10.1576/toag.7.4.245.27119 www.rcog.org.

uk/togonline

Dyspareunia following REVIEW

The Obstetrician
& Gynaecologist

childbirth 2005;7:245–249

Christine Kettle, Khaled Ismail and Fidelma O’Mahony

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

Introduction a reduction in libido.1,5 This is due to the Author details

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

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2004 Royal College of Obstetricians and Gynaecologists
© 2005
 REVIEW dyspareunia. Several research studies1,4,5,7-11,12 intervention.15 More recent research16,17 found
The Obstetrician have reported that 62-88% of women resume that women who delivered with an intact
& Gynaecologist intercourse by 8–12 weeks postpartum. perineum reported the best outcomes in terms of
However, 17–23% continue to experience sexual function and pain. The effect of suture
2005;7:245–249 superficial dyspareunia at three months after materials and methods used for repair of
delivery and 10–14% at 12 months. Barrett et al.1 episiotomies and perineal tears following delivery
reported a higher prevalence rate: 62% of has been assessed in several clinical trials with
women in their study experienced dyspareunia conflicting results relating to reported rates of
at some time during the first three months dyspareunia.4,7,10-11,18
postpartum and 31% still complained of
dyspareunia at six months. However, 12% of the Implementation of strategies to reduce assisted
study participants had experienced dyspareunia vaginal deliveries using the Ventouse vacuum
in the 12 months prior to conception. extractor as the instrument of choice rather than
forceps, reducing episiotomy rate and improving
perineal repair techniques, will probably help in
Associated risk factors decreasing the extent of postpartum sexual
morbidity experienced by women.
Type of delivery
Breastfeeding
Previous research has attempted to estimate the
prevalence of postpartum superficial dyspareunia Hormonal changes associated with breastfeeding
but few studies have been specifically designed to can lead to decreased libido and/or superficial
identify associated risk factors. Data from a large dyspareunia secondary to vaginal dryness.
longitudinal postal survey with a 90% response Confounding factors that can contribute to
rate, carried out by Glazener,5 demonstrated that postpartum sexual morbidity are: tiredness, change
perineal pain persisting after eight weeks was in role, depression, lack of privacy, poor housing,
significantly associated with assisted vaginal pressure to return to work and lack of financial
delivery (30%) when compared with spontaneous and social support. Glazener5 found that women
vaginal delivery (7%). Barrett et al.1 carried out a who breastfed their babies were three times more
multi-factorial data analysis and found that likely to be temporarily uninterested in sexual
dyspareunia at three months after delivery was intercourse. A subgroup analysis of data from the
significantly associated with the type of delivery, study carried out by Kettle et al.4 also showed that
extent of perineal damage and dyspareunia before the incidence of dyspareunia at three months
pregnancy. However, the causal effects of the type following delivery was increased among women
of vaginal delivery and perineal trauma sustained who were breastfeeding (21.2% versus 15.9%).
in relation to dyspareunia were no longer This finding was also supported by Barrett et al.1
significant factors by six months postpartum.
Diagnosis
Fear of dyspareunia following vaginal delivery is
sometimes cited as one of the main reasons why It is important to provide follow-up care for
women request caesarean section. However, a women who have experienced a traumatic birth
small study conducted by Goetsch13 reported or sustained complex perineal trauma to ensure
that 29% of women suffered postpartum that they are not experiencing any sexual
dyspareunia despite having a caesarean section. difficulties. For those who are, it is imperative to
Moreover, a cohort analysis of data from a large obtain a detailed history using a sensitive, non-
randomised controlled trial carried out by Klein judgmental approach. Understanding of the
et al.14 found that women who underwent organic aetiology must be incorporated with
caesarean section experienced more dyspareunia appreciation of underlying psychological factors
than those who had an intact perineum after such as postnatal depression, anxiety and negative
vaginal birth (40.7% and 26.2%, respectively). expectations that can perpetuate the pain cycle.

The woman’s perspective of the problems and

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

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

Figure 1. Flow chart

illustrating the
relationship between
postpartum dyspareunia
and non-organic sexual
dysfunction

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

Postpartum dyspareunia

Pre-existing History Acquired

Non-organic Examination ± investigations

Organic

Refer to psychosexual therapist

Vaginal dryness Scar tissue

Reassurance ± lubricants Reassurance

Modified Fenton's procedure

Figure 2. Algorithm of Perineal refashioning
management of
postpartum dyspareunia

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

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