and Filippo Murina2
(1)
Center of Gynecology and Medical Sexology, San Raffaele Resnati Hospital, Milan, Italy
(2)
Lower Genital Tract Disease Unit V. Buzzi Hospital, University of Milan, Milan, Italy
Pregnancy is a special period in a woman’s life. The childbirth involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of the couple’s sexual relationship.
Vulvar pain is often sadly neglected during pregnancy and particularly after delivery, despite its frequent comorbidity with introital dyspareunia in this vulnerable phase of a woman’s life.
Women’s sexual dysfunctions are frequently reported after childbirth. Among them, dyspareunia carries the highest risk of long-term systemic, genital, sexual, and relational consequences. Therefore, the twin problem “vulvar pain and dyspareunia” requires a very committed clinical approach, with specific medical/gynecological attention to its biological basis, as well as careful evaluation of the delivery outcome and the condition of the pelvic floor.
This chapter is prominently focused on the biological etiology of vulvar pain and dyspareunia, while psychosexual and contextual factors will be considered when appropriate for a balanced vision of the vulvar pain scenario at pregnancy and after childbirth.
7.1 Vulvovaginal Pain During Pregnancy
Vulvovaginal pain during pregnancy may have three major timing reading, according to the author’s clinical experience. It may:
Be rooted in previous vulvar vestibulitis/provoked vestibulodynia, inadequately diagnosed and addressed before pregnancy
Be the exacerbation of a vulvar pain caused by a previous delivery and remained untreated/insufficiently cured
Have the first onset during the current pregnancy
Vulvovaginal discomfort usually varies across pregnancy. In the first trimester, higher percentages of this symptom may be attributed to the concerns and anxiety related to the onset of the new pregnancy. In the second trimester, it is usually reported as significantly milder, coherently with the mother’s adaptation to pregnancy. Fears of early labor and the emotional alert toward the delivery tend to increase again the perception of it in the third trimester. It was demonstrated that 76–79 % of women enjoyed sexual intercourse before pregnancy (7–21 % not at all), while this decreased to 59 % in the first trimester, 75–84 % in the second trimester, and 40–41 % in the third trimester (Johnson 2011). Moreover, coital frequency tends to decline with advancing gestational age. This trend is further negatively influenced by dyspareunia and decreased orgasmic quality (Leeman and Rogers 2012).
As pregnancy progresses, vaginal discomfort may become more pronounced as a result of changes in vaginal physiology in response to hormonal changes wherein the connective tissue of the vagina decreases and the muscle fibers of the vaginal wall increase in size in preparation for delivery (Erol et al. 2007).
During the third trimester, vaginal contractions are weaker and tonic muscle spasms may occasionally occur, which may influence orgasmic response.
Candida vulvovaginitis (CVV) is a specific and usually neglected contributor of genital discomfort and introital dyspareunia in pregnancy. Frequency of Candida infections increases significantly during pregnancy. The vulnerability to CVV is higher in women who were already vulnerable to this germ’s infections, who had history of vulvar vestibulitis/provoked vestibulodynia, who are diabetic and/or presented with gestational diabetes, or have family/genetic predisposition to diabetes, and/or who have an excess weight gain in pregnancy (Martins and Kroumpouzos 2016).
In a recent prospective study on 210 pregnant women, aged 10–42, 38.1 % were symptomatic. Symptoms were most prevalent in the second and third trimesters of pregnancy coincident with a major prevalence of microorganisms. In this study, 39.5 % of pregnant women had normal microbial biota, and symptoms of CVV due to noninfectious causes were observed (6.2 %). The occurrence of vulvovaginal candidiasis was 25 %, and Candida albicans, with a prevalence of 80.7 %, was the dominant species (P = 0.005), while non-Candida albicans species and other yeast were more common in asymptomatic ones (P = 0.0038) (Mucci et al. 2016).
Key Points
CVV should be considered in women with vulvar pain and/or vulvovaginal discomfort in pregnancy.
