The Vagina Bible. Jen Gunter
do not do the therapy, you will not be worse off incontinence-wise in the long term.
• If you wish to strengthen your pelvic floor, have no symptoms, and are at least two months from delivery, then home exercises (see chapter 10) are a fine, low-cost way to start.
Pain with sex
Most health care providers recommend waiting 4–6 weeks after an uncomplicated vaginal delivery before resuming sex. The open cervix could theoretically increase the risk of infection (although I’m not sure this has been rigorously studied). Also, the tissues need time to heal.
By six weeks after a delivery, 41 percent of women have resumed sex; 78 percent by twelve weeks; and 90–94 percent by six months. Women with a third- or fourth-degree tear are slightly less likely to have resumed sex by six months (88 percent). Having any kind of tear with delivery increases the chance that there will be pain with sex. If you have pain with sex that persists beyond three months after a vaginal delivery, then you should be evaluated.
The three most common causes of painful sex after a vaginal delivery include the following:
• LOW ESTROGEN LEVELS IN THE VAGINA: This is almost exclusively seen in women who are breastfeeding, which can stop ovulation. A small amount of vaginal estrogen cream can solve the problem within a few weeks if lubricant is not sufficient. Once regular menstrual cycles return, your estrogen levels will go up and the vaginal estrogen may be stopped. Using a small amount of estrogen in the vagina is fine while breastfeeding.
• PROBLEMS WITH THE SCAR OR NERVE PAIN: Occasionally, the tissues may heal together in a way that creates a web of tissue at the opening, which can cause pain with penetration. Nerve pain is not common, but when tissues tear or are cut, nerves are injured as well. Prolonged pushing can also stretch nerves.
• MUSCLE SPASM: The muscles of the pelvic floor can become inappropriately tight after delivery. The cause is unknown, but as it can happen after a cesarian section, stretch or injury to the pelvic muscles does not seem to be a requirement. My theory is the rapid withdrawal of progesterone after the placenta is delivered predisposes women to muscle spasms, as progesterone is a potent muscle relaxant. Specialized pelvic floor physical therapy is the treatment and is highly effective.
IS THERE SUCH A THING AS A HUSBAND STITCH? There are stories that circulate about OB/GYNs who reportedly announce at the delivery that they are putting in an “extra stitch” to “tighten” things up for the male partner. In over twenty-five years in OB/GYN, I have heard one older physician many years ago make a bad joke like this, but I never saw him do it. What I have heard are many male partners joking about this in the delivery room and more than a few asking in all seriousness if an extra stitch were possible.
I have asked many OB/GYNs about the “husband stitch,” and uniformly they have all recounted almost identical experiences to my own.
It is important not to confuse a repair that has healed incorrectly or one that was not repaired correctly (mistake or error) with one that was sewn too tightly on purpose. There can be a lot of swelling after delivery, and occasionally this can make a repair technically challenging even for a highly skilled physician. Stitches can occasionally come apart a few days after delivery and then the raw edges heal together incorrectly or in a suboptimal way. There is also, unfortunately, incompetence.
Is it possible that some horrible doctors have done “a husband stitch”? Nothing would surprise me. After all, there are rare pilots who show up drunk and rare reporters who fabricate sources. However, the idea that this is common is not something that I can verify. As someone who specializes in pain with sex, I have not seen a case in over twenty-three years of practice.
If a woman feels too tight after a delivery and/or has persistent pain with sex, it is usually the result of muscle spasm. Narrowing of the vaginal opening after a vaginal delivery due to a poorly healed bridge of skin—either due to the way the tissues healed, complications afterwards, or the quality of the repair—does happen, but in my experience, this is less common than muscle spasm.
Long-term outcomes for sexual function
Studies have looked at whether childbirth affects long-term sexual function. A large study of over one thousand women from an ethnically diverse background showed no association between method of delivery or birth complications and long-term sexual satisfaction.
I found this surprising, as some women definitely do have difficulty recovering sexually after a vaginal delivery.
I suspect the answer is both complex and simple. There are so many variables in sexual functioning, but a caring partner who you love and who is a good lover (meaning the kind of lover you need) is probably the most important. Also, pain with sex and difficulties achieving orgasm are very common before pregnancy and can happen to women who have had C-sections and women who have never been pregnant.
Looking specifically at women over forty, this same study tells us that 56 percent of women had lost interest in sex, 53 percent had sex less than once a month, and 43 percent had low sexual satisfaction. The bad news is that is a lot of women. The good news is the method of delivery didn’t appear to be the driving factor. Sexual function just isn’t about a body part, it’s about you as a whole person.
To put it in perspective, changes in libido, sexual priorities, and satisfaction with their sexual relationship also happen to gay men who adopt a baby. Basically, a baby changes things even when there is no pain from delivery and no pregnancy-related hormonal changes postpartum.
BOTTOM LINE
• During delivery, 44–75 percent of women will tear.
• By six weeks after delivery, 41 percent of women have resumed sex.
• Breastfeeding is associated with pain during sex for the first six months.
• Pelvic floor PT is definitely recommended if you have incontinence; in other situations, Kegel exercises are likely as effective.
• The method of delivery may have a short-term impact on sexual function, but not likely a long-term one.
Everyday Practicalities and V Maintenance
CHAPTER 6
Medical Maintenance
THE VULVA AND VAGINA DO NOT REQUIRE regular checkups. If you have symptoms or concerns—for example, a pain or an itch, or even questions—then of course you need to be seen, but there is no reason your doctor needs to evaluate your vulva or vagina on a regular basis for disease prevention. Some organs do require screening for health purposes, including the cervix for cervical cancer (see chapter 26), screening for high blood pressure starting at the age of eighteen, and colon cancer screening for otherwise low-risk individuals starting at age fifty. However, not everything requires screening, and the vulva and vagina fall into that category. In fact, yearly pelvic exams are no longer recommended.
Screening vs. Diagnostic Test
A screening test is done when there are no symptoms of a condition—the idea is that finding and treating before there are symptoms will reduce complications and even save lives. As far as the lower genital tract is concerned, the best examples are screening for chlamydia and cervical cancer. Neither of those conditions produce symptoms in early stages, but identifying them early and starting therapy reduces complications, and in the case of cervical cancer, screening can save lives.
Screening can target everyone. For example, all women should be screened for cervical cancer. Screening may also target higher-risk individuals, such as people with multiple sexual partners and STIs.
A diagnostic test, on the other hand, is done to help identify the cause of symptoms. For example, if there is an ulcer on the skin, a swab may be taken to test for herpes or a biopsy may be taken to identify a skin condition. An important concept that doctors don’t always explain is that diagnostic tests are also ordered to rule out conditions—so the answer your doctor may be looking for is “not cancer.” This can be very frustrating for a patient who thinks they will be getting a definitive answer.