Ever Since I Had My Baby

by Roger Goldberg

  Think lubrication. Inadequate lubrication is probably the most common reason for painful intercourse. Some medical conditions (including long-standing diabetes) and medications (including certain antibiotics, or the breast-cancer drug tamoxifen) may cause decreased lubrication. Water-soluble lubricants (K-Y jelly, Replens, Astroglide) can often provide the solution. Avoid oil-based lubricants (baby oil, petroleum jelly), since they can linger in the vagina and promote infection.

  Fight atrophy. Atrophy of the vulva and vagina can lead to itching, irritation, and narrowing of the vagina, making sex difficult or impossible. This can be due to a temporary decline in estrogen supply for women who are breast-feeding, or a permanent decline for those who are past menopause. Ask whether vaginal estrogen—in the form of creams, tablets, or rings—might be for you (see chapter 12).

  Avoid vaginitis (yeast, bacterial vaginosis). Vaginitis is another common source of burning or pain with sexual activity, and one that can be fully treated or prevented (see chapter 12). Avoid treating recurrent or persistent yeast without seeing the doctor first, since other conditions can mimic a yeast infection, and the wrong treatment may aggravate your symptoms. Bacterial vaginosis, for instance, is an often overlooked source of vaginal irritation and discharge that will not improve with antiyeast treatment, but it can be easily treated with a different type of medication.

  Take care of the vulva. Vulvar irritation can result from exposure to chemicals, perfumes, soaps, powders, and clothing materials. If you become sore or overly sensitive, eliminate these potential irritants (see chapter 12).

  Recognize a painful bladder. Cystitis can cause pain during intercourse, whether it’s arising from a bacterial infection or another inflammatory condition. If your doctor identifies infection, inflammation, or abnormal tenderness of the bladder, treatment of the bladder problem may significantly improve your sexual function.

  Understand and treat vaginismus. Vaginismus refers to an involuntary tightening or spasm of the vaginal and pelvic-floor muscles, making penetration painful and sometimes impossible. Although it may relate to past sexual trauma or abuse, childbirth alone may account for enough stored memory of pain—indeed, trauma—to trigger the problem. The pain or sensitivity that accompanies healing of an episiotomy or spontaneous laceration of the perineum can lead to postpartum apprehension over just inserting a tampon, let alone having intercourse. In some women, this guarding of the pelvic area may persist well beyond the postpartum period, and tightening of the vagina and pelvic-floor muscles becomes a reflex in the bedroom.

  Mind-body approaches may sometimes help to reduce both mental and physical stress. Your doctor or nurse or a pelvic-floor physiotherapist may utilize biofeedback to show you how to relax the pelvic-floor muscles during vaginal dilation. Sexual apprehension stemming from problems of past or present relationship strain or abuse may ultimately respond best to counseling or therapy. Referral to a sexual therapist is sometimes advised in this case.

  A Kegel routine may help when used alone, or when enhanced by biofeedback (see Appendix A). Developing the strength and tone of the pelvic-floor muscles will help you to more effectively identify and relax them during intercourse.

  As with any other muscle spasm, your levators can get tense and sore. Pelvic-floor massage may help to release that tension and improve vaginismus. Some pelvic-floor physiotherapists have a focused interest in pelvic-floor massage. Pelvic-floor electrical stimulation (see Appendix A) may be used either in the doctor’s office or at home to accompany this therapy.

  LEAKING, BULGING, AND SEX: WHEN INCONTINENCE OR PROLAPSE ENTERS THE BEDROOM

  A loss of bladder or bowel control, or advanced pelvic prolapse, can dim just about any woman’s sexual spark. Not unlike impotence in males, these problems may diminish not only your physical pleasure but also your self-confidence, presenting a real challenge to sexual identity.

