Understanding and Addressing Pain During Sex After Childbirth

Childbirth is often a life-changing and affirming experience, but it can also lead to physical changes and challenges that are not often openly spoken about despite how common they are.

Tightness, tenderness, discomfort and pain during sex following childbirth is a common occurrence. In fact, a study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At three months postpartum, 45% were still experiencing pain, and at 18 months postpartum, 23% were still experiencing pain[i].

Getting the best treatment for postpartum pain starts with equipping yourself with a clear understanding of the condition and its symptoms. So, what causes it, how is it diagnosed and how can it be treated?

Discomfort and pain during sex post childbirth:

Childbirth, especially vaginal delivery, can result in stretching, tearing, or trauma to the vaginal tissues. The body's natural healing process aims to repair these tissues, but sometimes scar tissue or adhesions can form which create an intense feeling of discomfort when penetration is attempted. As the body begins to associate discomfort with intercourse, an additional sensation of involuntary tightness can occur in the vagina. This tightness, known as vaginismus, can make sexual intercourse painful or even impossible.

Vaginismus is described as the involuntary cramping, tensing or contracting of the pelvic floor muscles around the vagina[ii]. The muscles tightening is an automatic reaction from the body which stems from a stress response in relation to partial or full penetration. In some cases, even just the mere thought of it can trigger a response.

These sensations of tightness or discomfort can often be caused by vaginismus, but other factors can also play a part, including:

• Tissue healing and repair: During childbirth, the vaginal tissues may stretch, tear, or undergo trauma. As the body heals, scar tissue or adhesions can form, leading to a feeling of tightness.
• Hormonal changes: After giving birth, hormone levels in the body fluctuate, particularly estrogen. Reduced estrogen levels can contribute to vaginal dryness, which can exacerbate feelings of tightness[iii].

The symptoms of postpartum pain may include:

• Discomfort or pain: You may experience discomfort or pain during sexual intercourse due to the tightness of the vaginal muscles and tissues.
• Vaginal dryness: Reduced estrogen levels can cause vaginal dryness, leading to discomfort and friction during sexual activity.
• Reduced sexual desire: Pain or discomfort during intercourse can lead to a decrease in sexual desire and intimacy.

If you are unsure of your symptoms, a medical examination can help to identify if there are any other physical implications that could be causing pain or discomfort. You may feel embarrassed or ashamed of your condition, but this is understandable. Remember that your healthcare professional has supported countless people in treating things like this and is here to help you. Once symptoms have been identified, you can work with your healthcare professional on a treatment plan.

Treatment options:

It’s important to understand that these treatment options are also applicable for those who have not yet experienced painful sex post-partum but are anxious about the possibility. It’s normal to experience anxiety around your vagina after childbirth and as a result have a fear of intercourse.

These treatment options can help to prepare your vagina for penetration by alleviating any tightness or pain and most importantly rebuild personal confidence to get back into the bedroom.

Whilst symptoms may seem daunting, you must remember that there is always something that can be done, and fortunately there are several treatment options available to address your concerns. Here are some examples:

• Pelvic floor breathing exercises: One of the first steps to reducing painful tightness in the vagina is through ‘deep breathing’ exercises. Sit comfortably and take slow, gentle breaths in through the nose, and allow your belly and ribs to flare out, ‘opening’ your pelvic floor. Exhale slowly and gently through your mouth, letting the air out of your upper lungs and relaxing your belly and pelvic floor[i]. This approach frames the diaphragm to react with the pelvic floor, helping to stop involuntary tightening and relax the vaginal muscles. Regular practice of pelvic floor breathing exercises can lead to reduced tightness, alleviating discomfort and improving sexual function. From here, pelvic floor relaxation training can be introduced to help gain more control and flexibility.
• Lubrication: Using water-based lubricants during sexual activity can alleviate vaginal dryness, reduce friction, and enhance comfort.
• Talk to your partner: Having an open conversation with your sexual partner can go a long way in overcoming pain and gaining more control during postpartum intercourse. Set aside some time to discuss your experience and tell them specifically what hurts or feels good when you have sex.
• Hormone therapy: In cases of severe vaginal dryness or persistent discomfort, healthcare professionals may prescribe localised hormone therapy to restore estrogen levels and improve vaginal health.
• Pelvic physical therapy: Working with a pelvic physical therapist can be highly beneficial. They can provide specialised techniques to release tension, improve flexibility, and address scar tissue or adhesions in the vaginal area.
• Vaginal Dilators: Vaginal dilators are an effective tool for treating a number of symptoms caused by childbirth. Dilators help to gently massage the vaginal muscles and tissues, softly breaking down any scar tissue and preventing the formation of more. Flat top dilators in particular are ideal for this type of treatment as their shape allows you to comfortably reach areas where scarring has occurred. Gradually increasing the size of the dilators over time can help promote tissue healing, reduced tightness, and alleviate discomfort, all the while building up your sexual confidence post childbirth[ii].

