Is Sex Painful Postpartum? Here's What To Do About It
Painful sex, or dyspareunia, isn't uncommon no matter what your delivery experience. In the horrifying words of one of my dear friends, "It felt like I had been sewn shut the first time I tried having sex three months after my baby was born."
How does my doctor determine when I can have sex again?
Most women are cleared to resume sex between two and six weeks after the baby is born, according to Cleveland Clinic. Your pelvic floor muscles need a chance to recover. Your pelvic organs have been through a lot. It takes time to heal.
What is a physician going by when determining if you are ready for sexual intercourse after having a baby? The textbook answer is six weeks, but if the delivery didn't involve lacerations or suture (or they've healed), then some obstetricians may advise waiting until lochia, or vaginal discharge after delivery, has slowed or stopped.
"That's essentially what they 're looking for. Not pain, not dysfunction, not discomfort, not prolapse," said Oluwayeni Abraham (who goes by Yeni), P.T., D.P.T., pelvic floor therapist and founder of Triggered Pelvic Physical Therapy in Arlington, Texas.
What are the causes of painful sex postpartum?
It can take time before you are ready to have postpartum sex or feel a rekindling of your sexual desire. If it feels like your sex drive took a dive after the arrival of your baby, you aren't alone. It could be a few weeks postpartum before you want to start having sex again as you learn how to balance your new role as a parent.
But sometimes, resuming sexual activities isn't the pleasurable experience it once was. For many women, painful sex after childbirth persists long after those first few weeks.
Tearing or scar tissue
One of the more obvious causes of painful sex postpartum is from tearing or the resulting scar tissue that forms in the healing process.
"During delivery, women who experience tearing can also experience pain once scar tissue starts developing during the healing process. An episiotomy can also lead to painful intercourse during the healing process," said Monica Grover, D.O., M.S., OBGYN and Chief Medical Officer at VSPOT in New York City.
It may be especially painful if you've had third-degree tearing (which extends to the anus) or four-degree (which extends through the anus).
Even when your wound has healed, you may have a lot of "neural dysfunction going on, sending unnecessary pain waves," Yeni said. It can make penetrative vaginal sex difficult.
While you may think this pain is reserved for vaginal deliveries, the reality is that anyone can be affected, regardless of how their baby arrived.
"A lot of people assume that having a cesarean birth can spare your vaginal canal from a lot of the injury, but your body still goes through the same sequelae when it comes to labor. You're still experiencing the same level of hormonal release," Yeni said.
The body doesn't get the memo if you're having a scheduled C-section, so toward the end of pregnancy, the pelvis loses tone and has more laxity as the body prepares for labor and delivery, which can cause postpartum pain.
Hormone levels
Hormone changes can lead to dryness, especially in breastfeeding mothers for months postpartum—and dryness often causes painful sex.
"As a result of breastfeeding, the pituitary gland in the brain makes a hormone called prolactin, which can decrease the production of estrogen by the ovaries (estrogen stimulation keeps the vagina moist), and as such, the vagina gets dry, almost like a menopausal state," said Mary Jane Minkin, M.D., OB-GYN Clinical Professor at Yale University, in New Haven, CT.
Prolactin signals the body to make milk, but there's another purpose too.
"Oh, this person has a baby. This is not sex time. They don't need to procreate. Pleasure is not necessarily on the top of the list when it comes to the way our anatomy is," Yeni said.
Breastfeeding is not a reliable contraceptive as it "does not prevent all ovarian activities, and you can get pregnant while breastfeeding," Minkin said. You will need to choose a form of birth control that's right for you to prevent pregnancy.
Tilted uterus
Even when the uterus returns to its pre-pregnancy size, it may not return to its pre-pregnancy orientation. The uterus is anteverted or slightly tipped toward the bladder in most people.
When the uterus tilts backward, it 's called a retroverted uterus, a tilted uterus, or sometimes a mispositioned uterus.
"This is a major issue that a lot of us don't even talk about," Yeni said. "Sometimes after birth [the uterus] ends up being flipped or tilted back, which can cause a lot of pain and discomfort where they're unable to handle deep penetrative intercourse."
Anorgasmia
The inability to orgasm, or anorgasmia can be very upsetting for postpartum women who wade back into sex only to realize their body isn't responding or feeling the same pleasure as it did before labor and delivery.
"Anorgasmia is sometimes hormonally driven. Sometimes it's trauma driven as well," Yeni said. There is no one reason why you may not feel ready for sex like you did before.
