I hear some version of this almost every week: "I just assumed it was normal." A patient tells me they've had pain with sex for two years, five years, sometimes their entire adult life — and never mentioned it to a doctor because they figured it was just how their body was.
It's not. And I want to say that as clearly as I can: pain during sex is not something you have to accept.
Why it happens
Painful intercourse — clinically called dyspareunia — is almost always rooted in something physical that can be addressed. The most common culprit I see is pelvic floor muscle tension. When the muscles of the pelvic floor are hypertonic (too tight or unable to relax), penetration causes them to brace rather than yield. That guarding creates friction, pressure, and pain.
But there are other contributors too: hormonal changes (especially during perimenopause, postpartum, or while breastfeeding), scar tissue from birth injuries or surgeries, skin conditions like lichen sclerosus, nerve sensitivity, or a history of trauma that has been stored in the body as chronic tension.
Often it's a combination of factors — which is exactly why cookie-cutter advice like "just use more lubricant" or "try to relax" misses the point entirely.
What assessment actually looks like
When someone comes to me with pain during sex, the first thing we do is talk. I ask about where the pain is (at the opening, deeper inside, one side more than the other), when it started, what makes it better or worse, and what their relationship with their body has been like over time. All of that context matters.
From there, I do an external assessment of the pelvic floor — looking at muscle tone, sensitivity, and coordination — and, with consent, an internal assessment when that information would be helpful. This isn't uncomfortable when done gently, and it gives me a much clearer picture of what's actually happening in the tissues.
The goal is never to push through anything. It's to understand, and then treat.
What treatment can look like
For most people with pain during sex, treatment involves a combination of manual therapy to release tight tissue, breathing and nervous system work to help the body feel safe enough to let go, and gradual desensitization exercises to rebuild tolerance and confidence over time.
Progress is real and it's achievable — but it takes patience. This isn't a problem that developed overnight, and it won't resolve in a single session. What I can tell you is that most of my patients see meaningful improvement, and many resolve their pain entirely.
If this is you
You don't have to keep white-knuckling through something painful or avoiding intimacy altogether. You don't have to feel broken. And you don't have to figure this out alone.
If pain during sex is something you've been quietly carrying, please reach out. This is exactly the kind of thing pelvic floor PT is designed to help with — and you deserve to feel good in your body.