Vaginal atrophy is the most common cause after menopause, childbirth, or hormonal changes. Declining estrogen causes the vaginal walls to thin, lose elasticity, and produce less natural lubrication. What was once comfortable becomes painful as tissue can no longer accommodate without micro-tears.

Vascular insufficiency plays a larger role than most women realize. Healthy sexual response depends on blood flow to the vaginal and clitoral tissue — engorgement provides natural cushioning, lubrication, and sensation. When blood flow diminishes (from age, hormonal changes, or vascular health), the tissue doesn't respond adequately.

Pelvic floor dysfunction can cause or worsen pain. Hypertonic (overly tight) pelvic floor muscles create a tension pattern that makes penetration uncomfortable. Conversely, weakened pelvic floor muscles reduce support and sensation. Both patterns contribute to painful intercourse through different mechanisms.