Womens Health

Sexuality FAQs

by Frederick R. Jelovsek MD

Worse sex with Zoloft®

I just wanted to let you know that I have researched women using Viagra ® and some doctors are prescribing it to women to intensify orgasms and lengthen them. I just need to find a Dr. to go along with it. Basically we are guineas. Thanks for leading me in that direction. I have started Zoloft® for stress related depression and guess what -- sex is worse than ever now. I basically can't get into it much. I've been reading up on Wellbutrin® and this is supposed to have less sexual side effects maybe even increase desire. Any feedback on this would be appreciated.

In our practice, none of the doctors prescribe antidepressants/anti anxiety meds very frequently, so I'm not speaking from an extensive experience. We do have a rule-of- thumb, however in women who have a mixed anxiety/stress/depression symptoms, we use Zoloft® (sertraline) for those who have a predominantly depressive component, and Paxil® (paroxetine) for those who have predominantly a stress/anxiety component. We don't use Wellbutrin® (bupropion) much at all because it seems to have more side effects (G.I., headaches, dizziness).

In the PDR I notice that Zoloft® does have a high incidence of impotence in men (17%) whereas Paxil® and Wellbutrin® are under 4%. This would imply that women may have a similar difficulty in sexual response (not all women, however).

Viagra® (sildenafil) successfully treats many men with impotence. The lead article in the New England Journal of Medicine recently points out that it does NOT improve sexual desire in men but it did produce erection ONLY in response to sexual stimulation. The physiology of the sexual response is very similar in women so I would expect it to prolong the arousal phases of sexual activity but it won't prolong orgasm. It doesn't lower the thought barriers if desire is inhibited. Keep in mind before you try this experiment though that the doses may be different for women than men (more likely lower at least by body weight) and that Viagra® in the men's study had a (20%-30%) incidence of headaches and flushing, about 10% stomach upset and occasional visual disturbances. These are fairly high side effect rates as medicines go. Be careful!

In your situation it might make the most sense to work with your doctor to get on a medicine with the least effects on sexual response before trying any Viagra®.


Stingingly painful sex

My vagina is constantly tender inside. A gyn exam reveals redness and some inflammation. Sex is stingingly painful. My Gynecologist recommends cauterization(!!!) of the nerve endings. Currently applying Dermasone® cream which helps a little but the problem remains. We are both, my husband and I, anxious to solve this. It only began about 1 1/2 years ago and I've not had a similar complaint before. I'm 28 you. I had one kidney removed at a very early age. This complaint began(?) with a smelly discharge and pain, now only pain no smell, no discharges. Please help as we have very little money for these constant medical visits.

An infection or sore can heal poorly with scar tissue and constant nerve irritation. Treatment is often started out with corticosteroid creams or even injections. Sometimes destruction of the painful tissue can improve pain. For the most part, however, I prefer excision of the tissue.


Orgasm doesn't last

I'm 34 yrs old have had four children and find my desire to have sex still there and I enjoy foreplay but when I actually have an orgasm it stops as soon as it started, leaving me feeling disappointed and frustrated. I'm already using Kegel exercises - -any other ideas?

Are you on any medicines?

No, but my gyn has talked about putting me on an anti-depressant thinking stress is the culprit, but most contain sexual side effects and I'm not sure this is the answer.

I'm not sure either. You said the main problem was early stopping of orgasm. You didn't mention having decreased sexual desire in the first place or any difficulty having an orgasm. Are any of these a problem also? They go along more with stress than what you describe.

When you say orgasm occurs but stops quickly, what physical feelings are you referring to?

Well, I'm not sure if you can relate to this but here it goes. Everything is feeling great I can feel myself on the verge of orgasm. I start to have one and that's it- it is done- no wave after wave that slowly declines. I don't know maybe I just used to have super orgasms and now I have one that I feel that's it- its over. How disappointing! I can remember feeling slightly dizzy afterwards. My hubby takes this all personally like it is his fault I can't achieve the level of orgasm I used to. It is taking its toll on our love life. I feel like I'm always thinking, okay, this time its going to be normal so I'm sure I'm adding pressure to myself. But I really miss that exploding wave after wave. I'm content - I want to go to sleep orgasm. It is so frustrating!

