Understanding Postpartum Intimacy: 5 Reasons Behind Painful Sex After Birth

One of the top concerns I hear about as a pelvic floor PT is fear of having sex since giving birth.

This fear comes from not knowing what it’s going to feel like especially around pain, worried it looks different down there, anxiety of how the partner is going to react, and so on.

These concerns are legitimate, especially since 50% of women report having pain with sex after birth. Fortunately, this type of pain doesn’t need to last, or for some not even occur.

It all starts with understanding your body to prevent the pain or problem solving why you are experiencing pain to then treat it. Here are 5 reasons why you may have pain with sex after birth.

Hyper-mobile joints

During pregnancy your ligaments soften to prepare for a vaginal delivery. This puts more burden on the muscles to provide stability to the joints, especially around the pelvis. Without adequate training of the correct muscles, however, your body will compensate. This can lead to shortening and tightening of muscles around the pelvis, including the pelvic floor muscles.

A tight muscle has difficulty lengthening. Since the pelvic floor muscles wrap around the vagina, if they do not stretch well, penetration may be painful.

Emotional trauma

Birth is an emotional experience and unfortunately not always positive. When you have a negative or traumatic experience with your birth, your body turns on the fight or flight [sympathetic] side of your nervous system. This is like turning on the dial to adjust volume. If your brain can’t turn down the dial to this response, your body will react with muscle guarding and tension.

The pelvic floor is fed with both sympathetic and parasympathetic (the rest and digest portion of the nervous system) nerves. This means that when the pelvic floor muscles are greatly influenced by what is happening in your nervous system, beyond voluntary control [when you tell it to control or relax]. Thus, your pelvic floor may not be tight or shorten, but in a learned state of guarding.

Birth Injury

Trauma in birth can also come in the form of physical injury, such as a perineum tear. Birth is a very physical event and even though the pelvic floor muscles stretch 3-4 times the normal resting length, tissue injury can occur. When this happens, the healing process will create scar tissue. Any amount of scar tissue can lead to pain, regardless of severity of the injury. This is due to the fact that scar tissue does not stretch as well as regular tissue. Scarring can also restrict blood flow and bind nerves, which can interfere with muscle function and sensory input.

Another aspect of physical injury that can lead to painful sex is muscle guarding, just like with the emotional trauma. When your experience pain, your body signals to protect the area. This can then trigger the sympathetic nervous system in anticipation of pain.

Cesarean Scar

A cesarean brings different challenges than a vaginal delivery. Meaning you may have had a long labor or even pushed prior to the cesarean. When this is the case the pelvic floor can react the same as if you had a vaginal delivery, with microtrauma or minor injury. In addition you have a scar that runs through 7 layers of tissue. Not only does the proximity of the scar impact the pelvic floor, but the abdominal fascial layer connects to the pelvic floor fascia, including the uterus.

This can lead to a lack of flexibility in the pelvic floor constricted blood flow and nerve entrapment. Each of these an impact the health of the pelvic floor tissue and how it responds to touch, movement and sex.

Hormone changes

After birth your hormones are going to change again, typically with a big drop in estrogen. This leads to vaginal dryness, tissue sensitivity, reduced tissue integrity and even some atrophy to the tissues. When this happens the vaginal tissues are more susceptible to abrasions and pain when touched or moved across/stretched. This can happen during sex.

Hormone changes can persist longer while breastfeeding as well.

If you have pain with sex, you don’t need to live with it. Problem solve to figure out which of these causes may be contributing to your pain by scheduling with a pelvic floor PT.