Pain With Sex Postpartum? It Might Be GSL.

Why Does Sex Hurt After Having a Baby? Genitourinary Syndrome of Lactation Explained

Written by Dr. Fiona Callender, ND and Pelvic Therapist. Dr. Fiona supports patients through fertility, pregnancy to postpartum and with pelvic floor therapy in Toronto.

If you recently had a baby and are breast/chestfeeding, there are probably some aspects of this new phase of life that you expected, and other changes that might be catching you off guard.

For many, the six-week postpartum check comes with being “cleared” for a return to activities. This relatively arbitrary timeline can feel early (or way too early!) for many people, but if this is a time when you feel ready and eager to have sex with your partner, you might be surprised to find that it feels different - or even painful.

Healing tissues and pelvic floor muscle changes can be part of this, but there’s another factor that is very common and not often talked about.

Dryness, burning, urinary urgency or frequency, and pain with sex, can all be symptoms of a condition called genitourinary syndrome of lactation.

What is genitourinary syndrome of lactation?

Genitourinary syndrome of lactation describes changes to the vaginal, vulvar and urinary tissues that can occur during breastfeeding/lactation. If you've heard of genitourinary syndrome of menopause (GSM), the physiology is actually quite similar. In both situations, estrogen levels are low. The important difference is that during lactation, this hormonal shift is typically temporary. Research suggests vaginal dryness and/or atrophy affects roughly 60% of people who are lactating. Sexual concerns, including pain, are also extremely common postpartum. In my practice, I’ve found that many people are simply never told to expect these changes.

Why does breastfeeding cause vaginal dryness?

This starts with prolactin, the hormone involved in breast milk production. When you are breastfeeding, suckling stimulates prolactin release. Prolactin then suppresses some of the hormonal signalling between your brain and ovaries. This is part of the reason you may not ovulate or get your period for some time while breastfeeding. But there's another consequence of this hormonal shift: Your estrogen levels drop.

Estrogen does more than regulate your menstrual cycle. The tissues of the vagina, vulva, urethra and bladder are all responsive to estrogen. When estrogen drops, these tissues can become:

• Thinner

• Drier

• Less elastic

• Less well-lubricated

• More easily irritated

Blood flow to the area can also decrease.

So if you've thought:

“Why do I suddenly feel dry all the time?”

or

“Why does sex hurt now when it never did before?”

The hormonal changes that come with breastfeeding may be one piece of the puzzle.

Breastfeeding and the associated hormonal changes can impact the vaginal microbiome

Estrogen helps support glycogen storage within vaginal tissue. Glycogen is essentially a stored form of glucose (sugar), and it helps maintain a vaginal environment dominated by beneficial Lactobacillus bacteria. These bacteria play an important role in maintaining a more acidic vaginal pH, which in turn helps prevent less desirable microbes from multiplying. Less estrogen can mean less glycogen, fewer Lactobacillus bacteria, and a higher vaginal pH. For some people, these changes may contribute to symptoms such as irritation, burning with urination and potentially greater susceptibility to urinary or vaginal infections.

What does genitourinary syndrome of lactation feel like?

Not everyone will experience symptoms, and those who do may not experience all of them.

You might notice:

• Vaginal or vulvar dryness

• Burning or irritation

• Pain with penetration or intercourse

• Less natural lubrication

• Changes in arousal or sexual comfort

• Urinary urgency or frequency

• Urinary leakage

• Recurrent UTIs or UTI-like symptoms

Some research also suggests low estrogen may contribute to slower perineal wound healing after birth. It’s important to remember that more than one thing can be happening at the same time. Pain with sex after having a baby may involve vaginal dryness and/or scar sensitivity from a tear and/or pelvic floor muscles that are guarding or having difficulty relaxing. Adding lubricant might help, but there may be additional ways we can support you if we take the time to understand the more complete picture of your pain.

How common is painful sex postpartum?

Short answer? Very.

Research looking at postpartum dyspareunia—the medical term for pain with sex—estimates that it affects approximately:

~60% of people at 3 months postpartum
~40% at 6 months postpartum
~30% at 12 months postpartum

Common does not mean that it’s something you simply have to live with. One of the areas where I wish we did a better job in postpartum care is actually having these conversations. Knowing that you can talk about it - and get support! - is such an important starting point. Your six-week postpartum appointment doesn’t need to be the finish line for your recovery. If sex hurts, you are experiencing dryness, or your bladder suddenly feels completely different, those symptoms deserve attention.

Will vaginal dryness from breastfeeding go away?

Usually, yes.

During breastfeeding, the low-estrogen state is generally temporary. As breastfeeding frequency decreases, ovulation begins to return and ovarian estrogen production typically increases again. Symptoms often improve gradually during the first postpartum year and resolve after weaning. We are also living in a time when many people are starting or growing their families later in their 30s. For some, this means there may be a period when postpartum and perimenopausal changes overlap. If dryness isn’t improving after weaning, it’s worth discussing your symptoms with a healthcare provider.

