Questions and Answers

Q: Hi. I am 36 and recently had intercourse with a new partner who has a long penis. The sex was pleasurable and not painful, but afterwards there was blood on his penis and on the bed. This sort of thing has never happened to me before and I'm worried that it might be more serious.

Beverly Whipple, PhD, RN, FAAN

A: You should be worried. Vaginal bleeding during or after intercourse, called postcoital bleeding, or at any time outside of menstruation, is something to be concerned about. While it could result from the man's penis striking a tender spot of the internal vaginal wall, it may also be associated with a risk of cervical cancer. In one study of 142 women referred to a colposcopy clinic because of postcoital bleeding, 27 (19 percent) had precancerous or cancerous cells identified, even though most had had a negative Pap smear within the past three years. Another seven women had benign cervical polyps that were removed during colposcopy. Colposcopy is an exam in which the physician applies a vinegar solution to the cervix and vagina, then uses a special instrument called a colposcope (a large, electric microscope with a bright light on the end) to help identify abnormal tissue that may require further evaluation.

A similar study of 248 women with postcoital bleeding alone or postcoital bleeding plus an abnormal Pap smear found a rate of cervical cancer of 3.6 percent in the first group and five percent in the second, with rates of precancerous cells of nine percent and 66.1 percent respectively.

So even if you've recently had a normal Pap smear, I urge you to see your doctor immediately for another Pap smear, and, possibly, colposcopy.

Sources:

Abu J, Davies Q, Ireland D. Should women with postcoital bleeding be referred for colposcopy? J Obstet Gynaecol. 2006 Jan;26(1):45-7.

Shapley M, Jordan J, Croft PR. A systematic review of postcoital bleeding and risk of cervical cancer. Br J Gen Pract. 2006 Jun;56(527):453-60.

Khattab AF, Ewies AA, Appleby D, Cruickshank DJ. The outcome of referral with postcoital bleeding (PCB). J. Obstet Gynaecol. 2005 Apr;25(3):279-82.
Posted 10/22/2007

Beverly Whipple, PhD, RN, FAAN

A: "Honeymoon cystitis" is a very real medical condition that does not just affect women on their honeymoons. It occurs whenever vaginal intercourse leads to urinary tract infections (UTI). It is typically caused when the man's penile thrusting irritates the back wall of the bladder (through the front wall of the vagina), massaging organisms into the bladder which, if you don't pee right after sex, can multiply and cause infection. The condition is typically more common in women who haven't had children, and accounts for almost four percent of all UTIs and 60 percent of recurrences. There is also some evidence it is more common if condoms are used. But do consider safer sex practices.

The ideal way to avoid sexually related UTIs is to urinate right before and after intercourse. However, some women find they can't urinate immediately after sex, probably because the muscles that control the release of urine won't relax. So urine remains in the bladder, increasing the risk of infection. Postmenopausal women in particular may have difficulty urinating after sex because of changes in the vagina and urethra that occur with estrogen loss.

Start by asking your partner to be gentler during lovemaking. You might also try changing positions, perhaps with you on top. Also try a vaginal lubricant like Replens to keep the vagina moist, and make post-coital urination a regular part of your routine.

If the problem continues, I recommend you see your gynecologist for a complete examination. You may have a prolapsed bladder, in which the bladder has dropped into the pelvic cavity, increasing the likelihood of intercourse irritating it.

You can also take some preventive steps. Numerous studies show that drinking cranberry juice every day can help prevent urinary tract infections by making your urine more acidic and thus more lethal to pathogens. Also, make sure you're drinking enough other fluids so you go to the bathroom every few hours. You can talk with your doctor about taking an antibiotic. They can be taken prophylactically for women prone to UTIs, and studies also find that taking a single antibiotic pill immediately after intercourse can help prevent sex-related cystitis. Since you see your friend infrequently, a single antibiotic pill after sex may suffice.
Posted 7/16/2007

Sheryl A. Kingsberg, PhD

A: I can sense the pain you're feeling even in your short letter. The first thing I recommend is that you get your husband in to see his doctor for a complete physical examination. Numerous medical conditions and medications can affect a man's sex drive and ability to experience an erection, including depression, hypertension and diabetes. These become more common as men age.

