Sexual Health during Pregnancy and the Postpartum (CME)

Continuing Medical Education Sexual Health during Pregnancy and the Postpartum jsm_2223 1267..1284 Crista E. Johnson, MD, MSc, FACOG Departments Obstetrics and Gynecology, Maricopa Integrated Health System, Phoenix, AZ, USA DOI: 10.1111/j.1743-6109.2011.02223.x ABSTRACT Introduction. Pregnancy and childbirth is a special period in a woman’s life, which involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of a couple’s sexual relationship. Aim. To comprehensively review the literature on the effects of pregnancy and the postpartum period on a couple’s sexual health and well-being. Main Outcome Measures. Evidence from the published literature of the impact of pregnancy, childbirth, and the postpartum period on sexual function. Methods. Medline and PubMed search for relevant publications on the effects of pregnancy and childbirth on sexual health and function, with particular focus on the physical, hormonal, psychological, social, and cultural changes that may occur during the antepartum, intrapartum, and postpartum period. Results. Despite fears and myths about sexual activity during pregnancy, maintaining a couple’s sexual interactions throughout pregnancy and the postpartum period can promote sexual health and well-being and a greater depth of intimacy. Conclusions. Clinicians must seek to engage in an open discussion and provide anticipatory guidance for the couple on expected changes in sexual health as well as promote the design of rigorous, evidence-based studies to further elucidate our understanding of sexual function during pregnancy and the postpartum. Johnson CE. Sexual health during pregnancy and the postpartum. J Sex Med 2011;8:1267–1284. Key Words. Couples; Women; Sexual Health; Sexual Dysfunction; Pregnancy; Intrapartum; Childbirth; Postpartum Introduction I n the last two decades, there have been significant advances in the understanding of normal sexual response, and good sexual health is recognized as a critical aspect of one’s overall quality of life and well-being. Pregnancy and childbirth is a special period in a woman’s life, which involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of a couple’s sexual relationship. This transitional phase also prepares a couple for new roles as parents. For the first pregnancy, a transition takes place from being a couple to becoming a family, and from being a J Sex Med 2011;8:1267–1284 person in a relationship to motherhood and fatherhood. As with any transition, there may be a sense of loss as well as excitement of entering another phase of one’s life experience [1]. Sexual dysfunction may become pronounced during this period of profound physical, emotional, and psychological change [2]. Over the past four decades, there has been significant advancement in our understanding of female sexual response. The original model proposed by Masters and Johnson described sexual stimulation as a linear model progressing through sequential phases encompassing desire, arousal, orgasm, and resolution [3], and was extended by Kaplan to reflect a pattern of sexual desire, arousal, 1267 Continuing Medical Education and orgasm [4]. Basson later postulated that some women may be motivated to engage in sexual activity not necessarily out of desire, but for other reasons such as a wish for emotional intimacy, following instead a circular cycle of overlapping phases and varying sequences [5]. It is now recognized that no single model reflects a normative description of female sexual response [6], but rather may instead encompass heterogeneous patterns of response. Women who endorse the Masters and Johnson, as well as Kaplan models experience sexual desire, become aroused easily, may reach orgasm, and are satisfied with their sexuality and sexual relationships. The Basson model may provide an expansion of the earlier models, as it may be more reflective of women experiencing problematic, unsatisfying sexual response [6]. It has also been recognized that sexual satisfaction encompasses the environment and stimuli conducive to sexual feelings as well as one’s subjective experience [7]. Many interpersonal, contextual, psychological, and biological factors can influence sexual dysfunction, and may be altered during pregnancy and the postpartum. These factors include changes in a couple’s relationship, marital adjustment, developing a parental relation or consolidating a previous one, planned/ unplanned and desired/undesired pregnancy, first pregnancy, history of previous pregnancies or abortions, physical, and hormonal changes that can promote low self-image, mood instability, difficulty, and discomfort in executing vaginal intercourse [8]. This review examines how various physical, hormonal, and psychological changes of pregnancy can influence a couple’s sexual health throughout the antepartum period, and how the effects of delivery as well as the transition of the family unit to the additions of a newborn may impact postpartum sexual health. Common fears and myths debunked, and underlying sociocultural factors influencing sexual activity are explored. It is important to recognize that inherent limitations and biases do exist throughout the literature as sexual changes during pregnancy and the postpartum period may be coined as a “dysfunction” rather than reflect the appropriate and normal changes that occur in the majority of women. Moreover, by nature, there is publication bias in the literature as scientific studies tend to reflect the morbidity inherent among high-risk women, 1268 which may not be generalizable to the general population of women’s pregnancy and childbirth experiences and its perceived impact on a couple’s sexual health. Consequently, studies tend to focus more on sexual dysfunction rather than the positive impact pregnancy, childbirth, and the postpartum period may have on a couple’s sexual intimacy. The different levels of clinical evidence presented in this review have been ranked according to the U.S. Preventive Services Task Force designation as follows: Level I: Evidence obtained from at least one properly designed randomized controlled trial; Level II-1: Evidence obtained from welldesigned controlled trials without randomization; Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group; Level II-3: Evidence obtained from multiple time series with or without the intervention (i.e., crosssectional studies); Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees [9]. At the conclusion of this review, practical guidelines are provided to aid in a clinician’s ability to competently engage in appropriate anticipatory guidance, counseling, and reassurance of women and their partners. Antepartum Specific changes in each trimester of pregnancy may significantly impact sexual behavior. The body of evidence on the effect of pregnancy on sexual health concludes that sexual function declines throughout pregnancy, particularly during the third trimester [3,10–20]. This reduction does not resolve immediately postpartum, but may persist during the first 3–6 months after delivery, followed by a gradual and steady recovery. The main contributing factors that may affect the sexual health of pregnant women pertain to hormonal and physical changes that lead to a perceived lack of attractiveness, as well as emotional and psychological changes, which result in a loss of interest in sexual activity [21]. Physical Changes There are a number of physical factors associated with pregnancy that can reduce sexual activity [1,22]. These include fatigue [23,24], back pain, dyspareunia, infection (i.e., urinary tract infections and vaginitis), and vulvar varicose veins. The earJ Sex Med 2011;8:1267–1284 Continuing Medical Education liest studies on sexuality during pregnancy reported variable patterns of sexual desire and function in the first and second trimesters, and a sharp decline in the third trimester, with incorporation of more noncoital body contact [3,15,25]. In a metacontent analysis of 59 studies, von Sydow reported that 76–79% of women enjoyed sexual intercourse before pregnancy (7–21% not at all), while this decreased to 59% in the first trimester, 75–84% in the second trimester, and 40–41% in the third trimester [2,18–20,25–30]. Though these early studies were conducted prior to the growing evidence of female sexual response and the use of objective validated measures of sexual function, the outcomes have remained consistent. Recent studies indicate pregnant women experience symptoms of diminished clitoral sensation, lack of libido, and orgasmic disorder, which may persist up to 6 months postpartum [2,10,12,13,31– 33]. However, it is important to emphasize that the changes in sexual function during pregnancy are normal changes that occur in the majority of women. In a cross-sectional study incorporating a validated scale of sexual function, Erol et al. reported the most common sexual changes experienced among 589 healthy pregnant women as diminished clitoral sensation, observed in 94.2% of the women, followed by lack of libido in 92.6%, and orgasmic disorder in 81% (Level II-3) [13]. Among 81 primiparous couples in a longitudinal cohort, Bogren [18] noted that sexual satisfaction declined during pregnancy, most notably during the first and third trimesters. During the first trimester, 35% of the women and 22% of the men experienced diminished sexual satisfaction (P = 0.002). In the second trimester, 30% of the women and 26% of the men perceived diminished sexual satisfaction, while during the third trimester, 55% of the women and 76% of the men experienced diminished sexual satisfaction (P = 0.01; Level II-2). Coital frequency has been noted to decline with advancing gestational age and is influenced by dyspareunia and decreased orgasmic quality [34]. A number of factors may explain the decrease in sexual activity and desire that occurs during the third trimester (Table 1). These include deep engagement of the fetal head, stress incontinence, hemorrhoids, weight of the partner on the uterus during sexual intercourse, and subluxation of the pubic symphysis and sacroiliac joints [1]. As pregnancy progresses, the length of intercourse and J Sex Med 2011;8:1267–1284 Table 1 Physical changes of pregnancy which may impact sexual activity in the third trimester Deep engagement of the fetal head Stress urinary incontinence Hemorrhoids Weight of partner on uterus Subluxation of pubic symphysis and sacroiliac joints Vaginal discomfort/dyspareunia Pelvic and vaginal vasocongestion ability to experience orgasm decreases. Vaginal discomfort may become more pronounced as a result of changes in vaginal physiology in response to hormonal changes wherein the connective tissue of the vagina decreases and the muscle fibers of the vaginal wall increase in size in preparation for delivery [13,35,36]. During the third trimester, vaginal contractions are weaker and tonic muscle spasms may occasionally occur, which may influence orgasmic response. Furthermore, pelvic vasocongestion and vaginal congestion with reduced lubrication, can cause dyspareunia [1]. Hormonal Changes The increased levels of hormones such as estrogen, progesterone, and prolactin may cause many of the symptoms of pregnancy including nausea, vomiting, weight gain, fatigue, breast tenderness, and fatigue, all of which can reduce sexual desire and arousal. As pregnancy progresses, estrogen and progestin rise to progressively high levels, with estradiol rising to approximately 50-fold by the end of pregnancy [37]. Hormones such as relaxin act on vaginal tissue to enlarge the circumference of the vaginal lumen and increase epithelial cells, which may lead to a decrease in vaginal sensation [38,39]. There is growing interest in the literature to examine correlations between sexual function and circulating sex hormone levels [40,41]. During pregnancy, maternal serum testosterone levels rise along with serum sex hormone-binding globulin (SHBG), and plasma protein (which binds a large fraction of the testosterone in the serum of pregnant women). The free androgen index in the maternal serum is higher in the first trimester than in the nonpregnant state and returns to the nonpregnant reference range in the second and third trimesters [41], which should theoretically lead to a concomitant decrease in sexual desire [40,42–46]. Aslan et al. [11] measured sexual function in a prospective cohort of 40 1269 Continuing Medical Education healthy pregnant women using the validated Female Sexual Function Index (FSFI) and documented a fall in all domains of the FSFI beginning with the first trimester and progressing through each trimester of pregnancy. However, no significant association has been found between sex hormone levels and female sexual function as measured by FSFI scores (Level II-2) [11,13,41]. Erol et al. [13] assessed the sexual function of 589 pregnant women in a cross-sectional study to determine whether sexual function, as measured by the FSFI, correlated with serum androgen levels during each trimester of pregnancy. Lower sexual function scores were noted in the third trimester compared to the first two trimesters of pregnancy, but were not associated with lower androgen levels. Furthermore, while androgens produced by fetal gonads that cross the placenta do not appreciably increase the maternal androgen pool, the level of maternal testosterone does not alter due to the gender of the offspring (Level II-3) [13,47]. Hence, sex hormones are unlikely to have a major impact on sexuality during pregnancy [11,48]. Psychological Changes Sexual difficulties during pregnancy may be psychological in origin, occurring as an emotional response to the changed or changing state. Even if a child is planned and wanted, the pregnancy may not always be met with joy, but ambivalence instead [1]. There are many psychogenic factors related to pregnancy that may affect women’s sexual desire such as the anxiety of delivery and motherhood, changes in a couple’s rapport/ relationship, the negative psychological sequelae of miscarriage, lack of self-esteem, sexual guilt, and specific concerns about body image and general health status, may cause distress [1,13]. Self-consciousness about a growing and protuberant abdomen may lead to a gradual change in a pregnant woman’s self-image that may influence her self-confidence, while posing physical limitations to performing some sexual positions [10]. A careful history should be obtained to ascertain the potential etiology of changes in one’s sexual health and function. Pauls et al. conducted a prospective study of a cohort of 107 women to evaluate changes in sexual function throughout pregnancy and the postpartum and its relationships to body image using validated indices of sexual function. Body image did not change significantly during 1270 Table 2 Contraindications to sexual intercourse during pregnancy Absolute contraindications Unexplained vaginal bleeding (not yet evaluated by a provider) Placenta previa Preterm premature dilation of the cervix Preterm premature