Keywords

1 Introduction

Whereas Chap. 9 addressed various sexual aspects of the healthy breast and successful breastfeeding, this chapter will deal with the more challenging and problematic situations.

The relationship with sexuality is ‘the Red Thread’ throughout this chapter.

It will start with the situation when breastfeeding does not develop properly because of challenges experienced by many women, including pain. After that, we will highlight conditions where breastfeeding cannot or should not develop. We will then address situations where for various medical reasons, breastfeeding can be troublesome. Finally, we will focus on the more complex emotional connections interfering with breastfeeding, including depression and past traumatic experiences. We will devote a small part to lactation induction in the non-birthing woman, a possibility for a lactation stand-in when the mother cannot nurse or the co-mother in a lesbian relationship who opts for co-nursing. For more insight, we start with a short intermezzo about endocrinology and its implications.

2 Endocrinological Aspects of Breastfeeding

During full breastfeeding, female sexual function is under the influence of hyperprolactinemia, which is necessary to maintain milk production. The high prolactin levels cause a generalized suppression of ovarian functioning with a decrease in oestrogen levels (hypo-estrogenism) and testosterone levels.

The physiological hypo-estrogenism causes a situation comparable to menopause with high vaginal pH, increased parabasal and intermediate cells, and decreased superficial cells. Next to these atrophic changes, there is also a decrease in genital vasocongestion and dry vaginal mucosa.

The lowered testosterone levels cause fatigue, reduced mood, low sexual desire, and decreased arousability. The combination of these endocrinological factors can negatively affect the woman’s sexual life and satisfaction, independent of additional factors like perineal trauma, motherhood’s responsibilities, and childcare demands. Many other factors influence the resumption of sexuality and how sexuality and intimacy will redevelop. While some new mothers feel a loss of femininity by stretch marks and weight gain, others shine through motherhood. Breastfeeding itself is also experienced differently. For some as a very tiresome task; for others, it is close to experiencing sheer happiness. And last but not least, the sexual needs of the partner will influence when and how postpartum sexuality will get shaped.

3 When Breastfeeding Does Not Develop Properly for ‘Normal’ Reasons, Including Pain

3.1 Pain During Breastfeeding

During the first year of the life of their infants, about 50% of breastfeeding mothers have reported breastfeeding pain. The most common causes of breastfeeding pain include nipple pain, mastitis, candida infection, engorgement, and clogged milk ducts.

The incidence of each cause may vary from study to study in relation to the mother’s and the infant’s risk factors. Persistent nipple pain is one of the reasons for consultation in around 40% of cases due to incorrect positioning, infection, palatal anomaly, flat or inverted nipples, tongue tie, mastitis, and vasospasm [1]. Infectious skin disorders of the breasts can also cause physical discomfort, poor quality of life, and sexual problems for nursing mothers. It is important to diagnose them at an early stage. Pain is a relevant factor to decrease sexual desire and pleasure and, when experienced for a more extended period, can influence the couple’s relationship.

3.2 Mastitis

Mastitis is an inflammation of the breast, sometimes related and sometimes not to a bacterial infection. The clinical findings show up as wedge-shaped, hot, swollen, and tender areas of the breast with a temperature over 38 °C. Prospective studies estimate the incidence of mastitis in breastfeeding from 3% to 20%. Main factors related to mastitis include a history of mastitis, university education, blocked duct, and cracked nipples. The majority of cases appear during the first 6 weeks postpartum.

Good healthcare support will identify lactation mastitis early and make a full recovery possible. In general, the healing does not involve medical intervention and can be resolved by self-management through feeding, cold compresses for soothing, and massaging the affected breast area. Nonetheless, some cases may require antibiotic treatment. If under-treated, it can result in a breast abscess and may cause hospitalization and surgery. For the woman with mastitis, the sexual consequences will depend on how much the breasts are part of her erotic identity, and for both partners, it will depend on how much the breasts were an integrated part of initiating sexual contact and lovemaking.

3.3 Candida Infection

Candida infection (also known as thrush) is a fungal infection that also can develop on the breast and the nipples. It manifests clinically by stabbing and radiating pain through the breast tissue. White patches in the baby’s oral cavity and a white coating on the tongue are diagnostic signs. Maternal risk factors are recent antibiotic use and recurrent yeast infections. It is found more after vaginal candida and vaginal birth. The treatment of Candida mastitis involves topical antifungal application on the nipples after each breastfeeding session.

In recurrent candida infection of the nipple/breast, it is wise to consider candida transfer from the vulva to the nipples, either via the woman’s masturbating fingers or via the partner’s tongue.

