International Urogynecology Journal

, Volume 16, Issue 4, pp 263–267

Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study

Authors

    • Division of Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and GynecologyUniversity of North Carolina School of Medicine
  • John Thorp
    • Division of Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and GynecologyUniversity of North Carolina School of Medicine
  • Laurie Pahel
    • Division of Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and GynecologyUniversity of North Carolina School of Medicine
Original Article

DOI: 10.1007/s00192-005-1293-6

Cite this article as:
Connolly, A., Thorp, J. & Pahel, L. Int Urogynecol J (2005) 16: 263. doi:10.1007/s00192-005-1293-6

Abstract

This study was conducted to evaluate the effects of pregnancy and childbirth on postpartum sexual function. Nulliparous, English-literate women were enrolled who had presented to the UNC Hospital’s obstetrical practice; these women were 18 years of age and older and at 30–40 weeks’ gestation. Questionnaires were completed regarding sexual function prior to pregnancy, at enrollment, and at 2, 6, 12, and 24 weeks postpartum. Demographic and delivery data were abstracted from the departmental perinatal database. One hundred and fifty women were enrolled. At 6, 12, and 24 weeks postpartum, 57, 82, and 90% of the women had resumed intercourse. At similar postpartum timepoints, approximately 30 and 17% of women reported dyspareunia; less than 5% described the pain as major. At these times, 39, 60, and 61% of women reported orgasm. Orgasmic function was described as similar to that prior to pregnancy or improved by 71, 77, and 83%. Delivery mode and episiotomy were not associated with intercourse resumption or anorgasmia; dyspareunia was only associated with breast-feeding at 12 weeks (RR=3.36, 95% CI=1.77–6.37). Most women resumed painless intercourse by 6 weeks and experienced orgasm by 12 weeks postpartum. Function was described as similar to or improved over that prior to pregnancy.

Keywords

Postpartum sexual functionDyspareuniaOrgasmic function

Introduction

Speculation on the effects of pregnancy and childbirth on postpartum sexual function has focused on proposed risk factors such as mode of delivery, episiotomy, continuance of breast-feeding, and a history of dyspareunia. The study of these risk factors has proven challenging, given the variety in study design and outcome variables measured. Time has also proven to be a major barrier in the study of these relationships, as the event in question, childbirth, may precede pelvic floor dysfunction, including sexual dysfunction, by many years.

The literature primarily addresses time to resumption of intercourse and the prevalence of dyspareunia [16]. While some work characterizing dyspareunia has not reported an association with proposed risk factors like mode of delivery or breast-feeding [7], other research that reports such an association is limited by retrospective study design [8]. Lastly, orgasmic function during pregnancy and postpartum is often not studied [4, 5, 9]. Those who have reviewed orgasmic function most frequently report orgasm occurrence rates [6, 10], while other works report on postpartum sexual function with subjective terms [13, 7, 8, 11].

We designed this prospective longitudinal study to evaluate the effects of pregnancy and childbirth on sexual function. We examined the risk factors for postpartum sexual dysfunction, including episiotomy, mode of delivery, and breast-feeding. Time to resumption of intercourse and prevalence of dypareunia were examined while dyspareunia was characterized. We expanded beyond previous studies by specifically addressing orgasmic function. We aimed to describe, during pregnancy and after delivery, the frequency of orgasm; to characterize orgasm; and to evaluate for an association of orgasmic dysfunction, defined here as anorgasmia, with the risk factors listed above.

Materials and methods

The Institutional Review Board at the University of North Carolina School of Medicine at Chapel Hill approved this prospective, longitudinal study. Between 1 June 1993 and 31 March 1994, a convenience sampling of women, receiving prenatal care at the University of North Carolina School of Medicine Department of Obstetrics and Gynecology resident and faculty clinical practice, was undertaken. Women were approached for enrollment by a study author (LP) who obtained written consent. Eligibility criteria included nulliparous women, receiving prenatal care at the University of North Carolina School of Medicine Department of Obstetrics and Gynecology resident and faculty clinical practice, who were English-speaking, 18 years of age or older, and between 30 weeks’ and 40 weeks’ gestation. Parity was defined as any delivery after 20 weeks’ gestation. Enrolled women completed questionnaires themselves regarding sexual function prior to pregnancy and sexual function over the 7 days prior to enrollment. Questionnaires are available upon request. After delivery, women received self-addressed, stamped envelopes by mail with identical questionnaires querying about sexual function over the 7 days prior to questionnaire completion. Questionnaires were completed and returned at 2, 6, 12, and 24 weeks postpartum. Demographic and delivery data were abstracted from the University of North Carolina School of Medicine Department of Obstetrics and Gynecology perinatal database. Data analysis was performed with STATA (Stata Corporation, College Station, TX, USA). Independent sample t-test was used to analyze continuous variables and Pearson chi-square test to analyze categorical variables. A generalized linear model with a binomial family and log link was utilized. Data are presented as mean ± standard deviation and relative risk (RR) with 95% confidence levels (CI).

