If sex hurts, you won’t want to do it. For most of us, the pain stops desire cold. It’s estimated that about 20% of women suffer vaginal pain with foreplay or intercourse. Pain can be intermittent or chronic and can stem from a wide variety of causes, like infections, yeast, STDs, allergies, drug reactions, nerve damage, and chronic disorders. Unfortunately, many women complaining of pain during sex are dismissed as being inhibited, having psychiatric problems, or merely exaggerating the problem – when, in fact, their symptoms are related to legitimate medical issues.

Here are just a few common causes of sexual pain:

1. Poor arousal: When a woman becomes aroused, the labia, clitoris, and vagina swell and natural lubrication are produced inside the vagina – all of which help protect a woman from pain during intercourse.

2. Vaginal clenching: If you’re about to do something that has repeatedly caused you pain in the past, you are going to flinch. When sex hurts, women unconsciously squeeze their vaginal muscles contracting the space available for the penis to enter, causing intercourse to hurt more.

3. He has a large penis: While men may worry a great deal about being too small, women complain to me about twenty times as often about him being too big. Sex can hurt if he is well-endowed either by length or girth.

4. Menopause: As the hormone estrogen diminishes, a woman’s vulvar and vaginal tissue becomes thinner and less lubricated. And, to add to the problem, during mid-life, couples often stop having sex as often due to either his or her waning desire. Unfortunately, infrequent sexual intercourse can cause vaginal atrophy.

5. Vestibulitis: This pain, often described as burning, occurs just at the entrance or “vestibule” of the vagina – most frequently around the lower crescent of the vagina (in clock terms, from 4 o’clock to 7 o‘clock). With vestibulitis, the vagina usually has a red area surrounding the vaginal opening. Without this red demarcation, however, the diagnosis is sometimes missed at a regular gynaecological exam.

6. Vaginismus: An inability to be penetrated. Anxiety is at the root of a woman’s pain when her vagina contracts and will not allow any form of penetration. Women with vaginismus often have had trouble using tampons, painful gynaecological exams and fear of painful intercourse.