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Knowledge about the determinants of female sexual function in breastfeeding women is limited. A total of 355 breastfeeding women completed the Female Sexual Function Index (FSFI) and the Qol-8 quality of life questionnaire. FSFI scores decreased in the first six months of breast feeding. There was a positive relationship between FSFI scores and the importance of sex, level of communication, income, quality of life, and receiving brief sexual counseling.
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Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: https://www.tandfonline.com/loi/usmt20
Determinants of Female Sexual Function in
Breastfeeding Women
Miguel Fuentealba-Torres, Denisse Cartagena-Ramos, Lucia A. S. Lara,
Josilene D. Alves, Antônio C. V. Ramos, Laura T. Campoy, Jonas B. Alonso,
Lucila C. Nascimento & Ricardo A. Arcêncio
To cite this article: Miguel Fuentealba-Torres, Denisse Cartagena-Ramos, Lucia A. S. Lara,
Josilene D. Alves, Antônio C. V. Ramos, Laura T. Campoy, Jonas B. Alonso, Lucila C. Nascimento
& Ricardo A. Arcêncio (2019): Determinants of Female Sexual Function in Breastfeeding Women,
Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2019.1586020
To link to this article: https://doi.org/10.1080/0092623X.2019.1586020
Accepted author version posted online: 05
Mar 2019.
Published online: 11 Apr 2019.
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Determinants of Female Sexual Function in
Breastfeeding Women
Miguel Fuentealba-Torres
a
, Denisse Cartagena-Ramos
a
, Lucia A. S. Lara
b
, Josilene
D. Alves
a
, Ant^
onio C. V. Ramos
a
, Laura T. Campoy
a
, Jonas B. Alonso
c
, Lucila C.
Nascimento
a
, and Ricardo A. Arc^
encio
a
a
Department of Maternal-Infant Nursing and Public Health, University of S~
ao Paulo, Ribeir~
ao Preto, Brazil;
b
Faculty of Medicine of Ribeir~
ao Preto, Department of Gynecology and Obstetrics, University of S~
ao Paulo,
Ribeir~
ao Preto, Brazil;
c
Collage of Nursing, University of S~
ao Paulo, Ribeir~
ao Preto, Brazil
ABSTRACT
Knowledge about the determinants of female sexual function in breast-
feeding women is limited. A total of 355 breastfeeding women completed
the Female Sexual Function Index (FSFI) and the Qol-8 quality of life ques-
tionnaire. FSFI scores decreased in the first six months of breast feeding.
There was a positive relationship between FSFI scores and the importance
of sex, level of communication, income, quality of life, and receiving brief
sexual counseling.
Introduction
The female sexual function (FSF) which is stimulated by the need to increase emotional proxim-
ity, the desire to increase attractiveness and share physical sexual pleasure, or satisfying ones sex-
ual needs (Basson, 2001; Cooper, Barber, Zhaoyang, & Talley, 2011).
Global analysis of epidemiological studies has indicated that between 40% and 50% of women
report problems in sexual functioning (McCabe et al., 2016). This situation is consistent with cur-
rent reports issued by specialists from different regions of the world in the fourth International
Consultation on Sexual Medicine, in which a high rate for female sexual problems and few thera-
peutic alternatives was evidenced in comparison with the options available for the treatment of
male sexual dysfunction (McCabe et al., 2016).
The determinants of FSF are essential for improving our understanding of the problems
related to FSF as well guiding the clinical anamnesis and early diagnosis of sexual dysfunction,
which will contribute to sexual health policies, mainly in populations with higher risk.
Breastfeeding women present a higher risk of developing problems in sexual functioning, per-
haps due to changes in the levels of estrogen, progesterone, testosterone, follicle stimulating hor-
mone, and luteinizing hormone, but also because of increased oxytocin and prolactin (Leeman &
Rogers, 2012). These changes reduce sex hormone levels, which may increases the chances of
developing hypoactive sexual desire (LaMarre, Paterson, & Gorzalka, 2003; Mcbride & Kwee,
2017; Millheiser, 2012).
Although breastfeeding women are considered at increased risk of developing sexual problems,
the determinants that interfere with FSF of women who breastfeed are poorly understood. The
literature is limited, as has been evidenced by a scoping review protocol that investigated relevant
primary studies (Fuentealba-Torres et al., 2018).
CONTACT Miguel Fuentealba-Torres mfuentealba@usp.br Department of Maternal-Infant Nursing and Public Health,
University of S~
ao Paulo, Ribeir~
ao Preto, 14040-902 Brazil.
ß2019 Taylor & Francis Group, LLC
JOURNAL OF SEX & MARITAL THERAPY
https://doi.org/10.1080/0092623X.2019.1586020
According to the literature review mentioned above, biological, psychological, interpersonal
(Basson, 2000), and social determinants (Solar & Irwin, 2010) can influence FSF. Exploratory
studies have shown that low quality of life is related to problems in sexual functioning. In breast-
feeding women, the perception of quality of life could be particularly diminished due to physical
and emotional overload, fatigue, irritability, and changes in the body, especially during the first
6 months of breastfeeding, due to the free demand for breastfeeding.
There is an important knowledge gap regarding FSF among women who breastfeed and con-
sidering that this event is a common practice in this period, it is important for primary studies
to be conducted in this area. It will be necessary not only to develop a diagnostic study but
also to be able to analyze the determinants of FSF using a robust tool for the evaluation of sex-
ual function. The Female Sexual Function Index (FSFI) questionnaire (Rosen et al., 2000) has
been characterized as a gold standard for the evaluation of FSF (Sand, Rosen, Meston, &
Brotto, 2009). Thus, the aim of this study was to identify the determinants of the mean
FSFI score.
Method
Participants
A cross-sectional study was carried out. The study population consisted of 4839 breastfeeding
women from the northeast region of the state of S~
ao Paulo, Brazil. A probabilistic sample was
used, calculated in 355 participants, using an accuracy of 5%, a 95% confidence interval and a
power of 80%.
The inclusion criteria were as follows: women over 18 years old, sexual activity including
penis-vagina relationship, and exclusive, predominant, or complementary breastfeeding until
23 months after delivery. The exclusion criteria were pregnant women breastfeeding, use of anti-
hypertensive drugs, antidepressants, and/or antipsychotics, and an inability to read or understand
the instructions of the research.
