The frequency of depressive symptoms and the level of female sexual function were similar between women with persistent PGP and women in the control group. In the women with persistent PGP after childbirth, pain was experienced more frequently during sexual intercourse and they also more frequently avoided intercourse due to pain. This suggests that pelvic pain affects the sexual function of women with PGP.
Pelvic girdle pain may affect several aspects of women’s lives, including their sex lives during pregnancy [20] and in the postpartum period [2]. This is consistent with our finding that women with PGP avoid sexual intercourse more frequently because of pain. In the present study, quite intense provoked pain on anatomical landmarks within the small pelvis was an inclusion criterion for all the women with PGP. This could explain the increased pain intensity during penetrative sex reported by women with PGP.
To the best of our knowledge, this is the first detailed controlled study using the MFSQ to assess the sexuality of women with persistent postpartum PGP. In an earlier study, Mogren et al. [12]. used a simple questionnaire with yes/no answers to investigate whether women with PGP were satisfied with their sex lives. They concluded that women were less satisfied with their sex lives during pregnancy and that women with higher pain scores were more likely to be dissatisfied. In a 6-month follow-up study, they found that the women’s satisfaction had not returned to prepregnancy levels, but that it no longer differed between women with different intensity of pain during their pregnancy [13]. A 12-year follow-up study of the same group of women showed that most women were satisfied with their sex lives [21]. Their postpregnancy findings are consistent with how most women rate their sexual interest and activity after childbirth [22]. Tenfelde et al. studied women with musculoskeletal pain (the majority having PGP and pelvic floor myofascial pain) using Female sexuality function index subscales. Women with pain reported lower satisfaction with their sex lives and a greater degree of pain or discomfort associated with vaginal penetration, but had no changes in desire, arousal and orgasm [23]. Their findings of increased discomfort and pain during intercourse for women with PGP are consistent with our results.
Chronic pelvic pain includes all types of pelvic pain that persist for > 6 months, and is associated with a higher level of vaginismus, sexual avoidance, nonsensuality, and sexual dissatisfaction. Both anxiety and depression occur more frequently among women with chronic pelvic pain [14]. Verit et al. [11] concluded that sexual pain disorder was the commonest sexual dysfunction in their study population (women with chronic pelvic pain), and a longer period of pain was associated with higher levels of sexual dysfunction. We detected no correlation between the duration of pain and the MFSQ score in our study. However, in the study by Verit et al., the period of pain among the patients was longer than in our study. It is possible that pain causes more extensive sexual problems if it persists for a long time. In contrast, another study of sexuality in patients of both sexes with any type of chronic pain (predominantly musculoskeletal pain in the lower back, lumbar spine, sacrum, or coccyx) suggested that a shorter period of pain correlated with greater sexual dysfunction and less use of coping strategies to overcome that pain [24]. The authors explained these results by proposing that when patients learn to live with their pain, they report less sexual dysfunction.
Pelvic girdle pain is complex and multifactorial, with no obvious etiology. However, some common factors range from peripheral or central nervous system involvement, altered laxity/stiffness of the muscles or tendinous or ligamentous structures, and ‘maladaptive’ body mechanics [25]. Although it has been suggested that the development of PGP is associated with high levels of ovarian and placental hormones during pregnancy, the evidence is inconsistent [26, 27]. Different types of pain have different pathophysiological mechanisms, with different short- and long-term effects. It is unclear if PGP behaves in the same way as other musculoskeletal pains or chronic pelvic pain.
It have been shown that women with musculoskeletal pain including PGP are more likely to have pelvic floor and levator ani tenderness, but no difference in muscle strength [23]. Increased tenderness of deep pelvic flood muscles with maintained muscle functions has previously been shown in women with PGP during pregnancy [28]. Using a combination of palpation, manometry and 3D ultrasound in women with PGP more than 6 months after birth, Stuge [29] found no differences in voluntary pelvic floor muscle function but levator hiatus was smaller and there was a tendency for a higher resting pressure. These finding might indicate an increased muscle activity to protect from their PGP. An increased muscle activity could lead to muscle tenderness and pain during vaginal intercourse.
It has been suggested that painful intercourse and pain-related psychosocial factors increase the pain experience, but it is unclear how these factors affect one another. Women with pelvic pain may perceive stimuli as more painful than pain-free women when the magnitude of the stimulus is the same [30]. A study of women with chronic pelvic pain found that these patients may show pain-related psychological behavior (including catastrophizing) and hypervigilance during intercourse. It has been demonstrated that women with vulvodynia report hypervigilance to pain during intercourse, suggesting that increased attention to the threat of a painful stimulus during intercourse may interfere with and change the experience of intercourse [31]. However, some studies have offered physically based explanations [32].
