Sex after birth

Our relationships can grow and change after the birth of a baby, and having sex after birth can sometimes be difficult for women. We found out from the MAMMI study that one in two women experienced pain when they started having sex again, up to three months after birth. Women also told us that they had less vaginal lubrication and a loss of interest in sex.

Fortunately, for most women, these problems decreased over time. Here are some tips that they used to help themselves:

• Using water based lubricants
• Trying different positions where penetration can be controlled, such as the woman on top
• Open and positive communication between the couple

Let’s take a look at some physical factors that can lead to painful sex

Lack of lubrication in the vagina

Breastfeeding can lead to reduced oestrogen (a hormone) levels which causes less lubrication, so using a water-based lubricant and slowly building up to intercourse can help.

Musculoskeletal factors

Pelvic girdle pain, back pain, or having poor posture can indicate a musculoskeletal issue, which can cause painful intercourse. Some of these may have existed before pregnancy, and having an assessment with a women’s health physiotherapist can identify the issue and the best course of treatment.

Wound and injury

Physical injury during birth can also lead to painful intercourse. Rarely, injury may be because of an instrumental birth (where a forceps or vacuum are used during your baby’s birth) or there may be nerve damage or injury to the muscle or connective tissues in the vagina.

Episiotomies or a tear during birth are more common, and sometimes a wound may heal but leave a scar or scarring inside the vagina that can be painful or uncomfortable.

Infection and inflammation

An infection at the site of an episiotomy or tear can also cause pain. If the skin around the wound is red, tender or swollen, you should contact your local doctor to be examined. If there is pus (fluid or discharge) or a smell coming from the wound, seek medical care immediately.

Other infections that may lead to painful intercourse include; repeated thrush infections, a sexually transmitted infection, or a urinary tract infection. Eczema or other skin problems in your genital area such as lichen sclerosis can also cause pain.

Emotional factors can also be a factor for painful sex

Experiencing a past sexual trauma can lead to pain during sex, even with a trusted partner. Not every woman who has pain during sex has experienced abuse, and not everyone who has experienced abuse will have pain, however, it can be a factor.

Stress and anxiety can also have an effect on painful sex. Pelvic floor muscles tend to tighten in response to stress, making sex painful or uncomfortable. Vaginismus is a condition where there are involuntary spasms of the muscles of the vaginal wall, which can make penetration painful. Sometimes, having pain during intercourse might lead to a fear of the pain reoccurring, leading to more tension and more pain. Some women may start to avoid sex because it is associated with pain.

Pelvic floor pain

Having either physical or emotional factors can lead to pelvic floor pain. Women who have experienced vaginal pain or trauma may develop an overactive pelvic floor. Injury, trauma, infection or prolonged tension from poor posture or unconsciously holding the muscles can lead to a muscle that does not relax very easily.

The pelvic floor muscle becomes tight and shortened and it has a limited ability to let go and lengthen. This leads to a reduced range of movement and pain; which then limits the ability to do an effective pelvic floor contraction.

This can lead to pain trigger points – think of these as being similar to having a knotted muscle, which hurts when pressure is applied to the knotted area. For this reason, many women are unaware of injury to their pelvic floor until they engage in sex or during an internal examination when pressure is applied to the trigger point.

Seeking help

If you experience pain and discomfort during sex, it is important to seek help from a healthcare professional, such a women’s health physiotherapist. Women’s health physiotherapists have specialist training in the treatment and management of women’s health issues, and can help you with the physical factors that may be causing pain following childbirth. They use what is known as an holistic approach, or treating the whole person, to look at the different reasons you might have pain during intercourse following birth.

Speak with your local doctor, public health nurse or check with the maternity hospital you attended for the birth and ask about referral to a women’s health physiotherapist. In some places you can self-refer to a women’s health physiotherapist and you do not need a letter from a doctor.

Usually the physiotherapist will do an external pelvic and internal vaginal assessment to look at any scars, the quality of the muscle movement and ability to release, and any painful trigger points.

Treatment

Treatment for sexual health issues can include:

• Gentle manual therapy for the muscles in the abdomen, pelvis, and inside and outside the vagina.
• Abdominal breathing techniques and gentle exercises that help teach the muscles how to release and stretch, reducing painful areas. Often, you will be encouraged to commit to a home programme of treatment; this may include breathing, stretching or scar release, and will be very helpful in continuing the treatment on a daily basis between your visits to the physiotherapist.
• Trying positions that are better for starting to resume sex, use of lubrication and specific pain relieving gels.
• Relaxation, specific breathing techniques and stretches.
• Referral to a psychologist or therapist if you have suffered sexual abuse or trauma.

Whatever route you take in seeking help, it is very important that you don’t ignore painful sex and hope that it will just go away.

Pain during sex is not normal and, in most cases, it can be helped with treatment.