Whether you are still breastfeeding or have weaned, you don’t need to live with pain and discomfort. We have a number of treatment options, depending on your symptoms and needs.

What can you do for vaginal dryness while breastfeeding?

Treatment depends on your symptoms and what is contributing to them.

1. A good lubricant is a good first step

If dryness or friction is primarily happening during sex, adding a lubricant can make a big difference.

Water-, silicone- and some oil-based lubricants can all be options depending on your preferences and whether you're using condoms or other products that may not be compatible with oil. Needing lubricant is normal and common. Your hormones have literally changed the amount of lubrication your tissues produce, so adding some extra support can be helpful. I generally recommend choosing a lubricant that is pH-appropriate. I’ll link my guide to choosing a lubricant here. One of our favourites, IRIS, was actually created by a Naturopathic Doctor.

2. Consider a vaginal moisturizer

Lubricants and moisturizers aren't quite the same thing. Lubricants reduce friction during sexual activity. Vaginal moisturizers are used regularly to help with baseline dryness and irritation, whether you're having sex or not. Think of it a bit like how you would moisturize other parts of your body if they were feeling dry.

Options containing ingredients such as hyaluronic acid may be helpful for some people. You can find more options in my lubricant and vaginal moisturizer guide. IRIS also makes a vaginal moisturizer.

3. Consider having a pelvic floor assessment

If penetration hurts, dryness may only be part of the picture. The demands of pregnancy, birth, perineal tearing, Cesarean birth recovery, pain and even the anticipation of pain can all influence how the pelvic floor functions. In response to pain or stress, the pelvic floor muscles may tense or guard as a protective response.

Pelvic floor therapy can help determine whether your symptoms are related to muscle tension, scar sensitivity, coordination, weakness, pressure management - or a combination of factors. Treatment might include education, breathing and relaxation strategies, manual therapy, scar work, gradual exposure to penetration and an individualized exercise plan.

4. Talk to your healthcare provider about vaginal estrogen

For more significant symptoms that aren't responding to non-hormonal options, low-dose vaginal estrogen may be worth discussing with your healthcare provider.

Local vaginal estrogen is very effective for genitourinary symptoms in menopause and has minimal systemic absorption. The evidence specifically studying vaginal estrogen during lactation is more limited, but is often used as a support during this time as well. With minimal systemic absorption, this is another safe option to discuss with your healthcare provider based on your symptoms and individual circumstances.

For someone struggling significantly with dryness, burning or pain, it's an option worth knowing exists.

5. Investigate persistent urinary symptoms

Burning, urgency and frequency aren't always a UTI - but they might be. These symptoms can occur alongside lactation-related changes, but we shouldn’t automatically attribute them to breastfeeding without an appropriate assessment.

If you are experiencing urinary symptoms, including pain, increased frequency or burning, it’s important to investigate for infection and other possible causes. From there, treatment can be targeted to what is actually happening.

Painful sex postpartum isn't always just one thing

When someone comes to see me and we are talking about painful sex postpartum, I'm not just thinking:

“Use lubricant.”

I'm thinking about the whole picture. Could lactation-related dryness be contributing? Is there scar tissue from tearing or an episiotomy? What is happening with the pelvic floor? Is there pain at the vaginal opening or deeper in the pelvis? Are there urinary symptoms? Is there fear or anticipation of pain? How are sleep, stress, nutrition and postpartum recovery affecting sexual desire and arousal? And, maybe most importantly:

What does my patient actually want to be able to do right now?

It’s OK if sex is not on your radar at six weeks - or six months - postpartum. Your timeline is your own.

My goal is to help you understand what’s happening in your body and support you as you adapt to this huge physical, emotional and hormonal transition. You don't need to rush back to intercourse because you've reached six weeks postpartum. You don't need to push through pain.

There are supports available when you are ready.

If you're currently pregnant, this is also something worth knowing about before your baby arrives. We spend a lot of time preparing people for birth and relatively little time preparing them for what their pelvic floor, hormones and sexual health may feel like afterward.

And if you're already postpartum and experiencing pain with sex, vaginal dryness, urinary symptoms or pelvic pain, pelvic floor therapy can help us figure out what is contributing and build a treatment plan around you.

If you are curious about what care would look like with us, Dr. Fiona Callender is a Naturopathic Doctor and Pelvic Therapist at Crafted Balance Clinic in Toronto. She supports patients from fertility, through pregnancy and postpartum, as well as with pelvic pain and pelvic floor concerns. She offers complimentary meet and greet appointments to help you feel confident before booking an initial appointment.

This article is for general education and isn't a substitute for personalized medical advice. Talk with your care team about your own alcohol use, especially if you have concerns about your drinking or underlying health conditions.