What actually happens to your pelvic floor when you give birth, and why does no one explain it beforehand?
Dr. Alexandra Dubinskaya is a urogynecologist and pelvic reconstructive surgeon based in Los Angeles, treating urinary incontinence, pelvic organ prolapse and sexual dysfunction. She's built a following speaking plainly about the birth injuries most obstetric conversations skip over. This episode covers what actually causes pain during sex after childbirth, from hormonal shifts to nerve injury to scar tissue, and what you can plan for if you already live with pelvic pain before you give birth.
Painful sex after birth: why breastfeeding hormones are often the hidden cause
One of the most common reasons for painful sex after birth isn't a birth injury at all - it's vaginal atrophy, sometimes called genital urinary syndrome of lactation. Breastfeeding suppresses the hormonal support the vaginal tissue normally has, and postpartum women can experience dryness, urgency, or recurrent bacterial vaginosis as a result. It's a real, physiological cause of dyspareunia, not something to just push through.
The fix, Dubinskaya says, is the same local vaginal estrogen used for perimenopausal or postmenopausal women, and it's safe to use while breastfeeding. It's a treatable cause of postpartum sexual health problems that too often goes undiagnosed because no one mentions it's an option.
It's very important to start vaginal estrogen, similar to how any perimenopausal woman or postmenopausal woman will do. It's safe with breastfeeding and it will significantly improve quality of life and intimate health.
Tearing, scar tissue and granulation tissue: what actually needs to heal before pelvic floor therapy works
Tearing during birth usually heals, but sometimes granulation tissue forms at the site of a tear or episiotomy - tissue that struggles to heal properly and is extremely painful to the touch. Treatment can mean applying silver nitrate to the area or, in some cases, surgically excising the scar to let it heal again. Some women also develop a sensitivity to the sutures used to repair the tear, which shows up on allergy testing and can explain why a wound isn't closing the way it should.
Getting the order right matters. Dubinskaya is clear that the vaginal tissue needs to be optimised first - estrogen applied, granulation tissue resolved - before starting pelvic floor physical therapy. Jump straight to PT and you risk triggering more pain and muscle spasm rather than progress.
My only comment is make sure that your vaginal tissue is optimized first, so you use the vaginal estrogen, you don't have any granulation tissue, and then doing physical therapy. Because if you jump to physical therapy before your tissue optimizes, it's going to cause a lot of pain and spasm in the muscles.
Pudendal nerve injury and pudendal neuralgia after vaginal birth
Vaginal birth is, in Dubinskaya's words, blunt trauma to the pelvic floor muscles - even without a visible tear. The pudendal nerve, one of the major nerves supplying the pelvic floor, can stretch several centimetres during pushing, causing an injury that often presents as numbness or reduced sensation during penetrative sex. Many women describe this as their vagina feeling "loose," when it's actually nerve injury affecting sensation, not a change in anatomy.
Episiotomies are a common cause of pudendal neuralgia specifically, because the cut is typically angled through exactly the area where the pudendal nerve reaches the perineum. That's why so many women remember that scar for decades afterward, not always as sharp pain but as a constant background awareness.
It's actually very common for women to remember that scar 10, 20, 30 years after. It's not necessarily just sharp pain, but that constant awareness.
Planning a birth when you already have pelvic pain: what to discuss with your care team
If you already have baseline pelvic pain - provoked vestibulodynia, for example - going into pregnancy, it's worth having an honest conversation with your OB about family size and delivery options well before labour starts. The relative risks of repeat C-sections versus vaginal birth and its associated pelvic floor disorders should factor into that conversation, not just default assumptions about what's "normal."
Practically, that can mean requesting an early epidural to avoid repeated cervical checks, minimising internal exams, and agreeing on a "safe word" with your care team in advance - a clear signal that you need to pause, switch course, or move to a C-section. If pain after childbirth is already part of your story, Dubinskaya's message is simple: you're not alone, and in most cases, there's a plan to be found, even if the pain can't be eliminated entirely.
