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Postpartum dyspareunia and sexual functioning: a

prospective cohort study

Liesbet Lagaert, Steven Weyers, Helena Van Kerrebroeck & Els Elaut

To cite this article: Liesbet Lagaert, Steven Weyers, Helena Van Kerrebroeck & Els Elaut
(2017) Postpartum dyspareunia and sexual functioning: a prospective cohort study, The
European Journal of Contraception & Reproductive Health Care, 22:3, 200-206, DOI:
10.1080/13625187.2017.1315938

To link to this article: https://doi.org/10.1080/13625187.2017.1315938

Published online: 27 Apr 2017.

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THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE, 2017
VOL. 22, NO. 3, 200–206
http://dx.doi.org/10.1080/13625187.2017.1315938

EPIDEMIOLOGICAL STUDY

Postpartum dyspareunia and sexual functioning: a prospective cohort study

Liesbet Lagaerta,b, Steven Weyersb, Helena Van Kerrebroeckb
and Els Elautc
a
Department of Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; bDepartment of Obstetrics and
Gynaecology, Ghent University Hospital, Ghent, Belgium; cCentre for Sexuality and Gender, Ghent University Hospital, Ghent, Belgium

ABSTRACT ARTICLE HISTORY

Objectives: Sexual functioning is an important concern for women in the postpartum period. The Received 3 October 2016
aim of this research was to investigate the prevalence and determinants of dyspareunia and sexual Revised 22 March 2017
dysfunction before and after childbirth. Accepted 30 March 2017
Methods: Between November 2013 and April 2014, 109 women in their third trimester of preg- Published online 27 April
2017
nancy were enrolled in a prospective cohort study at Ghent University Hospital. Dyspareunia, sexual
functioning and quality of life (QOL) were evaluated at enrolment and again 6 weeks and 6 months KEYWORDS
postpartum. Sexual functioning and QOL were assessed using validated self-report questionnaires: Dyspareunia; FSFI;
the Female Sexual Function Index and the Short Form-36 health survey. Dyspareunia was evaluated postpartum period;
by a specific self-developed questionnaire. pregnancy; quality of life;
Results: One hundred and nine women were enrolled; respectively, 71 (65.1%), 66 (60.6%) and 64 sexual dysfunction
(58.7%) women returned the questionnaires prepartum, and 6 weeks and 6 months postpartum.
Sexual functioning at 6 weeks was predictive of sexual functioning at 6 months postpartum
(rs ¼ 0.345, p ¼ .015). The prevalence of dyspareunia in the third trimester of pregnancy, and 6 weeks
and 6 months postpartum was, respectively, 32.8%, 51.0% and 40.7%. The severity of pain decreased
significantly between 6 weeks and 6 months postpartum (p ¼ .003). In the first 6 weeks postpartum,
the degree of dyspareunia was significantly associated with breastfeeding (p ¼ .045) and primiparity
(p ¼ .020). At 6 months, only the association with primiparity remained significant (p ¼ .022).
Conclusions: The impaired postpartum sexual functioning, the high prevalence of dyspareunia
postpartum and their impact on QOL indicate the need for further investigation and extensive
counselling of pregnant women, especially primiparous women, about sexuality after childbirth.

