More Answers to FAQs on Concerns about Sex

Frederick R. Jelovsek MD

• Heavy bleeding after sexual relations
• Will hysterectomy alter orgasm?
• Decreased libido and orgasm on Paxil®
• Premenopausal vaginal dryness and decreased libido
• With a vaginal hysterectomy, will cervix removal affect sex?
• What kind of physician do I see for a decreased sexual desire?
• Pain with sex or full bladder or bowel movement
• Painful sex and pelvic adhesions
• Vulvar redness and itching with condom use

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?

The Board Certified gynecologist that I went to says a hysterectomy is the answer for my pain problems. I have all my children and I am 39 years old. I would love to not have anymore pain and constant bleeding but I keep hearing about total hysterectomies causing orgasm problems and decreased desire. Also, bladder problems and they call it being castrated. I am scared and don't know what is true! I have a wonderful sex life now when I am not in pain which is about 2 weeks out of every month! I also have powerful and fulfilling orgasms and I am scared that this will change after hearing and reading about Hysterectomies. Please help me as I am really scared. Some say, you will be so glad you did it and others say, DON'T DO IT NO MATTER WHAT! What is the truth??

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®

I am a 58 y.o. woman post hysterectomy 25 years ago. Recently due to a sudden onset of panic attacks, I have been perscribed to take 10 mg Paxil® 1x a day. This has caused a sudden lack of interest in sex as well as the inability to reach orgasm. What can I do about this? Is there any remedy while I am on Paxil which will be for about another 6 months if I go panic attack free for that time. Any suggestions would be helpful.

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

I am 23 years old and married. I have been having a problem for the last year or so with vaginal dryness during intercourse. We have stocked up on K-Y jelly and the like but I am a bit worried because it has been ongoing. In addition to the dryness and the pain (irritation) that it causes during sexual intercourse, I seem to have lost my sex drive (which has always been quite strong). I don't know if the low sex drive is psychological because sex is uncomfortable or if it is perhaps hormonal. I have mentioned the above to my doctors but they just blame it on my busy lifestyle and stress.

I have my life under control, the sex part is stressing me out though!! Please help, all of the books that I have looked at seem to be aimed at menopausal women.

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?

Thanks for your quick response. Let me try to answer some of your questions... My menses used to be very regular, when I was on the pill, but now they are more erratic. I stopped taking the pill in January of this year because I thought that the hormones might be causing the dryness and low sex drive as well as skin problems. I have been on OrthoNovum 7/7/7® (acne), Demulen® (severe mood changes, depression, loss of sexual appetite), and most recently Ortho TriCyclen®. I was fitted for a diaphragm, hoping that by using a contraceptive that was not hormonal, everything would go back to normal. It hasn't.

Diet: I have been lacto-ovum vegetarian since high school (1991). Dryness: The dryness isn't bothersome on a day to day basis (although I can tell a difference from how I used to be). It is mainly a nuisance when we try to make love. Sometimes we can't even finish. I don't think it has anything to do with my husband because even when I have tried to make myself wet by masturbating I am unsuccessful. I used to get wet just thinking about sex. We are in a monogamous relationship; I have absolutely no fears that he is unfaithful to me. He is also very sympathetic and understanding, not at all abusive. We do not use condoms any more, but I don't think I ever had a problem with being sensitive to them or to spermicides of any sort. The only major thing that happened in the last 1 1/2 years was that I had an abnormal pap smear and was told that I had cervical dysplasia due to HPV. I had a colposcopy and went back for repeated pap tests which have in the last 6 months been normal. Could HPV be the physical reason for the dryness as well as a mental reason for my lack of interest in sex? I think that this might have something to do with it but I don't think that it is the whole story. What else could it be and is there anything besides k-y jelly that would help make sex fun again?

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?

I am scheduled for a hysterectomy next week because of uterine prolapse and related bladder/rectal difficulties. My doctor is doing this vaginally and is taking out my cervix. He says there is no reason to leave it in and it won't affect my sex life. Friends have told me that I should keep my cervix to keep full sexual enjoyment after the surgery. Who is right?

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?

I am a 32 yr old mother of 3 boys (5 yr old twins, and 7 yr old). I've been married 9 years to my DH and we have a great relationship. What we don't have however is sex. Now he's okay with it, and I am somewhat okay with it.. although I'd like to improve it. Here's my problems..I have chronic yeast infections and anything can set them off from beer to sex. I get bacterial infections really easy (example oral sex). I also have absolutely NO sex drive. I mean none. I use to like to masturbate and I still can occasionally, but not half as much as I use to. Even if I do.. its just not very exciting. My question I guess I'm asking is I don't know which doctor to go see. I mentioned to the OBGYN once about my low sex drive, and basically the answer I got was very humiliating (seduce your hubby etc..) I'm wondering do endocrinologists test hormone levels?? OR should I just check with my family doctor first?? Or some kind of sex therapist?? I really am not sure who to turn to to help me straighten all this out. Any insight?

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

For the last 4 years I have experienced pain during intercourse. When I first told my doctor about it, he sent me for an ultrasound, it came out "negative". I figured it was all in my head (I was going through a divorce.) One year later, a new partner and no health insurance, I went to planned parenthood for my annual & BCP. I mentioned the still occurring pain to the nurse, she said my partner was hitting my cervix and to try different positions. So I did, but still had the pain, the next year was the same thing. This year I went back to my original doctor, let him know the pain was still there and getting worse. He sent me for two more ultrasounds; one on the lower right (where the pain is) then another one of my entire abdomen. Both were fine. My doctor is a general practitioner and he seems reluctant to send me to a gynecologist. I get the same pain when my bladder is full, having a bowel movement, and after a pelvic exam, or just pushing on the area. Since the ultrasounds are fine should I simply live with the pain or are there other tests? My paps come out normal, but I'm not sure what they are testing. I'm 27 years old. Thank you so much, I don't know where to go from here.

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.

Thank you for taking the time to answer my questions. I will ask my doctor about this

Painful sex and pelvic adhesions

My doctor said I have adhesions in the pelvis an will require a 3 hour laparoscopy to free them. In addition I was wondering if adhesions causing pain get worse over time? The pain I'm experiencing is getting worse and is suddenly very painful during sex.

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

Each time my husband and I use a condom to prevent pregnancy, I end up with redness and itching (about 12 hours later). Could this be an allergic reaction to the condom? I am not allergic to latex gloves. The condom was free of spermicide but did have a lubricant. HELP !! I was going to the doctor next month to get a diaphragm, but aren't those latex?

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.