Sex hurts at the entrance. Tampons are hard work. A cervical screening test feels like a fight your body is having without you. And you have been told everything looks normal.

Sometimes the reason is not the skin, the hormones or the lubrication. It is the muscle. The International Society for Sexual Medicine describes overly tight pelvic floor muscles as a common cause of pain with intercourse. Muscles that cannot let go make penetration hard and painful.

It is also one of the least explained causes. Most women have only ever been told to strengthen their pelvic floor. Almost nobody mentions that it can be too tense.

What your pelvic floor is meant to do

The pelvic floor is a group of muscles that sits like a sling across the base of your pelvis. It supports the bladder, bowel and uterus. It holds on when you need to hold on, and it lets go so you can empty.

It matters for sex too. These muscles need to soften for penetration to be comfortable. They contract rhythmically during orgasm. A healthy pelvic floor does both jobs. It tightens when it should and releases when it should.

What an overactive pelvic floor is

An overactive pelvic floor is one that does not relax properly when it is supposed to. You may hear it called hypertonic, tight or non relaxing. The muscles sit in a held position, a bit like a clenched jaw or shoulders up around your ears.

Most women with this have no idea it is happening. Jean Hailes for Women's Health notes that many women are unaware their pelvic floor muscles are tight and tender.

The signs tend to cluster.

Pain at entry. Burning, stinging, or a sense of hitting a wall on penetration. Sometimes penetration is not possible at all.

Tampons and examinations. Hard to insert, uncomfortable to wear, or a speculum examination that hurts far more than it should.

Aching afterwards. A dull ache in the vagina or pelvis after sex, sometimes lasting into the next day.

Bladder changes. Urgency, frequency, a slow stream, or a feeling you have not quite emptied.

Bowel changes. Constipation, or difficulty emptying your bowel.

Jean Hailes describes vaginismus as the point where the pelvic floor is so overactive that penetration is very painful or impossible. It is the same problem, at its most pronounced.

Why the muscles tighten

There is rarely one cause. These are the common contributors.

Pain somewhere else. Muscles guard against pain. Vulvodynia, endometriosis, recurrent infections and painful bladder conditions can all teach the pelvic floor to brace. The bracing then becomes its own source of pain.

Dryness after menopause. When vaginal tissue is dry and fragile, penetration hurts. Muscles can learn to tighten before anything has even happened.

Pelvic surgery. Operations such as hysterectomy are recognised contributors.

Stress and anxiety. Some women hold tension in the pelvic floor the way others hold it in their jaw. Long stretches of stress keep it switched on.

Anticipation. Once sex has hurt, expecting it to hurt again is enough to tighten. The International Society for Sexual Medicine notes that pain linked to the pelvic floor can create anxiety about sex, and that anxiety can lower desire and arousal as well. Less arousal means less lubrication and less softening. The loop feeds itself.

Why more pelvic floor exercises may not help

Pelvic floor exercises get handed out as the answer to everything. For a weak pelvic floor, they are useful. For a tight one, they can make things worse.

The Continence Foundation of Australia says pelvic floor muscles that are too tight and cannot relax can be made worse by squeezing exercises and by overworking the muscles without learning how to relax them.

Some women have a pelvic floor that is both tight and weak. A muscle that never lets go also tires. That is why a proper assessment matters more than a generic exercise sheet.

If you have done your exercises faithfully and sex is no easier, that is not failure. It may simply be the wrong prescription.

What a pelvic health physiotherapist does

This is the specialist most women have never heard of. A pelvic health physiotherapist, sometimes called a women's health physiotherapist, assesses and treats the pelvic floor directly.

In Australia you do not need a doctor's referral to see a physiotherapist privately. Private health insurance extras may cover part of the cost. Medicare may cover some visits for certain conditions if your doctor refers you under a care plan, so it is worth asking.

A first appointment usually starts with a long conversation about your symptoms, your bladder and bowel, and sex. An internal examination may be offered to see how the muscles contract and release. It is your choice. You can say no, say not today, or ask to stop at any point.

Treatment for an overactive pelvic floor focuses on release, not strength. Depending on what is found, it may include the following.

Learning to let go. Belly breathing, feeling the pelvic floor drop, and practising relaxation instead of squeezing.

Stretches and massage. Gentle stretches through the hips and pelvis, and massage of tender areas, including trigger point therapy.

Vaginal trainers. A graded set of smooth inserts, also called dilators, used at your own pace so the body can relearn that penetration does not have to mean pain.

For vaginismus, Jean Hailes recommends a team. That can mean a sympathetic general practitioner, a physiotherapist, a sex therapist and a psychologist. The muscle and the mind are working together, so good care includes both. Jean Hailes also notes that it can take time, and that small advances count.

What to raise with your doctor

Tight muscles are often part of the picture, not all of it. Other causes need their own treatment, so it is worth ruling them out.

The skin and tissue. Ask for the vulva to be examined for skin conditions, infection, or dryness and thinning. If you are perimenopausal or postmenopausal, ask whether vaginal oestrogen is appropriate for you.

Deeper pain. If the pain is deep inside, follows your cycle, or comes with painful periods, ask about endometriosis.

The referral question. Ask, "Could a pelvic health physiotherapist assess my pelvic floor?" If you have been told everything looks normal, this is the question to ask next.

The National Continence Helpline, run by the Continence Foundation of Australia, is another place to start. Call 1800 33 00 66 to talk through your symptoms and options.

Bringing pleasure back into it

Releasing a muscle is one part of this. The other part is what pain has taught you. Months or years of bracing against sex change how you approach it. Desire goes quiet. Touch starts to feel like a test you might fail.

That part is learned back, slowly, and on your terms.

The Sexual Wellness Reset is Hope's programme for rebuilding your relationship with your own body and with pleasure. It sits alongside your clinical care. It does not replace your physiotherapist or your doctor.

Start The Sexual Wellness Reset

Education, not medical treatment. Always speak with a qualified clinician about your own care.