PMS, pregnancy, postpartum,
infertility, contraception—strap in,
it’s going to be a bumpy ride
Women stoically ride the hormonal roller coaster of life navigating the ups and downs of PMS, contraception, attempting conception, pregnancy, and postpartum. And even before perimenopause hits, it’s pretty obvious that it too will be no day at the amusement park. Since the right balance of hormones is critical to maintaining a healthy sex life, anything that alters hormonal levels is going to have an impact. So strap in . . . it’s going to be a bumpy ride.
Premenstrual Syndrome
Prior to the 1970s, few people had heard of premenstrual syndrome (PMS). Today it’s hard to browse through a greeting card section without being inundated with dozens of examples of PMS “humor.” But for the 50 million women who suffer from monthly premenstrual mood swings, irritability, and weight gain, it’s no joke. Premenstrual syndrome is different for everyone, but one thing is consistent . . . women who suffer from PMS experience at least one physical or emotional symptom that starts five days before menses and disappears within four days after a period starts. (If moodiness and bloating come and go throughout the month, PMS is not the problem.)
There are more than 150 premenstrual symptoms that a woman might experience during the premenstrual phase of her cycle. Seventy to 90 percent of reproductive-age women report at least one adverse symptom, and up to 40 percent feel that their symptoms are bothersome enough to qualify as PMS because they not only interfere with their ability to think clearly and feel good but affect their relationships with everyone around them. It goes without saying that most women are not feeling particularly sexual when PMS hits.
It takes only one of these premenstrual symptoms to have PMS:
Emotional symptoms
Irritability
Depression
Angry outbursts
Anxiety
Confusion
Social withdrawal
Physical symptoms
Breast tenderness
Abdominal bloating
Headache
Swelling in the extremities
Is PMS the Same as PMDD?
Premenstrual dysphoric syndrome (PMDD), by contrast, is a far more severe and debilitating version of PMS that affects 3 to 8 percent of reproductive-age women. While a diagnosis of premenstrual syndrome requires the presence of only one of the symptoms just listed that are associated with PMS, women who suffer from PMDD have a minimum of five of those symptoms, and at least one of those five symptoms is depression, anxiety, or irritability severe enough to interfere with school, work, or relationships. Like PMS, PMDD symptoms are present five days before a period and are completely gone within four days of the onset of menses.
What Causes PMS?
The woman who lashes out at her family and friends the week before her period is not a wicked, nasty person—she is simply suffering from raging, out-of-control hormones. Women with PMS actually have normal estrogen and progesterone levels, but for reasons not really understood, they have an exaggerated response to normal cyclic changes. There does seem to be a genetic predisposition, but beyond that there is no way to predict who is going to have the most trouble.
Taming the Beast
Since PMS was identified as a specific phenomenon, many attempts have been made to control symptoms with progesterone, estrogen, vitamins, exercise, and dietary changes. Most women just live with the monthly misery, either because they think the symptoms are not severe enough to bother talking to a doctor or because they think nothing will help anyway. PMS is often accepted as another “natural” part of being a woman, like menstrual cramps and labor pain.
The data on diet changes and supplements is inconsistent, but some supplements, such as progesterone, evening primrose oil, and ginkgo biloba, have been definitively proven to be ineffective.
Some, but not all, studies show that vitamin B6 (100 milligrams a day), vitamin E (400 milligrams a day), calcium, and magnesium (200 to 300 milligrams a day) reduce PMS symptoms. And chocolate? Well, there is no question that women crave carbs during that time of month, so it’s not unexpected that carbohydrate-rich food and beverages reduce symptoms by boosting serotonin production.
Proven Treatments
Only two treatments, one an antidepressant, the other a birth control pill, have been FDA-approved for the treatment of premenstrual symptoms. Three of the selective serotonin reuptake inhibitors—fluoxetine, sertraline, and paroxetine—have been proven to alleviate symptoms.