Procedure
The data was collected in primary health care facilities. The participants were randomly selected
from lists of medical appointments. The selected participants were invited to participate volun-
tarily, and the objectives, risks, and benefits of the study were explained. The participants
agreed to participate and provided signed informed consent. Data collection was carried out by
trained professionals with clinical experience and the self-applied interviews were held between
June and September 2017. The average time for application of the questionnaire
was 20 minutes.
The study was approved on June 07, 2017 by the Research Ethics Committee of the University
of S~
ao Paulo, under authorization number CAAE 67039517.5.0000.5393, considering the ethical
principles of the Helsinki Declaration (1964).
Measures
Sexual function was evaluated using the FSFI (Rosen et al., 2000), a self-reporting questionnaire
that evaluates FSF in the last four weeks (Rosen et al., 2000). This tool is a gold standard test
(Sand et al., 2009) and has been validated in Brazil (Thiel et al., 2008). The questionnaire consists
of 19 items across six domains of sexual functioning: desire, arousal, lubrication, orgasm, satisfac-
tion, and pain. The scores of each domain are multiplied by a correction factor that standardizes
the total score, which varies from 2 to 36 points, to obtain the total score.
2 M. FUENTEALBA-TORRES ET AL.
Quality of life (QoL) was evaluated using the Eurohis-Qol-8 instrument (Schmidt, M
uhlan, &
Power, 2006). This is a self-reporting questionnaire that determines self-perceived QoL in the pre-
vious two weeks by evaluating the physical, psychological, social relations and environmental
domains. This questionnaire consists of eight items, with scores ranging from one to five points.
The total score varies from 8 to 40 points. A higher total score of Eurohis-Qol-8 indicates better
QoL. This questionnaire was adapted and validated for the Brazilian context (Rocha, Power,
Bushnell, & Fleck, 2012), and presents evidence of validity, and reliability (Pires, Fleck, Power, &
Da Rocha, 2018).
Women were evaluated using a semi-structured questionnaire to assess sociodemographic
determinants (age, race, marital status, religion, family income, years of study, employment, sex-
ual health counseling), biological determinants (type of birth, chronic illness, perineal trauma,
time of breastfeeding, type of breastfeeding, problems with breastfeeding and problems related to
this process), psychological (importance of sex by women, discomfort with the breasts, resump-
tion of sex, stress) and interpersonal determinants (level of communication between the couple,
time in the relationship, premature ejaculation between the couple). The variable sexual health
counseling was defined as exposure to at least one medical consultation or trained professional,
with the aim of advising women about sexuality after childbirth and attending to possible sexual
complaints by women in this period. Levels of communication between the couple and the
importance of sex and stress were assessed on a Likert scale, with a minimum score of 1 and a
maximum of 5 (Likert, 1932).
Statistical analysis
The database was constructed using double independent typing. A descriptive analysis was devel-
oped by SPSS program version 23.0. The predictive variables of the mean FSFI score were identi-
fied using a regression model of the class of Generalized Additive Models for Location, Scale, and
Shape Models (GAMLSS). These analyses were carried out using the program R, version 3.4.1 (R
Core Team, 2017), using the GAMLSS library (Stasinopoulos & Rigby, 2007).
Frequencies and percentages were calculated for the categorical variables and minimum,
maximum, median, mean, and standard deviation (SD) were estimated for numerical varia-
bles. The study-dependent variable was the total score of the FSFI questionnaire, and the
independent variables were the sociodemographic, clinical, psychological, interpersonal, and
QoL data.
A bivariate analysis was undertaken, crossing the total FSFI score with each independent vari-
able using the Mann-Whitney, Kruskal-Wallis, and Spearman Coefficients. Box plots and scatter
diagrams, plus a Loess curve, were used to analyze the dispersion and to identify a possible func-
tional relationship between the FSFI total score and independent variables.
Variables with value of p<0.05 or with functional relationship trends with the FSFIs total
score in the dispersion charts, were inserted into the models of the GAMLSS class. The Akaike
criterion (AIC) was used to select the most appropriate model for the data set provided by the
inserted variables (Akaike, 1974).
Multicollinearity of the independent variables was evaluated using the variance inflation factor
(VIF). The selection of the independent variables for comparison between adjusted models was
performed using the likelihood ratio test (LRT). The non-parametric Fligner-Killen test was then
used to verify the homogeneity of the model variance. Diagnostic graphs of the model were
made, and the Shapiro-Wilk normality test, was applied to the model residues.
The final adjustment of the model showed the predicted values of the means FSFI scores, as
percentages. Graphs of the values predicted by the model were drawn. The graphs were elabo-
rated with the variables adjusted in the model equation. The type I error was set at 0.05 for all
statistical tests. Variables either with a p-value <0.05 or with graphical trends of functional
JOURNAL OF SEX & MARITAL THERAPY 3
relationship between the total FSFI score and numerical variables in the dispersion analysis, were
also inserted to a multiple regression model.
Results
Initially, 372 women were recruited, but five declined to participate (0.01%) and 12 were excluded
because they had difficulty understanding the questionnaires (0.03%); thus, 355 women were
included in the study. Regarding sociodemographic characteristics, the average age was
26.5 ± 6.68 years, income was 450.83 ± 252.41 USD, and length of the relationship was
6.27 ± 4.50 years (Table 1). It was also observed that 34.4% of women were married, 51.3% had a
religion, 60% had 11 years of study, and 31.3% were wage earners.
Table 1 shows the Spearmans correlation coefficient (S) analysis between independent varia-
bles and the total FSFI score. The communication level score, sex importance level score, stress
level score, and QoL score, had p-values lower than 0.5 (p<0.5), which were inserted in the
GAMLSS regression model.
Table 2, shows the results of a bivariate analysis considering the categorical variables and total
FSFI score. The marital status, perineal trauma, breastfeeding type, breastfeeding problems, dis-
comfort with breasts, premature ejaculation of the partner, and sexual health counseling variables
had p-values lower than 0.5, which were inserted into the GAMLSS regression model.