3.4 Psychological Stress Associated with Breastfeeding Pain

Postpartum, there can be close encounters between breastfeeding and psychological stress. Mothers who were not depressed during pregnancy and intended to breastfeed have lower risks of depression postpartum. However, mothers who had that intention but did not succeed have a higher risk for depression. Therefore, conditions causing substantial breastfeeding pain and causing early weaning might increase the chances of postpartum depression and stress.

Providing specialized support to young mothers largely diminishes that risk [2].

Another factor affecting breastfeeding cessation is the mode of birth. After emergency or planned Caesarean section, women delay the initiation of breastfeeding and are less likely to breastfeed. Those deliveries influence, in some way, the physiology of lactogenesis resulting in more lactation difficulties. Research indicated the surgery-related decreased oxytocin secretion and increased maternal stress as factors disrupting the hormonal pathway for lactogenesis [3].

Breastfeeding is important for the infant’s health and is also a way for the mother to bond with her baby. So HCPs must be aware of the effect of early cessation of breastfeeding on the sexuality of the mother. Besides causing stress, involuntary early cessation has a higher risk for mastitis and pain.

In addition to parenting duties, having pain might cause a decrease in sexual desire and the quality of life and cause difficulties in concentrating on sexuality and self-esteem. Although there are barely any studies on breastfeeding disturbances and sexuality, we may say that it is paramount to prevent these conditions and, if they do arise, to treat them appropriately.

4 When Breastfeeding Cannot Develop or Should Not Develop

4.1 Sheehan Syndrome

Sheehan syndrome is a hormonal disturbance that develops when massive blood loss during childbirth causes shallow oxygen levels and necrosis in the anterior pituitary gland, later resulting in low levels of various hormones, including gonadal hormones. Among the consequences are no or poor development of breastfeeding and low androgen levels needed for energy and sexual desire. The psychotraumatic impact of such a sudden life-threatening experience will probably influence both partners and their sexuality. Nowadays, this Sheehan syndrome relatively seldom happens in more affluent medical care.

4.2 When Breastfeeding Is (Nearly) Impossible or Contraindicated

Lactation can be impossible when severe trauma or burns have damaged the breasts and sometimes after cosmetic breast surgery.

Breastfeeding can also be contraindicated. The mother needs, for instance, a treatment necessary for her health (e.g. chemotherapy) but dangerous for the baby because being passed into breastmilk. Or the mother has a high viral load (with HIV, HTLV-1, or cytomegalovirus) that reach the baby via breast milk.

Those situations can ask for pharmacological suppression with cabergoline or bromocriptine. These dopaminergic drugs are also in use for patients with pituitary failure, where they are known sometimes to cause a substantial increase in sexual desire (‘hypersexual side effects’).

A study comparing oral cabergoline (1× 1 mg) and oral bromocriptine (2× daily 2.5 mg for 14 days) for lactation suppression did not mention sexual side effects [4].

For some women, not being able or ‘not being allowed’ to breastfeed their baby can mean a real blow to her ‘maternal identity’ or her ‘female identity’, thus potentially diminishing her sexual identity. Whereas for other women, that will have far less emotional and sexual consequences.

5 Relevant Aspects of Breastfeeding Related to Some Medical Conditions

Chapter 18 will address various medical conditions that indirectly influence breastfeeding and sexuality. This paragraph will focus on three conditions with a more direct influence: spinal cord injury, multiple sclerosis, and breast eczema, followed by some relevant consequences of breast surgery.

5.1 Spinal Cord Injury (SCI)

Although women with SCI experience many sexual difficulties, there usually is no problem becoming pregnant. For these mothers, breastfeeding is more than average essential to develop an optimal bonding with the baby. But lactation goes accompanied by several difficulties.Footnote 1

One of the complexities is breastfeeding positioning [5].

People with an SCI have lower systolic blood pressure. Knowing that breastfeeding is accompanied by lowered blood pressure and heart rate, SCI women who breastfeed (and their HCPs) should be aware of developing low blood pressure and orthostatic hypotension. Women with a cervical or high thoracic level lesion deserve extra attention. During breastfeeding (or breast engorgement), they can face autonomous dysreflexia (with very high, dangerous systolic blood pressure) [5].

Another primary factor in women with an SCI is a non-functional let-down reflex essential for providing milk to a nursing infant. The infant’s suckling activates tactile receptors on the breast. Via sensory nerves and the T4–6 posterior root centres in the spinal cord, the signal goes to hypothalamic neurons, which release oxytocin to the bloodstream. That oxytocin release is required for milk ejection. In women with SCI above T4, the first step of this pathway is absent, meaning that the tactile receptors are not activated. Thus, the let-down reflex is not present. In women with SCI between T4 and T6, the reflex is reduced [6].

