I-U-Don't? I-U-Do!

Hi Dr. Kate!

I can't take hormonal birth control; I've had terrible side effects and I just don't like it! My question is; what is the best non-hormonal option? My doctor will not give me an IUD because I've never been pregnant. How effective is coupling condoms with a diaphragm or the sponge? I've read that The Sponge increases the risk of contracting HIV, but I've been with the same guy my entire life, so I don't think this is too much of a concern for me. Thanks!

No Pills for Me!

Dear No Pills,

My first thought is...find a different doctor! There's no reason that you shouldn't be able to get an IUD before a baby, that's outdated thinking. And a copper IUD will give you 99+% effectiveness for up to 10 years, so it's hands-down the best non-hormonal option. Condoms plus a diaphragm should get you over 90% effectiveness, especially if you use spermicide with the diaphragm (available as creams, suppositories or film). And condoms plus the sponge should be about that good as well.

The sponge - like other spermicides - may increase your HIV risk if you're having intercourse, and using the product, multiple times a day, every day. (The studies that showed us this were conducted in sex workers in Africa.) Since this isn't the sex pattern of most people in the world, spermicides are still a good option, when used in conjunction with a barrier method (condoms, diaphragm) for greater effectiveness.

But my guesstimates on effectiveness are based on PERFECT use - using both products, every time, with no spillage. And that can be tough to do, long-term. I'd still think about seeing another gyno to get the IUD, then going back to your guy for your check-ups, especially if you know you don't want to be pregnant for awhile.

Have you been told you couldn't get an IUD? What was the reason?

Photo credit: Liz Henry

Backside Bump

Dr. Kate,

I have a rather embarrassing question to ask. A couple of months ago, my guy and I decided to try full-out anal sex. I think he didn't actually use enough lube, because it hurt more than I'd ever imagined and it bled a little afterward. We didn't do this again because of the pain, and the blood. A couple of days later, I noticed that I had developed a fleshy bit on the edge of my anus, which felt, to the touch, sort of like a skin tag. But it is sometimes itchy, and has bled again, once or twice. Is it possible to develop a hemorrhoid, or something like it from anal sex? And is this something I need to be worried about?

Tag, I'm It

Dear Tag,

It does sound like you've developed a hemorrhoid, a small prolapsed (bulging-out) vein that can pop out on the inside or the outside of your anus. 'Roids are known for being itchy, a bit painful, and occasionally bleeding. It's unlikely, though, that one act of anal sex cause the hemorrhoid to develop - you need more pressure on your bottom for a longer period of time (like chronic constipation or pregnancy). So it's possible that you're either noticing the bump for the first time, or that it was there before, and after sex has now dropped down to be exposed on the outside where you can feel it. Either way, it's nothing to worry about. Preparation H can help with the itch, and you'll only need it removed if the bleeding becomes serious (more than the occasional drop or streak when you wipe).

If you ever want to try anal sex again, definitely use A LOT of lube, and make sure he thrusts slooowwwly and gently. The back door is not like the front, and requires its own technique.

Have you had any problems when trying anal sex?

Photo credit: bleggg

Exactly Why STDs Are Bad

One of the hardest parts of my job is calling a patient to tell her that she has a sexually transmitted infection (STD/STI). Every woman receives this news differently--shock, anger, horror, depression, resignation--but it always ruins her day and often sends her to the internet to find out what it means.

But STDs are not all alike (even if it always sucks to get one). This news may mean you need to take a single dose of antibiotics to cure it...or it may mean that your life is forever changed (HIV). In general, there's two kinds of STDs. Bacterial and parasitic infections include gonorrhea, chlamydia, trichomonas, and syphilis; these can be treated, and often cured, with medication. Viral infections infections are most often the big three: HIV, HPV and herpes. These infections cannot be cured, though their symptoms may be controlled.

Most of us are aware of the dangers around the viral infections (the gifts that keep on giving). But sometimes my patients are unaware of what exactly the consequences are of contracting a bacterial or parasitic STD. "You can just treat it, right? So what's the big deal?"