Although your husband says he "no longer feels the need for sex," the reality may be that he is having trouble with erections and so has cut himself off from sex to avoid embarrassment. As you're no doubt aware, there are numerous treatments for erectile dysfunction, ranging from medications like Viagra, Levitra and Cialis to injections, pumps and inserts.

Next—or at the same time—find yourself a good sex therapist certified by the American Association of Sexuality Educators, Counselors and Therapists (go to www.aasect.org and click on your state). Just because your husband doesn't want to go to counseling doesn't mean you can't. You need to talk to someone about your feelings of abandonment and insecurity, and why you have learned to equate sex with love. You also need to explore other options if it turns out that there is no physical problem with your husband, but his sexual drive remains missing. Will you stay in the marriage? Seek sexual intimacy outside the marriage?

That brings up another issue. During this investigative phase, do whatever you can to bring intimacy into your life with your husband without sexual intercourse. For instance, the two of you could shower together, take long walks while holding hands and give each other massages. Make sure you give your husband long, lingering kisses several times a day, reach out to give him hugs and tell him how you feel about him.

At the same time, don't ignore yourself. Take good care of yourself by eating right and exercising. And treat yourself as special with long baths, imported dark chocolate, or a facial or pedicure at a local day spa. And don't forget the emotional and physical benefits of masturbation—with or without a vibrator.

Most important, keep talking to your husband about your feelings. Your therapist can provide advice on how to start and hold such conversations, but at the very least, make sure your husband understands how unloved and insecure you're feeling. No one needs to spend years without sexual intimacy—and it obviously means a lot to you.
Posted 6/7/2007

Sheryl A. Kingsberg, PhD

A: Ah, you're dealing with the conundrum of parents everywhere: How to let go without completely cutting the cord. First, let me say what a good thing it is that you and your daughter were able to talk calmly about this. Many parents would have dealt with such a discovery with anger and recriminations. And let me say how healthy it is for both of you that you recognize that your daughter is growing up. By dealing with this—and similar situations—in the manner you have, you can rest assured that while she's growing up, she won't grow away from you.

There is no need for you to "condone" her becoming sexually active. However, as you clearly want your daughter to develop a healthy sexual identity, do not underestimate the power of a mother's opinion. Expressing your unhappiness about what you have already stated was a well-thought-out and unpressured (i.e., mature) decision may leave your daughter feeling guilty and "bad." It is appropriate for you to tell her how you feel about her becoming sexually active at this time in her life without judging her. Use phrases such as, "While I would prefer that you wait until you are older to be sexually active, I understand that this is your life, and you know that I support and love you no matter what you do." Then shift into mother-mode and make sure your daughter is safe.

Find out what type of birth control she's using. Given the maturity levels of teenagers and the complexities of college, suggest that she talk to her health care professional about a long-term form of birth control that she doesn't have to think about on a daily or even monthly basis, such as Depo Provera (an injection that lasts three months), Implanon (a rod implanted in the upper arm that provides protection for up to three years), or an IUD, which can provide protection for up to 10 years.

Also make sure that regardless of her contraceptive choice, your daughter and her boyfriend are also using a condom to protect against any sexually transmitted infections. Suggest (strongly) that she get vaccinated with Gardasil, a new vaccine that protects against the primary forms of a sexually transmitted virus that causes cervical cancer.

And don't forget to have a conversation about the emotional ramifications of sex. Assure her that you just want to make sure that she doesn't get hurt and make sure she's viewing this relationship in a realistic light.

Finally, it's OK to shed a few tears. Your little girl is really growing up—and that's a tough discovery for any mother.
Posted 5/11/2007

Jennifer Fariello, MSN, RNC, CRNP

A: First, it helps to understand what sexual addiction is. It goes by many names, including "impulsive-compulsive sexual behavior," "hyperactive sexual desire disorder" and "sexual impulsivity." It is believed to affect between five and six percent of the population—although some experts think it is much more common—and is more prevalent in men than women. People with the condition can be married or single, heterosexual or gay.

People with this condition find it very difficult to control their sexual behavior and thoughts despite significant harmful consequences, including the risk of sexually transmitted infections, marital conflicts, financial issues and even putting their own safety at risk. They may exhibit out-of-control sexual behavior, such as having sex with strangers several times a week or with more than one person at a time. They often have other mental health issues, including depression, anxiety and alcohol or drug abuse or addiction. Often, people turn to sex to meet nonsexual needs, such as the need for love, closeness, security or even just a connection with another person. As one woman said on the MSNBC program Dateline about her sexual addiction: "The sexual part was pleasurable, and it was a nice byproduct for me, but that wasn't the most important thing. I was trying to get non-sexual needs met sexually, and that was the only way I knew how to meet those needs."

