The mean (standard deviation) PISQ-12 score was 99.3 (11.7). Age of 50 years or older (difference in mean PISQ score −5.4, P = .019), stress urinary incontinence (–3.3, P = .02), urge urinary incontinence (−5.9, P < .001), parity (−6.5, P < .001), and fecal incontinence (−5.7, P = .048) were associated with decreased mean PISQ scores in the univariable analysis. In the multivariable regression analysis, parity (P < .001) and urge urinary incontinence (P = .009) were the only factors remaining independently predictive of diminished sexual function. Significantly higher mean scores were observed for nulliparous women compared with primiparous women (105.5 versus 99.5, −5.3 P < .001) and multiparous women (105.5 versus 100.6, −4.93, P < .001) in the multivariate analysis. (Table 4)
Model B, comparing twin pairs in which both sisters had given birth regardless of delivery mode, revealed that mode of delivery did not significantly affect sexual quality of life according to mean PISQ scores (P = .763). Among twin sister pairs in which both had delivered by vaginal route only (model C), neither episiotomy nor operative delivery was associated with change in sexual quality-of-life score (P = .553). Other factors found to not significantly impact sexual function included weight of largest baby, BMI, and hysterectomy (Table 4).
Multivariable linear regression analyses were also performed on individual questions in the PISQ-12 questionnaire, to gain insight into the effect of parity on specific domains of sexual function. Parity (−1.09, P = .007) and fecal incontinence (−1.74, P = .0001) were predictive of decreased sexual desire. In addition, increasing parity and age were predictive of decreased feelings of excitement at the time of intercourse. Parity did not affect patient reports of dyspareunia, leakage with intercourse, erectile dysfunction, or change in orgasm from 6 months prior.
Sexual function is multidimensional and is affected by psychological, physical, and relational factors.1 The majority of studies evaluating the effects of childbirth on sexual function have focused on immediate physical effects, namely episiotomy,2,10,11 and their conclusions are conflicting. Whereas some studies indicate no difference in short-term sexual function among women who have undergone vaginal delivery versus those delivering by cesarean,12,13 long-term sexual function after these two modes of delivery has not been compared. Even fewer studies have focused on emotional or partner-related aspects of sexual dysfunction specific to childbearing women.12,14 Certainly, for some individuals the psychological strains of parenting may represent a contributing cause for diminished frequency and desire.
Upon evaluating the psychological aspects of sexual function, previous investigators have demonstrated decreased sexual desire and frequency of intercourse within the first year after childbirth.3,15 Few studies, however, have assessed the specific reasons underlying these changes, or how long they persist. Barret et al3 demonstrated that sexual desire initially decreased at 3 months postpartum, and then increased at 6 months postpartum without fully returning to prepartum levels. Their follow-up period, however, did not extend beyond 6 months postpartum. Waterstone et al16 found that common reasons for not reestablishing intercourse after childbirth included lack of a partner, lack of interest, and concern relating to possible genital tenderness or pain. Interestingly, women who suffered severe obstetric morbidity were more likely to list fear of becoming pregnant again as a reason for decreased frequency of intercourse.
We found that decreased sexual desire and excitement were the two sexual function domains most significantly impacted by previous childbirth. Interestingly, mode of delivery (vaginal or cesarean) played no obvious role. In other words, the components of sexual quality of life significantly impacted by childbirth appear to be psychological rather than physical. Previous childbirth did not predispose to pain, anorgasmia, or any other discrete physical complaint within our cohort. We found that neither episiotomy nor mode of delivery significantly impacted the risk of dyspareunia, in agreement with some previous reports.13,17 Hannah et al13 reported, at the 2-year follow-up, that mode of delivery did not affect sexual function in a randomized control trial comparing breech vaginal delivery to breech cesarean section. Similarly, Hartmann et al17 in a meta-analysis comparing routine versus restrictive use of episiotomy, found that routine use of episiotomy did not increase the risk of dyspareunia. In contrast, Signorello et al2 found that at 6 months postpartum the strongest risk factor for dyspareunia was breastfeeding, and instrumental delivery was also a significant predictor of dyspareunia.
Few studies have evaluated partner-related factors in relation to decreased sexual function. Byrd et al12 evaluated pregnant women and their partners at 4 time points during pregnancy, and observed good correlation between the answers of women and their partners. Von Sydow et al14 performed a meta-analysis encompassing most studies relating to sexuality and pregnancy, parenting or childbirth. They found few articles addressing the partners of women who gave birth, and no studies comparing the sexual function of parous women with that of childless women or couples. With respect to “partner issues,” we noted an increase in premature ejaculation among partners of women who gave birth. This finding, however, did not remain significant in the multivariate analysis.
We performed a Medline and MD Consult search for articles in English published between 1966 and October 2005 using the search terms “sexual function,” “sexual dysfunction,” “sexuality,” “childbirth,” “parity,” “parenting,” “twin studies,” and “adoption studies.” To our knowledge, this study is the first to compare sexual function of parous and nonparous women, and the first to evaluate the potential impact of childbirth on sexual function years after the postpartum period. Moreover, the identical twin study design provides “biologic control” over known and unknown genetic determinants, and thus a unique opportunity to identify the impact of environmental predictors (eg, parity and birth mode) on the disease outcome of interest (eg, sexual dysfunction). Using this study design, we demonstrated that parous women have lower self-reported sexual function scores than women without children. In previous studies, lower scores on the PISQ were associated with decreased frequency of intercourse and increased likelihood of restricting sexual intercourse.18,19
Given that parous women report decreased sexual function scores well beyond the postpartum period, the question arises whether these findings are primarily related to physical aftereffects of childbirth, to the psychosocial and relational impact of rearing a child, or both. Although emotional rather than physical domains appeared to be the key factors within our cohort, the design of our study—while providing the first insight into this question—does not allow us to reach definitive conclusions. Future studies comparing the sexual function of women who gave birth with those who adopted children may help to clarify whether physical changes to the pelvic floor play a significant role.
One limitation of our study is that the PISQ-12 has not been validated in women without urinary incontinence or pelvic organ prolapse. The original PISQ had 2 phases of validation. The first took place in women without urinary incontinence or pelvic organ prolapse for generalizability of the instrument. We recognize the lack of validation in a general population as an inherent limitation of our study, but think that the PISQ-12 was the appropriate instrument because over 50% of our sample has self-reported urinary incontinence. It remains unclear whether depression could have played a role in the decreased sexual quality-of-life scores among postpartum women. Indeed, it has been demonstrated that depressed patients tend to report lower scores on the PISQ.5 The vast majority of respondents in our sample, however, were well beyond the postpartum period. Nonetheless, we have included a depression inventory in our survey to be administered at upcoming twin conferences to evaluate general mental health status within this population.
In conclusion, this study of 276 identical twin sisters provides new insight into female sexual dysfunction, and its “environmental” and obstetric determinants. Nulliparous women reported superior sexual function when compared with their biologically identical counterparts, regardless of their age, and irrespective of their mode of delivery. Obstetrical interventions, including episiotomy and forceps, demonstrated no impact on subsequent sexual function for better or worse. Having a child appears to have a lasting impact on sexual function—apparently due to emotional and relational factors, more than to discrete physical injury to the pelvic floor—that extends well beyond the postpartum period.
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© 2006 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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