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By Ella Vermeir
This blog is a summary of our published article: Rossi, MA.,* Vermeir, E.,* Brooks, M., Pierce, M., Pukall, CF., & Rosen, NO. (2021). Comparing self-reported pain during intercourse and pain during a standardized gynecological exam at 12- and 24-month postpartum. Journal of Sexual Medicine, 19(1), 116-131. https://doi.org/10.1016/j.jsxm.2021.11.004
There are lots of things you might have expected to change after having a baby—feeling more tired, being busier, and maybe even less interested in sex for a while. But for some women, they are surprised to experience pain during sex, which can last longer than 12 months postpartum for about 12% of women. This pain is pretty distressing,  and can impact a woman’s relationship and overall quality of life. [1,2]
Few studies have examined pain that lasts 12 months or longer following childbirth.  Although a gynecological examination is the standard way of assessing this pain, little is known about the findings from physical examinations (e.g., potential physical causes of the pain). Pain is usually affected by a complex interplay of biological and psychological factors, but their specific roles in postpartum pain is also not well understood. Finally, given that a physical exam is a common way of assessing this pain, how well does it relate to women’s own reports of their pain experienced during sex?
What did we want to know?
- What are the characteristics of pain during sex for women with little pain (3 out of 10 on a visual analogue scale) and clinically significant pain ( 4 out of 10 on a visual analogue scale) at 12- and 24-months postpartum?We assessed this using:
- Self-reports of pain during sex on a scale of 0 (no pain at all) to 10 (worst pain imaginable)
- Pain experience during a gynecological examination
- Gynecological exam findings (e.g., evidence of scar tissue, infection)
- What biological (i.e., pre-existing pain conditions, breastfeeding status, and birth characteristics) and psychosocial (i.e., pain catastrophizing, depression, relationship satisfaction, and sexual distress) factors are related to pain experienced during sex and during the gynaecological examination at 12- and 24-months postpartum?
- Is pain during sex reported in the survey similar to the pain experienced during the gynecological exam?
What did we do?
Women recruited from the IWK Health Centre completed online surveys and a gynecological exam at 12 months and at 24-months postpartum. Surveys assessed self-reported pain during sex, biomedical characteristics, and a range of psychosocial factors like sexual distress (negative emotions about sexuality) and pain catastrophizing (intense negative thoughts about pain). Women were divided into two groups as follows:
- At 12 months: 46 reported minimal pain and 51 reported clinically significant pain
- At 24 months: 21 reported minimal pain and 23 reported clinically significant pain.
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What did we find?
At both 12- and 24-months postpartum, and regardless of whether women reported experiencing pain or not, most women had normal findings on the gynecological examination. When problems did exist (e.g., fissures, redness), they were just as likely to occur for women in the significant pain and in the minimal pain group.
Biomedical characteristics were not related to pain during sex or pain during the gynecological exam at either timepoint or for either pain group.
Self-reported pain during sex and pain during the gynecological exam at both 12- and 24-months postpartum were positively related to each other.
The pain during the gynecological exam was lower than the pain women reported experienced during sex. Most women in the clinically significant pain groups indicated that the gynecological exam did not replicate the pain they experienced during sex.
What does this all mean?
- There were no physical differences found between women with and without pain during sex during the gynecological exam at both 12 and 24 months. By this time, most women have physically recovered from the effects of pregnancy and childbirth, which suggests that physical recovery from childbirth could have little influence on persistent genital pain experiences. 
- This study provides more information about the role of psychosocial factors in the experience and persistence of postpartum pain. Clinicians might offer referrals to evidence-based interventions that target these psychosocial aspects such as cognitive behavioural therapy. 
- Given that pain ratings tended to be higher for self-reported pain during sex, self-reported pain may be a suitable replacement for repeated painful gynecological exams, following an initial examination to rule out physical concerns. [6,7]
- The enduring nature of this pain for some women suggests that postpartum pain during sex should not be assumed to be a condition that will get better on its own. It is important that clinicians identify, act upon, and monitor this pain early in the postpartum period to prevent it from continuing.
 Rosen, N.O., & Pukall, C. (2016). Comparing the prevalence, risk factors, and repercussions of postpartum genito-pelvic pain and dyspareunia. Sexual Medicine Reviews, 4(2), 126-135. https://doi.org/10.1016/j.sxmr.2015.12.003
 Barret, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women’s sexual health after childbirth. BJOG, 107(2), 186-195. https://doi.org/10.1111/j.1471-0528.2000.tb11689.x
 Griffiths, A., Watermeyer, S., Sidhu, K., Amso, N., & Nix, B. (2006). Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section. Journal of Obstetrics and Gynaecology, 26(7), 645-649. https://doi.org/10.1080/01443610600903701
 Martin, A., Horowitz, C., Balbierz, A., & Howell, E.A. (2014). Views of women and clinicians on postpartum preparation and recovery. Maternal and Child Health Journal, 18(3), 707-713. https://doi.org/10.1007/s10995-013-1297-7
 Rosen, N.O., Dawson, S.J., Brooks, M., & Kellogg-Spadt, S. (2019). Treatment of vulvodynia: Pharmacological and non-pharmacological approaches. Drugs, 79(5), 483-493. https://doi.org/10.1007/s40265-019-01085-1
 Dargie, E.E., Chamberlain, S.M., & Pukall, C.F. (2017). Provoked vestibulodynia: Diagnosis, self-reported pain, and presentation during gynaecological examinations. Journal of Obstetrics and Gynaecology Can, 39(3), 145-151. https://doi.org/10.1016/j.jogc.2017.01.001
 Wammen Rathenborg, F.L., Zdaniuk, B., & Brotto, L.A. (2019). What do different measures of pain tell us? A comparison in sexually active women with provoked vestibulodynia. The Journal of Sexual Medicine, 16(2), 278-288. https://doi.org/10.1016/j.jsxm.2018.12.001