Why does sex hurt even when nothing is ‘wrong’?

By Dr. Sarah Shimanek, PT, DPT, WCS, PRPC

There are several reasons why someone might have pain with sex. For the purposes of this post, we’re talking about penetrative intercourse. If other medical causes have been ruled out, it usually comes down to two systems: the musculoskeletal system and the nervous system.

So what do I mean by that?

First, the muscles. If you’ve had pain with sex before, your pelvic floor muscles may have started to tense or even spasm—and tense muscles hurt. The reasons muscles become tense can vary, but one of the biggest contributors is the pain itself. When we experience pain, our body naturally tightens muscles to protect us.

On top of that, additional stress on the body can create or reinforce this tension pattern. That might include a recent infection, surgery, a stressful life event, or really any physical, emotional, or psychological stressor. Over time, the body can get stuck in this pattern of guarding.

Next is the nervous system.

Your brain and nervous system are responsible for all pain we experience. For example, if you cut your finger, sensors send a danger message to your brain. Your brain then decides how to respond based on how threatening it perceives the situation to be—taking into account past experiences and any other stressors present.

When pain happens repeatedly in the same area or during the same activity, your body starts to label that area as “high risk.” It essentially turns up the volume on pain and lowers the threshold for what triggers it.

So when it comes to painful intercourse, if you’ve had sex multiple times and it’s been painful, your body may begin to associate sex with threat. That means it can create a pain response even when there isn’t an actual injury or danger present.

I know this can sound a little like, “you have pain because you’ve had pain,” and to some extent, that’s true. But of course, something had to trigger the pain in the first place—and that part is different for everyone.

Common starting points can include hormonal changes that lead to dryness, infections, stress, muscle tension patterns, or scar tissue from surgery or childbirth. And sometimes, it’s not completely clear where it began.

The good news is this: when we address both the muscle tension and the nervous system sensitivity, pain with sex can improve—and often resolve—as long as the original cause is no longer present.

A pelvic floor physical therapist can evaluate what’s contributing to your pain and create a plan to help your body heal, so penetrative intercourse can become pain-free—and even pleasurable—again.

Is pain with sex normal? While it’s very common and occurs in up to 60% of individuals with vaginas at some point in their life, it is not normal and is fixable

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