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Postpartum Counseling

(Updated July 2013)

Sexuality and Contraception

Sexuality in the postpartum period is strongly influenced by a woman’s culture, her experience before pregnancy, her physiology, and her emotional and psychological make-up. Postpartum sexual changes and adjustment may not be easy to discuss, for the patient or the provider. Yet sexual concerns are common, and the majority of patients will welcome help from their primary care provider, especially one who is prepared to elicit patient concerns and respond to them.1,2

Postpartum Counseling Checklist: Sexuality and Contraception

  • Status of perineal healing
  • Resumption of intimacy and sexual intercourse
  • Alternatives to intercourse
  • Reassurance that lack of sexual desire is common and normal among women in the postpartum period
  • Comfort during sexual relations (e.g., healing and vaginal dryness)
  • Incontinence
  • Importance of pelvic floor muscle exercises (e.g., Kegels) and how to perform them
  • Contraceptive options
  • For the woman who is breastfeeding
    • Effect of lactation on vagina and lubrication
    • Effect of sexual activity on letdown reflex
    • Hormonal effects on sexual desire
    • Efficacy of Lactational Amenorrhea Method for contraception
    • Effect of estrogen-containing contraceptives
    • Alternative contraceptive choices

Download a PDF of the Postpartum Counseling Checklist: Sexuality and Contraception checklist

Patient attitudes about sexuality in the postpartum period. Perineal healing is normally sufficient to allow resumption of sexual intercourse somewhere between four and six weeks postpartum, and sometimes earlier.3 Women who undergo episiotomy or laceration and repair may be less comfortable resuming intercourse earlier than those who have not.

Short-term changes in sexual functioning have been noted among 22 to 86 percent of postpartum women, particularly those who have had assisted vaginal deliveries as opposed to spontaneous vaginal deliveries or cesarean birth.4 Several studies link episiotomy or perineal laceration and operative vaginal delivery to dyspareunia, which can persist for more than six months in a minority of women.5-7 Women who have experienced cesarean birth also may encounter discomfort with intercourse, and cesarean birth does not appear to have protective effects on women’s sexual functioning.4,8 Factors other than physical recovery from labor and delivery affect women’s decisions about resuming sexual relations. Providers should be sensitive to the possibility of religious or cultural beliefs, fatigue, intercourse somewhere between four and six weeks postpartum, and sometimes earlier.3 Women who undergo episiotomy or laceration and repair may be less comfortable resuming intercourse earlier than those who have not.

Short-term changes in sexual functioning have been noted among 22 to 86 percent of postpartum women, particularly those who have had assisted vaginal deliveries as opposed to spontaneous vaginal deliveries or cesarean birth.4 Several studies link episiotomy or perineal laceration and operative vaginal delivery to dyspareunia, which can persist for more than six months in a minority of women.5-7 Women who have experienced cesarean birth also may encounter discomfort with intercourse, and cesarean birth does not appear to have protective effects on women’s sexual functioning.4,8

COMMON FACTORS IN
POSTPARTUM SEXUAL
ADJUSTMENT11

• Episiotomy discomfort
• Fatigue
• Lack of sexual desire
• Vaginal bleeding or discharge
• Dyspareunia
• Insufficient lubrication
• Fears of awakening or failing to hear the infant
• Fear of injury
• Decreased sense of attractiveness, poor body image

Factors other than physical recovery from labor and delivery affect women’s decisions about resuming sexual relations. Providers should be sensitive to the possibility of religious or cultural beliefs, fatigue, or other influences on women’s attitudes toward sexual intercourse in the early postpartum period. In some instances, providers may want to suggest that other forms of sexual expression, such as touching, kissing, and mutual pleasuring techniques, can help to re-establish physical closeness with a partner.

Diminished sexual desire. Low or absent sexual desire is a very common experience in the postpartum period; a reduction in sexual interest and activity, compared with pre-pregnancy levels, is the norm during the first few months after childbirth.9,10 One study found that 57 percent of women had resumed intercourse at six weeks after delivery; 82 and 90 percent reported sexual relations by 12 and 24 weeks postpartum, respectively.7 The majority of the women reported experiencing orgasm by 12 weeks postpartum. Most researchers report gradual return to pre-pregnancy levels of sexual desire, enjoyment, and coital frequency within a year.11

Effects of breastfeeding. Breastfeeding may negatively affect sexual desire.12 The effect of lactation on hormone levels offers one explanation, because estrogen levels decline during breastfeeding.13 Decreased estrogen may indirectly affect sexual interest by decreasing vaginal lubrication, which can lead to pain with intercourse.12 The use of water-based vaginal lubricants can reduce discomfort during intercourse. (Petroleum-based products may cause irritation and can cause condom breakage.) Vaginal moisturizers also can relieve vaginal dryness and pain.

