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Home , Lochia, Midwifery, Postpartum period, Sex after pregnancy

How to prepare your patient for the many nuances of postpartum sexuality

Up-to-date strategies for educating and advising your patient are more effective (and efficient) than traditional counseling

Roya Rezaee, MD, and Sheryl Kingsberg, PhD

CASE Waiting for an OK to resume sex Before , L. L. had a normal L. L. is a 29-year-old woman, G1P1, who medical history and conceived spontaneously. delivered a healthy 4 weeks ago by Her antenatal course was uncomplicated. spontaneous vaginal birth. The delivery Today, she returns for her postpartum involved a 2-day induction of labor for visit. She reports being tired and says she preeclampsia and a second-degree tear that still has some pain at the site of the tear, but was repaired without complication. The patient reports no problems with urinary or fecal also experienced postpartum hemorrhage continence. She denies being depressed, that was managed with bimanual massage and her Edinburgh Postnatal Depression In this and uterotonics and for which she ultimately Article Scale (EPDS) score is consistent with that required transfusion of products. Her report. She is and appears to A model for hospital course was otherwise unremarkable. be doing well on the progestin-only pill for counseling contraception. She has not yet attempted intercourse because she is complying with page 26 Dr. Rezaee is Assistant Professor of and instructions to wait until she sees you for her Gynecology at the University postpartum visit. The 6-item Hospitals Case Medical How should you counsel her about Female Sexual Center, MacDonald Women’s Hospital, and Medical Director resuming sexual activity? Function Index of the Women’s Health page 29 Center at the University Hospitals Case Medical Center in Cleveland, Ohio. hildbirth is a central event in a wom- The female body Dr. Kingsberg is Chief of an’s life. Pregnancy and delivery are undergoes striking the Division of Behavioral a time of psychological, biological, Medicine at the University C changes after Hospitals Case Medical and physical transformation, and the post- delivery Center, MacDonald Women’s partum period—the “fourth trimester”—is Hospital, and Professor of page 32 Reproductive Biology and no exception. Sexual function may be affect- Psychiatry at Case Western ed. In fact, many women who seek assistance Reserve University School of for sexual dissatisfaction note that their prob- Medicine in Cleveland, Ohio. lem arose in the .1 On the Web Dr. Rezaee receives grant or research support Postpartum sexuality involves consid- from Paladin Technologies. Dr. Kingsberg erably more than the physical act of genital 5 tips for talking to receives grant or research support from BioSante patients about and Paladin Technologies, and is a consultant to stimulation—with or without intromission or postpartum BioSante Pharmaceuticals, Pfizer, Norvo Nordisk, penile penetration—and depends on more Viveve, Trimel Pharmaceuticals, and Sprout sexuality, at Pharmaceuticals. than the physical state of recovery of the vagi- obgmanagement.com na (after ). It also depends on:

24 OBG Management | January 2012 | Vol. 24 No. 1 obgmanagement.com Postpartum sexuality ock t rs tte shu : o t ho P

• the woman’s sexual drive and motivation A paucity of research • her general state of health and quality of To date, research into sexuality during the life postpartum period has focused primar- • her emotional readiness to resume sexual ily on the physical changes and constraints intimacy with a partner that affect the mechanics and frequency of • her adaptation to the maternal role and intercourse and overall sexual satisfaction ability to balance her identity as a mother and desire.2 This perspective has begun to Many women who with her identity as a sexual being broaden to include the psychological aspects seek assistance • her relationship with her partner. of sexuality. for sexual Given all these contributing factors, Women’s sexual health during the post- dissatisfaction report many of which fall outside the scope of the partum period has generally been under- that their problem clinical practice of obstetrics and gynecology, researched. It wasn’t until the past decade arose postpartum how do we go about counseling our patients that validated sexual function questionnaires about the resumption of sexual activity? were utilized. Although a number of these Other questions: instruments are now available (TABLE 1, • How can we help patients manage expec- page 28; TABLE 2, page 29; FIGURE, page 30), tations about the quality of their postpar- it remains unclear whether they can accu- tum sexual function? rately measure postpartum sexual function. • What guidance can we provide regarding Despite these limitations, significant infor- the interplay of psychosexual and physical mation has been elicited that can be used to aspects of the puerperium? counsel patients struggling with postpartum • Can we offer a method of screening for sexual concerns. in the puerperium? If so, will it help prevent sexual problems or Ideal period of abstinence is unknown hasten their resolution? Although our knowledge of the female geni- This article addresses these issues. Ultimately, tal tract in the puerperium is based upon the answer to the question of when to resume histologic evidence, there are no evidence- sexual activity should reflect an awareness of based policies to outline the ideal period cultural norms and taboos as well as familiar- of postpartum coital abstinence. It seems ity with empirically based recommendations. reasonable to assume that our traditional