  Relaxed vagina or perineum. We’ve discussed perineal relaxation and the reasons why the vagina and pelvic-floor muscles can become stretched out after childbirth. This can lessen a woman’s feeling of fullness during intercourse, or diminish the ability to reach orgasm. The loss of sensation may be enough to cause frustration for a partner, too. It’s unknown whether episiotomies make this postreproductive anatomic change more likely.

  Pelvic-floor exercises can help to restore vaginal muscle tone, but results may not be seen for several months. And sometimes exercises are simply not enough to rehabilitate and restore tissues that were stretched and weakened. Perineorrhaphy refers to surgically tightening the muscles of the perineum and vaginal opening—the same ones that might relax after childbirth—something like a delayed episiotomy repair. Decreasing the caliber of the vaginal opening may produce a fuller sensation with intercourse.

  Before signing on for this type of surgery, be sure to understand its risks, benefits, and limitations. Just because your perineum and vagina are restored closer to their prechildbirth virginal state doesn’t guarantee that life between the sheets will transform from ice-cold to torridly passionate. And though the risks are low, any vaginal operation carries a small chance of scarring, pain, or nerve injury. So be sure there aren’t other, less anatomic problems contributing to your sexual dissatisfaction, such as relationship stress, diminished libido, or insufficient foreplay.

  Outline clear goals and realistic expectations. Elective operations have their appropriate place in gynecology, but your decision to enter the operating room should never be made lightly.

  Tender prolapse bulge. A prolapsed cervix or uterus may create an uncomfortable thump during deep penetration, as if something is in the way. Similar symptoms can occasionally indicate an ovarian cyst, fibroid, or other abnormality in the pelvic area, so be sure to have this symptom checked out before making any assumptions on your own.

  Coital incontinence. The leakage of urine or stool during intercourse or foreplay is a condition that many women are reluctant to discuss, and it’s more common than most physicians suspect. One study found that among 324 sexually active women with incontinence, 24 percent experienced leakage during intercourse; among them, two thirds had leakage with penetration, and a third had leakage with orgasm. Incontinence can have a major impact on sexual function. For some women, diminished sexual pleasure—caused by a growing fear of embarrassment and an inability to let go and enjoy the moment—is one of the most troubling secondary effects of incontinence. One study recently found that women with urinary incontinence had fewer sexual thoughts and fantasies.

  Other studies have shown that women with urge incontinence tend to suffer the greatest impact on their sexual health. A European study involving 447 women and men with overactive bladder found that for over a third, their bladder problem was a major reason for sexual abstinence. Avoidance of intercourse, and intimate relationships in general, was surprisingly common among individuals with urge incontinence.

  Frequent leakage may also cause irritation of the vulvar area and vaginal opening, leading to diminished sexual function for purely physical reasons. Fortunately, coital incontinence is almost always remediable, if you understand its source.

  Leakage during penetration often indicates stress incontinence due to a floppy or thin urethra (see chapter 8) and pelvic-floor muscle weakness. As the bladder is bumped during intercourse, the sudden pressure increase may be too much for the weak urethra to hold back. To prevent this kind of leakage, you may wish to:

  Empty your bladder before intercourse.

  Start a pelvic-floor exercise routine (see Appendix A). Extra muscle tone around the bladder and urethra can make the urethral valve more effective.

  Wear a large contraceptive diaphragm, which will provide a stronger floor for the bladder and urethra.

  Leakage during orgasm can signal an overactive bladder in some cases and stress incontinence in others. As the nerves around the pelvis go a bit haywire, an involuntary bladder contraction can result, leading to a sudden uncontrollable urge or even silent leakage of urine. You migh
t want to try:

  Antispasmodic medication, taken an hour or two before intercourse (oxybutynin, Tofranil).

  Healthy voiding habits (bladder drills) and avoiding potential dietary irritants (bladder diet) (see chapter 8).