Results

A total of 327 women who met antenatal eligibility criteria were delivered at the University of North Carolina at Chapel Hill. A total of 328 births occurred in these women. One hundred and fifty (150) nulliparous, English-literate women were enrolled and completed the initial questionnaires. The demographic and delivery information of the 177 women not enrolled and the 150 women enrolled demonstrated significant differences between the two groups regarding three variables only: infant weight at delivery, gestational age at delivery, and the prevalence of forceps-assisted vaginal deliveries. Women enrolled had larger infants and longer gestations. Forceps were applied more frequently in deliveries of the enrolled women (26% vs 15%) (Table 1).
Table 1

Demographic characteristics of all women

 

Women enrolled (n=150)

Women not enrolled (n=177)

P-value

Age (years)

25.3±5.4

25.0±6.1

0.55

Race (%)

  

0.41

 African-American

41 (27)

57 (32)

 

 Caucasian

86 (57)

102 (58)

 

 Other

8 (5)

18 (10)

 

 Missing

15 (10)

0

 

Mean gestational age at delivery (SD)

39.4 (1.5)

38.5 (2.1)

<0.05

Range of gestational age

33–42

32–42

0.51

Infant birth weight (grams)

3,414±480

3,214±578

<0.05

Cesarean deliveries (%)

35 (24)

46 (26)

0.15

Vaginal deliveries, all (%)

115 (76.2)

131 (74)

0.39

 Forceps (%)

37 (24.5)

27 (15)

<0.05

 Vacuum extraction (%)

7 (4.6)

9 (5)

0.96

Episiotomy (%)

21 (13.9)

30 (17)

0.62

Repair of 3rd or 4th degree (%)

15 (9.9)

10 (6)

0.10

Table 2 summarizes demographics of women enrolled. Fifty-seven percent (57%) of women were Caucasian with average gestational age at delivery of 39.4 weeks. Cesarean deliveries accounted for 24% of deliveries with 25% of all deliveries assisted by forceps and 5% assisted by vacuum-extraction. The episiotomy rate was 14%. All episiotomies were midline. Table 3 summarizes the breast-feeding history of the study participants.
Table 2

Demographic characteristics of women enrolled

 

All women enrolled (n=150)

Women who completed all questionnaires (n=47)

Maternal age (years)

25.3±5.4

25.2±4.8

Race (%)

 African-American

41 (27.2)

5 (10.6)

 Caucasian

86 (57.0)

37 (78.7)

 Asian

4 (2.7)

1 (2.1)

 Hispanic

3 (2.0)

0

 Indian

1 (0.7)

0

 Missing

19 (12.6)

4 (8.5)

Mean gestational age at delivery (SD)

39.4 (1.5)

39.7 (1.4)

Range of gestational age

33–42

35–42

Vaginal deliveries, all (%)

115 (76.2)

39 (83.0)

 Forceps (%)

37 (24.5)

14 (29.8)

 Vacuum extraction (%)

7 (4.6)

5 (10.6)

Episiotomy (%)

21 (13.9)

6 (12.8)

Repair of 3rd or 4th degree (%)

15 (9.9)

7 (15.9)

Table 3

Breast-feeding

12 weeks postpartum

24 weeks postpartum

All women (n=150)

Women who completed all questionnaires (n=47)

All women (n=150)

Women who completed all questionnaires (n=47)

28 (35.4)

22 (46.8)

21 (27.3)

14 (29.8)

