Physiologic changes during pregnancy affect the body’s hormonal milieu as well as a woman’s sexual desires, responses, and practices. Typically, women’s sexual interest and coital frequency declines in the first trimester of pregnancy, shows variable patterns in the second trimester, and decreases sharply in the third trimester.1 Limited data and resources exist to guide patients on recommendations for sexual activity during pregnancy. In this review, we discuss knowledge gaps, the physiology of the female sexual response during pregnancy, types of sexual activity during pregnancy, and existing literature on anatomic and physiologic changes by trimester and postpartum. We hope that with improved knowledge, patients and providers will approach sexual health in pregnancy with less hesitation and more realistic expectations during this unique time in a woman’s life.
Many women have some level of apprehension about sexual intercourse during pregnancy, which may include fear of harming the fetus or potential for miscarriage or fetal demise, which can often precipitate avoidance of sexual activity during pregnancy.2 In 1 study, approximately 49% of women surveyed were concerned that intercourse could harm their pregnancy.3 The state of pregnancy is associated with a significant decrease in frequency of sexual activity, sexual desire, sexual satisfaction, and orgasm.4 In another study, 91% of pregnant women met the cut-off for sexual dysfunction (including desire, arousal, orgasmic, or a sexual pain disorder) in the Female Sexual Function Index (FSFI), compared to 68% of their non-gravid female counterparts.5 The FSFI is a validated questionnaire that assesses sexual functioning (ie, arousal, orgasm, satisfaction, and pain) in women.
Theoretically, sexual intercourse may stimulate contractions due to stimulation of the lower uterine segment, endogenous release of oxytocin from orgasm, direct action of prostaglandins in semen, or increased exposure to infectious agents. A few studies associating coital and orgasmic frequency with negative effects to the fetus have suffered from small sample size and incomplete control for confounders, including maternal history of preterm delivery or risk factors.6-10 Larger studies performed in women during all stages of pregnancy have observed no overall association between pregnancy complications (vaginal bleeding, premature rupture of membranes, preterm birth, low birth weight, or perinatal mortality) and coital frequency.11 The data, however, have not been stratified by women’s individual obstetrical history.
Evidence currently is insufficient to justify recommending against sexual intercourse during pregnancy. Overwhelmingly, studies of sexual activity in pregnancy have been unable to demonstrate increased risk of preterm labor, delivery, or infectious complications (in the absence of acquired sexually transmitted infections).11 Despite a dearth of evidence to suggest that sex is harmful during pregnancy, patients may still be apprehensive about engaging in sexual intercourse and may also be unsure of how best to broach this topic with their providers.
In not addressing sexual health in pregnancy with their patients, providers may be falling short of patients’ needs and expectations. In 1 study, most women (68%) did not remember discussing sexuality with their providers, and only 17% of them were counseled with respect to sexuality at the 6-week postpartum visit.12 Another study found that fewer than 10% of participants discussed their sexual health with their physicians, while a third study reported that only one-third of respondents had discussed issues relating to sexuality with any medical staff.13 Other authors contend that 34% of women felt uncomfortable broaching the subject and only 29% ultimately consulted with their physicians about the topic; 76% of women did not discuss sexual activity in pregnancy although they felt it should have been addressed.3
Because discussion between patients and clinicians about sex during pregnancy is lacking, patients in 1 study report that the Internet is their leading source of information on the topic.2 This is an area in which clinicians who treat women during the antenatal period can improve patient care by addressing unmet needs and gaps in patient knowledge. During each prenatal visit, simply asking patients about whether they continue to be sexually active during their pregnancy may be enough to make them comfortable asking questions about their sexual health. When implemented effectively, sexual knowledge education programs have been shown to improve both sexual function and sexual attitudes among pregnant women.14,15 Increasing health education can be crucial in informing pregnant women of normal changes that occur at different stages of pregnancy, reducing anxiety, and potentially improving sexual function.16
Sexual physiology in pregnancy
William Masters and Virginia Johnson, widely known for their work on human sexuality, conducted one of the few physiologic investigations of sexual response in pregnant women.17 Pregnancy markedly increases the vascularity of the pelvic viscera, leading to pelvic vasocongestion. Masters and Johnson found that a superimposed physiologic response to sexual stimulation further increases this already existing pelvic vasocongestion.17 In nulliparous women during the excitement phase, the labia minora and majora go through similar patterns of color change as in the non-pregnant state. In contrast, multiparous women can develop engorged labia majora and often localized engorgement of the lateral vaginal walls during the excitement phase.17
Orgasms can affect uterine contractions differently depending on gestational age. Following orgasm during the first trimester, intermittent cramping and uterine irritability can occur. By the third trimester, patients may experience tonic spasm of the uterus during orgasm for up to 1 minute. In some women after 36 weeks’ gestation, recurrent uterine contractions following orgasm have been demonstrated for up to 30 minutes. During the resolution phase after orgasm, pelvic vasocongestion is not entirely relieved; in the second trimester, it may take 10 to 15 minutes in nulliparous patients to see resolution of vasocongestion, and up to 30 to 45 minutes in multiparous patients.
Patients reevaluated at 4 to 8 weeks postpartum were noted to have the following physiologic and anatomical changes: fully healed episiotomies and lacerations, decreased vaginal lubrication, and thinned and fattened vaginal rugae, regardless of nursing. Although the cervix was closed in most women, the uterus remained in the abdomen (as opposed to the pelvis) during the early postpartum period. By 12 weeks postpartum, there was evidence of a return to ovulation in non-nursing women, a re-establishment of normal vaginal rugal patterns, and a return of the uterus to the pelvis. Vaginal secretions, labia minora and majora responses, vaginal expansion and lengthening, and contractions during the orgasmic platform all returned to the baseline response patterns typical of non-pregnant women. Overall, normal physiology of the sexual response and orgasm is re-established. Despite objective differences between 5 and 12 weeks postpartum, patients could not necessarily distinguish significant differences in the intensity of their sexual experiences.
Overall, there are no strong data on which to base recommendations regarding when to resume vaginal intercourse postpartum.18 The aforementioned study suggests that by 12 weeks postpartum, anatomy is restored and pre-pregnancy sexual physiology is re-established. Some authors have suggested that vaginal intercourse can probably be safely resumed in women as early as 2 weeks postpartum, as long as the perineum is healed, contraception is available, and the patient is ready.19 In Europe and the United States, vaginal intercourse is resumed, on average, at 6 to 8 weeks after birth.1