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scientific recommendations developed in by the American College of Obstetricians part to prevent uterine infection and dis- and Gynecologists (ACOG) in 1984.1 In 1985, ruption of sutured wounds. These concerns, Pritchard and colleagues wrote about the in- combined with cultural and societal norms, dividualization of postpartum prohibitions have led to the routine discouragement of of sexual activity in Williams Obstetrics.1 sexual activity until 4 to 6 weeks postpartum. The earliest time at which intercourse may The possibility of shortening the period be safely resumed is unknown, but the 23rd of postpartum abstinence was first suggested edition of Williams Obstetrics states that a

How to counsel patients about postpartum sex

Traditional postpartum sexual education is for intimate expression, non-coital sexual not evidence-based and has limited effec- activities, and mutual pleasure within her tiveness. More up-to-date strategies can cultural context. be easily incorporated into even the busi- est clinical practice. We offer the following Be thorough counseling model for you to consider when addressing the sexual health of patients Take a comprehensive medical, obstetric, postpartum. psychological, and social history as part of the sexual history. Also perform a physical intake and exam. Questions about urinary Educate, legitimize, and normalize and ought to be part of all postpartum assessment. The first sexual encounter after can Other potential areas to address include be an important step for couples to reclaim the quality of the relationship, prepreg- their intimate relationship. nancy sexual function, the support network, Adaptation to the parental role, physi- planned or unplanned state of the pregnancy, Be proactive cal healing, hormonal changes, breastfeed- previous pregnancy and delivery outcomes, in antepartum ing, and sleep deprivation contribute to the health status of current children, and and postpartum a profound psychosocial challenge. The present, previous, and future contraceptive counseling about resumption of sexual activities and a satis- use.29 fying postpartum sex life depend on many issues related to variables, many of which the patient may not Consider multiple visits sexuality. For even be aware. example, explain First, do not assume that all patients are It is hard to know exactly when to evaluate that a postpartum heterosexual and that intercourse is their only a patient for postpartum sexual dysfunction, decrease in the form of sexual activity. given the impact of pudendal nerve latency, Second, it is important to be proactive in fatigue, and breastfeeding. For this reason, frequency of sexual antepartum and postpartum counseling and assessment on multiple occasions may be activity is normal. to offer anticipatory guidance. Counseling appropriate. Numerous validated scales to can take place any time during routine pre- assess sexual function can be easily incorpo- natal care, as well as at the time of hospital rated into clinical practice. discharge and the postpartum visit. Couples counseling and therapy may be Reassure the patient that, if sexual activ- needed in some cases; be aware of refer- ity and frequency are lower during pregnancy ral services in your area for sexual wellness and the postpartum period, it is likely a specialists. normal transition. Also give the patient time The bottom line: A “successful” sexual to talk about her expectations and percep- life does not necessarily mean adequate tions. Explain to her the normal fluctuations genital function (e.g., coital , im- and variability of sexual interest and enjoy- proved clitoral blood flow, increased sexual ment in pregnancy and the puerperium, and frequency) but, rather, a sexual life that is inti- suggest that she consider alternative options mate and satisfying to the individual patient.