Per capita income was added into the GAMLSS model, because the quadratic parameters pre-
sented a functional relationship with the FSFI score in the dispersion analysis with the LOESS
curve. Figure 1 shows the functional relationships between the independent variables and the total
score for the FSFI, through dispersion analysis.
The Weibull distribution (WEI3) was selected for each independent variable according to the
AIC criterion. The results of the Shapiro-Wilk test confirmed normality on the residuals of the
model and the adjustment adequacy (W ¼0.99584, p-value ¼0.4717).
Table 3 shows the results of the GAMLSS regression model. Six variables were adjusted in the
final model: per capita income, up to six months breastfeeding, QoL score, sex importance level
score, communication level score, and sexual health counseling.
The model predicted that the mean FSFI score would be reduced by 4.06% in the group of
women who breastfed during the first six months, and conversely, that the mean FSFI score
would increase by 7.54% for each point in the QoL score, about 5.55% for each point in the
importance of sex score, 2.61% for each point in the communication score, and 6.50% in the
group of women who had access to at least one session of sexual health counseling. When the
model considered the quadratic terms of the income per capita variable in its final fit, it predicted
that the mean FSFI score would increase in quadratic form to higher per capita income.
Table 1. Correlation analysis with numeric variables and total scores of the female sexual function index (n ¼355).
Variables Min Max Mean ± DS Median Sp-value
Age, years 18 45 26.5 ± 6.68 25.00 0.05 0.36
Family income, USD
a
491.06 1.473,19 450.83 ± 252.41 1,600.00 0.04 0.44
Per capita income, USD
a
12.40 491.06 116.68 ± 69.19 116.88 0.07 0.17
Relationship time, years 1 28 6.27 ± 4.50 5.00 0.61 2.48
Resumption intercourse, days 1 120 44.96 ± 16.64 42.00 0.07 0.16
Communication level score
b
1 5 3.86 ± 1.25 4.00 0.34 <0.01
Sex importance level score
b
1 5 3.33 ± 1.91 3.00 0.35 <0.01
Stress level score
b
1 5 3.38 ± 1.38 3.00 0.15 0.03
Quality of Life score
c
14 40 29.44 ± 4.89 30.00 0.39 <0.01
S¼Spearmans correlation coefficient; SD ¼Standard deviation.
Correlation is significant at the 0.05 level.
Correlation is significant at the 0.01 level.
a
1 Dollar to USD ¼4.07 Brazilian Real/BRL (Date quoted rate: 9/21/2018).
b
Score Likert scale of the one at five points.
c
QoL total score.
4 M. FUENTEALBA-TORRES ET AL.
It is important to emphasize that the model has also adjusted two parameters of dispersion
(per capita income and communication level score), predicting that for each one Real in the per
capita income, the precision of the model is expected to increase by 0.04%, and, by 12.41% for
every extra point at the level of communication.
The variance inflation factor (VIF) did not show the presence of multicollinearity, with values
below 1.5 in all the variables of the model. The LRT test showed that variables improved the pre-
diction of mean FSFI score (AIC ¼20005.81, LRT ¼28.13, p-value <0.001). The Fligner-Killen
test confirmed the independence of errors and also homogeneity in variance. A likelihood ratio
Table 2. Bivariate analysis with total scores for female sexual function index (FSFI) and categorical variables (n ¼355).
Variables n (%) Mean ± SD p-value
Race 0.87
White 100 (28.2) 22.25 ± 1.16
Black 67 (18.9) 21.61 ± 2.11
Brown 146 (41.1) 22.60 ± 0.96
Asian 42 (11.8) 23.95± 2.28
Marital Status 0.04
Living as 233 (65.6) 22.11 ± 0.77
Married 122 (34.4) 24.09 ± 1.49
Religion 0.08
No 173 (48.7) 21.39 ± 0.99
Yes 182 (51.3) 23.04 ± 0.90
Years of study 0.96
Up to 8 years of study 113 (31.7) 24.75 ± 0.46
Up to 11 years of study 214 (60.2) 24.64 ± 0.31
12 or more years of study 28 (8.0) 24.91 ± 1.02
Employment 0.12
Employed 111 (31.3) 22.92 ± 1.27
Unemployed or in the home 244 (68.7) 22.21 ± 0.78
Type of delivery 0.74
Cesarean section 125 (35.2) 21.83 ± 1.27
Vaginal delivery 230 (64.8) 22.93 ± 0.80
Chronic Disease 0.26
No 324 (91.3) 22.41 ± 0.73
Yes 31 (8.7) 23.04 ± 2.15
Perineal trauma 0.01
No 336 (94.6) 22.67 ± 0.70
Yes 19 (5.4) 21.37 ± 2.69
Breastfeeding type 0.01
Exclusive 126 (35.5) 22.92 ± 0.93
Predominant 53 (14.9) 22.10 ± 1.10
Complementary 176 (49.5) 22.88 ± 1.62
Time of the breastfeeding <0.00
>6 months 173 (48.7) 22.57 ± 1.44
<6 months 182 (51.3) 22.48 ± 0.80
Breastfeeding problems <0.00
No 309 (87.0) 25.02 ± 0.27
Yes 46 (13.0) 22.50 ± 0.60
Decreased sexual intercourse <0.00
No 138 (38.8) 26.82 ± 0.33
Yes 217 (61.2) 23.34 ± 0.32
Discomfort with breasts <0.01
No 230 (64.8) 22.68 ± 0.95
Yes 125 35.2 22.24 ± 1.00
Premature ejaculation of the partner 0.01
No 228 (64.2) 22.34 ± 0.85
Yes 127 35.8 22.84 ± 1.22
Sexual health counseling <0.00
No 263 (74.1) 21.82 ± 0.86
Yes 92 (25.9) 23.78 ± 1.14
SD ¼Standard deviation.
p-value <0.05 of Mann-Whitney test.
p-value <0.05 of Kruskal-Wallis test.
JOURNAL OF SEX & MARITAL THERAPY 5
test (LRT) showed that the parameters as a whole improve the prediction of the mean FSFI score.
The t-scores indicated that all variables adjusted in the final model contributed significantly to
the prediction of the mean FSFI score, with values p<0.05. The model explained 35.79% of the
variance, according to R Cox Snell test. The Shapiro-Wilk test showed that the residuals follow a
normal distribution (W ¼0.99687, p-value ¼0.7268) (Figure 2).