rupture of membranes (PPROM) Relative contraindications History of premature delivery Multiple gestation pregnancy, but worsened 6 months after delivery, signifying a worse body image at that time. Of note, increasing weight (as measured by body mass index [BMI]) did not directly correlate with body image, as BMI increased significantly during the third trimester, but returned to the first trimester levels by 6 months postpartum (Level II-2) [14]. Fears and Myths There are both relative and absolute contraindications to sexual intercourse during pregnancy (Table 2). Absolute contraindications include unexplained vaginal bleeding (not yet evaluated by a provider), placenta previa, premature dilatation of the cervix, and preterm premature ruptured membranes. Relative contraindications include a history of premature delivery and multiple gestation [1]. A woman’s risk of an adverse pregnancy outcome as a result of sexual intercourse should be individually considered and discussed with her provider. Outside of these contraindications, sexual intercourse is acceptable and should be encouraged for women who desire sexual intercourse and are in safe and loving relationships throughout pregnancy. Nevertheless, fears and myths that sexual intercourse results in fetal injuries, miscarriage, infection, bleeding, and preterm labor have been propagated, which results in an avoidance of sexual intercourse during pregnancy [10,12,33,34,49,50]. These fears and myths however have been widely refuted [51–54]. Erol et al. [13] noted that 41% of 589 pregnant women in a cross-sectional study refrained from engaging in sexual activities in the third trimester due to fears of premature termination of pregnancy, preterm labor, and harming the baby, while the rate of abstinence was only 14.7% and 14.1% in the first and second trimesters, respectively (Level II-3). Bartellas et al. [12] investigated the impact of fears about sexual intercourse causing obstetric J Sex Med 2011;8:1267–1284 Continuing Medical Education complications on 141 couples’ sexuality during pregnancy in a cross-sectional study using a validated instrument of pregnancy and sexuality. Women were asked about their concerns and then couples were asked to report what they actually experienced after sexual intercourse. While the fear of abnormal bleeding was noted by 57% of the women, only 13% actually experienced this event. In contrast, 37% of the women reported experiencing changes in vaginal lubrication, while 22% of the women reported pain, neither of which had been predicted by the couple. In addition, neither premature rupture of membranes, preterm labor, infection, or damage to the fetus occurred (Level II-3). Sexual Behavior The morphofunctional alterations of pregnancy can cause discomfort with certain sexual positions, resulting in an adaptation to altered coital positions [55,56]. As pregnancy progresses, sexual positions such as woman-on-top, side-by-side, on-all-fours, or rear-entry, are used more frequently [33,55]. Studies have shown a decrease in such positions as the man-on-top and face-to-face during pregnancy, with positions with the womanon-top decreasing during the second trimester, and the side-by-side and on-all-fours positions being more frequently practiced during the third trimester [2,55,57]. Sacomori and Cardoso [55] investigated sexual initiative and change in sexual positions as measured by the Attitudes Toward Sexual Permissiveness Scale [58] among 156 pregnant Brazilian women in a retrospective cohort, and noted that before pregnancy, both partners usually initiated sexual intercourse, whereas during pregnancy, the male partner was generally more likely to begin sexual activity. Furthermore, independent of gestational age, women who initiated sexual activity demonstrated higher levels of sexual desire, frequency, excitement, satisfaction, and higher ratings of self-perceived intensity of the orgasm and the importance attributed to sex in their lives. In contrast, the lower mean of these variables usually belonged to women whose partners took the sexual initiative. Moreover, it was found that almost all sexual positions, except for the side-byby-side position, gradually and significantly decreased during pregnancy indicating that an adaptation occurs in sexual positions to accommodate the physical growth of the fetus. It was also J Sex Med 2011;8:1267–1284 noted that couples with a greater degree of intimacy accepted and negotiated a wider variety of sexual positions. In couples where both partners took sexual initiative, the frequency of rejection of some sexual positions was lower when compared with the couples in which only one of the partners (man or woman) took the initiative separately (Level II-2) [55]. Certain sexual practices, particularly oral sex and masturbation, may decline during or after pregnancy [59,60]. von Sydow et al. investigated sexual practices in 30 couples from the first trimester to 6 months postpartum in a prospective cohort study. Declines in breast stimulation, intercourse, cunnilingus, and self-stimulation were noted, which did not return to pre-pregnancy levels after delivery (Level II-2) [60]. Pauls et al. examined sexual practices and barriers to sexual activity among 107 pregnant women in a prospective cohort study using the FSFI. Of note, kissing/ fondling and vaginal intercourse remained stable throughout pregnancy and the postpartum period; however, oral sex (P = 0.004), breast stimulation, and self-stimulation declined in the third trimester of pregnancy [14]. The decline in oral sex may have reflected patients’ fears of complications, specifically the fear of air embolism following orogenital stimulation [61,62]. Vaginal pain was more bothersome in the third trimester (P < 0.001), and feelings of unattractiveness to partner was worse postpartum (P < 0.001). Vaginal looseness and vaginal dryness were not significantly different (Level II-2). Cultural Factors Social, cultural, and/or religious mores may influence a couple’s sexual behavior during pregnancy. In a Portuguese population [10], 20.4% of women practiced masturbation during pregnancy, in sharp contrast to an Iranian population [33] where only 6% reported this type of sexual activity. Cultural factors and inadequate knowledge may influence attitudes toward and fears of intercourse [10]. In a study in Pakistan [50] and Nigeria [49], women were convinced that sexual intercourse during pregnancy widens the vagina and facilitates labor, while women in a study in Iran [33] noted fear of causing rupture of the hymen of the female fetus or fetal blindness, and believed that it would be adultery to have intercourse while carrying a female fetus in the womb. A study of 298 Chinese women [17] reported that 80% of women and 1271 Continuing Medical Education their partners worried about the adverse effects of sexual activity on the fetus. Hence, positive or negative cultural attitudes toward sex during pregnancy can affect a couple’s sexual behavior. Intrapartum There is debate as to the contribution of factors such as mode of delivery, episiotomy and perineal tears, pelvic floor dysfunction, and dyspareunia on the decline in sexual well-being that occurs during pregnancy and childbirth [31,63,64]. The general health status of the mother may also have an impact on sexual function, particularly in women who experience severe obstetric morbidity, and the deleterious effects on general health and sexual function may persist for up to 1 year postpartum [65,66]. Waterstone