Dyspareunia is the medical term for recurrent or persistent pain with sexual activity, and can be further classified as superficial or deep depending on where a person feels the pain. There are about as many causes and contributing factors to it as there are ways to misspell the term itself, and different causes are predominant in different age groups. Dyspareunia affects an estimated 10-20% of women in the U.S. across all age brackets, which is a pretty significant number when considering how impactful this can be on relationships, confidence and overall quality of life.

After the six week postpartum check most women are typically cleared for intercourse. At this point, some women are excited to return to sexual activity, and some could care less because they are just getting used to breasts that shoot milk like fire hydrants and always smelling like spit up. All of the above and anywhere in between are normal for that early postpartum period (and the vastly fluctuating hormones during that time). But according to research, 45% of women have pain with intercourse at 3 month postpartum. So there is a good chance you know someone who has experienced or is experiencing it, or you may have dealt with postpartum dyspareunia yourself.

Pain with intercourse is present at 1 year postpartum in 10% of women, meaning that it can significantly impact relationships and quality of life in one in ten women for a long period of time. There are a number of risk factors that can contribute to postpartum dyspareunia according to the American College of Obstetricians and Gynecology (ACOG):

• Infection

• Operative vaginal delivery (forceps or vacuum assist)

• 3rd and 4th degree lacerations

• Wound separation of the laceration or episiotomy

• Pelvic organ prolapse

• Breastfeeding

The remainder of this blog article will address how you can help your own body to avoid postpartum dyspareunia in the first place, and how to address it should you be in the percentage of women who are affected. Most of the risk factors can be modified or addressed before they become a problem for you!!!

In terms of infection, it is important to keep any birth injuries as well as the vaginal area clean postpartum. The peri bottle issued to you after birth should be your BFF until any sutures are dissolved and you feel ready to tolerate gentle wiping with toilet paper. Remember to keep the bottle itself clean, and use fresh water after each urine and bowel void. Watch for signs of infection (fever, foul smelling discharge, increased pain at the site, increased swelling, or something just seems off) and schedule an appointment for yourself if there are any concerns. Ask your provider if you have any specific questions regarding your specific injury and how to address infection control. Different providers have different perspectives, and different injuries require different treatment. An infection that is caught early or, even better, never acquired, will result in easier postpartum healing. This is also definitely applicable to cesarean incision sites, and these are somewhat easier to visualize. If your pospartum stomach is preventing easy viewing (totally normal), please use a mirror to check both cesarean and perineal wounds. This will also help you follow your healing process to know if any area is not healing as fast as another at the incision site.

On to vaginal delivery: some moms or babies need some help during the delivery process for a variety of reasons. I'm not an OB so I can't elaborate on the when or why in the use of forceps or vacuum-assisted delivery, other than to say that they are typically used out of necessity. These tools are very important to have access to when considering the safety of mom and baby during critical moments, but they can be associated with an increase in various kinds of pelvic trauma (although, just to clarify, vaginal birth is basically pelvic trauma so don’t let the verbiage intimidate you). Please also keep in mind when you read this paragraph that there are various risk factors that determine how susceptible you might be to tearing, with or without an operative delivery, and this is something to bring up with your physician if you are concerned about this. If you end up experiencing an operative delivery, it is important to mitigate this in the postpartum period by allowing yourself plenty of rest and providing good nutrition for optimal tissue healing (although I would say the same for any mom postpartum regardless of delivery method). For this instance, I would recommend an automatic referral to physical therapy just to screen for potential issues that can easily be mitigated even before your six-week postpartum check. This will help improve your outcomes, and hopefully prevent experiencing dyspareunia when you are ready to get frisky.