Some sort of impulsive component—pleasure, arousal or gratification—leads the person to seek out sex, which is then compulsively repeated. As with many behavioral conditions, it's difficult to pinpoint exactly when a strong sexual desire becomes a sexual addiction.

Typical treatments for those struggling with sex addiction include group therapy, couple therapy and cognitive behavioral therapy, in which people learn to identify triggers for their behavior and develop better coping mechanisms. In addition medication such as antidepressants is sometimes used in combination with psychotherapy after medical evaluation. Some people find relief through a 12-step approach such as Sexaholics Anonymous or Sex and Love Addicts Anonymous (SLAA).

The first step for you, however, is to meet with an addiction or sex therapist to discuss your concerns and receive the appropriate diagnosis and treatment. You can find a sex therapist certified by the American Association of Sexuality Educators, Counselors and Therapists (AASECT) through its Web site at www.aasect.org.
Posted 4/18/2007

Q: Two to seven days after I have sex (which is sometimes painful) with my male companion, I begin to bleed. Could this be a result of the blood thinner I take?

Jennifer Fariello, MSN, RNC, CRNP

A: Bleeding after intercourse, also called postcoital bleeding, should be taken very seriously. Most women notice postcoital bleeding within one to two hours after having sex. The most worrisome possibility is that it might be a sign of cervical or endometrial cancer. In two studies in the United States, postcoital bleeding led to a diagnosis of cervical cancer between six and 10 percent of the time. So the first thing I urge you to do is to see your health care professional. Tell him or her what's going on. Your doctor may recommend a Pap smear, cervical and vaginal cultures or wet prep or may want to move right on to a colposcopy, with or without biopsy. A colposcopy is a procedure in which the doctor uses a special instrument to examine your cervical tissue and remove a small piece of tissue, a biopsy, for further evaluation in the lab if warranted.

However, there are other causes of postcoital bleeding including polyps, or abnormal tissue, on the lining of the uterus; vaginal dryness (the bleeding and pain you experience during sex could be related to the thinning and dryness of the vagina that often occurs during menopause, after giving birth, during breastfeeding or with the use of certain types of contraceptives); inflammation of the cervix (cervicitis); sexually transmitted infections such as chlamydia, gonorrhea or trichomoniasis; pelvic inflammatory disease (an infection of the reproductive tract usually related to a sexually transmitted infection); uterine fibroids (non-cancerous tumors in the uterus); low-dose birth control pills, which can leave the lining of the uterus too thin, causing bleeding; yeast infections and certain vulvar dermatosis, which can also cause the skin of the vulva and vagina to become thin and delicate sometimes leading to fissures (small tears in the skin that occur during intercourse that can cause pain and bleeding).

And yes, blood thinners can also cause post-coital bleeding. What concerns me most, however, is that your bleeding isn't right after sex but a few days afterward. This type of bleeding is not typically classified as "postcoital bleeding" but as "irregular" vaginal bleeding.

I don't mean to scare you, but I do want you to see your health care professional as soon as possible. He or she may want a pelvic ultrasound to evaluate your uterine lining and pelvic organs, along with the other tests mentioned above. Additionally, since you are on blood thinners, your health care professional may want to check your blood work.
Posted 2/5/2007

Q: What is a "normal" or typical amount of sex for a person to have per month? If a perimenopausal woman is only interested in sex once every three to four weeks, is that abnormal?

Sheryl A. Kingsberg, PhD

A: What a great question. I'm sure it's one many women think about but few have the courage to actually ask. Here is the most important thing you need to know: There is no such thing as a "normal" amount of sex. Sex is a very individualized thing. What I might consider normal might be way too often for you, and what the woman down the road considers normal might be not often enough. Also, "wanting" sex and "having" sex are two different things. For example, some women may "have" sex more often than their body actually craves it, to compromise with or please a spouse with higher drive.

A survey of 2,000 Americans published in 1993 found that 32 percent of women said they had sex one or two times a week, 18 percent had sex twice a month and 11 percent once a month. Among women 40 to 49 (those most likely to be perimenopausal), 38 percent had sex one or two times a week, 18 percent twice a month and about 11 percent once a month.

