Edited Transcript from a Presentation “Postpartum Rehabilitation Sexual Dysfunction and Body Shaping” by Gynaecologist Dr Natalia Novikova to the Aesthetic Medicine Congress of South Africa in 2021

Dr Natalia Novikova is an internationally acknowledged gynaecologist who specialises in minimally invasive medical and cosmetic gynaecology, as well as non-invasive body contouring. She currently works in South Africa with two practices in Johannesburg and Cape Town. Dr Novikova has personal experience in postpartum rehabilitation. Having given birth to three children through natural birth. She understands the complexities of postpartum, because her kids are close in age, and it took an effort to get back into shape. Owing to her non-invasive treatment method, Dr Novikova has explored various energy devices in her practice to treat conditions in this area. She has chosen them based on their performance and the available research done on the devices. Her clinical experience comes mainly from BTL and Alma laser devices.

What Are The Issues Post Childbirth?

Issues Relating to Sexual Dysfunction 

Common post-partum issues related to sexual dysfunction are urinary or faecal incontinence, perineal tears, pain from the tears that women sustain during childbirth, vaginal laxity, or looseness of the vaginal canal, post vaginal delivery, and a decreased sexual desire. These may be related to various reasons or could be the consequence of atrophy or the thinning of vaginal skin due to a prolonged hypo-estrogenic state during the pregnancy and breastfeeding period. This quite often results in vaginismus or involuntary spasm of the general muscles leading to pain upon penetration.

Issues Relating to Body Shaping

Most women who have had babies struggle to lose weight, while some develop pectoral muscle separation, most have sagging skin, stretch marks, and cellulite that they would want to address soon after birth.

Incontinence Issues Post Childbirth

The incontinence market is huge and there are billions spent worldwide. While an enormous number of women around the world suffer from this condition, they all too often take a very long time to seek help, 6.5 years on average. The unfortunate reality is that most women don’t necessarily get helped when seeking help for incontinence. 

To emphasize the lack of proper assistance, Dr Novikova recalled an article written to advise women who are embarrassed to exercise because of stress urinary incontinence. She recounted how the article gave ineffective and impermanent methods for women suffering from stress urinary incontinence. The advice included wearing dark clothing,  choosing to swim instead of jumping and wearing a tampon when they are exercising. She criticized these methods while holding with certainty that better methods exist.

The positive side is that more and more women are speaking out about this embarrassing topic. This includes Kate Winslet’s social media post where she admitted to “peeing herself” after having a baby. Urinary incontinence is very common and 25% to 55% of women may suffer from it.

What are the Options for Women with Incontinence?

It is best, to begin with, a thorough diagnostic process which includes history taking, clinical assessment, imaging, potentially urodynamic studies and urine analysis to find the problem, and then based on the type of incontinence found, various treatment options available will be discussed with the patient. The treatment could start with lifestyle modifications, a bladder diary, pelvic floor exercises, and progress to surgical or non-surgical methods of treatment depending on the type of incontinence a patient may have.

Vaginal Rejuvenation Treatment

Lifestyle modifications are a good place to start in treating mild urinary incontinence. On occasion, energy devices such as the BTL Ultrafemme 360 or Femilift can be used to treat the condition. They are also used for procedures such as vaginal rejuvenation for women who have none of the problems that have been mentioned but are interested in undergoing prophylactic vaginal rejuvenation post-childbirth as an elective procedure.

There are several other devices available such as ablative carbon dioxide (C02) lasers, non-ablative and ablative erbium lasers, combination lasers, radiofrequency and High-Intensity Frequency Electro-Magnetic energy (HIFEM). There is a variation in the technology, depth of penetration and number of treatments necessary but they similarly work by increasing temperature in the tissue which leads to collagen degeneration, shrinking collagen fibres and producing new collagen using fibroblast stimulation. The depths of penetration range from lasers that come up to the dermal level to intense pulsed light lasers which are slightly deeper. Frequency and fractional lasers are the most superficial while HIFEM levels provide a very deep penetrating treatment.

Choosing An Energy Device 

When choosing an energy device for a practice it should be based on the following reasons: type of energy, type of effect, available evidence, potential side effects, the time it takes to perform the procedure and the number of the procedures required. Most of the devices require several procedures, on a weekly or monthly basis. Other factors include ease of administration, potential the device has of performing other extragenital procedures, size, downtime, available marketing, cost of the device, cost of the servicing agreement as well as the availability of technical support. 