Laceration degree refers to the depth and extent of tearing one experiences with vaginal delivery. Some women are lucky enough to experience no tearing, while others experience a wound classified as grade 1 to 4. Sometimes babies come out in a way that requires a larger exit, i.e.: when an arm is reaching overhead. Your pelvis is designed to eject a baby in a very limited number of positions, but sometimes baby has a mind of his or her own despite your body’s best efforts. In this case, a larger laceration can occur. This might be a sign that your offspring is stubborn, but I don’t think there’s any research currently underway to support that! The main take-home for this point: discuss with your doctor beforehand if you believe you’re at risk of a 4th degree tear-see the obstetric anal sphincter injury (OASI) risk factors here-and ask what their repair protocol is. It is well known that 4th degree tears repaired in the operating room are superior to repairs that are done in the birthing suite, however many women are still being sutured in the birthing suite. If your physician is not interested in OR repair, consider finding a physician who is unless they have appropriate reasons as to why.

Third degree lacerations do not require operating room repair, but it is important to be vigilant about bowel habits for both types of lacerations as they both affect the anal sphincter (the band of muscle responsible for maintaining continence of stool). For both 3rd and 4th degree lacerations it is important to talk to your physician about managing your bowel movements to keep them soft and avoid constipation at all costs. Keep water intake high and consider fiber supplements. Ask your doctor if he or she recommends stool softeners or other alternatives while you allow the repaired tissue to heal. He or she may also consider prescribing topical estrogen due to the low estrogen states of postpartum women. Estrogen will help increase blood supply to the tissue to improve the speed of healing. The better you care for both grades of laceration the better the chance of avoiding long term complications. I would recommend a referral to PT for a 4th degree tear prior to your six week check to assist in management of bowel habits, and to provide another set of eyes to ensure the tissue is healing in a healthy and timely manner. Plus it doesn’t hurt to get some tips and tricks for making a smooth return to intercourse, because it’s very likely that you won’t want to abstain for longer than necessary!

Postpartum women who experience pelvic organ prolapse are also at higher risk of experiencing dyspareunia, however many women with POP do not become aware of a prolapse diagnosis for a while after delivery, and many women are completely asymptomatic. For someone who has never given birth before, it can be hard to know what is ‘normal’ and what is not when it comes to birth recovery and some women with symptoms are very aware something is not right, especially if prolapse is more advanced. Some women reported a bulge or excess vaginal tissue motion during intercourse as being the reason behind dyspareunia however, anecdotally, I see many women with prolapse who tend to hold their pelvic muscles very tightly. In this case, the pain is actually muscular and can be addressed in a method very similar to any other muscular pain and dysfunction in physical therapy (this is not something to treat on your own if you suspect its presence). There are also medical options to help more severe grades of prolapse, including pessaries or surgery. The likelihood of needing these interventions is low, however it is important to know they exist if you need them (especially pessaries, as I have found them to be relatively unheard of in the US). Also anecdotally, none of my patients have ever reported that POP has affected their partner’s perception of intercourse in case you’re reading this and concerned for your partner.

Breastfeeding is the last risk factor listed by ACOG as a possible contributor to dyspareunia. Fortunately, this one is also a pretty easy fix. Breastfeeding can result in drier vaginal tissues because of the hormones required to maintain lactation. This places the body into a hypoestrogenic for the duration of lactation, resulting in reduced blood flow, tissue thinning, and dryness of the vaginal tissues. Important considerations for the duration of breastfeeding include a good lubricant (silicone-based will give you much less friction than water-based products) used consistently with intimacy, adequate foreplay to maximize natural lubrication, and discussing this with your physician if it is still painful after the previous suggestions. If still painful, your doctor may consider a topical estrogen prescription that will help vaginal tissues without interfering with milk production.

It is this post’s intention to provide you with thorough information that you can use to keep yourself healthy, and to know your options when it comes to decisions regarding your own treatment. Knowledge of different issues is the best way to protect yourself, your baby and your body during the pregnancy and postpartum period, and so many women I meet wish they had just known a little more. This may be a little more than you bargained on reading, but preventive medicine is also the best medicine. I wish you health during your navigation of motherhood, and the knowledge that there are professionals willing and able to help should things not go as smoothly as anticipate. Also, I have resources on managing pain in the postpartum period here, and a discussion on pooping during pregnancy here that also applies to the postpartum period.