What does this mean for you? Absolutely nothing. Your desire for sexual activity is composed of so many variables that trying to determine what's "normal" or not is virtually impossible. For instance, if you have children still at home, particularly young children or teenagers, a stressful job, problems with your relationship or health problems, the thought of sex might be at the bottom of your list.

So how do you know if you have a "problem"? You may have a problem if the frequency (or lack thereof) of sex with your partner interferes with the quality of your life; if you find yourself worrying about it, wishing it were more (or less) frequent; or becoming a contentious topic in your relationship or in your overall ability to be intimate with your partner. That's when it's time to talk to a therapist or even your health care professional.
Posted 1/16/2007

Q: I have been sexually inactive for about a year now, but prior to that I had no problem achieving one or more orgasms. When I went for my annual gynecological exam, my doctor said I had vaginal thinning and prescribed Premarin 0.625mg/gm cream 1gm PV. I have a sister who is a breast cancer survivor, so I am concerned about taking any kind of hormone therapy. My question: Are there other health concerns associated with vaginal thinning or should I not worry about it unless it affects my ability to have pleasurable sex?

Beverly Whipple, PhD, RN, FAAN

A: Like many parts of your body, your vagina relies on estrogen to keep it healthy. You don't mention your age or menopause status, but as estrogen levels drop during perimenopause and after menopause, the walls of the vagina can become thinner, increasing the risk that they might tear, and often causing itching, burning and dryness. In addition, there may be less lubrication, which can make intercourse painful and contribute to the risk of vaginal tears. With less lubrication, the risk of vaginal infections also increases because the natural pH balance of the vagina, which protects it against bad bacteria and fungi, is disrupted. These vaginal changes result from "vaginal atrophy."

Estrogen is also critical for the health of parts of the urinary tract, including the urethra (the tube leading from the bladder to the outside of your body), bladder and pelvic floor muscles. As estrogen levels drop, you may experience urinary incontinence and more urinary tract and bladder infections.

All of these problems can be helped to varying degrees with estrogen, either oral or local, like the cream your doctor prescribed. However, given your sister's history, I can certainly understand your concerns about using hormone therapy. You probably know that studies find a slightly increased risk of breast cancer in women using estrogen therapy, and that many breast cancer survivors are told not to use estrogen therapy.

However, the studies evaluating the risks of estrogen therapy on breast cancer were conducted using oral forms of hormone therapy. These forms are metabolized by the liver and the estrogen sent throughout your body—including the breast where it can act upon estrogen-receptive breast tissue. Vaginal estrogen does not have a systemic effect—meaning it is not disseminated throughout your body. Thus, it is highly unlikely that it will contribute to any increased risk of breast cancer.

However, there have been no published studies evaluating this question. Some studies do find higher levels of estrogen in a woman's blood even with low-dose vaginal forms, particularly the vaginal cream. If you do want to try a vaginal form of estrogen, ask your health care practitioner to start you on the lowest possible dose and to start with the vaginal pill (Vagifem). Studies find no increase in blood levels of estrogen using the pill (which you insert into your vagina) vs. the cream.

If you are still concerned about using estrogen, however, you do have other options. You might start with water-based vaginal moisturizers like Replens, which studies find can be more effective for symptoms of vaginal atrophy than even estrogen cream. Vitamin E, in oral doses of between 100 and 600 IU, or administered directly to the vagina, can also improve vaginal dryness. Another option is a topical oil made from botanical ingredients, called Zestra Feminine Arousal Fluid, which one published study found significantly improved women's sexual experience (including orgasms) compared to a placebo topical oil.

Regardless of which option you choose, I strongly recommend you find something that works for you so you can enjoy a healthy sensual and sexual life and avoid the problems that can result from vaginal atrophy.
Posted 12/5/2006

Q: My partner and I both have diabetes and high blood pressure. I often don't feel sexually aroused (and certainly cannot climax), and he cannot hold an erection long enough to please me. Is there some type of sexual act or position that we can explore that will please us both?

Jennifer Fariello, MSN, RNC, CRNP

A: Conditions like diabetes and high blood pressure are among the most common chronic health conditions that can affect your sexual functioning. Given that you and your partner have both may create an even greater challenge.

