Sexual Pain in Women: It Is Treatable, and You Do Not Have to Accept It

Key takeaways

• Yes, sexual pain in women is treatable: almost every case has a findable cause and a proven first-line treatment.
• The most common cause after 40 is genitourinary syndrome of menopause, and low-dose vaginal estrogen is first-line for it.
• Pelvic floor tension, vestibular pain, skin conditions and deep pelvic disease each need a different plan, which is why an exam matters.
• Pain that is new, worsening, or comes with bleeding or discharge should be seen promptly.

Painful sex is one of the most common problems women bring to a medical provider, and one of the most consistently under-treated. Roughly 1 in 5 women in the United States will experience meaningful sexual pain during their lifetime. In perimenopause and the years that follow, somewhere between 30 and 60 percent of women report some degree of pain with intercourse. The number is high enough that "common" is the right clinical word. But common is not the same as normal, and it is certainly not something you have to accept.

What Are the Most Common Causes?

Sexual pain (doctors call it dyspareunia) is a symptom, not a diagnosis. The first job is to find out where the pain is and what is producing it. The main causes we see:

• Genitourinary syndrome of menopause (GSM). The modern term for vaginal atrophy. As estrogen (the main female sex hormone) drops, vaginal and vulvar tissues become thinner, less elastic, and less lubricated. It is the most common single cause of new sexual pain in women over 40, and the most clearly treatable.
• Vestibulodynia. Pain localized to the vulvar vestibule, the ring of tissue at the vaginal opening, often with a burning quality. It can be present from the first attempt at intercourse (primary) or develop later (secondary).
• Pelvic floor dysfunction. Chronic tension, trigger points, or guarding in the pelvic floor muscles that make penetration painful no matter how lubricated the tissue is. This often develops after pain from another cause, because the body learns to brace.
• Skin conditions of the vulva. Lichen sclerosus, lichen planus, and contact irritation from soaps, wipes or pads can all cause burning, tearing and pain. These need to be seen to be diagnosed.
• Infection and inflammation. Yeast, bacterial vaginosis, urinary tract infection and sexually transmitted infections can all make sex painful. They are simple to test for and simple to treat.
• Changes after childbirth. Scar tissue from a tear or episiotomy, and low estrogen while breastfeeding, both cause pain at the opening in the months after a birth.
• Endometriosis and other deep pelvic conditions. Endometriosis, fibroids, ovarian cysts, and adhesions can cause deep pain with intercourse, often worse at certain times in the cycle.
• Medications. Some antihistamines, antidepressants, and hormonal contraceptives reduce lubrication or lower the hormones that keep tissue healthy.
• Psychological and relational contributors. Performance anxiety, depression, a history of sexual trauma, and relationship distress can amplify pain that started for physical reasons. For desire concerns that persist alongside or after treating the pain, what to look at when hormone therapy is not the whole answer for low libido covers these in more detail.

Most women have more than one of these at the same time. Thin tissue leads to pain, pain leads to muscle guarding, guarding leads to more pain. That is why treatment often has two or three parts.

Where Does It Hurt? Why the Location Matters

Two questions sort most cases quickly. Is the pain at the opening or deep inside? And did it start with a clear event, or creep in over months?

Pain at the opening, on entry, with burning or tearing, points toward GSM, vestibulodynia, a skin condition, scar tissue, or pelvic floor tension. Deep pain, felt with full penetration or in certain positions, points toward endometriosis, fibroids, ovarian disease, a bowel or bladder condition, or a very tight pelvic floor. Pain that tracks with your cycle raises the odds of endometriosis. A clear start after a birth, a surgery, a new medication, or menopause narrows it further.

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When Should You Seek Care?

Any sexual pain that bothers you is reason enough. You do not need to wait for it to become severe. See a clinician promptly if:

• The pain is new or getting worse
• You have bleeding after sex, or bleeding after menopause
• There is unusual discharge, itching, an odor, or a sore
• You have pelvic pain outside of sex, painful periods, or pain with urination or bowel movements
• The pain started after childbirth and has not settled by your postpartum check
• You find yourself avoiding intimacy because you expect it to hurt

That last point matters. Avoidance is a normal response to pain, and it also feeds desire loss and relationship strain. Getting the pain treated is often what unlocks the rest.

What Are the Treatment Categories?

The right treatment depends on the cause, and most plans combine two or three of the following.

Local hormone therapy

For GSM, the 2025 AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause recommends vaginal estrogen for vulvovaginal discomfort, dryness, and painful intercourse. It has a strong evidence base and an excellent safety profile in well-chosen patients, with very little absorption into the body. Vaginal DHEA (prasterone) and oral ospemifene are other guideline-supported options. Significant improvement is typical within 8 to 12 weeks.

Non-hormonal moisturizers and lubricants

Regular vaginal moisturizers (used several times a week, not just during sex) and a good lubricant during sex are first-line for mild symptoms and a useful add-on for everyone else. They do not fix thin tissue, but they reduce friction and pain while other treatment takes effect.

