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6 Causes of Painful Sex After a C-Section or Vaginal Birth

At some point during your pregnancy, you probably heard jokes about how an OBGYN will tell a new mom to wait 6 weeks to have sex, and the mom — who is holding a newborn and reeling from childbirth — replies that they’d prefer to wait 6 years. It would be funny if it weren’t so true.

Even if you are craving intimate touch with your partner, finding the time, space, and energy to get frisky is a serious challenge. That’s why it can be especially upsetting if you stay awake long enough to have sex (yes, it’s happening!) only to discover that (ouch!) penetration hurts.

Unfortunately, scenarios like this one are incredibly common. Research shows that 43% of birthing people experience pain with sex, aka dyspareunia, at 2-6 months postpartum and 22% at 6-12 months. It’s important to know that not all vaginal pain is the same, and figuring out the cause is key to knowing how to treat it.

There are many possible reasons why you may have pain with sex postpartum, but below are six of the most common.

1. Scar tissue

According to ACOG, 53-79% of people who deliver vaginally will experience lacerations or tearing of some kind. A tear can range from first degree — affecting only tissue, skin or fascia of the vagina — to fourth degree lacerations, which extend from the vaginal opening to the rectum. Once muscle is torn, whether following a grade 2 to 4 perineal tear or an episiotomy, scar tissue will develop to replace any damaged layers.

Scar tissue is remarkable in its ability to help us recover and restore function, but for many people, it can also be a source of pain due to its decreased flexibility and increased sensitivity. Research shows that the degree of tearing and subsequent scar formation following birth is directly linked to increased pain during postpartum sex.

On the bright side, scar tissue is adaptable and treatable; a physical therapist can guide you through effective strategies to promote healing, reduce pain, and decrease thickness while increasing flexibility at the scar site. And although scars are something you can address at any time, due to the nature of scar tissue, most changes will take place in the first 1-2 years postpartum, so don't wait too long to seek help — the sooner you can begin working with a physical therapist, the better!

2. Vulvar and Vaginal Tissue Irritation

After delivery, your body's hormones shift dramatically. While pregnancy causes estrogen levels to steadily increase, as soon as you deliver, those levels drop severely in order to support lactation and milk production. And while breast or chest feeding has tremendous long term benefit for both the birthing parent and baby, for many people, breastfeeding has also been associated with increased pain with sex in the postpartum period.

Without estrogen, the tissue of your vaginal canal can become thinner, drier, and more vulnerable to irritation and inflammation which can lead to pain or discomfort during or after sex.

Fortunately, for many people, simply adding extra lubrication during sex can reduce and even resolve this pain altogether. That said, if lube alone doesn't resolve your symptoms, it can be helpful to speak with your OB regarding potential topical supplements that you can use while nursing in order to help improve your vaginal health and reduce pain with sex.

3. Nerve Damage

Our nerves relay messages between our brain and body. The primary nerve responsible for communicating with our vulva is called the pudendal nerve. It provides sensory, motor and autonomic function to the anus, genital, and perineal region, but because of the pudendal nerve's location, it can be especially susceptible to damage during vaginal delivery. Damage to the pudendal nerve may result in altered sensations like pain with sitting, persistent genital arousal disorder, and vestibulodynia, making activities like sex or cycling especially painful.

If your pudendal nerve was affected by pregnancy or childbirth, in most cases, this injury is temporary and symptoms should improve within 6 months. Still, it can be helpful to speak with a pelvic floor physical therapist to learn strategies to manage your symptoms, reduce irritation to your nerves, and support healing of the area in the postpartum period.

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4. Joint Dysfunction

Some degree of pelvic pain following pregnancy is considered normal, but this pain should fully resolve within the first 6 weeks postpartum. Unfortunately, for nearly 1 in 6 people, pain of the pelvic girdle will remain for several months after delivery. Often, this ongoing pelvic pain is actually linked to pelvic bone edema, pelvic fracture, or pubic symphysis separation.

For those experiencing prolonged pelvic pain following injury to the pelvis, more than 70% reported sexual dysfunction or inability to return to sex due to pain or fear of pain. If you continue to have pelvic pain months after delivery, reach out to your provider as most of these conditions can be diagnosed with imaging, such as MRI.

Injury to the pelvic bones and joints should heal within 6 months of delivery, but working with a physical therapist who specializes in the pelvic floor can help ensure proper healing while also reducing your pain and improving your function as your body recovers.

5. Muscle Dysfunction

The pelvic floor is a group of muscles located at the base of the pelvis, surrounding the vaginal, anal and urethral openings. These muscles contract in order to hold in urine, gas and feces, support your pelvic organs and stabilize your pelvic joints. They relax to empty your bladder and bowels, deliver a baby and allow for penetration during sex. If these muscles dysfunction, it can impact your bladder, bowel or sexual function.

Specifically, if your pelvic floor muscles do not effectively lengthen or relax to allow for penetration you can develop a condition called vaginismus, which is linked to pain during sex. This pain can occur whether you have had a vaginal or cesarean birth, but research shows that performing pelvic floor exercises and building coordination of this muscle group can lead to improved postpartum sexual function. Working with a pelvic floor physical therapist is a great way to rebuild control of your pelvic floor and reduce muscle-related pain during sex.

6. Vulvar Swelling

In pregnancy, the amount of blood flowing through your body increases by more than 50%. In order to accommodate this new fluid, our blood vessels dilate and more specifically, our veins will expand their capacity by 60%. For many people, their veins can take months to recover after delivery, leading to poor valve closure in the veins and increased swelling and distension.

When this swelling takes place within the pelvis and vulva, it can lead to pelvic congestion syndrome or vulvar varicosities, both conditions are commonly linked with pain during and after sex.

If you are experiencing vulvar swelling during or after pregnancy, speak with your doctor about potential management strategies, depending on your diagnosis and severity of symptoms, working with a physical therapist who specializes in the pelvic floor may be a potential resource for symptom reduction.

Pain with sex is never normal and should never be ignored. Talk to your primary care provider or OBGYN about what you’re experiencing — they should be able to help determine the potential source of your pain. No matter the cause, they will likely recommend that you work with a pelvic floor physical therapist who can support you in restoring your sexual function and help you feel good in your body.

Celeste Compton, PT, DPT
Dr. Celeste Compton, PT, DPT, WCS

Celestine Compton, PT, DPT is a doctor of physical therapy at Origin with a board-certified specialization in women's and pelvic health. She continues to expand her knowledge and capabilities within the field of women’s health PT to provide her patients and community with the best care, advocate for her profession on local and national levels, and support the advancement of women’s health through contributions to research, public awareness, and education. As part of the Origin team, she hopes to do her part to raise the standard of care that all women receive at every stage of life and to improve patient access to quality care so that no individual, regardless of location, race, identity, education, sexuality, or economic status is left behind.

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