The Figure 3 shows the multidimensional graphs of means FSFI scores predicted by the model
according to according to level of importance of sex, communication level, QoL, the breastfeeding
time (greater and less than six months), sexual health counseling and per capita income. The val-
ues for communication level and QoL were set at their averages for all the estimates of the graphs
(3.86 and 29.44, respectively).
In general, the graphs show, in a non-linear manner, that mean FSFI score tend to be higher
among breastfeeding women who receive sexual health counseling, who have per capita incomes
above USD$300, and with higher levels of importance for sex, communication between the couple
and QoL.
Table 3. Predictive model of the female sexual function index mean score.
Mean parameters FSFI Estimates SD TMean 95% CI p-value
Intercept 2.72 0.05 53.53 15.1977 13.756616.7899 <0.01
Per capita income 0.32 0.14 2.33 ——0.02
Per capita income (quadratic term) 0.31 0.10 3.11 ——<0.01
Up to six months breastfeeding 0.04 0.01 3.00 0.9594 0.93380.9857 <0.01
Quality of life score 0.07 0.01 5.46 1.0754 1.04771.1038 <0.01
Sex importance level score 0.03 0.01 5.15 1.0355 1.02181.0493 <0.01
Communication level score 0.03 0.01 2.83 1.0261 1.00801.0445 <0.01
Sexual health counseling 0.06 0.02 3.71 1.0650 1.03021.1010 <0.01
Dispersion parameters FSFI Estimates SD TDispersion 95% CI p-value
Intercept 1.37 0.14 9.97 3.9178 2.99525.1246 <0.01
Per capita income 0.00 0.00 2.74 1.0004 1.00011.0007 0.01
Communication level score 0.12 0.03 3.63 1.1241 1.05521.1975 <0.01
p0.05. t: value test; SD: Standard deviation; CI: confidence interval.
Figure 1. Graphics of relationships between total score FSFI and independent variables. A, C, D, E ¼Functional relationship by
Loess curve. B, F ¼Relationship by box charts.
6 M. FUENTEALBA-TORRES ET AL.
Discussion
The study aimed to identify the determinants of the mean FSFI score in breastfeeding women.
The findings revealed that per capita income, breastfeeding for up to six months, level of QoL,
level of sexual importance, level of communication, sexual health counseling and per capita
income are determinants of the mean FSFI score.
Figure 2. Diagnosis graphics of waste model.
JOURNAL OF SEX & MARITAL THERAPY 7
Figure 3. Predictive graphs of the FSFI mean score according to level of importance of sex, communication level, QoL, breast-
feeding time, sexual health counseling and per capita income.
8 M. FUENTEALBA-TORRES ET AL.
The FSF is influenced by socioeconomic status, because the mean FSFI scores were signifi-
cantly lower among women with lower incomes. Per capita income is a social determinant associ-
ated with poverty and social inequality, which has a negative impact on the general health of
people, as well as on sexual health (Solar & Irwin, 2010). Low socioeconomic status interferes
with womens mental health, affecting sexual responsiveness (Kingsberg et al., 2017), increasing
dissatisfaction in the relationship (Khajehei, Doherty, Tilley, & Sauer, 2015) and increasing vul-
nerability to develop problems with sexual function. It is advisable to carefully evaluate the sexual
functioning of low-income patients, because they are vulnerable to developing sexual dysfunction.
This study indicates that evaluation of QoL is relevant for the comprehensive assessment of
sexual health during breastfeeding because significantly lower FSFI scores were evidenced among
women with lower QoL. Previous studies suggest that a low perception of QoL could increases
the risk of female sexual problems (Hisasue et al., 2005; Laumann, Paik, & Rosen, 1999). Stress,
associated with demands for baby care, emotional overload, lack of sleep and fatigue (Mcbride &
Kwee, 2017; McDonald, Woolhouse, & Brown, 2015; Millheiser, 2012), can impact the perception
of QoL in women who practice breastfeeding. In addition, sexual QoL could be affected due to
increased vaginal dryness (Khajehei et al., 2015; Redelman, 2017), and the appearance of dyspar-
eunia in vaginal intercourse (Alligood-Percoco, Kjerulff, & Repke, 2016; Lagaert, Weyers, Van
Kerrebroeck, & Elaut, 2017). Despite this background, knowledge of the effect of low QoL in the
FSF is limited among women who breastfeed. The evidence found in this study predicts that the
FSF improves when the perception of QoL is high. Clinical evaluation of QoL and FSF among
breastfeeding women is recommended.
Multivariate FSFI analyses predicted that mean scores would be lower in the first 6 months of
lactation. In this period, the interest of the woman in maintaining sexual relations with the couple
may decrease, as, on many occasions, the woman is focused exclusively on breastfeeding
(Adanikin, Awoleke, Adeyiolu, Alao, & Adanikin, 2015; Barrett et al., 2000). A recently published
study reported significantly lower FSFI scores among women who exclusively breastfeed (Matthies
et al., 2019). In addition, in this period, the delay in the resumption of sexual relations has been
reported (Brtnicka, Weiss, & Zverina, 2009; Rowland, Foxcroft, Hopman, & Patel, 2005), along
with a decrease in the frequency of sexual relations (Matthies et al., 2019; van Anders, Hipp, &
Kane Low, 2013) and a decrease in sexual desire (Khajehei et al., 2015; Leeman & Rogers, 2012).
The study also showed that lower scores for the level of perceived importance of sexual rela-
tions correlated with lower average FSFI scores. Although this variable has not been investigated
in depth, one study indicated that the importance of sex is significantly lower in women who
breastfeed, compared with those who have stopped breastfeeding (Trutnovsky, Haas, Lang, &
Petru, 2006). The low importance of sex has a multifactorial origin and may be influenced by psy-
chosocial factors such as adjustment to becoming a mother, resentment of role changes, emotional
connection with the baby (Woolhouse, McDonald, & Brown, 2012) and by the practical need to
breastfeed frequently (Leeman & Rogers, 2012). Changes in body image such as weight gain after
childbirth, changes in the shape and function of the breasts, or the appearance of stretch marks or
scars on the skin (Ahn, Sohn, & Yoo, 2010; Barrett et al., 2000) can interfere with the sexual
motivation system (Bancroft & Graham, 2011) and contribute to the decrease in sexual interest.