Short-term misery.

• The infections themselves - while they may be silent, they can cause vaginal discharge, vulvar bumps, burning, and pain.
• Abscesses - when certain STIs make their way up to your tubes and ovaries, they can create a pocket of pus the size of a golf ball or larger, often leading to....
• Hospitalization, for both intravenous antibiotics and pain control. Sometimes time alone is enough to resolve an abscess, but sometimes you end up needing....
• Drainage or surgery. It can be a needle passed through the wall of your belly to drain the pus, or actual surgery to remove the mess--either way it's a nightmare.

Long-term consequences.

• The risk of surgical complications if surgery is needed--bleeding, further infection, damage to your bladder or bowels.
  
• Infertility, if your fallopian tubes are scarred. Even surgery is often not alone to repair such damaged tubes, and you're then facing in-vitro fertilization (IVF) if you want to get pregnant in the future.
• The "talk" with every future partner about your sexual history. First sexual encounters can be awkward enough, without having to talk about your herpes or HPV infection.
• Medical bills. Because these infections need to get treated, whether or not you've got insurance.

Finally, if you contract an infection from a partner and eventually sleep with someone else without treatment, you'll be spreading the STD wealth without knowing it. So if you're not in a monogamous relationship--or aren't sure if you are or not--please think twice about not wearing condoms. Use them for your health, both for now and for later.

Have any of you, or had someone close to you, had to deal with the consequences of an STD?

Photo credit: miszpinay

Oversleeping Plan B

Dr. Kate,

My boyfriend and I use condoms, but he also generally pulls out during sex. So we were having super hot sex and then he came inside me. Whenever this happens, I take the morning-after pill to be safe. But this time I was so tired that I took the second pill 21 hours later rather than 12 hours later. Because I slipped up taking the second pill does that increase my chance of getting pregnant?

Not 2 Late?

Dear Not 2 Late,

We don't know for sure what happens when you take the second pill of plan B late. My best guess is that it doesn't work as well, and perhaps not at all. So I'm glad you were using it as a back-up to your back-up method of birth control (withdrawal...yes, "pulling out" counts as birth control, albeit not a very effective one). Since you were using a condom, your chance of pregnancy from this one time is pretty low.The easiest way to prevent this very common plan B mistake is to take both pills at the same time. It's just as effective, and won't increase the chance of nausea or vomiting.

Using condoms + withdrawal each time you have intercourse? Not a bad combination if you can't get access to hormonal birth control or IUDs. But I'd encourage you to think about these other methods. They're much more effective, and certainly are easier to use than buying EC multiple times in a year.

Do any of you use condoms and withdrawal as your birth control combo?

Photo credit: evelynishere

Talking About HPV

Hi Dr. Kate,

Sadly, I went to my annual OB-GYN appointment 2 weeks ago and was told that HPV was present in the swab that was taken. My oh-so helpful doctor's office couldn't tell me which strain it was, only that it was present and that I needed to come back in 6 months for another checkup, so I'm guessing it's not the genital warts one, just the cancer causing one? It is really frustrating to me, as I've only been with two people in my whole life, and condoms were used both times. Plus, I've sat through the three Gardisil shots as well before I got busy with either one of my partners.

My main concern is the relationship I'm in now. We aren't seeing anyone else, and so far it's been going great, until now.... What is the protocol here? I understand with a regular STD you need to tell your partner and I'm prepared to fess up here as well, but it's hard to since I don't know what kind I have. Anyway, since my doctor isn't helpful, I was wondering what the correct behavior is here.

Tongue-Tied

Dear Tied,

Let's talk about you first. You've done all the right things to protect yourself, but as we know, nothing takes the risk away completely...which is why screening is so important. The majority of HPV testing looks only for high-risk strains. There are multiple versions of HPV that put you at risk for cervical cancer, but since they're all managed the same way, they're tested for in a batch. So unfortunately, yes, you've got a strain that puts you at risk. The Gardasil will still offer you protection from getting those strains in the future, though, so the shots weren't in vain. BTW, docs don't test for low-risk strains for two reasons: 1) we don't treat them directly unless warts appear, and 2) you don't need more frequent pap testing for the low-risk ones.