Figure 1 summarizes the number of questionnaires completed at the different time points in the study. Forty-seven (47) women completed all questionnaires. By 6, 12, and 24 weeks postpartum, 57, 82, and 90% of women completing surveys had resumed intercourse. At 12 weeks postpartum, 30% of women reported pain with intercourse. This decreased to 17% at 24 weeks postpartum. Four percent (4%) of women described pain at 12 weeks postpartum as major, precluding enjoyment of intercourse (Fig. 2). No women described dyspareunia that precluded enjoyment of intercourse at 24 weeks postpartum (Fig. 2). Mode of delivery (abdominal vs vaginal and spontaneous vaginal vs assisted vaginal delivery), episiotomy, and breast-feeding were not associated with resumption of intercourse. Persistent pain with intercourse was associated with breast-feeding at 12 weeks postpartum only, controlling for mode of delivery and episiotomy (RR=3.36, CI=1.77–6.37). The results regarding resumption of intercourse and dyspareunia for the 47 women who completed all questionnaires did not differ significantly from the above results.
Fig. 1

Number of surveys completed

Fig. 2

Character of pain with intercourse

During the third trimester and at 6, 12, and 24 weeks postpartum, 33, 39, 60, and 61% of women reported to have experienced orgasm (Fig. 3). Orgasmic function was described by participant self-report as similar to that prior to pregnancy or improved by 71, 77, and 83% of women at 6, 12, and 24 weeks postpartum (Fig. 4). Mode of delivery, episiotomy, and breast-feeding were not associated with the persistence of anorgasmia. Again, the results regarding orgasmic function for the 47 women who completed all questionnaires did not differ significantly from the above results.
Fig. 3

Occurrence of orgasm

Fig. 4

Character of orgasm

Discussion

Our findings concerning timing of coital resumption duplicate the conclusions of others [1, 3, 4, 69]. Likewise, our findings regarding the frequency of dyspareunia were similar to the results of others [3, 4, 7, 8, 10]. While many have reported the presence of dyspareunia, description of the character of postpartum dyspareunia is not frequently reported [16, 9, 11]. While Signorello et al. [8] reported on women with “severe” dyspareunia, no description of what constituted severe discomfort was given. Uniquely, we attempted to categorize the severity of dyspareunia by describing this as absent, minor (not precluding enjoyment of intercourse), or major (precluding enjoyment of intercourse). By 6 months, no woman was experiencing pain severe enough to limit coital function. Lactation was associated with dyspareunia at 3 months, but this association had disappeared by 6 months. Neither route of delivery nor perineal trauma was associated with painful coitus.

Our attempts to address orgasmic function make a unique contribution to the literature. Previously reported outcome measures related to orgasmic function have included the prevalence of orgasm as reported as percentages [10] or as “ever/never” [6], as well as indirect assessments such as a sexual satisfaction scale [1],“likelihood of orgasm” questions [8], and questions of sexual satisfaction with no further description [7, 8]. Clearly, the above variety of outcome measures reported speaks for the methodological difficulties encountered when researching sexuality.

In our study population, 87% of the women reported ever having had an orgasm. This echoes the meta-analysis findings of von Sydow who reported 51–87% occurrence of orgasm before pregnancy and the work of Ryding who reported an “ever orgasm” prevalence of 74% before pregnancy [6, 10]. At 6 weeks, 3, and 6 months postpartum 39, 60, and 61% of women reported having had an orgasm the preceding week in our study population. This parameter, which has not been previously reported in this fashion, provides objective information aimed at minimizing the effect of recall bias on the occurrence of orgasm. Ryding reported that 74% of women had “ever had” orgasm by 3 months postpartum with the meta-analysis of von Sydow reporting 75% of women having orgasm by 3–6 months postpartum [6, 10]. Signorello et al. [8] reported at 6 months postpartum that 73.8% of women were “just as likely or more likely” to experience orgasm as before pregnancy.

Similar to the return to coitus, women in this cohort reported a time-dependent increasing frequency of orgasm. Moreover, the quality of these orgasmic events was perceived to be similar to that of orgasms prior to and during pregnancy. Intrapartum events were not predictive of the inability to achieve orgasm.

Postpartum outcome measures with less specific definitions such as “sexual sensation,” “likelihood of orgasm,” and “sexual satisfaction” have been previously reported [1, 7, 8]. Time to resumption of orgasm and the quality of postpartum orgasm specifically have not been previously reported. These results, while limited by small numbers and the inherent problem of reliance on self-reports and the recall of function prior to pregnancy, should be reassuring to both clinicians and patients. Sexual function measured in a variety of ways improved and approached levels prior to pregnancy and delivery by 6 months postpartum. We could not detect an association between the mode of delivery and sexual function. Clinical experience leads us to believe that the association we detected between dyspareunia and lactation could be overcome with intravaginal estrogen.

