Wednesday, January 28, 2009

Why Higher STD Rates May Be A Good Thing

The CDC just released its annual report discussing trends in sexually transmitted diseases in the US (summary here). The upshot: chlamydia and syphilis are on the rise. And gonorrhea is stable (yay?) but at still-high rates. The CDC doesn't track HPV or herpes in the same way, so we don't know if these too are increasing.

Why in the world might this be a good thing? The increased rates of STDs may mean higher rates of infection...but it may represent better screening of these diseases. The scariest part of the STD crisis is just how many people have an infection, and don't know about it. I've had patients of all ages tell me they're too frightened to get tested, because they "really don't want to know." But the consequences of an undiagnosed STD can be devastating. Not only might you unsuspectingly pass chlamydia to a partner, for example, but the infection can cause irreversible damage to your fallopian tubes - leading to tubal pregnancy, chronic pelvic pain or infertility.

Knowing you have an STD may suck, but not knowing is worse. If you're under 25 (or have a partner who is), you should be checked at least once a year for the big three (chlamydia, gonorrhea and syphilis), and every 6 months if your sex life is particularly bountiful. If you're over 25, get tested with each new encounter or relationship. Treatment for these infections is very straightforward, from one to several doses of antibiotics.

How often do you get tested for STDs?

Tuesday, January 27, 2009

I Want Your Sex (more than you do)

I've posted this question before, but it's come up again in my office recently, so I thought I'd revisit the topic.

Dear Dr. Kate,

I am in a very happy monogamous relationship and I love my boyfriend very much. When we first got together, the sex was fantastic. We had it all the time and it was good. But since we moved in together, the sex life has slowed down. Here's the problem: my boyfriend really isn't interested in sex. We do still have sex, but not as often as I would like. When we do, it is fantastic, but it is rare when he comes. He does come both during intercourse and oral sex, but not always, and when he masturbates, he does come. Clearly my sex drive is higher, I'm 24 and he is only 23. Last night he said to me sometimes he worries why his sex drive is lower. He swears it isn't me and this has always been the way with girls and he doesn't like that I can't just pounce on and get him turned on. Therefore we always have to go on his schedule because when he is horny, he is ready to go. Am I being totally oblivious and not realizing he has ED? I asked him if he thinks too much about it and if that's the problem, and he thinks maybe that's it, but he isn't sure. He hates that he can't keep up with my needs and I haven't been complaining about it, but sometimes a girl just wants to get laid. I love him and am willing to work through it, but I just don't know what to think. I don't want to worry and I don't want him to worry either, but is it normal for a young guy's sex drive to be so low?

Sexless in the City

Dear Sexless,

All my patients--and I think everyone everywhere--wants to know what's normal. I think it comes down to how you feel you feel, who's feeling you, and the sex that you're having. If you're happy with how and how often you have sex, than you're healthy. If you're not happy, on the other hand, that's when it's time to seek help.

If your boyfriend is truly bothered by his sex drive, he should first see an internist. There are medical causes of low libido (such as heart disease, diabetes, hypothyroidism, Parkinson's disease, anemia, chronic pain), but if he's healthy, the likelihood of any of these is low. Same odds of erectile dysfunction- if he's young and healthy, it's not ED (plus it sounds like erections themselves aren't the issue here). Overindulging in alcohol, or any indulging in heroin, cocaine or marijuana, can also kill libido. If your guy is taking any medications, they too could play a role. And stress, fatigue, anger, depression, past abusive relationships--the same culprits for us also affect men. If your boyfriend thinks that depression or anxiety is a factor, talking to a therapist could help.

But the more likely answer is simply a lower libido. Decreased sex drive, while it's usually thought of as a woman's problem, affects up to one in four men. In the end, you and your boyfriend may have sex drives that don't match...requiring a little creativity to figure out what will keep you both happy.

What have you all tried when you want it more than your partner does?

Sunday, January 25, 2009

Migraines and The Pill

Dear Dr. Kate,

I want to go on birth control but I get frequent migraines with aura. My neurologist suggested trying the progesterone-only pill but my gyno said its only 90% effective. I did some further investigating and read that it is actually 97% effective. Which is right? Also, will being on the POP give me the same benefits as pills that contain estrogen such as predictability, less cramping, and a lighter flow?

