10.1576/toag.7.4.245.27119 www.rcog.org.uk/togonline

REVIEW Dyspareunia following The Obstetrician & Gynaecologist childbirth 2005;7:245–249

Christine Kettle, Khaled Ismail and Fidelma O’Mahony Keywords While a temporary reduction in libido is acceptable following dyspareunia, libido, childbirth, women should not expect postpartum dyspareunia to perineum, occur. If these symptoms are left untreated a woman can become postpartum, sexual afraid of having intercourse and the problem can escalate, causing intercourse, long-term physical and psychological morbidity. This can lead to vaginismus sexual disharmony and relationship breakdown. Early and sensitive management is crucial in the prevention of long-term problems. In this article we present a multidisciplinary approach for managing women with dyspareunia following childbirth.

Introduction a reduction in libido.1,5 This is due to the Author details physiological hyperprolactinaemia of lactation Dyspareunia can be defined as any pain or reducing the levels of maternal oestrogen, soreness that occurs during sexual intercourse. progesterone and androgens. Similarly, oestrogen Women can suffer from primary dyspareunia, in deficiency secondary to some types of hormonal which pain has always occurred during sexual contraception can lead to vaginal dryness and activity, or secondary dyspareunia, in which it vaginitis.6 Characteristically, the pain or occurs after a period of pain-free intercourse; for discomfort associated with superficial example,after childbirth.This can be sub-classified dyspareunia is located around the introitus or Christine Kettle SRN SCM Dip Mid as deep or superficial dyspareunia depending on PhD, Professor of Women’s Health, can involve the vulva or urethral areas. where the woman experiences the discomfort. Academic Unit of Obstetrics and Gynaecology, Staffordshire Women are usually unaware that it is quite University, University Hospital of Deep dyspareunia tends to occur secondary to normal for sexual interest to be decreased during North Staffordshire, Stoke-on- gynaecological and urological disorders. Pelvic Trent ST4 6QG, UK. email: pregnancy and the early postpartum period. [email protected] adhesions, infections, pelvic inflammatory Barrett et al.1 found that 53% of women at three (corresponding author) disease, cervicitis and cystitis are examples of months and 31% at six months reported loss of such conditions that can happen secondary to sexual desire following the birth of their first baby. childbirth. Similarly, a reduction in postpartum sexual desire was reported in other studies,2–4 and this did not Psychological dyspareunia can happen secondary seem to be affected by the mode of delivery.1 to a traumatic birth experience and can be While a temporary reduction in libido is associated with anxiety or depression. acceptable following childbirth, women should be Khaled MK Ismail MSc MD aware that pain during intercourse is not expected MRCOG, Senior Lecturer and Prevalence Consultant, Academic Unit of to occur unless such sexual problems were evident Obstetrics and Gynaecology, Keele prior to conception. Postpartum dyspareunia It is difficult to estimate the true prevalence of University Medical School, University Hospital of North should be managed appropriately to promote the dyspareunia following childbirth as many Staffordshire, Stoke-on-Trent ST4 resumption of normal sexual function and prevent women with persistent symptoms do not seek 6QG, UK. long-term physical and psychosocial problems. medical attention. Furthermore, when comparing the findings of research studies, Aetiology consideration must be given to both the obstetric and clinical variables of the population Dyspareunia following childbirth can be physical being studied, as these will affect the rates of or psychological, or a combination of both. dyspareunia reported. It is also important to Physical or organic superficial dyspareunia can highlight that most of the studies that reported Fidelma O’Mahony MRCOG, Consultant and Senior Lecturer, be secondary to scar tissue formation, poor rates of postpartum dyspareunia refer to Academic Unit of Obstetrics and anatomical reconstruction following perineal superficial dyspareunia or painful intercourse in Gynaecology, Keele University Medical School, University Hospital trauma or vaginal dryness. Breastfeeding is general; therefore, it is difficult to know the of North Staffordshire, Stoke-on- known to cause vaginal dryness, dyspareunia and actual prevalence of postpartum deep Trent ST4 6QG, UK.

