Natalie O. Rosen & Caroline Pukall

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POSTPARTUM PAIN

Comparing the prevalence, risk factors, and repercussions of postpartum genito-pelvic pain and dyspareunia

Natalie O. Rosen & Caroline Pukall

Manuscript accepted for publication inSexual Medicine Reviews.

doi:10.1016/j.sxmr.2015.12.003

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POSTPARTUM PAIN

ABSTRACT

Introduction: Childbirth is a risk factor for developing genito-pelvic pain and/or dyspareunia in the postpartum period and potentially, longer term.These two types of pain may occur simultaneously or sequentially, and could be affected by different risk factors and have a range of repercussions to women’s lives, including their sexual functioning.

Aim:This study aims to review available evidence that will compare and contrast the prevalence, risk factors, and repercussions of postpartum genito-pelvic pain versus dyspareunia.

Methods:All available data related to postpartum genito-pelvic pain and dyspareunia were reviewed.

Main outcome measures:A description of the prevalence, risk factors, and sexual and psychological consequences of postpartum genito-pelvic pain and dyspareunia, as well as methodological limitations of previous studies.

Results:The prevalence of postpartum genito-pelvic pain is much lower than that of postpartum dyspareunia.There is evidence of converging and differential risk factors with regard to both acute and persistent experiences of these two types of pain. Postpartum genito-pelvic pain and dyspareunia are each associated with impaired sexual functioning.Rarely are these pain experiences examined together in order to make direct comparisons.

Conclusions:There has been a critical lack of studies examining postpartum genito-pelvic pain and dyspareunia together, and integrating both biomedical and psychosocial risk factors. This approach should be spearheaded by a multidisciplinary group of researchers of diverse and relevant expertise including obstetricians, gynecologists, anesthesiologists, and psychologists.

Keywords: genito-pelvic pain; genital pain; postpartum pain; childbirth; dyspareunia; postpartum sexuality

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POSTPARTUM PAIN

INTRODUCTION

Genital and pelvic (“genito-pelvic”) pain is poorly understood, often misdiagnosed or ignored, and frequently viewed as shameful by the women who experience it1, 2. Genito-pelvicrefers to pain that can be located on the vulva (including the perineum), inside the vagina, in the pelvic region, or in any combination of these areas.It can be spontaneous or provoked. Population-based studies report the prevalence of genito-pelvic pain to be14 to 34% in younger women and 6.5% to 45% in older women3. The most common presenting complaint of women who suffer from this condition is dyspareunia, defined as pain during sexual activities involving vaginal penetration.The experience of genito-pelvic pain and/or dyspareunia adversely affects the quality of life, psychological and sexual well-being, and intimate relationships of affected women and their partners 4. The sexual repercussions of this pain are typically much more wide reaching; affected women report disruptions to all aspects of their sexual response including lower sexual desire, arousal, difficulties with orgasm and satisfaction compared to women without this pain5-7. Recently, controlled studies have found that male partners of women with genito-pelvic pain also experience more erectile problems and lower sexual satisfaction8, 9. The etiology and maintenance of genito-pelvic pain involves a complex interplay of biological, psychological, and social factors 4, 10.

Childbirth is a risk factor for developing genito-pelvic pain and/or dyspareunia in the postpartum period and potentially, longer term 11-15. This pain has,in turn, been associated with impaired sexual functioning compared with pre-pregnancy 16, 17.It involves an acute pain experience with associated trauma to the genital region, allowing for an explicit examination of the transition from acute to chronic pain. Additionally, there is the potential to examine the development and maintenance of chronic genito-pelvic pain postpartum, including dyspareunia,by tracking women’s pain and biopsychosocial predictors before, during, and after childbirth.Notably, studies have been divided in their examinationof postpartum genito-pelvic pain versusdyspareunia, rarely including both types of pain or examining their sexual and psychological consequences.These two types of pain may occur simultaneously or sequentially, and could be affected by different risk factors and have a range of repercussions to women’s lives.

AIM

The aim of this review is to compare and contrast the prevalence, risk factors, and consequences of postpartum genito-pelvic pain and dyspareunia. We also identify several methodological limitations of prior research and suggest directions for future study. An improved understanding of similarities and differences in the development and persistence of postpartum genito-pelvic pain and dyspareunia could inform assessment and treatment of both types of pain, and enhance the wellbeing of affected women and their romantic partners.

