“Can I get a doctor’s note so I don’t have to have sex with my husband for another six weeks?”

One of my postpartum patients recently asked this, only half-joking.

As usual, I laughed along with her at first and then got to the heart of the issue that was plaguing my 6-week sleep-deprived postpartum patient—low libido and sexual pain.  This was the beginning of an on-going treatment plan I developed that day for her sexual dysfunction.

What I have observed in my 14 years as an obstetrics/gynecologist specializing in sexual dysfunction is that while some patients can usually resume sexual relations with their significant other after the six- to eight-week postpartum check, this is a very common question. Many women are still asking it during the fourth trimester postpartum check.

Many factors impact a woman’s ability and desire to have intercourse after giving birth to a baby. These factors are often not addressed during the standard 15-minute postpartum visit. In a traditional busy OB/GYN practice, where the visit is covered under a global billing fee along with the prenatal visits, delivery and postpartum care, most clinicians have neither the time nor expertise to address significant issues with sexual function. Additionally, they do not get reimbursed from insurance companies for the extra time needed with the patients.

Unfortunately, this is a huge disservice to the patients who have multiple issues postpartum, including sexual pain and low libido or even postpartum depression. Many problems are missed or ignored and develop into much larger more complicated issues in the months to years it may take to obtain an adequate diagnosis and treatment.

Sexual health is also not given appropriate attention in all classes of women from premenopausal to postpartum to postmenopausal. According to the American College of OB/GYN, up to 40 percent of women do not even seek postpartum care.

I know. I am a recently postpartum working doctor mom. At five months postpartum, I still have not seen my OB/GYN. Like many other millions of women, we just deal with pain or lifestyle issues because we are not sure if they are abnormal. 

The first six months after giving birth can have a detrimental impact on a woman’s sexual health. Many women are recovering from various degrees of vaginal lacerations or episiotomies (some may cause perineal pain and prolonged recovery); sleep deprivation and fatigue; hormone decline; lactational issues for those who are breastfeeding; vaginal dryness and postpartum mood changes.

Women also experience a fear of waking up the baby; vaginal bleeding and discharge; pelvic floor dysfunction and urinary incontinence; fear of injury and a diminished feeling of attractiveness that diminishes their sexual drive and sexual health. When mothers are breastfeeding, they have a diminished amount of estrogen and testosterone, not only impacting libido but also sometimes resulting in dyspareunia (pain with sex), which results from a lack of hormones. This results in a vaginal status that is similar to that of a postmenopausal woman.

According to some studies, 41-67 percent of women have dyspareunia or pain with sex within the first two to three months postpartum. Seventeen percent have persistent dyspareunia six months later.

“Have a glass of wine to relax,” and “Use some lube,” are among the typical advice many of my patients receive prior to seeing me for my specialty. Without appropriate education and a formal work-up, clinicians are not able to give appropriate care to the patient. She might need hormones, pelvic floor physical therapy or even correction of her laceration or scar revision.

Unfortunately, in my opinion, sexual medicine is not a field that is given much credence in medical school or residencies or beyond. I remember having just one lecture about sexual and reproductive health during medical school. During my Ob/Gyn rotation and even residency, I recall that female sexual dysfunction issues were considered an enigma that many of my own attendings never really addressed.

In a recent survey of the 122 U.S. medical schools, of which 92 responded, only 55 percent had a formal sexual health curriculum, and even less if the school was religiously based. There have been advances in the field of sexual medicine since the first studies on human sexuality began in 1957 with the work of William Masters and Virginia Johnson at Washington University in St. Louis.

The International Society for The Study of Women’s Sexual Health is the only organization that is dedicated to study and research of women’s sexual function and dysfunction. It began almost 20 years ago. It includes a variety of mid-level clinicians, psychologist, pelvic floor and sex therapist and physicians from a variety of disciplines—and its formation was triggered by the discovery of Viagra in 1966, the first drug to treat erectile dysfunction in men. It was accidentally found by a group looking for an anti-hypertensive medication, and while Viagra was a failure at keeping blood pressure under control, it had the unanticipated side effect of promoting erections. Within two years, this drug was FDA approved and made Pfizer billions of dollars from a drug that is now so familiar that it’s simply known as the “little blue pill.”

After that, women started demanding treatment of their own problems from a prominent urologist and world-renowned female sexual medicine expert, Irwin Goldstein.

This was the first step that propelled the formation of a Female Sexual Medicine clinic at Boston University and, a year later, the first convening of what became ISSWSH—a story recounted in the 2018 Textbook of Female Sexual Function and Dysfunction—still the only textbook in the field.

Now there are 683 members of ISSWSH internationally; 600 are from the United States. Of those, there are only 75 members, or 11 percent internationally who are considered fellows, meaning they have the knowledge, expertise, and clinical and research experience to be considered specialists in the field.

This is unfortunate as female sexual dysfunction is more common than  male sexual dysfunction, at rates of 43 percent for women and  31 percent for men. There are at least 24 FDA approved treatments for male sexual dysfunction, yet two FDA-approved drugs for women.

Addyi, the first drug FDA approved to treat hypoactive sexual desire disorder in women took five years and multiple rejections from the FDA to approve it in 2015. In order to prescribe it for women who suffer from low sexual desire and associated personal distress, clinicians have to be a certified provider for the possibility of hypotension and black outs secondary to excessive alcohol use with this drug.  Unlike Viagra, women have to take this pill daily for at least eight weeks to see an improvement in sexually satisfying events. 

Recently the FDA improved a second non-hormonal method for treating hypoactive sexual desire disorder, Vyleesi, or bremelanotide, which works on the internal chemical pathways responsible for sexual desire. Unlike Addyi, it can be taken on an as-needed basis with an autoinjector 45 minutes prior to desired relations with fewer side effects and no significant alcohol interaction. Unlike Viagra, it is centrally acting.

For anyone who treats female sexual dysfunction, it’s well understood that a pill or injection will not cure all that ails a woman with HSDD. However, it is a great start and may help, along with therapy addressing other concerns. These two advances in female sexual medicine have been reassuring and a long time in the works.

But there more obstacles impeding progress in the validation of sexual medicine for women. In 2018, for example, the U.S State Department attempted to ban the phrases “sexual and reproductive health” in memos for United Nations resolutions on sexual health and violence against women.   Funding to the National Institutes of Health in the area of sexual medicine is non-existent, unless it is related to prostate cancer. 

With the taboos and stigmas attached to sexual education and medicine, the medical community needs to continue to validate this field and reassure patients. If education in female sexual health does not continue and research expands, clinicians will be unprepared to diagnose and treat these conditions.

Women’s sexual health is no joke.