Postpartum Dyspareunia

Postpartum dyspareunia is pain during or after sexual intercourse in the first year after birth. It affects up to 40 to 60 percent of women at 3 months and 20 to 25 percent at 6 months. Causes include perineal scars and tears, low oestrogen with breastfeeding, vaginal dryness, pelvic floor muscle tension, infection, fear and fatigue. It matters because it affects relationships and wellbeing, and most causes can be treated.

• Risk factors: perineal tear or episiotomy, instrumental delivery, breastfeeding, progestogen-only contraception, vaginal dryness, previous pain, depression, tiredness.
• Pain at the vaginal entrance suggests scar or dryness; deep pain suggests pelvic or uterine causes.
• Early review improves recovery.

Women report burning, tearing or stinging pain at entry of the penis, or deeper pain with thrusting, and often dryness, tightness and fear of intercourse. Examination may show a tender scar, thin dry vaginal skin or tight muscles.

• Pain on touching the scar or the entrance to the vagina.
• Thin pale vaginal lining in breastfeeding women.
• Differential diagnosis: perineal scar neuroma, vaginal atrophy, vaginismus, vulvovaginal candidiasis, bacterial vaginosis, vestibulodynia, endometritis, pelvic floor hypertonicity, retained suture, rectovaginal fistula, depression.
• Complications: avoidance of intercourse, relationship difficulties, loss of desire, depression, chronic vulvar pain, anxiety.

The approach is a sensitive history and gentle examination.

• History of onset, location of pain, relation to breastfeeding and contraception, previous tears, mood and relationship; screening for depression and abuse.
• Inspect the vulva and perineal scar; cotton swab test for localised tenderness at the vestibule; gentle single finger examination for muscle tension, scar, atrophy and masses.
• Vaginal pH and high vaginal swab for candidiasis and bacterial vaginosis; chlamydia and gonorrhoea tests if indicated.
• Pelvic ultrasound if deep pain or suspected endometritis.

The principle is to treat the cause, with lubricants, vaginal oestrogen, scar care and pelvic floor physiotherapy, and counselling for the couple.

• Supportive: counselling and reassurance; delay intercourse until the woman feels ready and the wound is healed (usually 6 weeks); water based lubricant at each intercourse; foreplay and positions that give the woman control; scar massage with an emollient for 5 minutes daily from 6 weeks; warm baths; pelvic floor relaxation exercises and physiotherapy; progressive vaginal dilator use for tight muscles.
• Pharmacological: vaginal moisturiser (hyaluronic acid gel) every 3 days; vaginal oestradiol 10 micrograms tablet at night for 2 weeks then twice weekly for 3 months (lowest effective dose in breastfeeding women); lignocaine 2 percent gel applied to the vestibule 5 minutes before intercourse; clotrimazole 500 mg vaginal pessary once for candidiasis; metronidazole 400 mg oral 12-hourly for 7 days for bacterial vaginosis; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); amitriptyline 10 mg oral at night, increased to 25 mg, for persistent vestibular pain (low dose in breastfeeding).
• Procedures: injection of lignocaine 1 percent 5 mL with a small dose of triamcinolone into a painful scar; surgical revision of a tight or painful scar (perineoplasty) after 6 to 12 months if conservative care fails; botulinum toxin A into pelvic floor muscles for severe hypertonicity (specialist).
• Special groups: women using depot medroxyprogesterone or progestogen-only contraception who have dryness are offered a change of method; women with depression or past abuse need counselling and mental health care.
• Red flags: severe pain, fever, foul discharge, bleeding, a mass, leaking stool or urine from the vagina, suicidal thoughts.
• Follow-up: review at 6 weeks and 3 months; referral to a gynaecologist or sexual health clinic if pain persists beyond 6 months; couple counselling.