Since PMS is hormonally driven, it makes sense that suppressing the normal menstrual cycle by taking birth control pills would eliminate symptoms. Unfortunately, until recently, no traditional oral contraception has been shown to alter the incidence or severity of premenstrual symptoms. Yaz is the only non-antidepressant and the only oral contraceptive to be FDA-approved for the treatment of premenstrual symptoms. Unlike other pills, Yaz contains drospirenone, the only progesterone that acts as a diuretic, encouraging water elimination, which in turn reduces bloating and breast tenderness. Because Yaz is taken 24 days a month rather than the traditional 21, the effects are maintained during the four-day “off” interval. Studies show that Yaz reduces premenstrual symptoms in at least 50 percent of women . . . much better than in placebo groups or with other remedies.
The Contraception Conundrum: When Taking the Pill Takes Away Your Sex Life
For the sexually active woman who is done having kids, not interested in having kids, not ready to have kids, or in between kids, fear of pregnancy is a major libido killer. For the last 50 years, however, women have enjoyed the almost 100 percent certainty of preventing pregnancy with birth control pills. But in an incredibly unfair twist, for some women the very pill that allows such freedom can affect libido and vaginal lubrication and make them not even want to have sex.
Before I launch into the obstacles that the pill causes for some women, I do want to emphasize that for the majority of users the pill is a really good thing—not only for sexual health but for general health as well. The list of the pill’s medical benefits for most women is a long one and includes:
Reduction in or elimination of heavy menstrual bleeding
Decrease in anemia
Reduction of pain during menses
Reduction of PMS symptoms
Reduction in perimenopausal hormonal swings
Prevention of menstrual migraine headaches
Reduction in the occurrence of acne
Decrease of facial and body hair
Control of bleeding from fibroid tumors
Decrease of pain in women with endometriosis
Decreased risk of uterine cancer
Decreased risk of ovarian cancer
Decreased risk of colon cancer
With a list like that, it’s not surprising that 58 percent of women rely on hormonal contraception for purposes beyond the prevention of pregnancy. Actually, at least 14 percent of women taking hormonal contraception pills use them exclusively for noncontraceptive purposes.
Aside from the medical benefits that indirectly enhance sexual health, the pill also has specific sexual benefits. Separating procreative sexuality from recreational sexuality is a good thing. There is no doubt that removing cramps, PMS, heavy bleeding, and the fear of pregnancy from the equation goes a long way toward increasing the desire to have sex. Clear skin is also a proven esteem booster.
For the Lucky Majority, the Pill Actually Enhances Libido
Many large studies have shown that libido is enhanced in the majority of pill users: they have a higher frequency of sexual thoughts and fantasies, have better orgasms, and are more interested in having sex. Overall, women who use reliable birth control, including the pill, have increased sexual enjoyment.
The Pill’s Negative Effects on Sexuality
It would be nice if this was the end of the pill story, but for a significant number of women, taking hormonal contraception has a negative impact on sexual health. It may seem odd that while estrogen increases sex drive, the pill, with relatively high levels of estrogen, can have the opposite effect. The explanation primarily lies in the other part of the hormone cocktail that’s responsible for that lusty feeling—testosterone.
Birth control pills contain both estrogen and progestin. The progestin prevents pregnancy, while the estrogen stabilizes the uterine lining to prevent pesky breakthrough bleeding. All progestins have androgenic (testosterone-like) properties, but newer pills contain progestins that are less androgenic. That’s a good thing if you are trying to reduce acne or excess hair growth (two of the negative side effects of androgenic progestins), but not such a good thing for your libido.
In addition, taking the pill inhibits your ovarian production of testosterone. The end result of the newer pills is that you are taking less androgen and making less on your own. Then comes the final blow. The estrogen in birth control pills increases the amount of sex-hormone binding globulin. As discussed in chapter 10, the more SHBG, the less active (unbound) testosterone is available to boost libido. So not only are your total testosterone levels lower, but what’s there is in an inactive form.
Less Testosterone, Less Libido
A decreased libido is the most common and best known negative sexual side effect of hormonal contraception. While some research clearly shows that the pill has a positive effect on libido for some women, there is no question that for others it’s a huge libido killer. If that wasn’t bad enough, in addition to decreasing libido, low testosterone can lead to fatigue, lethargy, and moodiness—all symptoms that make you more likely to want to take a nap than to make love.