With a complete SCI above T4, the woman will have no tactile sensation in the breasts nor any other lower part of the body. That should not be a reason for the partner to abstain from playing with breasts and nipples and everywhere else. Whereas that might not serve as direct neurological stimulation, the woman can experience such loving touch as an indication of still being attractive, and even it can arouse her into feeling a tactile sensation, a process called sensory integration.

5.2 Multiple Sclerosis (MS)

In MS patients, sexuality and sexual relationship are affected in multiple ways. The brain damage, the lesions in the sexuality-orchestrating centres in the spinal cord, and the peripheral neuropathy can directly damage sexual function. In addition, spasticity, fatigue, lethargy, urinary, and sometimes faecal incontinence are major symptoms interfering with sexual well-being.

MS causes many sexual worries about ‘being a good lover’, performance anxiety, and also insecurity because she can never be sure how her body will react this time during the sexual encounter.

When pregnant, the woman may not use the most current MS medication. However, relapses are significantly reduced during pregnancy, especially in the last 3 months, because of higher levels of oestrogen and progesterone in the cerebrospinal fluid. So above-mentioned sexual insecurity and distraction can diminish.

Since postpartum gonadal steroids go down, relapses are common, making disease-modifying medication recommended after childbirth. That, however, passes into breastfeeding. Gradually, it is becoming clear that (especially exclusive) breastfeeding is protective against postpartum MS relapses [7].

5.3 Eczema

We define the clinical presentation of several types of dermatitis eczema. Eczema in breastfeeding patients presents itself mainly on the areola, occasionally extending to the breast, with the nipple much less affected. Patients with these eczema lesions describe them as pruritic, painful, or burning [8]. Identifying a maternal history of eczema, atopic, and allergic dermatitis can prevent eczema cases in breastfeeding mothers.

For treatment, we use topical corticosteroids and antibiotics [8]. To prevent endocrine disturbances in the nursling, the woman should breastfeed the baby before applying the corticosteroids. Remember that neither the woman nor her partner should develop an aversion to the breast. Some couples prevent this when the partner applies the ointment while gently massaging the breast. Regarding other skin diseases, there is minimal scientific data on the various associations between eczema, hidradenitis suppurativa, prurigo, blistering disorders, psoriasis, urticaria, skin infections, and pruritus with sexual health, although the impact on sexual difficulties seems relatively high.

5.4 After Breast Surgery

Most breast surgery concerns aesthetic breast implant augmentation, the number one popular plastic surgery worldwide. Reports show that breast augmentation surgery can improve women’s sexual satisfaction and self-confidence by 80%. Since many women undergo these operations relatively young, many will bear childbirth later. A meta-analysis of studies showed that fewer women reach exclusive breastfeeding after this surgery [9]. Thus, when women want to proceed with this, the plastic surgery team should fully inform women of the negative influence of the operation on breastfeeding. Surgery can damage glandular tissue and the innervation of the breasts. The pressure made by implants on breast tissue may also affect lactation by damaging the breast tissue or blocking lactiferous ducts [10]. The authors remark that the lower breastfeeding rate after implants should not be a contraindication for aesthetic surgery but rather a stimulus for good breastfeeding counselling.

Although many studies deal with women’s sexuality after breast augmentation surgery, they do not target women with actual breastfeeding difficulties. Future research will lighten the effects of implants on lactation and sexual dysfunctions.

In breast reduction surgery, the surgical technique is essential. Preservation of the column of subareolar parenchyma does not impair lactation [11].

Unilateral mastectomy (e.g. for breast cancer) is no reason not to breastfeed since one breast can perfectly supply enough milk.Footnote 2

6 Emotional Connections Interfering with Breastfeeding

6.1 Depression and Breastfeeding

Breastfeeding may mediate the association between pregnancy and postpartum depression (PPD). A systematic review of several studies showed that postpartum depression predicts and is predicted by breastfeeding cessation [12]. Both pregnancy depression and postpartum depression are associated with shorter breastfeeding duration.

The estimated effect of breastfeeding on PPD differed according to whether women had planned to breastfeed their babies and whether they had shown signs of depression during pregnancy. For mothers who were not depressed during pregnancy, the ones who had planned to breastfeed, and who had actually breastfed had the lowest risk of PPD. Those who had planned to breastfeed but without continuation had the highest PPD chance [13]. Several studies report that women who are not breastfeeding are more likely to have depressive symptoms than breastfeeding women. A longitudinal Japanese study found that at 5 months postpartum, breastfeeding mothers had fewer signs of PPD compared to women who were formula-feeding (𝑝 = 0.04) [14].