Incontinence. Women may hesitate to raise the subject of incontinence, which can lead to sexual inhibition. Childbirth-related incontinence is usually temporary and nearly always diminishes over time. Kegel exercises strengthen the muscles of the pelvic floor and have been shown to improve urine control, especially in women with mild (rather than severe) stress incontinence.14

Choosing a contraceptive. Return to fertility is unpredictable and may occur before the onset of regular menstrual cycles, even in breastfeeding women. The first ovulation in non-lactating women typically occurs 45 days postpartum but may occur earlier.15 Use of birth control should begin before sexual activity is resumed. Ideally, choice of postpartum contraception should take place in the prenatal period. In general, most women should start contraception at the six-week visit or earlier, depending on when they resume intercourse. All women should be offered emergency contraception.

CDC updated its recommendations in 2011 to state that postpartum women should not use combined hormonal contraceptives during the first 21 days after delivery because of high risk for venous thromboembolism (VTE) during this period. During days 21-42 postpartum, women without risk factors for VTE can generally initiate combined hormonal contraceptives. Women with risk factors for VTE, such as previous VTE or recent cesarean delivery generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply.16

LAM. The Lactational Amenorrhea Method (LAM) has a contraceptive effect in the first six months postpartum if the woman is fully breastfeeding (i.e., the woman is amenorrheic, is breastfeeding every three to four hours, and is not supplementing infant suckling with bottle feedings or expressed breast milk).17 Separation from the infant for many hours may increase the risk of pregnancy in lactating women.18 The need for skilled counseling and support, the lack of protection from sexually transmitted infections, and the intensive demands on a woman’s time associated with LAM limit its suitability as a contraceptive choice. For some women, it can be an attractive, cost-effective, and temporary form of birth control.19

Hormonal contraception and breastfeeding. Estrogen may decrease the quantity and quality of breast milk.20 The standard of care for lactating women has been to avoid contraceptives containing estrogen, including oral contraceptives (OCs), the combination patch, and the combination vaginal ring. Estrogen-containing contraceptives should not be used until three to four weeks postpartum in non-breastfeeding women, to reduce the risk of venous thromboembolism.19 At that time, women can be offered the option of hormonal regimens that allow them to suppress menstruation if they desire to do so.

Recommended methods for women who are breastfeeding include the progesterone-only pill, Copper-T intrauterine device (IUD; ParaGard®), levonorgestrel intrauterine system (LNG IUS) (Mirena®, SkylaTM), depot medroxyprogesterone acetate injectable (DMPA; Depo-Provera® and Depo-subQ provera 104®) and the single-rod implant (Implanon®). DMPA has a black box on its labeling that warns it may be appropriate to restrict use to 21 months; a woman should use DMPA as long-term method of birth control (e.g., for longer than two years) only if other birth control methods are inadequate for her.21 At issue is concern that prolonged use may result in significant loss of bone density. The loss is greater the longer the drug is administered. However, recent research shows complete recovery of bone mineral density after DMPA use, and the World Health Organization does not recommend changes in prescribing practices because of concerns about bone loss in adult users. For adolescents, an increased risk of fracture with long-term use remains theoretical. Until more data are available, providers should reconsider the overall risks and benefits of long-term DMPA use in adolescents over time.

Diaphragm, cervical cap, sponge, spermicides, and condoms. Because pregnancy and childbirth influence vaginal tone and may alter the size of the cervix and vagina, women choosing the diaphragm or cervical cap will need to be refitted for their contraceptive. Fitting should occur no earlier than six weeks postpartum to ensure that the cervix is no longer dilated and that maximum healing has occurred.15 Use of the contraceptive sponge (Today®) should also be delayed until six weeks postpartum because of the risk of toxic shock syndrome.15 Spermicides and condoms may be initiated in the immediate postpartum period.

IUD and IUS. The Copper T IUD and the two types of levonorgestrel (LNG) IUS (LNG 52 mg, Mirena; LNG 13.5 mg, Skyla) are long-acting, highly effective contraceptive options for both lactating and non-lactating women. The Copper T IUD (ParaGard) is effective for 10 years. Expulsion rates are slightly higher when the IUD is inserted immediately postpartum, and many clinicians recommend delaying insertion for four to six weeks following delivery after complete uterine involution.22 The LNG 52IUS (Mirena) is effective for five years; the mechanism of action is similar to that of LNG implants or LNG-containing mini-pills. The LNG 13.5 IUS (Sklya) is effective for up to 3 years.23 Menstrual bleeding may be substantially . . . with either LNG IUS.24

Sterilization. The vast majority of women who undergo sterilization (or whose partners have a vasectomy) are satisfied with this method. An exception to this finding is young age, which is the strongest predictor of regret.26 Risk factors such as an unstable marriage, recent divorce, or other life changes should be taken into account when counseling women on this permanent contraceptive option. Immediately postpartum is the ideal time to perform surgical sterilization. This represents a convenient time if the woman delivers in a hospital setting, and the procedure may be covered by the patient’s medical insurance. Postpartum sterilization is also associated with a lower failure rate than procedures performed later. If surgical sterilization is requested later, the most common method is laparoscopy performed as ambulatory surgery with rings, clips, or cautery to the fallopian tubes.27