Introduction trauma or by the instrumental intervention itself (without

trauma) [1,6,11]. Caesarean section is thought to be a pro-
The prevalence of dyspareunia in non-pregnant women is
tective factor for the development of dyspareunia [3].
1.4–22% [1,2]. Despite the lack of large prospective stud-
However, several studies have failed to show a significant
ies, it is well known that women frequently experience
difference 6 months postpartum [11,12].
sexual problems in the postpartum period. Although little
In different studies, breastfeeding is the principal and
research has been conducted on the subject, studies have
only significant predictor of dyspareunia up to 6 months
found a prevalence ranging between 30% and 60% in the
postpartum. Studies have shown that both psychosocial
first 3 months postpartum, reducing to 17–31% after
6 months [3–7]. (fatigue, depression, stress, work, environment) and hormo-
Possible risk factors for perineal pain after childbirth nal factors have an influence on the relationship between
include: perineal trauma, mode of delivery, breastfeeding, breastfeeding and sexual functioning. Fatigue strongly
parity and a history of dyspareunia. Perineal trauma can be interferes with sexual functioning. As breastfeeding women
caused by an episiotomy or a spontaneous perineal tear. are more inclined to sleep deprivation, due to night-time
The presence and extent of the perineal trauma seem to feeding, breastfeeding can contribute to impaired sexual
be related to the presence and intensity of dyspareunia functioning [13].
3–6 months postpartum [3,6,8]. The influence of a spontan- Little is known about the influence of breastfeeding on
eous tear vs episiotomy has not been extensively investi- mood changes or depression. In turn, it is known that psy-
gated and the results are not uniform. Studies that mark a chosocial factors play a significant role in the maintenance
difference show lower pain scores in spontaneous trauma. of breastfeeding [14]. The relationship between hormonal
Pelvic floor musculature is weakest as a result of episiot- changes in breastfeeding women and sexual functioning is
omy, and third and fourth degree tears are more common clearer. The hypoestrogenic state in breastfeeding women
in this group. This may explain the lower pain scores [8,9]. can cause decreased vaginal lubrication and vasoconges-
Women who have undergone an assisted vaginal deliv- tion, as well as atrophy of the vaginal epithelium. In the
ery are at higher risk of developing dyspareunia compared absence of additional sexual stimulation (compensating for
with women who have had a spontaneous vaginal delivery the slower vaginal vasocongestion), inadequate vaginal
[3,5,6,10]. This may be explained by a higher risk of perineal lubrication could give rise to painful sexual intercourse

CONTACT Liesbet Lagaert [email protected] Department of Obstetrics and Gynaecology, Ghent University Hospital, De Pintelaan 185-9000
Ghent, Belgium

Helena Van Kerrebroeck is now at the Department of Obstetrics and Gynaecology, Ziekenhuis Oost Limburg, Genk, Belgium
ß 2017 The European Society of Contraception and Reproductive Health
 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 201

