Vaginal Laxity and Childbirth: Is a “Loose Vagina” Common? Treatable?

Woman on bicycle picture for vaginal laxityFollowing childbirth new mothers can feel distressed about the changes they see in their bodies. The majority of these changes go away naturally, but some changes can persist. One commonly held belief is that childbirth permanently stretches and thereby “loosens” the vagina. Is a “loose vagina” a common consequence of childbirth, and if so, is it treatable?

In this blog post Lindsay, with the help of our Pelvic Physiotherapist Katie, discusses vaginal laxity following childbirth: its prevalence, causes, risk factors, and treatment options.

Can vaginal birth really cause a “loose vagina”?

For some women the answer appears to be yes. Vaginal delivery can result in persistent feelings of vaginal laxity. This laxity can reduce vaginal sensation during intercourse and diminish sexual satisfaction of both partners, which can in turn lead to decreased sexual self-esteem and a drop in sexual intimacy.

How common is this complaint in mothers?

Vaginal looseness is a subjective and self-reported sexual health concern. There are no objective measures of it, and so there are few good statistics on the prevalence of vaginal laxity following vaginal childbirth.

When it is investigated, vaginal laxity is typically lumped in with other female sexual dysfunctions. One recent Australian study of FIRST-TIME mothers found that some form of female sexual dysfunction was reported in 58% of mothers ONE YEAR after childbirth (ref 1). The main complaints included insufficient lubrication, abnormal vaginal sensation, vaginal laxity, vaginal tightness, pain with intercourse and incontinence during intercourse.

An earlier (but perhaps less reliable) survey of 25 to 45-year-old women with at least one vaginal birth, reported that approximately half of women expressed concern over vaginal looseness (ref 2). It has also been reported to be the most common physical concern discussed with OBGYNs after vaginal childbirth (ref 3).

So vaginal looseness appears to be a rather common complaint, or at the very least, a meaningful concern for many women following vaginal birth.

How could vaginal birth cause vaginal “looseness”? Am I at risk?

The walls of the vagina contain an elastic muscle that is normally folded up, holding the vagina closed tightly. During sexual arousal and childbirth hormones cause the muscle to relax. The vagina is designed to be able to relax and re-tighten repeatedly, without any loss of tone or tissue elasticity.  Accordingly, regular sexual activity does not loosen the vagina. But there are limits to the elasticity of this muscle and associated tissues, and a few risk factors are known to contribute to chronic feelings of vaginal looseness.

Risk factors that contribute to vaginal laxity:

  1. Age. Vaginal laxity can occur naturally with aging in some women, the result of a gradual weakening and atrophy of the vaginal muscles and tissues over time.
  2. Multiple vaginal births. Evidence suggests that having multiple vaginal deliveries can increase the chance of vaginal fatigue and incomplete recovery of pre-pregnancy vaginal tightness.
  3. Trauma during vaginal childbirth or other event. This category includes damage to muscles of the pelvic floor which surround and help maintain the position and shape of the vagina. Varying degrees of musculoskeletal trauma occur commonly with vaginal delivery, and so this is likely to be a common occurrence.

So in broad terms, a young mother with an uncomplicated vaginal delivery will usually fully recover vaginal tightness within the first 6 months of having her first child. Whereas women having children later in life, having multiple vaginal births, or having more significant injury during childbirth, are at a greater risk of experiencing chronic vaginal laxity that lasts beyond the first 6-12 months.

Vaginal laxity, not prolapse

Vaginal looseness is a condition that is distinct from vaginal prolapse, but can sometimes be confused with it. With vaginal laxity the vaginal tissue becomes loose or relaxed, and this is associated with feelings of reduced tightness. In contrast, with vaginal prolapse, displacement of pelvic organs (such as the bladder, rectum, urethra or small bowel) pushes on the walls of the vagina causing it to leave its normal position. This can manifest as sensations of “falling out”, and uncomfortable or painful intercourse.

Pelvic floor physiotherapy for vaginal laxity

How might pelvic floor physiotherapy help increase vaginal tightness?

Even without looking at the clinical evidence, it seems like a good bet to assume that pelvic floor physiotherapy in the form of exercise therapy could help with vaginal looseness. Pelvic floor physiotherapy is a highly recommended non-invasive treatment for a wide variety of pelvic issues including incontinence, pelvic prolapse and pelvic pain. There is also a large body of literature supporting the effectiveness of physiotherapy treatments for a wide range of other musculoskeletal injuries, atrophies and deficiencies. So we might expect it to help with vaginal laxity as well.

