"Let's Talk About Sex..."

TOO EMBARRASSED TO ASK YOUR FRIENDS, EVEN YOUR DOCTOR? HERE ARE YOUR SEXUAL HEALTH QUESTIONS—ANSWERED

W

omen have many questions related to their sexual health, but too often they're not getting answers from the doctors who are best trained to provide them. According to a survey by the Women's Sexual Health Foundation, fewer than 8 percent of women are always asked during their annual exam if they have any sexual health concerns. Yet nearly three-quarters of women say they want their doctors to initiate the discussion. "Many women are suffering in silence and think they're the only ones who have a problem with their sexual health," says Lisa Martinez, executive director of the foundation. Here we direct some common sexual concerns to top experts. For more information, start a dialogue with your doctor and keep talking until you get the answers you need.

My vagina has been itching like crazy for weeks. What's going on?

Many things cause vaginal itching, notably yeast infections, which occur when too much yeast in the vagina overwhelms the vaginal defense system. Yeast infections are usually caused by the fungus Candida albicans, but other strains of Candida also can cause infection. The most common symptoms of a yeast infection are vulvar itching and itching around the vaginal opening. Women have long been told to look for a cottage-cheese-like discharge when, in fact, discharge isn't always a sign of a yeast infection, says Elizabeth Gunther Stewart, M.D., assistant professor of obstetrics and gynecology at Harvard Medical School and author of The V Book (Bantam, 2002). If you've had yeast infections in the past and you recognize the symptoms, go ahead and reach for an over-the-counter antifungal product. If the itching, swelling and redness subside within a week, you've probably treated the problem. But if you've never had a yeast infection or the antifungals don't work, make an appointment to see your ob/gyn, advises Dr. Stewart. You need some basic tests to diagnose the problem and rule out other causes. If it's not a yeast infection, what else could it be? Bacterial vaginosis is the leading cause of vaginal complaints, yet it's often mistaken for a yeast infection, according to Dr. Stewart. Vaginosis results from an imbalance of the bacteria that live in the vagina. Genital warts, herpes, eczema, and lichen sclerosus, an inflammatory skin disease, also cause vaginal itching.

I've just met Mr. Right and I want to make sure we're both free of sexually transmitted diseases (STDs) before we make love. What test should we have?

There is no single test for all STDs. And for some STDs, there is no available test yet. But it's important to always use a condom and to be tested for those STDs which have tests. Some tests require blood or urine samples, others require other bodily fluids. Start with a visit to a gynecologist (for women), urologist (for men) or family practice (for both sexes). According to Susan Kellogg, Ph.D., director of sexual medicine at the Pelvic and Sexual Health Institute of Philadelphia, both women and men should be tested for the following STDs: HIV, chlamydia, gonorrhea, syphilis, hepatitis B, and trichomoniasis. Women also need to be screened for human papillomavirus (HPV), the major cause of cervical cancer, which can be detected with a Pap test. At this time, there is no test for HPV in men, but a visual inspection can sometimes detect genital warts, a common problem caused by the virus. Hepatitis C is usually only tested for if there is a known exposure to someone with hepatitis C or if symptoms or abnormal liver blood tests are present. Genital herpes is usually diagnosed from the blisters, either by their characteristic clustered appearance or by a swab from the blister fluid to confirm the virus. Also, a blood test is available for the herpes simplex virus. It's important to note that in HIV and hepatitis B, antibodies might not develop right away, so it's smart to retest at intervals recommended by your health care provider.

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new attitude: Just 4 percent of respondents to a survey believe that sex is only for younger people.

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Is sex safe during pregnancy?

Sex during pregnancy is generally safe. But if you've had bleeding or cramping, stop having intercourse and notify your doctor, says Kellogg. Sex won't harm you or your baby, but it could exacerbate any existing problems with your pregnancy. As for satisfaction, how you feel about sex may depend on which trimester you're in and how you respond to the changes taking place within your body. During the first trimester, many women battle nausea and fatigue. The good news: These symptoms may lift by the second trimester, at which time you may feel more sexually aroused due to increased blood flow to the genitals and an appreciation for your changing body. But during the third trimester, sexual desire wanes for some women, who begin to feel uncomfortable as the baby grows. Varicose veins may develop in the vulva, adding to the discomfort. "Women still feel intimate toward their partners but often don't feel like making love during the final weeks of pregnancy," says Kellogg.

I've heard about birth control that can stop your period for months at a time. Is it safe to do that?