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TABLE 1 These validated tools can help you measure female sexual dysfunction

Tool Area assessed Female Sexual Function Index (FSFI)30 Desire, arousal, orgasm, and pain Female Sexual Function Index 6-Item (FSFI-6)31 Desire, arousal, orgasm, and pain McCoy Female Sexual Function Questionnaire*32 Presence of female sexual disorders Brief Sexual Symptoms Checklist33 Screener for sexual concerns Female Sexual Distress Scale – Revised34 Distress Intimate Relationship Scale*35 Changes in sexual relationship Sexual Quality of Life – Female (SQol-F)36 Quality of life in women with female sexual dysfunction Golombok Rust Inventory of Sexual Satisfaction (GRISS)37 Quality of sexual relationship Decreased Screener38 Brief diagnostic tool for hypoactive sexual desire disorder

* Validated in pregnant and/or postpartum women

woman can resume as 6 months postpartum.7 Using psychological early as 2 weeks, based on her comfort and and medical data banks, she brought together desire.3 The sixth edition of the American information from two branches of science Academy of Pediatrics (AAP) and ACOG and identified 59 relevant studies in English guidelines for perinatal care also states that or German between 1950 and 1996. Although the risks ought to be minimal at 2 weeks the majority of studies were retrospective and postpartum.4 failed to utilize a validated instrument, von Sydow determined that, overall, sexual in- terest and activity were low or nonexistent ACOG confirms Low desire is not unusual during the first months after delivery. There that sexual activity Although a patient may be granted “permis- was high variability between individuals, may be resumed sion” to engage in coital activity, other vari- however, and levels of sexual interest and ac- with minimal risk ables influence her decision. It is well known tivity of individual women remained relatively as early as 2 weeks that sexual desire may fluctuate during preg- constant from the time before pregnancy un- 7 postpartum nancy and typically decreases significantly til 1 year postpartum. von Sydow determined during the third trimester.2 Many women en- that there is great variability in female sexu- ter the postpartum period with lower levels ality during pregnancy and postpartum; this of sexual desire and satisfaction, and these variability may represent fluctuations during depressed levels may continue for some this phase of life. She also determined that time.2 Twenty-five percent of women report severe psychosexual and marital problems worsened sexual function, including dimin- are much more prevalent in the postpartum ished sexual satisfaction, during pregnancy period than during pregnancy and persist that persists for 6 to 12 months postpartum.5 long after a physical cause can be used as an By 12 weeks postpartum, 80% to 93% of ­explanation.7 women have resumed intercourse, but as many as 83% report sexual problems during Fatigue and quality of the relationship the first 3 months of the postpartum period. have an impact on sexual function At 6 months, 18% to 30% of these women De Judicibus and colleagues identified a may still be experiencing sexual problems, broad range of variables that have a detri- including .5,6 mental impact on sexuality at 12 weeks post- In 1998, von Sydow performed a meta- partum, most particularly: content analysis of all existing studies on pa- • marital dissatisfaction rental sexuality during pregnancy and the first • dyspareunia

28 OBG Management | January 2012 | Vol. 24 No. 1 obgmanagement.com TABLE 2 The 6-item Female Sexual Function Index*

Question Responses 0 points 5 points 4 points 3 points 2 points 1 point How would you rate your level of No sexual Very high High Moderate Low Very low or sexual desire or interest? activity none at all How would you rate your level of No sexual Very high High Moderate Low Very low or (“turn on”) during activity none at all sexual activity or intercourse? How often did you become No sexual Almost Most times Sometimes A few times Almost never lubricated (“wet”) during sexual activity always or or never activity or intercourse? always When you had sexual stimulation No sexual Almost Most times Sometimes A few times Almost never or intercourse, how often did you activity always or or never reach orgasm? always How satisfied have you been No sexual Very Moderately About equally Moderately Very overall with your sexual life? activity satisfied satisfied satisfied and dissatisfied dissatisfied dissatisfied How often did you experience Did not Almost A few times Sometimes Most times Almost discomfort or pain during vaginal attempt never or always or penetration? intercourse never always

*The components of this index are to be assessed over the past 4 weeks. The score is the sum of the ordinal responses to the 6 items and ranges from 2 to 30. A score of less than 19 indicates a need for further investigation, including the full-length Female Sexual Function Index.

