Feb. 4, 2011 -- "Is it normal to feel this way during sex?"
"Should I be concerned that I am bleeding right now?"
"Am I supposed to feel like this?"
"Am I normal?"
Questions like these have popped into the minds of most women at one time or another, but many are reluctant, or even ashamed, to discuss them in detail with their physicians. However, for doctors, no question is stupid and no woman should feel embarrassed to ask the most intimate of questions when it comes to her health and well-being.
"Most embarrassment comes from the perceived notion of what the physician's response will be, and how that physician has previously built trust with intimate issues," said Dr. Diane Harper, director of the Gynecologic Cancer Prevention Research Group at University of Missouri-Kansas.
And Dr. Margery Gass, executive director of the North American Menopause Society and a gynecological consultant at Cleveland Clinic, agreed, and said that any symptom or annoying condition that a woman experiences should be raised with their doctors.
"Doctors feel comfortable talking about these issues, and, what I'd really like, is for women to feel comfortable talking about them as well," said Gass.
Dr. June LaValleur, associate professor of obstetrics and gynecology at University of Minnesota, said it's the job of the doctor and the patient to create an open and inviting conversation.
"Women need to feel that their provider will be responsive to their question, so we teach residents to be 'askable' physicians," said LaValleur. "Being a gynecologist is such a special role, and it is indeed a privilege to have women as patients tell us things that are so hard for some to talk about."
Women's health experts say sensitive health concerns can range from natural body quirks to potentially life-threatening conditions. The next few pages feature a closer look at some disorders that, doctors say, women should never be ashamed to discuss.
While sex brings great pleasure and connection to many relationships, it can also be a source of stress when intimacy problems are not discussed. And that doesn't change outside of the bedroom: doctors say sex is one of the main topics that women have trouble discussing with their doctors.
First, let's talk orgasm.
"Women who have not had orgasms will very seldom say, 'I've never had an orgasm,'" said LaValleur. "They'll often skirt around the idea, so we are conscious to ask specific questions relating to orgasms and intimacy."
To note how closed-off some women can be when discussing their sex life, LaValleur recalled a patient in her 40s who came in for an annual appointment with her husband of two years. The woman had never had an orgasm. When the patient left the room to get dressed after the appointment, her husband pulled LaValleur aside to ask where the clitoris was on the body.
"Most women need to have the clitoris stimulated to orgasm and their partners sometimes don't know where it is," said LaValleur. "It's amazing what women don't know about their own body and body functions, and sometimes they're too afraid to tell their partner that what they're doing is not working for them."
"I always let a woman know that her orgasms are her own responsibility and she needs to tell her partner what she wants and needs," continued LaValleur.
Communication is often the answer to many of the sex questions that women pose, and can also be at the root of a secondary problem: a low sex drive.
Doctors say that a low libido is often a reflection of problems in the relationship, especially in pre-menopausal women. While a woman's sex drive will naturally hit highs and lows throughout her life, psychological problems, like a poor body image, history of physical or sexual abuse, and anxiety and low self-esteem can all contribute to a lack of desire. Certain medications, like anti-anxiety and anti-depressant pills, can also add to a low sex drive.
Moreover, relationship problems, like unresolved conflict, lack of trust, and poor communication of sexual preferences, can all lead to a decreased desire for sex.
Surveys reveal that about 40 million Americans live in a no-sex or low-sex marriage, defined as having intercourse ten times a year of less. Whether or not this sex life is sufficient depends on the couple. But, like most things sex-related, communication is significant, with a woman's partner and with her doctor.
Pain during Sex
Of course, if a woman experiences pain during sex, it will certainly lead to a lack of sexual desire. Doctors say that it is not normal to experience pain during intercourse, but there are many treatments available, so a woman should talk to her doctor about any sort of discomfort during intercourse.
"Pain during sex … should be thoroughly evaluated to rule out physical causes, such as infection, scarring, [or] vulvodynia," said Dr. John Repke, chairman of the department of obstetrics and gynecology at Penn State College of Medicine.
Vulvodynia is defined as chronic pain in and around the opening of the vagina. Symptoms include burning, soreness, itching and throbbing in the genital area.
Doctors suggest that women who suffer from pain during sex use lubricants and get adequate foreplay into the mix before having sex. While not in the bedroom, women should avoid tight pants and underwear, stay active and use cold compresses to ease the pain.
If lifestyle and home remedies still don't ease the pain, there are several medications and treatments that a woman can discuss with her doctor.
Pain and dryness is particularly common in older women, said LaValleur. There are three layers of cells on the vagina, but, as women age, the layers decrease, getting down to two, then one. The opening of the vagina also gets smaller with age and women can lose their ability to lubricate. Intercourse can be very painful, and women can even bleed when trying to have intercourse without foreplay.
"There may also be a psycho-physiologic reason for painful intercourse that sometimes requires the intervention of a skilled sexual medicine specialist," Repke said.
About one in four women will experience some sort of domestic abuse in their lifetime. While most cases of domestic violence are never reported to the police, many physicians have started to screen for emotional and physical violence during annual gynecological appointments.