Yes, it's okay to have your period less often than you're used to having it. In fact, our ancestors probably had only one-quarter of the number of menstrual periods women have today, due typically to more pregnancies and longer breastfeeding. Traditional birth control pills were designed to mimic the natural pattern of bleeding that women were used to—hence the 28-day pill pack. The birth control you're referring to is a pill that limits your period to four times a year instead of once a month. It prevents pregnancy like other birth control pills by stopping the release of an egg from your ovaries. The difference is that you take an active pill every day for 12 weeks instead of three weeks, followed by a week of placebo pills. "There's no medically established minimal number of periods for a woman on the pill," says Kellogg. Menstrual blood does not build up in the body between flows, as many women think. If you can take conventional birth control pills, then you're also a likely candidate for this longer acting pill. However, sometimes taking pills over an extended period of time may increase your chances of breakthrough bleeding (spotting between periods). Discuss the pros and cons of any birth control options with your health care provider to see what's right for you. Avoid any birth control pills if you have a history of heart disease or if you smoke.

What is emergency contraception, and how does it work?

Emergency contraception can help prevent pregnancies when a condom breaks. It's also intended for victims of sexual assault and for any woman who has had unprotected intercourse but doesn't want to get pregnant. Emergency contraception works by stopping ovulation, preventing fertilization of the egg, or keeping the fertilized egg from attaching to the uterus. There are two types: emergency contraceptive pills (ECPs) and the intrauterine device (IUD). ECP, commonly known as the morning-after pill, contains higher doses of the same hormones you'll find in some brands of birth control pills. Some are made with progestin and estrogen; others are progestin only. The second type of emergency contraception, the IUD, is a plastic, T-shaped device that your doctor places into your uterus. It works by keeping sperm from meeting the egg or by preventing the egg from attaching to the uterus. Your doctor can remove the IUD after your next period, or you can opt to leave it in for up to 10 years for birth control. Speak to your health care provider for more information.

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It's okay to have your period less often than you're used to having it.

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My husband and I don't have sex as often in our 40s as we did in our 30s. Should I be worried about what this means for our relationship?

"As long as it's not a source of ongoing conflict for you and your husband," says Kellogg, "you can rest assured that you're perfectly normal"—and not at risk of a rocky relationship. Between the demands of kids and careers, couples often find it difficult to keep sex in the forefront of a relationship. As a result of fatigue, one or both partners may prefer sleep over sex more often than they used to. Of course, if there are medical reasons for waning sex, you need to get them checked out by a doctor. Erectile dysfunction in men and vaginal pain from dryness are two reasons why partners in their 40s start to retreat from intercourse. But when a couple's hectic life starts to calm down, sex often does become a priority again, says Kellogg, as long as their relationship is healthy.

Could a hysterectomy affect my sex life?

The physical effects of hysterectomy depend on the type of surgery, says Beverly Whipple, Ph.D., R.N., professor emerita at Rutgers University and author of The Science of Orgasm (Johns Hopkins University Press, 2006). Hysterectomy is an operation to remove a woman's uterus, often necessitated by fibroids, endometriosis or cancer. If your ovaries and cervix remain, you shouldn't experience physical changes that would affect your sex drive. In some cases, however, the ovaries and cervix are removed as well. Women who undergo this type of hysterectomy are more likely to have low sexual desire, says Whipple, and may find it difficult to experience orgasm. Sometimes, nerve pathways affecting sexual response can be cut during a hysterectomy, affecting your ability to enjoy vaginal stimulation. If you've been told that you need a hysterectomy for a gynecological problem not related to cancer, explore other options first, including retaining your cervix. And read up on the nerve-sparing type of hysterectomy, which aims to spare the genital nerves so that women still have some sensation. Interview potential surgeons and ask them about their track record with these different types of surgery. That said, the physical effects of a hysterectomy can be modest in comparison to the possible psychological issues, warns Whipple. Some women (knowingly or not) conceptualize the uterus—and the ability to carry a baby—as the essence of feminity and may become depressed after a hysterectomy. And feeling depressed and less feminine can lead to diminished sex drive and sexual activity, says Whipple. On the other hand, many women feel relief with the knowledge that pregnancy is not possible and become much more interested in sex and more sexually active.

I'm in my early 60s and my sex drive has all but disappeared. What can I do?

Have a medical checkup to make sure there is no physical or physiologic cause. For example, certain medications, such as antidepressants, can lower sex drive. If you are medically clear, try nurturing the intimate side of your relationship. Talk with your partner about what you enjoy. Think about things you did when you were younger that brought you sensual and sexual pleasure, in and out of bed, such as going on dates, holding hands, sharing laughs over dinner and anything else that led to feelings of togetherness. You can try the sensate focus technique, described in the box below. "Women sometimes find that this brings their sex drive back," says Whipple. If not, talk with your doctor about other treatment options.

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For more information, click here or search The Merck Manual Home Edition.

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FOR MORE INFORMATION

MerckSource.com/yhn Provides information on a number of sexual health concerns—from sexually transmitted diseases to sexual dysfunction.

NurtureYourNature.org A program designed to help women understand, appreciate and enjoy their sexuality, with a focus on communicating with partners and health care providers. Sponsored by the Association of Reproductive Health Professionals and the National Women's Health Resource Center.

Photo of bed with yellow rose by Botanica/Jupiter Images.

Photo of yellow rose by Botanica/Jupiter Images.