Source: Adapted from Isidori et al.31

• fatigue Don’t underestimate the impact of • depression obstetric morbidity • breastfeeding.2 Surprisingly, the long-term impact of severe There is evidence to suggest that the addition obstetric events on postpartum maternal Fatigue is a common of the first child reduces marital quality af- health is often overlooked. Waterstone and reason given for loss ter the first month postpartum, and this de- colleagues found that women who have of sexual desire and cline in marital satisfaction continues for 6 to severe obstetric morbidity, such as mas- interest, infrequent 18 months postpartum.2 Witting and cowork- sive hemorrhage, preeclampsia, , sexual activity, and ers suggested that this decline may represent and , experience significant lack of enjoyment a transitional phase of parenthood for some changes in sexual health and well-being.10 couples; data support the positive effects on They conducted a prospective cohort study overall marital satisfaction with the addition of such women, measuring sexual activity, of children.8 Women who were more satis- general health, and . fied with their relationships reported high- They utilized two validated postnatal -ques er sexual satisfaction and greater frequency tionnaires—the Short Form 36 (SF-36) to of intercourse.2,8 measure general health and the EPDS. Fatigue is one of the most common Women who had uncomplicated pregnan- problems women experience during preg- cies and childbirth tended to perform well nancy and postpartum and is a common in most SF-36 categories, whereas women reason given for loss of sexual desire and who had experienced severe morbidity interest, infrequent sexual activity, and lack scored worse in almost every category. These of enjoyment.5 A high level of exhaustion is women also reported problems with inter- found during the first 8 weeks postpartum. course. Thirteen percent of women had not Although it declines over the next 6 months, resumed sexual relations by 6 to 12 months it does not appear to resolve completely in a postpartum; of these women, more than half good number of women.9 reported a fear of conceiving as a reason. continued on page 30

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Brief Sexual Symptoms Checklist for Women (BSSC-W)

Please answer the following questions about your overall sexual function: 1. Are you satisfied with your sexual function? Yes___ No___ If “No,” please continue: 2. How long have you been dissatisfied with your sexual function? ______3a. The problem(s) with your sexual function is: (Mark one or more) ___1 Problem with little or no interest in sex ___2 Problem with decreased genital sensation (feeling) ___3 Problem with decreased (dryness) ___4 Problem with reaching orgasm ___5 Problem with pain during sex ___6 Other:______3b. Which problem is most bothersome? (Circle) 1 2 3 4 5 6 4. Would you like to talk about it with your doctor? Yes___ No___

Reprinted from Hatzichristou et al.33

Exploring the role of body image the third trimester and postpartum, whereas Paul and coworkers prospectively assessed feelings of unattractiveness and issues of female sexual function, body image, and pel- body image were present throughout preg- vic symptoms from the first trimester until nancy and at their worst in the postpartum 6 months postpartum.11 They utilized the val- period. Sexual function scores based on the idated questionnaire instruments of the Fe- FSFI declined during pregnancy and did Sexual activity and male Sexual Function Index (FSFI), the Body not return to pre-pregnancy or first-trimes- sexual function Exposure during Sexual Activities Ques- ter levels by 6 months postpartum. Urinary scores were highest tionnaire (BESAQ), the short forms of the symptoms, as measured by the UDI-6, were before pregnancy, Urogenital Distress Inventory (UDI-6), the associated with lower sexual function scores declined between Incontinence Impact Questionnaire (IIQ-7), during the postpartum period. The asso- the first and third and the Fecal Incontinence Quality of Life ciation between and Scale (FIQOL). They found that sexual activ- sexual dysfunction has been seen in other trimesters, and ity and sexual function scores were highest studies.13,14 did not return to before pregnancy, declined between the first baseline even by and third trimesters, and did not return to The enduring effects of 6 months pre-pregnancy baselines even by 6 months perineal trauma postpartum postpartum.11 Childbirth may physically affect a woman’s Differences in sexual practices contrib- sexual function through perineal trauma, uted to these patterns. Kissing, fondling, and pudendal neuropathy, and vaginal dryness vaginal intercourse remained stable across associated with breastfeeding. There is an pregnancy, whereas oral sex, stimula- obvious connection between perineal lac- tion, and declined in the third eration and perineal pain and problems with trimester. intercourse.5 Overall, dyspareunia is report- The decline of these activities during ed by 41% to 67% of women 2 to 3 months pregnancy and postpartum has been seen in after delivery.15 Women who have an episi- other studies as well.12 otomy complain of increased perineal pain Obstacles to sexual activity also changed and delayed return of sexual activity, com- across pregnancy and the postpartum pe- pared with women who deliver with an in- riod. Vaginal pain was more problematic in tact .16

