Pregnancy's lasting toll

photo of three generations of women, with the middle on the left, youngest in the middle, and oldest on the right

It's said that once we've given birth, we're forever postpartum. Indeed, the effects of pregnancy on our bodies often last far beyond the six-week checkup — when an OB/GYN typically declares us fully recovered — with some damage not apparent until our babies go to school or even become parents themselves.

Carrying a child and giving birth, whether vaginally or by cesarean section, can stress muscles, ligaments, and nerves responsible for sexual function and bladder and bowel control. While genetics certainly play a part, pregnancy by itself can lead to later problems such as pelvic pain, urine or stool leakage, or sagging or bulging pelvic structures known as pelvic organ prolapse. And the odds of these problems rise with the number of babies you've delivered — especially vaginally — along with their birth weight, Harvard experts say.

"There's a big misconception out there: people think you have a baby and six or eight weeks later, you're all healed," says Jenna Leader, a pelvic floor physical therapist at Harvard-affiliated Beth Israel Deaconess Medical Center. "What I end up seeing are patients 15 or more years after they've had a child, with life-altering issues they've been living with all these years."

Dr. Mallika Anand, a urogynecologist in the Division of Female Pelvic Medicine and Reconstructive Surgery at Beth Israel Deaconess, agrees. "Symptoms can certainly show up soon after delivery, but most will show up years — and even decades — later," she says.

Protect your pelvic floor

We can't change the number of times or the ways we've given birth. And, although vaginal birth may be more strongly associated with pelvic organ prolapse, there are many benefits to delivering vaginally. That said, Harvard experts offer these tips to protect our pelvic floor from further weakening:

Maintain a healthy weight through exercise and proper nutrition.
Prevent constipation (and straining in the bathroom) by drinking plenty of water and eating fiber-rich foods.
Diligently manage conditions contributing to chronic cough, such as asthma or COPD.
Seek out a pelvic floor physical therapist for an evaluation and guidance.

Short-term problems

Think of the pelvic floor as a sling or hammock of muscles stretching from the pubic bone to the tailbone. This tissue supports the pelvic organs, including the bladder, uterus, vagina, and rectum. When your pelvic floor is weakened by pregnancy and childbirth or for other reasons, you may deal with a variety of distressing symptoms.

Often, Leader says, the first problem to show up after childbirth is stress incontinence — urine leakage when you cough, sneeze, laugh, or exercise. That's because pelvic floor muscles weakened or damaged during delivery can't tighten as strongly around the urethra where urine exits the body.

Painful sex is also common in the months after childbirth, with slow healing from vaginal tears or episiotomy cuts, she says. Even a cesarean birth doesn't ward off this problem, since the resulting scar can hold tension in the abdominal wall that affects comfort and pleasure. Meanwhile, breastfeeding changes the body's hormonal balance, sometimes causing the vaginal skin to be more sensitive and irritated, particularly during vaginal intercourse. Such issues "can take a toll on a woman's relationship as well as her mental health," Leader says.

Long-haul effects

Down the line, a startling proportion of mothers cope with pelvic floor disorders, which can be influenced by type of delivery. A 2018 study in JAMA of more than 1,500 women showed that more than one-third were experiencing stress incontinence 15 or more years after childbirth. Meanwhile, 22% had overactive bladder, 31% dealt with stool leakage, and 30% developed pelvic organ prolapse over that long span.

Compared with vaginal delivery, cesarean section was linked with significantly lower risks of stress incontinence, overactive bladder, and pelvic organ prolapse. Forceps-assisted vaginal delivery was associated with much higher risks of stool leakage and pelvic organ prolapse at the 15-year point and beyond.

"With the hormone shifts of menopause along with aging itself, our muscles get weaker," Leader explains. "Many women never have issues, and then suddenly around age 50 they start to have urinary leakage or frequency. They don't necessarily trace this back to pregnancy."

These problems often come on gradually, Leader adds. "You start to notice a little leakage when you cough or sneeze. Then you need to wear a pad. Now you feel you need to use the bathroom anytime you see one. Many women are astonished by the behavioral changes they need to make."

Certain reproductive factors might raise dementia risk

The indelible physical toll childbirth takes on the body apparently doesn't translate to brain decline. But a new study suggests a host of other reproductive factors — including starting periods late, starting menopause early, and having a hysterectomy — is linked to higher odds of dementia.

The study, published April 5, 2022, by the journal PLOS Medicine, aimed to tease out the relationships of lifelong hormone exposure and socioeconomic status to brain health. It included data on more than 273,000 women and nearly 229,000 men without dementia, all of whom were registered with a large biomedical database in the United Kingdom.

Over a follow-up period averaging nearly 12 years, researchers found that factors linked to shorter lifetime exposure to natural estrogen production in women were associated with up to one-third higher risk for developing dementia. These factors included older-than-average age (13) at first period, younger-than-average age (50) at menopause, and hysterectomy surgery. Conversely, later menopause or having been pregnant were tied to lower dementia risk.

But hormone levels likely don't tell the whole story, says Dr. Mallika Anand, who specializes in female pelvic medicine and reconstructive surgery at Beth Israel Deaconess Medical Center. Lower socioeconomic status increased the dementia risk even further in women with less total hormone exposure over all.

Because the study was observational, the researchers also couldn't establish a cause-and-effect relationship between reproductive factors and dementia risk.

"The important takeaway is that additional research must be performed in women's health to better understand the impact of hormones, other biological factors, and socioeconomic factors on brain health," Dr. Anand says.

Treatment approaches

Women often dismiss pelvic floor weakness as a normal part of aging and might not be aware of treatments that can ease or eliminate symptoms, Dr. Anand says. Here are some options.

Pessary. Dating to ancient Egypt, this supportive device is inserted into the vagina to diminish stress incontinence or prop up prolapsed organs. "It's like wearing a bra or glasses," Dr. Anand explains. "When it's in the vagina, it will reduce symptoms; when it's removed, symptoms can return."

Surgical repair. Stitching mesh material or a woman's own tissue to nearby pelvic support structures can permanently elevate and anchor prolapsed pelvic organs.

Hysterectomy. This procedure takes care of a prolapsed uterus by removing it. Hysterectomy alone will not treat urinary incontinence, but it might be done along with other procedures to address several pelvic floor problems at once.

Closing the vagina. An option only for women who are no longer sexually active, this procedure (which may be combined with hysterectomy) involves stitching together the front and back walls of the vagina. The effect is to create "a pillar of support, like a pessary," Dr. Anand says.

Pelvic floor physical therapy. The least invasive treatment can be an excellent first-line option, Harvard experts say. It coaches women to strengthen (or relax, if needed) muscles in the pelvic floor — along with those in the back and hips — using techniques ranging from exercise and deep breathing to electrical stimulation and manual stretching of the tissues. And it's never too late to seek it, Leader says.

"Don't be afraid to ask," she says. "Just because you're 30 years postpartum doesn't mean it's not an appropriate thing to do."