A 27-year-old woman, gravida 2 para 2, comes to the office for follow-up for postpartum depression. Five months ago, she underwent an operative vaginal delivery complicated by a second-degree perineal laceration. After delivery, the patient was started on a selective serotonin reuptake inhibitor for postpartum depression. Her mood has improved, but she is now having relationship issues. The patient reports no change in libido, but she has been avoiding sexual intimacy since delivery due to pain and dryness during intercourse. She is exclusively breastfeeding, and her menses have not returned. Vital signs are normal. The perineal laceration is intact. The vulva is nontender and normal perianal sensation and wink reflex are present. Pain is not reproducible on speculum examination. The vagina has minimal rugation with scant clear discharge. Which of the following is the most likely underlying cause of this patient's symptoms?

Question

A 27-year-old woman, gravida 2 para 2, comes to the office for follow-up for postpartum depression.  Five months ago, she underwent an operative vaginal delivery complicated by a second-degree perineal laceration.  After delivery, the patient was started on a selective serotonin reuptake inhibitor for postpartum depression.  Her mood has improved, but she is now having relationship issues.  The patient reports no change in libido, but she has been avoiding sexual intimacy since delivery due to pain and dryness during intercourse.  She is exclusively breastfeeding, and her menses have not returned.  Vital signs are normal.  The perineal laceration is intact.  The vulva is nontender and normal perianal sensation and wink reflex are present.  Pain is not reproducible on speculum examination.  The vagina has minimal rugation with scant clear discharge.  Which of the following is the most likely underlying cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d9b9_9d9f_bc81_d9a14f938dca_MD0003_00 This patient's pain and dryness with postpartum intercourse are most likely due to hypoestrogenism secondary to lactation. In breastfeeding patients, elevated prolactin levels suppress GnRH release from the hypothalamus, which causes low FSH, LH, and estrogen levels. Low estrogen levels inhibit ovulation (ie, lactational amenorrhea) and may induce menopause-like vasomotor symptoms (eg, hot flashes, night sweats) and vulvovaginal atrophy. Atrophic vulvovaginal changes cause dyspareunia due to decreased blood flow and collagen content, which lead to epithelial thinning (eg, loss of vaginal rugae) and decreased vaginal lubrication (eg, dryness). Treatment is supportive with nonhormonal lubricants and moisturizers; refractory cases may require vaginal estrogen. Symptoms typically resolve with cessation of breastfeeding and normalization of estrogen levels. (Choice B) Selective serotonin reuptake inhibitors are first-line medications for postpartum depression due to their high efficacy and tolerability. Sexual side effects with these medications are common; however, low libido is more typical than dyspareunia, making this diagnosis unlikely. (Choice C) The pudendal nerve is vulnerable to a compression or stretching injury during labor, particularly during an operative vaginal delivery or with an extensive (eg, third and fourth degree) perineal laceration. This diagnosis is unlikely because this patient has normal perianal sensation and a wink reflex, indicating an intact pudendal nerve. pudendal nerve (Choice D) Vaginismus, also known as genitopelvic pain/penetration disorder, describes pain with both sexual and nonsexual vaginal penetration (eg, tampon insertion, pelvic examination), likely due to involuntary pelvic floor contraction. This patient had no pain with speculum examination, making this diagnosis unlikely. (Choice E) Vestibular hypersensitivity (vulvodynia) is persistent localized vulvar pain with light touch (ie, pain with Q-tip test) with no detectable cause. This patient's vulva is nontender. Educational objective: Elevated prolactin levels associated with breastfeeding suppress GnRH release and induce a hypoestrogenic postpartum state. Patients may experience dyspareunia due to atrophic vaginal changes (eg, dryness, loss of rugation). Treatment is supportive with nonhormonal lubricants and moisturizers. References: Postpartum sexuality and the lactational amenorrhea method for contraception. (http://www.ncbi.nlm.nih.gov/pubmed/26457855) Interactions between metabolic and reproductive functions in the resumption of postpartum fecundity. (http://www.ncbi.nlm.nih.gov/pubmed/19298003)

A 27-Year-Old Woman, Gravida 2 Para 2, Comes to the Office