Clinical Review

How to prepare your patient for the many nuances of postpartum sexuality

OBG Manag. 2012 January;24(1):24-38

	Dr. Rezaee offers 5 tips for talking to patients about postpartum sexuality

References

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11. Pauls RN, Occhino JA, Dryfhout VL. Effects of pregnancy on female sexual function and body image: A prospective study. J Sex Med. 2008;5(8):1915-1922.

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13. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Rsearch Group. Neurourol Urodyn. 1995;14(2):131-139.

14. Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC; Continence Program for Women Research Group. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 2002;99(2):281-289.

15. Handa VL. Sexual function and childbirth. Semin Perinatol. 2006;30(5):253-256.

16. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol. 1994;171(3):591-598.

17. Barrett G, Pendry E, Peacock J, Victor C, Thakar, Manyonda I. Women’s sexual health after childbirth. BJOG. 2000;107(2):186-195.

18. Barrett G, Peacock J, Victor CR, Manyonda I. Cesarean section and postnatal sexual health. Birth. 2005;32(4):306-311.

19. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol. 2000;95(3):464-471.

20. Leeman LM, Rogers RG, Greulich B, Albers LL. Do unsutured second-degree perineal lacerations affect postpartum functional outcomes? J Am Board Fam Med. 2007;20(5):451-457.

21. Signorello L, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: A retrospective cohort study of primiparous women. Am J Obstet Gynecol. 2001;184(5):881-890.

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24. NIH State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request NIH Consens Sci Statements. 2006;23:1-29.http://consensus.nih.gov/2006/cesareanstatement.htm. Accessed December 6 2011.

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26. Chivers ML, Pittini MD, Grigoriadis S, Villegas L, Ross LE. The relationship between sexual functioning and depressive symptomatology in postpartum women: a pilot study. J Sex Med. 2011;8(3):792-799.

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28. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin No.119: Female sexual dysfunction. Obstet Gynecol. 2011;117(4):996-1007.

29. Read J. Sexual problems associated with infertility pregnancy and ageing. BMJ. 2004;329(7465):559-561.

30. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208.

31. Isidori AM, Pozza C, Esposito K, et al. The Female Sexual Function Index (FSFI): Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction. J Sex Med. 2010;7(3):1139-11.

32. McCoy NL. The McCoy Female Sexuality Questionnaire. Quality Life Res. 2000;9(suppl 6):739-745.

33. Hatzichristou D, Rosen RC, Derogatis LR, et al. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med. 2010;7(1 Pt 1):337-348.

34. DeRogatis LR, Allgood A, Rosen RC, Leiblum S, Zipfel L, Guo CY. Development and evaluation of the Women’s Sexual Interest Diagnostic Interview (WSID): a structured interview to diagnose hypoactive sexual desire disorder (HSDD) in standardized patients. J Sex Med. 2008;5(12):2827-2841.

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36. Sillis T, Wunderlich G, Pyke R, et al. The Sexual Interest and Desire Inventory-Female (SIDI-F): item response analyses of data from women diagnosed with hypoactive sexual desire disorder. J Sex Med. 2005;2(6):801-818.

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A paucity of research

To date, research into sexuality during the postpartum period has focused primarily on the physical changes and constraints that affect the mechanics and frequency of intercourse and overall sexual satisfaction and desire.² This perspective has begun to broaden to include the psychological aspects of sexuality.

TABLE 1

These validated tools can help you measure female sexual dysfunction

Tool	Area assessed
Female Sexual Function Index (FSFI)³⁰	Desire, arousal, orgasm, and pain
Female Sexual Function Index 6-Item (FSFI-6)³¹	Desire, arousal, orgasm, and pain
McCoy Female Sexual Function Questionnaire*³²	Presence of female sexual disorders
Brief Sexual Symptoms Checklist³³	Screener for sexual concerns
Female Sexual Distress Scale – Revised³⁴	Distress
Intimate Relationship Scale*³⁵	Changes in sexual relationship
Sexual Quality of Life – Female (SQol-F)³⁶	Quality of life in women with female sexual dysfunction
Golombok Rust Inventory of Sexual Satisfaction (GRISS)³⁷	Quality of sexual relationship
Decreased Sexual Desire Screener³⁸	Brief diagnostic tool for hypoactive sexual desire disorder
* Validated in pregnant and/or postpartum women

