Sex is not supposed to hurt. If it does, and especially if it has started to, that is your body telling you something, not a character flaw, not something to grit your teeth through, and not something you have to accept as the price of getting older. Painful sex is remarkably common, it almost always has an identifiable cause, and the great majority of those causes are treatable. The hardest part, for most women, is simply saying it out loud.
The medical word is dyspareunia: recurrent or persistent pain before, during or after sex. It is far from rare. Surveys suggest around three in four women experience painful sex at some point in their lives, and at any given time it affects an estimated 10 to 20 per cent of women. Yet it is chronically under-reported and under-treated, largely because of embarrassment on both sides of the consulting room. So let us talk about it plainly.
Before anything else, one distinction does more than any other to point at the cause: where the pain is.
You do not need to diagnose yourself. But noticing whether the pain is at the door or deep in the house is the single most useful thing you can bring to a doctor.
After perimenopause and menopause, the most frequent reason sex becomes painful is the change in the vaginal and vulval tissue as oestrogen falls. Doctors call the wider picture the genitourinary syndrome of menopause (GSM). Oestrogen keeps these tissues thick, elastic, well lubricated and well supplied with blood. As it declines, the tissue becomes thinner, drier and less stretchy, the vagina can shorten and narrow, and the natural lubrication that used to arrive with arousal no longer does. Friction that was once nothing now causes soreness, stinging, tiny surface splits, and pain that can linger for hours or days afterwards.
This is extremely common: vaginal dryness affects around three-quarters of women after menopause, and painful sex affects a large share of those. It is also the cause with the clearest, most effective treatments, which is the good news buried inside a symptom most women suffer in silence.
Two things worth knowing. First, unlike hot flushes, GSM does not tend to fade on its own, because it stems from a lasting low-oestrogen state, so it usually needs treating rather than waiting out. Second, it is not only a menopause phenomenon: the same low-oestrogen tissue changes happen while breastfeeding, and after some cancer treatments, which is why younger women are sometimes caught out by it too.
This is the part that generic articles skip, and skipping it leaves women misdiagnosed. Painful sex has several distinct causes, and more than one can be present at once. If dryness treatments alone are not fixing it, one of these may be why:
Pain and desire are wired together. When sex has hurt, the body learns to brace for it, and anticipation of pain suppresses arousal, which reduces natural lubrication, which makes the next time hurt more. It is a genuinely physical loop, not a psychological weakness, and it is one reason painful sex and low libido so often travel together. Stress, exhaustion, low mood and relationship strain all feed into it as well. None of this means the pain is "in your head." It means the fix often has to address more than one thread at once.
Because the causes differ, so do the solutions, but there is a sensible order to work through, from simplest to most medical.
Occasional, minor soreness is usually nothing to worry about. But it is worth booking an appointment if pain is frequent or intense, if it is getting worse, if it is making you avoid intimacy, or if it comes with any of these: bleeding after sex, bleeding after menopause, unusual discharge, or pelvic pain outside of sex. And any bleeding after menopause always needs checking, regardless of the cause.
Raising it is the hard part, so borrow a script. A plain opening works best: "Sex has become painful and it is affecting me, and I would like to work out why." From there it is reasonable to say whether the pain is at entry or deep, how long it has been happening, and to ask whether local oestrogen, a referral to pelvic-floor physiotherapy, or an examination would help. Clinicians deal with this constantly. You will not be the most awkward conversation of their day.
Painful sex is common, it is not your fault, and it is not something you are stuck with. Almost every cause, from the dryness of menopause to muscle tension to endometriosis, has a real treatment behind it. The barrier is rarely the medicine. It is the silence. Breaking that, with a partner, a GP, or a pelvic-health physiotherapist, is usually the first step towards getting your comfort, and your intimate life, back.
Why does sex suddenly hurt after menopause?
Most often because falling oestrogen thins and dries the vaginal tissue (genitourinary syndrome of menopause), so friction that was once painless now causes soreness. It is very common and very treatable, usually with moisturisers, lubricants or local vaginal oestrogen.
Is painful sex always caused by menopause?
No. Dryness is the most common cause in midlife, but pelvic-floor tension, vaginismus, vulvodynia, endometriosis, fibroids, infections and skin conditions can all cause it, at any age. Where the pain is, at entry or deep inside, is a useful clue to which.
Can painful sex be cured?
In most cases the cause can be identified and treated. Dryness responds to moisturisers and local oestrogen, muscle tension to pelvic-floor physiotherapy, and specific conditions to their own treatments. Getting a diagnosis is the key step.
Should I just push through the pain?
No. Repeated painful sex can train the pelvic-floor muscles to guard and tighten, which makes the pain worse over time. It is better to pause, use lubrication and arousal time, and get the cause looked at.
Keep reading: Vaginal dryness and intimacy · Low libido in women: the full picture · Where did my libido go? · Endometriosis and period pain · The truth about HRT · Take the free Hormone Quiz