By Rebecca H. Allen, MD, MPH, Editor
Synopsis: In this systematic review of 65 studies, the prevalence of vaginal atrophy among postpartum breastfeeding patients was 63.9% (95% confidence interval [CI], 55.3% to 71.6%) and vaginal dryness symptoms occurred in 53.6% (95% CI, 33.6% to 72.5%). Dyspareunia also was elevated, with a prevalence of 60.0% at three months, (95% CI, 45.1% to 73.3%), 39.7% at six months, (95% CI, 28.9% to 51.5%), and 28.5% at 12 months (95% CI, 26.3% to 30.9%).
Source: Perelmuter S, Stokes C, Chapalamadugu M, et al. Postpartum and lactation-related genitourinary symptoms: A systematic review. Obstet Gynecol. 2025;146(1):59-72.
The authors of this study conducted a systematic review to describe the frequency and characteristics of genitourinary syndrome of lactation (GSL). They searched the English-language medical literature from inception through April 2024 to identify studies regarding postpartum breastfeeding and genitourinary symptoms. Articles were assessed for quality of evidence. At least two independent reviewers identified full-text articles eligible for inclusion.
The primary outcomes were the prevalence of dyspareunia (at three, six, and 12 months postpartum), vaginal atrophy, vaginal dryness, average Female Sexual Function Index (FSFI) score, and odds ratios (ORs) for dyspareunia and vaginal atrophy for breastfeeding women. Control groups were postpartum patients who were not breastfeeding.
A total of 1,234 studies were identified. Abstracts then were screened. After this, the full texts of 278 articles were reviewed, and 65 studies met the inclusion criteria. After assessment, 79.6% of studies were appraised as high quality, 14.3% were rated as moderate quality, and 6.1% were rated as low quality. There were four studies that evaluated vaginal atrophy, and the pooled prevalence was 63.9% (95% confidence interval [CI], 55.3% to 71.7%), with a risk ratio (RR) of 2.34 (95% CI, 1.65 to 3.32) for breastfeeding patients compared to control patients.
A total of 21 studies assessed vaginal dryness and reduced lubrication and showed a pooled prevalence of 53.6% (95% CI, 33.6% to 72.5%) for increased dryness and decreased lubrication. The prevalence of dyspareunia was 60.0% at three months (95% CI, 45.1% to 73.3%), 39.7% at six months (95% CI, 28.9% to 51.5%), and 28.5% at 12 months (95% CI, 26.3% to 30.9%), and a pooled OR of 2.33 (95% CI, 1.91 to 2.83) for breastfeeding individuals compared with controls.
Commentary
GSL now is being recognized as a significant clinical phenomenon that warrants further investigation. A group of experts recently coined the term.1 The elevated prolactin levels that occur during lactation suppress the secretion of gonadotropin-releasing hormone, which, in turn, reduces levels of estrogen and androgens. Hypoestrogenism leads to vaginal atrophy and dryness, as well as dyspareunia, dysuria, and recurrent urinary tract infections.2 This can affect the quality of life of postpartum individuals who are breastfeeding. Many patients may not be aware that this condition exists. Therefore, individuals may not know to ask their provider for help.
This systematic review demonstrates that the symptoms of GSL are quite prevalent among breastfeeding individuals. Just more than half of patients will have vaginal dryness, atrophy, and dyspareunia. The vaginal changes of GSL, as well as hormonal changes, postpartum recovery from delivery, and the stress of caring for a newborn all can affect postpartum sexual function.
GSL mirrors the genitourinary syndrome of menopause, and, presumably, treatment would be similar. However, after lactation ends, the patient should recover from this condition. It is estimated that 83% of U.S. women initiate breastfeeding postpartum and that 56% still are breastfeeding at six months.3 The American Academy of Pediatrics recommends continued breastfeeding up to two years.4 However, after menstrual cycling resumes as lactation tapers off, the symptoms of GSL should resolve.
Although most providers counsel patients not to have sex the first six weeks postpartum, we should ask our postpartum patients about sexual function and vaginal atrophy symptoms at their later postpartum visits. We often focus more on breastfeeding, postpartum symptoms such as bleeding, mood changes, and pain, and contraceptive needs. Nevertheless, obstetrics providers should add anticipatory guidance regarding the vaginal changes patients may experience while breastfeeding.
Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