Indeed, it is common practice in the medical community to use targeted pelvic physiotherapy interventions, specifically pelvic exercise therapy, to help reduce feelings of vaginal laxity. Kegels and other exercises are often recommended to patients suffering from a variety of pelvic health concerns (although sometimes incorrectly) including women with complaints of having a “loose vagina”. These exercises are not intended to tighten the muscles of the vagina directly, instead, they may be used to help strengthen and tighten the pelvic floor muscles that surround the vagina. This in turn may increase feelings of vaginal tightness both at rest and when the woman voluntarily contracts her pelvic floor muscles.

It has also been suggested by clinical researchers that good pelvic floor muscle tone, strength and the ability to effectively contract these muscles, can improve vaginal sensations during intercourse including feelings of tightness, orgasmic response and the pleasure of both partners (refs 4,5,6). However, it’s still a pretty small field of research with small study sizes and simple study designs, and so it’s not surprising that there are also a few studies that offer contradictory results as well (refs 7,8). More research is needed.

So, although pelvic floor muscle strengthening exercises to treat vaginal looseness makes good sense physiologically, is often recommended, and is supported by anecdotal evidence, clinical research evidence has been slow to accumulate.

What clinical evidence is there to support pelvic floor physiotherapy for treating vaginal looseness?

As mentioned, there is not a large body of research in this field yet, however, the clinical studies that have been done are beginning to show promising results that pelvic floor physiotherapy can indeed help vaginal looseness.

One such study published this year directly asked this question in first-time mothers – would pelvic floor physiotherapy help with symptoms of sexual dysfunction following childbirth (ref 9). In this study the researchers evaluated 175 first time mothers and gave them either pelvic floor physiotherapy or no treatment, between 6 weeks and 6 months postpartum, and then examined the differences in sexual function between the two groups.

Overall, women in the physiotherapy group had the same outcomes as the non-physiotherapy group –  there was no difference in vaginal symptoms or sexual dysfunction at 6 months postpartum between the groups as a whole. This is not surprising nor discouraging for the potential benefit of pelvic floor physiotherapy, as negative results are common in clinical trials of physiotherapy treatments. Sample sizes are often too small to show statistical differences when only a small percentage of study participants should be expected to have a condition that might benefit from physiotherapy. In other words, any positive effects experienced by the small sub group of patients that might benefit from the therapy is lost in the crowd. Pelvic floor physiotherapy is also not intended as a cure-all for all forms of sexual dysfunction, and sexual dysfunction is a hard subject to study.

Despite the challenges of this particular study, and the fact that it only evaluated first-time mothers, a subgroup of these study participants that had experienced trauma during childbirth to the levator ani muscle (a muscle of the pelvic floor that runs adjacent to the vagina) showed a 45% decreased risk of having feelings of vaginal looseness when they received pelvic floor physiotherapy, compared to the control group. Therefore, in new mothers with a risk factor for vaginal looseness (see risk factor #3 above), pelvic floor physiotherapy appears to help.

So alongside the anecdotal and theoretical support for pelvic floor physiotherapy, there is now some direct clinical data suggesting that pelvic floor physiotherapy could act to prevent symptoms of vaginal laxity, at least in one group of high-risk mothers who endured muscular trauma/damage during childbirth.

Overall, the best evidence suggests that pelvic floor physiotherapy helps encourage healthy pelvic floor muscle function and can thereby decrease feelings of vaginal looseness resulting from childbirth.

Are there other options for treating vaginal laxity besides physiotherapy?

Surgery for vaginal tightening

Reconstructive surgery can be used to shorten and/or change the shape of the muscles and tissues around the vagina, and fat transplantation can be used to increase the fullness of the tissue. These and other surgical approaches can be very effective at increasing vaginal tightness in patients. However, surgery is invasive, and has associated risks including the potential for nerve damage and loss of vaginal sensitivity.

Surgical approaches are typically only recommended for patients with vaginal laxity that appears unresponsive to pelvic physiotherapy. If you are considering surgery, please discuss your candidacy and your options with your family doctor.

Creams, pills and ointments for vaginal tightening

There does not appear to be any creams, pills or ointments with actual clinical data to back up their claims of improving vaginal tightness.

Non-prescription creams and pills are not medical products, and are not held to the same regulatory or efficacy standards as actual medical treatments. The claims made on such bottles often have no clinical data to support them. Nor are there any compelling reasons to believe that these products would work, especially as a long term solution for vaginal laxity.