[3,4,6,11,13]. A history of dyspareunia is also an important Six months postpartum, follow-up questionnaires were sent
risk factor for developing dyspareunia postpartum to the participants by regular post. Participants were
[1–3,11,15]. encouraged to return the forms and questionnaires using
Certain studies show a higher rate of postpartum dys- prepaid envelopes.
pareunia in primiparous women [3,16]. However, parity has At recruitment, participants were given the following
not been extensively studied as a risk factor for dyspar- baseline questionnaires: a questionnaire on general patient
eunia. In fact, most studies only include primiparous characteristics (age, weight, height, ethnicity, frequency of
women when investigating the influence of other risk fac- intercourse, use of contraception, parity, medical history
tors on dyspareunia. and surgical history), a specific self-assessment non-vali-
Studies on dyspareunia with long-term follow-up are dated questionnaire on dyspareunia (Appendix 1), the vali-
scarce. Those with long-term follow-up (12–18 months) dated Female Sexual Function Index (FSFI) and the
show that long-term dyspareunia is more prevalent in validated Short Form-36 health survey (SF-36) (the higher
women who have had a perineal trauma, an assisted vagi- the score, the better the QOL). The last three were also
nal delivery, an emergency caesarean section or a history used 6 weeks and 6 months postpartum. The FSFI covers
of dyspareunia [5,12,15]. Studies investigating the degree of six sexual domains: desire, arousal, lubrication, orgasm, pain
perineal pain show that severe pain is infrequent. and satisfaction. The full scale score ranges from 2.0 to
Signorello et al. [6] evaluated the degree of postpartum 36.0, with higher scores associated with better sexual func-
dyspareunia after vaginal delivery in 615 primiparous tioning. Data on delivery and on breast- vs bottlefeeding
women. They found that only 4% (9/228) experienced were obtained from the patients’ medical records and from
severe pain during intercourse (defined as pain precluding a follow-up questionnaire that was sent out 6 months after
enjoyment of intercourse) at 3 months, declining to 1.6% delivery.
(2/124) at 6 months. Connolly et al. [4] found in 150 Data were analysed using the statistical software pack-
women that none experienced pain precluding enjoyment age IBM SPSS, version 22 (IBM, Armonk, NY). Comparisons
of intercourse 6 months postpartum. Moreover, the severity were made using non-parametric tests. The relationship
of dyspareunia is associated with the duration of dyspar- between dyspareunia and categorical variables was
eunia [4,6,16]. Considering the existing literature, we assessed using the v2 test. Women were categorised as
noticed that besides the quantity of studies dealing with having dyspareunia if they reported that they had experi-
this subject, there is a lack of high-quality studies with a enced pain during sexual intercourse in the previous 6
prospective study design that use validated questionnaires weeks. Women who had not yet resumed sexual inter-
to assess the extent of dyspareunia. course were not included in the statistical analysis.
The purposes of this study were manifold. First, we Correlations between continuous variables were calculated
wanted to investigate sexual functioning in the first 6 using Spearman’s rho value. Comparison between the
months postpartum and compare it with prepartum sexual degree of dyspareunia, the total FSFI score, SF-36 scores
functioning. Second, we aimed to define the prevalence, and the various obstetric factors were examined using the
severity and duration of dyspareunia after delivery. Third, Mann–Whitney U test for factors with two categories
we set out to quantify the association of perineal trauma, (breastfeeding). The Kruskal–Wallis test was used for factors
mode of delivery, breastfeeding, age, BMI and parity with with more than two categories (mode of delivery). Women
postpartum sexual functioning, in particular with dyspar- who did not report experiencing dyspareunia or had not
eunia. Finally, we examined quality of life (QOL) after deliv- resumed sexual intercourse were excluded from the ana-
ery and its association with sexual functioning. lysis of the degree of dyspareunia.
The Wilcoxon signed-rank test was used to compare the
severity of dyspareunia and the FSFI scores 6 weeks and 6
Methods months postpartum. The Friedman test was performed to
This prospective cohort study was carried out at the compare the SF-36 scores at the three different time points.
Department of Obstetrics and Gynaecology, Ghent The statistical program R was used (R Foundation for
University Hospital. Permission to perform the study was Statistical Computing, Vienna, Austria) to compare the aver-
given by the ethics committee of Ghent University Hospital. age scores of the FSFI/SF-36 questionnaires in our study
Pregnant women were invited to participate in the study with those of a non-pregnant population. We considered a
over the 6 month period from November 2013 to April p value <.05 to be significant and a p value between 0.05
2014. Inclusion criteria were: age >18 years, adequate and 0.10 to indicate a possible trend towards significance.
knowledge of the Dutch language, gestation >24 weeks at
enrolment, and postpartum follow-up by a physician at the
Results
hospital. Women with a history of pelvic or perineal sur-
gery, women without a partner and non-heterosexual Pregnant women who met the inclusion criteria (n ¼ 112)
women were excluded. Recruited women were enrolled were enrolled. Two women were excluded after enrolment
during the third trimester of their pregnancy (between 26 (one who was not heterosexual, and one who was sexually
and 36 weeks). At the prenatal consultation, the research inactive); one woman was lost to follow-up. Questionnaires
procedure was explained and an invitation package given. were recovered from 71/109 (65.1%) women prepartum,
The invitation package consisted of an information sheet 66/109 (60.6%) 6 weeks postpartum and 64/109 (58.7%) 6
and an informed consent sheet and baseline questionnaires months postpartum. Fifty-three of the 109 women (48.6%)
that had to be returned before delivery. Six weeks postpar- returned all three questionnaires; 31 (28.4%) did not return
tum, participants were given follow-up questionnaires. any of the questionnaires (non-responders); 78 (71.6%)
202 L. LAGAERT ET AL.

