Beth Safarian PT, MSc PT, BSc

There is a common misconception that cesareans are less likely to result in painful intercourse postpartum compared to vaginal deliveries. However, research shows that dyspareunia after a cesarean is much more common than most would anticipate. While many people report painful sex at 6 and 18 months after childbirth, the odds of postpartum dyspareunia at 18 months were substantially higher for those who delivered by cesarean, whether it was emergency or elective. In this blog, we will explore the factors that contribute to painful sex after a cesarean.

Hormones

 If a person decides to breastfeed, their estrogen levels are suppressed, regardless of the mode of delivery. It is similar to being in a mini-menopause in which the vaginal tissues become more dry, thin and sensitive. Typically, these symptoms will persist until a person resumes their regular menstrual cycles. This is why using a lubricant postpartum is always strongly recommended. If lubricant doesn’t seem to be enough for the tissues, the next approach would be to introduce vaginal moisturizers. Some options include Repagyn, Gynatrof and Replens (none of which require a prescription). If a vaginal moisturizer is still not doing the trick, vaginal estrogen supplementation may be prescribed by your family doctor or obstetrician. There are a few options to discuss which include a pill, a cream and a ring.

Pelvic Floor and Abdominal Tension

Regardless of how someone gives birth, the pelvic floor plays an important role supporting the uterus and growing baby. All of this increasing pressure over the course of a pregnancy can lead to elevated pelvic floor tension. On top of the tension that begins during pregnancy, a cesarean can also lead to further tone in the pelvic floor during recovery. A cesarean section is a major abdominal surgery which often results in significant pain, soreness and swelling in the pelvic region. When there is discomfort, there is often a lot of guarding and protecting that comes a long with it. If someone is clenching their lower abdominals constantly during their recovery due to pain, they will also most likely be engaging their pelvic floor muscles at the same time. This tension that develops during recovery can be a big component of painful sex, particularly difficulty with insertion. This is where pelvic floor therapy can be extremely helpful. Your physical therapist may suggest manual therapy, stretches and/or dilators to help address muscular tension in the pelvic floor and abdominal wall.

Scar Tissue

The scar tissue formed after a cesarean travels through many layers of tissue including skin, fascia, and all the way down to the uterus. If there are adhesions, the movement of the uterus may be restricted which can be a cause of pain with deeper penetration. If fascia is restricted in the supra pubic region, this can affect the tissues all the way down into your labia and pelvic floor. Restricted scar tissue may also limit your mobility and affect comfort with certain positions during sex. Scar tissue massage is a great strategy to mobilize the scar. There are techniques and strategies that your pelvic floor physiotherapist can teach you to do at home that include self massage and cupping. The goal is to get your scar as mobile and flexible as your unaffected tissues.

Psychological Impacts

Lastly, it is important to recognize the emotional impacts of a cesarean. While there are planned or elective cesareans, there are also many situations in which they become an emergency situation. This can be a traumatic experience for many, and therefore it’s important to address the psychological impacts that it may have on a person. After going through a traumatic birth, it is common for one’s desire for sex to be reduced which can really impact pain. This is why it’s so important to wait until you are feel emotionally ready, rather than having sex because you feel like you should. Additionally, I often recommend my patients speak with a therapist if there is trauma associated with their cesarean.