Sometimes, after a traumatic birth, it can be challenging for the body to release oxytocin, thereby making it difficult to achieve orgasm, and anorgasmia can also go hand-in-hand with nursing issues, as oxytocin is needed to lactate, Yeni said.
"We're not looking for a high frequency [orgasm] goal right now. We're just looking for quality over quantity and making sure because when we orgasm, we really do help our overall mental health, our emotional health and it helps with partner bonding," Yeni said.
What can you do about painful sex postpartum?
There are ways to help alleviate the pain you're feeling during sex. It is possible to reclaim your sexual health.
See a pelvic floor therapist
"I can't emphasize enough that people should see a pelvic floor therapist," Yeni said, adding that if you can make an appointment before you even conceive, that 's the best-case scenario.
"You want to make sure that the person who you're working with doesn't just have postpartum experience but [has] sexual medicine experience too. That can really help a lot," Yeni said.
A pelvic floor therapist will be able to see what muscles were affected by childbirth and give you adjustments in-office and exercises you can do at home, like perineal massage.
You'll learn if your pelvic floor is weak, which can cause leaking, or overly tight, which can make it hard to fully eliminate your bladder—and is a condition made worse by Kegels. Your pelvic floor therapist can create a plan for your specific situation.
Use lube
There are a variety of lubrication options, from oil-based, which can last longer, to water-based.
If you prefer water-based lube, look at its osmolality factor. Osmolality means the amount of other ingredients that are not water. You'll want water-based lube to be around the same osmolality as the vaginal and rectal tissue so the body stays in balance.
Look for a lube that's no higher than 380, according to the World Health Organization (WHO). You should be able to find this number clearly stated on the packaging. You may be surprised by the high osmolality of popular water-based lubes.
Try vaginal moisturizers
Many women respond well to vaginal moisturizers like Replens. It's available over-the-counter and is hormone-free.
"You can use it two to three times a week and it provides long-term moisture," Minkin said. It may help replenish the moisture you're missing.
Consider visceral manipulation
If your pelvic floor therapist suspects that your uterus has shifted during childbirth, it can be alarming to hear, but it 's not a permanent condition. Sometimes the uterus will return to its typical state with the help of exercise or movement, but sometimes, it takes a bit more.
Visceral manipulation is a manual technique that can get the uterus into its integrated position. It may be used for other health conditions, including endometriosis, painful periods, pelvic or hip pain.
Vaginal estrogen suppositories
For breastfeeding mothers who are experiencing dryness due to a lack of estrogen, estrogen suppositories may be helpful.
"Estrogen suppositories help to raise estrogen levels to relieve vaginal dryness, discomfort and pain during sex. Some women may need estrogen vaginally if they haven't responded completely to over-the-counter remedies," Minkin said.
The effects of estrogen suppositories are local, or just on the vulvar and vaginal tissue. They do not affect milk, milk production or the nursing infant.
Talk openly with your partner
"[Postpartum sex] is a bit more psychological than people want to talk about," Yeni said.
You 're tired, your body looks and feels different, and there may be postpartum depression in the mix. If you try to dive back into the same sex life you had before giving birth, you 'll likely be frustrated or disappointed.
"Having more healthy discussions with your partner about what sexual expectations look like in this new season will be really helpful because if we just go back to what we were, we'd be cheating ourselves," Yeni said.
Things will be different, and it 's important to address that.
"The reality is if you're lactating and you orgasm, your boobs might leak. We just don't even talk about the new norms," Yeni said.
Discuss your concerns. You may feel bonded and intimate with your partner even if you 're not having regular sex. At least you'll be on the same page. It could help set the stage for more open communication and a fulfilling sex life—even if it looks different than before.
Try other types of sex
You don 't have to dive right back into penetrative sex, especially if it doesn't feel right.
"Another thing I like to recommend a lot of couples do is to revisit other forms of sexual pleasure," Yeni said. "Oral sex is really great too, especially since [something like] 85 percent of women can only orgasm through clitoral stimulation. So a lot of times we just forget about the clitoris for whatever reason."
You may not feel like you have a ton of time for sex, but it's a great way to maintain closeness with your partner.
The bottom line
Too many women grit their teeth, thinking pain or discomfort is the new norm.
"Our bodies are remarkable and have the ability to return to pleasurable intercourse pain-free, but the issue is we have really poor expectations about what sex should look like postpartum, especially if you have a very active sex life pre-baby," Yeni said.
Practice open communication with your partner, relearn your new body and consider clothes or underwear that make you feel good. Speak with your doctor or consider seeing a pelvic floor therapist to help you address your physical concerns.