The study indicates that the level of communication is a predictor of FSFI scores, showing
lower scores among women who perceive poor communication in the couples relationship. It has
been shown that a high level of communication improves FSF (Lianjun et al., 2011; MacNeil &
Byers, 2005; Montesi, Fauber, Gordon, & Heimberg, 2011), contributes to the well-being of the
couple, stimulates the need for emotional closeness, and contributes to the development of sexual
motivation in women who breastfeed (Convery & Spatz, 2009). A recently published survey indi-
cated that an adequate level of communication improves sexual performance and increases the
frequency of sexual relations (Zhang et al., 2018). Good communication with the couple has been
associated with a higher level of intimacy, satisfaction in the relationship (Ahlborg, Dahl
of, &
JOURNAL OF SEX & MARITAL THERAPY 9
Hallberg, 2005) and an increase in well-being in the couples relationship (Convery & Spatz,
2009). In contrast, poor communication has been linked to higher rates of sexual dissatisfaction
(Blair, Pukall, Smith, & Cappell, 2015), higher incidence of marital problems (Connolly, Thorp, &
Pahel, 2005) and a fear of experiencing genital pain during vaginal sex (Blair et al., 2015).
Strengthening communication can positively impact the intimacy of the couple (McCabe &
Connaughton, 2017) and can improve the female sexual response (Lianjun et al., 2011; Montesi
et al., 2011). In the clinical interview, it is advisable to consult about the communication and guide
the couple in a timely manner to seek specialized help when there are communication problems.
The findings indicate that sexual health counseling is a protective factor for FSF and show that
the average FSFI scores improve when women receive sexual health counseling. Sexual health
counseling prepares women and their partners to face possible changes in female sexual response
during breastfeeding. Because women are exposed to an increased risk of developing sexual dys-
function after childbirth, it is advisable for health professionals to expand sexual health counsel-
ing activities spatially during the period of breastfeeding. Guidance on the use of vaginal
lubricants among breastfeeding women (Leeman & Rogers, 2012; Millheiser, 2012) can help to
decrease the decrease in vaginal lubrication and can prevent the occurrence of dyspareunia. To
prevent the occurrence of problems in the sexual function of women who breastfeed, it is recom-
mended that sexual health counseling begins early in pregnancy, continues in the postnatal period
and that the monitoring of sexual problems extends throughout the period of breastfeeding.
Although this study identified some determinants of FSF during breastfeeding, further evi-
dence is needed. In future studies evaluating the FSF post-partum, it is recommended that FSF
analyses, for the group of women who practice breastfeeding, be performed separately. This could
help to more clearly identify those factors that intervene in the FSF of women who breastfeed
and avoid the development of incorrect conclusions, because breastfeeding could be a confounder
for the measures of association.
Conclusions
The determinants of FSFI should be carefully evaluated among breastfeeding women because they are
characterized by a sophisticated interrelation between the variables level of income per capita, quality of
life, the first six months of lactation, the level of importance of sex, and communication with the couple.
Sexual health counseling is an important determinant for improving sexuality in breastfeeding women.
Funding
This research was funded by the Coordination for the Improvement of Higher Education
Personnel (CAPES) and the National Council for Scientific and Technological Development
(CNPq), Program PEC-PG, Processes numbers 9243143 and 9191134.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
Miguel Fuentealba-Torres http://orcid.org/0000-0003-4343-6341
Denisse Cartagena-Ramos http://orcid.org/0000-0002-8828-2190
Lucila C. Nascimento http://orcid.org/0000-0002-7900-7111
10 M. FUENTEALBA-TORRES ET AL.
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12 M. FUENTEALBA-TORRES ET AL.
... Neste contexto, o resultado do estudo sobre a influência da qualidade da parceria e amamentação no desempenho sexual nos quatro meses após o parto demonstrou que as mulheres que amamentam com baixa qualidade da parceria apresentaram maior probabilidade de problemas na atuação sexual, tendo efeito negativo nos seguintes domínios: "desejo", "excitação", "satisfação", "lubrificação" e "dor" (MATTHIES et al., 2018). No que concerne a percepção da qualidade de vida entre mulheres que amamentam, esta pode ser diminuída devido à sobrecarga física e emocional, fadiga, irritabilidade e alterações no corpo, especialmente durante os primeiros seis meses de amamentação (FUENTEALBA-TORRES, et al., 2019b). ...
... Sendo assim, é essencial avaliar cuidadosamente durante a consulta pré-natal e puerperal os determinantes que podem interferir na dinâmica/atuação sexual, como renda per capita, fatores fisiológicos, fatores emocionais, qualidade de vida, amamentação, nível de importância dada a atividade sexual, qualidade da parceria e a comunicação do casal (FUENTEALBA-TORRES, et al., 2019a;FUENTEALBA-TORRES, et al., 2019b, CHAPARRO et al., 2013MATTHIES et al., 2018;HEIDARI et al., 2009). É importante mencionar ainda que o aconselhamento em saúde sexual constitui um fator primordial para melhoria do desempenho sexual entre as lactantes. ...
... É importante mencionar ainda que o aconselhamento em saúde sexual constitui um fator primordial para melhoria do desempenho sexual entre as lactantes. Para tanto, faz-se necessário que os profissionais de saúde promovam uma abordagem positiva da sexualidade por meio do estabelecimento de um ambiente acolhedor, onde as mulheres sejam encorajadas a falar sobre suas preocupações sexuais, informadas quanto as mudanças fisiológicas ocorridas que podem refletir na sexualidade, durante o aconselhamento pré-natal (FUENTEALBA-TORRES, et al., 2019a;FUENTEALBA-TORRES, et al., 2019b, CHAPARRO et al., 2013MATTHIES et al., 2018;HEIDARI et al., 2009). ...