Recent large-scale studies have confirmed that some pill users have decreased desire, arousal, and sexual thoughts. One of the largest studies, published in 2010 in the Journal of Sexual Medicine, followed the sex lives of 1,000 German medical students, some pill users and some not. The pill users had significantly more libido and arousal issues.
Studies also confirm that women on hormonal contraception with decreased libido generally have lower free testosterone levels than women who do not take hormonal contraception. However, before you run off to get a testosterone blood test, be aware that taking a measurement is not helpful, since specific testosterone levels do not always correlate with sexual satisfaction. Many women with low numbers have a very robust libido.
Decreased Lubrication
While many women have heard about the libido issues associated with the pill, far fewer women are aware of the profound effect it can have on vaginal lubrication. Your gynecologist may not even be aware of this side effect. New studies show that a small but significant percentage of women on hormonal contraception have a reduction in vaginal lubrication due to both relatively low levels of estrogen and low testosterone. Women who take the pill stop making estrogen on their own since the pill takes over and suppresses natural estrogen production. Because the estrogen component of the pill is responsible for an increase in blood clots, most new pills have a very small amount of estrogen. Here’s the problem. The estrogen in a very low-dose pill is high enough to suppress the ovaries (excellent for contraception!) but too low to provide lubrication for some women. Testosterone receptors in the vagina also contribute to lubrication, so the lack of androgenic activity can not only kill the libido but dry things up.
There also seems to be a genetic component to this response to the pill, which occurs in about 3 percent of the population. So, if you can’t figure out why your vagina is like the Sahara Desert even though you are 30 years old, totally in lust with your partner, and feel great otherwise, you are not imagining it. It’s real.
Vestibular Pain
Some pill users find that total lack of lubrication is the least of their problems. Seemingly out of nowhere, some women on the pill develop vestibular pain that precludes even getting to the gate. Acquired vestibulodynia caused by using oral hormonal contraception results in painful hypersensitivity when any area of the vestibule is touched. If you are frantically doing gymnastics with a mirror to see why you are suddenly having pain, you may see some obvious areas of redness, but in most cases everything looks completely normal (see chapter 8 on vestibulodynia). This appears to be more of an issue with newer pills that contain less estrogen, particularly in women who start the pill prior to age 19.
Anatomical Changes
And as if you needed any more convincing that the changes that occur on the pill are not just “in your head,” a small study published in the Journal of Sexual Medicine in 2012 reported that measurements of the thickness of the labia minora and the vaginal tissue at the entry of the vagina showed that pill users had a significant decrease in thickness. In that study, the thin tissue was associated with an increased risk of pain during intercourse, decreased libido, decreased arousal, and a decrease in orgasms. Not really a surprise, is it?
And it’s concerning that almost 70 percent of women ages 30 to 40 were the least aware of the negative effects of birth control on their sex lives.
The Fixes
So, if you are on the pill and find you would rather play Sudoku than play with your guy, what options do you have?
Yes, you can alleviate the dryness with lubes, moisturizers, and vaginal estrogens, as discussed in chapters 5 and 7, but since most women need contraception for an average of 25 years, you may want to consider a different option.
Dr. Streicher’s SexAbility Survey
Asked which method of contraception can kill your sex life,
11.1 percent of women said “IUD”
9.7 percent said “birth control pills”
2.0 percent said “vasectomy”
77.2 percent said “none”—because reliable contraception can only improve your sex life!
Try a Different Pill
Some pills may be better for you than others. One study showed that pills that contain newer progestins, such as drospirenone, desogestrol, and norgestimate, might have more impact on libido and vaginal dryness than other progestins.
Pills that contain a lower dose of estrogen seem to be more problematic, so consider switching to a 30-microgram pill, which is still low enough to minimize the risk of blood clots but may be high enough to eliminate sexual problems.
The Nuva ring and progestin-only contraception options, such as Depo-Provera or Nexplanon, appear to have fewer sexual side effects, but some studies show a negative impact with these methods as well.