245 © 20052004 Royal College of Obstetricians and Gynaecologists REVIEW dyspareunia. Several research studies1,4,5,7-11,12 intervention.15 More recent research16,17 found The Obstetrician have reported that 62-88% of women resume that women who delivered with an intact & Gynaecologist intercourse by 8–12 weeks postpartum. perineum reported the best outcomes in terms of However, 17–23% continue to experience sexual function and pain. The effect of suture 2005;7:245–249 superficial dyspareunia at three months after materials and methods used for repair of delivery and 10–14% at 12 months. Barrett et al.1 episiotomies and perineal tears following delivery reported a higher prevalence rate: 62% of has been assessed in several clinical trials with women in their study experienced dyspareunia conflicting results relating to reported rates of at some time during the first three months dyspareunia.4,7,10-11,18 postpartum and 31% still complained of dyspareunia at six months. However, 12% of the Implementation of strategies to reduce assisted study participants had experienced dyspareunia vaginal deliveries using the Ventouse vacuum in the 12 months prior to conception. extractor as the instrument of choice rather than forceps, reducing episiotomy rate and improving Associated risk factors perineal repair techniques, will probably help in decreasing the extent of postpartum sexual morbidity experienced by women. Type of delivery Breastfeeding Previous research has attempted to estimate the prevalence of postpartum superficial dyspareunia Hormonal changes associated with breastfeeding but few studies have been specifically designed to can lead to decreased libido and/or superficial identify associated risk factors. Data from a large dyspareunia secondary to vaginal dryness. longitudinal postal survey with a 90% response Confounding factors that can contribute to rate, carried out by Glazener,5 demonstrated that postpartum sexual morbidity are: tiredness, change perineal pain persisting after eight weeks was in role, depression, lack of privacy, poor housing, significantly associated with assisted vaginal pressure to return to work and lack of financial delivery (30%) when compared with spontaneous and social support. Glazener5 found that women vaginal delivery (7%). Barrett et al.1 carried out a who breastfed their babies were three times more multi-factorial data analysis and found that likely to be temporarily uninterested in sexual dyspareunia at three months after delivery was intercourse. A subgroup analysis of data from the significantly associated with the type of delivery, study carried out by Kettle et al.4 also showed that extent of perineal damage and dyspareunia before the incidence of dyspareunia at three months pregnancy. However, the causal effects of the type following delivery was increased among women of vaginal delivery and perineal trauma sustained who were breastfeeding (21.2% versus 15.9%). in relation to dyspareunia were no longer This finding was also supported by Barrett et al.1 significant factors by six months postpartum. Diagnosis Fear of dyspareunia following vaginal delivery is sometimes cited as one of the main reasons why It is important to provide follow-up care for women request caesarean section. However, a women who have experienced a traumatic birth small study conducted by Goetsch13 reported or sustained complex perineal trauma to ensure that 29% of women suffered postpartum that they are not experiencing any sexual dyspareunia despite having a caesarean section. difficulties. For those who are, it is imperative to Moreover, a cohort analysis of data from a large obtain a detailed history using a sensitive, non- randomised controlled trial carried out by Klein judgmental approach. Understanding of the et al.14 found that women who underwent organic aetiology must be incorporated with caesarean section experienced more dyspareunia appreciation of underlying psychological factors than those who had an intact perineum after such as postnatal depression, anxiety and negative vaginal birth (40.7% and 26.2%, respectively). expectations that can perpetuate the pain cycle.

