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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.

     

    Second trimester

    The second trimester usually allows for increased libido and less physical discomfort as symptoms typical in the first trimester subside. Masters and Johnson noted that second-trimester patients had a marked increase in eroticism and effectiveness of sexual performance regardless of their parity or age. Eighty-two of 101 women described a significant improvement in basic sexuality, not only over the first trimester but well beyond their concept of previously established norms of performance in non-pregnant states.17

    In general, women experience increased vaginal lubrication and genital blood flow that favor orgasm, generally increasing women’s desire to engage in sexual activity.35 Interestingly, 1 study found that 36% of women were interested in sexual intercourse in the second trimester compared to 45% during the first trimester.38 Although the second trimester may afford patients higher tolerability to engaging in sexual activity, changes in sexual desire, sexual satisfaction, and coital frequency remain widely variable from the first trimester to the second trimester.

    Increased sensation of fetal movements can also impact quality of sexual contact and choice of sexual position.38 In 1 study of women at 23 to 26 weeks’ gestation, the authors demonstrated that in the absence of maternal vaginal infections, frequent intercourse (defined as 1 or more episodes of vaginal intercourse per week) was actually associated with significantly reduced risk of preterm delivery.39 Tis may have been associated with the relative good health and lack of pregnancy complications in women who engage in frequent intercourse during pregnancy.

    Third trimester

    Decline in sexual activity is most prominent during the third trimester of pregnancy.34,36

    Several studies report significant reductions in FSFI scores between the first and third trimesters.33,40 Factors that contribute to this drop in sexual function include fear of obstetrical complications and delivery, emotional stress, decreased libido, anatomical changes, and late symptoms of pregnancy.41-44

    During the third trimester, women express decreased desire and attenuated sexual arousal, lubrication, and sexual satisfaction, making sex more difficult and less frequent.3,13,35 Erol et al found a reduction of 94.2% in clitoral sensitivity, 92.6% in libido, and 81% in orgasm.34 Some women abandon sexual activity during pregnancy altogether due to pain during genital-to-genital contact.4,41 Some studies suggest that decreasing androgen levels in the third trimester also decrease sexual desire, although studies have shown no relationship between serum androgen levels and sexual function.45

    Anatomically, when the presenting part of the fetus is engaged in the true pelvis and the cervix is brought into the vaginal axis, direct penile-cervical contact can result in vaginal spotting or bleeding.17 Bartellas and colleagues found that 57% of women feared vaginal bleeding from intercourse but only 13% recorded its occurrence.3

    Later in gestation, women also experience increased dyspnea, edema, contractions, and fatigue.4,38,46,47 Discomfort due to abdominal enlargement and mass effect can lead to discomfort with certain positions, which also leads to decreased frequency of sex.48 Sources of discomfort such as shortness of breath, increased abdominal distention, and downward pressure on the pelvis can also lead to a reduction in sexual desire.3 Studies have found no change in women’s body image based on the Body Exposure During Sexual Activities Questionnaire (BESAQ) over the trimesters, despite significant increases in body mass index (BMI) over the course of pregnancy.40 Some studies found that obesity negatively affected sexual function in pregnant women but others report no effect of BMI on sexual function.5,49

    It is worth mentioning again that between one-third and one-half of women continue to be sexually active throughout the third trimester.1 Although marked physical changes in this trimester can preclude patients from engaging in sexual activity, those who do not feel limited by advancing gestational age may feel fine about continuing sexual activity based on personal comfort and discretion.

    Postpartum

    Postpartum resumption of intercourse is variable. Rates of reinitiation of coitus range from 9% to 17% before the sixth postpartum week, 50% to 62% in the sixth week, 66% to 94% in the second month, 88% to 95% in the third month, and 95% by the seventh month.1 Another study reported 78% return by the third postpartum month and 97% by 1 year.50

    Barriers also exist to return to pre-pregnancy sexual function. In a large study of over 1400 primiparous Australian women, researchers found that 89% reported sexual health difficulties in the first 3 months postpartum.50 Some factors that contribute to postpartum sexual dysfunction include vaginal or perineal lacerations, low lubrication levels, and postpartum mood changes and fatigue.51-53 Typically by 12 months postpartum, vaginal pain and lack of vaginal lubrication will have resolved, yet higher rates of low postpartum libido compared with pre-pregnancy levels have been noted.50 Psychosocial factors, particularly postpartum anxiety and depression, have been shown to impact all domains of sexual function and can affect the return of sexual activity.54,55 A woman’s perception of her partner’s sexual desire can impact the timing of reinitiation of sexual activity as well.17 Interestingly, neither stress nor body image (as evaluated by validated stress and body image self-consciousness scales) has been shown to correlate with return to sexual activity.49

    More: Are MRI scans safe during pregnancy?

    Ultimately, given the multitude of changes and stress factors with the arrival of an infant, the etiology of postpartum sexual dysfunction is multifactorial and warrants a discussion that is beyond the scope of our paper. From reluctance to eagerness, patients and their partners may have a range of feelings and expectations associated with resuming sexual activity following delivery. There may be a tendency on the part of clinicians to assign an arbitrary length of time (usually 6 weeks) after which intercourse is deemed “safe.” However, we encourage clinicians to individualize recommendations based on a comprehensive understanding of the patient’s history, a postpartum exam and the patient’s readiness to resume sexual activity.

    NEXT: Conclusion and references

    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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