It sounds as if the uterine contractions that occur with orgasm are almost absent. The only easily changeable things I can think of would be medications (which you said you weren't taking) such as aspirin, non steroidal anti inflammatory drugs such as Alleve®, Motrin®, pain medicines, antihypertensives, alcohol, asthma medicines or anything that would interfere with smooth muscle contractions.

Putting pressure on yourself can certainly change sexual response. It does in men with premature ejaculation.

I guess that is a good way to describe it..(the uterine contractions aren't present) I do take ibuprofen. How would this effect things?

Ibuprofen is the same as Motrin®, a non-steroidal, anti inflammatory drug (NSAID) and it does inhibit uterine contractions. I wouldn't think you were using it so often that it would interfere with relations. It has a short duration of about 6-8 hours. If you are taking it daily maybe it could be affecting this problem.


Intercourse pain with pelvic congestion syndrome

I have been reading about pelvic congestion syndrome, and cannot seem to find out the answer to this one question. They give as part of the list of symptoms "pain with sexual intercourse"... Do they mean pain from the physical mechanics of intercourse, or pain from orgasm, or what exactly?

Most of time, it is thought to be directly mechanical due to movement of the pelvic organs during the thrusting of intercourse. Think of it as varicose veins in the pelvis. There is a chronic discomfort in between sexual relations also. Many physicians consider it a cause of chronic pelvic pain but it is somewhat controversial since it is very difficult to study this type of problem.


Headache at sexual climax

What causes and what cures headache at sexual climax? Does this require medication or behavior modification? Subject is normal 46 y.o. female in good health.

Sex headaches are not common. I've only seen a few women in whom it has been a significant problem requiring treatment. I've just looked at Medline at National Library of Medicine to brush up. Here is what I've been able to glean: It is called different things, sex headache, coital cephalgia, orgasm migraine etc. It is closely related to an entity called exertional headache and may actually be the same thing.

The headache can last minutes to days and can be quite painful. It is actually more common in men than women by a 5:1 ratio. The distribution of the headache can be that of a migraine, a cluster headache or just like a tension headache. One French author (see below) classifies it into three subtypes. The treatment is usually common, generic medicines such as propanolol (Inderal®, the same anti-hypertensive medicine that many public speakers use not to be so nervous) or indomethacin (Indocin®, an anti-arthritis medicine that also blocks smooth muscle contractions).

Steps to diagnose and treat would probably include a referral from the primary care physician to a neurologist. The neurologist is going to determine the exact type of headache it is, if there are other times that headaches take place and an exam. He/she will need to decide if any MRI or CAT scan is needed to rule out a brain vessel or neoplasm lesion (unlikely but possible depending on the patient's history and exam. After that, the treatment would likely be propanolol prior to intercourse -- prophylactically so to speak! Enclosed below are some abstracts of scientific articles from Medline.


Sands GH, Newman L, Lipton R.

Cough, exertional, and other miscellaneous headaches.

Med Clin North Am 1991 May;75(3):733-747

Long Island Jewish Medical Center, Albert Einstein College of Medicine, New Hyde Park, New York.

We have discussed several miscellaneous headache disorders not associated with structural brain disease. The first group included those headaches provoked by "exertional" triggers in various forms. These include benign cough headache, BEH, and headache associated with sexual activity. The IHS diagnostic criteria were discussed. Benign exertional headache and cough headache were discussed together because of their substantial similarities. In general, BEH is characterized by severe, short- lived pain after coughing, sneezing, lifting a burden, sexual activity, or other similar brief effort. Structural disease of the brain or skull was the most important differential diagnosis for these disorders, with posterior fossa mass lesions being identified as the most common organic etiology. Magnetic resonance imaging with special attention to the posterior fossa and foramen magnum is the preferred method for evaluating these patients. Indomethacin is the treatment of choice. The headache associated with sexual activity is dull in the early phases of sexual excitement and becomes intense at orgasm. This headache is unpredictable in occurrence. Like BEH, the headache associated with sexual activity can be a manifestation of structural disease. Subarachnoid hemorrhage must be excluded, by CT scanning and CSF examination, in patients with the sexual headache. Benign headache associated with sexual activity has been successfully treated with indomethacin and beta-blockers.