SHBG remains elevated until six months after you stop taking the pill, so don’t expect instant improvement.
Switch to a Different Kind of Contraception
Birth control pills are not the only way to prevent pregnancy. Not every woman can use, or wants to use, hormonal contraception. For them, an intrauterine device (IUD), with or without progestin, is a great solution.
The first IUD was reportedly a stone placed in a camel’s uterus to prevent pregnancy during the long desert trek, when a camel pregnancy would have been catastrophic. (Evidently camels are pretty randy.) The modern IUD came along in the 1960s and hit its peak during the 1970s, when 10 percent of women used an IUD for contraception. The design of the original IUD, particularly the outmoded Dalkon Shield, increased the risk of pelvic infection, and many women who used IUDs in the 1970s had serious complications. Forty years later, mention IUD and words like “dangerous” and “infertility” still come to mind. It’s no wonder that many women steer clear. Fortunately, the new IUDs are designed differently, do not have the same issues, and may in fact be one of the safest, most beneficial contraceptive options.
Currently there are three intrauterine options available. All can be placed in the uterine cavity during an office visit. All provide excellent contraception protection—about 99 percent.
The copper IUD, Paraguard, lasts for ten years and prevents pregnancy by preventing implantation of the fertilized egg in the wall of the uterus. The main downside to the copper IUD is that it may make your periods heavier than usual.
The other available IUDs, Mirena and Skyla, contain a small amount of progestin called levonorgestrol. While strictly speaking they are hormonal contraceptives, they are not in the same category as other hormonal options since the hormone is released in the uterus with minimal systemic effects. The primary way levonorgestrol IUDs prevent pregnancy is by making the mucous in the cervical opening so thick that even the most motivated sperm can’t get through. If one hardy sperm does manage to get past the cervical barrier, implantation is unlikely since the progestin makes the uterine lining thin and inactive. Mirena offers many noncontraceptive benefits such as reducing menstrual bleeding by 95 percent, preventing uterine cancer, and treating endometriosis and other gynecologic conditions.
Skyla, the newest IUD, is a lower-dose version of Mirena. It has an even smaller amount of progestin (causing fewer systemic effects) but provides contraception for only three years and may not have the same noncontraceptive benefits as Mirena.
All three IUDs give excellent contraception in addition to scoring A+ for convenience. This is not just my opinion. Women who use IUDs are usually the biggest fans, which is why there is an 86 percent continuation rate. Birth control pills have only a 55 percent continuation rate after 12 months of use.
The number-one group of women who choose IUD contraception for themselves? Female gynecologists. Need I say more?
Injectables and Implants
Injectable and implanted birth control is another option that many women choose over the pill. Nexplanon is a matchstick-size rod that is placed under the skin of the arm, where it slowly releases a progestin called etonorgestrol. It lasts for three years.
Depo-Provera is a progestin shot administered every three months. While some women love it, others find that it causes weight gain and irregular menses.
Barricading the Sperm Meets Egg Highway
If you have given your maternity clothes to Goodwill and used the crib for firewood, it may be time to consider permanent sterilization.
While “tubal ligation” and “getting your tubes tied” are the commonly used terms, the more appropriate term is “tubal interruption.” That’s because there is no actual “tying” involved in the techniques currently used to block the road between the ovary and the uterus.
The very first tubal interruptions were performed as major surgery requiring a large abdominal incision. By the 1970s, a woman requesting sterilization required only an outpatient laparoscopic procedure involving a small incision in the belly button and one or two other tiny incisions in the lower abdomen. The surgeon would then use clips, rings, or cautery to seal the fallopian tubes. No matter the method, the result was the same: an egg could no longer rendezvous with a sperm.
Today a new “no incision” sterilization can be performed in a doctor’s office with local anesthesia and essentially no recovery time. “Essure” is a technique in which a slender scope is inserted through the cervix, enabling the gynecologist to place tiny coils inside the tubes as they enter the uterus. The coil doesn’t block the sperm; instead, it stimulates scar tissue to grow around the coils, which eventually occludes the tube. An X-ray is performed a few months after the procedure to ensure that the tubes are completely closed.
