CLINICAL

SUPPORTING POSTPARTUM PATIENTS

As more postpartum women present in clinic, practitioners must distinguish physiological recovery from pathology. Ellen Cummings asks the experts where aesthetic medicine fits in – and where it doesn’t

Pregnancy and childbirth bring huge anatomical, biomechanical and hormonal shifts. Yet when it comes to postpartum vaginal, vulval and pelvic symptoms, women are often told simply that what they are experiencing is “normal after a baby”.

For aesthetic practitioners increasingly seeing postpartum patients in clinic, the challenge lies in understanding which changes reflect expected recovery, which are hormonally driven, and which require intervention or referral. As consultant gynaecologist Miss Smita Sinha and aesthetic doctor Dr Shirin Lakhani explain, the answer is rarely as simple as delivery method alone.

THE POSTPARTUM HORMONAL LANDSCAPE

From a gynaecological perspective, the hormonal changes following birth are immediate and significant.

“Following childbirth, and specifically placental delivery, there is a rapid decline in circulating oestrogen and progesterone levels, returning to pre-pregnancy levels by approximately day five postpartum,” explains Miss Sinha, who is the founder of Serenity Women’s Clinic in Taunton, Somerset.

Oestrogen plays a central role in vulvovaginal tissue health. “Oestrogen is integral to maintaining vulvovaginal tissue thickness, elasticity, vascularity and lubrication. This transient hypoestrogenic state may lead to increased tissue sensitivity and reduced lubrication, contributing to symptoms such as dryness, irritation and discomfort during the postpartum period,” Miss Sinha adds.

These changes are not confined to women who have had vaginal births. Hormonal shifts occur regardless of mode of delivery. Breastfeeding can also extend this period of low oestrogen. “Breastfeeding prolongs the hypoestrogenic state through prolactin-mediated suppression of ovarian function,” says Miss Sinha. “As a result, vulvovaginal dryness, burning or dyspareunia may persist throughout lactation. Symptoms often improve once breastfeeding reduces or ceases, although the duration and severity vary considerably between individuals.”

Dr Lakhani sees this frequently in her clinic, Elite Aesthetics in Greenhithe, Kent. “Breastfeeding suppresses ovarian oestrogen production, creating a temporary low-oestrogen state that can resemble menopausal vulvovaginal atrophy,” she explains.

“In clinic, this commonly presents as dry, pale or fragile vaginal tissue, pain or tearing with intercourse, stinging or burning sensations, external vulval discomfort, recurrent UTIs and sometimes delayed tissue healing. The epithelium can appear thin and less elastic on examination.”

Importantly, women often do not connect these symptoms to hormones. “Many women assume that pain or dryness must be due to trauma from delivery, but in reality, hypoestrogenism is often the primary driver. This is why these symptoms can occur regardless of whether a woman has had a vaginal birth or a caesarean section,” says Dr Lakhani.

Miss Sinha also notes the overlap with menopausal symptoms: “Symptoms such as dryness, irritation, burning, dyspareunia and urinary discomfort can closely resemble those seen in genitourinary syndrome of menopause, particularly in breastfeeding women. This overlap is frequently under-recognised and may delay appropriate management and reassurance.”

WHAT’S NORMAL IN THE MONTHS AFTER BIRTH?

While hormonal shifts play a significant role, many postpartum symptoms reflect physiological healing and neuromuscular recovery.

“Common postpartum changes include lochia, vulval or vaginal swelling, soreness, transient dryness, altered sensation, dyspareunia, mild urinary leakage, vulval sensitivity, and a subjective sense of pelvic laxity or heaviness,” says Miss Sinha.

“These symptoms typically reflect tissue and neuromuscular recovery, hormonal adaptation, and often improve gradually over the first six to 12 months postpartum.”

Dr Lakhani emphasises that recovery is rarely linear. “The early postpartum period is one of healing and hormonal recalibration. Many symptoms are expected, and reassurance can be incredibly powerful.”

At the same time, both experts caution against dismissing persistent symptoms.

“Postpartum symptoms are frequently normalised to the point of dismissal,” says Miss Sinha. “While many changes are transient and part of physiological recovery, persistent symptoms are not inevitable and warrant appropriate clinical assessment.”

Dr Lakhani echoes this balance. “Recovery can take many months and sometimes up to a year or longer depending on the birth and individual healing. Mild dryness, early pelvic weakness and scar sensitivity are common. These often respond to conservative measures and reassurance. However, persistence without improvement, worsening symptoms, or significant impact on quality of life shifts the conversation.”

VAGINAL BIRTH VS CAESAREAN SECTION: DISPELLING THE MYTH

A persistent belief among patients is that caesarean section protects against postpartum intimate symptoms. Both experts are clear that this is misleading.

“This belief is largely inaccurate,” says Miss Sinha. “While caesarean section may reduce the risk of certain perineal injuries, it does not protect against postpartum hormonal changes or pelvic floor dysfunction. Intimate symptoms can occur regardless of mode of delivery.”

Dr Lakhani sees this misconception regularly. “There is a widespread misconception that a C-section protects the pelvic floor and vaginal tissues. In reality, pregnancy itself places significant biomechanical and hormonal stress on the pelvic floor, connective tissue, nerves and core musculature.”

She continues, “I frequently see women following C-section presenting with urinary incontinence, pelvic floor weakness, reduced sensation, vaginal dryness and pain with intercourse. Many feel confused or even guilty because they believe they ‘avoided trauma’. Education is key here. Pregnancy alone is enough to influence pelvic health.”