Nick J, Bakouche P.

[Headache related to sexual intercourse].

Sem Hop 1980 Apr 8;56(13-14):621-628 [Article in French]

Coital cephalgia (CC) is rare (1/360 headaches); it occurs more frequently among men. Out of 16 unpublished cases, in 4 cases, CC was the inaugural symptom of vascular attack. In the 12 other cases, CC was isolated or primary. According to the time of onset of headache during coitus one may distinguish three types: 1) early CC usually moderate and short lasting; 2) orgasmic CC, abrupt, severe, lasting 15 to 20 minutes; 3) late CC of long duration (hours, days) follows sometimes orgasmic CC. Isolated CC is usually repetitive but capricious, episodical, not periodical. Prognosis is good. Mechanism is mainly vascular and muscular. The role of high blood pressure, migraine, and psychological factors is discussed.


Johns DR.

Benign sexual headache within a family.

Arch Neurol 1986 Nov;43(11):1158-1160

The occurrence of the vascular type of benign sexual headache (BSH) is described within members of a family. The most severely affected of the four sisters was successfully treated with propranolol hydrochloride prophylaxis. The literature on headache related to sexual activity is reviewed and the clinical features of BSH are formulated. The familial occurrence is put forth as further evidence to consider the vascular type of BSH as a migraine variant.


Silbert PL, Hankey GJ, Prentice DA, Apsimon HT.

Angiographically demonstrated arterial spasm in a case of benign sexual headache and benign exertional headache.

Department of General Medicine, Royal Perth Hospital, WA, Australia.

Benign headaches related to sexual activity and exertion are being recognized with increasing frequency. We wish to report a case of benign sexual headache (Type 2) and benign exertional headache, occurring sequentially in the same patient. Multiple areas of cerebral arterial spasm were demonstrable on angiography. This observation would support the concept that benign sexual headache (Type 2) and benign exertional headache may have a similar pathophysiology.


Pain with sex since starting intercourse

I have been experiencing pain with intercourse for as long as I've had intercourse. The last few years I have been more sexually active. It feels like a cut inside me or maybe a tear; it stings. The last six months I have had a slight pink blood with my burning and stinging anywhere from one hour after sex to three days later. I recently went to a urologist for recurrent bladder infections. The medicine he gave me helped a bit with frequency but not for pain after and during sex. I went to him thinking that there might be a tear or something. I am 35 yrs. old and had 3 or 4 dilations of the urethra when I was 18. Could this have given me the problems? Any ideas? Pap smear was normal about 1 yr and a half ago, but I didn't tell gyn about this new bleeding and stinging, only told the urologist. I don't want to get to the point that I fear having sex!

It is unlikely that the urethral dilations at age 18 are related to the current problem. You were right to go to the urologist to get it checked out, however. The next step would be to have your gynecological exam and be sure to tell all of the symptoms and fears you are having. The gynecologist, through symptom questioning and pelvic exam, will probably try to classify the problem into whether it is a superficial (near the outer 1/2 of the vaginal or vulva) problem or whether it is a deep (near the cervix, uterus and internal pelvis) pain with intercourse. There are many causes of superficial dyspareunia, (pain with intercourse) and many causes of deep dyspareunia The fact that you are having light, bright red bleeding with intercourse would slightly favor a superficial dyspareunia category. This is a serious problem, not inasmuch as it may be a life threatening disease such as cancer, but because it will forever affect sexual desire and fear of vaginal intercourse. It needs to be evaluated. This type of a problem does not usually get better spontaneously.