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who had a low rate of and op- The female body undergoes dramatic changes erative vaginal delivery.6 They utilized the after delivery Intimate Relationship Scale (IRS), a vali- dated questionnaire to measure postpartum The female body undergoes dramatic physiologic, anatomic, and sexual function in couples. Most women in psychological changes immediately following delivery and throughout this study had resumed sexual activity by the restoration of its pre-pregnant state. This fourth trimester usually 3 months postpartum and did not have post- lasts 6 to 12 weeks.39 partum inactivity or dysfunction, based on . The uterus undergoes rapid involution after separation of the . By 2 to 4 weeks postpartum, it may no longer be palpable their IRS scores. However, women who were abdominally, and by 6 weeks, it usually has returned to its nonpreg- identified as having experienced major trau- nant state and size. Seven to 14 days after delivery, a woman often ma (second-, third-, or fourth-degree lacera- experiences an episode of heavier vaginal that corresponds tion or a repaired first-degree laceration) had with the sloughing of the placental bed eschar. During this time of significantly less desire to engage in activi- 40 involution, myometrial vessels may be 5 mm or larger in diameter. ties such as touching and stroking with their . The postpartum lochia begins to change within days of birth, partner.6 transitioning through its stages of lochia rubra, serosa, and alba. It decreases by 3 weeks postpartum and is likely completely resolved Present-day limits on the routine use by 6 weeks. of episiotomy and operative vaginal deliv- is responsible for lactogenesis. When the prolactin level is ery have yielded a lower rate of third- and maintained through breastfeeding, it depresses ovarian production of fourth-degree laceration.19 Second-degree by suppressing pituitary gonadotropin secretion, triggering a lacerations are common and constitute the period of “steroid starvation” after the loss of estrogen and progester- majority of perineal trauma in births without one production from the placenta.1 episiotomy.20 There is evidence that the use . Early in the postpartum period, the vagina is typically - tous and lax and, as a result of parturition, there may be not only a of synthetic absorbable suture, such as poly- spontaneous tear or episiotomy that must heal, but superficial small glactin, rather than chromic suture, results tears that do not require suturing. Ruggae begin to reappear by 3 in less postpartum perineal pain, as does weeks, and the vaginal epithelium will begin to mature under the influ- leaving the well-approximated perineal skin ence of estrogen production. Much of this tissue damage is healed by edges unsutured.20 6 weeks postpartum. Signorello and coworkers found that The perception of pregnant and postpartum women’s sexuality second-, third-, and fourth-degree lacera- varies, based on religious and cultural norms. In some religions and tions increased the risk of postpartum dys- cultures, sexual activity is forbidden for 2 to 3 months postpartum; in others, it is prohibited until the child is weaned from the breast. The pareunia; operative vaginal delivery (forceps postpartum woman and lochia have traditionally been perceived as or vacuum) was also an independent risk unclean, and many religions have specific proscriptions regarding the factor for dyspareunia.21 management of this time in a woman’s life.1 Although early cultures did not study these issues specifically, their doctrines suggest that The impact of route of delivery they had some awareness of the natural physiologic transition of a Some researchers have concluded that woman’s body after she has given birth. the route of delivery has an impact on the long-term pelvic floor health of women.18 In 1986, Snooks and colleagues analyzed Persistent dyspareunia is strongly as- possible obstetric risk factors for damage sociated with the severity of perineal to the innervation of the pelvic floor, which trauma and operative vaginal delivery.3,17 can lead to both stress urinary and ano- Multiple studies have investigated this asso- rectal incontinence.22 They found that the ciation and found a positive correlation 3 to process of vaginal delivery causes a com- 6 months postpartum,6,9,17 but the long-term pression and stretch type of injury to the effects and association remain unclear.18 pudendal nerve, as well as the possibility Findings from research. Rogers and col- of severe perineal lacerations. This injury leagues prospectively studied the effect of may be less likely to occur when cesarean perineal trauma on postpartum sexual func- delivery is performed before labor, avoid- tion in a population of women ing direct perineal trauma and possible

