect, but they map the terrain: dyspareunia usually sits at the intersection of physical, relational and psychological factors, which is why assessment is meant to cover all three [s1].

What causes it

Clinical guidance from the American College of Obstetricians and Gynecologists groups the causes into a manageable list [s2]. The most common is a lack of lubrication, often from falling oestrogen around menopause or while breastfeeding, for which vaginal moisturisers, lubricants or hormone therapy are options [s2]. Infections and inflammation of the vagina, or vaginitis, are another frequent and treatable cause [s2].

Two conditions produce pain focused at the vaginal opening. Vulvodynia is a pain disorder of the vulva; when confined to the vestibule, the area around the vaginal opening, it is termed vestibulodynia [s2]. Vaginismus is a reflex tightening of the muscles at the opening of the vagina that can make penetration painful [s2]. Skin disorders of the vulva can also be responsible, and deeper pain — felt in the lower back, pelvis, uterus or bladder — can signal a gynaecological problem such as ovarian cysts or endometriosis [s2]. Where no physical cause is found, difficulties with sexual response, such as low desire or arousal, can themselves produce pain [s2].

The location of the pain is the most useful clue a person can bring to a clinician: pain on entry points toward dryness, vestibulodynia or vaginismus, while deep pain during intercourse points toward pelvic causes [s2]. Treatment follows the cause — lubricants, moisturisers or vaginal oestrogen for dryness, treatment of the specific infection for vaginitis, and physiotherapy or graded approaches for muscle-related pain — which is why a diagnosis matters more than any single remedy [s2]. ACOG's guidance is that frequent or severe pain during sex warrants assessment rather than endurance, because the treatment depends entirely on the cause [s2].

The Natsal-3 authors made the same point from the population data: because painful sex clustered so tightly with other sexual, relational and mental-health difficulties, they argued that a narrow physical work-up alone will miss what many women need, and recommended a holistic assessment [s1].

Where the deeper evidence lives

Several of these causes the site covers in their own right, with the trial evidence behind each treatment. Endometriosis is a leading cause of deep dyspareunia and a frequent reason for years of diagnostic delay. Menopausal dryness and the genitourinary syndrome it belongs to are the subject of trials comparing vaginal oestrogen against moisturisers. Lichen sclerosus is one of the vulval skin conditions that can make sex painful, and painful periods have a separate evidence base of their own. The common thread is that "painful sex" is a symptom, not a diagnosis, and naming the cause is what makes it treatable.