Now the tough question--if and how to discuss your diagnosis with your boyfriend. It's likely that he too has the virus, though you'll never know which one of you had it first. You can look at this situation in two ways:

• Since 80% of sexually-active adults have or will acquire HPV, your boyfriend likely had the virus (and gave it to you) or would have gotten it from someone else. Since the virus won't affect his health, there's no need to tell him about it while you're together. And if you break up, you can tell him then, so he'll know to warn future partners.
• HPV is still an STD, and most of us want to know about any infection that we've been exposed to, whether or not we can do anything about it.
  

Personally, I believe that the best course of action is generally openness and honesty. If you're close enough to someone to get naked and swap bodily fluids, you should be able to share bad news as well. You can bring it up when you're not in bed (or at least not post-coital), at a moment that you've got time to talk. And you can give him resources about where to go for more information, like here and here.

How have you handled a diagnosis of HPV? Have you told all to your partner? How did you do it?

Photo credit: kimberlyfaye

Lovely Lady Lumps?

Dr. Kate,

I had a baseline mammogram, and two lumps were found in my left breast, so I was sent to get an ultrasound. The doctor did not really say too much. She asked me if I had an infection in my breast, I said no and that was that. She said that she really couldn't tell anything else because this was my baseline and that I needed to come back in 6 months to see if the lumps have grown. Is this a normal answer? Do I wait 6 months to see if it is cancer? I had one lump removed from my right breast in 1993 which was not cancer but is that what you do? Should I go see another doctor?

Leery About Lumps

Dear Leery,

Breast lumps can be tricky to manage. There are several features of a lump that doctors consider in trying to figure out if a lump is benign (not cancerous) or not:

• Smooth or rough? A lump that's smooth like a marble is more likely to be benign thank one that is bumpy around the edges.
  
• Mobile or fixed? A lump that you can squish around between your fingers is more likely to be benign than one that feels cemented in place.
  
• Fluid-filled or solid? A cyst filled with fluid is 99% of the time benign.
  

Additionally, your medical history can provide clues. If you're a breast-feeding mom, a lump is more likely to be a blocked milk duct. Similarly, if you've got fibrocystic breast disease, a lump may be cyclical thickening of normal tissue. The radiologist, too, looks for features of the lump on the scan to give their best estimate of what the lump is.

But in the end, the only way to know that a lump is not cancer is to sample it--using a needle (with or without ultrasound or CT scan) to extract cells, then examine them under a microscope. No doctor can tell you with certainty that a lump is benign until you've had it biopsied. But if your doctor or the radiologist has a low suspicion that the lumps are cancer, waiting 3-6 months for another exam and mammo/ultrasound is reasonable.

Bottom line? Ask your doctor why she thinks it's okay to wait 6 months for another check. And if you're not reassured, seek a second opinion. It's your body, and you need to feel good about what's happening with it.

Have you ever had a breast lump? Did you have a biopsy, or did your doctor say it was okay to wait?

Photo credit: zpeckler

"Trust Women."

I have been trying to find words to write about the murder of Dr. George Tiller on Sunday. But the first words that spring to mind--outrage, devastation, fear, anger--don't begin to scratch the surface for me.

Dr. Tiller provided a service to women in need that few others have the courage to give. Had he died in a car accident, it would be a loss for women and their families. But murdered in his church? It's a loss for humanity.

I can't seem to find answers, or solace in the knowledge that there are other abortion providers who are bravely going to work this week to do the work that is so necessary. I'm only finding endless questions.

Where are we as a nation that anyone can see assassination as justifiable, for anything?

Why can't people trust women to make the best decision for themselves and their family?

Why does the provision of LEGAL medical care put a doctor's life at risk?