32 OBG Management | January 2012 | Vol. 24 No. 1 obgmanagement.com pudendal neuropathy.15 Because the pu- dendal nerve mediates some of the reflex Women are reluctant to discuss sexual needs pathways in the female sexual response, it is plausible that damage to it could result The majority of women will discuss contraception with a health pro- in sexual dysfunction. vider, but only 15% will voluntarily discuss their sexual needs or dys- function.17 This finding is alarming given that, during the postpartum Women who deliver vaginally have a period, two of every three new mothers will experience at least one higher rate of fecal and urinary incontinence problem related to sexual function, including dyspareunia, decreased 16,23 than women who deliver by cesarean. The , difficulty achieving orgasm, and vaginal dryness.41 This lack of presence of incontinence, however, does not discussion with a health-care provider may be the result of several always have a significant long-term effect on variables: incomplete knowledge on the part of the provider about one’s sexual life.6 what affects sexual function, poor training in the taking of an effec- In the Term Breech Trial, the route of tive sexual history, and uneasiness on the part of the patient about 5,42 delivery had no impact on the resumption discussing the issue. of intercourse, dyspareunia, or sexual satis- faction.23 Although the trial was randomized and controlled, it had many limitations that of intercourse.1,5 A high level of prolactin call its generalizability into question in re- suppresses ovarian production of estrogen, gard to postpartum sexual dysfunction. thereby reducing vaginal lubrication. Some The National Institutes of Health (NIH) women and their partner may identify this State-of-the-Science Conference on Cesar- loss of lubrication as a lack of arousal. This ean Delivery on Maternal Request indicated type of vaginal dryness should be explained, that, by 6 months postpartum, there is no and the use of a lubricant should be encour- difference in sexual function based on the aged in breastfeeding women. route of delivery.24 However, Lydon-Rochelle Nipple sensitivity may develop, mak- and colleagues used the SF-36 to assess re- ing touching and foreplay uncomfortable in ported general health status and found some women. One third to one half of moth- that women who had cesarean delivery or ers find breastfeeding to be an erotic expe- Women who assisted vaginal delivery exhibited signifi- rience, and one fourth feel guilty about this undergo cesarean cantly poorer postpartum functional status sexual excitement; others stop or delivery may have 1,7 than women who had spontaneous vaginal wean early due to these feelings. Women an elevated risk of delivery in five areas at 7 weeks postpartum: are often not educated about the relation- nondyspareunia– physical functioning, mental health, gen- ship between the release of , uterine related causes of eral health perception, bodily pain, social contractions, milk ejection, sexual arousal, sexual dysfunction functioning, and ability to perform daily and orgasm; raising the subject can help to activities.25 Women were more likely to be diminish any potential distress over this re- readmitted to the hospital and more likely sponse. to report fatigue during the first 2 months Sleep disturbances from feeding on de- after cesarean delivery.9 It appears that mand contribute to fatigue and exhaustion. women who undergo cesarean delivery Many women may not realize that their have an elevated risk of nondyspareunia- loss of interest in sex may be because they related causes of sexual dysfunction. Any are receiving sufficient physical contact protective effect of cesarean on sexual func- or touching through their nurturing inter- tion is limited to the early postnatal period actions with the baby. This may leave the and is related to the absence of perineal partner feeling isolated and envious of the injury.18 mother-baby relationship. Couples should be encouraged to dis- How breastfeeding can affect cuss these feelings to avoid misperceptions sexual desire and to maintain the relationship dyad as a Evidence is strong that breastfeeding reduces priority to prevent the development of rela- a woman’s sexual desire and the frequency tionship problems. continued on page 34

