Renewing your Sex Life after Childbirth
Irwin Goldstein, MD
Women’s sexual function is a complex integrated phenomenon that reflects both her psychological sociocultural, interpersonal influences as well as her biologic influences including the health of her gynecologic, urologic, endocrinologic, cardiovascular and central and peripheral nervous systems. If a woman has a sexual dysfunction that causes personal distress, she has the right to appropriate holistic (biologic and organic) sexual health management. At the Institute for Sexual Medicine at Boston University School of Medicine, we have evaluated over 1200 women for psychologic and biologic concerns with sexual dysfunction since 1998. One of the most common complaints has been persistent or consistent sexual dysfunction since childbirth. Post-childbirth sexual complaints include: loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, decreased genital sensation, decreased genital arousal and new onset pudendal neuropathy (associated with a forceps delivery).
While there are limited data on the topic, a recent 2002 publication in the International Journal of Gynecology and Obstetrics was entitled Sexual function after childbirth in Nigerian women by Dr’s Oboro and Tabowei. The study examined the post-natal sexual health of Nigerian women via self-administered questionnaire in a longitudinal survey at 6 weeks, 3 months and 6 months following childbirth in 122 married Nigerian women who were primiparas (first time delivery). Responders to survey (48%) did not differ from non-responders to survey with regards to demographic characteristics. The pattern of sexual intercourse was significantly (P<0.001) altered by childbirth. There was a decrease in coital frequency reported in 77% of women. There was a diminished sexual satisfaction in 37%. There was an increase in sexual dysfunction (47% post-natally vs. 21% pre-natally). Multiple sexual problems were present in 95% of the women at 6 weeks post-partum, 74% at 3 months post-partum, and 51% at 6 months post-partum. At 6 months, the sexual problems of 102 respondents included: loss of sexual desire (27%), painful penetration (21%), painful intercourse (19%), difficulty achieving orgasm (15%), lack of vaginal lubrication (13%), vaginal tightness (11%), Lack of vaginal muscle tone (10%) and irritation or bleeding after sex (6%). Compared with women who did not have, women who had instrumental vaginal delivery were more likely to experience dyspareunia at 3 months post-partum (Yes – 59%, No – 35%). Compared with women who did not have, women who had perineal trauma during pregnancy were more likely to experience dyspareunia at 3 months post-partum (Yes – 42%, No – 22%). Compared with women who did not have, women who had pre-pregnancy dyspareunia were more likely to experience dyspareunia at 3 months post-partum (Yes – 73%, No – 27%).
One possible biologic explanation for the high prevalence of sexual dysfunction after childbirth relates to consistent and persistent sex steroid hormonal changes, especially in androgens, which have been found in the mother after the childbirth. Recent research has shown that sex steroids are critical for sexual activity. Based on animal research, sex steroid hormone deficiency states are associated with atrophy of the clitoris and vagina, changes in the androgen and estrogen receptors, diminished ability to relax vaginal smooth muscle and diminished vaginal blood flow and lubrication. One hypothesized action of how sex steroids improve function in the genitals is to activate transcription in the cell nucleus and increase protein synthesis. The sex steroid induced proteins include growth factors which maintain genital smoothy muscle, nerve and blood vessel tissue health.
Guay and colleagues studied the sex steroid blood levels of women with and without sexual dysfunction. Statistically different differences in several precursor sex steroid adrenal hormones were observed. They postulated that in women with sexual dysfunction certain critical adrenal enzymes involved in sex steroid synthesis become inactive for unknown reasons. It is hypothesized that in particular the enzyme 17-20 lyase enzyme becomes inactive after childbirth for unknown reasons. It has been shown that progesterone, which is dramatically elevated during pregnancy, acts to inhibit this enzyme.
In women with sexual dysfunction (including after childbirth), the first management strategy is to undergo “identification of the sexual dysfunction” by psychologic interview, history (medical, sexual and psychosocial), physical examination, genital sensory and blood flow testing and blood testing. The next management strategy is to undergo “education” of the patient (and the partner) by reviewing the initial psychologic and biologic findings, educating the patient (and the partner) as to anatomy, physiology and pathophysiology. The first treatment strategy is to undergo “modification of reversible factors” by sexual therapy, medication changes, hormone therapy, lifestyle change and corrective surgery as indicated and when appropriate. The second treatment strategy is to undergo “first-line therapy” by vacuum clitoris device, oral and/or topical vasodilator therapy.
One key diagnostic strategy for women with sexual dysfunction after childbirth has been to record sex steroid blood levels. If sex steroid levels are abnormal, based on symptoms and needs, individualized hormone therapy with dehydroepiandrosterone, androstenedione or testosterone may be indicated as treatment. Follow-up blood tests every 3 months are suggested. This approach is standard with other endocrinologic hormones such as thyroid hormone, but it has not been applied to sex hormones until recently. A woman should only take what sex steroids she needs at the lowest dose to maintain the “optimal” level of hormones in her body.
In summary, sexual problems in women are highly prevalent, frequently distressing, and poorly understood at present. This is especially true for women with sexual dysfunction after childbirth. The causes and treatment of sexual dysfunction in women has been a topic of academic concern for more than half a century. There is much research needed. There has been a long history of neglect of sexual problems generally in medicine, especially the current lack of knowledge about causes and treatment of sexual dysfunction in women. What appear to be needed are more integrative (psychologic and biologic) therapies.