More Answers to FAQs on Concerns about Sex
Frederick R. Jelovsek MD
   
Heavy bleeding after sexual relations
Atypical squamous cells of unknown significance (ASCUS) is often
due to an inflammation or irritation of the cervix. The bleeding
after intercourse is also often a sign of
irritation/inflammation. Cervical polyps will often cause the
type of bleeding you are describing. A pelvic exam is needed to
see if you need any treatment for a cervicitis or any cervical
lesion.
Will hysterectomy alter orgasm?
There is no truth and no answer that applies to all situations.
For every woman it is a trade-off of symptoms (i.e., pain in your
case) versus possible change in orgasmic response.
The physiology of female orgasm is comprised of two events
basically: release of blood vessel engorgement (which
accumulated during arousal phase) and uterine, vaginal and some
say, clitoral contractions. After hysterectomy there are no more
uterine contractions with orgasm. There are still vaginal and
possibly clitoral contractions. Some women perceive all of these
while many only perceive some, it varies. As far as the vascular
response there probably are less blood vessels to get engorged
over time because they are not having to supply the uterus any
more.
The most common thing physicians hear from women concerning
orgasm after hysterectomy is that it is different but still
present and pleasurable. There are some women, however, who say
that orgasm is gone. I suspect those women were very sensitive to
the uterine contractions part of orgasm. Other women will also
admit to problems with sex but it is really because of decreased
libido (desire) or decreased arousal.
Removal of the ovaries can affect decreased desire but if
estrogen is replaced, that can account for most but, not all of
the decrease.
Everything you hear is correct but the proportion is not equal,
at least from a physician's view. The majority (let's say 75-85%)
of women having a hysterectomy have a substantial net improvement
in their daily lives. The rest don't and some feel worse off than
before.
Decreased libido and orgasm on Paxil®
Paxil usually has less effect on libido than other mood
altering meds but it can have the effects you describe. Right now
I don't know of any way to counteract that problem except make
sure you are taking your dose in morning or as far removed in
time from when you are likely to have sexual relations. Are you
sensitive to normal doses of other medicines or weigh less than
120; maybe half the Paxil® dose will keep the panic attacks in check
and not suppress sexual desire so much. Be sure to keep up
an exercise program. Restricting calories usually picks up energy
levels if that's a problem.
I haven't heard of Paxil® affecting orgasm. I would more
likely suspect blood pressure meds for that.
Some day we may know that Viagra helps this problem but at
that it's only a temporary solution. I don't think androgens will
help counteract this libido depression unless you are menopausal
or you take high doses that might end up causing masculinization
side effects. The truth is we do not really know and this
subject has not been studied much at all.
Premenopausal vaginal dryness and decreased libido
Vaginal dryness can play a role in the cause of decreased libido.
As you say, you begin to fear pain with relations because of
the lack of lubrication and that in turn "turns" you off. There
are other causes of vaginal dryness. Decreased estrogens from
anovulation. Reaction of the vagina to spermicides, condoms, even
sometimes K-Y jelly doesn't help it.
Fear of pain with relations, anger at one's spouse or
something else, can also suppress lubrication at the time of sex.
Certain medications, dietary ingestions can also affect lubrication.
Several questions: Are your menses regular? Are you on any
hormones, medications, dietary supplements? Is the dryness just a
problem at the time of having sexual relations or does it seem to
be a problem in between or all of the time? Are you concerned
about your husband's lovemaking skills, hygiene, verbal or
physical threats or possible extramarital behavior?
HPV isn't known to decrease vaginal lubrication on a
physiological basis. As to whether it is a mental reason, that's
possible. It depends on what thoughts you have about HPV. What do
you think are the consequences of HPV? How do you think you got
HPV? If you don't really think about those questions on a
conscious or a subconscious basis, then it shouldn't be having a
mental effect.
The physiological "wetness" with sex comes during arousal when
the blood vessels are congested and excess fluid "weeps" thru to
the vagina. As you said, just thinking about it can cause wetness
if you are aroused. That response is not happening in you. "Why"
is not clear. Remember there is some natural decrease in sexual
arousal as marriage progresses from its early stages to more
familiarity with each other and more tasks of just getting a
family unit operational for the long run. Some of that has to be
taken into account but as you say, its probably not the entire
answer.
