Clinical Review

How to prepare your patient for the many nuances of postpartum sexuality

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References

A paucity of research

To date, research into sexuality during the postpartum period has focused primarily on the physical changes and constraints that affect the mechanics and frequency of intercourse and overall sexual satisfaction and desire.2 This perspective has begun to broaden to include the psychological aspects of sexuality.

TABLE 1

These validated tools can help you measure female sexual dysfunction

ToolArea assessed
Female Sexual Function Index (FSFI)30Desire, arousal, orgasm, and pain
Female Sexual Function Index 6-Item (FSFI-6)31Desire, arousal, orgasm, and pain
McCoy Female Sexual Function Questionnaire*32Presence of female sexual disorders
Brief Sexual Symptoms Checklist33Screener for sexual concerns
Female Sexual Distress Scale – Revised34Distress
Intimate Relationship Scale*35Changes in sexual relationship
Sexual Quality of Life – Female (SQol-F)36Quality of life in women with female sexual dysfunction
Golombok Rust Inventory of Sexual Satisfaction (GRISS)37Quality of sexual relationship
Decreased Sexual Desire Screener38Brief diagnostic tool for hypoactive sexual desire disorder
* Validated in pregnant and/or postpartum women

Women’s sexual health during the postpartum period has generally been under-researched. It wasn’t until the past decade that validated sexual function questionnaires were utilized. Although a number of these instruments are now available (TABLE 1, TABLE 2, FIGURE), it remains unclear whether they can accurately measure postpartum sexual function. Despite these limitations, significant information has been elicited that can be used to counsel patients struggling with postpartum sexual concerns.

TABLE 2

The 6-item Female Sexual Function Index*

QuestionResponses
0 points5 points4 points3 points2 points1 point
How would you rate your level of sexual desire or interest?No sexual activityVery highHighModerateLowVery low or none at all
How would you rate your level of sexual arousal (“turn on”) during sexual activity or intercourse?No sexual activityVery highHighModerateLowVery low or none at all
How often did you become lubricated (“wet”) during sexual activity or intercourse?No sexual activityAlmost always or alwaysMost timesSometimesA few timesAlmost never or never
When you had sexual stimulation or intercourse, how often did you reach orgasm?No sexual activityAlmost always or alwaysMost timesSometimesA few timesAlmost never or never
How satisfied have you been overall with your sexual life?No sexual activityVery satisfiedModerately satisfiedAbout equally satisfied and dissatisfiedModerately dissatisfiedVery dissatisfied
How often did you experience discomfort or pain during vaginal penetration?Did not attempt intercourseAlmost never or neverA few timesSometimesMost timesAlmost always or always
*The components of this index are to be assessed over the past 4 weeks. The score is the sum of the ordinal responses to the 6 items and ranges from 2 to 30. A score of less than 19 indicates a need for further investigation, including the full-length Female Sexual Function Index.
Source: Adapted from Isidori et al.31

Ideal period of abstinence is unknown

Although our knowledge of the female genital tract in the puerperium is based upon histologic evidence, there are no evidence-based policies to outline the ideal period of postpartum coital abstinence. It seems reasonable to assume that our traditional scientific recommendations developed in part to prevent uterine infection and disruption of sutured wounds. These concerns, combined with cultural and societal norms, have led to the routine discouragement of sexual activity until 4 to 6 weeks postpartum.

The possibility of shortening the period of postpartum abstinence was first suggested by the American College of Obstetricians and Gynecologists (ACOG) in 1984.1 In 1985, Pritchard and colleagues wrote about the individualization of postpartum prohibitions of sexual activity in Williams Obstetrics.1 The earliest time at which intercourse may be safely resumed is unknown, but the 23rd edition of Williams Obstetrics states that a woman can resume sexual intercourse as early as 2 weeks, based on her comfort and desire.3 The sixth edition of the American Academy of Pediatrics (AAP) and ACOG guidelines for perinatal care also states that the risks ought to be minimal at 2 weeks postpartum.4

BRIEF SEXUAL SYMPTOMS CHECKLIST FOR WOMEN (BSSC-W)


Reprinted from Hatzichristou et al. 33

Low desire is not unusual

Although a patient may be granted “permission” to engage in coital activity, other variables influence her decision. It is well known that sexual desire may fluctuate during pregnancy and typically decreases significantly during the third trimester.2 Many women enter the postpartum period with lower levels of sexual desire and satisfaction, and these depressed levels may continue for some time.2 Twenty-five percent of women report worsened sexual function, including diminished sexual satisfaction, during pregnancy that persists for 6 to 12 months postpartum.5 By 12 weeks postpartum, 80% to 93% of women have resumed intercourse, but as many as 83% report sexual problems during the first 3 months of the postpartum period. At 6 months, 18% to 30% of these women may still be experiencing sexual problems, including dyspareunia.5,6

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