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Sexual Health

Our guest expert in April 2010 was Dr. Stephen Holzapfel, medical director of the Sexual Medicine Counselling Unit in the department of family and community medicine at Women’s College Hospital in Toronto.

Here are his answers on Sexual Health.

Q: Can vaginal varicose veins cause pain with intercourse? Is it possible to repair a vaginal varicose vein? I am 59 years old.

A: Varicose veins (often secondary to pregnancy, or obesity) can cause pain. Because they are gravity dependant, they usually are not a problem lying down, but can be more distressing when standing up. It would be worthwhile having these assessed by a gynecologist.


Q: Can genital mutilation involving infibulation and removal of the clitoris cause sterility in a woman?

A: Genital mutilation does NOT usually cause sterility, as this involves the external genital structures, and not the ovaries or uterus. This could lead to sterility indirectly, by either preventing insemination due to blocking penetration, intercourse and intra-vaginal ejaculation.


Q: I have had normal sexual relations for the last year but I haven’t become pregnant. Someone told me that it might be that my uterus isn’t placed properly. Should I consult a gynecologist?

A: In couples where the woman is menstruating regularly and the man is generally well, about six out of seven couples will be pregnant after one year of regular unprotected intercourse. A “misplaced” uterus, such as a retroverted uterus, is not a major cause of infertility. I would suggest seeing a gynecologist after one year of infertility for women under 35, and after six months of trying for women over 35 years of age.


Q: My question is about sexual activity after age 60. If one does not have a partner, is it healthier to stay self-engaged sexually rather than have no sexual activity at all?

A: Self-pleasuring is a healthy, normal sexual behaviour, no matter what your age. Staying active will increase the chances of having an enjoyable intimate relationship should you meet a new partner in the future.


Q: I am 61 and have been through menopause for five years, yet I have started having night sweats and hot flashes. Why?

A: Usually sweats and hot flashes start in the perimenopause, around age 50, and can continue for a number of years, including into the 60s. They are due to the brain trying to signal the ovaries to make more estrogen. When women have been menopausal for a period of time without sweats or flushing, and then develop them later on, I would want them to see their physician to make sure that there aren’t other causes going on, unrelated to menopause, that can cause these symptoms.


Q: How do you deal with one partner (male) being primarily interested in oral sex and the other (female) primarily interested in genital sex?

A: Sexual behaviour, like any other couple interaction, needs to be respectful of each partner’s needs. If one person really likes a certain activity, and the other feels neutral about it, then there is a net win for the couple to engage in this. Presumably there are things the second partner would like that the first partner might reciprocate with.

When one person really likes an activity, and the other person feels negatively about it, this is never a positive act.

Counselling can help explore reasons around why a behaviour is not accepted.  In the case of oral sex a number of factors might be influencing the more negative partner.  Some of these can be helped through education, discussion between the partners, and negotiation:

  1. Hygiene is important. We feel better having sex when we’ve brushed our teeth, or shaved. Oral sex often goes better when both partners feel clean.
  2. Dispelling myths. Bacteria in our mouths pose a greater health risk than those usually present in our genitals.
  3. Cultural and social taboos. Oral sex was illegal in many parts of the world until recently. Some religious prohibitions exist against it.
  4. Helping couples define their terms. A partner might not like one part of oral sex, such as their partner ejaculating in their mouth, but might be otherwise OK with the rest of oral sex.
  5. Many women are only orgasmic with a partner performing oral sex on them.
  6. Younger people today are more likely to engage in oral sex than their parents or grandparents did – but this doesn’t make it right for everyone.


Q: Can a young woman with Down syndrome get pregnant by a young man with Down syndrome? Can the young woman with Down syndrome get pregnant by a man who does not have Down syndrome but has other developmental disabilities?

A: People with Down syndrome usually have needs for intimacy, affection and sex no different from people who do not have Down syndrome. Down syndrome women can get pregnant, though they may be less fertile than their non-Down sisters. Therefore they need contraception if they are going to be sexually active and don’t want to get pregnant. Men with Down syndrome are also less likely to be fertile, but this is not 100 per cent. A man with developmental disabilities may still be able to father a pregnancy.


Q: I am in my late 20s and have been experiencing vaginal dryness and itching along with lack of sexual desire for several years now. What would be some of the reasons for this, given that I have not experienced any really stressful situations during this time?

A: There are a number of potential causes of vaginal dryness and itching, including infections such as yeast, bacterial vaginosis and trichomonas, among others. Dryness can be caused by some birth control pills. If you are having regular periods, it would be unlikely for there to be a major hormonal cause for this. Some women have a bladder condition called interstitial cystitis, that can have vaginal symptoms associated with it.

Decreased sexual desire is the commonest sexual concern expressed by women, with about 30 per cent endorsing this when we survey reproductive aged women. About one-half of these women are distressed by their low desire and would like to do something to fix this.