The upside to sterilization? It is a onetime procedure with no hormonal changes and afterward there is no further need for contraception. Another bonus is that women who have undergone tubal sterilization have a decreased risk of developing ovarian cancer. Keep in mind that while these new methods of sterilization are much safer and easier than they used to be, small risks still remain.
The major downside to any permanent sterilization? It’s permanent. That means you have to be completely, absolutely, totally, 100 percent sure that you don’t want to become pregnant. That might sound obvious, but a lot of women who think they are sure change their minds. Studies have shown that 3 to 25 percent of women regret getting a tubal ligation. The most common reason is a change in marital status, particularly in young women. While post-sterilization pregnancy is possible utilizing in vitro fertilization (IVF) techniques, the expense is prohibitive and the procedure is not always successful.
Is It His Turn?
And then there’s vasectomy. Before you skip over this section, think about this. Women willingly accept years of contraceptives, pregnancies, labors, deliveries, and postpartums. Yet, once the decision for permanent sterilization has been made, the men who have watched them experience all that often balk at the very notion of undergoing the comparatively minimal discomfort and inconvenience associated with having a vasectomy. That has always been the case, which is why it’s the women who end up taking responsibility for permanent contraception 75 percent of the time. Every year 1.5 million tubal ligations are done in the United States, compared to only 500,000 vasectomies.
Since the women are the ones who endure the discomfort, risks, and inconvenience of years of contraception and/or pregnancies, it seems to me that by the time a couple is ready to call it quits, vasectomy is the perfect “thank you” gift. And if you are single and looking and not interested in having kids, you might want to think of adding “has vasectomy” to your perfect guy wish list along with “great sense of humor” and “likes pets.”
I’m just waiting for Match.com to list “vasectomy” as a part of the profile. Talk about a popularity booster!
The Impact of Infertility on Sexual Health
After years of preventing pregnancy, it’s a cruel turn of events when a woman finds that she can’t get pregnant once she decides she is ready. Women who go through fertility treatments deal with not only astronomical expense but incredible stress, not to mention unpleasant physical changes as a result of being barraged with hormones. Did I mention the massive weight gain that many women experience as a result of fertility medications?
Nothing is more associated with having sex than actively trying to get pregnant, yet the difficulties that come with sex during fertility treatment are pretty much never discussed.
Sex on demand doesn’t help make an already difficult situation any less so, and a woman can hardly expect to be aroused, moist, and “good to go” just because the ovulation predictor kit says it is the right time. There is an unspoken assumption that sexual pleasure is completely irrelevant for the infertile couple. This wouldn’t be such a big deal if it lasted only a few months, but for many couples fertility treatment drags on for years, or over multiple pregnancy attempts. Recently, there has been some research about sexuality during fertility treatment. A 2012 study out of the Indiana University School of Public Health confirmed what most couples have already figured out—assisted reproductive techniques, especially IVF, cause problems with sexual desire, interest, and satisfaction. As expected, “mood-type symptoms” that could be attributed to the stress of going through fertility treatments, like sadness and anxiety, were huge, but the study also found that women had physical issues such as vaginal pain and dryness.
What Is the Solution for Couples Struggling with Infertility?
For couples who can’t conceive, there aren’t a whole lot of options when it comes to dealing with the sexual difficulties that sometimes accompany the process. (I know, since when did sex become a “process”?) A good lubricant can be helpful, but people trying to get pregnant often avoid using one, since lubricants can have a negative impact on sperm. The lube Pre-Seed, as I mentioned in chapter 5, does not have any impact on sperm count or motility. A long-acting vaginal moisturizer or local vaginal estrogen is also a solution to make all that sex on demand more comfortable.
Fortunately, for most couples treatment doesn’t last long, and the sexual issues associated with infertility treatment will disappear right around the time the sexual issues associated with pregnancy start.