METHODS

A search was conducted of English language studies published up until November 2015 on postpartum genito-pelvic pain and/or dyspareunia. The search engines PubMed, PsycInfo, and Google Scholar were used with combinations of search terms including “postpartum,” “genital pain,” “genito-pelvic pain,” “dyspareunia,” “childbirth,” “pelvic pain,” and “sexual function”. Identified studies were read, and reference lists from each study were examined for additional relevant research. We did not include studies in our review that focused on the experience of general pain in the postpartum period; that is, we did not review studies that did not include a specific assessment of pain related to the genito-pelvic region 18. In addition, we did not include studies that were specific to pain related to caesarian delivery (i.e., pain located at the incision scar; e.g., 19). Given the heterogeneity of the quantitative data, we conducted a narrative review of the study results.

RESULTS

POSTPARTUM GENITO-PELVIC PAIN AND DYSPAREUNIA

As can be seen in Tables 1 and 2, ninestudies have focused on postpartum genito-pelvic pain, and 10studies have examined dyspareunia, typicallywithin the greater context of postpartum sexual function. Surprisingly, only fivestudies (Table 3) have combined the investigation of thesetwo“types” of pain despite the fact that dyspareunia is a common symptom of genito-pelvic pain.Further, to our knowledge, no studies have conducted a systematic comparison of these pain profiles including validated measures of pain.When conducting a comprehensive postpartum pain assessment, one would expect—at the very least—questions about both the location and the temporal pattern of any pain experienced. Although these two pieces of information might go together (e.g., provoked pain at the vaginal entrance), they might not (e.g., constant, deep pelvic pain and provoked pain at the vaginal entrance), revealing the co-occurrence of both pain “types”. The importance of asking questions about both the pain location and its interference with functioning (i.e., sexual response) and carefully documenting this pain is high: as can be seen in the Tables, the prevalence of postpartum genito-pelvic pain is much lower than that of postpartum dyspareunia.

Prevalence

The prevalence of genito-pelvic pain after childbirth has been found to be four to 27% at six weeks to three months20-27, three to 21% at six months23, 24, 28, 29, and one to 33% at one year11, 23, 30-32. The prevalence of dyspareunia is much greater: 12 to 62% at seven weeks to three months12, 13, 15, 24-27, 33-35, 17 to 45% at six months12-15, 24, 34-36, and eight to 33% at one year to 18 months13-15, 32, 36, 37. Only a handful of prospective studies have examined the prevalence of persistent postpartum genito-pelvic pain and dyspareunia. One study assessing genito-pelvic pain found a strikingly low occurrence(less than 1%) at 12 months postpartum 23. However, the three prospective studies assessing dyspareunia demonstrate that asking questions targeting provoked pain upon penetration result in a higher reported rate of persistent pain: ranging from 11 to 33% at one year for vaginal deliveries (vs. 4% for cesarean), and 23% at 18 months 13-15.One possibility for the higher rates of dyspareunia in comparison to genito-pelvic pain may be that activities involving dynamic stimulation (e.g., thrusting during sexual activities involving vaginal penetration) involve greater friction—and increased pain—than pain that is not necessarily provoked38. It is also noteworthy that there is a great range of estimates in prevalence for both pain types. These discrepancies may be explained by methodological limitations including low response rates, small sample sizes, lack of standardization in the assessment of the frequency and severity of the pain, lack of differentiation between possible pain locations (e.g., perineum vs. vulvar vestibule vs. pelvis), and use of retrospective reports. Importantly, several studies have not assessed the onset of the pain (i.e., it may have predated pregnancy or childbirth), potentially leading to inflated estimates of the prevalence of postpartum genito-pelvic pain and dyspareunia.Furthermore, the prevalence rates of postpartum genito-pelvic pain and dyspareunia are not the only issues that appear to differ between the two pain types.

Risk Factors

From the Tables, it is clear that similar biomedical risk factors have been studied with regard to acute (less than three months) and persistent (greater than three months) pain, yielding different results. Perineal trauma heightens risk for genito-pelvic pain in the short-term only20-22, 30, whereas the evidence is mixed in terms of both acute and persistent dyspareunia32-34, 36, 37, 39. There are equivocal findings as to the impact of parity status 20, 24, 28-30, 36and mode of delivery on both genito-pelvic pain and dyspareunia12, 21, 25, 26, 30, 35, 40, 41;however, instrumental vaginal deliveries appear to heighten risk for both pain profiles13, 15, 20, 24, 27-29, 34, 35, 37, 41. Episiotomy and epidural analgesia are not linked to dyspareunia 12, 36, 37,but there is conflicting evidence for genito-pelvic pain20, 21, 24, 30. Breastfeeding appears to be unrelated to genito-pelvic pain21, 30, while it enhances risk of dyspareunia at six months postpartum12, 34, 35. Several risk factors have been examined only in the context of postpartum genito-pelvic pain (e.g., severity of acute pain, recall of labor pain, ethnicity, time since birth)11, 40-42or dyspareunia (stress/urge incontinence, recurrent urogenital infections, intimate partner violence, depressive symptoms, fatigue, pelvic floor muscle function)14, 15, 37, 39, but not both. Most notably, a history of other types of chronic pain conditions (e.g., back pain, migraines) is associated with a greater risk of postpartum genito-pelvic pain11, 21, 30, whereas a history of dyspareunia is associated with postpartum dyspareunia15, 34, 35, 37. Yet, each of these factors has not been examined for the other type of pain.