... Neste contexto, o resultado do estudo sobre a influência da qualidade da parceria e amamentação no desempenho sexual nos quatro meses após o parto demonstrou que as mulheres que amamentam com baixa qualidade da parceria apresentaram maior probabilidade de problemas na atuação sexual, tendo efeito negativo nos seguintes domínios: "desejo", "excitação", "satisfação", "lubrificação" e "dor" (MATTHIES et al., 2018). No que concerne a percepção da qualidade de vida entre mulheres que amamentam, esta pode ser diminuída devido à sobrecarga física e emocional, fadiga, irritabilidade e alterações no corpo, especialmente durante os primeiros seis meses de amamentação (FUENTEALBA-TORRES, et al., 2019b). ...
... Sendo assim, é essencial avaliar cuidadosamente durante a consulta pré-natal e puerperal os determinantes que podem interferir na dinâmica/atuação sexual, como renda per capita, fatores fisiológicos, fatores emocionais, qualidade de vida, amamentação, nível de importância dada a atividade sexual, qualidade da parceria e a comunicação do casal (FUENTEALBA-TORRES, et al., 2019a;FUENTEALBA-TORRES, et al., 2019b, CHAPARRO et al., 2013MATTHIES et al., 2018;HEIDARI et al., 2009). É importante mencionar ainda que o aconselhamento em saúde sexual constitui um fator primordial para melhoria do desempenho sexual entre as lactantes. ...
... É importante mencionar ainda que o aconselhamento em saúde sexual constitui um fator primordial para melhoria do desempenho sexual entre as lactantes. Para tanto, faz-se necessário que os profissionais de saúde promovam uma abordagem positiva da sexualidade por meio do estabelecimento de um ambiente acolhedor, onde as mulheres sejam encorajadas a falar sobre suas preocupações sexuais, informadas quanto as mudanças fisiológicas ocorridas que podem refletir na sexualidade, durante o aconselhamento pré-natal (FUENTEALBA-TORRES, et al., 2019a;FUENTEALBA-TORRES, et al., 2019b, CHAPARRO et al., 2013MATTHIES et al., 2018;HEIDARI et al., 2009). ...
... Sexual Functioning. Lower levels of functioning were associated with lower household income (Amiri et al., 2020;Fuentealba-Torres et al., 2019;Güleroğlu & Beşer, 2014;Llaneza et al., 2011), perceived income insufficiency (Aşkin et al., 2019), lower socioeconomic status (Jain et al., 2019), and poverty (Güleroğlu & Beşer, 2014). Other researchers documented associations between socioeconomics and individual domains of sexual functioning such as desire and orgasm (Gallup et al., 2014(Gallup et al., , p. 2014). ...
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Sexual health includes positive aspects of sexuality and the possibility of having pleasurable sexual experiences. However, few researchers examine how socioeconomic conditions shape sexual wellbeing. This paper presents the concept of "erotic equity," which refers to how social and structural systems enable, or fail to enable, positive aspects of sexuality. In part one, we use this concept to consider potential pathways through which socioeconomic conditions, especially poverty, may shape sexuality. Part two builds from this theoretical framework to review the empirical literature that documents associations between socioeconomics and sexual wellbeing. This narrative review process located 47 studies from more than 22 countries. Forty-four studies indicated that individuals who reported more constrained socioeconomic conditions, primarily along the lines of income, education, and occupation, also reported poorer indicators of sexual wellbeing, especially satisfaction and overall functioning. Most studies used unidimensional measures of socioeconomic status, treating them as individual-level control variables; few documented socioeconomics as structural pathways through which erotic inequities may arise. Based on these limitations, in part three we make calls for the integration of socioeconomic conditions into sexuality researchers' paradigms of multi-level influences on sexuality.
... Another important factor is that some medicinal vaginal creams (not just for lubricant effects) can weaken the latex in people who use barrier methods for preventing pregnancy. Therefore, the most common methods for the management of atrophic vaginitis in breastfeeding women are water-based lubricant vaginal gels [49,53,54]. ...
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Background Considering the importance of sexual function, high prevalence of sexual dysfunction (especially dyspareunia caused by atrophic vaginitis) in breastfeeding women, and lack of effective interventions, the present research aimed to determine the effect of oxytocin (OXT) vaginal gel on sexual function (primary outcome), sexual satisfaction, and depression (secondary outcomes) in the breastfeeding women. Methods This randomized triple-blind controlled trial was conducted on 64 breastfeeding women who referred to health centers in the city of Tabriz, Iran, in 2020-21. Participants were equally assigned to intervention/control groups using block randomization. 200 IU of OXT vaginal gel was given to the participants in the intervention group daily for eight week and the same protocol was carried out for the control group with placebo. Standard questionnaires of Female Sexual Function Index (FSFI), Edinburgh Postpartum Depression Scale (EPDS) and Sexual satisfaction scale for women (SSSW) were completed at baseline and 8 weeks after intervention. ANCOVA test was used to compare post-intervention mean score of the groups, adjusted for the baseline values. Results After intervention, there was no statistically significant difference between groups in terms of mean total score of FSFI (Adjusted Mean Difference (AMD): 1.14; 95% Confidence Interval (95% CI): -1.28 to 9.16; P= 0.349) and sexual satisfaction (AMD: 5.01; 95% CI: -0.53 to 10.56; P= 0.075). However, there was statistically significant difference between the groups in terms of mean scores of sexual contentment (AMD: 1.56; 95% CI: 0.29 to 2.83; P = 0.017) and depression (AMD: -1.90; 95% CI: -1.27 to -2.54; P < 0.001). One participant in the OXT group and one participant in the placebo group reported mild uterine contraction and one person in the placebo group reported vaginal burning sensations. Conclusions No evidence was found for the effects of OXT gel in the improvement of FSFI, even though, OXT significantly improved sexual satisfaction in the domain of contentment, and improved the symptoms of depression in comparison to the placebo group. However, a definite conclusion requires more research in this regard. Trial registration the Iranian Registry of Clinical Trials (IRCT), code: IRCT20120718010324N55, Date of registration: 27/05/2020, URL: https://en.irct.ir/user/trial/44986/view.