returned at least one questionnaire. Table 1 shows the (49/66) had resumed sexual intercourse and 51.0% (95% CI
demographic characteristics of the participants. Responders 37.5%, 64.4%) of these women reported dyspareunia. Six
and non-responders were compared for the variables age, months postpartum, 92.2% (59/64) had resumed sexual
BMI, parity and mode of delivery. Non-responders were sig- intercourse and 40.7% (95% CI 29.1%, 53.4%) experienced
nificantly more likely to be multiparous (p ¼ .04). dyspareunia. Six weeks and 6 months after delivery, 80%
First, we assessed the participants’ sexual functioning at and 75% of women, respectively, experienced superficial
each time point (Table 2). Significant differences in the vari- dyspareunia. Among those women who had not resumed
ous domains between different time points are shown. sexual intercourse at 6 weeks, 35.3% (6/17) reported dys-
Looking into associations, we found a significant positive pareunia and 11.8% (2/17) still had not resumed sexual
association between total FSFI scores at 6 weeks and 6 intercourse by 6 months postpartum. Fisher’s exact test
months postpartum (rs ¼ 0.345, p ¼ .015). Compared with was used to investigate whether not having sexual inter-
women with dyspareunia 6 weeks postpartum, women course 6 weeks postpartum was a predictive factor for hav-
without dyspareunia had significantly better domain scores ing dyspareunia 6 months postpartum (p ¼ .059). In
for lubrication (p ¼ .011), arousal (p ¼ .032) and pain addition to a decline in prevalence, there was also a signifi-
(p <.001). Six months after delivery, only pain had higher cant decrease in median severity from 3.36 (visual analogue
domain scores (p <.001). scale [VAS]) at 6 weeks postpartum to 0.51 at 6 months
Although participants were recruited in the third trimes- postpartum (Wilcoxon’s signed-rank test, p ¼ .001) (Figure
ter of pregnancy, their results cannot be considered ideal 1). Women experiencing dyspareunia 6 weeks postpartum
baseline information from which to compare postpartum appeared to have an increased risk of dyspareunia 6
results. Therefore, the FSFI scores in the third trimester months postpartum (p ¼ .004). Even so, the degree of dys-
were compared with those of a reference population of pareunia at that moment was a determining factor for pain
Dutch women without sexual problems (Table 3) [17]. scores 6 months after delivery (rs ¼ 0.362, p ¼ .019).

Resumption of sexual intercourse and dyspareunia Factors associated with dyspareunia

postpartum
Table 4 shows the association of different obstetric and
At the time of recruitment in the third trimester of preg- postnatal characteristics (parity, breastfeeding, mode of
nancy, 85.9% (61/71) of the women were sexually active delivery, perineal trauma) with dyspareunia. Women who
and 32.8% (95% confidence interval [CI] 22.3%, 45.3%) started breastfeeding after delivery reported significantly
experienced dyspareunia. Different types of dyspareunia more severe dyspareunia 6 weeks after childbirth (p ¼ .045).
were reported: predominantly superficial (60%), deep (25%) Six months postpartum this association was no longer sig-
and position-related (15%). Six weeks after delivery, 74.2% nificant (p ¼ .482). Six weeks (p ¼ .020) and 6 months
(p ¼ .022) after delivery, primiparous women reported more
Table 1. Demographic information.
pain than multiparous women. Sexual intercourse was
Participants’ data (n ¼ 78)
Age, years, mean (range) 30.6 (21–40)
more painful among women who had undergone an instru-
BMI, kg/m2, mean ± SD 22.5 ± 3.31 mental delivery compared with women who had had a
Parity, n (%)
Primiparous 39 (50)
Table 3. Average absolute FSFI scores of the study population compared
Multiparous 39 (50)
with a non-pregnant population.
Neonatal data (n ¼ 78)
Fetal weight, kg (mean ± SD) 3.34 ± 0.43 Women without Pregnant women in
Mode of delivery, n (%) sexual problemsa third trimester of pregnancyb
Vaginal 63 (80.8) FSFI domain (n ¼ 108) (n ¼ 60) p Valuec
Spontaneous 55 (70.5) Desire 6.7 ± 1.3 5±2 <.001
Operative (forceps/vacuum-assisted) 8 (10.3) Arousal 17.6 ± 2.8 14 ± 5 <.001
Caesarean section, n (%) 15 (19.2) Lubrication 19.0 ± 3.2 16 ± 5 <.001
Elective 7 (9.0) Orgasm 12.8 ± 2.8 11 ± 4 .002
Emergency 8 (10.2) Satisfaction 13.4 ± 2.1 11 ± 3 <.001
Perineal trauma, n (%) 55/62 (88.7) Pain 14.2 ± 1.9 10 ± 5 <.001
Lacerations 21/62 (33.9) Total score 83.7 ± 10.7 67 ± 20 <.001
Episiotomy 34/62 (54.8) a
Absolute values of FSFI domain and total scores (mean ± SD) [17].
Breastfeeding, n (%) b
Absolute values of FSFI domain and total scores (mean ± SD).
At hospital discharge 69/78 (88.5) c
Data analysed using the Kolmogorov–Smirnov two-sample test (alpha at
At 6 months 15/56 (26.8)
<0.05).