Pregnancy Pitfalls
Name a common medical condition, other than cancer, in which over the course of a year you go through major hormonal, cardiovascular, hematologic, metabolic, and pulmonary changes, not to mention a massive change in your body habitus. That “medical condition,” of course, is not a disease, but the normal physiologic change most women go through at least twice in their life—pregnancy.
Yet in spite of the fact that women spend an average of two and a half years of their adult lives pregnant and others spend far longer (Mrs. Duggar!), little attention is paid to sex during pregnancy other than the advice to “follow the advice of your doctor.” A 2012 study showed that only 17 percent of ob-gyn residents even asked their patients about sexual concerns during pregnancy, confirming that this is a conversation that most doctors don’t initiate beyond, “It’s safe,” or “Please abstain.”
I was once asked to go on The Jenny Jones Show (Remember that one? It was one of the first in the too-much-information-about-your-personal-life TV genre) to talk about sex during pregnancy. I declined (an excellent decision on my part), but one of my patients agreed to be a guest. Jenny asked her how her sex life was during her high-risk pregnancy. I had advised her to abstain from having intercourse because of preterm labor. She replied (on live national TV): “If I give one more blow job, my lips are going to fall off.” As I said . . .
So here’s the rundown: During the first trimester, most women have significant breast tenderness (as in they hurt so much you order your partner to not get anywhere near them), nausea, vomiting, extreme fatigue, and in some cases fear of miscarriage. Real aphrodisiacs, right?
The second trimester is when most women are told that intercourse is the most pleasurable and comfortable, and for many it is. It is also the time when it becomes physically obvious to your husband that you have an actual human being inside you. Now, some men are totally turned on by a pregnant belly and are not in the least bit freaked out by a little kick or reminder that there are now three people in the bed instead of two. Others worry that they are hurting the baby or feel like they are having sex with the children watching. This is particularly a problem as you get closer to delivery and a moving human being is obviously in your belly. Even if both of you remain interested, by the third trimester, in spite of creative arrangement of pillows and positions, intercourse is physically very uncomfortable for some women.
Comfort aside, there seem to be two groups of women . . . those who have an amazing libido and incredible orgasms during pregnancy (these are the women with really large families) and women who feel asexual and have zero interest (mostly parents of only children?!).
So, a few tips if you are currently pregnant or thinking about becoming pregnant:
Unless your doctor tells you otherwise, you can continue to do pretty much anything you would ordinarily do, as long as you want to. If it doesn’t hurt, it’s okay. If your doctor tells you to abstain, ask him or her to get specific. Should you abstain only from intercourse? Or should you abstain from any sexual activity that might result in an orgasm?
I still remember the woman who asked me, when I told her she should abstain from intercourse, if anal intercourse was acceptable. I was so taken aback by her question that I don’t remember what I said. I think I mumbled something like, “I guess so.” This was before I became an expert in medical sexuality! In retrospect, I should have told her no, since what I was trying to have her avoid were the uterine contractions that occur as a result of orgasm. I honestly don’t think I was aware at the time that women can have orgasms from anal intercourse.
Most women are fine with giving up their sex lives for a few months for the sake of having a healthy baby, but be aware that if you are in that group experiencing no desire and no pleasure during pregnancy, you still have the postpartum to look forward to—and that’s where the real trouble can start.
Postpartum: The Big Secret
Everyone assures you that you will be ecstatically happy once you are no longer pregnant and have a healthy baby. It’s funny how everyone forgets to mention the part about peeing in your pants every time you laugh, cough, or sneeze after childbirth, the chronic exhaustion, and not being sure you even like, much less love, your baby. It doesn’t help that your body no longer even remotely resembles your pre-pregnancy figure and shows no signs of returning to form anytime soon. Put that together with healing vaginal tears, a crying baby in the next room, and a useless husband in the room and many women wonder if they are destined to have only one child simply because they can’t imagine ever having sex again. When you finally do try to revisit your sexual side, your vaginal walls are more often than not thin, dry, and nonresponsive.
What’s going on down there, other than the obvious, is that nursing, postpartum women have low estrogen levels. The good news is that those low levels prevent ovulation and provide automatic contraception. The bad news is that it doesn’t do you any good to have natural contraception if you can’t have sex.
