Painful Intimacy: Why Healthy Women Still Have Pain During Sex

By Subrat Bahinipati, PT · Physical therapist and co-founder, Synergy Therapeutic Group, Carbondale, Illinois · 30+ years treating chronic and complex pain

Clinically reviewed by Subrat Bahinipati, PT on November 12, 2026 · Last updated November 12, 2026

Pain during intercourse, what I call painful intimacy, is pain during or after sex, and it is one of the most common problems I treat. Once your doctor has ruled out infection, dryness, and hormonal changes, in my experience the cause is often a tight pelvic floor on top of a pelvis that is not sitting right. And the woman who has it is often the last one you would expect.

She is fit. She eats well. Maybe she runs the trails around Carbondale. So when intimacy hurts, she asks herself the question everybody else would ask her: you look good, you exercise, you eat right, so what could be wrong?

So she says nothing. Not to her friends, often not to her partner, many times not even to her doctor. I have been a physical therapist for over 30 years, and I want to tell you what I have learned. Because for a long time, I did not know it either.

Nobody taught me this in PT school

When I went to physical therapy school in 1988, nobody told us that painful intimacy was even a thing, let alone that a physical therapist could help. We had a few hours filed under OB-GYN conditions, and that was it.

My early career was all about the spine. A lot of manipulation, a lot of manual therapy. And like most of my generation, I was taught to more or less disregard the SI joint, where the spine meets the pelvis. Then the research on the SI joint started to come out. I began treating it, with muscle energy techniques and other gentle methods, and my patients did well. That changed how I looked at the pelvis.

Many years back, I also started getting referrals from OB-GYN offices with vague diagnoses. Pelvic pain. Pain, unspecified. The referral never said why she was being sent to me. So I started asking questions, and slowly I started putting two and two together.

The path most women take, and where it stops

Here is the usual path. A woman has pain during intercourse. The only place she thinks to go is her OB-GYN, and that is a good first step. Her doctor checks for infection. If she is around menopause, her doctor checks for dryness. Those things need to be ruled out first.

But suppose everything comes back normal, and she is still hurting. At some point she hears, “Therapy might help you.” Nobody tells her why, and that is usually where the trail goes cold. But a normal test does not mean the pain is imaginary. It only means the test did not find the cause.

Foot pain, you see a podiatrist. Painful intercourse, you see your OB-GYN. The medical word, dyspareunia (dis-puh-ROO-nee-uh), simply means pain during or after intercourse. It is not the same as vaginismus, where the muscles at the vaginal opening tighten on their own and make penetration difficult or impossible, though the two can overlap. But the word hides a question almost nobody asks: what is the pelvis itself doing?

Why women do not bring it up

Very few women walk in and tell me first that intimacy hurts. They come in for the obvious complaint. Low back pain. A hip that aches. “I can’t get up after I have been sitting.” And the healthy woman has one more reason. She does not think she fits the picture, and nobody asks her, because she looks fine.

So I ask every woman I see for back, hip, or pelvic problems the same questions. Hip pain? How is your bladder? Any constipation or diarrhea you cannot explain? Any pain with intimacy?

When I ask about the bladder, most women say no, no leaking. So I ask it another way. “Imagine you are busy at work. When you have to go, do you have to go? Right now?” And many of them stop and say, “Oh, yeah. That.” That urgency is often the beginning of the problem, and they have never told anyone. The answers about intimacy come the same way. Slowly. But they come.

Pain during intercourse rarely comes alone

These are the doors I see women walk in through:

• Low back pain that is really low, around the SI joint and the pelvis, not the spine
• Hip pain, often on one side, that keeps coming back
• Pelvic pain, or pressure when standing or walking
• Outer knee pain. The TFL, a small muscle at the front of the hip, pulls on the IT band, the band of connective tissue down the outside of the thigh. When the TFL works overtime to steady the pelvis, the knee can feel it.
• Urgency, or going “just in case” all day
• Constipation or diarrhea that nobody can explain

Patients sometimes think I can read minds. I can’t. I ask the right questions, and we put two and two together.

A short self-check. Ask yourself honestly:

• Does intimacy hurt, or have you started avoiding it because you expect it to hurt?
• Is there one hip, or one side of your low back, that never quite settles?
• When you have to go, do you have to go right now?
• Have your bowels changed for no clear reason?
• Where does it hurt: at the opening, deeper inside, or afterward? Is it new, or has it been building?
• What changed around the same time? A hip, your back, your bladder, your stress?

If you said yes to painful intimacy and to even one other question, I would want to look at your pelvis.

One woman’s story: the hip, then intimacy, then the bladder

Let me tell you about one patient, without her name. She is in her 60s, very active, not heavy, otherwise healthy, and very careful about what she eats and drinks. Her job asks a lot of her, physically and mentally.

She came to me for left hip pain. She had already been treated for that hip at many places. During my usual questions, she told me she had not been intimate for seven or eight months, because it was too painful. The painful intimacy was the first new symptom after the hip pain. And about seven months after that, her bladder had started to leak.

