There is marked synergy between cancer of the cervix and sexual abuse as a cause of sexual dysfunction (79). An absence of sexual satisfaction was reported by 20% of women with neither abuse nor cancer of the cervix, by 31% of women who were sexually abused and did not have cancer of the cervix, by 28% of women with cancer of the cervix and who were not abused, but by 45% of women with a history of both abuse and cancer of the cervix. The lack of sexual satisfaction resulted in a decrease in well-being in 18% of women with neither a history of abuse nor cancer of the cervix, 39% of women who were abused and did not have cancer of the cervix, 23% of women with cancer of the cervix who were not abused, and in 44% of women with a history of both abuse and cancer of the cervix. Dyspareunia was extremely rare in women without cancer of the cervix, but it was reported by 12% of those with cancer of the cervix and by 30% of those with cancer of the cervix and past sexual abuse.
Pregnancy Physical, emotional, and economic stressors of pregnancy may negatively affect emotional and sexual intimacy. Sexual value systems, folklore, religious beliefs, physical changes, and medical restrictions inﬂuence sexual attitudes and behavior during pregnancy and postpartum. In the absence of preterm labor, antepartum bleeding, or an incompetent cervix, there is no evidence that sexual activity, orgasm, or intercourse increases the risk of pregnancy complications. Normal changes that occur with sexual activity during pregnancy include increased breast tenderness, increased sensitivity to uterine contractions with orgasm, general discomfort, less mobility, and fatigue. Sexual satisfaction in pregnancy is closely related to feeling happy about the pregnancy, continuing to feel attractive, and understanding that in a healthy pregnancy sexual activity and orgasm do not harm the fetus.
Toward the end of the third trimester the need for closeness, emotional support, and nurturing may be far greater than any desire for orgasms or intercourse. Nevertheless, a study noted that 39% of 188 women reported being engaged in intercourse during their birth week (80). Difficulties may arise from the partner’s reaction to the woman’s pregnancy, the physical changes of pregnancy, lack of information regarding sex and pregnancy, and lack of direction from the physician when complications arise. A general lessening of sexual desire in both pregnancy and the postpartum period is common and considered normal. A prospective analysis of sexual function of 40 healthy pregnant women showed a reduction in desire and in all aspects of sexual response beginning in the first trimester, changing little in the second, and reducing further in the third trimester (81). Couples should be encouraged to continue their usual patterns of lovemaking during pregnancy if they are emotionally and physically comfortable and there are no contraindications to either orgasm or intercourse.
Postpartum The ongoing vaginal bleeding and discharge, perineal discomfort, hemorrhoids, sore breasts, and decreased vaginal lubrication associated with nursing, compounded by fatigue from disturbed nights, all contribute to decreased motivation for sexual activity. Further complicating factors include fear of waking the baby, a decreased sense of attractiveness, change of body image, or mood change. Many couples resume sexual activity and include intercourse by 6 to 8 weeks postpartum, but some couples wait as long as a year before resuming their prepregnancy level of sexual intimacy. Typically women who nurse report less sexual activity and less sexual satisfaction than those who bottle feed. The effect of the mode of delivery on sexual function is still unclear. Two studies showed operative vaginal delivery confered the highest risk of dysfunction (82,83).
Physicians can provide considerable help to patients and their partners by acknowledging and discussing the normal ﬂuctuations in sexual desire and frequency of sexual activity during and after pregnancy.
Assessment of Sexual Problems