Some of these products may also pose a safety concern, causing vaginal irritation, infection, and allergic reaction. In general, I would say that these products should be avoided. If you feel compelled by the claims made by the manufacturers of these products, please discuss them with your family doctor before trying them out.

Radiofrequency thermal therapy for vaginal tightening

Another product on the market directed towards vaginal tightening is radiofreqency thermal therapy. This is basically a device that can warm the vaginal tissue without burning the surface of the skin. The idea behind this product is that local heating of the tissue will stimulate collagen formation in the vaginal tissue and thereby re-tighten the tissue at the opening of the vagina. The commercial leader in this space appears to be the Geneveve product by Viveve.

Although marketing materials for these products claim that they are “clinically proven”, they are not. There have been a very small handful of studies published on this type of therapy, and nothing before 2010. All of these studies were designed without a proper control group, and used subjective (patient reported) measures for vaginal tightening and sexual satisfaction as the exclusive outcome measure. This means that the studies didn’t include a group of women who received no treatment that they could compare their test subjects to. Even better would have been a group of patients who believed they were receiving the treatment but were in fact receiving no therapy at all (a “blinded control”) – which presumably could easily have been achieved by disabling the machine so that the patient doesn’t know that it’s not working (as is commonly done in well-designed clinical trials of this sort).

So the studies published to date are basically only usable to show the safety of radiofrequency thermal therapy rather than the efficacy of it. Uncontrolled studies with subjective outcome measures such as these can suffer enormously from the placebo effect, and in most instances are entirely unreliable when it comes to determining how well a therapy actually works. In other words, there is currently NO clinical data supporting the proposed benefits of radiofrequency thermal therapy for vaginal laxity whatsoever.

Is there anything I can do about vaginal laxity on my own?

Currently the best non-invasive treatment for vaginal laxity is pelvic floor strengthening. This can be accomplished on your own with a little effort and practice. Kegel exercises are a well-known example of a pelvic floor exercise, and one that is well suited to this task.

So how do I get started with using kegels to increase vaginal tightness?

#1 Learn to find and contract the muscles

The first and possibly most difficult step is to identify the correct muscles in your pelvis to strengthen. The best description I have heard for finding these muscles is to try to stop urinating mid-stream. Other common cues include trying to “stop gas” or “hold in a tampon”. The muscles that help you do this are the muscles that you need to contract to do a “kegel”. You should actually try this, don’t just imagine trying it and assume you’ve found the muscles. You may be very good at finding these muscles, or you may be surprised that you can’t. A word of caution though: don’t regularly perform kegels while urinating.  It’s more just a way to try to “find” them so that you know which muscles to target.

For some women finding these muscles and learning to consciously contract them can be very challenging. This is particularly true for women with low muscle tone, women that have sustained muscle injury in the area (which may reduce the tone and contractility of the affected muscles) and women with reduced pelvic floor sensation – all of which can be common in mothers. Finding the muscles and learning to contract them can also be very challenging for women who previously learned to do kegels the wrong way.

This is where asking for a bit of help can go a long way. A pelvic physiotherapist can help you quickly identify and learn to contract the correct muscles. They do this by offering you the right verbal cues while examining your body externally and/or internally (which is optional but very effective). A pelvic physiotherapist can not only ensure that you are using the correct muscles, but also  confirm that you are contracting them to the correct amplitude (strength of contraction). They will teach you supportive breathing, help you progress your strengthening routine with time, and help you develop a maintenance program to keep your gains in the future.

After you have found the correct muscles, now it’s time to do some work. Thankfully this can be quite quick and completely discrete. A simple isometric approach (contracting and holding the contraction) can be effective, but some women may want to include physical devices in their exercise routines, such as trying to hold vaginal cones inside their vagina. As strengthening progresses, it can also be beneficial to practice pelvic floor muscle contractions in different positions and during different activities, to help train the muscles to provide support for various demands.

A pelvic physiotherapist has many tools at their disposal that can be recommended to their patients, based on their individual needs.

#2 How much and how often?

This is something that varies a great deal between patients, based on the nature of their particular vaginal laxity, their ability to locate and contract the pelvic floor muscles correctly, the degree of weakness, and so on.  Again, the exercise guidance that a pelvic physiotherapist provides can vary significantly between individuals, but generally you can think of pelvic muscle strengthening programs as very similar to other endurance strengthening exercise programs.

