Sexual Pain Not All The Same

“It hurts during sex.” Many people come after hesitating for a long time before bringing up this single sentence in the clinic. Yet within the same word ‘painful sex’ are mixed completely different causes. A stinging pain at the entrance and a heavy pain deep inside differ in where they begin and in how they are resolved. So “it’s painful sex” alone cannot determine treatment; you must first distinguish what type it is. Rather than addressing the treatment of post-menopausal painful sex, this article is organized with a focus on ‘differentiating the type’ of pain.

Painful sex is not a single disease but a symptom that appears from several overlapping causes. The American College of Obstetricians and Gynecologists (ACOG, 2019) explains that gynecological, urological, musculoskeletal, neurological, hormonal, and psychosocial factors can act together in painful sex, and that these factors often coexist. That is, rather than the cause falling cleanly into one, two or three overlapping is more common.

Clinically, the first criterion for division is ‘where’ the pain begins. The method of distinguishing pain into superficial (near the entrance/vaginal opening) and deep (the deep side of the vagina/lower abdomen) is known as the most basic framework for differentiating painful sex (StatPearls, 2024). In the clinic, when the patient points with her hand to explain where the pain begins, nearly half the clues are already gathered.

For reference, the psychiatric diagnostic criteria DSM-5-TR (2022) group painful sex and vaginismus together and classify them as ‘genito-pelvic pain/penetration disorder (GPPPD).’ The classification system reflects that pain and muscle tension influence each other, and in actual practice we approach it more finely by cause.

Entry pain is superficial pain that appears as a ‘stinging’ or ‘tearing’ sensation the moment penetration begins. Common causes include inflammation of the vaginal entrance (candida, bacterial vaginosis, etc.), Bartholin gland inflammation, vulvar dermatitis after overusing soaps/cleansers, and a state where the moisture barrier has collapsed from dryness or post-menstrual irritation.

• A stinging or pricking pain the moment of penetration
• A repeated tearing sensation like a paper cut
• The same spot hurting with each condom use or timing of penetration

In premenopausal women, a common cause of entry pain is pain localized to the vulvar vestibule, so-called provoked vestibulodynia (StatPearls, 2024). It is differentiated by checking whether pain is reproduced at a specific point when the vestibule is lightly pressed with a cotton swab. Treatment is set in the direction of treating infection according to the cause, stopping irritating cleansers, combining vulvar moisturizing and pH management, and adding low-dose local treatment if needed. If frequent vaginitis accompanies it, it is good to also check the causes of repeatedly recurring vaginitis.

If a ‘sore, burning’ pain spreads from the middle onward, suspect dryness and atrophy of the mucosa. This type shows a pattern of pain worsening as time passes after penetration and when the position changes, and becoming more sensitive with condom use. When estrogen decreases around menopause, the mucosa thins and loses elasticity, sharply increasing the sense of friction, and these changes are collectively called genitourinary syndrome of menopause (GSM).

The term GSM is the name the International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society agreed upon to replace the former ‘vaginal atrophy’ (2014), and it looks together at changes encompassing not just the vagina but the vulva and urethra. A recent joint urological/gynecological guideline (AUA·SUFU·AUGS, 2025) also treats vaginal dryness and painful sex as core symptoms of GSM. Treatment combines local vaginal hormones, non-hormonal moisturizers, and energy-based treatments that aid collagen regeneration, according to the condition. The specific treatment scenarios for post-menopausal painful sex are covered separately in detail in how post-menopausal painful sex can improve and the point that vaginal dryness is not simply a lack of moisture, so please refer to them.

If you are confused about whether your symptom is entry pain or dryness, it is faster to directly check the mucosal condition through an examination rather than judging on your own.

If it hurts ‘heavily’ when going in deep, this is deep pain for which you must examine the inner pelvic structures. Unlike superficial pain, the entrance is fine but pain begins inside, and in many cases it worsens especially in certain positions or around menstruation. Commonly cited causes include endometriosis, pelvic adhesions, ovarian cysts, and chronic pelvic pain.