et al. investigated 331 women who had experienced complicated deliveries (i.e., eclampsia, intrapartum hemorrhage, and sepsis) to 1,339 controls in a prospective cohort study which incorporated validated indices of general health, depression, and sexual function. Women with severe obstetrical morbidity were more likely to report poor general health 6–12 months after delivery, and experienced a delay in the resumption of sexual activity and problems with sexual function (43% vs. 19%, P < 0.01; Level II-2) [66]. Route of Delivery A protective role of cesarean section has been noted as contributing to an early recovery of sexual function postpartum [14,63,67–69]. Potential mechanisms may include minimal pudendal nerve injury, less trauma to the pelvic floor by the process of labor, and the elimination of lacerations, episiotomy and diminished pain in the postpartum period [70–72]. Women undergoing vaginal delivery are noted to have a higher rate of dyspareunia 3 months postpartum compared to women who undergo planned cesarean deliveries [23,71,73– 77]. The protective effect to dyspareunia-related symptoms after cesarean delivery in the first 3 months is most likely due to the absence of perineal injury [69]. After the first year postpartum, no significant differences can be observed [75,76,78,79]. Studies examining obstetricians’ personal preferences toward delivery have indicated the major reasons for avoiding vaginal delivery were the fear of childbirth and the concern for postpartum sexual health [80]. 1272 Several studies have investigated the relationship between sexual function and mode of delivery, but the results have been inconsistent [81,82]. Several factors may influence and confound study findings such as age, parity, associated comorbidities, substance abuse, relationship problems, and the use of validated measures/instruments [77]. Vaginal delivery is known to expose the genitalia and anal sphincter to lacerations, particularly during the first delivery, operative vaginal deliveries or when a high birth weight is present [83]. Of note, operative vaginal deliveries are associated with the highest rate of short-term maternal and neonatal complications [69,72,77,79,84–87]. Safarinejad et al. [77] investigated the effect of mode of delivery on the quality of life, sexual function, and sexual satisfaction of primiparous women and their husbands using validated instruments in a prospective observational cohort of 912 healthy low-risk primiparous women and their husbands. Operative vaginal delivery (i.e., vacuum or forceps application) was associated with the highest rates of long-term maternal and paternal sexual dysfunction, while planned cesarean delivery was associated with the lowest rates. Quality of life parameters were higher among women who had undergone planned cesarean delivery than for all other modes of delivery (Level II-2). It is important to note that an inherent bias may exist among those women who chose a planned cesarean delivery to avoid perineal trauma or labor pain, as they may have been more likely to report improved function postoperatively. Trauma to the pudendal nerve has been demonstrated after vaginal delivery [88–91], and pudendal neuropathy may have a negative impact on sexual function [65]. The pudendal nerve is the primary afferent nerve for the perineum, vulva, and clitoris, and mediates some of the reflex pathways involved with female sexual function [92]. Intrapartum pudendal nerve injury may occur from compression of the nerve by the fetal head resulting in acute nerve dysfunction and ischemic injury [88,93], which is similar to the neuropathy that can occur from compartment syndrome [65]. Stretch injury to the pudendal nerve can also occur with a prolonged second stage of labor [94], operative delivery, and large fetal birth weight [90]. Recovery from pudendal neuropathy occurs within the first 2–6 months postpartum [89,95]; however, the long-term impact on female sexual function remains unknown. J Sex Med 2011;8:1267–1284 Continuing Medical Education Genital Tract Trauma Secondary analyses of a prospective cohort of 565 midwifery patients with low rates of episiotomy and operative delivery demonstrated very low rates of postpartum perineal pain as measured by a validated pain scale among women with spontaneous perineal trauma [96]. Compared to women with an intact perineum, women who experience episiotomies complain of increased perineal pain, decreased sexual satisfaction, and delayed return of sexual activity postpartum [72,79,87,97–99]. Although episiotomy is no longer routinely practiced, spontaneous perineal tears have been shown to increase the risk of postpartum dyspareunia. While perineal pain typically resolves by 3 months postpartum, dyspareunia usually takes longer to resolve. Severe perineal lacerations, complicate 5% of vaginal births [100], and contribute to longterm persistent dyspareunia [72,101,102]. In a prospective cohort study, Leeman et al. compared the postpartum pelvic floor function of 172 women with sutured vs. unsutured second-degree perineal lacerations, and intact perineums using validated questionnaires to assess functional outcomes, and found no difference in sexual activity or sexual function between the groups (Level II-2) [103]. However, in the same study, Rogers et al. [23] noted significant differences between women who experienced major trauma (i.e., second-, third-, or fourth-degree lacerations or any trauma-requiring suturing) and minor trauma (i.e., no trauma or first-degree perineal or other trauma that was not sutured). While both groups were equally likely to be sexually active, and demonstrated no difference in complaints of dyspareunia; women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma. In addition, women who required perineal suturing reported lower postpartum sexual function scores than women who did not require suturing (Level II-2). Other components of sexual response such as arousal, lubrication, orgasm, and satisfaction are affected by performing mediolateral episiotomy during vaginal delivery [82]. In a systematic review of the literature, Hicks et al. [75] concluded that the greatest risk for increased perineal pain occurred among women with assisted vaginal delivery. Spontaneous vaginal delivery was associated with decreased sexual problems compared with assisted vaginal delivery or cesarean delivery. However, reported associations between cesarean J Sex Med 2011;8:1267–1284 delivery and perineal pain, dyspareunia, and delay in resumption of sexual intercourse postpartum were inconsistent. While genital tract trauma can impact postpartum sexual function, it must be considered in the context of a woman’s relationship with her partner as well as her relationship with her own body [23]. A woman’s satisfaction with her relationship has been shown to have a larger impact on sexual satisfaction than trauma at childbirth or mode of delivery [104]. Ahlborg and Strandmark [105] conducted an inductive qualitative content analysis of a cross-sectional study incorporating a validated measure of marital satisfaction among 535 respondents (N = 277 [51.8% mothers] and N = 258 [48.2% fathers]) at 6 months postpartum, and concluded that most couples were happy in their relationships even when discontent with sexual activity. Good communication and higher levels of sensual activity appeared to play a compensatory role during times of decreased sexual activity (Level II-3). Postpartum The first 6 months after delivery can have a