Decreased desire can be due to medical issues, such as premature ovarian failure, side-effects of medications such as many antidepressants, the birth control pill, and many others. Sexual pain often causes a protective decrease in desire. The meaning of sex is important. If a woman has depression, anxiety, or has experienced trauma in her life, these can all adversely affect her desire. How did she learn about sex growing up? Was sex spoken of in the home, or was it a secret to be revealed later? The place of sex in her relationship is also relevant. Does the woman have a supportive, positive relationship with her partner? Is the balance of roles equitable for each member of the couple? Are there young children draining emotional and physical energy? Is the woman breastfeeding? What external stresses are going on for them? In the family? At work? The list of reasons for low desire is long. To keep sex positive in a relationship needs attention not only in the bedroom, but in all aspects of the couple’s interaction.


Q: I am going to see a gynecologist in a few weeks. During a pelvic exam, my doctor found a large fibroid. Ultrasound confirmed that I have several large ones pressing on my bladder. I don’t know the size, other than my uterus size is 10 weeks. I am 48 years old and I am on the pill, so I don’t have heavy periods or clotting or pain. I have no idea whether these are fast-growing or not. My previous doctor did not feel them (or did not mention them) during a prior exam, which was two years ago. My question is, what do I need to ask the specialist when I go? Because I have no symptoms other than urinary urgency/frequency, is he going to recommend anything?

A: Most fibroids are benign and are not cancerous. Rapidly growing masses need to be assessed to make sure they are not more sinister. You might have a endometrial biopsy taken through your cervix, in the office. You might have an ultrasound called a hysterosonogram done to assess the inside of your uterus.

Fibroids that are not causing symptoms are common and can usually be monitored on a yearly basis by clinical examination and/or ultrasound.

Symptomatic fibroids can be treated in a number of ways, including surgery to remove the fibroid itself (in an attempt to preserve fertility), a hysterectomy to remove the entire uterus along with the fibroids. A non-surgical technique involves embolization, or plugging (with “Crazy Glue”-like medications) of the arteries feeding the fibroid. This causes gradual shrinkage of the fibroid without the need for an operation, but can be uncomfortable for a number of weeks after the procedure.


Q: : While tree climbing as a child, I fell on a branch and hurt my vagina. I joke that I lost my virginity in a cherry tree. I'm now in my early 50s and scar tissue has formed outside my labia which is quite painful when I have intercourse. I asked a doctor about having the scar tissue removed and he said it would be classified as cosmetic surgery, so it would not be covered by OHIP. As well, he said more scar tissue would be created. I have a buildup of genital tissue at the bottom of the lip/vagina. It can be painful when I menstruate. I use Vagisil cream regularly to keep it moistened, and the area has turned white from this. Do you have any suggestions on how I might better deal with this? Thank you.

A: It sounds as if you have more symptoms than something “cosmetic.” I would ask for another gynecological opinion, perhaps from a gynecologist specializing in “vulvar” (opening of the vagina) issues.


Q: Can people with IC and vulvodynia have a normal sex life? How does one tell a new partner of this condition before having sexual relations with them?

A: Interstitial cystitis is a painful condition affecting the bladder that causes ongoing irritation, urinary frequency and pain. It can frequently make intercourse uncomfortable to the point of making it impossible.

Vulvodynia is a medical term meaning ongoing pain of the vulva, or outside of the vagina. This is a neuropathic (meaning nerve-burning) type of pain that is constantly present, independent of sexual activity. This is a very difficult condition to treat, and usually benefits from a multidisciplinary team in a dedicated pain clinic. There are a number of medications that can help reduce the pain, but none are curative. These include gabapentin, pregabalin and tricyclic antidepressants.

New partners need to understand the condition, so that they can avoid causing additional pain for the woman with vulvodynia. While intercourse may sometimes not work easily, often the labia and clitoris are spared and “outercourse” may be a positive option for the couple Helping the couple discuss this together and providing support for both is a mainstay of treatment.


Q: I am a healthy 34 year old woman who has always experienced painful intercourse. I have talked to my family doctor who referred me to a gynecologist and have been told that I do not have endometriosis or any other obvious reasons for the pain. Is there something else that can be causing this pain during intercourse and how can it be made better?

A: There are many causes of painful intercourse, also called “dyspareunia.” It is beyond the scope of this reply to answer all of the causes. Some of these are included in the 4 V’s:

  1. Vaginitis - vaginal infection, such as yeast, bacterial Vaginosis - herpes genitalis isn’t a vaginitis, but is a viral infection that can cause recurrent pain.
  2. Vaginisumus - spasm of the muscle at the opening of the vagina can cause pain, decrease lubrication and even block intercourse - it is felt to be a phobic response to the thought of having intercourse.
  3. Vestibulitis - this is inflammation at the bottom part of the vagina that causes pain when anything is put into the vagina.
  4. Vulvodynia - this is pain at the outside of the vagina that is a constant neurological burning pain, independent of intercourse.

Vaginismus and vestibulitis have been combined into one term “vestibulodynia,” which describes pain at the bottom of the vagina.

Many physicians, gynecologists included, are uncomfortable in diagnosing and managing these pain syndromes. In one study, women had seen seven doctors before the correct diagnosis was made. Unfortunately, even with the right diagnosis, our understanding of the causes and the treatments of these pain syndromes is still in the early stages. We do have some medications that can often help somewhat, but seldom a cure.

I would encourage you to try to see another gynecologist and get another opinion.


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