Timing. Returning to sex may sometimes prove a slower process than you or your partner had expected; healing, after all, is a dynamic process that occurs over a span of months, with many stages of wound remodeling. Some women feel ready and able soon after delivery; others have zero interest or too much discomfort for quite some time. The Harvard/Nebraska study found that six months after their first vaginal childbirth, around a quarter of women still reported decreased sensation, worsened sexual satisfaction, and a reduced ability to achieve orgasm. When the time feels right for you and your partner, choose a part of the day or night when the baby sleeps deeply, if such a time exists. Start by relaxing with a bath and massage, and take it slow. If you notice bleeding or feel a strong pulling or tearing sensation, listen to your body and stop. A bit more time for healing is usually all you’ll need.
If all else fails. If tenderness persists along the perineum or inside the vagina after the full healing process is complete, on rare occasion, other treatments may be warranted. For instance, antiinflammatory injections, referred to as trigger-point injections, can be used to treat certain tender areas. In other cases, removal or revision of scarred or stretched tissue, with a minor surgical procedure, may ultimately provide the best relief.
DON’T RUSH IT
There’s a long-standing belief out on the street that returning to sex is a breeze after childbirth. Doctors typically give couples the green light somewhere around four to six weeks. But how often are couples able to return to having sex at this point? One study in The Journal of Family Practice reported that less than 20 percent of couples had resumed intercourse by four weeks, and not until four months had 90 percent of them resumed. The average time to resume activity was seven weeks. A report from the University of North Carolina found that 17 percent of women still reported pain with intercourse at six months after delivery. Similarly, in Australia, it was found that one in five mothers needed up to six months to feel fully comfortable during sex. Resuming relations after childbirth needs to occur at your own personal pace.
Pelvic floor. A strong and careful repair of your perineum after childbirth—whether it follows an episiotomy or a spontaneous laceration during delivery—will often restore a normal anatomy and tone to the vaginal opening. But it can’t restore the function of the deeper muscles, nerves, and connective tissues of the pelvic floor. Weak and deconditioned levator muscles may decrease sexual satisfaction by making you feel too loose. In other cases, tenderness or spasm of the levator muscles may lead to pain and hesitation during penetration. As mentioned earlier, starting a Kegel routine (see Appendix A) can improve your vaginal tone and ability to find pelvic muscles that are overly tense and tender during penetration. In doing this you may improve your ability to relax the muscles during intercourse.
Pelvic-floor physiotherapy may also help to reacquaint you with the pelvic-floor muscles after childbirth, even if Kegel exercises fail. Biofeedback sensors signal when you’re contracting the correct pelvic-floor muscles, and will improve your workouts. Pelvic-floor stimulation, with electrical or magnetic energy, is a means to rehabilitate the pelvic nerves and muscles when exercises have failed.
Hormones. It’s impossible to discuss the postpartum transition without some mention of hormones and the roller-coaster swings they can undergo after childbirth. Bodily chemicals that were surging during pregnancy are suddenly in free fall until the return of menstrual cycles, when a natural nonpregnancy hormone mix resumes.
The hormonal changes accompanying lactation can have a negative impact on sexual function, lasting until breast-feeding ends. Reduced estrogen levels account for the majority of problems by causing severe vaginal dryness and temporary atrophy. It’s also been proposed that breast-feeding temporarily decreases male-type androgen hormones responsible for libido. The short-term use of vaginal estrogen cream or tablets can improve vaginal blood flow and sexual lubrication, if approved by your doctor. Urinary incontinence during intercourse (coital incontinence) can result from estrogen-deprived bladder, urethra, and vaginal supports. Extra Kegel exercises, and low-dose estrogen cream if approved by your doctor, may help.
Postpartum depression and the blues. Whether these postpartum mood disorders are of hormonal origin remains a subject of debate. Whatever their biological or psychological cause, sexual interest can be among the first bodily functions to fall by the wayside.
AND NOW FOR SOME GOOD NEWS
Lest you begin to feel that statistics are all gloom and doom, here’s one to cheer you up. Around 25 percent of women will enjoy sex more after their first childbirth than before they conceived. This was reported in The British Journal of Obstetrics and Gynaecology in the early 1980s and confirmed by a more recent study; this study also found, though, that women with perineal injury during childbirth were only about half as likely to enjoy this unexpected natural boost.
The Postreproductive Years Before and After Menopause
LIBIDO, AROUSAL, ORGASM: POTENTIAL PROBLEMS IN EACH “ACT”—AND THEIR TREATMENTS
ACT 1: LIBIDO
For the average woman (not that average applies to you!), sex drive does decline to some degree as years go by. On the other hand, many individuals notice no change for the worse during their postreproductive years, continuing to enjoy an active sex life just as before, and sometimes even more so. What’s the secret? Is it their hormones, the quality of their relationships, or their physical health? Actually, a combination of several factors is at work.
General health. Anemia, diabetes, and thyroid disease are among the more common specific medical conditions that can affect libido. But even without a specific medical problem, your general physical shape and well-being can strongly influence sexual function. Feeling well tuned and well toned—close to your optimal weight, body shape, and cardiovascular conditioning—is one of nature’s most potent aphrodisiacs.