What happens to women if abortion providers stop practicing out of fear?

Since my words are inadequate, I'm linking to a site with women's stories, those who have experienced the worst news you can receive about a wanted pregnancy. Those who are making the toughest decision of their lives, and were lucky enough to find a doctor who could give them the care they needed. Activists on both sides of the issue--aided by the media--so often paint all women who receive 2nd- and 3rd- trimester abortions with the same brush. Let these women break out of the caricatures and become real to you.

And I'll end with words from Dr. Tiller, words that I wish everyone who is anti-choice could read and truly understand:

"Abortion is a matter of survival for women. It is a matter of the survival of their hopes, their dreams, their aspirations, and their potential. Abortion is not a cerebral or reproductive issue. Abortion is a matter of the heart. For until you understand the heart of a woman, nothing else about abortion makes any sense at all."

* If you want to give a donation, consider: Medical Students for Choice (helping to educate and train the next generation of doctors about reproductive health) and the National Network of Abortion Funds (who help poor women access abortion care).

Photo credit: qwrrty

High and Dry

Dr. Kate,

I need answers to this question or I'm afraid it'll ruin my relationship. When I'm having sex with my boyfriend, most of the time I do not get wet at all. He says I used to, but now I don't. Even when I orgasm sometimes it doesn't get wet. Sometimes even when he's performing oral on me. He thinks he doesn't turn me on anymore or I'm with someone else, but that's not true. I'm enjoying every second of fooling around with him, so I don't understand why this happens so often.

How Dry I Am

Dear Dry,

Lubrication is tricky beast--we always seem to have either too much of it, or not enough. First thing, you may actually be getting wet, but he's not always noticing. Vaginal fluid can pool in the back of the vagina, where it's less noticeable, or it may be drying very quickly (on you or on the sheets). And if he's using saliva at all during oral sex (and how could he not?), how can he tell what "wetness" is from you versus what's from him?

But your boyfriend may be accurate in his perception that you're more dry than before. There are many causes of vaginal dryness:

Overdrying your vulva, from excessive washing or douching

Medications, including
• allergy medications used regularly
• anti-depressants
• any medication that says "anticholinergic" on the package insert

Low estrogen levels, from:
• cigarette smoking
• hormonal birth control
• really low body weight (along with no periods)
• removal of your ovaries
• cancer therapy
• childbirth
• breastfeeding
• menopause or perimenopause

Vulvodynia (because the pain isn't bad enough)

Chronic illnesses like:
• high blood pressure
• atherosclerosis
• diabetes,
• connective tissue disorders (especially Sjogren's syndrome)

Yes, lack of arousal can cause it, too...but it's possible to be aroused without much lubrication. (In the same way, you can actually get wet in a situation where you're not turned on in the slightest.) And orgasm won't often make you wet, either--medically, it's a series of muscle contractions that aren't linked to lubrication.

The most important thing is that you're enjoying yourself during foreplay and intercourse--if everything feels okay, then nothing is physically wrong. So tell your boyfriend to be happy that you're so pleased in bed...and to stop using your amount of lubrication as a barometer of enjoyment (or fidelity).

Best,
Dr. Kate

Photo credit: Alireza Teimoury

The Sponge Is Back (Again)

The Today contraceptive sponge is once again returning to U.S. drugstore shelves. The sponge has been intermittently available over the last 15 years, due to production problems and ownership switches. By this summer, we should once again be able to find the sponge in the major pharmacy chains, and not just have to search for it online.

The sponge is a little polyurethane pillow (with no latex) that contains nonoxynol-9 spermicide. It may be placed up to 24 hours before intercourse, and it protects against pregnancy for up to 24 hours, no matter how many times you have sex. After intercourse, you should leave the sponge in place for at least 6 hours, to allow maximum spermicide action. But make sure you remove it before 30 hours--just like a tampon, you don't want it to remain in your body past its prime or you risk infection (toxic shock syndrome).