It’s pretty clear that for at least the first three months postpartum the couple with a “normal” sex life is the exception, not the rule. By three months postpartum, 80 to 93 percent of women have resumed sexual intercourse, but in a study of over 400 first-time moms, 83 percent reported sexual problems at three months postpartum, and 64 percent reported that intercourse was still painful at six months postpartum owing to healing vaginal tears or decreased lubrication. Sexual problems were strongly correlated with poor body image, urinary incontinence, and painful intercourse for postpartum women.
The majority of studies that look at postpartum sexual issues look only at intercourse—who is having it, when penile-vaginal intercourse is resumed, and whether or not it hurts. But what about oral, digital, or self-stimulation? A 2012 study looked at postpartum sexuality in much broader terms, with really interesting results. An online questionnaire was sent to 300 women in a study out of the University of Michigan. These researchers found that the length of time it took before resumption of any kind of sexual activity after childbirth (not just intercourse) was variable and primarily driven by fatigue. Partner interest was the other driver behind earlier rather than later sexual activity. Men evidently have no postpartum sexual issues and expect that as soon as the doctor says a woman is “good to go,” she will be “good to go.” And most women comply. Variables that didn’t seem to matter in terms of resumption of sexual activity were breast-feeding status, stress, and body image.
During the three-month postpartum period, 85 percent of the women surveyed had intercourse, 65 percent had oral sex, and 61 percent masturbated. The types of activities were initiated in the following order:
First: Oral sex on partners (I feel sorry for the poor guy, he’s been waiting forever)
Second: Self-stimulation/masturbation (I’m not ready for intercourse, but an orgasm might be nice)
Third: Intercourse, usually after six weeks, when most doctors give the green light
Fourth: Receiving oral sex (generally the last kind of sexual activity reinitiated)
Engaging in sexual activity is not the same as enjoying it; the women surveyed in the University of Michigan study had the most pleasure from masturbation.
The Challenges of Postpartum Sexuality
Obviously, not every woman has difficulty with postpartum sexuality, and many are able to ignore a screaming a baby long enough to engage in satisfying, pain-free sex. But for many women, primarily first-time moms, who are more likely to have vaginal tears (and less likely to be able to ignore a screaming baby), the following factors have the biggest impact on postpartum sexuality:
Fatigue
Multiple studies show an association between fatigue and libido in any circumstance. Postpartum is a time of extreme, chronic fatigue, since it’s the rare baby that says, No problem, tonight I’ll sleep all night and give you a little break.
This is where an otherwise overbearing mother-in-law comes in very handy. Enlist her to stay overnight, and splurge on a night in a local hotel. Get some sleep and maybe you will get some sex. Either way, you will be grateful for the sleep. Trust me.
Relationship Dissatisfaction
This kind of emotionally laden issue is often overlooked as a possible cause by women who don’t want to have sex postpartum. It isn’t hard to understand, however, that some women just aren’t all that interested in having sex with the guy who was all over the idea of having a baby but has zero interest in changing poopy diapers, taking on the 2:00 AM feeding, or doing the mountains of laundry that are inexplicably generated by a tiny human with no job or social life.
Body Image
In most studies, women who perceive themselves to be attractive have more interest in sex. There’s something about carrying around an extra 50 pounds, a belly that still looks like you are in your second trimester, and dark circles under your eyes that makes most women feel slightly less attractive than usual . . . you know?
Postpartum Depression
Postpartum is a difficult time, for so many reasons. With all the attention on labor and delivery (classes, books, birth plans), it has always been a mystery to me why virtually no attention is paid to the first couple of weeks postpartum, which is physically and emotionally a far more difficult time. (There is no equivalent of an epidural to numb you for the first two weeks after delivery!)
The typical new mom is sleep-deprived, has a painfully throbbing vagina and sore, leaky breasts, and may be secretly wondering why she was so anxious to have a baby in the first place. Not to mention it’s a major miracle if at the end of the day she has had an opportunity to take an actual shower and brush her hair. And yet, the first two weeks after having a baby, you would think she’s a movie star what with the constant taking of photos. Then there’s the fact that she seldom gets out of her yoga pants. Oh, and on discovering that the scale is not broken and that, no, the weight doesn’t all disappear after delivery, being less than ecstatically happy is not a surprising reaction.