The prevalence of depressive symptoms has been studied with different instruments, but the one used most frequently both during and after pregnancy is EPDS. The prevalence of depression in a Swedish population at 6 months postpartum was reported to be 13% on EPDS, when a cut-off of > 10 was used [33]. In our study population, the prevalence of depressive symptoms was higher than expected in both groups. Using a cut-off value of ≥13 for MADRS-S, we detected depression in 26.1% of women with PGP and in 28.2% of women in the control group. Studies have shown a correlation between the MADRS and EPDS [34]. MADRS is rated by a physician and MADRS-S is the self-rated version, and moderate to good agreement between the two scales has been demonstrated [35]. We have found no studies that compared the MADRS-S and EDPS instruments. It is possible that the use of MADRS-S contributed to the higher rate of reported depressive symptoms in our study.
A systematic review recently suggested that pain has negative emotional and psychological effects on patients with pregnancy-related PGP. Women reported feelings of frustration and guilt and were upset because they were unable to carry out their normal roles, and PGP may also have affected the women’s sense of identity and ability to care for their children [36]. A large Norwegian cohort study showed that the risk of persistent PGP after delivery is increased in women who report higher levels of emotional distress during pregnancy, and this remained true after adjustment for pain severity [8]. Similar results were obtained in a study from the Netherlands [37]. In contrast, another Norwegian cohort study found no significant correlation between the emotional distress measured 6–16 weeks after delivery and recovery from PGP at 12 months after delivery [38].
Few studies have used a validated instrument to detect depression in women with PGP. Using EPDS, Gutke et al. [9], suggested that women with lumbopelvic pain are three times more likely to suffer postpartum depressive symptoms than those without pain, and after subgrouping for PGP, the differences were significant for a cut-off value of > 10 (but not for a cut-off of > 13). Similar results were reported in an Australian study of pregnant women, in which lower back pain was associated with an increased risk of depression [39], but that study did not differentiate between lower back pain and PGP. In contrast, in our study, the total MADRS-S score and the number of women scoring ≥13 did not differ between the two groups. Because the association with depressive symptoms was stronger for back pain than for PGP in the study by Gukte et al. [9] and the location of pain was not specified in the Australian study [40], back pain may have a greater effect on psychological wellbeing than PGP. Elden et al. [10] observed higher levels of depressive symptoms and anxiety in women with PGP about 11 years after they had given birth. Therefore, we speculate that a longer period of PGP is required to affect psychological wellbeing than is required for other types of pain.
In women, chronic pelvic pain, regardless of the underlying cause, is correlated with depression [6, 14]. It has been suggested that among women with PGP, the patient’s belief in an early-postpartum improvement in their condition is positive factor, reducing her functional disability and pain in the first year [38]. In other words, if a patient believes that she will become healthy, the pain may affect her mood less strongly during that period.
Associations between depression and sexuality have been demonstrated in both the general population [41] and in women during the first year after childbirth [39, 42]. The correlation we observed between MFSQ and MADRS-S is consistent with those study results.
The number of women who smoked was significantly larger in the group with PGP than in the control groups. European guidelines (2007) state that smoking is not a risk factor for PGP [1], and this has been supported by studies of women with postpartum PGP, [43] although other studies have disagreed [7]. We identified no relationship between smoking and the scores for sexuality or depression.
One of the strengths of this study is that all the women with PGP underwent clinical examinations to confirm the diagnosis. We also used a valid instrument to assess sexuality and as far as we know, MFSQ has not been used previously in a similar population. The study has several limitations which affects the generalizability. We recruited the control group separately from the women with PGP and did not match them to the women with PGP. With limited time and resources, we decided to not examine the women that reported that they are pain free. We cannot be certain what factors prompted women to participate but our analysis of baseline characteristics shows now significant differences between the group except from smoking habits. Since, there was no prior studies on PGP, power calculations in this study was based on sexual dysfunction among women with chronic pelvic pain and not PGP specifically. Given that the mechanism of pain may be different in chronic pelvic pain and PGP, it may have caused the study to be underpowered. On the other side, the study sample was small, which might increase the risk of type 2 error.