Hip. Intimacy. Bladder.

Follow the usual path and that is three problems and three specialists. To me it looked like one problem showing up in three places. So we treated the pelvis as a whole.

In my experience, you cannot treat these symptoms one by one and expect the pelvis to settle. By the time she was discharged, it had all settled. The hip pain, the bladder leakage, and the pain with intimacy. She told me she was doing extremely well. That is not luck. In my experience, it is often what happens when we find where the problem actually lives. Every body is different, and I will not promise you her result. But her story is not rare.

Why painful intimacy gets missed: the ten-specialists problem

A woman like her can end up seeing close to ten different specialists. The hip specialist for the hip. The OB-GYN for painful intimacy. Urology for the bladder. But nobody puts the pieces together.

I am not here to say who is wrong. OB-GYNs rule out what must be ruled out, and I am grateful for every referral. Many physical therapists do careful pelvic work. But women who came to me after other pelvic therapy had often been given Kegels and internal work, and nobody had looked at the whole pelvis in a systematic way. I think that is part of why some of them had lost trust.

So my purpose here is awareness, for patients and for professionals. If you are a clinician, the next time a woman’s hip will not settle, ask about her bladder, and ask about intimacy.

Why does sex hurt? What I think is going on

Here is the short answer. When the medical tests are normal, sex often hurts because the pelvic floor is tight, and in my experience it is tight because the pelvis underneath it is not sitting right. Think of the pelvis as the foundation of a house, and the pelvic floor as the sling across the bottom of it. So before the pelvic floor comes the pelvis. There is no such thing as a normal pelvis. But when a pelvis is not sitting right, in my experience the sling often ends up weak on one side and tight on the other. More on that on our pelvic floor therapy page.

Why weak on one side and tight on the other? For that, I go to the connective tissue, the fascia. Imagine you are wearing a T-shirt. Grab the fabric at one hip and twist it. The shirt pulls tight across one side and goes slack on the other. That is the picture I give my patients for the fascia around a pelvis that is not sitting right, alongside the house and the sling. To be clear, this fascia explanation is my own clinical take, not proven research. It is what many years of hands-on work have shown me.

What a tight pelvic floor feels like

So what does a tight pelvic floor feel like? Clinicians call it hypertonic pelvic floor muscles, which simply means muscles that stay partly clenched and cannot fully let go. So a woman feels it as deep pain during intercourse, or an ache afterward that hangs around. A tight muscle hurts with pressure and stretch, and that is exactly what intimacy asks of it.

Research does support the bigger idea that the pelvis and pelvic floor are connected. In a Dutch study of women with pregnancy-related low back and pelvic pain, 52 percent also had pelvic floor dysfunction, and their pelvic floor muscles were more active than in healthy women. A 2023 US study of 177 women seen at a pelvic medicine clinic found that those with low back, hip, or pelvic girdle pain were about seven times more likely to have painful pelvic floor muscles on examination.

And the healthy woman? Being strong does not protect the pelvic floor. Strength at the gym does not tell us how comfortably a pelvic floor can relax. It is a muscle that needs a different kind of attention, and in my experience it is very sensitive to hormones. In a 2026 survey of 366 women runners at the Santiago Marathon in Chile, 20 percent reported pain during sexual activity and about a third leaked with effort.

Stress plays a part too. In my experience, relationship strain, a divorce, or a demanding job can tighten the connective tissue around the pelvis. The emotional side deserves its own post, and I will write it.

In my experience, it starts with the pelvis and it stops with the pelvis. Your body is not broken, it is adapting. That tightness is your body trying to hold a shaky foundation together.

A quick word about surgery. If you have had endometriosis surgery, an ablation, a hysterectomy, or a C-section, scar tissue can be part of your picture, and that is a different story. This post is for the woman who never had surgery and has been told, one way or another, that nothing is wrong.

Pelvic floor therapy for painful sex: external, gentle, nothing forced

At Synergy we do not do internal exams or internal treatment. Everything is external. We call our approach Whole Body Synergy Techniques because we treat the pelvis as a whole: the SI joints, the hips, the fascia, and the muscles holding it together.

The pressure is very gentle and sustained. We hold, we wait, and we let the tissue let go. Nothing is forced. You can ask questions, set boundaries, or stop at any time. Much of this comes from the John F. Barnes Myofascial Release Approach, which you can read about on our myofascial release page.

In many places, an internal exam is the standard. My position is simple: internal exams and internal treatment are not necessary at all. In my view, when an area is already this painful, internal work can create fear, and fear creates more tightness. The patient has to be comfortable first, because a body that feels safe is a body that can let go.

Understanding matters as much as the hands. When a woman understands why intimacy hurts, she relaxes. That is the reason I created the Synergy Healing Program. It teaches how your body and mind work, so you can learn this at home, at your own pace.

And Kegels? Supervised pelvic floor training is recognized care, and Kegels help many women, especially with leaking. But if a pelvic floor is already tight, squeezing harder is not the whole answer for everyone. And physical therapy itself has research behind it: a 2023 review of 19 studies found that physical therapy improved pain and quality of life in women with dyspareunia, though it did not clearly improve sexual function. I wrote more about that in leaking when you sneeze or laugh, and our women’s health physical therapy page has more.