One large study of men with type 2 diabetes found their risk of erectile dysfunction (or not being able to have or maintain an erection) was nearly twice that of men without diabetes. The researchers also found that half the men in the study who had both diabetes and high blood pressure had erectile dysfunction (ED). Other studies find that between 40 and 80 percent of people with diabetes and hypertension (men and women) have sexual problems.

There are many reasons for diabetes' effect on erections. Over time, the disease damages nerves as well as blood vessels, both of which are required for an erection. It can also interfere with the production of nitric oxide, which helps blood vessels dilate (including those in the penis) and is required for erections. Another effect may be reduced levels of the hormone testosterone, also required for erection. One study found that a third of men with type 2 diabetes had low testosterone levels, which the researchers call "a new complication of diabetes."

We understand much less about the mechanisms behind sexual dysfunction in women with diabetes, although we know it exists. One study found sexual dysfunction in 71 percent of married women with type 1 diabetes and 42 percent of women with type 2 diabetes compared to 37 percent of women without diabetes. The disease may have some physical effect on women, such as decreased vaginal lubrication and a predisposition for vaginal infections, which can result in pain during or after intercourse, also called dyspareunia. One large study of women with type 1 diabetes found the women's sexual dysfunction was also closely related to a variety of emotional and lifestyle issues. These included satisfaction with their marriage, understanding of their diabetes, emotional adjustment to their diabetes, the impact of their diabetes treatment on their daily life, and satisfaction with their diabetes treatment.

As for the effects of high blood pressure on sexuality, one culprit may be the medication you're taking. Diuretics and beta blockers, both commonly prescribed for high blood pressure, can also cause sexual problems. We also know that the effects of high blood pressure on blood vessels, such as stiffness and narrowing, can interfere with the ability of the vessels in the penis to fill with blood and remain full. Again, we have less information on the effects of hypertension on women's sexual function.

The good news is that there are treatment options. The first thing your partner may want to consider is a medication for ED. Studies find the three available medications—Viagra (sildenafil), Levitra (vardenafil) and Cialis (tadalafil)—are safe for most men with diabetes and hypertension. An added bonus: If your husband's ED problem improves, you may find your own sexual satisfaction improves. The use of a glycerin-free lubricant may alleviate some of the vaginal dryness and resulting dyspareunia.

The first step, as with most health conditions, is a comprehensive medical evaluation. Your partner should probably see a urologist in addition to his regular health care professional; you may want to talk to a gynecologist or a pelvic and sexual health specialist in addition to your regular health care professional.

In addition to medical approaches, you may want to explore sexual therapy. A trained sex therapist can work with you both to help you discover ways to improve your sexual relationship. To find a qualified therapist in your geographic area, visit the American Association of Sex Educators, Counselors, and Therapists (AASECT) at www.aasect.org and click on your state.
Posted 11/30/2006

Q: It was discovered through an ultrasound that I have a retroverted uterus. My doctor told me that it may cause painful sex. Now I'm worried. I'm 19, a virgin and feeling depressed that sex may always be painful for me. I have always had very painful periods. What can I do to reduce the pain involved with sex?

Beverly Whipple, PhD, RN, FAAN

A: First, relax. You don't know for sure that sex will be painful, but if you get it into your mind that it will, then it most assuredly will! Such is the power of the mind. You have what is also known as a retroflexed uterus, or a tipped uterus. About one in four women have this anatomical difference. It simply means that your uterus is tilted away from your abdomen instead of in a straight, up-and-down position or tilted slightly toward the abdomen. Most women are born with a retroflexed uterus, although it can occur as a result of pregnancy, aging or scar tissue from reproductive surgeries.

There is little evidence that a tipped uterus can cause painful intercourse. Only one study has ever been conducted to explore this issue, and it wasn't a very well-designed study. Nonetheless, while it found that 67 percent of women with a retroverted uterus had pain during intercourse, the pain was relatively low level and didn't interfere with the women's daily activities or their sexual activity.

The pain is thought to be caused when the tip of the penis hits the cervix of the uterus during intercourse. Another theory is that the ligaments holding the uterus actually move in a different direction than the uterus during intercourse, causing pain. Finally, a third theory suggests that having a tipped uterus leads to another condition called pelvic congestion, or venous congestion, which often results in pelvic pain.