  DEALING WITH SEXUAL CHANGES DURING AND AFTER MENOPAUSE

  The transitions of menopause, whether relating to mood, to sense of well-being, or to sexuality, affect each woman in a unique way. Some studies have suggested that diminished desire and sexual function can be expected to accompany “the change,” whereas others have found no such association. For some women, sex may become even more enjoyable with the freedom from fear of unwanted pregnancy, or from motherhood, or from the grind of a full work week. For others, hormonal swings, irregular periods, and hot flashes may take their toll on sexual desire, moods, and overall sense of well-being. One Australian study found that among women followed through their menopausal transition, 61 percent noticed no change in their sexuality, 7 percent reported an increase, and 32 percent noticed a change for the worse. Surveys in the United States reveal similar trends, with around 39 percent of menopausal women reporting a decreased interest.

  What if, despite those better-than-even odds, you’re among the women who have noticed decreased function after menopause? We’ve already discussed a number of basic strategies to get you started on the right path. But above all else, one rule may be most important: use it or lose it! Whether it’s biceps, triceps, or washboard abdominal muscles, most parts of the body follow this universal rule. Your pelvic and vaginal areas are no exception: if they’re not properly exercised, their tone and function will slowly but surely fade. Narrowing, dryness, irritability, and pain become common with a lack of sexual stimulation. One study published in The Journal of the American Medical Association showed that women over fifty who had intercourse at least three times each month had less vaginal atrophy than women who were less sexually active. Another study looking at vaginal skin cells under the microscope also found that sexually active women experience fewer atrophic changes than similar women who are not sexually active. Sexual activity, in other words, actually prevents vaginal atrophy.

  Moral of this story? Keeping your postreproductive body in shape sometimes takes a strong commitment between the sheets!

  PART 4

  YOUR SYMPTOMS ARE STILL TROUBLING YOU

  WHAT’S THE NEXT STEP?

  Maintaining Your General Health to Minimize Symptoms

  TIPS ON HORMONES AND MENOPAUSE,

  YOUR GYNECOLOGIC HEALTH, AND HIDDEN

  TRIGGERS OF PELVIC-FLOOR PROBLEMS

  By now you’ve learned a great deal about the most common pelvic-floor conditions that might affect your postreproductive body, and the specific ways to treat them. But if you’re coping with troubling symptoms down there—whether it’s incontinence, pelvic discomfort, bladder irritation, or vague symptoms that are tough to figure out—more general medical and gynecologic conditions may be playing a role. For example, in your postreproductive body, the symptoms triggered by vaginal infections and irritation may be far less familiar or typical than they once were. Bladder infections may present themselves in new and unexpected ways, becoming more common or exacerbating existing pelvic-floor symptoms. The changes of menopause may have a ripple effect throughout the urinary tract and pelvic floor. Commonplace gynecologic problems of many different types may feel peskier to your postreproductive body than they did before.

  By familiarizing yourself with the following tips, you’ll help to minimize some of the most common hidden triggers of pelvic-floor symptoms.

  Tip #1: Prevent Vaginal and Vulvar Symptoms

  YEAST INFECTIONS

  Vaginal itching and burning are the most well-known symptoms that lead young women to suspect a yeast infection. But as the years go by, yeast infections might reveal themselves through less typical clues.

  Urinary burning, urgency, and frequency. When vaginal yeast infections involve the tissue around the urethral opening, urinary symptoms (rather than vaginal ones) may be the most severe complaint. Even though it arises from a vaginal infection, this so-called urethral syndrome can feel like cystitis.

  Urge incontinence. If a bad yeast infection irritates the urethra enough to trigger bladder spasms, leakage from an overactive bladder may actually worsen.

  Sexual discomfort. Intercourse can trigger a yeast infection, leading to rawness and discomfort during intercourse. The usual cause is irritation of the vaginal skin and a change in the vaginal acid balance caused by the male ejaculate, not an actual infection transmitted from one partner to the other. Nevertheless, if intercourse remains a constant trigger and all other means of prevention have failed, some clinicians will recommend treating a male partner with oral medication for up to fourteen days, in case he has a yeast infection and is transmitting it to you.