Vaginal dilators and progressive desensitisation:

Vaginal dilators play a key role in one of the most important treatment steps; progressive desensitisation. In this therapy, dilators are introduced to help you gradually become more comfortable with touching around the vagina[iii], and to repair any damaged scar tissue caused by childbirth. Scar massage with dilators can help to increase the elasticity of vaginal tissues and decrease the area of scar tissue, in turn alleviating some of the discomfort caused by sexual intercourse or daily activities.

Dilators are designed to help you familiarise yourself with your body and build your confidence until you feel able to progress to natural penetration with your partner. The various sizes allow you to start small and gradually move up the range at a pace that is comfortable and safe for you.

Never rush the process. Start off with baby steps, first just massage the labia with the smallest dilator and when you are ready progress towards the entrance. See how that feels for you. Remember you have all the time in the world and taking your time to feel comfortable is key to your success with overcoming pelvic pain.

Work up to inserting the dilator about 1-2cm from the opening towards the hymen, and always focus on your breathing to relax your body. Week by week or even month by month slowly progress to the larger dilators. Remember if you don’t feel ready, go back to the smaller dilator. There is no rush.

You are not alone

Postpartum tightness and other symptoms are completely normal, clear to identify and treatable.

Understanding the causes and symptoms is crucial for seeking appropriate treatment. Vaginal dilators, along with other therapeutic approaches, offer an effective solution for addressing postpartum tightness and alleviating any associated discomfort. By gently massaging and rehabilitating the vaginal muscles and tissues, dilators help women regain their comfort, confidence, and sexual satisfaction.

Embracing these treatment options empowers you to take an active role on your healing journey, promoting physical and emotional well-being as you embrace the joys of motherhood. Remember, seeking guidance from healthcare professionals specialising in women's health is important for personalised advice and support throughout the postpartum recovery process.

[1] McDonald, E.A. et al. (2016) ‘Frequency, severity and persistence of postnatal dyspareunia to 18 months post-partum: A cohort study’, Midwifery, 34, pp. 15–20. doi:10.1016/j.midw.2016.01.012.

[1] Siang, D.Y.W. (2022) How do I know if I have vaginismus?, DTAP Clinic. Available at: https://dtapclinic.com.my/how-do-i-know-if-i-have-vaginismus/ (Accessed: February 8, 2023).

[1] Colleen de Bellefonds, C.E. (2021) What really happens to your vagina after birth, What to Expect. Available at: https://www.whattoexpect.com/first-year/vagina-after-birth/ (Accessed: 06 June 2023).

[1] Jenna Leader (2016) Learn to relax your pelvic floor muscles. Boston, MA: Beth Israel Deaconess Medical Centre. Available at: https://www.bidmc.org/centers-and-departments/rehabilitation-services/outpatient-rehabilitation-services/outpatient-occupational-and-physical-therapy/conditions-we-treat/pelvic-floor?utm_source=bidmc&utm_medium=vanity&utm_campaign=pelvicfloorpt (Accessed: 23 June 2023).

[1] Cleveland Clinic, C.C. medical (Reviewed: 2023) What is a vaginal dilator, and should I use one? Available at: https://my.clevelandclinic.org/health/treatments/24971-vaginal-dilators (Accessed: 23 June 2023).

[1] National Health Service (UK) (2021) Vaginismus, NHS choices. NHS. Available at: https://www.nhs.uk/conditions/vaginismus/ (Accessed: February 8, 2023).