In the clinic, patients often describe deep pain as “a feeling of something bumping inside.” Because this type does not improve with mucosal treatment alone, the process of first confirming a structural cause with imaging exams such as pelvic ultrasound is important. Depending on the cause, it leads to hormone treatment or pain control, and to additional tests if needed. If you have severe menstrual cramps, a history of pelvic inflammatory disease, or have been diagnosed with endometriosis, it is good to get examined while keeping the possibility of this type open.

If, upon penetration, you feel ‘a tightly shut door’ and strong resistance, suspect overtension of the pelvic-floor muscles. This type shows a pattern in which even tampon insertion is uncomfortable, and the muscles do not relax to the point that it is hard to insert an instrument in a gynecological exam. Stress or anxiety, decreased muscle function after childbirth, and a ‘tension pattern’ formed by repeating painful sex over a long period tend to be the background.

What is interesting is that pain and muscle tension amplify each other. Pelvic-floor muscles that have experienced pain reflexively contract more tightly, and this tension again worsens pain, creating a vicious cycle, as has been reported (ISSWSH-related research, 2018). So for this type, training to ‘release force’ becomes the center of treatment.

• Pelvic-floor relaxation treatment and biofeedback
• Myofascial trigger-point release
• Muscle stabilization using breathing and gentle entry training

When muscle tension is strongly suspected, pelvic-floor muscle evaluation and training first measures the degree of tension. Also, because the cause and treatment differ from ‘vaginismus,’ in which muscle tension is prominent, if you are curious about the difference between the two, I recommend reading the difference between painful sex and vaginismus.

If pain persists even when no major abnormality is found on examination, you must look at psychological factors and ‘anticipatory pain.’ This type is characterized by the body stiffening even before penetration, and pain continuing even though there is actually no inflammation or hormonal problem. Anxiety about sex, past difficult experiences, and a pattern of tensing in advance, anticipating that ‘it will hurt again’ as long-standing pain accumulates, maintain the pain.

ACOG (2019) also states that psychosocial factors such as anxiety, depression, and past trauma can contribute to painful sex. However, the word ‘psychological’ does not mean “it’s all in your mind.” Because it is closer to a state in which the nervous system has learned pain as the pain repeats, we approach it by gradually combining progressive exposure, tension-relieving breathing, and, if needed, professional counseling with the treatments described earlier. If you have come to avoid sex itself out of fear of pain, the longer the avoidance lasts, the more anticipatory pain hardens, so it is good to consult early. The lifestyle routine checklist for reducing painful sex also helps reduce tension in daily life.

Because painful sex does not have a single cause, accurate diagnosis by type comes first, and treatment must be designed on top of that to improve. Even when it feels like the same pain, the treatment direction differs completely depending on whether it is a mucosal problem at the entrance, atrophy due to hormones, a problem of the inner pelvic structure, muscle tension, or psychological anticipatory pain. And in reality, these types often overlap in two or more, so approaching by looking at just one does not heal well.

That is why at Wooahan Women’s Clinic we first confirm the location and timing of pain through detailed history-taking, look at the vaginal mucosa and the degree of pH/atrophy, evaluate pelvic-floor muscle tension, and after confirming the pelvic structure by ultrasound, propose the most appropriate treatment. The more sensitive and hard-to-broach the topic, the more important a space where you can speak calmly with a female specialist becomes. If you are confused about the type of pain, please check carefully through a consultation for pain during intimacy.

Get a comfortable consultation about what type your pain is

Written by: Lee Dong-hee, Director · OB-GYN specialist · View doctor profile

First published December 3, 2025 · Last reviewed May 30, 2026

References: American College of Obstetricians and Gynecologists (2019), DSM-5-TR / American Psychiatric Association (2022), ISSWSH·NAMS GSM Consensus (2014), AUA·SUFU·AUGS GSM Guideline (2025), StatPearls Dyspareunia (2024)

This article is intended to provide general health information and does not replace individual diagnosis or treatment. If you have symptoms, please consult through an examination.