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Sexual health resources on the Web

For clinicians • American Association of Sex Educators, Counselors, and Therapists – A not-for-profit, in- terdisciplinary professional organization comprising sexuality educators, sexuality counsel- ors, sex therapists, , social workers, and other clinicians. Its home page links to a referral page and other resources. http://www.aasect.org

• Association of Professionals offers a resource for clinicians on post- partum counseling about sexuality. http://www.arhp.org/publications-and-resources/ quick-reference-guide-for-clinicians/postpartum-counseling/contraception

For patients • Mayo Clinic provides a fact sheet entitled “: Set your own timeline.” http://www.mayoclinic.com/health/sex-after-pregnancy/PR00146

• Sex and a Healthier You – This site offers information for patients on sexuality and relation- ships. http://www.sexandahealthieryou.org/sex-health/index.html

Postnatal depression Role of pharmacotherapy takes a toll Many women are started on antidepres- Depressed mood and emotional lability in sant medication near the time of delivery or the postpartum period are negatively as- during the immediate postpartum period. sociated with sexual interest, enjoyment, Often, serotonin reuptake inhibitors (SRIs) coital activity, and perceived tenderness are used because there is minimal trans- If a woman initiates of the partner.7 Conversely, reduced sexual mission of this class of medication through antidepressant interest, desire and satisfaction; a lower . However, the potential sexual therapy near the frequency of intercourse; and later resump- side effects of these medications should be time of delivery or tion of intercourse are associated with a discussed because they are the agents most during the immediate higher number of psychiatric symptoms in commonly associated with female sexual 2 28 postpartum period, the postpartum period. Between 10% and dysfunction. 15% of women experience postpartum de- counsel her about pression (PPD).26 Depression has been as- References potential sexual side 1. Reamy KJ, White SE. Sexuality in the puerperium: a review. sociated with a decreased frequency and Arch Sex Behav. 1987;16(2):165–186. effects interest in sexual activity at 8 to 12 weeks 2. De Judicibus MA, McCabe MP. Psychological factors and the sexuality of pregnant and postpartum women. J Sex Res. 2,5 postpartum. 2002;39(2):94–103. Chivers and colleagues assessed sexual 3. The puerperium. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, eds. Williams Obstetrics. 23rd functioning and sexual behavior in women ed. New York, NY: McGraw-Hill Co.; 2010:646–660. with and without symptoms of PPD using the 4. The American Academy of Pediatrics (AAP), American College of Obstetricians Gynecologists (ACOG). Guidelines FSFI and EPDS. Although theirs was a small for perinatal care. 6th ed. Washington, DC: AAP, ACOG; study, they found that women who had de- 2008. 5. Glazener CM. Sexual function after childbirth: women’s pressive symptoms also reported poorer experiences, persistent morbidity and lack of professional functioning in regard to sexual arousal, or- recognition. Br J Obstet Gynaecol. 1997:104(3):330–335. 6. Rogers RG, Borders, N, Leeman L, Albers L. Does gasm, pain, lubrication, and sexual satis- spontaneous genital tract trauma impact postpartum sexual faction.26 Morof and coworkers found that function? J Midwifery Womens Health. 2009;54(2):98–103. 7. von Sydow K. Sexuality during pregnancy and after women who had PPD were less likely to have childbirth: a metacontent analysis of 59 studies. J resumed intercourse by 6 months postpar- Psychosom Res. 1999;47(1):27–49. 8. Witting K, Santtila P, Alanko K, et al. Female sexual tum; they were also less likely to engage in function and its associations with number of children, other sexual activities.27 pregnancy, and relationship satisfaction. J Sex Marital Ther.

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