Depression, stress, and substance abuse. Sex drive is often the first bodily function to fail when you’re coping with emotional baggage, or battling an addiction with alcohol or drugs. Women who are happy outside of the bedsheets are far more likely to feel contentment between them.
Medications. Antidepressants, blood-pressure medication, and sedatives are among the drug types that should be reviewed by a physician to be sure they’re not contributing to a flagging sex drive, slowed arousal, or difficulty with orgasm. In some cases, substitutes can be found. Never discontinue a medication without your doctor’s approval.
Hormones. During your postreproductive years right on through menopause, sexual interest and function can mirror your hormonal swings. A lack of androgens (the male hormones that are also present in women) occurs naturally after menopause, and a more dramatic drop occurs after surgical removal of the ovaries. Abnormally low testosterone levels may sometimes lead to diminished libido. Testosterone-replacement therapy can be used to improve sex drive, which you’ll learn all about in the section ahead.
Levels of estrogen, the staple female hormone, may fluctuate more widely as your postreproductive years progress, but this shouldn’t directly affect libido much until after menopause or surgical removal of the ovaries. Indirectly, varying estrogen levels can occasionally affect sexual function even before menopause. For example, if premenstrual symptoms or irritability become more pronounced, or vaginal atrophy causes you to associate intercourse with physical discomfort, sex drive can certainly suffer. Estrogen therapy to counteract these problems will be discussed in the pages ahead.
ACT 2: AROUSAL
Arousal is your physical response to stimulation—the process of warming up during foreplay, becoming physically primed for intercourse. The arousal process, including vaginal engorgement and lubrication, normally occurs at a slower pace as years go by. Before menopause, women can usually adjust to this change quite easily, relying on nothing more sophisticated than a warm bath, perhaps a glass of red wine, and longer foreplay. But after menopause, a lack of estrogen in the vaginal tissues makes the process of arousal a much greater c
hallenge. Atrophy can lead to progressive vaginal dryness, thinning, irritation, itching, and even narrowing of the vagina. The skin of the vagina actually becomes less flexible, causing friction during intercourse. To make matters worse, atrophy of the urogenital tract may increase your risk for bladder and vaginal infections. Any or all of these changes can ultimately dull your desire, slow your arousal, and make intercourse downright uncomfortable. The use of vaginal estrogen creams or tablets—to restore the normal thickness, blood supply, and lubrication to the vaginal skin—can work wonders. Use water-soluble lubricants liberally, and keep yourself well hydrated, since dehydration dries the skin of the vagina just like anywhere else.
ACT 3: ORGASM
The inability to reach orgasm can be caused by a lack of sufficient stimulation but can also result from specific medications or disease states. Be sure to review your overall medical history with your doctor while considering a few easy tips.
Location, location. It’s one of the most important elements not only in real estate but also in sexual pleasure. Think about your physical surroundings, the answer to minimizing inhibition. Are you and your partner taking some time to set the mood and to allow the arousal phase to occur? A warm bath, some well-placed aromatherapy candles, and slow foreplay can go a long way. As years go by, you’ll need more time for arousal—and orgasm—to occur. And contrary to popular belief, up to two thirds of women do not have orgasms during intercourse.
Also pay attention to the anatomic places where your stimulation is maximized down below. Some partners need help learning how to find this location and deal with it properly. If you’ve had no luck teaching your partner after a glass or two of wine, well … try champagne.
Get estrogenized, or at least lubricated. A healthy estrogen supply increases blood flow to the genitals, promoting engorgement of the areas responsible for orgasm. The use of estrogen-containing vaginal creams or pills may help, though their full effects may not be seen for months. Simple lubricating gels can provide a substitute if you’re not interested in using estrogen, or if you can’t use it for medical reasons. Although it won’t enrich atrophic vaginal skin like estrogen, it will provide temporary lubrication for intercourse, which may further stimulate your own natural secretions. Only water-based products should be used.
Local estrogen products. Estrace or Premarin (cream), Vagifem (tablets); your physician will determine the appropriate dosage.
Water-based lubricants. K-Y jelly, Astroglide, Replens, Liquid Silk, Gyne-Moistrin, Slippery Stuff
Exercise for better sex. Because the levator muscles contract during orgasm, building them may cause the intensity of orgasm to increase. By improving the tone of your levator muscles, pelvic-floor exercises can help you develop better control over your sexual tension. Well-toned muscles may also help to eliminate any urine leakage that might occur during intercourse—relieving fear of accidents, boosting self-confidence, and improving your ability to relax and let go.
ESTROGEN: A KEY INGREDIENT FOR SEXUAL FUNCTION
Whenever estrogen levels decline—whether from natural menopause, surgical removal of the ovaries, or breast-feeding—the vagina and bladder may become thin, dry, and atrophic. These are among the most common changes affecting sexual arousal and overall sexual function. Local estrogen-containing creams, vaginal pills, or rings can replenish the vaginal skin, restoring its thickness and moisture. Estrogen is one of the most important treatments for menopausal women coping with diminished sexual satisfaction. The cream should not, however, be used as a lubricant during intercourse, since absorption into the male organ can occur.
