Pain During or After Sex (Dyspareunia): Common Causes, Including Pelvic Veins

Dyspareunia is the medical term for pain during or after sex. It is more common than many people realise, and it can affect anyone, at any age. Many women live with it quietly for years because they feel embarrassed or assume nothing can be done. In fact, most causes can be found and treated. This guide explains the main types of painful sex, the many possible causes, and the deep, lingering ache that can come from congested pelvic veins.

What is dyspareunia?

Dyspareunia means pain that happens before, during or after sexual intercourse. It can be a sharp, burning or stinging pain at the entrance of the vagina, or a deeper ache inside the pelvis. Some women feel it every time, others only in certain positions or at certain times of the month.

Pain during sex is not “just in your head”, and it is not your fault. It deserves the same attention as any other kind of pain.

Superficial pain and deep pain

Doctors often divide painful intercourse into two broad types, because they point towards different causes:

• Superficial (entry) pain is felt at the opening of the vagina or the vulva, usually as penetration starts. It often eases when penetration stops.
• Deep pain is felt further inside, low in the tummy or pelvis, usually with deeper thrusting or in certain positions. It can last for minutes, hours or even into the next day.

Some women have both, and one type can lead to the other. For example, deep pain can make the pelvic floor muscles tense up, which then causes entry pain too.

Common causes of pain at the entrance

• Vaginal dryness. Not enough lubrication causes friction and soreness. It can happen with low arousal, breastfeeding, some contraceptives and medicines, and after menopause, when lower oestrogen makes the tissues thinner and drier.
• Infections. Thrush, bacterial vaginosis, sexually transmitted infections and urinary infections can all make sex sore.
• Vaginismus. The muscles around the vagina tighten involuntarily when penetration is attempted. It can make sex painful or impossible, and it is treatable.
• Skin conditions. Eczema, lichen sclerosus and other vulval skin problems can cause soreness, itching and splitting.
• Vulvodynia. Ongoing pain or burning in the vulva without an obvious visible cause.
• After childbirth or surgery. A healing tear, episiotomy or scar can be tender for some time.

Common causes of deep pain

• Endometriosis and adenomyosis. Tissue similar to the womb lining grows outside the womb or into its muscle wall. Deep pain during sex is a classic symptom. See pelvic congestion and endometriosis compared.
• Pelvic infection. Pelvic inflammatory disease can cause deep pain, often with discharge or fever.
• Ovarian cysts and fibroids. These can be pressed on or moved during sex.
• Bowel and bladder conditions. Irritable bowel syndrome, constipation and bladder pain syndrome can all cause deep discomfort.
• Pelvic floor muscle tension. Tight, overworked pelvic muscles can ache deeply.
• Pelvic congestion syndrome. Widened, refluxing pelvic veins, explained in the next section.

Many of these overlap, and more than one can be present. Our guide to chronic pelvic pain explains how doctors approach long-term pelvic pain.

The deep ache of pelvic congestion syndrome

In pelvic congestion syndrome, the veins around the womb and ovaries are widened and blood flows backwards through them instead of draining away. The pelvis is, in effect, carrying too much blood.

Sexual arousal and intercourse increase blood flow to the pelvis. When the veins are already congested, this can cause:

• Deep pain during intercourse, often worse in certain positions
• A throbbing, dragging or heavy ache afterwards that can last for hours, sometimes into the next day
• An ache that eases when lying down, especially with the hips raised

This lingering ache after sex is one of the more typical features of pelvic congestion. It often comes with other clues: a dull pelvic ache that builds through the day or after standing, pain that is worse around periods, and sometimes visible varicose veins on the vulva or upper thighs. Read the full list of pelvic congestion syndrome symptoms, or see a Singapore vascular surgeon’s summary of PCS symptoms.

Having these symptoms does not prove the veins are the cause. Widened pelvic veins are also found in women without pain, so other causes need to be considered too. If tests do point to the veins, treatment options include hormonal medicines and embolisation. See how pelvic congestion syndrome is treated.

Talking to a doctor about painful sex

It can feel awkward to bring up, but doctors are used to these conversations. It helps to note:

• Where it hurts: at the entrance, deep inside, or both
• When it hurts: at the start, during, or afterwards, and for how long
• Patterns: certain positions, times in your cycle, or after standing all day
• Other symptoms: dryness, discharge, bleeding, period pain, bowel or bladder changes
• Whether you have recently had a baby, are breastfeeding, or are near menopause

The doctor may examine you gently, take swabs to check for infection, or arrange an ultrasound. You can ask for a female doctor or a chaperone, and you can ask to stop the examination at any time. Depending on the cause, you may be referred to a gynaecologist, a pelvic health physiotherapist, a sexual health service or a vein specialist.

Things that may help in the meantime

• Use a water-based or silicone-based lubricant.
• Allow more time for arousal before penetration.
• Try positions that give you more control over depth.
• Empty your bladder before sex.
• If deep aching follows sex, lie down with your hips raised for a while.
• Talk openly with your partner, and explore other kinds of intimacy while you get help.

These steps can ease discomfort, but they do not replace finding the cause.

Can dyspareunia be treated?

Yes, in most cases. Treatment depends on the cause. Infections can be treated with medicines. Dryness after menopause often responds to moisturisers or local treatments prescribed by a doctor. Vaginismus and pelvic floor tension usually improve with a pelvic health physiotherapist, sometimes alongside psychosexual therapy. Endometriosis and vein-related pain have their own medical and procedural options. Painful sex can also affect confidence, desire and relationships, so support from a counsellor or sex therapist can be a helpful part of care.

When to see a doctor

See a doctor if sex is painful more than occasionally, if pain lasts for hours afterwards, or if it is affecting your relationship or wellbeing. Also see a doctor if you have bleeding after sex, unusual discharge, pain on passing urine, or a pelvic ache that is worse after standing. Our pelvic symptom check can help you prepare for the appointment.

Get urgent medical help for sudden severe pelvic or abdominal pain, heavy bleeding, fever with pelvic pain, fainting, or pain or bleeding when you might be pregnant. In Singapore, call 995 in an emergency.

This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.