Your neurologist is right to advise you against birth control methods that don't contain estrogen (most pills, the patch and the ring). Women who have migraines with aura (visual or auditory symptoms that precede their headaches) have an increased risk of stroke if they're on an estrogen-containing method of contraception. But for most women with "common" migraines (no aura funny business), these methods are all fine.

Progesterone-only pills are about as effective as "combination" pills, but there's a catch. You need to take them at the same time every day. Taking a pill three hours late is like not taking it at all. I know, most of you pill takers have heard the same things about your "regular" birth control pills. But the truth is that estrogen-containing pills are a lot more forgiving, and the timing isn't as crucial. I think doctors still advise the same-daily-time for the sake of developing good pill-taking habits...but it's not related to how well the pill works.

So taking the POP pills at the same time daily give you the same level of protection against pregnancy. They'll also give you lighter periods and fewer cramps. Unfortunately, they don't give you the same kind of bleeding predictability as combination pills. You may get monthly may bleed irregularly throughout the month...and you may not get periods at all. The only way to know for sure is to try them out.

Have any of you tried the progesterone-only pill (Micronor)?

Thursday, January 22, 2009

Rx for Painful Sex

Dr. Kate-

Since I started having sex (4 years ago, I'm 20 now) I've never been able to handle penetration for a very long time. After a while it loses its fun and becomes painful. My current boyfriend and I use lube and we make sure I get aroused so that I'm very wet. He takes a while to come from sex and I can't help but make him stop after a while. How do I make sex less painful? I want to be able to handle him a little bit better (he's a little bit on the larger side) but it hurts when we start and just gets worse. I'm becoming discouraged from having sex since its losing its fun for me. Help!

In Pain

Dear In Pain,

No wonder you're discouraged from having sex - it's hard to think about pleasure when you're just trying to avoid pain. While pain during sex is unfortunately common - and 2/3 of women will experience it at some point - it's never normal. And it's not that you're not a good fit with your guy - the vagina was designed to fit a baby, so unless he's book-of-records large, it's not his size that's the problem.

You're doing one of the best things already by using lubricant. But wetness isn't the only sign of arousal - you want your pelvis to be engorged, as well. Make sure you get enough foreplay so you're really aroused before intercourse (you want to have plenty of blood flowing to your vagina to make penetration easier). Your boyfriend can also insert a finger in your vagina first, so you can judge how you're doing arousal-wise before actually having intercourse. Don't worry about taking "too long" - women on average need 20-30 minutes of good foreplay to become physically aroused enough for comfortable intercourse.

The fact that sex hurts when you start could mean that you're not getting the foreplay you need...but it could signify that you have vulvodynia, or pain in the vulva not just caused by sex. If you experience vulvar pain at other times - like with tampons or gyn exams, or even tight jeans - vulvodynia may be the culprit.

There are a lot of reasons why sex can hurt, and almost all of them can be addressed. Your gyno can also help you figure out what's happening, and help you make sex fun, not just bearable.

Are any of you struggling with painful sex?

Tuesday, January 20, 2009

Does a Grapefruit a Day Keep My Contraception Away?

Hi Dr Kate,

I've heard that a chemical in grapefruit juice blocks the absorption of some medications. I've been on birth control for a month, and generally eat one grapefruit a day. Could this lower the effectiveness of the pill?

Fruit Fan

Dear Fan,

You're right, grapefruit juice can interact with some medications - but your birth control pill is fine. Only anti-seizure meds, certain strange antibiotics and St. John's Wort have been found to lower the pill's effectiveness. If anything, your pill will be more effective (in a sense) because it will absorb more slowly, leading to higher hormone levels in your blood. So f you're going to continue to eat a grapefruit each day, I'd let your gyno know, so she can keep you on the lowest possible dose pill.

Keep up the healthy eating!
Dr. Kate

Monday, January 19, 2009

Say Goodbye to Bush?

I'm for any and all reasons to celebrate Inauguration Day - but to celebrate by pain?

