3 Common Reasons for Postpartum Sex Pain And What to Do About Them

"Why didn't anyone tell me that sex was going to feel like a cactus trying to fit through a cheerio?" my patient asks me.

It may sound like a funny question, but I can hear the frustration in her voice. She asks why no one recommended pelvic floor physical therapy sooner. She's six months postpartum and still has a lot of discomfort with penetration. To be honest, it makes me frustrated too. Despite penetrative sex being the most common way that people become pregnant, medical providers and society at large typically communicate that sex shouldn't be a priority for new parents.

Many of my patients feel their sexual health concerns have been dismissed by other providers. Feeling uncertain about what to expect around returning to sex postpartum can be hard enough. It's harder still when you can't imagine a pathway to getting the help you need.

You don't have to settle for painful postpartum sex. As a pelvic floor physical therapist, I am here to tell you that with the right knowledge, tools, and providers, you can have the great post-baby sex you want and deserve. Here's a rundown of the three big contributors to painful sex and how to address them.

Tissue Changes

Becoming pregnant impacts the appearance and function of the pelvic tissues, including the pelvic floor muscles. A baby's exit also puts new stress on the tissues, regardless of whether they exit through a big stretch of the pelvic floor muscles or through a multi-layer incision through the abdomen.

Our pelvic floor muscles can play a major role in painful sex, even though we can't see them. They sit like a hammock at the bottom of our pelvis and have important jobs that include helping us stay continent, contributing to arousal and orgasm, and keeping our pelvic organs inside our body, to name a few.

When our tissues, including skin and muscle, are interrupted, injured, or cut, those tissues have to knit back together. Scar tissue forms, and that tissue can be tougher, less stretchy, and have increased or decreased sensitivity. While the scar itself does the very important job of holding us together, the combination of the decreased stretch of the tissue and the potential for increased sensitivity can cause pain.

What to do

Not all pelvic floor muscles respond the same way to pregnancy and delivery, and a pelvic floor physical therapist can help you navigate the best course of treatment. Common treatments I offer to patients include pelvic floor muscle exercises that focus on getting the muscles to move through their full range of motion, coordination exercises, breathing exercises, scar massage, and strategies for using a pelvic wand or vibrator to help the pelvic floor muscles relax.

Hormonal Changes

Hormonal changes can also have a powerful impact on painful postpartum sex. Immediately following delivery, estrogen will drop significantly and stay low, especially if the parent is breast or chestfeeding. Vulvar and vaginal tissue, particularly at the opening of the vagina, called the introitus, is very sensitive to estrogen. When the introitus is deprived of estrogen, the tissue can become inflamed, and vaginal lubrication can decrease. Dryness can impact your ability to have a good time during sex but can also impact your ability to wipe without pain or wear tight clothing.

What to do

Vaginal dryness, while expected postpartum, can be very uncomfortable and is important to address. Keeping vaginal tissue moisturized (all of the time, not just during sex) is the first step in improving pain associated with decreased estrogen.

Vaginal moisturizers or a small amount of coconut oil can be helpful in reducing the sting of angry tissue. (You can talk to your doctor to see what might work best for you.) Ice packs and sitz baths can be used to soothe and reduce inflammation. OB-GYNs and midwives can prescribe a topical estrogen cream that is used at the very opening of the vagina to help soothe the estrogen-depleted tissue.

Shifts in Sexual Habits

One of the most significant contributors to painful postpartum sex is the change in sexual habits that occurs after having a baby. Between managing caregiving, juggling work, being "touched out," body changes, self-esteem, lack of sleep, and the multitude of other changes that come with being a new parent, sexual pleasure is often not at the forefront of my patient's list of needs.

People have sex for lots of reasons besides their own pleasure, all of which are valid. But when sexual practices aren't built around pleasure—like if you skip foreplay to save on time—arousal, blood flow, and lubrication can all be negatively impacted.

What to do

Try to prioritize pleasure and arousal. Identify the greatest barrier to physiological arousal or pleasure for you. A few common concerns are:

• Not enough time
• Low libido or sexual appetite
• Concern about being naked in a body that feels unfamiliar
• Pain
• Lubrication issues

Problem solve the biggest barriers first. If time and arousal are the limiting factors, vibrators and lubricants can be game changers. Not all barriers to good sex are physical. Recognizing the ways that your feelings are showing up in the bedroom is also an important step to having fun and fulfilling sex postpartum.

The Bottom Line

Here's the good news about postpartum painful sex: it often gets better on its own within the first year. There is no required timeline for returning to sex postpartum; the right time to address concerns about sexual health is the time when it feels relevant and meaningful to you; that doesn't have to be right at the six-week checkup.

You are allowed to want and work for a fulfilling sex life, and you're also allowed to have much higher priorities than sex. Navigating postpartum sex is an individual journey. But it's important to know there can be different reasons for postpartum sex pain. If that's a concern, you should seek help, and a pelvic floor physical therapist can act as a guide.