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Sex Matters

Sexuality In Pregnancy

Michael L. McDaniel, MD

While the conception of a child is viewed as the ultimate expression of a couple’s love, pregnancy is not always compatible with sexuality. The physician can help to minimize
any negative impact by explaining the complex conditions affecting desire and satisfaction and encouraging a positive, pragmatic approach.

Avariety of physiological, social, psychological, and anatomical changes occur in the gravid state. Although most of these changes have been well documented, there is a paucity of US data regarding the female sexual response during pregnancy, leaving clinicians to rely on anecdotal experience to address patient concerns. This review draws from research worldwide to help health care providers assist couples in making adjustments.

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FIRST TRIMESTER

Sexuality from conception through the first trimester generally reflects the sexual, emotional, marital, financial, and cultural well-being of the couple prior to conception. The transition to parenthood has been described as a psychosocial crisis. Any problems in the relationship will be exacerbated by the stress and change in roles during this time, possibly creating anxiety and frustration. As a result pregnancy may herald a time of marital discord and sexual dissatisfaction. The physician can help the couple to anticipate these changes and assist them with negotiating potential obstacles to facilitate intimacy that is mutually satisfying.1

Numerous reports demonstrate a progressive decrease in sexual desire and satisfaction throughout gestation for the gravid woman. 2-4 This phenomenon is least pronounced in the first trimester, which is nonetheless a critical adjustment period for the couple.5 This is the optimal time to establish a strong sense of intimacy and mutual commitment. However, while women have diminished sexual satisfaction beginning at this stage of pregnancy, men seldom report similar changes—probably because of the hormonal, physiological, and psychological changes experienced by women.6,7 This is supported by the finding that men worry little about the pregnancy initially, whereas women have expectations and fantasies from the start, as well as fears of miscarriage even before conception is confirmed.7 To promote sexual intimacy during this time, the man can focus on caressing, massaging, and accompanying the woman to antepartum visits and childbirth and parenting classes.8,9

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SECOND TRIMESTER

Traditionally, the increase in pelvic blood flow during the second trimester was thought to promote greater sexual activity, desire, and satisfaction especially at midtrimester. However, more recent research contradicts these views. A review of the literature has demonstrated a linear decline in sexual activity as pregnancy progresses.10 In addition, due to the quickening of the fetus at this time the couple may feel like there is a ñthird personî present during lovemaking, impeding intimacy, and possibly contributing to erectile dysfunction.9 Numerous myths and taboos may preclude sexual activity (Table) including fears of injuring the fetus, though these fears are generally unfounded.11 Body image may also be a factor as the gravid uterus becomes obvious and weight gain occurs. Finally, if the pregnancy is complicated by incompetent cervix, placenta previa, or other high-risk conditions, intercourse may be medically restricted.

Table not available online

Table. Myths, Taboos, and Restrictions Complicating Sexuality in Pregnancy

The OB/GYN can be very helpful in alleviating fears, dispelling myths, minimizing proscriptions to intercourse when medically appropriate, and facilitating discussions of alternatives to traditional sexual intercourse. Fantasizing, solitary or mutual masturbation, experimentation with different sexual positions, and anal or oral intercourse (with the appropriate safety and hygiene precautions) can be explored if the couple is comfortable with these practices.9

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THIRD TRIMESTER

There is a dramatic decline in sexual activity, interest, and satisfaction in women and men alike during the third trimester. This phase of pregnancy is marked by physical awkwardness and discomfort, heightened awareness of maternal body image, and preparations for birth.6 The couple may fear that sexual activity will induce labor, bleeding, injury to the fetus, and pain (Table).12 Patients consistently report that they rarely raise these issues with their OB/GYN but overwhelmingly wish that the physician would initiate discussions.13,14 This highlights the importance of the OB/GYN’s role as nurturer and counselor, recognizing how critical sexuality and intimacy are at a time when the couple is feeling vulnerable.1,5

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POSTPARTUM

The postpartum period is characterized by rapid psychological, physiological, and hormonal changes as estrogen and progesterone levels drop precipitously. Indeed, this state of ñsteroid starvationî mimics menopause. Changes include vaginal atrophy, decreased lubrication, and mucosal compliance, making intercourse uncomfortable. These symptoms are exacerbated by lactation and breastfeeding as prolactin further inhibits ovarian estrogen production. However, new mothers often experience sensual stimulation and pleasure during breastfeeding—including nipple erection, uterine contractions, and milk ejection—facilitating the bonding process.