Pubic hair trends seem to wax and wane (pun intended). There was a time that I could guess the age of a patient by simply looking at her lower half when undressed for an exam. If she had pubic hair simply trimmed, she was likely over thirty. (Untrimmed at all, probably over fifty.) But if she's as hairless as a Peruvian, I would bet she was in her teens or twenties.

As a gyno, I'm all for panty line maintenance, but I'm doubtful about going the fully monty. Waxing, even done by professionals, can lead to folliculitis - painful blisters at best, infected pustules at worst. And the red bumps resemble herpes - causing several of my frequent-waxer patients to call me in distress. Plus, the hairless vulva strikes me as prepubescent, rather than attractive.

These days, patients sporting a full Brazilian wax are less common. Perhaps it's the economy, and days at the salon are simply too expensive. But I hope we're returning to a trend of tidying up, not taking off. That's a change that this doc can believe in.

Have any of you changed your shaving/waxing habits lately?

Saturday, January 17, 2009

Spotting on the Pill

Dr. Kate,

About six weeks ago, I started a 21/7 birth control pill called Yasmin. My doctor told me to start taking the pills the very day of my appointment. When I told her I was due to start my period the following day, she said that was no problem and told me to start taking them anyway, which I did. A couple days after that, I had period-like spotting which lasted about two weeks, meanwhile I continued to take the pills. I had no spotting after that, but when I started the placebo pills, I still had no spotting--nothing to imitate the natural period at all. The first day I started the new pack of pills, the spotting came back. I am in my final week of green pills, and I have had spotting the entire time. It's not fresh blood, like a regular period, but it's dark and not really heavy enough to use a tampon, more like it is on the last few days of a regular period, and it is sometimes accompanied by cramping. This never-ending spotting is really starting to aggravate and worry me; it's getting in the way of my social and romantic life on the sheer basis that it makes me feel less confident and less pretty. Mostly, I am concerned about the health aspect. Is this common, or something I should be worried about? Will it go away with the next pack of pills? Will it interfere with the effectiveness of the birth control?

So Sick Of Bleeding

Dear Sick,

Your doctor was right to have you start the pills the day she saw you. This new method of starting your birth control, called "Quick Start," was developed by doctors at my hospital, and is the best way to begin your pills. Instead of waiting for your period to start, you can start getting protection right away--though you should always use condoms as back-up for a week, till the pill becomes effective.

It's totally normal to have crazy bleeding (generally spotting) in the first THREE months of starting hormonal birth control--no matter when you start your first pack. It's your body's way of adjusting to the new levels of hormones. This spotting doesn't mean you're unhealthy, or that the pill isn't working. I'd try to ride it out, and see what happens in the next 2 months.

One of the benefits of the pill is that your periods become lighter, and shorter - and most of all, predictable. If you're still having "unscheduled" (not during the placebo pills) after the third pack, I'd recommend switching to another pill to see if you find a pill that works better with your body.

Have any of you had bleeding weirdness when you began your birth control?

Wednesday, January 14, 2009

How to Have a Better Pelvic Exam

Okay, so you think there's no such thing as a decent pelvic exam - it's up there with paying taxes and flossing. But there are a few things that you can do before and at your annual exam to make it go a bit easier.
  • Keep out before going in. To make it easier for your gyno - and reduce the chance that you need to come back for another exam - don't have sex or use vaginal products (creams, douches) for 2 days before your exam.
  • Smart scheduling. If you get the first appointment of the day, or the first appointment after lunch, you're less likely to have to wait around (with increasing anxiety).
  • Slippery speculum. Ask your gyno to heat up a metal speculum with hot water - and she can use lubricant on either a plastic or metal speculum.
  • Talk it out. Chat with your gyno during the exam. It may sound crazy, but talking during a pelvic exam really helps to relax your pelvic muscles, and reduces your discomfort. You can ask her to tell you what she's doing...or talk about celebrity gossip...whatever works.
Do any of you have tips to share about making pelvic exams easier?

Monday, January 12, 2009

Dual Protection

Hi Dr. Kate,

I am on the pill and my boyfriend and I are using condoms every time we have sex. We're saving the 'bareback' experience for later on, when we're married. My question is how protected are we from pregnancy? Does it give a smaller chance of falling pregnant using both, or is it basically the same thing?