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Background: Although postpartum sexual problems are common, the impact of the infant feeding method on sexual life is still unclear. The aim of this study was to investigate the effects of different infant feeding methods and other influencing factors on female sexual life 3 months postpartum. Materials and Methods: Three hundred women from three obstetrical institutes were enrolled in this cross-sectional study. An online questionnaire was administered 3 months postpartum. Women were categorized into three groups: exclusive breastfeeding (n = 180), mixed feeding (n = 75), and formula-feeding (n = 45) groups. The infant feeding method was assessed by self-constructed questions. Sexual dysfunctions were evaluated by the Hungarian version of the Female Sexual Function Index (FSFI). Results: Of the women, 50.55% reported sexual dysfunction in the exclusive breastfeeding group, 42.66% in the mixed feeding group, and 31.11% in the formula-feeding group. Lack of sexual desire was the most prevalent dysfunction regardless of the infant feeding method. Significantly lower median scores were found in the exclusive breastfeeding group compared with the formula-feeding group for the total FSFI score (p = 0.002), arousal (p = 0.034), lubrication (p = 0.020), orgasm (p = 0.015), and pain (p = 0.021) subgroups. Breastfeeding (p = 0.032) and the quality of prepregnancy sexual life (p < 0.001) were significant factors, whereas prepregnancy dyspareunia, parity, age, income, and educational level did not predict women's postpartum sexual function. Conclusions: Our findings indicate that exclusive breastfeeding women have an increased likelihood of sexual problems 3 months postpartum. Extensive and professional counseling is needed for couples about postpartum sexuality and influencing factors such as breastfeeding to maintain sexual health and promote long-term breastfeeding.
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Introduction Female sexual dysfunction is known to have a huge impact on quality of life and is highly prevalent during the peripartum period. Several influencing variables were found to be associated with impaired sexual function postpartum, among them breastfeeding and partnership quality. However, little is known about the predictive value of these variables. Therefore, this longitudinal cohort study aimed to examine prospectively the influence of the two variables on sexual function 4-month postpartum. Materials and methods Questionnaires were administered to 330 women prenatally (TI, third trimester) and postpartum (TII, 1 week; TIII, 4 months). Medical data were collected from the respondents’ hospital records. The Female Sexual Function Index (FSFI) was used to determine overall sexual function, desire, arousal, lubrication, orgasm, satisfaction, and pain perinatally. Results At all timepoints, mean FSFI scores were below the critical FSFI-score of 26.55. Partnership quality, breastfeeding, high maternal education, and maternal depressive symptoms correlated significantly with FSFI scores postpartum. Further analyses confirmed antenatal partnership quality and breastfeeding behavior as strong predictors of sexual function 4-month postpartum, explaining 24.3% of variance. Women who stopped breastfeeding or never breastfed at all showed the highest FSFI scores. Conclusion Our findings indicate that exclusively breastfeeding women and those who report low partnership quality have an increased likelihood of sexual functioning problems 4-month postpartum. Health-care providers need to be encouraged to counsel on postpartum sexuality and influencing factors during prenatal classes to de-pathologize those changes and to foster a positive approach to peripartum sexuality.
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Introduction Female sexual dysfunction is a public health problem. Evidence suggests that the population of nursing women is more vulnerable to the phenomenon due to breast feeding. Thus, this protocol was developed to explore the factors that contribute to the development of sexual dysfunction in breastfeeding women. Methods and analysis The systematic scoping review will be conducted in six stages, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. The databases used will be: PubMed, Excerpta Medica Database, Cumulative Index for Nursing and Allied Health Literature, PsycINFO, Science Direct, Web of Science and Google Scholar. The searches were made until 1 June 2018, and no retrospective time limit was used. For the organisation of the literature retrieved from the databases, the EndNote Basic manager will be used. The Cochrane model will be used for the data extraction. The analysis of the quantitative data will be carried out through descriptive statistics and the qualitative data will be submitted to thematic analysis. The methodological quality of the empirical studies will be evaluated using the Mixed Methods Appraisal Tool. Ethics and dissemination As it will be a review study, without human involvement, there will be no need for ethical approval. The results will be disseminated in a scientific journal, as well as in various media, such as: conferences, seminars, congresses or symposia.
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Background: Sexual frequency is associated with the quality of life. China's internal migrants that are sexually active are more likely to participate in sexual behavior. However, less work has been undertaken to assess the sexual frequency and its predictors in migrants. Aim: This study seeks to explore which factors were related to sexual frequency in migrants and how the association varies with different levels of sexual frequency. Methods: A total of 10,834 men and 4,928 women aged 20-49 years from 5 cities in China were enrolled by multi-stage sampling during August 2013-August 2015. Outcomes: Sexual frequency among migrants was determined by asking: How many times have you had sexual intercourse with a man/woman in the past 30 days? Results: In this study, sexual frequency with an average age of 38.28 years was 5.06 (95% CI 5.01-5.11) time per month. Negative binomial showed that male gender, younger age, earlier age of sexual debut, masturbation, more knowledge of sexual and reproductive health, longer time together with a spouse, and higher school education and incomes were predictors of increased sexual frequency in migrants. Communicating with sexual partners frequently had the largest effect on sexual frequency compared with occasional communicating (β = 0.2419, incidence rate ratio = 1.27, 95% CI 1.23-1.31). In the quantile regression, months of cohabitation (β = 0.0999, 95% CI 0.08-0.12), frequent sexual communication (β = 0.4534, 95% CI 0.39-0.52), and masturbation (β = 0.2168, 95% CI 0.14-0.30) were positively related to lower levels of sexual frequency. Interestingly, migrants who had low and high sexual frequency would be affected in opposite directions by the knowledge of sexual and reproductive health. Clinical translation: Clinicians can more understand the relationship between sexual frequency and its factors that can as the symptom basis of sexually-related diseases. Conclusions: The present findings indicate that specific demographic, socioeconomic, and epidemiological characteristics influenced sexual frequency among migrants. Sexual communication as the largest effect predictor to sexual frequency should be paid more attention to, to improve sexual activity of migrants. Zhang J, Wu J, Li Y, et al. Influence factors of sexual activity for internal migrants in China. J Sex Med 2018;XX:XXX-XXX.