Table 2. FSFI scores in the third trimester of pregnancy (3T) and at 6 weeks (6W) and 6 months (6M) postpartum.
FSFI domain 3Ta (n ¼ 60)b 6Wa (n ¼ 49)b 6W vs 3Tb p Valuec 6Ma (n ¼ 59)b 6M vs 3Tb p Valuec 6M vs 6Wb p Valuec
Desire 3.04 ± 1.01 2.94 ± 1.06 1.67 .335 3.16 ± 0.99 þ2.00 .094 þ3.67 .009
Arousal 4.13 ± 1.53 4.11 ± 1.41 0.30 .283 4.52 ± 1.22 þ6.50 .665 þ6.83 .006
Lubrication 4.89 ± 1.61 4.74 ± 1.57 2.50 .335 5.04 ± 1.12 þ2.50 .978 þ5.00 .032
Orgasm 4.45 ± 1.73 4.14 ± 1.56 5.17 .103 4.76 ± 1.29 þ5.17 .672 þ10.33 .019
Satisfaction 4.37 ± 1.29 4.32 ± 1.27 0.83 .784 4.52 ± 1.06 þ2.50 .465 þ3.33 .158
Pain 4.11 ± 1.98 4.04 ± 1.88 1.67 .550 4.96 ± 1.29 þ14.17 .022 þ15.33 .001
Total score 25.00 ± 7.41 24.64 ± 6.04 1.00 .212 26.90 ± 5.29 þ5.28 .237 þ6.28 .005
a
Domain scores and total scores are depicted as mean ± SD (maximum domain score is 6, maximum total score is 36).
b
Number of sexually active women (prepartum: 61/71, one incomplete questionnaire; 6 weeks postpartum: 49/66; 6 months postpartum: 59/64).
c
Percentage change. Data analysed using the Wilcoxon signed-rank test (alpha at <0.05).
 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 203

10

6
VAS score

6 weeks postpartum 6 months postpartum

Figure 1. Box plot showing median degree of dyspareunia (VAS) 6 weeks and 6 months postpartum (Wilcoxon’s signed-rank test, p ¼ .001).

Table 4. Prevalence and degree of dyspareunia after delivery.

Dyspareunia 6 weeks postpartum Dyspareunia 6 months postpartum
Prevalence n (%) a
p Value b
Degree c
p Value b
Prevalence n (%)a p Valueb Degreec p Valueb
Mode of delivery
Spontaneous vaginal delivery 16/34 (47.1) Ref. 2.75 ± 1.36 Ref. 18/45 (40.0) Ref. 2.34 ± 1.81 Ref.
Caesarean section 5/9 (55.6) .721d 3.61 ± 1.88 .482e 5/10 (50.0) .562d 2.74 ± 1.63 .314e
Operative vaginal delivery 4/6 (66.7) .661f 4.39 ± 1.51 .059e 1/4 (25.0) 1f 5.76 .201e
Perineal trauma (vaginal delivery)g
Intact perineum 4/5 (80) .342f 3.25 ± 1.32 .850e 3/7 (42.9) 1f 1.71 ± 0.80 .655e
Spontaneous tear/episiotomy 16/34 (52.9) – 3.04 ± 1.59 – 16/41 (39) – 2.67 ± 2.04 –
Breastfeeding immediately postpartum
No 3/6 (50) .482f 3.42 .045e – – – –
Yes 22/43 (51.2) – 1.5 – – – – –
Breastfeeding 6 months postpartumh
No – – – – 16/28 (42.1) .818d 2.42 .482e
Yes – – – – 5/13 (38.5) – 1.61 –
Parity
Nulliparous 11/21 (52.4) .869d 4.04 .022e 12/28 (42.9) .746d 3.53 .022e
Multiparous 14/28 (50) – 2.51 – 12/31 (38.7) – 1.59 –
Dyspareunia prepartumi
Yes 8/16 (50) .901d 3.31 .832 7/15 (46.7) .239d 2.54 .832e
No 12/25 (48) – 3.21 – 9/31 (29) – 2.31 –
Data are presented as n (%) or mean ± SD.
a
Number of women with dyspareunia out of all sexually active women.
b
All p values are vs spontaneous vaginal delivery.
c
The degree of dyspareunia was rated by the participants using a 10 cm VAS, which scores experienced pain from 0 to 10.
d
Data analysed using the v2 test (alpha at <0.05).
e
Data analysed using the Mann–Whitney U test (alpha at <0.05).
f
Data analysed using Fisher’s exact test (alpha at <0.05).
g
nvaginal delivery 6W ¼ 40 (one missing value for perineal trauma), nvaginal delivery 6M¼49 (one missing value for perineal trauma).
h
Data on breastfeeding 6 months postpartum: 41/59 (18 missing values).
i
Data on prepartum dyspareunia 6 weeks postpartum: 41/49 (eight missing values); 6 months postpartum: 46/59 (13 missing values).