Perineal injury The woman’s perspective of the problems and details of the order of events in relation to her Factors strongly associated with both the severity presenting symptom should be obtained during and rate of postpartum dyspareunia are the type assessment. For example, organic dyspareunia can and degree of perineal injury sustained and the be secondary to scar tenderness and this can lead method of delivery. Follow-up of participants in to vaginismus or arousal dysfunction resulting a study comparing restricted versus liberal use of from fear of expected pain. Similarly, arousal episiotomy found that 14% of women disorders that can affect vaginal lubrication can experienced dyspareunia up to three years cause painful intercourse. Figure 1 is a following delivery, irrespective of the allocated diagrammatic representation of this complex

246 © 2004 Royal College of Obstetricians and Gynaecologists sequence of events. It is essential to establish anatomical alignment of perineal tears or REVIEW whether the problem is pre-existing or acquired episiotomy and scar tissue. During the The Obstetrician following childbirth and this must include details examination the woman must be treated & Gynaecologist of past sexual experiences, onset, duration of the sensitively and reassured that she can stop the problem, location, description of the pain, its procedure at any time. Physical examination can 2005;7:245–249 intensity and also whether the pain is associated elicit tenderness similar to the pain experienced with physical or psychological components. by the woman during sexual activity. The Quite often depression or anxiety disorders are muscular involuntary spasm associated with present in women experiencing dyspareunia and vaginismus can be replicated by inserting one sometimes it is difficult to unravel the underlying finger into the vagina.This should be carried out cause. Furthermore, there may be dissonance prior to proceeding to full pelvic assessment, within the partnership. It is therefore important including bimanual examination, to minimise to take a detailed history to assess whether the confusion arising from abdominal tenderness.19 relationship is suffering due to sexual problems or Pressure exerted on the cervix can reproduce the whether the sexual problems are secondary. same deep pain or discomfort experienced during intercourse. Palpation of the lateral The characteristics of the pain experienced can vaginal walls can elicit the source of pain and can help with diagnosis of the problem. For example, also reveal if there is pudendal neuropathy. If the pain associated with superficial dyspareunia infection is suspected a speculum examination may be described by the woman as sore, splitting, should be performed and swabs taken. tearing or burning on entry, whereas deep dyspareunia may be described as a shooting pain Management on deep penetration or as a dull ache following intercourse. In contrast, women suffering with Postpartum perineal problems can lead to more vulvodynia tend to present with a more constant complex sexual disorders. Hence, it is important generalised vulval pain, which is sometimes to deal with them promptly and effectively. In described as a feeling of having broken glass our unit there is a dedicated perineal care clinic under the skin’s surface. and a structured care pathway for managing women with such problems. This service is Assessment should include careful inspection of backed up with a multidisciplinary team that the external genitalia and introitus for swelling, provides expert input for the management of irritation, warts, varicosities, abrasions, poor more complex cases.

Figure 1. Flow chart illustrating the relationship between postpartum dyspareunia and non-organic sexual dysfunction