profound impact on a woman’s sexual quality of life. Of note, spontaneous genital tract trauma, episiotomy discomfort, fatigue, vaginal bleeding, discharge, dyspareunia, decreased lubrication and vaginal dryness, pelvic floor dysfunction, fear of awakening the baby or not hearing him/her, fear of injury, breastfeeding-induced amenorrhea, and decreased sense of attractiveness, all can impact a couple’s sexual function and result in a loss of libido, anorgasmia, and vaginismus [16,23,59, 72,75,106,107]. Within 3 months of a first delivery, 80–93% of women have resumed intercourse, with sexual function complaints typically resolving during the first year postpartum [16,59,72]. In a prospective cohort of 107 pregnant women, Pauls et al. [14] demonstrated that sexual function, as measured by the FSFI, decreases between the first and third trimesters of pregnancy, and does not improve at 6 months postpartum. This reduction in sexuality may be a result of worsening body image (despite a BMI that returns to prepregnancy levels), and the onset of urinary symptoms. Significant associations were not found between sexual function and age, parity, delivery characteristics, perineal injury, or breastfeeding (Level II-2). 1273 Continuing Medical Education In a prospective cohort study of 484 women incorporating validated indices by Barrett et al. dyspareunia, vaginal dryness, anorgasmia, vaginal tightness, vaginal looseness, bleeding or irritation after sex, and loss of sexual desire, were all reported as having significantly increased from 38% before delivery to 64% at 3 months postpartum [59]. Within 6 months of delivery, 89% of participants had resumed sexual activity. While significant improvements were noted in all of these parameters, they had not returned to predelivery levels (Level II-2). A prospective longitudinal cohort of 377 nulliparous women by van Brummen et al. incorporating a validated questionnaire of marital and sexual adjustment demonstrated that satisfaction with one’s sexual relationship 1 year after childbirth appears not to depend on factors associated with pregnancy and parturition. Instead, not being sexually active in early pregnancy (i.e., 12 weeks gestation), followed by older maternal age are the most important factors predicting dissatisfaction with the sexual relationship and for not being sexually active 1 year postpartum (Level II-2) [73]. Dyspareunia A critical determinant of postpartum sexual function is perineal pain and resultant dyspareunia [65]. Dyspareunia is reported by 41% to 67% of women within 2–3 months postpartum [59,72], and is strongly associated with the severity of perineal trauma sustained at the time of vaginal delivery [59,79,97]. Postpartum genital and pelvic pain has also been shown to persist for longer than a year, particularly for women with a history of nongenital chronic pain [64]. In a retrospective study by Glazener [24], a clear association was found between perineal pain and problems with sexual intercourse, particularly in the first 2 months after delivery (Level II-2). In a prospective cohort study, Connolly et al. interviewed 150 women using a nonvalidated questionnaire about sexual function 2, 6, 12, and 24 weeks postpartum. Within 6 months postpartum, 90% of the participants reported a resumption of sexual activity. At 3 months postpartum, 30% of women reported persistence of dyspareunia, while 17% continued to experience dyspareunia at 6 months postpartum. However, no association was found with mode of delivery or the use of episiotomy (Level II-2) [16]. Signorello et al. investigated the association between the occurrence and persistence of dys1274 pareunia postpartum and obstetric history among 615 primiparous women in a retrospective cohort [72]. It was found that second, third, and fourth degree perineal lacerations increased the risk of dyspareunia postpartum. In addition, operative delivery (i.e., vacuum or forceps application), was an independent risk factor for dyspareunia postpartum (Level II-2). Serati et al. investigated the incidence of de novo postpartum sexual disorders after childbirth in 336 women in a prospective cohort incorporating a validated scale on incontinence as well as individual question items measuring sexual function [31]. At 6 and 12 months postpartum, 89.9% and 98.2% had resumed sexual activity, respectively. However, 23.8% reported de novo dyspareunia 6 months after delivery, decreasing significantly in the ensuing 6 months to only 7.9%. However, from 6 to 12 months postpartum, a decrease in libido and anorgasmia were reported. At final follow-up, 83% of the participants considered their sexual life unchanged, while 5% considered it improved, and 12% reported that it worsened. Episiotomy, perineal tears, parity, fetal weight, labor induction, duration of labor, lactation, and use of epidural analgesia, were not significantly associated with dyspareunia or a worsened sex life (Level II-2). In a prospective cohort study by Barrett et al., the sexual function of 484 women was evaluated postpartum using validated indices. Of note, 12% of the participants reported dyspareunia prior to childbirth. However, during the postpartum period, this increased fivefold to 62% at 3 months, and 31% at 6 months [59]. Previous dyspareunia was identified as a statistically significant predictor (odds ratio [OR] 4.97 [95% confidence interval [CI] 2.57–9.60]) of dyspareunia at 6 months postpartum. In contrast, the mode of delivery and presence of obstetric perineal lacerations did not represent relevant risk factors for long-term persistent dyspareunia (Level II-2). Pelvic Floor Dysfunction Studies suggest that vaginal delivery is associated with pelvic floor disorders, as anal sphincter lacerations are associated with 2.2–19% of vaginal deliveries resulting in short- and long-term perineal pain and dyspareunia [108]. Women who deliver vaginally have a higher rate of urinary and fecal incontinence than women who undergo cesarean delivery [31,67,78,97,109–112]. FurtherJ Sex Med 2011;8:1267–1284 Continuing Medical Education more, complaints of postpartum urinary or fecal incontinence have been shown to correlate with impaired sexual function and quality of life [81]. The high persistence of urinary and fecal incontinence could result from neuromuscular stretching, which may not be evident at the moment of delivery [113]. However, while women may report incontinence, it may not have a profound impact on one’s quality of life. Rogers et al. conducted a nested prospective cohort of 444 low-risk women examining the impact of genital trauma on pelvic floor function after vaginal birth using validated scales. Women with genital trauma were no more likely than those without trauma to complain of urinary or anal incontinence, sexual inactivity, or perineal pain postpartum. While pelvic floor complaints were common postpartum, they were not associated with severity of genital trauma. (Level II-2) [114]. Furthermore, among 436 women in the same cohort, urinary incontinence was common postpartum, although most women had mild symptoms. The inclusion of a quality of life scale found that fewer women reported quality of life changes from their incontinence than those who complained of symptoms (Level II-2) [115]. In addition, the long-term sexual outcomes of women who experienced such severe perineal injury as rupture of the anal sphincter during childbirth have shown a significant increase in dyspareunia and fecal incontinence during sexual intercourse [116]. However, while