Is this normal? Postpartum Sexual Dysfunction: Managing Expectations

After having a baby, new moms have a lot to deal with – caring for the newest addition, sleep deprivation, hormonal changes, physical issues/pain – and for a lot of new moms, sexual dysfunction as well. 

“I don’t even want to have sex because of the pain; is that normal?”

“I just can’t get in the mood, I’m tired and would rather sleep.”

“It just doesn’t feel the same as it used to.  Will it ever get back to normal?”

As a pelvic health physical therapist, these are very real concerns that I have heard from women in the postpartum period.  Having a baby really does change everything, and it seems that sexual function is no exception.  In fact, a recent systematic review estimates that up to 80% of women may experience some degree of postpartum sexual dysfunction¹.  Sexual dysfunction and the postpartum period remain two topics that are widely under addressed by healthcare providers – put the two together, and its unsurprising women are left confused and wondering.  

Sexual dysfunction refers to a multitude of problems, and can affect desire, arousal, orgasm, satisfaction or pain.  Factors that contribute to poor sexual function in the postpartum period can include changes in body image, perineal pain from labor and delivery, the stress and lack of sleep associated with caring for a baby, and urinary complaints like incontinence¹.  Women who breastfeed have significantly higher rates of dyspareunia (which is painful vaginal penetration), due to a lack of estrogen, which can affect lubrication². This may last until the new mom begins to wean her baby.  Perineal trauma is also predictive of sexual dysfunction – both second degree (involving skin and perineal muscle) and third degree (which extends to muscles of the anus) tears are associated with dyspareunia at 6 months after birth, and this link persists at 12 months for those with third degree perineal tears³.  Another study reports that vacuum extraction and Cesarean section (emergency as well as elective) can increase rates of dyspareunia even at 18 months postpartum⁴. 

There are also significant emotional factors at play during this period. A significant number of women continue to have poor perception of their body image at 6 and 12 months postpartum, contributing to decreased sexual function³.  It has also been reported that women who report higher levels of stress and fatigue postpartum are at greater risk for sexual dysfunction².  As any new parent will tell you, there is bound to be some degree of stress and fatigue after bringing home a new baby!

Given the scope of this issue, it is obvious that postpartum sexual health needs addressed – however, it doesn’t appear to be getting the spotlight it deserves.  A recent study published in Obstetrics and Gynecology reports that half of women were told when they could safely resume sexual activity – but aside from this proverbial green light given at 6 weeks postpartum, none reported receiving any other education on sexual function⁵.  This is concerning, and yet not all that surprising; our current healthcare system is not set up in a way that supports women in the postpartum period (often called the 4th trimester).  There is great focus on infant care (and rightfully so), yet very little focus on postpartum maternal care, during a period of time when women are faced with huge physical, hormonal and emotional changes. Forty percent of women do not receive any postpartum healthcare, and those who do typically receive only one visit due to insurance restrictions⁶.  This visit most often occurs at 6 weeks postpartum, when most women have not resumed sexual activity, and therefore have no idea if they are going to have any issues if/when they choose to engage in sexual activity.  The shortage of postpartum sexual health education is doing a disservice to women.

So where does that leave us as physical therapists who may treat women with these concerns?  More importantly, where does it leave these women?  Having a baby is difficult enough with the hormonal, physical, and emotional challenges of a changing body and changing roles, without adding the challenge of sexual dysfunction, which continues to be stigmatized.  Further, our culture tends to place importance on a speedy postpartum recovery (“get your body back”) without acknowledging the difficulties of this time period.  Fortunately, there is evidence that pelvic floor physical therapy can be beneficial in reducing sexual dysfunction for postpartum women.  A 2019 systematic review found that pelvic floor muscle training can improve sexual function and quality of life in the postpartum period.  The authors suggest that healthcare providers should be screening women for sexual issues in the postpartum period ⁷.  This could mean referring to a pelvic floor PT.  Another study determined that pelvic floor muscle training is beneficial for women’s sexual health postpartum; women in the study who underwent pelvic floor muscle training reported improved arousal, lubrication and orgasm at 7 months postpartum, compared to those who didn’t⁸.  A 2019 study showed that pelvic floor rehabilitation (which included intravaginal manual techniques, biofeedback, pelvic floor muscle exercise and TENS) improved sexual functioning and decreased pain for women experiencing dyspareunia⁹. 

It is clear that pelvic floor physical therapy could play a significant role in assisting women with sexual dysfunction in the postpartum period.  As providers who may treat women during this time of huge transition in their lives, it is vital that we are well-informed in order to educate and help them manage expectations.  Armed with this information, we can be a source of information for women as well as for other healthcare providers and the community at large. There are some concrete ways we can do this:

• Advocating for greater awareness and support during the postpartum period (I highly recommend the webinar on this exact topic on the APTA Pelvic Health site, called Fourth Trimester Care: Advocacy in Action) 
• Encouraging referring providers to screen for sexual dysfunction; the American College of Obstetricians and Gynecologists (ACOG) recommends this, as well as appropriate referral to physical therapy as needed⁶.
• Talking about these issues as needed with our own clients during pregnancy and postpartum to help manage expectations and prepare women

New moms have enough things to worry about already; let’s try to make sure sexual dysfunction doesn’t have to be one of those.

References:

1. Gutzeit O, Levy G, Lowenstein L. Postpartum female sexual function: risk factors for postpartum sexual dysfunction. Sex Med. 2020; 8(1): 8–13.  doi: 10.1016/j.esxm.2019.10.005
2. Alligood-Percoco NR, Kjerulff K, Repke JT. Risk Factors for dyspareunia after first childbirth. Obstet Gynecol. 2016; 128(3): 512-518. doi: 10.1097/AOG.0000000000001590
3. O’Malley D, Higgins A, Smith V. Postpartum Sexual Health: a principle-based concept analysis. J Advanced Nursing. 2015; 71(10): 2247-2257. doi.org/10.1111/jan.12692
4. McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG. 2015; 122(5): 672-679. doi: 10.1111/1471-0528.13263
5. Guendler J, Katz L, Flamini ME, Lemos A, Amorim M. Prevalence of sexual dysfunctions and orientations on sexuality in postpartum women: cross-sectional study.  Obstet and Gynecol. 2019; 133: S213-S214. doi:10.1097/01.AOG.0000559105.67034.96
6. American College of Obstetricians and Gynecologists. 2018. ACOG Committee Opinion 736. Washington, DC. American College of Obstetricians and Gynecologists.
7. Hadizadeh-Talasaz Z, Sadeghi R, Khadivzadeh T. Effect of pelvic floor muscle training on postpartum sexual function and quality of life: A systematic review and meta-analysis of clinical trials. Taiwan J of Obstet Gynecol. 2019;58(6): 737-747. doi: 10.1016/j.tjog.2019.09.003.
8. Citak N, Cam C, Arslan H, et al.  Postpartum sexual function of women and the effects of early pelvic floor muscle exercises. Acta Obstet Gynecol Scand. 2010;89(6):817-822. doi: 10.3109/00016341003801623
9. Ghaderi F, Bastani P, Hajebrahimi S, et al. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(11): 1849-1855. doi: 10.1007/s00192-019-04019-3

About the Author

Kathryn Goncalves, PT, DPT is a physical therapist in the Indianapolis area who is certified in Pelvic Health Physical Therapy (CAPP-Pelvic) through the Academy of Pelvic Health Physical Therapy.  She treats people with pelvic floor disorders as well as pregnancy and postpartum related concerns.