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    Sexual health and function in pregnancy

    Counseling about sexuality in pregnancy and postpartum offers an opportunity to allay fears and increase patient satisfaction during a unique period in a woman’s life.

     

    Influences on type of sexual activity

    Pregnancy can affect the type of sexual activity in which patients feel comfortable engaging.

    Coital activity appears to decline sharply by the third trimester. At 28-weeks of gestation, most couples continue with intercourse; at 32-weeks, about half to three quarters; and at 36-weeks, about one-third are still having sex.1 One report cited 40% of women engaging in intercourse within 2 weeks of the onset of labor and 17% in the 2 days before the onset of labor.20 Approximately 10% of women will abstain from coitus once pregnancy is confrmed.21

    Over the course of pregnancy, the use of man-on-top position declines, and woman-on-top, side-by-side, or rear entry positions are practiced more often.22 One large meta-analysis showed that up to 98.3% of pregnant women preferred genital-to-genital contact, with other types of sexual activity also being desired: 38.1% oral sex, 20.4% masturbation, and 6.6% anal sex, consistent with a non-pregnant cohort.1 Another study cited that up to 75% of European and American couples will practice mutual manual genital stimulation and up to 50% will practice oral genital stimulation during pregnancy.23 In the first and second trimesters, non-genital contact remains unchanged (94% of couples caress more than once a week).1 With respect to masturbation, up to 31% of women have reported self-stimulation during pregnancy, and up to 20% in the 3 to 6 months postpartum.21

    Cultural influences can largely affect forms of sexual contact in some populations. Many ethnic and religious factors may come into play which can propagate fears about sexual intercourse, thereby leading to avoidance during pregnancy.24-27 Authors of a Turkish study contend that rates of sexual dysfunction may be higher than average in Turkish women due to women’s attitudes about sexuality issues related to parental teaching.24 A study from Iran demonstrated that 52.9% of pregnant Iranian women believed that intercourse during pregnancy could result in abortion, and the same number considered it a cause for fetal infections.28 Fok, et al demonstrated that 93% of Chinese couples reported an overall reduction in sexual intercourse by the third trimester, with 80% attributing it to fear of possible harm to the fetus.2 Given the diversity of different cultures and backgrounds of pregnant patients in the United States, apprehension about sex in pregnancy remains prevalent in various communities. Clinicians should do their best to assuage patient fears while remaining sensitive to the background from which these fears may have arisen.

    Recommended: Should women with intrahepatic cholestasis of pregnancy be delivered early?

    For pregnant women with female partners, other concerns specific to lesbian couples may arise. However, very limited research has been done on sexual practices of pregnant women with female partners.29 Wilton, et al found that when pregnant lesbians did not reveal their sexual identity, it was due to fear of prejudice, altered medical care practices, or lack of confidentiality.30 The rate of intimate partner violence (IPV) increases during pregnancy and IPV is associated with poor pregnancy outcomes. Unfortunately, the rate of IPV is higher in the lesbian community.31-32 As such, universal screening for all women is imperative.

    First trimester

    Some of the first studies of female sexual response during pregnancy showed that women aged 21 to 43 years reported a 33% to 43% reduction in sexual desire and subjective effectiveness of sexual performance due to nausea, sleepiness, and chronic fatigue, similar to symptoms of the first trimeter.17,33,34 Sixty percent of these same women reported that fear of injury to the fetus affected the freedom of their physical response in sexual activity.17 In another study of first-trimester gravid women, while 45% expressed a desire to have sexual intercourse, 27.7% experienced a decrease in sexual satisfaction, and 32.5% had a decrease in sexual desire.35 Increasing estrogen, progesterone, and prolactin lead to biological changes that precipitate nausea and emesis, weight gain, fatigue, and breast pain that can affect sexual desire and arousal.36 In addition, increased levels of relaxin can lead to enlargement of vaginal epithelial cells, which theoretically can reduce vaginal sensitivity.37 In a cross-sectional study of 589 women, a decrease in clitoral sensitivity, reduction in sexual desire, and orgasm dysfunction were shown to be the most prevalent sexual disorders during pregnancy.34 Patients should be reassured that physiologic and hormonal changes in the first trimester commonly potentiate variable changes in pre-pregnancy sexual function.

     

    NEXT: Second and third trimester

    My-Linh Nguyen, MD
    Dr Nguyen is a Fellow in the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, ...
    Yalda Afshar, MD, PhD
    Dr. Afshar is a Maternal-Fetal Medicine Fellow in the Department of Obstetrics and Gynecology, University of California, Los Angeles
    Jenny Mei, MD
    Dr Mei is Resident Physician in the Department of Obstetrics and Gynecology, University of California, Los Angeles.
    Tamara Grisales, MD
    Dr Grisales is an Assistant Clinic Professor in the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of ...

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