Changes of sexual function in women

Lubrication (vaginal lubrication)

Lubrication is a lubricating fluid that is secreted by glands during sexual arousal. Lubrication occurs during the peak period of sexual arousal and facilitates penetration.

Depending on the level of paralysis, women with spinal cord injury (SCI) might show fewer or no physical signs of sexual arousal. However, this does not mean that they are not aroused.

Psychogenic lubrication

Attractiveness and charisma of the partner are effective psychological stimuli that can evoke lubrication. Odours, visual and acoustic stimuli, as well as one’s own imagination, expectations and sexual desires might also cause psychogenic lubrication. Psychogenic lubrication can basically occur in paraplegic women with a spinal cord injury below the Th11 level – in the case of a complete paralysis above Th11, lubrication is rather unlikely.

Reflexogenic lubrication

Women with complete paralysis above the Th11 level can experience vaginal lubrication via direct stimulation. Women with complete paralysis at a lower level have no reflexogenic lubrication.

Assistive devices

If the vagina is too dry, the use of lubricants can facilitate penetration of the penis or sex aids. Oils, Vaseline, water or silicone-based lubricants can be applied. If condoms are used, avoid oil-based lubricants, as these can cause microscopic cracks in latex condoms. Oils and Vaseline are therefore not suitable for safe sex. Lubricants are available in pharmacies, drugstores, supermarkets and sex shops.

Orgasm

Depending on the level of paralysis, women with SCI may or may not have orgasms. Women with SCI no longer sense the physical stimulation of the genitals and the pelvic area as intensely as they did before the SCI. The orgasm is sensed differently, e.g. as a comfortable and warm feeling in the pelvic area, not at all or even as unpleasant. The unpleasant feeling can be caused by spasticity occurring in the legs or the abdominal area, or by an autonomic dysregulation. Furthermore, it takes longer to achieve orgasms than before the SCI.

Women often report what they describe as so-called “para-orgasms”. Para-orgasms are unique. They can involve a combination of physical sensations, emotional reactions, memories, imaginations and visual and / or acoustic stimuli – therefore, these orgasms are holistic body experiences that are not limited to the genital area.

Fertility

Menstruation might stop right after a traumatic spinal cord injury, but will start again after 2 – 12 months. Conception is absolutely possible in women with SCI. When a woman is born, her ovaries already contain all the ova she will ever produce. Oogenesis and ovulation are controlled hormonally, and the transport of the egg through the fallopian tube to the uterus is ensured by uncontrolled muscle movements of the fallopian tube and by the movements of the cilia.

Contraception

The absence of menstruation following spinal cord injury does not necessarily mean that the woman is protected against pregnancy. Contraception is therefore recommended. Basically, all common contraceptive methods are suitable for women with SCI. The different methods have pros and cons – it is therefore important to talk to your gynaecologist before choosing one: hormonal contraception with oestrogens (birth control pill) increases the risk of thrombosis. Methods based on temperature monitoring may not be reliable in women with spinal cord injury. Frequent infections or tetraplegia-related temperature regulation disorders can affect body temperature.

Mirena®

The application of the hormone spiral Mirena® is recommended. Mirena® exerts its effects locally in the uterus and thus ensures long-lasting, extremely reliable protection against pregnancy. A flexible plastic cylinder containing a hormone that has been used in contraceptive pills for many years is placed in the uterus. Mirena® releases small amounts of the hormone locally into your uterus at a slow and steady rate – there it starts to work. The hormone reduces the monthly growth of the uterine mucosa. This may prevent the egg from implanting, and periods will be reduced naturally. With there being no more periods, there is no longer any need to change tampons or sanitary towels.

Pregnancy

Women with SCI can experience completely normal pregnancies; however, some things have to be considered or done:

• Cooperation between gynaecologist, paraplegiologist and midwife must begin as quickly as possible.
• Make sure your medication does not harm the embryo.
• Physiotherapy, elevation of legs, compression stockings or medication to prevent thrombosis.
• Pregnant women should learn how to palpate the abdomen by themselves, in order to control labour (abdomen is hard, uterus grows upwards). In the case of no sensitivity, the pregnant woman needs to know which signs might possibly indicate labour.
• Most women know their bodies very well and know exactly what kind of symptoms replace pain, e. g. spasticity, feeling of pressure, headache, and goose bumps or sweating.
• Adaptation of assistive devices, e. g. a wider wheelchair, new seat cushion to compensate for weight gain and thus prevent decubitus, wheelchair accessible cot
• Pay attention to any signs of autonomic dysregulation: the closer the delivery date, the higher the risk.
• Adaptation of delivery date: women with SCI usually deliver prior to the expected date of delivery. Tetraplegic women generally deliver 24 days earlier, paraplegic women 5 – 6 days earlier. This normally does not pose any problem for the baby as the newborns do not require special monitoring. The advantage for the mothers is that they do not have to go through those final, most difficult weeks of the pregnancy.

Delivery

It is basically possible to experience a spontaneous delivery without complications even if the mother is unable to actively assist. The uterus has an independent conduction system that significantly influences delivery. In most cases, completely relaxed abdominal and pelvic floor muscles facilitate delivery. In the case of delay in the second stage of labour, instrumental vaginal delivery is recommended (forceps delivery, ventouse). The necessity for a C-section is the same as in women without SCI.

However, the situation is more difficult in women with high-level paraplegia or tetraplegia with autonomic dysregulation. Symptoms that may indicate autonomic dysregulation can be headaches, sweating and slow pulse and impeded nasal breathing as a result of a swollen mucous membrane. Due to these possible complications, women with spinal lesions at Th6 or higher require regional anesthesia when delivering.

Abortion

Abortion can be induced by medication or surgical procedures, such as vacuum aspiration or scraping (curettage). In women with complete sensory paralysis, this should be performed under anaesthesia, in order to prevent autonomic dysregulation.

Medical check-up

The annual medical check-up is also necessary for ensuring the health of women with SCI. However, only very few gynaecological practices can provide the necessary infrastructure or auxiliary staff. For help with this, contact the outpatient unit of your local spinal cord injury centre.