Short answer

Painful sex (dyspareunia) localizes the problem by location: entry pain points to surface causes (herpes outbreaks, irritation, dryness, dermatitis, vulvodynia), deep pain to internal ones (PID, endometriosis, fibroids, ovarian pathology, prostatitis in men).

Location plus timing plus accompaniments (discharge, bleeding, sores, exposure history) directs testing. And most causes are treatable, so persistent pain deserves evaluation rather than endurance or avoidance alone.

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  • Herpes: entry burning with visible outbreaks or prodromes (abstain through episodes. Continuing transmits and worsens).
  • Chlamydia/gonorrhea cervicitis: bleeding with intercourse plus pelvic ache and discharge.
  • PID: deep thrust pain with discharge and fever. Continuing through PID pain risks tubal damage.
  • Trichomoniasis: irritation with frothy discharge and odor.
  • Male urethritis and prostatitis: ejaculatory or post-sex burning with discharge or pelvic ache.

New painful sex with discharge, bleeding, sores, or exposure history warrants STI testing promptly; see Pelvic Pain and Possible STIs for the pelvic-pain companion.

Non-STI causes. The commoner majority

  • Inadequate lubrication (arousal, foreplay, and lubricant deficits. The commonest reversible cause).
  • Postpartum and menopausal dryness (estrogen states thinning mucosa. Lubricants plus hormonal options).
  • Endometriosis (deep pain, cyclical pattern, often with severe menstrual pain).
  • Fibroids and ovarian cysts (bulk and pressure pain, positional).
  • Interstitial cystitis and IBS (bladder and bowel pain referred to intercourse).
  • Pelvic-floor hypertonus (chronic muscle tension. Responsive to physiotherapy).
  • Vulvodynia (chronic vulvar pain syndromes needing specialized care).
  • Psychological sequelae of prior pain (anticipatory tension perpetuating cycles. Counseling plus physiotherapy breaks them).

Evaluation path. Mapping before treating

  • Pain mapping (entry versus deep, timing within acts, cycle relation, positional triggers).
  • Speculum and bimanual examination (lesions, discharge, cervical motion and adnexal tenderness).
  • NAAT and infection labs by risk and pattern.
  • Transvaginal or pelvic ultrasound for structural causes (fibroids, cysts, endometriomas).
  • Pelvic-floor assessment for chronic cases (tone, trigger points, coordination).

Complete mapping precedes treatment. Dyspareunia workups that skip mapping mistreat regularly.

Care directions. Matched therapy resolves most

  • Infections: organism-directed therapy with partner treatment and abstinence windows.
  • Dryness: lubricants generously plus moisturizers and hormonal options (vaginal estrogen where indicated).
  • Endometriosis and fibroids: gynecologic management (hormonal suppression, surgical options by severity and fertility plans).
  • Pelvic-floor dysfunction: specialized physiotherapy (the highest-yield intervention for chronic cases. Underused, highly effective).
  • Pain-psychology loops: counseling integrated with physical therapy.

Most dyspareunia resolves with matched care. The evaluation is the treatment’s prerequisite.

When to seek care

Promptly for new painful sex with discharge, bleeding, sores, or exposure; urgently for severe pain with fever; electively but firmly for persistent pain of any pattern.