That seems at odds with the information from the beginning of this chapter about lactation-related low oestrogen levels causing an atrophic vagina and low testosterone levels causing fatigue, lowered mood, less sexual desire, and less arousability. The likelihood that lactation-related dyspareunia and decreased sexuality contribute to the development of depression is apparently counterbalanced by other factors like the joy of parenthood and the bonding with the baby.

For the sexual consequences of depression and antidepressant medication, see Chap. 17.

6.2 Dysphoric Milk Ejection

Dysphoric milk ejection reflex (D-MER) is a relatively new phenomenon, described as an overwhelming flow of negative emotions during breastfeeding that corresponds precisely to the milk ejection. Some researchers find it common among breastfeeding mothers [15].

It occurs just before the milk is released and continues for a few minutes. A drop in the dopamine level and the release of oxytocin during the let-down is one of the explanations [15]. But many other elements seem to play a role, including hormonal, psychological, and neurobiological mechanisms. Due to the modern media, the sexualization of the female breasts influences the thoughts and fantasies about breastfeeding with a wide range of emotions between mystification of the nursing mother, high levels of modesty, and embarrassment about the carnal aspects (with self-objectification and ‘reproductive shame’), all influencing both the willingness to breastfeed, the success of it, and sexuality. In other words, D-MER is a bio-psycho-socio-cultural phenomenon needing a BPSC-approach and BPSC-aware research. That research should also include attention to the influence of D-MER on sexuality.

6.3 Past Traumatic Experiences

Child sexual abuse (CSA), with or without physical and emotional abuse, can have many consequences for the woman’s sexual life and her sense of safety and integrity. In various ways, it can also influence breastfeeding. A US representative sample on breastfeeding compared women with and women without CSA. With CSA, women were more than twice likely to initiate breastfeeding [16]. The authors’ explanation for this somewhat surprising finding is that these women appear to be more attentive to good parenting. The breastfeeding experience boosts the sense of having value for some women and it can be a discovery (or rediscovery) of sensuality.

Other women cannot handle the physical connection with the baby. Breastfeeding, requiring an intimate touch between the mother’s breast and the baby’s mouth, might feel uncomfortable. Some mothers indeed experience the sucking baby nearly as a sexual aggressor.

Narratives indicate that a few women do not want to breastfeed because their breasts have become a no-go zone, having been part of the abuse.

In women with CSA, unintended pregnancies or a low socioeconomic situation may also decrease the likelihood of breastfeeding.

7 Induced Lactation in Another Woman

In some situations, the need arises for a woman to breastfeed a baby she is not carrying. Examples of such lactation stand-in are as follows: when adopting a newborn baby; when the mother died; when the mother is under chemotherapy treatment or too weak; or when another woman carried the pregnancy. In the ideal situation, a protocol (e.g. the Newman-Goldfarb protocol)Footnote 3 should start already 6 months before expected childbirth with combined oral contraceptives and domperidone, a peripheral dopamine antagonist. In the last 6 weeks, that should change to domperidone combined with breast stimulation and pumping the breast. The milk quality is just as good as the milk on the normal tenth postpartum day. Only a minority of women will be able to produce all the milk the baby will need. However, it will facilitate emotional bonding with the child and transmit extra protection from antibodies, other proteins, and immune cells with the milk.

The domperidone will increase the prolactin level, potentially diminishing sexual desire. However, the lactation stand-in woman will not suffer from vaginal atrophy and low testosterone levels, the common reasons for dyspareunia in postpartum women.

Induced lactation in a newer form is becoming common in lesbian relationships when the co-mother wants to co-nurse the baby. For more details on lesbian motherhood, see Chap. 21.

8 Conclusions

Pregnancy comes with many changes affecting the physical health and well-being of mothers. When a mother has planned to breastfeed but is unable because of illness and pain, many consequences will affect the mother–infant dyad, the mother and her sexuality, and the woman–partner dyad, including their mutual sexuality.

Disordered sexual function postpartum is highly affected by the lack of appropriate sexual health counselling in prenatal and postnatal care. Better qualified professionals can help maintain or improve the sexual life of breastfeeding mothers by guiding them through topics such as lubrication and breastfeeding periods. Furthermore, during months of lactation, professional guidance of the woman and her sexual partner can help readjust their sexual relations.