If you find intercourse painful once you are in a sexual relationship, something as simple as changing the positions of vaginal intercourse may reduce the pain. If the pain continues and is affecting your relationship and/or quality of life, you may wish to talk to your health care professional about surgery, although this should only be considered as a last resort. You should probably also talk to your health care professional or a mental health professional about the depression you say you feel over this. Talking through your fears is often the best way to banish them.
Posted 10/3/2006

Q: I am 56 and had a complete hysterectomy five years ago for uterine fibroids. I have been sexually inactive for about one year now, but prior to that I had no problem with intercourse. When I went for my annual gynecological exam, my health care provider said I had vaginal thinning and prescribed a product called Vagifem, tablets (one or two) that are inserted in the vagina weekly. I have a sister who is a breast cancer survivor, so I am concerned about taking any kind of hormone therapy. My question: Are there other health concerns associated with vaginal thinning or should I not worry about it unless it affects my ability to have pleasurable sex?

Susan Kellogg-Spadt, CRNP, PhD

A: First, let me put your mind at ease regarding the therapy your health care provider has prescribed. Because it is specifically designed as local estrogen therapy, very little of the hormone is absorbed systemically, meaning throughout your body. Although the increased risk of breast cancer with systemic hormone therapy has been well-documented, there is no evidence that local-acting estrogen creams, rings or tablets carry the same risk.

The reason your vagina is thinning is because of the lack of estrogen in your body after menopause. The vagina and other parts of your urinary and reproductive tract are heavily dependent on estrogen to remain in peak working condition. As estrogen levels drop, many women begin experiencing problems in this area, including vaginal dryness and the vaginal thinning your health care provider diagnosed, both of which can lead to painful intercourse. There are other repercussions of this estrogen loss: The vagina becomes less acidic, which increases the risk of urinary tract infections (UTIs), itching and burning. In fact, these symptoms seem to be more frequent in women who aren't sexually active because intercourse brings additional blood supply to the area, which can help maintain vaginal health.

Since estrogen also affects the bladder and urethra, you may find you begin having some leakage of urine and/or feel the need to urinate frequently. In fact, about 70 percent of women link the beginning of these types of urinary symptoms to menopause.

Use of any form of hormone therapy (local or systemic) is a very personal decision that should be reviewed with your health care provider. If you choose not to use hormones, there are other options you can pursue, including over-the-counter vaginal moisturizers, which, over time, have been shown to improve vaginal irritation, itching and dryness.

Vitamin E doses between 100 and 600 IU, applied vaginally, may also help. If you're experiencing recurrent urinary tract infections, adding cranberry pills to your vitamin regimen may reduce the incidence of UTIs.

If you wish to pursue any of these options, it is always best to discuss them with your health care provider, as well as to educate yourself about vaginal health.
Posted 9/1/2006

Q: Two months ago, my very sexually active and pleasurable, but emotionally and physically abusive, relationship ended. My question has to do with crying during or shortly after orgasm. Why do I cry-sometimes to the point of sobbing? Does it have to do with some type of hormonal release? I am 47 years old.

Sheryl A. Kingsberg, PhD

A: I am so sorry to hear that you were in an abusive relationship, but very proud of you for ending it. You don't say if you cry all the time with orgasm, i.e., even when you masturbate, or only when you're with a partner. And you don't say if it occurs only since the relationship ended.

If your crying began once you ended the relationship, it could be a reflection of your grief. Grief after ending an abusive relationship? Certainly. You probably still have strong feelings for your ex-lover, and are grieving the end of the relationship and the loss of the strong sexual relationship you had, even though this loss may benefit you in the long run. Why after orgasm? Because the intensity of an orgasm can leave you feeling very emotionally raw. Thus, the strongest emotion you're experiencing under the surface is now free to be expressed.

If your crying occurred during the relationship, it's not surprising that the mix of love, fear and anger you likely felt would result in an overwhelming emotion when you were most emotionally open and vulnerable, i.e., during orgasm. Another way to look at it is that you were caught in the conundrum of a relationship with someone who could bring you such pleasure (as experienced as an intense orgasm), but at the same time cause such emotional and physical pain. The acute awareness of this at the moment of orgasm could certainly trigger sobbing.

Having said all that, it is also not out of the question for a 47-year-old woman to experience some hormonal fluctuations at orgasm, with the release of the hormone oxytocin contributing to the crying jag.