Attention should increase in women with history of CVV and/or leading risk factors such as diabetes.
Accurate diet, change of the circadian rhythm of sugar/carbohydrates intake, and control of weight increase are leading preventing strategies to reduce the vulnerability to CVV in pregnancy (Box 7.1).
Box 7.1. Prevention of Candida Vulvovaginitis in Pregnancy
Control weight gain: the woman who has a normal body weight at the onset of pregnancy should ideally increase on average of 1000 g per month in the first trimester, 1.200 g/month in the second trimester, and 1.500 g/month in the third trimester, with a total weight gain ranging between 11 and 13 kilograms at term. Overweight/obese women should ideally reduce their body weight before the onset of a new pregnancy, to prevent/reduce the risk of fetal and maternal complication, including but not limited to CVV. Combined diet and physical exercise appear to be significantly effective in reducing gestational weight gain (GWG) (Muktabhant et al. 2015).
Change the circadian rhythm of source of calories intake. Human placental lactogen (HPL) is a placenta hormone leading the placental control of maternal glucose homeostasis. Its activity is aimed at maintaining a favorable gradient between the plasmatic levels of glucose in the mother blood (physiologically, between 80 and 90 mg/dL) and that of the child (physiologically, between 50 and 60 mg/dL). Passage of glucose from mom to child is essential to guarantee his/her optimal growth. The night hours of fasting are more likely to reduce the gradient, impairing child nutrition, more so when animal protein intake is preferred in the evening, while higher carbohydrate intake at lunch turns into conversion into glycogen and fat. Authors’ clinical wisdom, physiologically based, suggests therefore to prefer moderate sugar/fruit intake at breakfast, protein intake (fish or meat with vegetables) at lunch, and carbohydrates (rice and legumes, cereals, raw pasta) in the evening, to maintain a long-lasting modest increase of plasmatic maternal glucose levels and a persisting favorable gradient during the night hours while preventing hypoglycemic night crisis in the mother. Prevention of glucose daily peaks further reduces the vulnerability of Candida shifting from the spora to the active hypha state (Groot et al. 2014; Mending and Brash 2012).
Reduce the intake of yeast-containing food (bread, cakes, biscuits) and prefer fresh vegetables and fruits.
Avoid alcohol completely: to prevent embryo and fetal toxicity, to reduce useless calories intake, and to prevent changes in the colonic microbiota.
Enjoy 45 min/1 h of brisk walking every day: it optimizes the peripheral insulin metabolism, contributes to maintain physiologic glycemic levels, reduces the risk of gestational diabetes and contributes to an optimal weight gain, reduces systemic inflammation associated with overweight, improves mood, contributes to a better pregnancy outcome, and is very democratic as it can be practiced at every income level.
The preventive impact of daily exercise on onset and progression of gestational diabetes is discussed in the comprehensive work of Angina et al. (2016).
Benefits of physical exercise on diabetic risk are reviewed as well in the meta-analysis of Di Mascio et al. (2016) on 2019 pregnant subjects randomized to aerobic exercise and controls before 23rd week. Women in the exercise group (35–90 min of aerobic exercise 3–4 times a week) had a significantly lower incidence of gestational diabetes mellitus (2.4 % vs. 5.9 %; RR 0.41, 95 % CI 0.24–0.68) and significantly lower incidence of hypertensive disorders (1.9 % vs. 5.1 %; RR 0.36, 95 % CI 0.19–0.69) compared to controls.
7.2 Etiology of Women’s Sexual Dysfunctions After Childbirth
Vulvar pain and dyspareunia after childbirth are usually rooted in a more complex biological and psychosexual dysfunctional scenario that must be understood and investigated to prevent/avoid minimalistic approaches and therapeutically disappointing outcomes.