Investigators wishing to explore puerperal sexuality must depend on self-reports regarding this sensitive behavior. These self-reports have been obtained by various methods, including interviews, diaries, and postal questionnaires [15, 69, 11]. No method of assessment is clearly superior to another. von Sydow [10] summarized research findings in this area by completing a meta-analysis. Our study design incorporates recommendations made by von Sydow [10] by querying women about their sexuality in the preceding 7 days, thereby minimizing the recall bias inherent in queries about function weeks to months earlier. We also extended follow-up to 6 months postpartum.

Characterizing orgasm postpartum is even less objectively reported in the literature. In our study, women were asked to describe their orgasmic function over the preceding week as the same, improved, or worse as compared to their function before pregnancy. At 6 weeks, 3, and 6 months postpartum, 71, 77, and 83% of women, respectively, described function as the same or improved compared to function before pregnancy. The persistence of orgasmic dysfunction, as described as anorgasmia in this study, was not associated with episiotomy, mode of delivery, or the persistence of breast-feeding at any of the time points studied. This clearly defined characterization of orgasm, as well as the examination for a relationship between orgasmic dysfunction and the possible risk factors listed above, has also not been described in this fashion previously. Descriptions of postpartum sexual function have been reported in the literature. Klein et al. [7] reported 79–95% of women studied reported that they were “satisfied or very satisfied” with their sexual relationships at 3 months postpartum, although no further description of “sexual satisfaction” was provided. Signorello et al. [8] reported that, at 6 months postpartum, 65.8% of women reported that their sexual satisfaction was the same or better compared to that before pregnancy, though no description of what constituted “sexual satisfaction” was included in their work. None of the work referenced above examined for a relationship between sexual satisfaction and potential risk factors for sexual dysfunction.

A limitation of this study was the convenience-sampling nature of the enrollment. The women not enrolled significantly differed from the study participants with lower gestational ages at delivery and with lower infant birth weights. The clinical relevance of the differences, however, is likely minimal (Table 1). The role of marital status/on-going relationships and the status of these relationships at the time of questionnaire completion were not examined and may have introduced the potential for bias. The recall nature of the study could also be viewed as a limitation. During postpartum, women recalled occurrence of orgasm from the 7 days prior to questionnaire self-administration. This parameter has not been reported previously in this fashion and was structured as such in an effort to decrease recall bias. Patients recalling orgasmic occurrence before pregnancy, however, may have interpreted the question as asking if they had ever experienced orgasm. Women in our study reported prepregnancy orgasm rates comparable to that in the literature [6, 10]. The rates of postpartum orgasm in this study population were also comparable to those reported in the literature of roughly 75% by 3–6 months postpartum [6, 8, 10].

Glazener [5] reported that little help and information are offered to the new parents regarding what to expect of their sexual relationship and sexual function postpartum. As the sexual relationship may be a most vulnerable area in the relationship of “young and expectant couples” [10], given that sexual problems are often not discussed during routine antenatal and postpartum visits [3, 6, 10], and given that roughly 30% of couples report that sexual counseling might have been helpful [3, 10, 12, 13], this clearly is an area worthy of attention from health-care providers. The above data support the assumption that by 3 months postpartum, the majority of women experience pain-free intercourse with orgasm similar to or better than that experienced before pregnancy. The information presented here provides data that can be used to counsel patients both antenatally and postpartum. The health-care provider can provide the much-sought reassurance, during the emotionally charged postpartum time period, that a woman may quite likely regain her prepregnancy level of sexual function.

Editorial

The impact of pregnancy on female sexual function is controversial. Many studies have shown declining sexual function associated with pregnancy, but whether this is sustained in the postpartum period is unclear. The authors present a prospective study of 150 women, with about 50% completing the study. A nonvalidated questionnaire was utilized. Problems with the study design are the potential for recall bias and the losses to follow-up. Results reported dyspareunia postpartum in about one-third, but this was minor and did not hamper participation in sexual activity, as most were sexually active at 6 weeks. Orgasmic function was stable or improved in the majority. Overall, the results provide reassuring information and a basis for counseling patients. However, it remains unclear why some of the women had decreased orgasmic capacity postpartum, which may be a subject of future research.

Copyright information

© International Urogynecology Journal 2005