What is perhaps the most striking is that the two pain types are rarely investigated simultaneously. As shown in Table 3, only five studies to our knowledge have examined an aspect of genital or perineal pain as well as dyspareunia24-27, 32, 41. All studies used non-validated measures of pain, and only four compared risk factors24-26, 41.At three months postpartum, Hannah et al. 25found that planned vaginal deliverieswere associated with a higher risk of genital pain compared to planned cesarean deliveries, but there were no differences between modes of delivery for dyspareunia. Kennedy et al. 26 found the opposite result in a retrospective study at three months postpartum: vaginal deliveries were associated with dyspareunia but not vulvar pain. Declercq et al. 24found that instrumental deliveries were associated with both perineal pain and dyspareunia at two months postpartum; however, being primipara was related to dyspareunia (but not perineal pain) and having an episiotomy was related to perineal pain (but not dyspareunia) in multiparous women only. Finally, in a retrospective study at 12 months postpartum, Williams et al. 41found that instrumental delivery and being of Asian ethnicity were associated with perineal pain but not dyspareunia, whereas older age and perineal trauma were linked to dyspareunia but not perineal pain. Taken together, this review highlights the many equivocal findings regarding the role of biomedical risk factors in the presentation of acute and persistent pain postpartum, and suggests some evidence in favor of different risk factors for genito-pelvic pain and dyspareunia.

Psychosocial predictors have been understudiedin both pain types in the postpartum period. Glowacka and colleagues 21 found that greater pain-related anxiety in late-pregnancy predicted higher genito-pelvic pain intensity at three months postpartum. A recent study indicated that experiencing intimate partner violence in the first 12 months postpartum, depressive symptoms, and fatigue increased the odds of dyspareunia at 18 months postpartum 15. The neglect of psychosocial risk factors is significant given a growing body of evidence that implicates these factors in the exacerbation and maintenance of other types of genito-pelvic pain that are not explicitly linked to childbirth4. Indeed, women who attribute their genito-pelvic pain to psychosocial factors have been found to report greater pain as well as more sexual dysfunction and psychological distress than those who attribute their pain to physical factors 43. Thus, the role of psychosocial variables in the experience of genito-pelvic pain and dyspareunia in the postpartum period should not be underestimated.

Repercussions

As most studies focus on prevalence and risk factors, less is known about the repercussions of postpartum genito-pelvic pain and dyspareunia. It is essential to not only look at pain intensity, but also the extent to which pain interferes with valued, daily activities because this ‘disability’ (i.e., sexual impairment in the case of genito-pelvic pain) may be the key trigger for seeking treatment, and subsequent coping and recovery44.In one retrospective study of 600 women, of the 10% who experienced genito-pelvic pain one year after a vaginal birth, 15% reported that the pain disturbed their daily life, and 1% suffered from constant or daily pain 11. Acute genital pain related to childbirth is a risk factor for postpartum depression, which has a prevalence of 8 to 20% 31, 45, further compromising the health of new mothers.In one retrospective study of 1456 Chinese women who gave birth in the preceding 10 years, greater chronic pelvic pain(excluding dyspareunia) was linked to more depressive symptoms and poorer quality of life42. Research on postpartum sexuality tends to focus on time to resumption of penile-vaginal intercourse, although lower desire, arousal, difficulties reaching orgasm, decreased intercourse frequency and lower sexual satisfaction have been implicated35. Indeed, 41 to 83% of women met criteria for a sexual dysfunction between two and three months postpartum46. Within three months of delivery, 80 to 93% of women have resumed intercourse 35, 45, 47 and both greater vaginal trauma and dyspareunia has been associated with a greater time to resume intercourse, as well as with impaired sexual functioning compared with pre-pregnancy 16, 17.