Double Down

Dear Double,

I think you're making a wise choice by using two methods--using the pill perfectly--every day, no skipping, no missing--is almost superhuman, and very few of us never get it wrong. But even if you are one of those wonder women, the pill is 97% effective. That means that 3 out of 100 perfect users gets pregnant each year (shiver). One way to make this number even smaller is "dual method use," or using a second method (generally condoms or a diaphragm) with your first. There's no good data on how effective this is, but I've been a gyno for 10 years, and I've never had a patient get pregnant while consistently using pills and condoms. The other benefit, of course, is fantastic STD protection...lots of bang for your buck during your bang, so to speak.

Using two methods of birth control certainly isn't easy, especially in a committed relationship. You may feel that sticking to one method is tough enough. And if you're using your pill/ring/patch very consistently, you may not feel as motivated to slap a condom on him as well. But consider dual method use the "sexual self-protection" you deserve, both for your body and your peace of mind.

Do any of you use condoms with your pill/patch/ring all the time?

Friday, January 09, 2009

HPV Treatment

Getting the diagnosis of HPV from your gyno can be really confusing. Unlike many other STDs, there’s not a quick cure—sometimes the treatment is really involved, and sometimes you can’t be treated at all. If your gyno tells you:

You have genital warts. This is considered “low risk” HPV, because it doesn’t increase your risk of cervical cancer. The biggest problem with warts is cosmetic—they’re simply unsightly. Your gyno may offer you several treatments:
  • TCA, essentially burning off the lesions in the office. Most often you have weekly treatments for 3-6 weeks until the warts are gone. A little painful, but not awful, and the fastest non-surgical option.
  • Cryosurgery, essentially freezing the lesions. May hurt less than TCA, but many docs don’t have cryo in their office.
  • Laser surgery, often done in the operating room, and generally reserved for large warty patches.
  • Aldara, a cream that you apply yourself at home, three times a week, and wash off in the morning. The most comfortable (and private) treatment, but may take several months to get rid of all the warts.
You have HPV on your pap smear. This kind of HPV is “high risk,” so you’ll need more frequent pap smears and possibly colposcopy. Unfortunately, there’s no direct treatment for this kind of HPV. Your gyno will treat any pap smear abnormalities, but otherwise, you’ll just wait for your body to clear the virus.

Do you find anything confusing about HPV treatment?

Wednesday, January 07, 2009

Ring Warning?

Dr. Kate,

I'm writing you because I'm a bit confused about NuvaRing. I would like to try it and I'm fitted to do so (no weight, age, smoking issues...) but I can read a lot of negative testimonies on the internet and it seems that many lawyers are trying to do a class action against this product. The abundance of negative info makes me confused. Do you think that they are just motivated by greed and that the product being FDA approved should no present more dangers than any other contraceptives? Do you think that these lawyers are right and that NuvaRing presents more dangers than other contraceptives?

Wannabe Ringer

Dear Ringer,

Birth control in all its forms is a magnet for negative feelings, bad press, and class-action lawsuits. So many folks find the idea of birth control abominable at heart, that it's not "natural," or that women shouldn't be interfering with their fertility in any way. And these feelings influence how they talk about their experiences—or worse, about what's "right" for other women. You'll often find that unhappy people are the ones motivated to blog about their experiences, or talk to reporters, or approach lawyers. And if it makes for a good story, or a possible case in court, they'll find reporters and lawyers who are only too eager to listen.

The FDA, for all its faults, puts all birth control methods through a rigorous approval process—manufacturers seem to have even MORE hoops to jump through than makers of other drugs and devices. So once a contraceptive has been FDA-approved, you can take some comfort in what the studies must have shown about its efficacy and safety. I can tell you that the studies of the NuvaRing—and there are many—are all in agreement about both the effectiveness and the safety of the ring. While all contraceptives carry rare to small risks of serious side effects, the NuvaRing is no worse than the others.

Have any of you heard scary things about the NuvaRing, or other birth control methods?