A transcervical sterilization method (Essure™) provides another option for delayed postpartum sterilization. With this method, microinserts, placed into the fallopian tubes via the uterus, promote formation of scar tissue that blocks the tubes. By three months, both tubes are closed in 96 percent of women, and by six months, 100 percent of women experience tubal occlusion. Reliable contraception is required until a hysterosalpingogram demonstrates that the inserts have been correctly placed and the tubes are occluded.28

References

  1. Nusbaum MR, Gamble G, Skinner B, Heiman J. The high prevalence of sexual concerns among women seeking routine gynecological care. J Fam Pract 2000;49(3):229-32.
  2. Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 2003;24(4):221-9.
  3. Richardson AC, Lyon JB, Graham EE, Williams NL. Decreasing postpartum sexual abstinence time. Am J Obstet Gynecol 1976;126(4):416-7.
  4. Hicks TL, Goodall SF, Quattrone EM, Lydon-Rochelle MT. Postpartum sexual functioning and method of delivery: summary of the evidence. J Midwifery Womens Health 2004;49(5):430.
  5. Buhling KJ, Schmidt S, Robinson JN, Klapp C, Siebert G, Dudenhausen JW. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol 2006;124(1):42-6.
  6. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184(5):881-8; discussion 888-90.
  7. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005 16(4):263-7.
  8. Barrett G, Peacock J, Victor CR, Mayonda . Cesarean section and postnatal sexual health. Birth 2005;32(4):306-11.
  9. Von Sydow K, Ulmeyer M, Happ N. Sexual activity during pregnancy and after childbirth:results from the Sexual Preferences Questionnaire. J Psychosom Obstet Gynaecol 2001;22(1):29-40.
  10. Von Sydow K. Sexuality during pregnancy and after childbirth: a metacontent analysis of 59 studies. J Psychosom Res 1999;47(1):27-49.
  11. Reamy KJ, White SE. Sexuality in the puerperium: a review. Arch Sex Behav 1987;16(2):165-86.
  12. Kayner CE, Zagar JA. Breast-feeding and sexual response. J Fam Pract 1983;17(1):69-73.
  13. Alder EM, Cook A, Davidson D, West C, Bancroft J. Hormones, mood and sexuality in lactating women. Br J Psychiatry 1986;148:74-9.
  14. Elia G, Bergman A. Pelvic muscle exercises: when do they work? Obstet Gynecol 1993;81(2):283-6.
  15. Kennedy KI, Trussell J. Postpartum contraception and lactation. In: Hatcher RA, et al. Contraceptive Technology. 18th revised ed. New York, NY: Ardent Media; 2004, pp 575-600.
  16. Centers for Disease Control and Prevention (CDC). Update to CDC's U.S. Medical
    Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for theuse of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):878-83.
  17. Kennedy KI. Efficacy and effectiveness of LAM. Adv Exp Med Biol 2002; 503:207-16.
  18. Valdes V, Labbok MH, Pugin E, Perez A. The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception 2000;62(5):217-9.
  19. Kennedy KI, Kotelchuck M, Visness CM, Kazi A, Ramos R. Users’ understanding of the lactational amenorrhea method and the occurrence of pregnancy. J Hum Lact 1998;14(3):209-18.
  20. Hatcher RA, Nelson A. Combined hormonal contraceptive methods. In: Hatcher RA, et al. Contraceptive Technology. 18th revised ed. New York, NY: Ardent Media; 2004, pp 391-460.
  21. Depo-Provera Physician Information. Pfizer, Inc. Available from: http:// www.pfizer.com/pfizer/download/uspi_depo_provera_contraceptive.pdf. [Revised November 2004.]
  22. Grimes D, Schulz K, Van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2003;(1):CD003036.
  23. Skyla [package insert] Wayne, NJ: Bayer HealthCare Pharmaceuticals; 2013.
  24. Cox M, Tripp J, Blacksell S. Clinical performance of the levonorgestrel intrauterine system in routine use by the UK Family Planning and Reproductive Health Research Network: 5-year report. J Fam Plann Reprod Health Care 2002;28(2):73-7.
  25. Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, Peterson HB, et al. A comparison of women’s regret after vasectomy versus tubal sterilization. Obstet Gynecol 2002;99(6):1073-9.
  26. Wilcox LS, Chu SY, Eaker ED, Zeger SL, Peterson HB. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991;55(5):927-33.
  27. Westhoff C, Davis A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000;73(5):913-22.
  28. Association of Reproductive Health Professionals. An update on transcervical sterilization. Clin Proc 2002.