Everything you need to know about Postpartum Vaginal Dryness

From hair loss to night sweats, postpartum is no joke. Oftentimes postpartum symptoms go unspoken about, leaving women shocked, scared, and unprepared when normal, common symptoms arise. 
One of the least talked about parts of postpartum is vaginal dryness. This is common, normal, and continues well beyond six weeks postpartum. Vaginal dryness can cause irritation, burning, and pain with intercourse. It can be accompanied by a dry vulva as well. Around 43% of postpartum women experience vaginal dryness. And we need to talk about it more; because talking about it allows people to prepare for it! 

What causes postpartum vaginal dryness?
Postpartum vaginal dryness is caused by hormonal changes. Estrogen and progesterone trigger puberty and they also cause the buildup of a lining in your uterus during your menstrual cycle. If a fertilized egg isn’t implanted in this lining, estrogen and progesterone levels drop, and the uterine lining is shed as your period. Estrogen is a hormone that helps maintain the vagina’s lubrication, elasticity, and thickness. These levels increase throughout pregnancy. As the placenta forms it begins producing these hormones as well! After giving birth these levels rapidly decline. Within 24 hours of giving birth estrogen and progesterone are back at their pre-pregnancy levels. The increase in estrogen during pregnancy enables the uterus and placenta to improve vascularization (the formation of blood vessels), transfer nutrients, and support the developing baby. The rapid increase in estrogen levels during the first trimester may cause nausea. During the second trimester, it plays a major role in the milk duct development that enlarges the breasts.

What symptoms occur when experiencing vaginal dryness?
Inability to maintain lubrication during sex; burning, discomfort, or itching in the vagina; painful urination due to irritation of vaginal tissue; dryness during intercourse and difficulty inserting tampons; and increased frequency of urinary tract infections (UTIs) are common symptoms of vaginal dryness. 

Estrogen levels can also drop because of:

• Childbirth and breastfeeding
  
• Radiation or chemotherapy treatment for cancer
  
• Surgical removal of the ovaries
  
• Anti-estrogen medications used to treat uterine fibroids or endometriosis
  
• Sjögren's syndrome (an autoimmune disorder that attacks cells in the body that produce moisture)
  
• Allergy and cold medications
  
• Certain antidepressants
  
• Douching
  
• Not enough foreplay before sex
  

Breastfeeding:
Normal estrogen levels are what help maintain the tissues of the vagina. Low levels seen in breastfeeding can mimic the decreased hormone levels seen in menopause. This can result in thinning of the skin and increased vaginal dryness, the same way postmenopausal women experience this. All women have low levels of estrogen for the first couple of months after giving birth. Continued breastfeeding extends this period for at least six months and for some women the lower levels may last as long as they are breastfeeding.
Milk volume may decrease with the use of estrogen; however, no detrimental effects have been shown on infant growth or development.

Postpartum thyroiditis:
Postpartum vaginal dryness can also be caused by postpartum thyroiditis. This is an inflammation of the thyroid gland. The thyroid produces hormones that are vital to various bodily functions, including metabolism, but sometimes these hormones become imbalanced. Postpartum thyroiditis affects up to 10% of postpartum women. For an overproducing thyroid, your doctor may suggest beta-blockers to help reduce symptoms, or your doctor may recommend thyroid hormone replacement therapy for an under producing thyroid.
Symptoms include:

• Shakiness
  
• Heart palpitations
  
• Irritability
  
• Difficulty sleeping
  
• Weight gain
  
• Fatigue
  
• Sensitivity to cold
  
• Depression
  
• Dry skin
  
• Vaginal dryness
  

Let’s Talk About Sex:
Many changes throughout pregnancy and childbirth change sex for couples. While most mothers are cleared at 6 weeks to resume sexual activty it is important to remember that this is strictly from an infection risk standpoint. You may not feel ready at 6 weeks and your partner should be aware that most women are not ready at that point! Educating your partner can help reduce the pressure you feel to resume sexual activity. Vaginal dryness can make sex uncomfortable and cause small tears during intercourse. This is because without enough estrogen, not only will you not have the same level of moisture, your vaginal tissue can shrink and become thinner.

When you do feel ready to resume sexual activity keep these tools in your toolkit:

• Use a lubricant when you’re having sex. (If your partner uses a condom, avoid petroleum-based lubricants, which can damage condoms.)
  
• Increase foreplay and try different techniques or positions.
  

Healthy @ UH says:
“If you are concerned about sex being painful, you can seek out pain relief options before having sex, such as a warm bath or an over-the-counter pain reliever. Using a lubricant is also recommended to combat vaginal dryness and make sex more comfortable. Relax, take it slow and communicate with your partner what does and does not feel good in order to make the experience a positive one. You can also consider other forms of sexual intimacy – such as massage or oral sex – as alternatives to vaginal intercourse.”

How to handle vaginal dryness?
Some women choose to take an estrogen supplement, but these do increase the risk of cancer and blood clots.  

Three types of vaginal estrogen:

• Ring (Estring): You or your doctor inserts this soft, flexible ring into your vagina where it releases a steady stream of estrogen directly to the tissues. The ring is replaced every 3 months.
  
• Tablet (Vagifem): You use a disposable applicator to put a tablet into your vagina once a day for the first two weeks of treatment. Then you do it twice a week until you no longer need it.
  
• Cream (Estrace, Premarin): You use an applicator to get the cream into your vagina. You'll typically apply the cream daily for 1 to 2 weeks, then cut back to one to three times a week as directed by your doctor.
  
  

You can also try:

• Staying hydrated!
  
• Talk to your doctor about using an estrogen vaginal cream, like conjugated estrogens (Premarin) or estradiol (Estrace).
  
• Avoiding douches
  
• Applying a vaginal moisturizer every few days.
  

What other vaginal changes occur postpartum?
A person can expect vaginal changes after giving birth. It can take anywhere from 12 weeks to a year for your vagina to go back to its pre-birth state. Common changes include perineal pain, pain during sex, bleeding, and vaginal dryness as well as:

• Soreness
  
• Itching 
  
• Discharge
  
• Scar tissue
  
• Increased risk of UTI
  
• Vulvar color
  

Contact your provider if you experience the following postpartum:

• Heavy vaginal bleeding such as filling more than 2 pads in 1–2 hours
  
• Passing large blood clots
  
• Fever
  
• Dizziness or fainting
  
• Blurred vision
  
• Severe, persistent headaches
  
• Vaginal discharge with a foul or strong odor
  
• Vomiting
  
• Progressively worse abdominal pain or new abdominal pain
  
• Swelling or pain in the legs
  

When it comes to postpartum vaginal changes, specifically ones that impact sexual activity it is important to keep the conversation with your partner continuous and ongoing. Sex will not be what it was pre-pregnancy, at least not for a little while, but that does not mean it needs to be scary or bad. 
If you feel ready and are cleared by your provider try having sex, and have lots of lube handy! But remember that you can stop at any point. Communication during sex is not a mood-killer! Let your partner know what is working and what isn’t, and have fun! 

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References:
Kelsey JJ. Hormonal contraception and lactation. J Hum Lact. 1996 Dec;12(4):315-8. doi: 10.1177/089033449601200419. PMID: 9025449.
UHBlog. (2022, February 24). Sex after birth: Resuming sexual intimacy after having a baby. University Hospitals. Retrieved May 23, 2022, from https://www.uhhospitals.org/Healthy-at-UH/articles/2022/02/sex-after-birth-resuming-sexual-intimacy-after-having-a-baby