On one hand, I think the sponge's return is wonderful. It's available over-the-counter, no prescription required, and women can buy them ahead of time just like condoms, to be used when you've deemed a fellow "sponge-worthy". And the more birth control options that women have, the better. The sponge is to be packaged in boxes of three and sell for $14.99.

But before you flush your pills or yank out your ring, be warned. The sponge is primarily a vehicle for spermicide--yes, there's a small physical barrier in front of your cervix that helps prevent sperm passage. But it's not that much more effective than the many spermicide products (film, foam, suppository) that have been available for years. How effective is the sponge? If you haven't had a baby, the failure rate is around 16%...and if you have had a baby, the failure rate is a whopping 32%. And unlike condoms, the sponge won't protect you against STDs. Risks of sponge use include vaginal irritation, allergic reaction, and trouble removing the sponge. So don't choose the sponge over more effective methods, if you're happy with what you're using now.

If you've used the sponge before, what did you think? Do you think you'd ever use the sponge in the future?

Photo credit: m kasahara

G Spot Not the Great Spot

Dr. Kate,

I have this great new boyfriend and we have fantastic sex--often including orgasm, sometimes rough and with lots of oral, all of which includes some heavy use of the G-spot (none of which I've done much of before). I am enjoying it and so is he, but I've been having a problem with feeling like something isn't quite right "down there" after our sessions. It basically feels like I have to go to the bathroom all day (but I don't need to actually go - it just feels that way) and is a general discomfort/feeling like I have some sort of problem with that area. It doesn't burn when I urinate and it doesn't seem to be a yeast infection. Could this discomfort be from over-stimulation of the G-spot? Is it a normal reaction or should I worry that this could be a signal for something else?

Thanks,
G-Spot Gal

Dear G-Spot Gal,

Discomfort isn't normal, especially when it lasts for hours after sex. The first thing to do is to rule out a bladder infection--not all UTIs have burning with urination, and they can present just like your other symptoms. Plus, it's more common to develop a UTI when you're having lots of sex. (Your gyno can also test you for STDs from your urine sample, just to make sure there's nothing scary going on, either.)

If your doc tells you that your urine is clear, your discomfort may be from vaginal chafing (ouch). The "g-spot" is really just part of your upper vaginal wall--it's not a separate structure. And any part of your vagina can become sore from too much friction. Perhaps your marathon sex sessions are leaving you a bit dry, or there's a bit too much attention paid to such a small area. Try adding lubricant during intercourse, or balancing tongue-attention to your labia and clitoris with your g-spot during oral. And you might want to think about giving the g-spot a bit of a break altogether for awhile, to see if that resolves the discomfort. Such an attentive, giving boyfriend is sure to work with you to keep the sex fantastic--as well as pain-free.

Best,
Dr. Kate

Photo credit: ubiquity zh

The Reason I Haven't Posted In A Week

Zachary Parker, born April 14th (by emergency c/section - but that's a topic for a future post). Healthy and lively, though he hasn't quite grasped the concept of day and night yet.

I'll be slowly resuming blogging as I get more sleep (and my typing skills return to normal). Please keep your questions and comments coming - I'll get to all of them in time. Thanks for your understanding!

Do I Need Lead-Lined Condoms?

Hi Dr. Kate,

My long term boyfriend recently had radioisotope therapy to treat his hyperthyroidism. He's received all the necessary info about precautions, including no sex for 2 weeks, and using condoms for 6 months thereafter. However, I'm wondering about blow jobs...is the use of condoms to protect any transfer of radioactivity in the event of an accidental pregnancy, or is there a real danger to me? I'm thinking if we're allowed to kiss, oral contact with bodily fluids is okay?

Future X-Woman?

Dear X-Woman,

To the best of my knowledge, the sexual precautions are to prevent an accidental pregnancy - radiation early in pregnancy spells trouble for fetal development (mutant sperm and all that). If his doc has given him the okay to kiss you, I can't see semen exposure being a problem, either. He won't emit radiation through his skin or into his fluids - so you won't turn into a mutant (or develop cancer) by swallowing. But you might want to double-up on the contraception during this time, to make sure that you don't become pregnant.