spontaneous vaginal delivery. Six weeks postpartum, the An association between SF-36 scores and mode of delivery,
difference in severity between spontaneous and instrumen- breastfeeding, parity and perineal trauma was explored. Six
tal delivery showed a strong trend towards significance months postpartum, women who had had a caesarean sec-
(p ¼ .059). tion had significantly worse scores for the domain of
energy/fatigue compared with women who had had a vagi-
nal delivery (p ¼ .041). For the other domains, there were
no significant differences according to the mode of deliv-
Postpartum QOL
ery. However, the scores in the domains of physical func-
The mean SF-36 scores were calculated at each time point tioning (p ¼ .082), mental health (p ¼ .065) and general
for all women who completed the questionnaires (Table 5). health (p ¼ .091) were lowest among women who had had
204 L. LAGAERT ET AL.

Table 5. SF-36 scores in the third trimester of pregnancy (3T) and at 6 weeks (6W) and 6 months (6M) postpartum.
SF-36 domain 3Ta (n ¼ 71) 6W (n ¼ 66) 3T vs 6Wb p Valuec 6M (n ¼ 64) 3T vs 6Mb p Value 6W vs 6Mb p Valuec p Valued
Physical functioning 49.71 ± 25.03 83.77 ± 17.38 þ34.06 <.001 90.08 ± 15.31 þ40.37 <.001 þ6.31 .092 <.001
Limitations due to 38.73 ± 40.04 63.46 ± 41.24 þ24.73 <.001 80.08 ± 34.27 þ41.35 <.001 þ16.62 .004 <.001
physical health
Pain 64.08 ± 23.45 74.50 ± 22.05 þ10.42 .001 80.47 ± 24.35 þ16.39 <.002 þ5.97 .163 <.001
General health 73.10 ± 17.72 73.77 ± 15.39 þ0.76 .188 71.43 ± 18.13 1.67 .531 2.34 .150 .386
Energy/fatigue 53.36 ± 14.36 53.41 ± 18.27 þ0.05 .385 57.11 ± 20.31 þ3.75 .107 þ3.70 .185 .237
Social functioning 73.94 ± 27.77 81.44 ± 19.88 þ7.50 .011 84.57 ± 21.33 þ10.63 .002 þ3.13 .318 .004
Limitations due to 82.16 ± 34.66 79.80 ± 35.99 2.36 .923 79.69 ± 36.91 2.47 .482 þ0.11 .895 .638
emotional problems
Mental health 75.32 ± 13.74 75.02 ± 16.39 0.30 .459 77.02 ± 17.02 þ1.70 .279 þ2.00 .337 .233
a
Domain scores are shown as mean ± SD.
b
Absolute changes in SF-36 scores.
c
Data analysed using the Wilcoxon signed-rank test (alpha at <0.05).
d
Data analysed using the Friedman test (alpha at <0.05).