anal sphincter lacerations have been reported to decrease the proportion of women who return to sexual activity within 6 months after delivery compared with women without this event [109,117], no difference was noted in sexual function scores [117]. There is an association between the late onset of fecal incontinence and obstetric anal sphincter injury due to persisting sphincter defects despite primary repair [118–121], which may be further exacerbated by subsequent vaginal deliveries [101]. Fifteen and 25 years after the occurrence of obstetric anal sphincter rupture, women may experience sexual complaints and fecal incontinence, and this has been found to increase with age irrespective of menopausal state [116]. The presence of urinary symptoms can alter sexual function through loss of urine or urgency to urinate during sexual activity, reduced lubrication and dyspareunia [14,122–129]. Baytur et al. [110] investigated long-term sexual function more than 2 years postdelivery to examine the relationship J Sex Med 2011;8:1267–1284 between mode of delivery and strength of the pelvic floor muscles in a prospective cohort study among 32 women who delivered vaginally and 21 women who underwent cesarean delivery. In regards to sexual function, no difference was found among the groups, and there was no correlation found between sexual function and pelvic muscle strength as measured by the FSFI (Level II-2). Postpartum pelvic floor muscle exercises can improve urinary incontinence, sexual satisfaction, and dyspareunia [76,81,122]. Breastfeeding Breastfeeding is associated with postpartum dyspareunia due to the relatively low estrogen and progesterone levels and high levels of prolactin associated with lactation that may cause vaginal dryness [106], and can be considered a predictor of delayed recovery of sexual function after childbirth [16,59,63,72,113]. However, there is conflicting data on whether breastfeeding increases sexual desire and eroticism due to the increased size, sensitivity, and direct stimulation of the breasts [130]. For some women, the natural effects of oxytocin can cause arousing sensations similar to orgasm in the form of intense uterine contractions [131]. A metacontent analysis found 33–50% of breastfeeding mothers described breastfeeding as erotic [2]. It has been shown that at 6 weeks, bottle-feeding women are more likely to return to intercourse and their rates of sexual difficulties fall [132], while breastfeeding women may experience the hormonal and physical characteristics of lactation including vaginal dryness, dyspareunia, increased nipple sensitivity, leaking milk, decreased arousal, and erotic feelings during breastfeeding [16,133– 136]. In a prospective cohort of 832 breastfeeding primiparas, Avery et al. reported an association between longer breastfeeding duration (3–6 months) and decreased arousal and sexual satisfaction in comparison to women who ceased breastfeeding earlier in the postpartum period (1 month; Level II-2) [133]. Postnatal Depression Postnatal depression affects 8% to 20% of women, and it is a complex interplay of physical, social, and psychological factors which may contribute to worse sexual health for affected women. Underlying mental health conditions such as anxiety and depression may appear and/or become exacerbated during pregnancy and the postpartum period, and 1275 Continuing Medical Education is often underdiagnosed and undertreated [137], having an impact on a couple’s sexual health. Socio-behavioral factors that have been linked with postnatal depression include personal and family history of mood disorders, young age, unmarried status, low socioeconomic status, stressful situation during pregnancy, low social support, unplanned pregnancy, use of cigarettes, alcohol and illicit drugs, and poor relationship with an intimate partner [138]. Of note, psychological violence during pregnancy by an intimate partner is strongly associated with postnatal depression, independently of physical or sexual violence [139]. Depressed women have decreased sexual desire [140], which may contribute to increased postpartum sexual dysfunction [141]. In addition, women with postnatal depression are less likely to have resumed sexual intercourse at 6 months and more likely to report sexual health problems. Of those who resumed sexual activity, 25% felt that they had resumed intercourse too soon, reflecting changing feelings a woman may experience about herself, her new role as a mother, and her relationship with her partner [142]. De Judicibus and McCabe [140] incorporated a validated measure of sexual function in a prospective cohort of 138 primiparous women of whom 104 responded at 12 weeks postpartum, and 70 responded at 6 months postpartum. The influence of role quality, relationship satisfaction, fatigue, and depression on women’s sexuality during pregnancy and up to 6 months postpartum was examined. They concluded that women with higher relationship satisfaction experience higher rates of sexual desire and satisfaction (Level II-2). Experiencing an adverse pregnancy outcome such as a miscarriage, stillbirth, or adverse or debilitating neonatal morbidity can be a significant source of additional stress in a couple’s sexual relationship. Although the majority of couples are able to adjust to a loss or adverse event and may even grow closer, there may be a subgroup whose relationships are particularly vulnerable to this source of stress, which may contribute to marital strain and relationship dissolution [143]. Effect of Parity on Sexual Function It has been shown that higher sexual satisfaction and less pain problems are associated with multiparity and relationship satisfaction. A plausible explanation is that unrealized parenthood, due to difficulties with conception, may have psychologi1276 cal consequences that affect sexual function. It has also been hypothesized that the adaptive function of female orgasm is to increase sperm retention, thereby increasing the chance of conception [144]. Therefore, women with better orgasm function may have a higher likelihood of getting pregnant. In a population-based study of 2,081 women incorporating validated indices of sexual function and relationship satisfaction, Witting et al. [141] elucidated that level of relationship satisfaction may be moderated by parity as multiparous women (regardless of number of children) had less problems with orgasm, while nulliparous women had more pain and were less sexually satisfied. In addition, women pregnant with the first child had less pain and were more sexually satisfied compared with matched nonpregnant controls. Furthermore, the level of sexual satisfaction may have been elevated in a planned and wished for pregnancy (Level II-3). Due to potential cultural and methodological differences, these findings are in contrast to a population-based study of 491 Moroccan women conducted by Kadri et al. [145], who found that women with four or more children had lower levels of desire than women with fewer children as measured by an adapted questionnaire administered in Arabic (Level II-3), and also in part to Botros et al. [146], who reported parity to be predictive of decreased desire in a prospective cohort of 542 nulliparous and parous twin sisters using a validated measure of the effects of urogynecologic symptoms on sexual function (Level II-2). Nonetheless, the body of evidence supports that being more satisfied with the overall relationship may be related to higher sexual satisfaction and less sexual