Pelvic floor physical therapy

The guideline recommends pelvic floor physical therapy for patients who also have pelvic floor dysfunction. A specialist therapist teaches the muscles to release rather than brace, and treats trigger points directly. It is the most effective treatment for pain driven by muscle tension, and no injection or cream replaces it.

Treating the underlying condition

Infections are treated with the right medication. Skin conditions such as lichen sclerosus need prescription steroid treatment and follow-up. Endometriosis, fibroids and ovarian conditions need their own workup, often with imaging and a gynecology referral. Medications that cause dryness are reviewed and, where possible, adjusted.

Pain-focused treatments for vestibulodynia

Vestibular pain is often treated with topical numbing or nerve-calming preparations, pelvic floor therapy, and in some cases oral medications that quiet nerve signaling. Care is stepwise, starting with the gentlest options.

Counseling and sex therapy

When pain has been present for a while, anxiety about pain becomes part of the problem. Sex therapy, cognitive behavior therapy and mindfulness-based approaches are recognized parts of treatment, not a sign that the pain is "in your head." They work best alongside physical treatment, not instead of it.

Regenerative adjuncts: PRP and the O-Shot

The O-Shot places PRP (platelet-rich plasma, a concentrate of your own blood platelets) into the front vaginal wall and nearby tissue to support tissue quality and blood supply. A systematic review of PRP for female sexual dysfunction found gains in sexual function and vaginal health scores, while rating the evidence as low quality because the studies were small. We offer it as an adjunct when first-line treatment has helped but not fully resolved the problem, and only after the tissue and hormone picture has been addressed. It is not a first-line treatment for sexual pain. Our guide to who is and is not a good O-Shot candidate sets out where it fits. CO2 Lift-V carboxytherapy is another adjunct some patients ask about; it is used the same way, after first-line care.

What Does a Visit Involve?

A sexual pain visit at Arbour Longevity is a clinical assessment, not a sales conversation. It includes:

• A full history. When the pain started, where it is, what it feels like, what makes it better or worse, births, surgeries, medications, and how it is affecting you and your relationship.
• An exam. A careful, gentle exam of the vulva, vestibule, vaginal tissue and pelvic floor muscles. This is what tells atrophy from a skin condition from muscle tension, and it cannot be done by questionnaire. You set the pace, and you can stop at any point.
• Labs where they add information. Hormone levels (estradiol, testosterone, thyroid) when the picture suggests it, and swabs or urine tests if infection is possible.
• A written plan. Usually two or three parts, with a clear review date, so you know what to expect and when.

Gandhi Bhattarai, FNP-BC, PMHNP-BC, is triple board certified across family practice, psychiatric mental health, and anti-aging and functional medicine. That means the hormonal, physical and emotional parts of sexual pain are addressed in one place rather than across three referrals.

Frequently Asked Questions

Is sexual pain after menopause something I have to live with?

No. Postmenopausal sexual pain almost always has identifiable causes (most often GSM) and well-evidenced treatments.

How long does it take to see improvement?

GSM treated with vaginal estrogen or DHEA: significant improvement within 8 to 12 weeks. Pelvic floor PT: several sessions for first effect, full benefit over a few months. O-Shot and CO2 Lift-V, when used as adjuncts: visible improvement at 6 to 12 weeks.

Is vaginal estrogen safe?

Local low-dose vaginal estrogen has very low absorption into the body and an excellent safety profile. Many women who cannot take body-wide hormone therapy can safely use local vaginal estrogen. The 2025 guideline recommends it as first-line therapy.

Will I need to see a gynecologist or a specialist?

Sometimes. If the exam suggests endometriosis, a skin condition that needs a biopsy, or a structural problem, we refer you and coordinate care. Pelvic floor physical therapy is delivered by a specialist therapist, and we arrange that referral.

How private is the first visit?

Sexual wellness visits at Arbour are conducted with the same privacy and clinical respect as any medical visit. Notes are confidential within the chart. We do not share details outside the clinical team.

The Next Step

If sex hurts, that is a medical problem with medical answers, not something to endure. Book your $35 first visit or call (734) 436-3357; the $35 is applied toward your plan. Arbour Longevity, 2217 Packard St #15, Ann Arbor, MI 48104, open Thursday through Monday, 10am to 7pm.

References

1. AUA/SUFU/AUGS. Genitourinary Syndrome of Menopause Guideline. 2025.
2. Sorrentino L, et al. Evaluation and Treatment of Sexual Pain Disorders. 2025.
3. Aslan T, et al. Efficacy and Safety of PRP Injections for Female Sexual Dysfunction. 2023.
4. PRP injection of the anterior vaginal wall improves female sexual function: a randomized controlled trial. Obstet Gynecol, 2025.

This article is educational and does not replace individualized medical advice.