Table 6. Average SF-36 scores of the study population compared with those of a reference population.
Dutch-speaking residents Pregnant women in
of the Netherlandsa third trimester of pregnancy
SF-36 domain (n ¼ 766) (n ¼ 71) p Valueb
Physical functioning 74.8 ± 22.1 49.71 ± 25.03 <.001
Limitations due to physical health 82.7 ± 31.1 38.73 ± 40.04 <.001
Pain 68.8 ± 29.9 64.08 ± 23.45 .110
General health 65.4 ± 21.2 73.10 ± 17.72 <.001
Energy/fatigue 65.3 ± 18.5 53.36 ± 14.36 <.001
Social functioning 81.3 ± 23.9 73.94 ± 27.77 .031
Limitations due to emotional problems 77.6 ± 35.0 82.16 ± 34.66 .289
Mental health 70.5 ± 19.2 75.32 ± 13.74 .007
a
Domain scores are shown as mean ± SD [18].
Data analysed using the Kolmogorov–Smirnov two-sample test (alpha at <0.05).
b

a caesarean section. Multiparous women scored signifi- find a significant difference. The finding is, however, in line
cantly worse in the general health domain compared with with results from other studies investigating the influence
primiparous women 6 weeks postpartum (p ¼ .046). of mode of delivery on dyspareunia [5].
We also investigated the relationship between total FSFI Caesarean section as a protective factor for dyspareunia
scores and QOL parameters. Women with lower total FSFI and sexual dysfunction has not been extensively investi-
scores 6 weeks postpartum scored poorer on general gated and is controversial. Our results cannot confirm the
health (rs ¼ 0.270, p ¼ .034). Six months postpartum, besides protective function of caesarean section; indeed, in our
poorer scores on general health (rs ¼ 0.320, p ¼ .022), study the total FSFI scores were lower in women who had
women also had significantly lower scores for physical func- had a caesarean delivery. These women also reported a
tioning (rs ¼ 0.419, p ¼ .002). worse QOL 6 months postpartum compared with women
The SF-36 scores in the third trimester of pregnancy who had had a vaginal delivery. This can probably be seen
were also compared with those of a reference population as a long-term effect of surgery. Kabakian-Khasholian et al.
(Table 6) [18]. investigated postpartum pelvic pain in 238 Lebanese
women, and found that women who underwent a caesar-
ean section were more likely to experience pain during
Discussion
intercourse between 6 weeks and 6 months after delivery
Most women quickly resume sexual activity after childbirth. (adjusted odds ratio 1.96; 95% CI 1.29, 2.63) [22]. Our
The average time between giving birth and completing the results reinforce the importance of counselling pregnant
first follow-up questionnaires was 57 days (8 weeks, one women who request a caesarean section about the benefits
day). This is higher than in other studies that have reported and disadvantages of this intervention. Another explanation
on sexual activity 6 weeks postpartum [3,5]. The proportion for the lower FSFI scores in our study could be that primary
of women who had resumed sexual intercourse in our and secondary caesarean sections were considered as one
study (74.2%) corresponds to the proportion who had category. Further research on this topic with a larger sam-
resumed sexual intercourse 7–8 weeks postpartum in the ple that distinguishes between primary and secondary cae-
large prospective study of McDonald and Brown [19]. sarean section and takes into account QOL should be
Considering the severity of dyspareunia, most women conducted in order to draw further conclusions.
experience mild pain. This may be one of the reasons why In other studies, breastfeeding is most frequently associ-
they do not discuss it with their physician. Besides this, ated with dyspareunia. This may be explained by a hypoes-
general difficulties in addressing sexuality by patients and trogenic state resulting in vaginal dryness [3,4,6,11,13].
especially health professionals certainly contribute to the However, in the present study no significant link was found
lack of information gathered on this subject [3,20,21]. Six between the prevalence of dyspareunia and breastfeeding
weeks postpartum, women undergoing operative vaginal 6 months postpartum. Yet, 6 weeks postpartum, dyspar-
delivery showed a tendency towards more severe dyspar- eunia appeared to be more severe in women who had
eunia compared with those who had had a spontaneous started breastfeeding. These women did not have signifi-
vaginal delivery. If we increased the sample size we might cantly lower scores for the FSFI domain of lubrication.
 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 205