dysfunction [141,147–152]. Male Partners Changes in sexual function during pregnancy and the postpartum period affects the couple rather than just the individual, and regardless of etiology may negatively impact the sexual partner [153]. The partner’s reaction to the birth process may also have an impact on a new mother’s sexual health, as well as the alterations in relationships, roles, and lifestyle caused by the presence of a child in the family [23,65]. In addition, partners may become jealous of the infant–mother relationship as breastfeeding involves constant tactile stimulation and closeness, which may be satisfying to the woman who may not desire additional touching by the partner [154]. Little attention has been paid to J Sex Med 2011;8:1267–1284 Continuing Medical Education Table 3 Impact of pregnancy on male sexual partners Lower desire Erectile dysfunction Premature ejaculation During childbirth Reaction to the birth process Postpartum Transition to fatherhood Fear of causing pain on sexual intercourse Jealousy of mother-infant bond/relationship (i.e., breastfeeding) Altered relationships, roles, lifestyles with presence of a child the sexual interest and function of male partners, which may have an additional adverse impact on the sexual function of pregnant women. Male partners may experience sexual problems before, during and after pregnancy (Table 3). This may entail lack of desire, erectile dysfunction, and premature ejaculation, which may be associated with fears raised by watching the delivery, causing pain on intercourse, or fatherhood [1,155]. Pregnancy does not lead to a decline in sexual practices that are preferred by the male partner, but may lead to a reduction in female-oriented activities, reflecting lower desire in pregnant women [14]. In a crosssectional study using a nonvalidated questionnaire, Pauleta et al. reported that 75% of women (N = 188) did not report diminished sexual interest from their partner (Level II-3) [10]. It has also been shown that male interest toward their partners remains mostly unchanged until the end of the second trimester, when it decreases sharply [2]. However, sexual demand by the partner has been found to influence the resumption of sexual intercourse postpartum [156,157]. Premature ejaculation has been reported as high as 49.5% in one study, which warrants the need for increased attention by providers to the sexual health needs and concerns of both partners, not just the woman [158]. There is inconsistent evidence on the association of male sexual function and the partner’s parity or mode of delivery. Using a validated instrument, Gungor et al. [158] evaluated 107 men whose partners had undergone either an elective cesarean delivery, a vaginal delivery with a mediolateral episiotomy, or had not given birth in a prospective cohort study. While not statistically significant, the prevalence of male sexual dysfunction was 28.6% among those in the elective cesarean group, 19.4% in the vaginal delivery group, and 30.0% in the nulliparous group. Overall, male sexual function was not affected by the partner’s J Sex Med 2011;8:1267–1284 mode of delivery or parity. The presence of sexual dissatisfaction was similar among the three groups, and men whose wives had delivered by elective cesarean section demonstrated a statistically significant worse score in degree of satisfaction compared with those whose wives had not given birth. These findings suggest that an elective cesarean section due to concerns for postpartum sexual function would not provide additional benefit to men [158]. Furthermore, there was no difference in the reporting of sexual pleasure with regard to vaginal functioning of the partner between men whose wife had an intact perineum and those with an episiotomy (Level II-2). In contrast, a prospective observational cohort using validated instruments of 912 women and their husbands demonstrated a significant association between erectile dysfunction and various modes of delivery (i.e., spontaneous vaginal delivery, vaginal delivery with episiotomy or perineal laceration, operative vaginal delivery [vacuum or forceps application], planned cesarean section, and emergency cesarean section]), with the greatest reduction in erectile function associated with husbands of women with forceps-assisted deliveries (27.8% reduction 1 year postpartum; Level II-2) [77]. This finding suggests that erectile dysfunction may have a deeper impact on men’s psychological status than just its physical consequences. Intimate Partner Violence Gender-based violence (GBV), and specifically sexual coercion, have received increasing global attention in recent years as a sexual health and public health issue as it exposes a woman to early sexual debut, sexual risk-taking behavior, as well as unintended pregnancy, and challenges a woman’s ability to control her own reproductive decisionmaking and health [159]. Among vulnerable populations such as minority women and women from low-income and low-education groups, estimates of lifetime GBV have been reported as high as 62% to 68% [160]. Intimate partner violence (IPV) during pregnancy affects 4–8% of pregnant women in the United States, with worldwide prevalence rates ranging from 3–31% [139,161]. IPV is associated with women not using their preferred contraceptive method, sexually transmitted infections including HIV/AIDS, miscarriages, repeat abortion, a high number of sexual partners, poor pregnancy outcomes [162], and may promote or exacerbate postnatal depression [138]. More1277 Continuing Medical Education over, HIV-positive women who are in abusive relationships are less likely to use condoms and more likely to be pregnant, experience physical abuse, and threats of physical abuse when requesting condoms [163]. For women in abusive relationships, pregnancy can be a vulnerable time, as violence has been shown to increase during pregnancy [164], with unintended pregnancies carrying an even greater risk of violence than intended pregnancies [165]. This violence may be the result of the partner’s jealousy and resentment toward the unborn child [166], and/or the partner’s increased feelings of insecurity and possessiveness during the pregnancy [167]. Women’s financial worries and their reduced physical and emotional availability during pregnancy may lead their partners to physical violence [167]. Furthermore, male reproductive control encompassing pregnancy-promoting behaviors (i.e., male partner attempts to impregnate a woman through verbal threats about getting her pregnant, unprotected forced sex, and contraceptive sabotage) as well as control and abuse during pregnancy in an attempt to influence the pregnancy outcome may lead to violence [168]. Health care providers play a critical role in assessing for the risk of IPV in their patients receiving antenatal care, as they can provide education, care, counseling, as well as referrals to communitybased programs, which can help to protect a woman’s reproductive health and physical safety. Practice Guidelines Pregnancy, childbirth, and the postpartum period is a time of incredible change as a couple adapts to the new addition to their family as well as alterations in their own sexual functioning. Couples may not be aware that these changes commonly occur in the majority of women, as they may not receive adequate information or anticipatory guidance on these expected alterations from their health care providers [2,12,24,56,59,169,170]. In one study, less than 30% of women received information