Men undergoing treatment for cancer have similar sexual issues. Chemotherapy can make spunk taste even funkier, so condoms can be helpful for oral sex aesthetics. Radiation therapy using implants that are left inside the body may halt sex of any kind temporarily, but usually it's due to issues of his comfort (and that he's feeling like crap during treatment, and may not have the energy for sex).

Enjoy being as close as you want--
Dr. Kate

Photo credit: jpeepz

Prolonged Pills = Postponed Pregnancy?

Dr. Kate,

Right now I am absolutely not interested in having children. But in time, all things change. I have been taking birth control pills since I was 18. There hasn't been any period between then and now where I haven't taken a pill. Somewhere down the line (4 to 6 years from now) I may want to have kids and by then I will have been on the pill for 10+ years straight. So my question is, will this affect my chances of getting pregnant? I've heard of women taking a few months to a few years to get pregnant after getting off the pill. Will the time it takes for me to get pregnant be longer than most since I will have been on the pill for so long?

CB

Dear CB,

First, congratulations on being such a successful birth control pill user! Happily, there's no downside of long-term use of hormonal birth control. In fact, if you use the pill for over 10 years, you'll reduce your chances of ovarian cancer by 50 percent, and your chances of endometrial cancer by almost 80 percent. So not only have you avoided an unplanned pregnancy, but you've actually reduced your risk of cancer.

The pill is very effective at turning off your ovaries, but it doesn't put them in a deep-freeze. As soon as you stop the pill, your ovaries will wake up and begin to prepare for ovulation again. Yes, some women have trouble conceiving after they stop their birth control. But be assured: your fertility off the pill is the same as it would have been if you had never taken it in the first place. So if you were always able to get pregnant at age 28, you'll have no difficulty once you start trying. But if you were destined to have fertility trouble at the same age, you'll still have it anyway.

When you're ready to start trying for pregnancy, your ovaries will be there for you. So enjoy your baby-free existence (and happier periods) as long as you want to.

Best,
Dr. Kate

The Pill Is Killing My Libido

Dr. Kate,

I'm a 28 year old married woman who isn't intending on having children. I've been on various birth control pills for about 10 years now. Some have made me moodier than others, but in general I've been satisfied, except for one issue. I feel as though my sex drive is diminishing more and more and more and almost doesn't exist now. I still enjoy sex, but never seem to want it enough to initiate, which has (as you can imagine) caused a few marital issues. Fortunately I have a very understanding husband, but I still want to solve this problem. I've read a lot recently about the hormones in birth control pills having this side effect. I am currently considering switching to an IUD and leaning towards the copper option to avoid ingesting more hormones. Do you think this is a wise choice and could/should help? Do you have any other suggestions?

Thanks,
Desireless

Dear Desireless,

The pill's relationship to libido is a complicated one. Some women report decreased sex drive when they're on the pill, and other women report an increase in their drive. In studies where women using the pill are compared with women not using the pill, women complain about lower sex drive about equally in both groups. In other words, loss of libido is a common complaint, whether or not you're on the pill.

Paragard, the copper IUD, is an excellent birth control choice for many women who don't want to or can't use hormones. It's 99% effective and lasts for 10 years--especially good if you know you don't want children in the near future (or ever). It may make your periods heavier or longer, or increase your menstrual cramps, but taking ibuprofen or naproxen can help.

You may find, though, that stopping the birth control pill doesn't bring your libido back. Heaven knows there are plenty of reasons why you may not want to have sex--stress, illness, not having a very good time when you do have sex. And there's nothing wrong with not initiating as much as your partner, if you respond to his advances as much as you want to. So if changing your birth control doesn't change your libido, try to figure out what would make sex better for you, and enlist your husband in your efforts to achieve it.

Have you felt that your birth control has affected your sex drive?