Domestic abuse is broadly defined as a pattern of behavior where one partner tries to dominate and control the other person by using fear, guilt, shame and physical or emotional intimidation to wear the other person down. Both physical and emotional abuse threaten the livelihood and well-being of the person involved.
"These are issues that many primary care physicians cringe to hear a patient say," said Harper. "And the patient can feel that the physician is uncomfortable with the topic. [So], unless the woman is near dying from the abuse, she may choose not to say anything to the physician."
While women are much more resistant to discussing domestic abuse than almost any other subject, many doctors say that, once the trust is built, some women will begin to open up about their home life.
"We ask questions that give them the idea to talk about it," said Dr. Paula Hillard, professor in the department of obstetrics and gynecology at Stanford University School of Medicine. "For some, it takes several visits with me for them to feel comfortable enough to acknowledge [the problem]. They're ashamed."
LaValleur agreed that many women see abuse as a badge of shame, but those same women might be surprised by the prevalence of women who are affected by domestic violence.
"People have a mistaken idea that domestic abuse happens in people who are poor or in alcoholic homes, but it can happen in any socioeconomic strata," said Hillard.
Domestic violence comes in many forms, including physical aggression, sexual abuse, intimidation, stalking and neglect. Abuse does not have to be physical.
"Calling someone a bitch is abusive," said LaValleur.
When doctors find out that a patient is in an abusive household, the next question is almost always whether the woman has an escape plan for herself, and, if applicable, her children.
"A woman needs to know where she can go that is safe and who she can depend on," said LaValleur.
If you or someone you know suffers from domestic abuse, call the National Domestic Violence Hotline at 1-800-799-SAFE (7233) to gather information on a safe way out. The hotline is anonymous, confidential, and lines are open 24 hours a day, 7 days a week.
Urinary incontinence is another touchy subject for women. It is defined as an involuntary leakage of urine. It is a common problem in women of all ages, but leakage is most prevalent among older women. Approximately 13 million men and women experience incontinence in the United States. As women get older, their muscles relax in the body, causing a higher likelihood of leakage. Pregnancy, weight gain and various conditions like diabetes and stroke can also increase the risk of incontinence. Up to 50 percent of post-menopausal women may experience the condition.
"Incontinence usually is not caused by a serious problem," said Gass. "It's more of a quality-of-life issue and a nuisance," said Gass.
Treatment for incontinence varies, from bladder training and scheduled toilet trips, to Kegel exercises, medications, interventional therapies and surgery.
"Incontinence can be a reason that women end up in assisted care, or make choices to not exercise or have chronic infections related to anatomic abnormalities," said Dr. Joanna Cain, chair of obstetrics and gynecology at Warren Alpert Medical School at Brown University. "The important thing is that nowadays the majority of incontinence is treatable, including for women with other medical conditions."
Many women experience some sort of problem bleeding at one point or another in their lives. Vaginal bleeding is considered abnormal if it occurs when a woman is not expecting her period, the period is much lighter or heavier than normal, she is bleeding while pregnant or after menopause.
Normal menstruation occurs every 21 to 35 days, when the uterus sheds its lining. While abnormal bleeding can be harmless due to ovulation or hormone changes, it can also be a sign of a variety of conditions, including endometrial cancer, miscarriage, sexually transmitted disease, hormonal changes and uterine fibroids.
Especially in older women, Repke said, "Post-menopausal bleeding should never be ignored, and should never be considered normal. While the leading cause of post-menopausal bleeding is atrophic vaginitis, this is a diagnosis of exclusion and the diagnosis that must be ruled out is cancer, specifically cancer of the endometrium."
Am I Normal?
Some of the questions that cause women the most concern and thought have nothing to do with serious medical issues, but rather, the physical appearance of their breasts and vagina.
Breasts, nipples, labia and pubic hair come in all sorts of shapes and sizes, and by and large, a woman is more likely normal than not.
While doctors said that the 'am I normal' questions are not as prevalent in older women, many teens and women in their 20s often wonder what they are supposed to look like.
"Few women put a mirror down there and look at their vulva, and they want to know if they're normal in regards to looks," said LaValleur. "They often just need reassurance that they're normal."
Along with appearance of the vagina, another worry for some women is smell. Doctors say a slight musky scent is totally normal. A fishy smell can indicate a yeast infection, which can be easily treated with prescribed medication. In some cases, a bad odor can also indicate a sexually transmitted disease. A woman should see her doctor if an odor persists. In the meantime, she should clean the external pubic area with a mild soap and avoid douching, as it can make the potential infection worse.
Whatever the condition or question, doctors encourage all their patients to feel comfortable sharing any concern they have when it comes to their well-being or their body. And, because of this, women should find a doctor with whom they feel comfortable discussing personal matters.
"I wish there was a social network for trying out doctors," said Harper. "Because we discuss personal and detailed parts of our intimate life with a doctor, it would be nice if there was some way to preview what a doctor's personality was like."