The first 6 months after delivery can have a profound impact on a woman’s sexual quality of life. Sexual dysfunctions usually recognize a multifactorial etiology that should be carefully investigated in the presenting woman and couple (Table 7.1). Vulvar pain and dyspareunia may indeed just be the tip of the iceberg of multiple biological and psychosexual causes, easy to be addressed when appropriately diagnosed. Leading neglected contributors include:
Table. 7.1
Leading contributors to sexual dysfunction after childbirth
Biological factors |
|---|
Systemic |
Breastfeeding-induced amenorrhea |
High prolactin and low levels of estradiol and testosterone |
Iron deficiency anemia |
Depression |
Fatigue |
Sleep reduction/insufficient quality |
Obesity |
Genital |
Vulvovaginal tears during delivery |
Spontaneous genital tract trauma |
Episiotomy discomfort |
Inadequate healing of episiorrhaphy |
Pelvic floor trauma during operative delivery |
Pelvic floor dysfunction |
Pudendal nerve trauma |
Vaginal bleeding |
Vaginal discharge |
Urinary stress incontinence |
Anal incontinence |
Postcoital cystitis |
Psychosexual factors |
Decreased sense of attractiveness |
Reduced sexual drive and central arousal |
Decreased lubrication |
Vaginal dryness |
Dyspareunia |
Fear of further genital injuries and pain |
Contextual/relational factors |
Inadequate transition to parenthood |
Marital crisis |
Loss of desire in the partner |
Concerns about the child’s health, in case of baby’s perinatal problems |
Fear of awakening the baby or not hearing him/her |
7.2.1 Systemic Factors
Hormonal contributors, prominent in breastfeeding women, where high prolactin causes the “ovarian silence,” with minimum levels of estradiol, progesterone, and testosterone. This hormonal milieu leads to consequent silencing of the first endocrine motor of sexual drive and of central and genital arousal, leading to vaginal dryness, and changes in the vaginal microbiota and pH. It was demonstrated that breastfeeding confers an increased odds ratio of 4.4 (95 % CI 2.7–7.7) for dyspareunia at 6 months. It has been shown that at 6 weeks, bottle-feeding women who have an earlier recovery of ovarian function are more likely to return to intercourse and their rates of sexual difficulties fall (Rowland et al. 2005).
Iron deficiency anemia (IDA), highly prevalent after delivery. Iron is key for the dopaminergic system mediating sexual drive, vital energy, mood and physical strength. IDA increases depression and pain perception, an aspect that few physician seem to consider. Early iron supplementation in mothers with postpartum depression (PPD) significantly improves the iron stores and causes a significant improvement in PPD with a 42.8 % improvement rate during 6 weeks (Sheikh et al. 2015).
Low mood/depression, due to anemia (which doubles the risk of depression) and neuroinflammation. Inflammatory cytokines may increase dramatically during the immediate postpartum, due to (1) the massive physiologic uterine muscular catabolism (from 1000 to 1500 g at the end of pregnancy of uterine muscle to average 70–80 g of uterine weight in a nonpregnant woman) and (2) the intense adipocyte production, higher in overweight/obese women.
Sleep reduction, due to night breast feeding and/or child’s frequent awakenings. Poor quality of sleep is another neglected contributor of depression, fatigue, low vital energy and consequently low sexual drive.
Fatigue, which recognizes biological and psychological contributors.
Obesity, because of systemic and brain inflammation, skins stretches and marks, fatigue, poor body image.
7.2.2 Genital Factors
Genital tract trauma during delivery, either spontaneous or iatrogenic, with episiotomy discomfort and/or inadequate healing of episiorrhaphy.
Pelvic floor trauma during spontaneous or operative delivery and Kristeller maneuver, more practiced than reported in the medical chart, is another neglected factor of lesions of the pubococcigeal component of the levator ani, contributing to loss of vaginal sensitivity and urinary incontinence. Operative deliveries may further contribute to subclinical lesions of the anal sphincter, which are diagnosed with the ecographic probe up to 25–33 % of postpartum women.