When to see your doctor first

Pain during intercourse can have medical causes that need a doctor first. Please see your OB-GYN or primary care doctor if you have:

• Bleeding after intimacy, or any vaginal bleeding after menopause
• Painful intimacy that is new after menopause
• Fever, unusual discharge, sores, or itching
• Burning or pain when you urinate
• A new lump, or a bulge you can see or feel
• Any new pelvic pain during pregnancy
• Sudden, severe pelvic pain. Go to emergency care.

If sex became painful after menopause, do not just tolerate it. Those changes can be treatable, and the pelvis may need attention too. We are always glad to work alongside your doctor. We are on the same team.

So let me sum this up

Number one: pain during intercourse is common, and it is not something you have to accept, even if you look perfectly healthy.

Number two: it rarely travels alone. Hip, low back, bladder, bowel. Ask whether they are connected.

Number three: in my experience, it starts with the pelvis and stops with the pelvis. Care can be gentle, external, and at your pace.

I have seen this pattern too many times to let another woman sit with it quietly. You do not have to explain it perfectly. You can start with: “Sex hurts, and I think my hip or pelvis may be involved.” Call us at (618) 243-7822. We are at 1110 N Cedar Court, Carbondale, IL 62901, and women come to us from all across Southern Illinois. You can also book your first visit online, or start at home with the Synergy Healing Program.

Men have their own version of this story. That one deserves its own post, and it is coming.

Frequently asked questions

Why does it hurt when I have sex?

There are many possible causes, and your doctor should check the medical ones first: infection, dryness, skin conditions, and hormonal changes. When those tests come back normal, in my experience the answer is often a tight pelvic floor, and a pelvis that is not sitting right underneath it. A tight muscle hurts with pressure and stretch, and that does not show up on a lab test.

Why does sex hurt all of a sudden?

Pain that is new or sudden should be checked by your doctor first, because infection, dryness, and hormonal changes are common causes. If sex hurts after menopause, dryness and thinning tissue are common and treatable. If the medical side is clear, look at what else changed. In my experience, new pain with intimacy often shows up alongside a hip, low back, or bladder problem that started a few months earlier.

What is dyspareunia?

Dyspareunia (dis-puh-ROO-nee-uh) is the medical word for pain during or after intercourse. It is a description, not a cause. It is different from vaginismus, where the muscles at the vaginal opening tighten on their own and make penetration difficult or impossible, though the two can overlap.

Can a tight pelvic floor cause pain during intercourse?

Yes, it can. A tight pelvic floor, sometimes called hypertonic pelvic floor muscles, stays partly clenched and cannot fully let go, so it can hurt with pressure and stretch. That can mean deep pain during sex or pain after intercourse. In my experience, the tightness is often tied to a pelvis that is not sitting right, so we treat the pelvis as a whole.

Can pelvic floor therapy help painful sex without an internal exam?

Yes. At Synergy Therapeutic Group in Carbondale, Illinois, everything is external. We work on the pelvis, hips, and connective tissue with very gentle, sustained pressure, and nothing is forced. In my view, internal work on an area that is already painful can create fear, and fear creates more tightness.

What is the difference between pain at the opening and deep pain?

Where it hurts gives your clinician clues. Pain at the opening, sometimes called entry pain, is felt as penetration starts and is often linked to dryness, hormonal changes, irritation, infection, or pelvic floor muscles that guard and tighten. Deep pain is felt with deeper penetration and can come from bladder or bowel conditions, endometriosis, or a tight pelvic floor. Tell your doctor exactly where it hurts, whether it lingers afterward, and whether positions change it.

Can hip pain and painful intimacy be connected?

In my experience, often. Both can come from the same pelvis. When the pelvis is unstable, the muscles around the hip work overtime to steady it, and the pelvic floor can tighten on one side. In a 2023 study of 177 women seen at a pelvic medicine clinic, those with low back, hip, or pelvic girdle pain were about seven times more likely to have painful pelvic floor muscles on examination.

Are Kegels enough for pelvic floor tension?

Not for everyone. Kegels strengthen, and supervised pelvic floor training helps many women, especially with leaking. But if your pelvic floor is already tight, squeezing harder is not the whole answer. The muscle may need to relax first, and the pelvis it hangs from may need attention.

Written by Subrat Bahinipati, PT, co-founder of Synergy Therapeutic Group in Carbondale, Illinois, and a physical therapist with over 30 years of experience treating chronic and complex pain, including pelvic and hip problems, across Southern Illinois. He is trained in the John F. Barnes Myofascial Release Approach.

Clinically reviewed by Subrat Bahinipati, PT on November 12, 2026. Last updated November 12, 2026.

This article is for medical information and education only. It is not medical advice, and it does not replace an evaluation by your physician or a licensed physical therapist. Everyone’s body and history are different, so please talk to your healthcare provider about your own situation.

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