Painful sex and pelvic pain in women

Also called: Vulvodynia; dyspareunia; pelvic floor hypertonicity

Exercise strongly helps Stretch Massage Strength

Pain with penetration, or persistent burning at the vulva, with a pelvic floor that has been guarding so long it will not let go. The trigger has often resolved years earlier and the muscle pattern and the sensitisation remain.

How common: 8-16% of women experience vulvodynia at some point; dyspareunia is far more common

Open the Pelvic Floor & Core Recovery routine All problems

What it is

Persistent pelvic pain and painful sex in women commonly involve two things: pelvic floor muscle hypertonicity - the muscles held in sustained contraction - and central sensitisation, where the nervous system has become more efficient at producing pain.

The original trigger has frequently resolved. A thrush infection, a difficult birth, an episode of cystitis, a period of stress: something started the guarding, and the guarding and the sensitisation persist long after. That is why examinations often find nothing and why treating the muscles and the pain system, rather than searching for infection, is what works.

What it feels like

Pain on penetration, or a sense of a wall or a burning at the entrance
Burning, rawness or stinging at the vulva, sometimes constant
Pain worse after sex and lasting hours or days
Urinary urgency and frequency, and sometimes constipation
Repeated negative swabs and tests, which is a characteristic and demoralising part of the picture

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Pelvic floor muscle hypertonicity: The pelvic floor muscles are held in sustained contraction. That produces pain in itself, narrows the entrance, and creates trigger points that refer pain across the vulva and into the bladder and rectum.
Central sensitisation: Persistent pain amplifies the nervous system's response, so light touch becomes painful and the pain spreads beyond the original area. This is why the pain often outlasts and exceeds anything findable.
A trigger that has since resolved: Recurrent thrush, cystitis, a difficult birth, a procedure or a period of stress. Something started the protective guarding; the guarding then persists on its own.
Anticipation and protective tightening: Once sex has hurt, the body tightens in anticipation. That tightening produces the pain that confirms the expectation, which is a genuine physical loop rather than a psychological one.
Hormonal change: Falling oestrogen at menopause, on some contraceptives, and while breastfeeding thins the vulval and vaginal tissue and reduces lubrication. Local oestrogen treatment is often transformative and frequently not offered.
Endometriosis and other gynaecological conditions: Deep pain during sex can indicate endometriosis, adenomyosis or other pelvic pathology. Deep pain and superficial pain point in different directions and both may be present.
Skin conditions: Lichen sclerosus and lichen planus cause vulval pain and need specific medical treatment. They are treatable and frequently diagnosed late.
Constipation: Straining and a loaded rectum both increase pelvic floor tension and are very commonly present alongside.
Kegels making it worse: Pelvic floor strengthening is the standard advice for anything pelvic. In an already overactive floor it is the opposite of what is needed, and many women get worse doing exactly what they were told.
Years of not being taken seriously: The average time to diagnosis in vulval pain conditions is measured in years, with multiple negative tests and repeated antifungal treatment. The delay itself increases the sensitisation.

Who tends to get it

Women with a history of recurrent thrush or urinary infections
Anyone after a difficult birth or perineal trauma
Postmenopausal women, and those on some hormonal contraceptives or breastfeeding
Women with endometriosis or other pelvic pain conditions
Anyone with a history of anxiety or of other chronic pain conditions

What makes it worse, and what settles it

Makes it worse

Kegels and pelvic floor squeezing, which is exactly wrong for an overactive floor
Pushing through painful sex, which reinforces the guarding and the sensitisation
Repeated antifungal treatment for negative swabs
Constipation and straining
Being told nothing is wrong, which delays the treatment that works

Settles it

Pelvic floor down-training with a pelvic health physiotherapist - learning to release rather than contract
Diaphragmatic breathing, which relaxes the pelvic floor directly
Manual therapy and trigger point release of the pelvic floor
Local oestrogen where hormonal change is a factor, which can be transformative
Vaginal trainers used graded and slowly, alongside the muscle work rather than instead of it

What actually helps

The short version: Pelvic floor muscle hypertonicity and central sensitization, often with a trigger that has since resolved

Strength work: Core: Pelvic Floor - RELAXATION and down-training; strengthening comes much later if at all

Stretching: Hips: Adductors; Hips: Flexors; Glutes: Piriformis

Massage: Glutes; internal pelvic floor release is specialist work

Also worth doing: Diaphragmatic breathing to down-regulate; dilator therapy where indicated

What the evidence says: Pelvic floor physical therapy is first-line. As with male pelvic pain, KEGELS MAKE THIS WORSE - the app must not offer the same pelvic floor routine to the female incontinence entry and the female pelvic pain entry.

The names above are the Targets qFIT tracks — the Muscle Guide explains what each one does, and Quick Add switches on the Exercises you already have.

The qFIT routine for this

Ready-made routinePelvic Floor & Core Recovery

qFIT already has this one built. It runs massage first, then stretching, then strength — the order that works on a body that is already sore — and every activity in it carries the reason it is there.

The button below opens your Checklist with this routine already selected, so instead of your whole list you land on just its Categories, Targets and Exercises, each with its checkbox, ready to tick as you work through them.

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Have more than one problem? Tick yours under My Problems on My Profile and your Checklist's Routine list gains Recommended for my problems — every routine for the problems you picked, merged into one. Your picks stay private; that filter is the only thing they feed.

Get it checked if…

New pain with bleeding, discharge or a lesion needs gynecological review first

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

Pelvic floor physiotherapy with down-training and manual therapy improves symptoms substantially in a majority of women over three to six months, and it is the treatment with the best evidence for this presentation. It works better combined with addressing hormonal factors, skin conditions and any underlying gynaecological cause. Finding a pelvic health physiotherapist is the most useful step, and the delay most women experience before that happens is the biggest modifiable problem here.

Prevalence basis: Gynecology epidemiology

Others the same routine covers

These share the Pelvic Floor & Core Recovery routine, so the work is the same. If one of them also sounds like you, that is a reason to expect more from it, not less.

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.

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