Up to 80 percent of women develop mood changes shortly after giving birth. This temporary feeling of sadness, irritability, insomnia, and tearfulness, referred to as “postpartum blues,” is almost always transient and does not require treatment. But that isn’t true for everyone. Postpartum depression (PPD) affects up to one in ten women. The cause of postpartum depression is not entirely understood, but normal post-pregnancy hormonal fluctuations seem to affect certain women more than others. A family history of postpartum depression, a personal history of depression, and a difficult pregnancy are just a few of the underlying conditions that might cause a woman to develop PPD.
Women with postpartum depression suffer with all the symptoms of postpartum blues, but those feelings don’t go away. Feelings of sadness not only persist beyond the two weeks after the baby is born but are accompanied by anxiety, panic attacks, intense anger, feelings of guilt, and a sense of being overwhelmed. Women with postpartum depression often do not feel as if they love their baby and even sometimes have thoughts of hurting their baby. This leads to more guilt and causes many women to avoid seeking the care they need. I can’t emphasize how important it is to seek professional help, particularly if you are feeling hopeless, feel panicked, or have thoughts of hurting yourself or your baby. Start with your OB, who will refer you to a mental health professional, but if you are not immediately getting the help you need, it is totally appropriate to go to the emergency department of your hospital.
Breast-feeding
Yes, breast-feeding causes low estrogen and low testosterone, which in turn causes vaginal atrophy such that intercourse is as excruciating as it can be in a postmenopausal woman. But it doesn’t end there. Women who breast-feed sometimes downplay their sexuality (breasts are for food, not stimulation) and take on the role of a feeder only, as opposed to a sexual partner.
Stress Incontinence
Many women panic when they discover that in addition to all the other new surprises that come with motherhood, they are also unable to make it to the bathroom in time, or cough, laugh, or sneeze without losing urine. Thirty to 50 percent of women experience incontinence at least once in their life, and for many it occurs during the first few months after delivery. Before running out and buying diapers in two sizes (newborn and adult), it’s important to not overreact over this.
For most women this is only a temporary issue. Once your baby is weaned and your estrogen levels increase, your pelvic tissues will tone and you will once again only be buying one size of diapers. Kegel exercises or an Apex device are commonly recommended postparum to help strengthen the pelvic floor. In the meantime, it’s understandable that this involuntary loss of urine is a real libido killer (see chapter 10).
Your Vagina Has Gone to War!
Take a 22-hour labor, followed by three hours of pushing, resulting in a forceps delivery and an episiotomy, or vaginal tear, and throw in low estrogen from nursing . . . and the result is a vagina that’s pretty much been through the war and is now in a refugee camp.
It goes without saying that women who have had difficult deliveries, vaginal tears, or episiotomies are going to need significant healing time before intercourse is even on the table.
Solutions
Fortunately, the physical and hormonal problems that present postpartum are generally temporary. Once your ovaries kick in and start producing estrogen again, you’ll be fine. In the meantime, follow the advice for the postmenopausal women in regard to vaginal dryness (see chapter 13). And yes, you can use vaginal estrogen products while you are nursing, regardless of the gender of your baby. Your blood estrogen levels are far too low to show up in breast milk or affect your baby in any way.
Some women have vaginal scarring from a tear or episiotomy that remains painful despite time and a bucketful of lubricant. In most cases, pelvic physical therapy, along with vaginal dilators and local estrogen, will alleviate that problem. Some women will require a minor surgical procedure to remove scar tissue.
In the best of times, libido is complex and dependent on a lot of variables. Add in the extraordinary fatigue and stress associated with the arrival of an infant and sexual problems in the postpartum period can extend well beyond physical and hormonal changes. The fact that most women have more than one baby is the greatest reassurance that things will improve enough to have sex at least one more time. And yes, the second time will be easier.