That said, there are differences in recovery profiles. “Vaginal delivery may be more commonly associated with perineal pain or soreness and early pelvic floor symptoms, particularly following operative delivery or higher-degree tears,” says Miss Sinha.

“Caesarean section, however, involves major abdominal surgery with its own recovery challenges, including wound healing and abdominal wall dysfunction. Long-term pelvic floor outcomes are influenced by multiple factors beyond delivery method alone.”

For practitioners, Dr Lakhani stresses the importance of avoiding assumptions. “Delivery method is one part of the clinical picture, but it should never be used in isolation. Assessment must be individualised and holistic rather than assumption based.”

PERINEAL TRAUMA, SCARRING AND SEXUAL WELLBEING

For women who have experienced perineal tears or episiotomy, symptoms may extend beyond the immediate postpartum period.

“Poorly healed perineal trauma may result in chronic pain, dyspareunia, altered sensation and pelvic floor dysfunction,” says Miss Sinha. “Psychological and sexual sequelae may also persist, particularly where birth trauma has occurred, even when anatomical healing appears satisfactory.”

Referral should not be delayed if symptoms persist. “Referral should be offered at any time at the patient’s request,” she advises. “Clinically, referral is particularly appropriate if symptoms persist beyond three to six months postpartum, or earlier if symptoms are severe, progressive or significantly impacting quality of life.”

Dr Lakhani uses quality of life as a key marker. “If incontinence prevents a woman from leaving the house confidently, if infections are recurrent, or if pain is ongoing and distressing, we need to intervene or refer appropriately.”

RED FLAGS NOT TO MISS

While reassurance is appropriate for many women, certain symptoms require prompt medical assessment.

Miss Sinha highlights “persistent or escalating pain, unexplained bleeding or bruising, suspected infection or sepsis, poorly healed perineal or caesarean wounds, worsening prolapse symptoms, and urinary or bowel dysfunction” as red flags requiring referral.

Dr Lakhani adds that signs of infection such as fever, abnormal discharge or severe pelvic pain, persistent heavy bleeding, significant prolapse symptoms, severe or worsening urinary or faecal incontinence, neuropathic pain not improving with conservative management, and concerns about obstetric anal sphincter injury should all prompt referral. She also emphasises that “a woman’s emotional state must never be overlooked… appropriate referral for mental health support is essential”.

WHERE DO AESTHETIC PRACTITIONERS FIT?

With more postpartum women presenting to aesthetic clinics, practitioners are increasingly part of this landscape.

“I have absolutely noticed an increase in postpartum women seeking support for intimate and pelvic health concerns,” says Dr Lakhani. “I see this as a positive shift. Women are more informed, stigma is reducing, and they are seeking help earlier rather than suffering in silence.”

She notes that most are not motivated by appearance. “Importantly, many women are not coming in primarily for ‘aesthetic’ reasons. They are worried about comfort, function and intimacy.”

For Miss Sinha, the role of aesthetic practitioners is supportive rather than primary. “Aesthetic practitioners can play a valuable supportive role through education, reassurance and appropriate signposting, provided they have a sound understanding of postpartum physiology and work within clearly defined professional boundaries. Collaboration with gynaecology and pelvic floor specialists is essential.”

Dr Lakhani frames the role similarly. “Our role is to differentiate physiological recovery from pathology, and to avoid pathologising normal change.”

She continues, “We can provide education around hormonal shifts, pelvic floor awareness, scar care and tissue health. Signposting to pelvic health physiotherapy is invaluable. Where appropriate, supportive treatments may have a role, but the focus should always be functional restoration and quality of life, not cosmetic perfection or ‘bouncing back’ to their pre-pregnancy state.”

Miss Sinha adds that, “where appropriate, and within the limits of current evidence and scope of practice, supportive and regenerative interventions, including polynucleotides, platelet-rich plasma, electrical muscle stimulation and energy-based therapies such as radiofrequency may be considered as adjunctive options in supporting postpartum recovery. Their use should be guided by clinical judgement, regulatory requirements, patient-specific factors and informed consent, with appropriate referral pathways in place.”

Timing is critical. “The first six to 12 weeks postpartum are primarily for healing,” says Dr Lakhani. “Energy-based or invasive procedures should not be considered in early recovery.”

Consent must also be handled carefully. “Postpartum women can be physically and emotionally vulnerable. It is essential to ensure that decisions are autonomous, free from external pressure, and that expectations are realistic.”

A BALANCED PERSPECTIVE

Perhaps the most important takeaway is the need for balance.

“Conversely, there is also a risk of over-medicalising normal postpartum recovery; a balanced, individualised approach remains essential,” says Miss Sinha.

Dr Lakhani concludes, “The biggest oversight is underestimating the impact of hormonal shifts in the first year postpartum. Many intimate symptoms are endocrine driven rather than purely structural. Our responsibility is not to restore a ‘pre-baby body’, but to support safe, ethical, function-led recovery with empathy, clinical integrity and a truly holistic understanding of postpartum physiology.”

For aesthetic practitioners, that means understanding physiology, respecting recovery timelines, recognising red flags and working collaboratively. Postpartum change is neither something to dismiss nor something to automatically treat. It is, as both experts suggest, something to assess carefully, contextualise thoughtfully and manage with clinical integrity.