Methodological limitations

This review has highlighted how prior studies of postpartum genito-pelvic pain and dyspareunia are severely limited by the lack of a comprehensive, standardized pain assessment of each pain experience. Additional shortcomingsincludelow response rates12, 35, 37, 41 and the use of retrospective reports (see Tables).Some studies fail to take into account mode of delivery (see Tables). This is a significant oversight given recent evidence indicating that endogenous oxytocin may confer some protection from chronic pain in the context of surgical pain (i.e. cesarean delivery) but not visceral pain (i.e., labor pain and vaginal delivery)48, 49. Therefore, it is possible that comparing vaginal and cesarean deliveries may result in different conclusions. Another key limitation is that the onset of the pain is rarely assessed (i.e., it may have predated pregnancy or childbirth). However, in a recent prospective study by Glowacka et al.21, of 150 pregnant women (32 to 38 weeks gestation), 73 (49%) reported genito-pelvic pain in pregnancy. At three months postpartum, the pain resolved for 43 (59%) of these women, persisted for 30 (41%), and 11 (7%) of the total sample reported a new onset of genito-pelvic pain after childbirth.These findings suggest that previous studies of postpartum genito-pelvic pain may haveoverestimated the prevalence if they have not taken into account whether the pain began in pregnancy. Such findings also highlightan important and necessary shift toward examining pain processes and experiences in pregnancy, rather than solely focusing on the biomedical factors related to labor and delivery, as contributing to the onset of genito-pelvic pain and dyspareunia.In this same study by Glowacka et al. 21, pre-pregnancy non-genito-pelvic pain was associated with an increased likelihood of postpartum onset of genito-pelvic pain.Taken together, these resultsunderscore the importance of tracking the course of women’s pain experience and associated sexual difficulties from pregnancy through the postpartum period, and open the possibility of examining biopsychosocial predictors of theseexperiences, for bothgenito-pelvic pain and dyspareunia.Finally, there has been a critical lack of focus on the role of psychosocial factors,or, an integration of both biomedical and psychosocial risk factors into a comprehensive study design.Such an approach would be most successful if spearheaded by a multidisciplinary group of researchers of diverse and relevant expertise including obstetricians, gynecologists, anesthesiologists, and psychologists/sexologists.

CONCLUSIONS

Recent data in other chronic pain populations suggests that the risk factors that predict the transition from acute to chronic pain and the maintenance of chronic pain may differ 50, 51. This review has provided evidence of similar differential risk factors of postpartum genito-pelvic pain and dyspareunia over time. Unfortunately, methodological and practical limitations—particularly, the fact that large, young, community samples are needed in order to capture women before they develop the pain—has likely precluded studies related to the natural history of genito-pelvic pain. Although other models may exist based on known biomedical risk factors of genito-pelvic pain (e.g., recurrent yeast infections), the events surrounding childbirth offer one possible avenue to pursue this goal by tracking women’s experiences of genito-pelvic pain before, during, and after childbirth.

Considering the number of women giving birth worldwide, acute and persistent postpartum genito-pelvic pain affects an enormous number of women, even more so for dyspareunia. Yet whether these two types of pain occur simultaneously or sequentially, or are affected by different risk factors—and how they ultimately impact women’s lives, including their sexuality—requires further study. Future studies should include prospective, longitudinal designs that follow women to a period when childbirth related injuries have healed, hormonal fluctuations have stabilized, and women may have stopped breastfeeding. Ideally, the methodological approach of these studies should reflect the complex, dynamic, and biopsychosocial elements of the experience of pain. Specifically, the examination of multiple components of the pain experience should be considered: detailed genito-pelvic pain symptomatology and fluctuations, self-report of other pain and health conditions, andpsychosocial function (e.g., mood, self-efficacy, relationship adjustment, social support). Furthermore, studies must take into account the interpersonal context in which the pain is frequently elicited, that is, during sexual activity given that this focus has yielded important information about the effects of interpersonal dynamics in other genital pain conditions (see52 for review).Clinicians should assess women’s sexual response (desire, arousal, orgasm), satisfaction, and behaviors that trigger the pain, as well as how the sexual partner may be impacted or contribute to the pain experience.These components should be assessed at multiple time points in pregnancy and in the postpartum period in order to assess predictors of the transition from acute to chronic pain and to examine pain patterns over time. Studies that establish a trajectory – that is, potential changes across the postpartum period – of the development and persistence of postpartum genito-pelvic painand dyspareunia could help identify the most critical time points to assess and intervene in order to best prevent and treat both types of pain, and enhance the wellbeing of affected women and their partners.