Here’s a good way to start your own exercise program for vaginal tightening:

  1. Perform your kegel exercises twice per day. Performing the exercise more frequently may not significantly improve gains, but will certainly make it harder for you to stick with it.
  2. Get in a comfortable sitting or lying position and locate your pelvic floor muscles (as described in the proceeding section).
  3. Hold a 10 second contraction of your pelvic floor muscles 10 times in a row. Do this for three sets with a minute rest in between sets. So this equals 30 contractions, twice per day.

As your pelvic floor muscles improve their strength and endurance, progressing your exercise program can offer additional improvements in vaginal tightness. Such progression could include training the muscles while you are in other positions, or with movement such as during transition from sitting to standing. As with other strengthening exercises, it’s important to exercise them to the point of fatigue in order to build the muscles.

To help you keep your hard-fought gains it is also important to develop a maintenance program. Similarly, you wouldn’t stop working out at a gym and expect to keep the results. Performing kegel exercise three times per week is typically enough to maintain gains, while not being too big of a commitment to stick with it.

The bottom line on vaginal laxity and childbirth

Vaginal looseness can be a difficult topic to discuss, and so the frequency of this condition is likely to be underreported clinically (ref 3). Despite this, accumulating evidence suggests that it is a common condition following vaginal childbirth. Risk factors for vaginal looseness include the mother’s age, the number of vaginal births and vaginal / pelvic floor trauma during childbirth.

If you’ve recently given birth, be patient with your body. It could take more than 6 months to recover normal vaginal tightness and sensation. But for those women with persistent laxity concerns that continue beyond the first year, or who otherwise wish to be proactive, you can get started right away on improving the fitness of your pelvic floor muscles.

In fact, for many women the best time to begin pelvic floor strengthening or to seek the advice of a pelvic physiotherapist is during pregnancy. Unfortunately, it can be more difficult to feel your pelvic floor muscles during pregnancy due to a natural loss of body awareness (“proprioception”). Despite the added challenge, this can be fruitful. It stands to reason that appropriate pelvic floor strengthening during pregnancy would lead to better pelvic floor health outcomes post-partum for a wide range of pelvic disorders including vaginal laxity. Kegel exercises are generally safe for women with uncomplicated pregnancies, and most women would benefit from doing them (unless they have over-active pelvic floor muscles), but you should consult your health team before starting any exercise program during pregnancy.

If you are suffering from chronic feelings of vaginal looseness, try our suggestions above, and consider seeking out the advice of a pelvic health physiotherapist or other sexual health specialist. With a little bit of guidance, you may achieve some meaningful and lasting improvements.

References

  1. Durnea C.M., Khashan A.S., Kenny L.C., Tabirca S.S., O’Reilly B.A. The role of prepregnancy pelvic floor dysfunction in postnatal pelvic morbidity in primiparous women. Int Urogynecol J. 2014;25:1363–74.
  2. Millheiser L., Kingsberg S., Pauls R. A cross-sectional survey to assess the prevalence and symptoms associated with laxity of the vaginal introitus [abstract 206]. Presented at: ICS Annual Meeting; Toronto, Ontario, Canada. August 23-27, 2010.
  3. Pauls R.N., Fellner A.N., Davila G.W. Vaginal laxity: a poorly understood quality of life problem; a survey of physician members of the International Urogynecological Association (IUGA). Int Urogynecol J. 2012;23:1435–1448.
  4. Martinez C.S., Ferreira F.V., Castro A.A.M., Gomide L.B. Women with greater pelvic floor muscle strength have better sexual function. Acta Obstet Gynecol Scand. 2014;93:457–502.
  5. Lowenstein L., Gruenwald I., Gartman I., Vardi Y. Can stronger pelvic muscle floor improve sexual function? Int Urogynecol. J. 2010;21:553–6.
  6. Braekken I.H., Majida M., Ellstrom E.M., Bo K. Can pelvic floor muscle training improve sexual function in women with pelvic organ prolapse? A randomized controlled trial. J Sex Med. 2015;12:470–80.
  7. Chambless D.L., Stern T., Sultan F.E., Williams A.J., Goldstein A.J., Lineberger M.H., et al. The pubococcygens and female orgasm: a correlational study with normal subjects. Arch Sex Behav. 1982;11:479–90.
  8. Baytur Y.B., Deveci A., Uyar Y., Ozcakir H.T., Kizilkaya S., Caglar H. Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynaecol Obstet. 2005;88:276–80.
  9. Kolberg Tennfjord M., Hilde G., et al. Effect of postpartum pelvic floor muscle training on vaginal symptoms and sexual dysfunction-secondary analysis of a randomized trial. BJOG. 2016 Mar;123(4):634-42.

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