Pelvic floor dysfunction, due to functional/anatomic lesions of the levator ani in case of macrosomic babies and/or prolonged second phase of labor or posterior rotation of the baby’s head.
Pudendal nerve trauma: is a most concerning complication of delivery. It can be subclinical or overt and can occur more during operative than during spontaneous delivery.
Vaginal bleeding due to prolonged postpartum endometrial involution.
Vaginal discharge due to vaginitis.
Urinary stress incontinence: stress incontinence may specifically affect women during thrusting, while urge incontinence is more reported at orgasm.
Anal incontinence to gas and feces, in more serious cases. Incontinence, either urinary and/or anal, is a threatening consequence of delivery. It is underdiagnosed, underreported and undertreated, therefore persisting as a major neglected contributor to sexual dysfunction long term after delivery. It has both biological and psychosexual consequences as it may affects the sense of self-worth, self-esteem with heavy impairment of the social life, dramatically reduced because of the incontinence (Rezvan et al. 2015).
Postcoital cystitis: reduction of the congestion of periurethral corpus spongiosum (equivalent of part of male’s urethral corpus spongiosum) deprives the woman’s urethra of a functional protective “airbag” during thrusting, with increased risk of postcoital cystitis, more frequently complained of 24–72 h after intercourse. Hypoestrogenism during breastfeeding changes the vaginal microbiota and pH, further increasing vaginal and urethral vulnerability to microtraumas and pain after delivery.
7.2.3 Psychosexual Factors
Decreased sense of sexual attractiveness.
Reduced sexual drive and reduced central arousal with decreased lubrication, because of the abovementioned systemic and genital factors, which are prominent after delivery. They set the biological and psychosexual scenario of an increased psychosexual vulnerability to vulvovaginal discomfort and vaginal dryness after delivery. All these factors potentiate each other in a vicious circle, where negative feedbacks play a prominent role (Fig. 7.1).
Fig. 7.1
Impact of dyspareunia on women’s sexual function. Dyspareunia and vulvar pain directly impair genital arousal and vaginal lubrication. Indirectly they may affect coital orgasm and level of sexual satisfaction, thus modulating both mood and levels of sexual desire and central arousal
Dyspareunia: introital pain is a powerful reflex inhibitor of genital arousal, worsening vaginal dryness and reducing cavernosal bodies’ congestion.
Fear of further genital injuries and pain may further contribute to sexual dysfunction after delivery.
7.2.4 Contextual/Relational Factors
Transition to parenthood is a major revolution in the couple’s affective and sexual relationship. When the transition is difficult or inadequate, it may affect as well partner’s sexual drive and motivation to sexual intimacy, impairing the woman’s sense of self-worth and self-esteem and further affecting her sexual desire.
Marital crisis, because of an inadequate transition to parenthood or other factors, may increase the physical and emotional distance in a subset of vulnerable couples: vulvar pain may be even “used” or read as the last straw, or the “drop that makes the vase overflow” of a prolonged sexual dissatisfaction. Unaddressed or inadequately treated vulvar pain before pregnancy, further worsened after delivery, may turn into becoming the precipitating factor of a major marital crisis up to divorce (Korja et al. 2016).
Loss of desire in the partner: depression triggered by the baby’s birth because of jealousy toward the newborn, sense of inadequacy, and sexual difficulties worsening after a long period of abstinence during pregnancy and/or of economic concerns may further affect the partner’s sexual desire in a complex relational interplay of negative factors.
Concerns about the child’s health, in case of baby’s perinatal problems, premature deliveries, need of intensive care, and risk of long-term consequences, may affect mood and motivation to intimacy in both partners, with mothers usually reporting the more severe negative impact on mood and desire.
Fear of awakening the baby or not hearing him/her.
7.2.4.1 Practical Tips
All these negative biological, sexual, and contextual factors set the scenario of an increased woman’s sexual vulnerability to genital pain after delivery.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