CO2 lasers can only be administered by a medical practitioner and radiofrequency treatments can be administered by an Aesthetician or a nurse. HIFEM is a fantastic treatment for women who struggle to adhere to pelvic floor exercises which amount to about 80%. 

BTL Emsella Pelvic Floor Exerciser Chair

Research has found the BTL Emsella chair to be an extremely powerful device that administers 11,200 pelvic floor muscle contractions in a 28-minute treatment session. It is a non-invasive procedure, so women can be fully dressed when they undergo the treatment and the key to its effectiveness is based on the focused electromagnetic energy and depth of penetration and stimulation of the entire pelvic floor area. A single session produces thousands of pelvic floor muscle contractions, which is extremely important for muscle education and contractions for patients living with incontinence.

There are several approved positive reports of improvement in sexual function besides the treatment of stress and urge urinary incontinence. The recommended treatment plan is six sessions twice per week, for 28 minutes per session. It can be used for all types of incontinence, vaginal laxity and includes men struggling with an overactive bladder or who have undergone prostatectomies.

Evidence Of The Efficiency Of Pelvic Floor Exercises 

The use of pelvic floor muscle training for the prevention and treatment of urinary and faecal incontinence has been recommended for women for a very long period of time. The Cochrane Studies have shown that one-third of women who have urge incontinence and one in ten who have faecal incontinence after birth, improve after the use of pelvic floor muscle training, during their antenatal and postnatal phase. It is important to undergo the treatment during early and mid-pregnancy, primarily because it is not as effective for women who are at the last stage of their pregnancy even though the treatment affects the reduction of urge incontinence postpartum.     

The Cochrane Review includes 31 trials with close to 2000 women with a moderate risk of bias. The review found that women with stress urinary incontinence were eight times more likely to report that they have been cured after having undergone pelvic floor muscle training.

Women with any type of urge incontinence were five times more likely to report “cured” in their treatment groups. The field has seven completed clinical trials on HIFEM, four completed in 2019 with over 300 study patients for all types of urinary incontinence. 95% of the patients were satisfied with a notably significant improvement in their quality of life. The results were confirmed by a six month follow up. 

Women with moderate to severe urinary incontinence will need different types of treatments such as surgical interventions for stress urinary incontinence and medical interventions for overactive bladder. 

Vaginoplasty / Vaginal Repair

Vaginal laxity can be addressed with energy devices and pelvic floor exercises as well as lifestyle modifications. Women who have significant tears that were not repaired accordingly or did not heal well will need surgical intervention. Energy devices and pelvic floor exercises do not help with pain during intercourse.

Patients should be counselled on all the options available to them and the appropriate treatment chosen for each patient individually.

What Are the Causes and Treatments for Sexual Dysfunction?

Sexual dysfunction is a complex problem and must be addressed from all aspects. To treat the condition, gynaecologists start with addressing the general wellbeing of women who have just had a baby. Sleep is a very important aspect and women who have interrupted sleep for months and years because of baby co-sleeping and breastfeeding and other factors report having a low sexual desire or changed sexual function. These women are not likely to be helped by medication or other treatments because their lifestyle must adjust to the new life and that would be the most important factor in improving their sexual function.

To improve the lifestyle, patients need to address sleep stress, exercise, eating, body image and their relationship with their partner. Sexual education is also quite important because having a baby does not mean that women understand everything about sex or their bodies or what they respond to. Any type of underlying illnesses like depression, lichen sclerosis, hypertension diabetes can play a big role in changing sexual function. Chronic medication, supplements or illicit substances, also have an impact. Women who are breastfeeding, who experience vaginal dryness, or pain upon penetration develop vaginismus as a result and have to understand the treatment processes in place to address the issue one step at a time. Living arrangements are also quite important in working out sexual dysfunction problems.


Vaginismus is not a common postpartum issue, but it can be related to traumatic childbirth. Most women have bad tears that don’t heal well, or experience pain during penetration or have painful scars. The condition can be related to the thinning in the vagina scheme, atrophy, relationship discordance, or the avoidance of sexual activity for various medical reasons during pregnancy and postpartum or for other reasons. It is very important to find the cause of vaginismus but the most important part of the treatment process is to ensure that the woman understands the condition and is getting appropriate counselling; psychological support and an understanding of how the treatment works.

Treatment For Sexual Dysfunction

For sexual dysfunction, Dr Novikova recommends a treatment program that first addresses lifestyle followed by examination for any type of desire issues which would then lead to hormonal testing and potentially hormonal supplementation such as testosterone or JHAS to improve desire. Vaginal atrophy can be treated with vaginal moisturizers, estrogen as well as energy device treatments, which are quite effective. Her trust in the efficacy of these devices stems from several randomized control trials proving their safety and efficiency. That is why she is confident that a combination of energy devices with local estrogen treatments are quite effective in the treatment of vaginal atrophy. 