  PREVENTION

  A handful of tips may help to reduce the odds of having to cope with yeast infections and the symptoms they trigger.

  Avoid Unnecessary Antibiotics

  The vagina and perineum have their own balanced ecosystem, inhabited by both good and bad types of bacteria. Antibiotics taken for any reason can disrupt this ecosystem by reducing the population of good bacteria and providing yeast with more opportunity to flourish.

  Keep Dry and Cool

  The temperature and texture of your vulvar and vaginal skin plays a large role. Trapped moisture makes yeast feel right at home. Staying dry and cool down there is the most basic prevention.

  Dress wisely. Avoid tight clothing, nylons, and other noncotton undergarments that don’t breathe. Remove wet bathing suits ASAP. After showers and baths, if towel drying still leaves you damp, try a cool hair dryer on your bottom area. During your period, use a tampon instead of a menstrual pad.

  Cornstarch. A simple, very inexpensive absorbent powder, very gentle on the skin. Be wary of medicated powders. They may keep you dry, but their additives can occasionally irritate sensitive skin.

  Lactobacillus acidophilus. Lactobacillus is the most common good bacteria found in the vagina. When its population is strong, there is little room for yeast to thrive. Some women supplement each time they have intercourse, swim, or take antibiotics, to rebalance the vaginal ecosystem and possibly help to prevent vaginitis. If you already are suffering from a yeast infection, however, taking acidophilus is unlikely to offer a cure.

  One 1992 study suggested that eating eight ounces of yogurt each day reduced the risk of yeast vaginitis after six months. Be sure that the yogurt contains acidophilus and not too much added sugar. Acidophilus-containing milk, miso, and tempeh are also available, as are acidophilus vaginal cream and suppositories, although it’s unclear whether these are any more or less effective than the dietary form. You can also take acidophilus in oral tablets and powders.

  TREATMENT

  Most yeast infections can be handled with an over-the-counter medications or a homespun remedy. But before starting any treatment, be sure to run it by your doctor.

  Boric Acid

  Vaginal tablets, suppositories, or even ointments containing boric acid are a time-tested remedy for yeast infections. The treatment works without the use of antifungal medication by simply helping to rebalance the vaginal pH. It may occasionally cause a mild burning sensation or general discomfort in the vagina. You can also try Aci-Gel, an acidic vaginal gel available through the pharmacy.

  Douching

  For most women, douching is not necessary and may actually cause problems. But for some women, they can provide periodic relief.

  Vinegar. Although an occasional vinegar (acetic acid) douche can help to lower pH, control a heavy discharge, and calm early yeast infections, douching too often will disrupt the vaginal ecosystem and increase your risk of a yeast outbreak. The usual mix is two tablespoons of white vinegar with a quart of water. It’s best to check with your doctor before douching on any sort of regular basis.

  Peroxide douche. Hydrogen peroxide—the same brown-bottled subst
ance you’ve used to clean wounds—is naturally produced in the vagina by lactobacilli, and it helps maintain a healthy vaginal pH that is resistant to infection. A teaspoon of 3 percent hydrogen peroxide in a cup of water can be used for occasional douching, but only if approved by your physician.

  Antifungals

  Over the past several years, many of the common antifungals have become available over the counter.

  Vaginal creams and suppositories. You’ll find a whole pharmacy aisle devoted to these products, now available in one-, three-, and seven-day forms. Some of the more common ones are miconazole (Monistat), clotrimazole (Gyne-Lotrimin, Mycelex), butoconazole (Femstat), tioconazole (Vagistat), and terconazole (Terazol).

  Pills. Fluconazole (Diflucan), ketoconazole (Nizoral), nystatin, amphotericin B.

  BE SURE IT’S YEAST

  Some women will self-treat for years with antifungal creams and tablets only to find it was something else! Other conditions can mimic typical yeast infections. Have a close exam by your doctor to find out for sure.