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Objective: To test the psychometric properties of the EUROHIS-QOL 8-item index in a Brazilian sample. Methods: The sample consisted of 151 patients and 174 healthy controls (n=325). Several psychometric properties were tested. Results: Reliability showed good internal consistency (Cronbach's alpha = 0.81). The measure showed good discriminant validity between patients and healthy controls (mean1 = 3.32, SD1 = 0.70; mean2 = 3.77, SD2 = 0.63, t = 6.12, p < 0.001). Convergent validity showed significant correlations (p < 0.001) between the EUROHIS-QOL 8-item index and all domains of the WHOQOL-Bref (overall r = 0.47; general health r = 0.54; physical r = 0.69; psychological r = 0.62; social relationship r = 0.55; environment r = 0.55) and between the EUROHIS-QOL 8-item index and the domains of the SF-36, except for the social domain (p = 0.38). On Rasch analysis of unidimensionality, general fit measures showed adequate performance. The EUROHIS-QOL 8-item index also showed good fit on confirmatory factor analysis (CFA) (chi-square = 18.46, degrees of freedom [df] = 15; comparative fit index [CFI] = 0.99; root mean square error of approximation [RMSEA] = 0.03; goodness of fit index [gfi] = 0.99; root mean square residual [RMR] = 0.03; p = 24). Conclusion: The EUROHIS-QOL 8-item index showed good psychometric properties. It is a reliable quality of life measure that can be used in Brazilian populations.
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Purpose of Review This paper is written to introduce postpartum sexual functioning through a biopsychosocial lens, including challenges and interventions for optimal sexual functioning during the postpartum period, both for women and their partners. Recent Findings While considered to be dysfunctional compared to sexual functioning outside of the perinatal period, changes to sexual functioning in the year following childbirth are common. Biological and physiological factors which affect postpartum sexual functioning include method of delivery, breastfeeding and hormonal changes, and sleep. Psychosocial factors impacting postpartum sexual functioning include mental health, identity transition with adjusting to parenting, body image, social support, cultural context, and romantic relationships. Basson’s model of female sexual response is also discussed. Summary Sexual functioning during the postpartum year is a biopsychosocial process which is challenging for most couples, although there are exceptions. These challenges need to be pathologized. Healthcare providers need to better support new parents with their sexual health.
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Introduction: Since the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner. Aims: To review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders. Methods: The committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods. Results: Using a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders. Conclusion: The numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts). Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463-1491.
Article
Objectives: Sexual functioning is an important concern for women in the postpartum period. The aim of this research was to investigate the prevalence and determinants of dyspareunia and sexual dysfunction before and after childbirth. Methods: Between November 2013 and April 2014, 109 women in their third trimester of pregnancy were enrolled in a prospective cohort study at Ghent University Hospital. Dyspareunia, sexual functioning and quality of life (QOL) were evaluated at enrolment and again 6 weeks and 6 months postpartum. Sexual functioning and QOL were assessed using validated self-report questionnaires: the Female Sexual Function Index and the Short Form-36 health survey. Dyspareunia was evaluated by a specific self-developed questionnaire. Results: One hundred and nine women were enrolled; respectively, 71 (65.1%), 66 (60.6%) and 64 (58.7%) women returned the questionnaires prepartum, and 6 weeks and 6 months postpartum. Sexual functioning at 6 weeks was predictive of sexual functioning at 6 months postpartum (rs = 0.345, p = .015). The prevalence of dyspareunia in the third trimester of pregnancy, and 6 weeks and 6 months postpartum was, respectively, 32.8%, 51.0% and 40.7%. The severity of pain decreased significantly between 6 weeks and 6 months postpartum (p = .003). In the first 6 weeks postpartum, the degree of dyspareunia was significantly associated with breastfeeding (p = .045) and primiparity (p = .020). At 6 months, only the association with primiparity remained significant (p = .022). Conclusions: The impaired postpartum sexual functioning, the high prevalence of dyspareunia postpartum and their impact on QOL indicate the need for further investigation and extensive counselling of pregnant women, especially primiparous women, about sexuality after childbirth.
Article
Objective: To investigate risk factors for dyspareunia among primiparous women. Methods: This was a planned secondary analysis using data from the 1- and 6-month postpartum interviews of a prospective study of women who delivered their first neonate in Pennsylvania, 2009-2011. Participants who had resumed sexual intercourse by the 6-month interview (N=2,748) constituted the analytic sample. Women reporting a big or medium problem with painful intercourse at 6 months were categorized as having dyspareunia. Multivariable logistic regression was used to evaluate the effect of patient characteristics, obstetric and psychosocial factors, and breastfeeding on dyspareunia. Results: There were 583 women (21.2%) who reported dyspareunia at 6 months postpartum. Nearly one third of those breastfeeding at 6 months reported dyspareunia (31.5%) compared with 12.7% of those not breastfeeding (adjusted odds ratio [OR] 2.89, 95% confidence interval [CI] 2.33-3.59, P<.001); 32.5% of those reporting a big or medium problem with perineal pain at 1 month reported dyspareunia at 6 months compared with 15.9% of those who did not (adjusted OR 2.45, 95% CI 1.93-3.10, P<.001); 28.3% of women who reported fatigue all or most of the time at 1 month reported dyspareunia at 6 months compared with 18.0% of those who reported fatigue less often (adjusted OR 1.60, 95% CI 1.30-1.98, P<.001); and 24.1% of those who scored in the upper third on the stress scale at 1 month reported dyspareunia at 6 months postpartum compared with 15.6% of those who scored in the lowest third (adjusted OR 1.55, 95% CI 1.18-2.02, P=.001). Conclusion: In this prospective cohort study, we identified specific risk factors for dyspareunia in primiparous women that can be discussed at the first postpartum visit, including breastfeeding, perineal pain, fatigue, and stress.
Article
This paper examines the association between relationship stress and sexual dysfunction. The results demonstrated a strong association between female sexual dysfunction (FSD) and relationship stress, and between male sexual dysfunction (MSD) and relationship stress among their female partners. No studies examined the association between FSD and relationship stress of male partners. Treatment for MSD was associated with improved relationship stress for female partners, but no studies were located that examined this association for treatment of FSD. These findings suggest that FSD and relationship stress are strongly related, but the association does not seem to be so strong for men. The review highlights the need for further research in this field to inform therapy for both sexual dysfunction and relationship problems.