247 © 2004 Royal College of Obstetricians and Gynaecologists REVIEW The management of dyspareunia should focus months postpartum a modified Fenton’s on the underlying cause. Indeed, it can procedure can be performed. Occasionally, The Obstetrician sometimes take a considerable amount of time to extensive scarring secondary to delayed wound & Gynaecologist work out the true cause and provide appropriate healing, infection or poor tissue alignment treatment. As previously discussed, the main aim requires perineal refashioning. 2005;7:245–249 of diagnosis is to confirm or exclude organic problems that can be the underlying cause of the Vag inismus woman’s symptoms (Figure 2). Involuntary spasm of the introital muscles (vaginismus) can occur secondary to localised Decreased libido pain or discomfort associated with perineal scarring or vaginal dryness following childbirth. In most women decreased libido is simply due to The pain causes a conditioned response with tiredness caused by the demands of the newborn subsequent spasm of the superficial perineal and other family members. This can be muscles (organic vaginismus). In view of the exacerbated by the hormonal changes associated complexity and limited evidence of best therapy with lactation. The couple should be reassured for vaginismus, women in whom muscle spasm that these symptoms are expected to happen in persists despite treating the underlying cause of the postnatal period and, given time, they should pain and women with non-organic vaginismus improve spontaneously provided there are no should be referred to an expert sex therapist.20–21 underlying organic causes, depression or relationship problems. Vag inal dryness Scar tenderness In the absence of any physical cause, the most likely source of superficial dyspareunia is A thin band of scar tissue at the introitus is a inadequate arousal resulting in decreased vaginal fairly common cause of superficial dyspareunia. lubrication.When the woman is fully aroused the Typically this causes severe pain during vagina becomes lubricated, enabling pain-free penetration and sometimes splits and bleeds penetration by the erect penis. Vaginal dryness during intercourse. These distressing symptoms can also occur secondary to the hormonal can be relieved by division of the band of scar changes in the postpartum period. Reassurance tissue using a modified Fenton’s procedure, and advice should be given regarding ensuring which can be performed under local anaesthetic. adequate vaginal lubrication before penetration, We would initially advise the woman to massage and a water soluble lubricant can be used to the area of scar tissue with good quality oil (such relieve vaginal dryness and minimise associated as vitamin E or sweet almond oil) and if the pain. If the woman repeatedly experiences pain superficial dyspareunia does not improve in 3–6 on intercourse it is likely that she will tense up on

Postpartum dyspareunia

Pre-existing History Acquired

Non-organic Examination ± investigations

Organic

Refer to psychosexual therapist

Vaginal dryness Scar tissue

Reassurance ± lubricants Reassurance Modified Fenton's procedure

Figure 2. Algorithm of Perineal refashioning management of postpartum dyspareunia

248 © 2004 Royal College of Obstetricians and Gynaecologists future occasions in anticipation of further pain. vibrator to alleviate pelvic congestion in the REVIEW Hence, relaxation exercises prior to or during shortest time possible. The Obstetrician intercourse can be helpful.20 & Gynaecologist Where symptoms of deep dyspareunia persist Following childbirth women can have low levels despite the above advice, further investigations 2005;7:245–249 of oestrogen due to breastfeeding or the use of may be needed to exclude underlying hormonal contraception, which can lead to gynaecological or urological causes. vaginal dryness and atrophic vaginitis.6 Topical oestrogen is used successfully in relieving Non-organic causes symptoms relating to atrophic vaginal changes in postmenopausal women. However, there is sparse This diagnosis is made after exclusion of an information relating to application during the underlying organic cause for the woman’s postpartum period. Vaginal lubricants can be symptoms. It is important to emphasise that the offered to women wishing to avoid the use of generalist obstetrician and gynaecologist is topical oestrogen. unlikely to possess the skills necessary to assess and treat the complex problems associated with non- Deep dyspareunia organic sexual dysfunction. Hence, once an organic cause has been excluded, couples should When managing deep dyspareunia, initial advice be referred to a specialist in psychosexual disorders should be given regarding modification of for further counselling, advice and management. intercourse positions and adopting those in which the woman is in control of the depth of Conclusion penetration (woman on top) or in which penetration is not too deep (side by side or Dyspareunia affects many women following ‘spoons’ position).20 childbirth. However, the true extent of the problem is difficult to estimate due to the fact If the woman experiences deep pain in the hours that many women are reluctant to seek medical or days following intercourse, this can be advice. Women should be informed that secondary to pelvic congestion syndrome. This although it is quite normal for sexual interest to pain is sometimes associated with backache and decrease during the early postpartum period, urinary and breast symptoms. Pelvic congestion painful intercourse should not be expected to can be due to failure to achieve orgasm; occur. For those women who suffer postpartum however, this assumption should only be made dyspareunia it is important to provide prompt, after excluding an underlying organic cause. In appropriate management to promote the such cases, advice should be given to the woman resumption of normal sexual function and to ensure that she achieves orgasm either prevent long-term physical and psychosocial through intercourse, masturbation or the use of a morbidity. ■

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