It is now the six week mark and you are at your postpartum check up and are told by your doctor, everything looks great, you can resume having sex. You’ve finally hit this goal that everyone talks about- “six weeks.” But what does that really mean? Does it mean that everything ‘down there’ is back to normal? Sex will now become a regular part of life again? If you are like most women who have just had a baby, sex is probably not the first thing on your mind.
I have asked two women who have recently had their first baby about their experience at the six week mark. One is a friend of mine who demonstrates the ‘typical’ postpartum mom, minimal complications, just normal changes that occur in your body after giving birth. The second interview is from a patient at PHRC who was willing to share her journey through recovery postpartum.
Cindy (31) – Four and a half months postpartum
What type of birth did you have and were there complications?
“I had a vaginal delivery and I didn’t have any tearing or trauma.”
At your six week check up with your MD when you were cleared for intercourse, what were some of the thoughts you had about regaining intercourse? Were you ready? Did you have any concerns?
“Yes, I was ready for intercourse. I didn’t have a strong desire for intercourse mainly because of the fatigue that comes with caring for a newborn and it wasn’t a priority but I didn’t really have any concerns.”
When did you first resume sexual intercourse? Was there pain? Was there any dryness? Was it a pleasant experience?
“I actually ended up having intercourse prior to my six week check up, probably around four weeks, and figured I was ok because I didn’t have any injuries. There was no pain, but there was some dryness which wasn’t necessarily painful but different than before. We just used lube.”
Prior to delivery or at a postpartum visit, did your doctor discuss contraception options with you? What did they recommend?
“She prescribed the mini-pill which is what I was on previously. She actually wanted me to do something like an IUD but I wasn’t into it. I haven’t started the mini-pill though because I was worried it would affect my milk supply.”
Are you breastfeeding?
“Yes, I currently breastfeed exclusively.”
Our bodies change after having a baby, especially our abdominopelvic region. How has this (if at all) impacted your sex life or body image? Many women report feeling “loose” down there or lack some sensation, how do you feel your body has changed postpartum and is this a concern for your sex life?
“Nothing about my body image has changed or is affecting my sex life. The only physical symptoms I have is a small pinch that reminds me of some sciatic issues and affects my ability to stand. But nothing affects my body image or sex life.”
Now Cindy is quite lucky! This is probably a “best case scenario” postpartum mom. While she demonstrates some things that her Ob/gyn could offer treatment for (which we will discuss below) generally her problems may resolve once she completely stops breastfeeding. Additionally, this “pinch” she feels is likely a pelvic floor issue that she could seek treatment for but like most ob/gyns – they do not recognize this as an issue as it is not limiting her daily activities at this time.
This is the goal most women want – return to normal life after baby. The next interview is completely the opposite. This is a woman who struggled even before pregnancy with dyspareunia (painful intercourse) and her experience postpartum considering her pelvic pain prior to pregnancy.
Veronica (25) – currently 1.5 years postpartum
What type of birth did you have and were there complications?
“Vaginal delivery, it was a quick and easy labor, I only pushed for 30 minutes. I sustained a second degree tear and it went directly through the tissue that was already painful with sex.”
At your six week check up with your doctor, when you were cleared for intercourse, what were some of the thoughts you had about resuming intercourse?
“I was thinking my doctor is nuts and there is no way there is anything touching there for a long time. I was in so much pain still, even sitting was hurting, sitting on the toilet or laying on my back. If I leaned to one side where my tear was, it felt like when you are sewing and the thread gets stuck and it is just pulling.”
Were you ready physically or emotionally?
“No, physically it wasn’t going to happen and I was so tired after giving birth and not sleeping through the night. Waking up every few hours to nurse which I was also having issues with successful breastfeeding and was dealing with pain in my breasts and ‘down there.’“
On a scale of 1-10 what was your desire?
“0-1/10”
How did your partner react?
“It was very hard. He was just not able to understand the pain and couldn’t really relate. It was so new and different and so overwhelming.”
How did you approach dealing with all of these issues since it was so overwhelming?
“I talked with my mom, someone who could relate to having a baby. I started to take walks with the baby to get out of the house despite the pain and get outside so I wasn’t trapped in the house. I had a lot of anxiety regarding leaving the house and safety concerns which I realize is normal for new moms. I then started going to a friends group and a mommy and me group, which helped a lot. I even hosted one and it made me feel I was a part of something.”
When seeking out medical advice, what did they suggest?
“Go back to PT; I was having painful intercourse prior to pregnancy and when I was pregnant I was told by my current PT at the time that there wasn’t anything else they could have really done. I ended up doing a lot of my own research and went through 3 PTs before finding PHRC.”
Prior to delivery or at a postpartum visit, did your doctor discuss contraception options with you? What did they recommend?
“Yes, he recommended the mini-pill which I didn’t end up taking per the recommendation of the physical therapist and was advised to use condoms – which I wasn’t completely sure I wanted to do.”
When did you first resume sexual intercourse? What was your experience?
“Five to six months postpartum, after seeking out pelvic floor PT for a few sessions. There was excruciating pain. It was disappointing because I thought I was further along with physical therapy than I was.”
How long did you breastfeed for?
“8 weeks. I stopped because there were a lot of issues I was having successfully feeding the baby.”
Our bodies change after having a baby, especially our abdominopelvic region. How has this (if at all) impacted your sex life or body image? Many women report feeling “loose” down there or lack some sensation, how do you feel your body has changed postpartum and is this a concern for your sex life?
“My stretch marks are really bad on my stomach and makes me feel less sexy in general and I have looser skin. I feel generally “thicker” and was always very lean.I have started yoga to address this but my body is different than I am used to. Emotionally it is very draining to want to fix this issue. I have had to look at so many different options, and that kills the romance and passion.”