Monday, January 05, 2009

Come On Already

Dr. Kate,

So, here's a twist: I (the girl) orgasm super easily, while my boyfriend does not--in fact, he's only come during sex with me once, and that was the first time in his life (he's almost 30). He can come if I go down on him (although I am the first girl he has been able to with and he didn't for the first few months of our relationship) and it took him a while to even come when I used my hand. He thinks something is physically wrong with him, and that something wasn't done right when he was circumcised. He may be right--his most sensitive spot is actually a little bit of what seems like leftover foreskin on one side of the head of his penis. I know he CAN ejaculate (and does pretty regularly with non-penetration methods), so it doesn't seem to be a problem with his plumbing. Have you ever heard of loss of sensation like he describes?

I'm sure the problem is compounded by other stuff. He's less self-conscious about this than he used to be, but if in 10 years of having sex YOU weren't able to orgasm, it would just be like the biggest, most embarrassing elephant in the room, right? I can't help but think that there's something more I could do. I really, really want him to be able to come again, and now it's all I think about! Before he did, I didn't think much of it because he had said he wouldn't be able to and I just went with that. But then he did, and it was amazing for both of us, and now it's like my hopes are up.

Wishing for Coming

Dear Wishing,

I don't think that your boyfriend's issues are physical ones - a circumcision (good or bad) shouldn't affect his ability to orgasm (though yes, it can affect his surface sensitivity) - for most men, it's primarily a pressure/friction issue, not a skin-touch issue, like for women. And the fact that he can come "pretty regularly" in ANY way, means that his "plumbing" is fine. So that's the good news, since most physical problems don't have easy answers.

But what I think is happening is that he has some mental difficulty with intimacy and sex - if he can regularly come through masturbation, but has a harder time with a partner, then something larger is going on. Kudos to you for being so caring and concerned about his pleasure, and clearly he feels more comfortable with you than with previous partners. But there may not be anything else that you can do - this isn't a matter of your technique or enthusiasm. And pressure on him to come, from either of you, and no matter how well-intentioned, may actually be making it harder for him. Has he ever thought about talking with someone? I don't think he's crazy, or "sick," but a few sessions with a therapist may help him to unlock some of these things.

Best of luck,
Dr. Kate

Saturday, January 03, 2009

No Big O

Dear Dr. Kate,

I have a big issue. I have been sexually active for about 4 years now and I have had my share of partners, but for some reason I just cannot seem to be able to have an orgasm. I have never had one, whether it was through intercourse, oral sex, or masturbation. I have tried everything I possibly could but nothing seems to work. At times I get so close but then I just lose it. Most of the time I think the problem is that I cannot seem to relax, I always have a million things running through my head. It's gotten to the point where I don't even want to have sex anymore. My sex drive is way off because I want to be able to enjoy sex fully instead of just being disappointed every time. I have also heard that there are women that never get an orgasm, is that true? Do you have any suggestions on what I can do?


Dear Disappointed,

Even though sex is about more than orgasms, I can understand why not having an orgasm is affecting how you feel about sex in general. But I've never had a patient who is simply not able to have an orgasm - in my experience, EVERYONE can have them, it just may take more time to figure out how to get there. So don't lose hope!

For my patients who are having difficulty with orgasms, I recommend starting with masturbation - I think you'll find that it's going to be easiest to come by yourself, before trying to come with someone else. Yes, part of having an orgasm is being able to "let go" - so you'll want to be in a place where you won't be bothered or interrupted, where you'll have plenty of time and won't be rushed. This is how you'll be able to figure out what kind of touch feels best for you, and follow the sensations where they lead. My other recommendation is a vibrator - it can pull an orgasm out of you almost against your will. There's lots to choose from on sites like Good Vibrations or Babeland.

When you try a vibrator, don't start out with it directly on your clitoris - that's often too intense. Try it on your labia, then on the sides of your clit. Vary the amount of pressure you use, and try alternating leaving it in place and moving away. See what feels good, and don't be afraid to give into the sensations if they get intense.

Once you can figure out what feels good, you can then teach your partner how to touch you like that. Fingers and tongue often work best - climaxing during intercourse can take a long time to figure out, so don't try for that right away. If you're with a considerate, caring partner, he'll be eager to try different things to make you feel good.

Best of luck (and let me know how things go),
Dr. Kate