From what you've said so far, it's difficult to say what the
cause might be. The end result is a lack of arousal which in turn
produces a lack of lubrication. Since you are not on any
medicines and since the dryness predated the diaphragm use, I
would suspect that there are some mental barriers that are adding
to the problem. The exception is the menstrual irregularity. You
could still be somewhat estrogen deficient and that could
contribute. I would suggest one alternative would be to ask your
physician to prescribe an Estring®. This is and estrogen
impregnated silicone ring that you wear in the vagina all of the
time. It will help increase your overall lubrication which is at
the base of your problem. Very little is absorbed systemically
into your blood stream so you will not have any other effect from
it. It might help you with this.
With a vaginal hysterectomy, will cervix removal affect sex?
There's not any scientific right or wrong answer to this. In
general, women with prolapse have the cervix removed with the
uterus. It has to be in order to have a vaginal hysterectomy. In
order to not remove it, you would have to have the procedure done
abdominally.
There can be some differences in sexual response after
hysterectomy. The uterus undergoes contractions with orgasm as
does the vagina, but the uterine contractions are more prominent.
Leaving the cervix in place may preserve some of those
contractions. Arousal should be the same in both cases because it
is primarily due to congested blood vessels just like a male
erection. The blood vessels are still there after hysterectomy.
Most patients I have had will tell you that sexual response
after hysterectomy (removing cervix too) is slightly different,
but no less enjoyable. Many women with prolapse have discomfort
or pain with sex and fixing the prolapse makes such a positive
difference that they wish it had been done earlier. Your friends
are correct though, that some women have a negative change in
sexual response with hysterectomy but it is not known if that
would change if the cervix was left in.
What kind of physician do I see for a decreased sexual desire?
This isn't an easy question. Decreased sexual desire is a
complex subject. See our news article about libido at:
Sexual
desire
The best physician to find is a gynecologist who has an
interest in or specializes in sexual therapy. There's not a
comprehensive list anywhere that I know of. The next person
might be a Gyn endocrinologist. If medical diseases and hormone
levels measure out as normal, a psychologic counselor/therapist
who specializes in women's problems would be next. That person
could examine to what degree feelings play a role. These
types of problems are never 100% hormonal nor are they 100%
emotional.
Pain with sex or full bladder or bowel movement
This is the type of question that is very difficult to answer
without an exam. A pelvic exam by a gynecologist could quickly
confirm what the health department nurse mentioned which is a
degree of uterine prolapse. In that condition the uterus has
lost its support and has dropped lower in the vagina and can
undergo painful movement during sexual relations. Since you are
having pain all of the time with relations and, I assume, this is
interfering with your ability to have a physical relationship
with your partner, I would keep pursuing trying to figure out
what is causing it until all possibilities are ruled out.
The fact that the pain is similar to when the bladder is full
or having a bowel movement tells me there is likely to be either
adhesions in the pelvis (scar tissue) or bowel or bladder disease
such as irritable bowel syndrome or interstitial cystitis,
assuming uterine prolapse has been ruled out. If you
are not having urinary frequency during the day and having to
urinate at night more than once or twice, that is against
interstitial cystitis.
Therefore, I would ask your G.P. if irritable bowel syndrome
is likely. If so see a gastroenterologist. If not, you need to
see a gynecologist. It's likely that a laparoscopy will be
recommended. It may be positive or negative for a cause such as
adhesions or endometriosis, but at least you'll know.
Painful sex and pelvic adhesions
Adhesions do tend to get "thicker" or more dense over time.
Pain can increase due to adhesions up to about one year then
stays the same.
Vulvar redness and itching with condom use
Yes. You are probably having a contact allergy. Most often it
is the lubricant and not the latex. You have to be your own
detective to determine which brand is the problem. There are
unlubricated condoms you can try and then add Replens as a
lubricant. You may want to try the Replens first to make sure you
don't react to it but it is one of the least reactive ones to
try.
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