How did the PT/treatments help even though you are not 100%?
“I no longer have any pain related to my scar – it was extremely painful and even thinking about it I can still remember how excruciating it was. The vaginal entrance is no longer as tight or painful as it once was and the vestibule burning is dramatically less than prior to therapy when I use my dilators or have sex.”
Is there anything else you would like to add?
“The six week mark is such a goal, something to get to. At six weeks I was not better, I still felt like S#!%”
I’d like to discuss some of the common postpartum changes women go through and how seeking out PT may help with recovery in these areas. Many of these issues are demonstrated by one or both of the above women, and there are some other issues that neither woman described but are often a concern postpartum which we will discuss below.
Dryness
Vaginal dryness occurs in the postpartum period because of a lack of estrogen while breastfeeding. It is our body’s natural “birth control” to ensure that while you care for one infant, you will not be preparing for another in nine months. Now, this is not a 100% sure way of preventing pregnancy as there are cases of “irish twins” but it still causes a lot of vaginal dryness with the lack of hormones. On a positive note, there are things that you can do to help the dryness. Many ob/gyns can prescribe a topical estrogen cream that you can apply locally to the vaginal area that will help. There are also non-hormonal topicals women can try using such as “Vital V” or coconut or emu oils. You’ll also want to use a good lubricant. As a pelvic floor PT I am generally pretty specific when it comes to which brands are best to use – you’ll want to stay away from the KY’s that can have drying agents or harsh chemicals, you can check Melinda’s blog for more information on lubricants: Slippery when wet: Is your lubricant causing pelvic pain, infections, or fertility problems?
As we talk about hormones (or the lack thereof) during this postpartum period, as you read above, both women were prescribed the “mini-pill.” The mini-pill is a progesterone only oral contraceptive pill (OCP) that given to women who 1. Cannot tolerate other forms of OCPs or 2. Women that are breastfeeding. It contains no estrogen and there is less progestin than in a combo oral contraceptive. It is given to women who are breast feeding because it used to be thought that the estrogen contained in combo OCPs inhibited milk production.
Pain
Pain with intercourse can be caused by a number of reasons.
- Birth Trauma. Perineal tearing, episiotomies, vaginal assisted deliveries such as vacuum assisted or forceps, may cause trauma to the tissue and/or muscles in the pelvic region. There may be scar tissue present that is restricting normal movement or that has become hypersensitive.
- Hormonal changes (like we discussed above in the case of vaginal dryness) which can cause pain to the vestibule – this is the area of tissue around the opening of the vagina and urethra that is hormone dependent. This means that a sudden shift in hormones (usually a lack of estrogen and/or testosterone) causes this area to become painful and most women describe pain upon initial penetration, pain with insertion of tampons and/or pain with vaginal exams. A previous history of oral contraceptives or acne treatments such as Accutane or use of spironolactone may predispose you to irritation of this tissue as well.
- Pelvic floor dysfunction and the tight muscles may be the source of pain. As I mentioned earlier in Cindy’s case, the pinch and “sciatic” symptoms she is experiencing can be from a tight muscle in the pelvic floor or hip region – possibly the piriformis or obturator internus muscle which can be affected during pregnancy and/or childbirth. A pelvic floor physical therapist can thoroughly assess the pelvic floor muscles and the muscles surrounding the pelvic girdle and can help you to differentiate the cause of your pain and get you back to full function, pain-free. For more information on pelvic floor physical therapy, check out our website here. And find out what a good pelvic pain PT session is like in our blog.
Body Image Issues
Like in Veronica’s case, there are changes in the body such as stretch marks, weight gain, and scarring that can make a woman feel less than ideal when returning to intimacy. In part, PT can help with a safe return to exercise program to help shed some of the baby weight and return to a healthy postpartum body. We can also evaluate for a diastasis recti, a split of the abdomen that commonly happens with pregnancy, which you can read more about here and here, to ensure that the ab exercises you may want to quickly get back to are actually safe for you to do. It is also not uncommon for women to seek out professional help from a counselor, mommy support group, or psychotherapist to help with some of the “bad” feelings that accompany these issues.
Lack of Desire
In both cases, both women reported that their desire was next to nothing, mostly because of baby fatigue. You have a new priority and are likely sleep deprived for quite some time and it takes a lot of energy to care for a newborn. However, there may be more to it than that – hormones can play a role, body image issues, marital concerns, and pelvic pain.
Pelvic Organ Prolapse
Pelvic organ prolapse (POP) occurs when the vagina and/or uterus have dropped from their normal position in the pelvis. Prolapse can be caused by injuries sustained during childbirth, aging, chronic coughing and/or heavy lifting. This can cause a woman to feel abnormal pressure or a feeling of something “falling out of the vagina.” This may pose some concerns with body image if it is visible and it can affect how we function and perform our daily activities and can be a problem when trying to return to exercise. To read more about POP and how physical therapy can help check out our website.
So what is the big deal behind this six week mark? Clearly both women who I interviewed didn’t really have a desire to go back into the bed, though Cindy did, the desire was not quite there because of many other reasons. Typically, six weeks is when it is safe to return to sexual intercourse and the risk for infection is minimal. Whether you return to intercourse is a personal decision between you and your partner and there may be many factors that influence this decision.
Many women have issues that they believe are “normal” postpartum. While they are common, I want to emphasize that this does not always mean “normal.” If you are unsure if you are appropriate for physical therapy, contact your local pelvic floor therapist. You can visit www.womenshealthapta.org/pt-locator/ to find someone near you. Fun fact: All postpartum women in France have to talk to a pelvic floor physical therapist before leaving the hospital!