Vagina laxity can be addressed with pelvic floor exercises, HIFEM treatments, laser radiofrequency treatments, or surgery if all device methods fail. Genital treatment known as the “O-Shot” was developed by Dr Charles Runnels from the USA to enhance sexual pleasure. It treats vaginal atrophy and works well for mild urinary incontinence. It often allows women to reset and feel better about themselves which enhances sexual pleasure.  Dr Novikova postulated that women would be more open to the O-shot as it is a great regenerating treatment for the tissue and works well for women seeking to enhance their sexual pleasure and function.

Body Image

Body image plays a huge role in sexual function. Sexual pleasure comes from our minds and not so much from the vagina. However, not being happy with the vagina creates a lot of problems in women’s minds. For instance, Dr Novikova treated a patient who had saggy labia majora and darker, prominent elongated labia minora. She had no functional problems or anatomical issues, only cosmetic ones. To treat them she did a labia majora reduction, labia minora reduction, lipo filling of the labia majora and skin lightening, which she was very satisfied with afterwards. The patient now comes in regularly for an O-Shot to enhance her sexual pleasure and it works really well for her. 

Plumping, tucking, lightening and tightening are all the available options for women and they are all quite useful in the postpartum period to improve body image and help women get their self-confidence back while improving sexual function.

What is a Mommy Makeover?

Body Reshaping / Mommy Makeover

Plastic surgeons will do a procedure called the mommy makeover, which involves breast augmentation/lift, liposuction of the stomach (tummy tuck), buttocks augmentation and vaginal rejuvenation. Dr Novikova is a big fan of non-invasive options for body reshaping, and that includes fat reduction with various devices. 

She is a great advocate for radiofrequency because it has a lot of advantages and is a more effective treatment for fat reduction. It can be used for skin tightening, fat reduction and muscle toning. Ultrasound devices are used to treat cellulite, producing beyond satisfactory results. 

The BTL Emsculpt is the most popular treatment in her practice for women with normal BMI looking to tone, reduce a bit of fat, tighten their skin and get back into shape. Four sessions twice a week are recommended. During this treatment, muscle increases by 19% and fat decreases by 16%. The results remain in place for over a year. The treatments can be used to improve their muscles to get back into the gym so it is easier to start working out. HIFEM with muscle toning can be used for a bum lift and getting a six-pack.

The BTL VanquishMe and BTL Exilis have a range of frequencies that give great results in shedding fat and reducing centimetres for women with a BMI of over 30. However, the treatments have to be combined with strict lifestyle measures such as exercise and healthy eating which are very important for their general wellbeing, mood, and definitely for maintaining the results of the body shaping treatments. All of the non-invasive body reshaping treatments available usually demand quite a bit of involvement and several sessions are required, approximately four to six to eight sessions every week.

Surgical treatment remains an option but it is associated with a higher risk of complications, longer recovery periods, and more pain. Non-invasive options are safer and are subject to minimal external influence, especially in the current circumstances where elective surgeries all over the world tend to be interrupted from time to time.

Risks of Home and Beauty Postpartum Remedies

An Instagram image posted in 2019 depicted a girl promoting vaginal steaming. It got close to a million likes which may be attributable to the 25 million followers she has. This is unsettling as Dr Novikova has seen a 16-year-old girl with terrible burns from steaming. A 2019 academic paper discusses the risk of second-degree burns sustained after vaginal steaming. One must see an experienced and appropriately qualified professional before trying the home remedies that are available out there.

 Vaginal rejuvenation in a spa type of facility may be dangerous. Vaginal steaming should not be done anywhere and the image on Instagram clearly shows that the individual in that picture is at home. In the background among the furniture, there is something that seems like a baby’s crib which suggests that the steaming is a postpartum treatment. This home treatment method is strongly advised against.

Seeking Post-Childbirth Rehabilitation?

There are various non-invasive postpartum treatments available to treat a range of post-childbirth conditions provided by specialists like Dr Novikova. The treatment process depends on the severity of the condition. Each treatment should be tailored to your specific problem as a one size fit all approach can be disastrous. 

Dr Novikova has a depth of knowledge and ensures that her patients receive treatment specifically suited to them, delivering beyond satisfactory results. Click here to find out more about the post childbirth treatments she offers.

Watch presentation below:

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