Nevertheless, the potential effects of breastfeeding on vagi- study subject and this could also have biased the study
nal lubrication should be included in prenatal counselling. results. Women with a history of dyspareunia may be more
Health care professionals should emphasise the importance likely to participate in studies concerning this subject.
of adequate arousal, followed by adequate lubrication, to Women completed the questionnaires at home. As a conse-
achieve pain-free intercourse. Furthermore, they could sug- quence, the period in which the questionnaires were com-
gest the use of lubricants or estrogen pessaries to achieve pleted ranged from 24 to 98 days after delivery, with an
adequate lubrication in breastfeeding women and in non- average of 57 days postpartum for the first postpartum
breastfeeding women with arousal difficulties. It may also questionnaire. We may assume that the point prevalence at
be helpful to emphasise the importance of pain-free inter- 6 weeks is more an assessment of the prevalence at
course to prevent secondary sexual complaints. However, 8 weeks. Due to these large intervals, we cannot rely on
studies investigating the effect of using these tools in the point prevalences prepartum and at 6 weeks and 6
breastfeeding women are lacking. months postpartum. It is better to consider the broad CIs
Our study results show that primiparous women experi- as an estimation of the prevalences at the specific time
ence more severe dyspareunia both 6 weeks and 6 months points.
after delivery. This is in accordance with the published lit- Another criticism is the point of recruitment. Research
erature and could be caused by different factors. First, mul- results indicate that sexual functioning is already compro-
tiparous women and couples are more experienced and mised in the third trimester. As described above, this point
feel more secure about the postpartum sexual life. is not an ideal baseline from which to compare postpartum
Primiparous women can have unrealistic expectations con- results.
cerning the postpartum period (e.g., existence and duration Finally, no data were collected on the women’s partners
of healing of perineal trauma); for example, Avery et al. [23] and on non-sexual aspects of their relationships. As sexual
reported that 71.1% of primiparous women said it was functioning and satisfaction depend on the couple (not
somewhat, quite or extremely important that their sexual only the woman), we think this could be an important
interest returned rapidly after delivery. Second, primiparous limitation.
women have higher rates of episiotomy and instrumental Strong elements of the research design are the
delivery [3,16,22,23]. prospective data collection and use of validated
Our study shows that dyspareunia is a very common questionnaires.
complaint in the postnatal period. Both the severity of dys-
pareunia and the total FSFI scores showed significant Conclusions
improvement 6 months postpartum compared with 6 weeks
postpartum. In the first week postpartum, women are still Our findings affirm that dyspareunia is a very common
recovering from pregnancy, and delivery and sexual prob- complaint after childbirth. We are the first to measure
lems are frequently reported. Although sexual function women’s postpartum QOL. The results show that sexual
improves, according to our results, the existence and functioning strongly influences a woman’s QOL, thereby
degree of sexual dysfunction 6 weeks postpartum have a confirming the need for counselling to women during the
long-term predictive value. pre- and postpartum periods.
The prevalence of dyspareunia in this and other studies The results indicate that assisted vaginal delivery is
requires that patients be counselled during pre- and post- probably associated with more dyspareunia. We found no
natal visits and that attention be paid to this postnatal protective effect of caesarean section. Indeed, we noted
complaint in obstetric textbooks. poorer QOL in women who had undergone this procedure.
This finding should be taken into account in the debate
about the provision of elective caesarean section on
Strengths and limitations of the study request.
Finally, our results show that primiparous women experi-
This study has several limitations. First of all, the study
ence more dyspareunia compared with multiparous
population was too small to investigate specific factors. We
women. We conclude that primiparous women in particular
conducted a post hoc power analysis to assess the accuracy
need to be informed of what to expect after childbirth.
of our results on the prevalence of postpartum dyspar-
Since we were unable to show other predictive factors
eunia. The power based on our sample sizes pre- and post-
of dyspareunia and long-term sexual functioning, larger
partum was >99.9% for a CI half-width of 15% on the
scale studies with longer follow-up periods should be car-
proportions of women experiencing dyspareunia, which is
ried out. In particular, the influences of breastfeeding, peri-
acceptable.
neal trauma and mode of delivery have yet to be
The exclusion of women who had not resumed sexual
investigated in large-scale prospective observational trials.
intercourse might have severely biased the study results.
Hence, there is a clear tendency towards more dyspareunia
at 6 months in women who had not yet resumed sexual Disclosure statement
intercourse at 6 weeks. Exclusion of these women might
The authors declare that there is no duality of interest associated with
have resulted in an underestimation of the prevalence of this manuscript.
dyspareunia.
Only 48.6% of participants completed all three question-
naires. The low response rate could imply an overesti- References
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