THE ROLE OF TESTOSTERONE … AND OPRAH!
Did you know that testosterone is actually a part of your chemical mix? It’s the basic fuel of libido, arousal, and orgasm, and it also provides the building block for one type of estrogen in the female body. By menopause, somewhere around 50 percent of testosterone production is lost; after surgical removal of the ovaries, the decline is more dramatic. But even for women with working ovaries who haven’t yet reached menopause, symptoms of androgen deficiency may occur as early as the late thirties. The use of oral contraceptives may also occasionally contribute to a mildly testosterone-deficient state. A decline in testosterone activity can place a slow, indefinite chill on sexual desire.
In October 1998, Oprah Winfrey and guests on her show shared some spicy news with the female world, a hormonal shot heard round the world on daytime television: the use of testosterone propionate cream for improving female libido. Androgen replacement has been known for quite some time to increase sexual desire and arousal, helping to improve a flagging libido more effectively than estrogen alone. Relatively new, however, is the variety of ways this hormone can be used—including oral pills, or as a cream for application to the genitals or elsewhere.
FORMS AND DOSES
Determining the safest and most appropriate role for testosterone in treating decreased libido or arousal has proven to be a difficult task. Very high doses of androgens will increase the sex drive of almost any woman, but these levels would be unsafe. The smaller doses used for replacement have demonstrated a rather unpredictable effect. Only your doctor can judge your safest and most effective dose.
Injection. Muscular injections have been shown to increase the intensity of desire, arousal, and fantasy, as well as the frequency of sexual activity and orgasm.
Cream and gel. Applied directly to the labial, vaginal, or clitoral areas by some women; once you see improvement, you may want to switch to oral form. It remains unclear whether there are long-term side effects and at what dosages they’re likely to occur. More research is needed to guide the proper use of these products.
Oral therapy: Combination estrogen and testosterone. Oral testosterone therapy has become increasingly popular in recent years. For women without functioning ovaries, the estrogen included in these combination pills may, at least in theory, balance the potentially bad cardiovascular effects of testosterone. But in reality, the side effects of long-term testosterone usage are unknown, and certain estrogen-progesterone combination therapy may also pose significant risks if taken on a long-term basis (see “Estrogen and Other Hormones,” chapter 12). Therefore, the dosage and duration should be carefully discussed with your doctor. There are only a few approved products in the United States: Estratest and Estratest HS (Solvay Pharmaceuticals); and Premarin with Methyltestosterone (Wyeth-Ayerst).
Skin patches and implants. Testosterone skin patches (transdermal) are available for men, but there is no such product approved for women. The main theoretical advantage of taking testosterone through the skin, rather than by mouth, is to avoid its chemical breakdown in the gastrointestinal tract. Implants for beneath the skin (subcutaneous) are another emerging option but are not yet available for women.
SIDE EFFECTS
The challenge of testosterone replacement is achieving the good effects without running into potentially serious side effects. They range from cosmetic—such as deepening of the voice, acne, increased facial hair, hair loss (male pattern baldness)—to clitoral enlargement and alterations in cholesterol profiles marked by lowering of good cholesterol (HDL) and elevation of bad cholesterol (LDL). Especially if you’re using a noncommercial cream or gel, the amount of active medication you’re receiving can vary widely from dose to dose. Be sure to work closely with your doctor to keep your regimen safe.
OTHER ELIXIRS DHEA
Dehydroepiandrosterone is a relatively weak steroid hormone (androgen) that’s widely prevalent in fountain-of-youth supplements. Your own body’s production of DHEA reaches its peak in your mid-twenties, then slowly tapers off; commercial DHEA, in contrast, is extracted from plants. Although research has been scarce, one three-month study of DHEA supplementation failed to show any improvement in libido or mood. It also hasn’t been found to help prevent heart disease in women, despite initial hopes. Concern has been raised over its possibly lowering HDL levels. DHEA has not received FDA approval for medical use an
d is not recommended at this time.
Viagra: Not Just for Men Anymore?
As many women watched the born-again response of their male partners to this arousal-enhancing little blue pill, it didn’t take long for the collective question to arise: “Hey, what about me?” Unfortunately, based on results of the first Viagra-for-women study conducted at Columbia Presbyterian Center in New York, women receiving a twelve-week course of the medication were no more likely to report improved sexual function than those who took placebo during the same period. Undoubtedly, more data on the use of Viagra for women will emerge; for now it appears to have no established role.
PAINFUL INTERCOURSE: UNDERSTANDING AND ALLEVIATING IT
Painful intercourse for the postreproductive woman can signal a number of possible underlying causes. The discomfort can be deep or superficial. It can arise from any number of structures, including the labia, perineum, levator muscles, bladder, urethra, vagina, cervix, or uterus. It may relate to vaginal dryness or atrophy, chemical irritation, infection, endometriosis, ovarian cysts, or fibroids. The list goes on, and sorting through all the possibilities may take effort, but it’s worth it. Find a doctor interested in sticking with you and your problem until a solution is found. In the meantime, a few tips may help.
Ever Since I Had My Baby Page 24