<div>Sexual Function the First Year Postpartum: A Mini-Commentary</div><div>Rachel Pope MD, MPH</div><div>Urology Insitute, Division of Female Sexual Health</div><div>University Hospitals, Cleveland Medical Center</div><div>11100 Euclid Avenue, Cleveland, OH 44106</div><div>Rachel.pope@uhhospitals.org</div><div>Running Title: Postpartum Sexual Function</div><div>In the first year postpartum, women tend to be burdened by physical
exhaustion due to interrupted and lack of sleep, breastfeeding and the
potential challenges therein, and chemically-induced anxiety and
depression. Literature in the field of behavioral health has long-since
described the high prevalence of postpartum mental health disturbances
of 20% of all women, and the impact of mental health on quality of life
documented world-wide (O’Hara MW et al. Perinatal mental illness:
definition, description and aetiology. Best Pract Res Clin Obstet
Gynaecol. 2014 Jan;28(1):3-12). Sexual dysfunction, however, is a
lesser-known challenge and one that is notably under-reported and
addressed in the medical literature, likely due to other dominating
discomforts and an overall stigmatization of female sexual health.
Furthermore, scheduled visits with medical providers rarely extend
beyond six weeks postpartum and most women have not resumed sexual
activity at this time.</div><div>Sexual function is an important aspect of quality of life. There is
straight-forward treatment for dysfunction and dyspareunia that may be
caused by hypo-oestrogenized tissues and pelvic floor injuries. Cattani
et al. highlight the experiences of women around the world through a
comprehensive systematic review. It is not surprising then, that
obstetric anal sphincter injuries (OASIS), episiotomies, and
instrumental vaginal birth are all associated with sexual dysfunction
and/or dyspareunia. While anal sphincter injuries affect approximately
6% of women (Jha S et al. Risk factors for recurrent obstetric anal
sphincter injury (rOASI): a systematic review and meta-analysis. Int
Urogynecol J. 2016 Jun;27(6):849-57.) and episiotomies continue to be on
the decline, the paper by Cattani et al does show less dyspareunia among
women who deliver by cesarean compared to spontaneous vaginal birth. One
might assume this is related to the pelvic floor injuries. However, mode
of delivery is not associated with overall sexual dysfunction.
Strikingly, OASIS was associated with an odds ratio of 3 (1.28-7.03) for
sexual dysfunction and 1.92 (1.47-2.52) for dyspareunia. While these
injuries are not easily preventable, these data inform and strengthen
the need for specialized clinics, follow-up care and increased attention
to individuals who have sustained them (Madsen A, Hickman L, and Propst
K. Recognition and Management of Pelvic Floor Disorders in Pregnancy and
the Postpartum Period, Obstetrics and Gynecology Clinics of North
America. 2021. 48; (3):571-584). For example, if an individual with a
third or fourth degree laceration is identified as having increased risk
for pain and dysfunction sexually, she should be counseled on this as to
empower her to seek care should the concern arise. Lubricants, vaginal
estrogens and DHEA can all be appropriately prescribed even if
breastfeeding and could greatly improve her experience (Donders GGG, et
al. Pharmacotherapy for the treatment of vaginal atrophy. Expert Opin
Pharmacother. 2019 May;20(7):821-835.). Furthermore, this information
underscores the need for women who have sustained a higher order
laceration to present for pelvic floor physical therapy and rehabilitate
as a preventive and therapeutic measure. Specialized clinics can help
patients navigate this.</div><div>Vaginal dryness from lactation is extremely common. This review only
identified one study on vaginal dryness and sexual concerns. This does
not indicate that vaginal dryness is not a problem, but rather that more
research is indicated. Another unexplored variable is urinary
incontinence. A large proportion of women experience urinary
incontinence in the first year postpartum. It would be worth exploring
the connection between UI and sexual dysfunction.</div><div>Therefore, while this review represents progress in understanding the
mechanism of sexual dysfunction and dyspareunia the first year
postpartum, there is still more to be learned in the form of empiric
evidence, especially regarding vaginal dryness and urinary incontinence.</div>