on sexual function in pregnancy from their providers [12]. Furthermore, women are not always comfortable in raising sexual concerns, and may be reticent to discuss their concerns with their providers [10,12], but instead may find it easier to share their problems with friends [33]. Silence by providers on the subject of sexual function will only serve to keep women and their partners in 1278 ignorance of normal changes during pregnancy and the postpartum period, or deprive them of solutions to problems, which can be easily remedied or at least explained [23]. Hence, open conversations and anticipatory guidance about sexuality during pregnancy and possible postpartum changes may improve sexual function and reduce stress, emotional strain, and concern about expectations [23,99,171–173]. When taking a patient’s history, there are important points to consider obtaining: an assessment of the relationship, sexually and otherwise; the patient’s support network; whether the pregnancy was planned; previous outcomes of pregnancies (i.e., miscarriage or termination); previous deliveries (type and presence of trauma); current children’s health; contraception (past and current use, as well as plans for the future) [1]. While a multidisciplinary approach is optimal when providing sexual health counseling encompassing sexual therapy, physical therapy, gynecologists, urologists, and midwives; in the realities of most general practice settings, this may not be the most practical or cost-effective approach. Rather in these circumstances, providers should incorporate targeted counseling on expected changes in sexual health for women and their partners, which should include a discussion of the impact of pregnancy, childbirth, and the postpartum period on one’s sexual health during prenatal and postpartum care [48]. Moreover, providers should reinforce the normal reduction in the frequency of sexual intercourse as well as decline in libido, sexual desire, and orgasm, that commonly occurs, particularly in the third trimester of pregnancy, and persists well into the first 3–6 months postpartum [113]. These changes need not be pathologized, but instead reinforced as part of a normal sequence of events that gradually recovers over time. The decision to resume intercourse after childbirth should be made mutually between a woman and her partner [174]. The AAP/ACOG Guidelines for Perinatal Care (6th edition) indicate that while the earliest time at which coitus may be resumed safely after childbirth is unknown, the risks of hemorrhage and infection are minimal by 2 weeks postpartum [175]. Clinicians typically recommend that women may consider resuming sexual intercourse 6 weeks after delivery, which is typically after their first routine postpartum visit which allows sufficient time for surgical and vaginal/ perineal wound healing and suture absorption. J Sex Med 2011;8:1267–1284 Continuing Medical Education It is essential that couples are also reassured that sexuality includes a wide range of expression, and while sexual activity is safe throughout a healthy pregnancy, it does not necessarily have to include only vaginal intercourse. Noncoital contact can also be an expression of emotional intimacy reinforcing a couple’s sexual health and well-being. One study found manual genital stimulation to be a form of sexual activity considered most exciting and most pleasant by both partners postpartum [136]. Discussing alternatives to intercourse and acknowledging the importance of maintaining intimacy, may enable partners to discover new and satisfying ways of expressing their sexuality [131]. In the postpartum state, due to the relatively low level of progesterone, women and their partners should routinely use a vaginal lubricant when resuming intercourse after delivery. Sexual positions that allow shallow penetration or give the woman more control over the depth of vaginal penetration (i.e., woman-on-top) may be beneficial [174]. Couples with ongoing sexual concerns several months after pregnancy may benefit from discussions with their health care provider in order to mitigate any negative impact on their overall quality of life (Table 4) [14]. Conclusion Pregnancy is a unique period in a woman’s life, and healthy sexual function reinforces a couple’s Table 4 Practice guidelines Initial assessment Assessment of current/past sexual relationship Exploration patient/couple’s support network Ascertainment of whether pregnancy was planned Outcome previous pregnancies (i.e., miscarriage, fetal loss, pregnancy complication, adverse neonatal outcome) Previous deliveries (mode of delivery, type/presence of trauma) Current child/children’s health Contraception (past, current use, plans for the future) Antepartum counseling Avoid pathologizing range of sexual changes that may be experienced during pregnancy Incorporation of education on safe sex practices as deemed appropriate (i.e., to reduce exposure to STDs) Reassurance of wide range of normal sexual expression during pregnancy Exploration of alternate sexual positions and/or noncoital contact (i.e., manual genital stimulation) Postpartum counseling Couples mutually decide on appropriate timing of resumption of intercourse after 6 week postpartum visit Advise use of vaginal lubricant when resuming sexual intercourse Exploration of alternate sexual positions which give women greater control over the depth of vaginal penetration J Sex Med 2011;8:1267–1284 emotional intimacy as well as facilitates the hormonal, physical, and psychological transitional changes that occur during this period [56]. While significant advances have been made in our understanding of the mechanisms that impact sexual function during pregnancy and the postpartum period, future research must incorporate prospective, longitudinal study designs that include comparisons with baseline data, as well as validated instruments of sexual function, which can also be implemented as tools in routine outpatient clinics to aid in the identification of sexual health concerns arising during pregnancy as well as documenting the real prevalence of this problem so as to devise effective manage strategies [113]. It is critical for future research to establish high quality, rigorous normative data on sexual functioning during pregnancy and the postpartum period. More research is also needed to evaluate male sexual function during pregnancy and the role of the partner in a couple’s overall sexual health, decision-making regarding mode of delivery, and the impact of postpartum sexual changes on quality of life. Furthermore, efforts should be made to account for social, cultural, and/or religious factors which may influence how sexual health is embodied during pregnancy and the postpartum period across diverse populations. Corresponding Author: Crista E. Johnson, MD, MSc, FACOG, Department of Obstetrics and Gynecology, Maricopa Integrated Health System, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA. Tel: 602344-1445; Fax: 602-344-5894; E-mail: cejohn11@ asu.edu Conflict of Interest: None. Statement of Authorship Category 1 (a) Conception and Design Crista E. Johnson (b) Acquisition of Data Crista E. Johnson (c) Analysis and Interpretation of Data Crista E. Johnson Category 2 (a) Drafting the Article Crista E. Johnson (b) Revising It for Intellectual Content Crista E. Johnson 1279 Continuing Medical Education Category 3 (a) Final Approval of the Completed Article Crista E. Johnson References 1 Read J. 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