Women’s sexual health during the postpartum period has generally been under-researched. It wasn’t until the past decade that validated sexual function questionnaires were utilized. Although a number of these instruments are now available (TABLE 1, TABLE 2, FIGURE), it remains unclear whether they can accurately measure postpartum sexual function. Despite these limitations, significant information has been elicited that can be used to counsel patients struggling with postpartum sexual concerns.

TABLE 2

The 6-item Female Sexual Function Index*

Question	Responses
Question	0 points	5 points	4 points	3 points	2 points	1 point
How would you rate your level of sexual desire or interest?	No sexual activity	Very high	High	Moderate	Low	Very low or none at all
How would you rate your level of sexual arousal (“turn on”) during sexual activity or intercourse?	No sexual activity	Very high	High	Moderate	Low	Very low or none at all
How often did you become lubricated (“wet”) during sexual activity or intercourse?	No sexual activity	Almost always or always	Most times	Sometimes	A few times	Almost never or never
When you had sexual stimulation or intercourse, how often did you reach orgasm?	No sexual activity	Almost always or always	Most times	Sometimes	A few times	Almost never or never
How satisfied have you been overall with your sexual life?	No sexual activity	Very satisfied	Moderately satisfied	About equally satisfied and dissatisfied	Moderately dissatisfied	Very dissatisfied
How often did you experience discomfort or pain during vaginal penetration?	Did not attempt intercourse	Almost never or never	A few times	Sometimes	Most times	Almost always or always
*The components of this index are to be assessed over the past 4 weeks. The score is the sum of the ordinal responses to the 6 items and ranges from 2 to 30. A score of less than 19 indicates a need for further investigation, including the full-length Female Sexual Function Index. Source: Adapted from Isidori et al.³¹

Ideal period of abstinence is unknown

Although our knowledge of the female genital tract in the puerperium is based upon histologic evidence, there are no evidence-based policies to outline the ideal period of postpartum coital abstinence. It seems reasonable to assume that our traditional scientific recommendations developed in part to prevent uterine infection and disruption of sutured wounds. These concerns, combined with cultural and societal norms, have led to the routine discouragement of sexual activity until 4 to 6 weeks postpartum.

The possibility of shortening the period of postpartum abstinence was first suggested by the American College of Obstetricians and Gynecologists (ACOG) in 1984.¹ In 1985, Pritchard and colleagues wrote about the individualization of postpartum prohibitions of sexual activity in Williams Obstetrics.¹ The earliest time at which intercourse may be safely resumed is unknown, but the 23rd edition of Williams Obstetrics states that a woman can resume sexual intercourse as early as 2 weeks, based on her comfort and desire.³ The sixth edition of the American Academy of Pediatrics (AAP) and ACOG guidelines for perinatal care also states that the risks ought to be minimal at 2 weeks postpartum.⁴

BRIEF SEXUAL SYMPTOMS CHECKLIST FOR WOMEN (BSSC-W)

Reprinted from Hatzichristou et al. ³³

Low desire is not unusual

Although a patient may be granted “permission” to engage in coital activity, other variables influence her decision. It is well known that sexual desire may fluctuate during pregnancy and typically decreases significantly during the third trimester.² Many women enter the postpartum period with lower levels of sexual desire and satisfaction, and these depressed levels may continue for some time.² Twenty-five percent of women report worsened sexual function, including diminished sexual satisfaction, during pregnancy that persists for 6 to 12 months postpartum.⁵ By 12 weeks postpartum, 80% to 93% of women have resumed intercourse, but as many as 83% report sexual problems during the first 3 months of the postpartum period. At 6 months, 18% to 30% of these women may still be experiencing sexual problems, including dyspareunia.^5,6