I strongly recommend that you seek help from a qualified health care practitioner, as well as a qualified mental health therapist, to work through the complex issues you are most likely dealing with, as well as to evaluate your overall physical health.
Posted 8/1/2006

Q: I am 41 and had a hysterectomy one year ago. I would like to know if that is why I can't have an orgasm when I have sex with my boyfriend. Aside from the lack of orgasm, the sex is quite good.

Beverly Whipple, PhD, RN, FAAN

A: First, let me congratulate you on having an otherwise satisfying sexual relationship with your boyfriend. Now let's see if we can't help you find a way to make it as satisfying as you would like.

There are a few things you don't say here, so I'm going to make some assumptions. First, that your boyfriend was in your life pre-hysterectomy; second, that you can't experience orgasm during sexual intercourse but you can experience orgasm with other forms of sensual and sexual stimulation; and third, that you had your uterus and cervix removed, but not your ovaries, since your sexual desire doesn't seem to be affected. Removing the ovaries significantly decreases a woman's production of testosterone, a key hormone involved in sexual desire or libido.

There is some evidence that removing the uterus and cervix, as is done during a total hysterectomy, can affect the quality and intensity of orgasm. That's because the uterus as well as the vaginal muscles contracts during orgasm and because the nerve pathways that are involved in sexual response and orgasm with vaginal stimulation (pelvic, hypogastric and sensory vagus nerves) may have been cut or destroyed.

There's also evidence that the cervix plays a major role in orgasm. First, it dilates to improve the likelihood of conception. Second, it is very sensitive to touch, so the pressure of the penis on the outside of the cervix can stimulate nerve endings that trigger an orgasm. In women who say this pressure is a trigger for orgasm, many find they're unable to orgasm after hysterectomy.

One of the studies conducted on the issue of post-hysterectomy orgasm found about one in five women reported fewer orgasms after a total hysterectomy. Additionally, other studies find significant differences in the frequency of orgasm in women who don't have a uterus and/or cervix compared to women who still have those organs.

Ok, so now that you know there is likely a physical reason for your inability to experience orgasm during vaginal intercourse, what can you do about it? One thing I'd suggest is learning to induce orgasm through the clitoris and/or "G spot," the very sensitive area felt through the front of the vaginal wall halfway between the back of the pubic bone and the cervix. The G spot surrounds the urethra and swells when it is sexually stimulated.

For some women, the G spot plays an important role in orgasm and sexual pleasure; for others, it makes no difference. Additionally, some women find the only way they're able to experience orgasm is with clitoral stimulation. You and your boyfriend might also try changing positions to stimulate your clitoris and G spot so you can have an orgasm.

You could also experiment with your hands and a vibrator to induce orgasm this way. In some women, the results of these efforts transfer to intercourse.

If you're still unable to experience orgasm during intercourse, then I suggest you ask your boyfriend to stimulate you to orgasm manually before or after sexual intercourse, so you can still experience the pleasure in a way that provides you with satisfaction.
Posted 7/5/2006

Q: I was diagnosed with endometriosis in 2002 and would now like to get pregnant. What are my chances?

Susan Kellogg-Spadt, CRNP, PhD

A: That depends on many things, particularly the severity of your endometriosis. As you undoubtedly know, endometriosis is a condition in which endometrial tissue, which typically lines the uterus, grows outside the uterus. No one really knows what causes it, but it can be a very painful, debilitating condition, significantly affecting quality of life. It affects between five and 15 percent of premenopausal women, and up to 40 percent of infertile women.

However, whether the endometriosis causes the infertility is unclear. So there is a chance you could become pregnant on your own with no intervention. If you have trouble getting pregnant (generally, if you're young and otherwise healthy, there may be cause for concern if you have been having unprotected sexual intercourse at mid-cycle for a year or more without conceiving), there are surgical procedures that may help.

These include laparoscopy, or "belly-button surgery," in which the surgeon uses a tiny lighted telescope inserted through one or more small incisions in the abdomen to destroy endometrial tissue with heat, laser or by cutting it out. A similar procedure called a laparotomy is used for more extensive endometriosis, requiring a full abdominal incision and longer recovery period.

Studies find that destroying endometrial tissue can improve your chances of pregnancy in cases of mild endometriosis. Additionally, certain assisted reproductive techniques, such as intrauterine insemination (IUI) (in which sperm is placed in the cervix or uterus after you've taken medication to produce more than one egg) or in-vitro fertilization (IVF), can also increase the likelihood of pregnancy depending on the extent of your endometriosis.

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