Bleeding after intercourse

Lately I have started bleeding after having intercourse, I had an infection a few weeks ago and now the lining of my vagina seems very thin and it hurts to have sex and then I bleed. I am 39 years of age and I have had two children. They are aged 18 and 20.

Bleeding after intercourse (post coital bleeding) usually means either the skin lining the cervix or vagina is thin or inflamed, or there is an anatomical lesion on the cervix such as a polyp or a precancerous or cancerous lesion. A normal Pap and pelvic exam within the last year makes cancer highly unlikely, but precancerous lesions (abnormal pap smears, dysplasia) are possible so a physician's visit is indicated with any post coital bleeding.

At the time of a visit, in addition to a PAP smear, the physician should be able to tell if there is an anatomical lesion causing the bleeding or if the vagina is thin due to low estrogens and just gets irritated with intercourse. The thinness of the vaginal skin and pain with sex indicate the lining of the vagina may be the likely problem. It sounds as if there are low estrogens such as may be seen in menopause or with the absence of ovulation due to other non menopausal causes. A history of infection may be related or an independent event. If the vagina skin (epithelium) is thin and atrophic, the infection can be a bacterial vaginitis known as atrophic vaginitis. Infections can be other etiologies however, so more information about that would be helpful.

Age 39 is quite young for menopause so the recent menstrual history would help too. Many things such as medications, diseases, stress etc., can suppress ovulation which in turn causes low estrogens, which in turn causes atrophic vaginitis, which in turn causes painful sexual relations and sometimes bleeding after sexual relations. The physician may order a serum follicle stimulating hormone (FSH) to rule out menopause and possibly a thyroid stimulating hormone (TSH) and serum prolactin to investigate the possibility of a central nervous system cause of the blocked ovulation.

In summary, the problem you describe may not just be a simple infection problem. It can be a symptom of other bodily changes that bear investigating. You shouldn't have to fear having sex!


Anal sex

On another bulletin board, this discussion of sexual freedom between married couples came up. Specifically a man wanted to have anal sex with his wife and wanted to know if there were any reasons why they should not. There were postings that this is a common practice in South America and Africa, as a type of birth control. It was also posted that this practice is physically damaging to the woman, due do the lack of mucosal protection, and the extreme absorbability of the lining of the large intestine. Finally, there was wondering if it damaged the sphincter and caused hemorrhoids. This was disputed by the gentleman. I could not find much information on the potential risks of anal sex to a woman, the search engines mostly pulled up cyber sex sites. Would appreciate any information on this that I can share with others on the board.

Anal intercourse isn't practiced much in U.S. by women with male partners that I know of. It is practiced some. It initially causes rectal fissures and bleeding but not hemorrhoids. It can be damaging to the external anal sphincter. In the long run that will lead to rectal incontinence. Some women can get used to it over time but they have learned to voluntarily relax the rectal sphincter. I don't recommend it at all.

Gay men practice anal intercourse but they also tend to have a high incidence of genital warts, herpes and gonorrhea. Hepatitis and HIV often have their ports of entry by anal intercourse. Presumably there are small tears in the rectal mucosa quite frequently that allow this.

What do you think the probability is that a man who wants to practice anal intercourse with his female partner, is having intercourse with another male/female partner? Sounds like suicide to me.

Thank you for your reply. The board is a Christian apologetics board, and the discussion was on guilt or freedom in the marriage bed. I am agreed that guilt is a strong inhibitor of marital bliss....but freedom should not entail practices that are harmful to either partner. Again, I thank you for this information.



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I have anal fissures and husband can't stop having anal sex with me. The penetration is extremely difficult and painful as well as the whole process. Pain eases a bit during sex but even when my bowel is completely empty, I feel urge to pass stool and once I have just after sex on bed, a little spec mixed with semen. What should I do?
8 years ago