Both positive and negative sexual responses have been described between the new father and lactat- ing mother, with the degree of postpartum adjustment having a significant effect.10 Maternal exhaustion can contribute to depressed feelings and diminished sexual desire. Other negative influences include dyspareunia from perineal trauma, poor body image, adjustment to parental roles, and fears of awaken- ing the baby or failing to hear the baby cry.

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CONCLUSION

Researchers have consistently described a progressively negative effect of pregnancy on sexual activity and satisfaction, but health care providers have traditionally failed to address this issue. Although patients want to discuss this topic, they do not feel comfortable broaching the subject.14 It is the health care provider’s responsibility to recognize the profound impact that pregnancy has on sexuality, encourage open discussion with the patient and her partner, and help the expectant couple to successfully negotiate this period of adjustment. As up to 33% of couples develop serious, long-term psychosexual disturbances after the birth of their first child,5 it is vital that the physician assume a more proactive role in problem-solving and prevention.

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Michael L. McDaniel, MD, is private practitioner, Obstetrics and Gynecology, Peachtree Women’s Clinic, Northside Hospital, Atlanta, GA; and completed his residency training at the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.

References

1. Byrd JE, Hyde JS, DeLamater JD, Plant EA. Sexuality during pregnancy and the year postpartum. J Fam Pract. 1998;47(4):305-308.
2. Ryding EL. Sexuality during and after pregnancy. Acta Obstet Gynecol Scand. 1984;63(8):679-682.
3. Solberg DA, Butler J, Wagner NN. Sexual behavior in pregnancy. N Engl J Med. 1973;288(21):1098-1103.
4. Landis TJ, Poffenberger T, Poffenberger S. The effects of first pregnancy upon the sexual adjustment of 212 couples. Am Sociol Rev. 1950;15(6):766-772.
5. von Sydow K. Sexuality during pregnancy and after childbirth: a metacontent analysis of 59 studies. J Psychosom Res. 1999;47(1):27-49.
6. Lumley J. Sexual feelings in pregnancy and after childbirth. Aust N Z J Obstet Gynaecol. 1978;18(2)114-117.
7. Bogren LY. Changes in sexuality in women and men during pregnancy. Arch Sex Behav. 1991;20(1):35-45.
8. Toler A, DiGrazia PV. Sexual attitudes and behavior patterns during and following pregnancy. Arch Sex Behav. 1976;5(6):539-551.
9. Coppens M. Sexual intimacy during pregnancy. Midwifery Today Int Midwife. 2002;(62):21-24.
10. Reamy KJ, White SE. Sexuality and the puerperium: a review. Arch Sex Behav. 1987;16(2):165-186.
11. Mills JL, Harlap S, Harley EE. Should coitus in late pregnancy be discouraged? Lancet. 1981;2(8238):136-138.
12. Sipi`nski A, Kazimierczak M, Buchacz P, Sipi`nska K. Sexual behaviors of pregnant women [in Polish]. Wiad Lek. 2004;57(suppl 1):281-284.
13. Hamela-Olkowska A, Marcyniak M, Sienko J, et al. Sexuality in pregnant women [in Polish]. Med Wieku Rozwoj. 2003;7(3 suppl 1):175-180.
14. Bartellas E, Crane JM, Daley M, Bennett KA, Hutchens D. Sexuality and sexual activity in pregnancy. BJOG. 2000;107(8):964-968.

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